RETURN DEMO

TRANSFERRING BETWEEN BED & CHAIR

Purpose:
1. To strengthen the patient gradually
2. To provide a change in position

Equipments:
- Robe or appropriate clothing
- Slippers or shoes
- Chair or wheelchair

Assessment:
- The clients body size
- Ability to follow instructions
- Activity tolerance
- Muscle strength
- Joint mobility
- Presence of paralysis
- Level of comfort
- The technique with wich the client is familiar
- The skill & strength of the caregiver

Preparation:
- Plan what to do & how to do it.
- Obtain essential equipment before starting & check if it is functional
- Remove obstacles from the area used for the transfer

Performance:
1. Introduce self & verify the clients identity using the agency protocol. Explain the transfer
process to the patient.

- This facilitates cooperation of the patient

2.Perform hand hygiene.

- Hand hygiene deters the spread of microorganisms.

3. Provide for client privacy.

4. Position the equipment appropriately.

- Lower the bed to its lower position so that the clients feet will rest flat on the floor. Lock the
wheels of the bed.

- Place the wheelchair parallel to the bed as close to the bed as possible.

Put the wheelchair on the side of the bed that allows the client to move toward his or her
stronger side.

- Lock the wheels of the wheelchair & raise the footplate.

5. Prepare & assess the client

- Assist the client to a sitting position on the side of the bed.

- Assess the client for orthostatic hypotention before moving the client from the bed.

- Assist the client in putting on a bathrobe & slippers

- Place a transfer belt snugly around the client’s waist. Check to be certain that the belt is
securely fastened.

6. Give explicit instructions to the client;

Ask the client to:

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- Move forward & sit on the edge of the bed. This brings the clients center of gravitycloser to the
nurse’s

- Lean forward sligtly from the hips. This brings the clients center of gravity more directly over
the base of support & positions the head & trunk in the direction of the movement.

- Place the foot of the stronger leg beneath the edge of the bed & put the other foot forward. In
this way, the client can use the stronger leg muscles to stand & power the movement. A broader
base of support makes the client more stable during the transfer.

- Place the client’s hands on the bed surface or on your shoulders so that the client can push
while standing. This provides additional force for the movement & reduces the the potential for
strain on the nurse’s back. The client should not grasp your neck for support. Doing so can
injure the nurse.

7. Position yourself correctly.

- Stand directly infront of the client. Encircle the clients waist w/ your arms & grasp the transfer
belt at the clients back if there is any. The belt provides a secure handle for holding on the client
& controlling the movement.

8. Assist the client to stand & then move together toward the wheelchair.

- On the count of three, ask the client to push with the back foot, rock to the forward foor &
extend the joints of the lower extremities. Push or pull up with the hands, while pushing w/ the
forward foot, rock to the back foot, extend the joints of the lower extremities & pull the client into
a standing position.

- Support the client in an upright standing position for a few moments. This allows the nurse &
the client to extend the joints & provides the nurse w/ an oportunity to ensure that the client is
stable before moving away from the bed.

- Together, pivot or take few steps toward the wheelchair.

9. Assist the client to sit.

Ask the client to:
a. Back up to the wheelchair & place the legs against the seat.
- Having the client place the legs against the wheelchair seat minimizes the risk of the client
falling when sitting down.

b. Place the fot of the stronger leg sligtly behind the other.
- This supports body weight during the movement

c. Keep the other foot forward.

- This provides a broad base of support.

d. Place both hands on the wheelchair arms or on your shoulders.

- This increases stability & lessens the strain on the nurse.
• Stand directly infront of the client. Place one foot forward & one back.
• Tighten your grasp on the trasnsfer belt & tighten your leg, gluteal, abdominal & arm musles.
• On the count of three, have the client shift the body weight & lower the body onto the edge of
the wheelchair seat by flexing the joints of the legs arms.

10. Ensure client safety.

- Ask the client to push back into the wheelchair seat.
- Lower the footplates & place the clients feet on them.
- Apply a seat belt as required.

11. Documentation
- Clients ability to bear weight & pivot
- Number of staff needed for transfer
- Length of time up in chair
- Clients response to transfer & being up in chair or wheelchair.

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Cleaning Living Room & Bathroom

Cleaning Living Room

1. Start w/ ceilings – using two tract technique. Start from the farthest to nearest area.

2. Walls – using two cleaning cloth 1 dry & the other is moist. Clean the walls using a circular
motion , 1st w/ moisten cloth follow with dry, both hands are holding them at the same time. It is
also advised to partition the walls to four parts so it will be easy.

3. Picture Frames – using a feather duster starting from top using circular motion.

4. Furniture – using a vacuum start from the top going down, then side, last throw pillows.

5. Floors – vacuum from farthest to nearest, don’t step on the vacuumed area.

Cleaning Bathroom
Bathroom – walls, (same as living room), lavatory, bowl, floors

Removing Indwelling Catheters

Procedure:
1. Confirm the physicians order to remove. Assume handwashing & prepare the equipment
needed such as receptacle for the catheter, clean disposable towel, clean gloves & sterile
syringe to deflate the balloon, a large one.

2. Prepare the client. Explain the procedure & assist to a supine position. Optimal: Obtain a
sterile specimen before removing the catheter. Check agency protocol.

3. Remove the tape or catheter securing device attaching the catheter to the client, put on
gloves & then place the towel between the legs of the female client or over the thighs of the
male.

4. Insert the syringe into the injection port of the catheter & withdraw the fluid from the balloon. If
not all of the fluid can be removed report this fact to the nurse incharge before proceeding.

5. Do not pull the catheter while the balloon is inflated; doing so may injure the urethra.

6. After all of the fluid is withdrawn from the balloon, gently withdraw the catheter & place it in
the waster receptacle.

7. Dry the perineal area w/ a towel.

8. Remove gloves.

9. Measure the urine in the drainage bag & record the removal of the catheter

- Time the catheter was removed

- Amount, color & clarity of the urine

- Intactness of the catheter

- Instructions given to the client

10. Provide the client w/ either a urinal (M) bedpan, commode or toilet collection device to be
used w/ each subsequent unassisted void.

11. Following removal of the catheter, determine the time of the first voiding & the amount

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voided during the first 8 hours. Compare this output to the client intake.

12. Observe for dysfunctional voiding behaviors which might indicate urinary retention. If this
occurs, perform an assessment of post void residuals using a bladder scanner if available.
Generally postvoid residuals greater than 200 cc will require straight catheterization as needed.

Providing Special Oral Care For the Unconscious Client

Purposes:
- To maintain the intactness & health of the lips, tongue & mucous membrane of the mouth.
- To prevent oral infections
- To clean & moisten the membranes of the & lips.

Equipment:
- Towel
- Curved basin
- Disposable clean gloves
- Tissue or piece of gauze
- Mouthwash
- Bite block to hold the mouth open & teeth apart
- Suction catheter with suction apparatus when aspiration is a concern
- Toothbrush
- Cup of tepid water
- Dentrifice
- Denture container
- Rubber tip bulb syringe
- Foam swabs & cleaning solution for cleaning the mucous membrane
- Water soluble lip moisturizer

Procedure
1. Introduce yourself.
2. Perform hand hygiene
3. Provide privacy
4. Prepare the client

- Position the client in a side-lying position w/ thehead of the bed lowered. – In this position the
saliva automatically runs out of gravity rather than being aspirated into the lungs. This position is
chosen for the uconscious client receiving mouth care. If the clients head cannot be lowered
turn it to one side. – The fluid will readily run out of the mouth or pool in the side of mouth where
it can be suctioned.

- Place the towel under the clients chin

- Place the curved basin against the client’s chin and lower check to to receive the fluid from the
mouth.

- Put on gloves

5. Clean the teeth & rinse the mouth

- If the person has natural teeth brush gently & carefully to avoid injuring the gums. If the client
has artificial teeth clean it the way w/ the dentures.

- Rinse the client’s mouth by drawing about 10ml of water or alcohol free mouthwash into the
syringe & injecting it gently into each side of the mouth. – If the solution is injected w/ force,
some of it may flow down the client’s throat & be aspirated into the lungs.

- Watch carefully to make sure that all the rinsing solution has run out of the mouth into the

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basin. If not suction the fluid from the mouth. – Fluid remaining in the mouth may be aspirated
into the lungs.

- Repeat rinsing until the mouth is free of dentrifice, if used.

6. Inspect & clean the oral tissues.

- If the tissues appear dry or unclean, clean them w/ the foam swabs or gauze & cleaning
solution following agency Policy.

- Picking up moistened foam swab, wipe the mucous membrane of one cheek. Discard the
swab in a waste container, use a clean one to clean the next area. – Using separate applicators
for each area of the mouth prevents the transfer of microorganisms from one area to another.

- Clean all mouth tissues in an orderly progression, using separate aplicators. The cheeks, roof
of the mouth, base of the mouth & tongue.

- Observe the tissues, for inflammation & dryness

- Rinse the client’s mouth

- Remove & discrad the gloves.

7. Ensure client comfort.

- Remove the basin & dry around te client’s mouth w/ the towel. Replace artificial dentures.

- Lubricate the client’s lips w/ water-soluble moisturizer. – Lubrication prevents cracking &
subsequent infection.

8. Document assessment of the teeth, tongue, gums & oral mucosa. Include any problems such
as sores, or inflammation & swelling of the gums.

Providing Perineal – Genital Care

Purpose:
- To remove normal perineal secretions & colors
- To promote client comfort

Assess for:
- Irritation, excoriation, inflammation swelling
- Excessive discharge
- Odor, pain or discomfort
- Urinary or fecal incontinence
- Recent rectal or perineal surgery
- Indwelling catheter

Determine:
- Perineal-genital hygiene practices
- Self-care abilities

Equipment:
- In conjunction w/ bed bath
- Bath towel
- Bath blanket
- Washcloth
- Clean gloves
- Soap

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- Bath basin w/ water 43-46 degree Celsius

Special perineal-genital care:

- Bath towel
- Bath blanket
- Clean gloves
- Cotton balls or swabs
- Solution bottle, pitcher or container filled w/ warm water or a prescribed solution
- Bed pan to receive rinse water
- Moisture-resistant bag or receptacle for used cotton swabs
- Perineal pad

Procedure:
1. Introduce self
2. Perform hand hygiene
3. Provide client privacy
4. Prepare the client
- Drape the client
- Fold the top bed linen to the foot of the bed & fold the gown up to expose the genital area.
- Place a bath towel under the client’s hips. – The bath towel prevents the bed from becoming
soiled.

5. Position & drape the client & clean the upper inner thighs.
6. Provide the patient a bed pan.

For Females:
- Position the female in a back lying position w/ the knees flexed & spread well apart.

- Cover her body & legs w/ the bath blanket positioned so a corner is at her head, the opposite
corner is at her feet & the other two on the sides. Drape the legs by tucking the bottom corners
of the bath blanket under the inner sides of the legs.

– Minimum exposure lessens embarrassment & helps provide warmth. Bring the middle portion
of the base of the blanket up over the pubic area.

- Start cleaning from the cleanest to dirtiest.

- Pour on water starting from the farthest thighs, to the upper

For Males
- Position the male client in a supine position w/ knees slightly flexed & hips slightly externally
rotated.

- Put on gloves; wash & dry the upper inner thighs.

7. Inspect the perineal area.

- Note particular areas of inflammation, excoriation or swelling, especially between the labia in
females & the scrotal folds in males.

- Also note excessive discharge or secretions from the orifices & the presence of odors.

8. Wash & dry the perineal-genital area.

For Females

- Clean the labia majora. Then spread the labia to wash the folds between the labia majora &
labia minora. – Secretions that tend to collect around the labia minora facilitates bacterial
growth.

- Use separate quarters of the washcloth for each stroke & wipe from the pubis to the rectum.

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For menstruating women & clients w/ indwelling catheters, use clean wipes. Take a clean wipe
for each stroke. – Using separate quarters of the washcloth or new wipes prevents the
transmission of microorganisms form one area tot the other. Wipe from the area of least
contaminated (the pubis) to that of greatest contaminated (the rectum)

- Rinse the area well. You may place the client on a bed pan & use a periwash or solution bottle
to pour warm water over the area. Dry the perineum thoroughly, paying particular attention to
the folds to the labia. – Moisture supports the growth on many microorganisms.

For Males:
- Wash & dry the penis using firm strokes.

- If the client is uncircumcised, retract the prepuce (foreskin) to expose the glans penis for
cleaning. Replace the foreskin after cleaning the glans penis. – Retracting the foreskin is
necessary to remove the smegma (thick, cheesy secretion) that collects under the foreskin &
facilitates bacterial growth. Replacing the foreskin prevents constriction of the penis which may
cause edema.

- Wash & dry the scrotum. The posterior folds of the scrotum may need to be cleaned when the
buttocks are cleaned. - The scrotum tends to be more soiled than the penis because of its
proximity to the rectum; thus It is usually cleaned after the penis.

9. Inspect perineal orifices for intactness.

- Inspect particularly around the urethra in clients w/ indwelling catheters. – A catheter may
cause excoriation around the urethra.

10. Clean between the buttocks.

- Assist the client to turn onto the side facing away from you.

- Pay particular attention to the anal area & posterior folds of the scrotum in males. Clean the
anus w/ toilet tissue before washing it, if necessary.

- Dry the area well.

- For post delivery or menstruating females, apply a perineal pad as needed from front to back.
– This prevents contamination of the vagina & urethra from the anal area.

11. Document any unusual findings such as redness, excoriation, skin breakdown, discharge or
drainage & any localized areas of tenderness.

Evaluation
- Relate current assessments to previous assessments

- Conduct appropriate follow-up such as prescribed ointment for excoriation.

- Report any deviation from normal to the primary care provider.

Providing Hair Care for Clients

Purpose:
- To stimulate the blood circulation to the scalp
- To distribute hair oils & provide a healthy sheen
- To increase the clients comfort
- To assess or monitor hair or scalp problem.

Equipment:

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- Clean brush & comb
- A wide tooth comb
- Towel
- Hair oil preparation

Procedure:
1. Introduce self.
2. Perform hand hygiene & other appropriate infection control procedures.
3. Provide privacy
4. Position & prepare client appropriately
- Assist the client who can sit to move to a chair. – Hair is more easily brushed & combed when
the client is in a sitting position. If health permits assist a client confined to a bed to a sitting
position by raising the head of the bed. Otherwise assist the client to alternate side-lying
position & do one side of the head at a time.

- If the client remains in bed, place a clean towel over the pillow & the client’s shoulders. Place it
over client’s shoulders. – The towel collects any removed hair, dirt & scaly materials.

- Remove any pins or ribbons in the hair.

5. Remove any mats or tangles gradually.

- Mats can usually be pulled apart w/ fingers or worked out w/ repeated brushings.

- If the hair is very tangled, rub alcohol or oil such as mineral oil, on the strands to help loosen
the tangles.

- Comb out tangles in a small section of hair toward the ends. Stabilize the hair w/ one hand &
comb toward the ends of the hair w/ the other hand. – This avoids scalp trauma.

6. Brush & comb the hair.

- For short hair, brush & comb one side at a time. Divide long hair into two sections by parting it
down the middle from the front to the back. If the hair is very thick divide each section into front
& back subsections or into several layers.

7. Arrange the hair as neatly & attractively as possible. Braiding long hair prevents tangle.

8. Document assessment & special nursing interventions. Daily combing & brushing of the hair
is not normally recommended.

Providing Foot Care

Purposes:
- To maintain the skin integrity of the feet
- To prevent foot infections
- To prevent foot odors
- To assess or monitor foot problems

Assess:
- Skin surfaces for cleanliness, odor, dryness & intactness
- Each foot & toe for shape, size, presence of lesions & areas of tenderness, ankle edema.
- Skin temperatures of both feet to assess circulatory status
- Pedal pulses: dorsalis pedis & posterior tibialis
- Self-care abilities

Equipment:
- Wash basin containing warm water
- Pillow
- Towels

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- Washcloth
- Lotion/Foot powder
- Moisture resistant disposable pad
- Soap
- Toenail cleaning & trimming equipment
- Lotion/Foot powder

Procedure:
1. Introduce self.
2. Perform hand hygiene
3. Provide privacy
4. Prepare the equipment & the client
- Fill the washbasin w/ warm water at about 40 degree Celsius to 43 degree Celsius (105
degree F to 110 degree F). – Warm water promotes circulation, comfort & refreshes.

- Assist the ambulatory client to a sitting position in a chair or the bed client to a supine or semi-
Fowler’s position.

- Place a pillow under the bed client’s knees. – This provides support & prevent muscle fatigue.

- Place the washbasin on the moisture-resistant pad at the foot of the bed for a bed client or on
the floor infront of the chair for an ambulatory client.

- For a bed client pad the rim of the washbasin w/ a towel. – The towel prevents undue pressure
on the skin.
5. Wash the foot & soak it.

- Place one of the clients feet in the basin & wash it w/ soap, paying particular attention to the
interdigital areas. Prolonged soaking is not recommended for a diabetic clients or individuals w/
peripheral vascular disease. – Prolonged soaking may remove natural skin oils, thus drying the
skin & making it more susceptible to cracking & injury.

- Rinse the foot well to remove soap. – Soap irritates the skin if not completely removed.

- Rub callused areas of the foot w/ the washcloth. – This helps remove dead skin layers.

- Clean the nails as required w/ an orange stick. – This removes excess debris that harbor
microorganisms.

- Remove the foot from the basin & place it on the towel.
6. Dry the foot thoroughly & apply lotion or foot powder.

- Blot the foot gently w/ the towel to dry it thoroughly, particularly between the toes. – Harsh
rubbing can damage the skin. Thorough drying reduces the risk of infection.

- Apply lotion or lanolin cream to the foot but not between the toes. – This lubricates dry skin &
keeps the area between the toes dry or

- Apply a foot powder containing a nonirritating deodorant if the feet tend to perspire
excessively. – Foot powder have greater absorbent properties than regular bath powders; some
also contain menthol, which makes the feet cool.

7. If agency policy permits, trim the nails of the first foot while the second foot is soaking.

- Nail is cut or filed straight across beyond the end of the finger or toe. Avoid trimming or digging
into nails at the lateral corners. This predisposes the client to ingrown toenails. Clients who have
diabetes or circulatory problems should have their nails filed rather than cut; inadvertent injury to
tissues can occur if scissors are used. After the initial cut or filling the nail is filed to round the
corners & then cleans under the nail. Then gently pushes back the cuticle taking care not to
injure it. Then the next finger.

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8. Document any foot problems observed.

- Foot care is not generally recorded unless problems are noted.

- Record any signs of inflammation, infection, breaks in the skin, corns, troublesome calluses, &
pressure areas. This is of particular importance for clients with peripheral vascular disease &
diabetes.

Evaluation:

- Isnpect nails & skin after the soak

- Compare to prior assessment data.

- Report any abnormalities to the primary care provider.

Nebulization

Definition:
-a process of adding mixture to inspired air by mixing particles of varying sizes w/ the air.
-a production of fog/mist used
-used often w/ bronchodilator drugs

Bronchodilator drugs – are agent that dilates the bronchioles of the lungs.

Effects of Bronchodilators
1. Tachycardia
2. Dyspnea
3. Palpitation
4. Nausea & Vomiting
5. Dizziness

Purposes of Nebulization
-To deliver medication in droplet form & to soothe irritated, inflamed & congested mucous
membrane
-To loosen secretion in the respiratory

Equipment
1. Nebulizer machine
2. Nebulizer kit – cup, dome, tubing, t-piece, mouthpiece & mask
3. Drug ordered

Things to Remember Before the procedure

1. Check the doctors order
2. Make sure that the medication has a ticket
3. Identify the patient & explain the procedure
4. Always do handwashing & observe appropriate infection control measures

Procedure
1. Assemble all the equipment needed
2. Place ordered medication on the nebulizer bottle
3. Attach tubing to connector
4. Assess the patient to a Fowlers position
5. Instruct the patient on the following:
A. Mouthpiece
- Keep lips closed tightly around the mouthpiece
- Breath only through the mouth

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-Observe the expansion of the chest
-Tell the patient to take a deep breath from the mouthpiece

6. Instruct the patient to breath slowly & deeply until all the medication is consumed.

7. On completion of medication
-Encourage patient to cough after deep breaths/do chest tapping

8. After the medication; remove the nebulizer kit to the nebulizer machine & make the client
comfortable

9. Disassemble, clean the nebulizer machine kit after each use.

10. Do handwashing
12. Documentation/Record the assessment, observation during the procedure.

Oxygen Therapy

-provision of therapeutic oxygen

Purposes
-To provide supplemental oxygen to patient needing an increased amount of oxygen for
inspiration

-To prevent hypoxia (occurs if the amount of oxygen delivered to the body tissues is too low.

Signs & Symptoms

-Tachycardia
-Dyspnea
-cyanosis
-restlessness

Equipment
1. Oxygen supply (tank, built in O2)
2. Flow Meter Gauge – indicate the gas flow in liters
3. Cylinder Content Gauge – indicates the amount of oxygen in the tank
4. Humidifier Bottle – prevents dryness of oral & nasal mucous membrane
5. Nasal Cannula/Face Mask
6. “No Smoking” sign
7. Tape/micropore
8. Gauge

Things To Remember
-Oxygen can be delivered from wall outlet or portable cylinder
-Oxygen can cause drying of mucous membrane

Safety Measures
1. Avoid open flames in the patients room
2. Place “No Smoking” sign in the areas where Oxygen be used especially in the patients room
& instruct the patient visitors the danger of smoking.
3. Avoid using oil or any clothing stained w/ oil
4. Receiving oxygen is a frightening experience for patient
5. The patient should wear clothes made of cotton
6. Make sure there are no short circuit on the nasal Cannula or nasal prong.

Procedure
1. Determine the need for oxygen therapy & verify the order for the therapy
2. Assemble all the equipment needed
3. Identify the patient & explain what you are going to do.

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4. Wash hands.
5. Provide privacy
6. Set-up the oxygen equipment & the humidifier bottle

a. Attach the flow meter to the wall outlet or tank

b. Fill the humidifier bottle w/ distilled water

c. Attach the humidifier bottle to the base of the flow meter

d. Attach the prescribed oxygen tubing & delivery device to the humidifier bottle

7. Turn-on the oxygen at the prescribed rate & ensure proper functioning

a. Check that oxygen is flowing freely through the tubing by putting th outlet of the nasal cannula
to the face or hands & feel if there is air coming out.

b. There should be bubbles in the humidifier bottle

c. Set the oxygen at the flow rate prescribed

8. Apply the appropriate oxygen delivery device

a. Nasal Cannula or Nasal Prong – Put the cannula over the clients face with the outlet fits into
the narease & the elastic bond around the head. If the cannula will not stay in place, ask
permission from the patient that you are going to put a tape; then tape it on the sides of the
face. Pad the tubing & bond over the ears & cheek bones.

b. Face Mask – Guide the mask towards the clients face & apply it from the nose downward.

-Fit the mask to the contour of the clients face.

-Secure elastic bond around the clients head.

-Pad the bond behind the ears and bony prominences.

9. Assess the client regularly.

-Vital signs
-Anxiety level of the patient
-Color of the patient
-Ease of respiration
-Assess for signs of hypoxia

10. Inspect the equipment regularly

-Checking the flow meter & the level of the humidifier bottle

11. After care, handwashing then documentation.

Nasogastric Tube Feeding

Definition: also known as gastric gavage; installation of especially prepared formula into the
digestive tract through a tube that is inserted through one of the nostrils down to the alimentary
tract.

Purpose:
- Prevent nausea, vomiting & gastric distention following surgery
- Remove stomach contents for laboratory analysis
- To lavage (wash) the stomach in cases of poisoning & overdose of medication

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- To administer medication
- To administer supplemental fluid
- To provide feeding

Procedure:
A. Assess & Prepare the Client
1. Check the clients chart or confirm the physician’s order for NGT feeding, this is done for us to
be sure that we are doing the right procedure to the right client/patient.

2. Assume handwashing..

3. Prepare the needed materials such as the correct amount of feeding solution as ordered by
the physician, asepto syringe/bulb syringe, emesis basin/kidney basin, 60 to 80 ml of water,
stethoscope & disposable pad.

4. After preparing the materials we are now ready to head to the clients room. Before entering
knock on the door, greet the patient if he/she is conscious or significant other if the client is
unconscious. Introduce self, ask the patient/client or significant others for any allergies if it is the
first time to do the NGT feeding.

5. Provide privacy because NGT feeding is embarrassing to some people.

6. Assist client to a fowler’s position in bed or sitting position in a chair. – This position enhance
the gravitational flow of the solution & prevent aspiration of fluid into the lungs.

7. Place a disposable pad on the area where you are working. – To prevent client’s gown from
getting soiled or to avoid being messy.

8. Unpin the tube from under the pillow or from the client’s gown.

B. Assess the Patency of the Tubing

9. Inject 5-20 ml of air through the feeding tube while auscultating the left upper abdomen while
listening to gurgling, whoosing & bubbling sound. If you hear gurgling, whoosing & bubbling
sound we are now sure that the tube is patent.

C. Assess the Residual Feeding Contents

10. Aspirate all the stomach contents & measure the amount prior to administering the feeding.
– This is done to evaluate the absorption of the last feeding. If >50 ml of undigested formula is
withdrawn in adults & >10 ml in infants & its color is okey somewhat like yellow. Reinstill the
gastric contents into the stomach. – Removal of contents disturb the clients electrolyte balance.
If 50 ml or more of undigested formula is withdrawn in adults & 10 ml < in infants check w/ the
nurse incharge before proceeding. The precise amout is usually determined by the Physician’s
order or by Policy of the agency. At some agency it is withheld when the specified amount &
more formula remains in the stomach. In other agencies, the amount withdrawn is subtracted
from the total feeding & that volume is administered slowly. And feeding is also withheld if the
color of the aspirated fluid is coffee ground. – There is bleeding in the stomach.

D. Administer the Feeding

11. Before administering the feeding add 20 ml of water. – To clean the tube & facilitate the
smooth flow of the solution, be sure not to drain all the water.

12. When using the asepto syringe connect the syringe to a pinched or clamped nasogastric
tube. – Prevent excess air from entering the stomach & causing distention.

13. Permit the feeding to flow slowly. Raise or lower the syringe to adjust the flow as needed.
Pinch or clamp the tubing to stop the flow for a minute if the client experiences discomfort.
Quickly administered feedings can cause flatus, crampy pain & reflux vomiting.

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E. Rinse the Feeding Tube Immediately before all the formula has run through the tubing.

14. Instill the feeding tube w/ 60ml of water. – Water cleans the lumen of the tube, preventing
future blockage by sticky formula.

15. Be sure to add water before the syringe or tubing is empty. – Prevents the instillation of air
into the stomach or intestine which causes unnecessary distention.

F. Clamp & Cover the Feeding Tube

16. Clamp the feeding tube before all of the water is instilled. – Prevents leakage & air from
entering the tube if done before water is instilled.

G. Ensure Client Comfort & Safety

17. Pin the tubing to the client’s gown. – This minimizes pulling of the tube thus preventing
discomfort & dislodgement.

18. Ask the client to remain sitting in Fowler’s position or in slightly elevated right lateral position
for at least 30 minutes. – These position facilitate digestion & movement of the feeding from the
stomach along the alimentary tract & prevent potential aspiration of the feeding into the lungs.

H. Thank the client for the cooperation & dispose equipment properly, if it is to be reused, wash
it thoroughly with soap & water so that it is ready for reuse. Afterwards do handwashing &
document relevant information, kind, duration of feeding. Assessment of the client & record the
volume of the feeding & the water administered on the clients intake & output record & lastly,
monitor client for possible problem.
Removing NGT
1. Confirm the physician’s order to remove the tube. Assume handwashing to reduce the
number and transmission of microorganisms. Prepare the materials/equipment needed such as
tissues, clean disposable gloves, disposable pad, disposable plastic bag & asepto syringe/bulb
syringe. After preparing the equipment we are now ready to head on to the client’s room. Knock
on the door before entering the room, greet the patient upon entering. Introduce yourself &
verify the client’s identity by asking the client’s fullname.

2. Prepare the client. Explain that the procedure will not cause any discomfort. Assist the client
to a sitting position if health permit’s. Place disposable pad across the client’s chest to collect
any spillage of mucous. Provide tissue to the client to wipe the mouth & nose upon removal of
the tube. Unpin the tube from the client’s gown. Remove adhesive tape securing the tube to the
nose.

3. Remove the tube.

- Put on disposable gloves. – Gloves prevent soiling the hand & clothing when handling
secretions & excretions.
- Instill 50 ml of air into the tube. – Air clears the lumen of any contents such as food & gastric
drainage.
- Ask the client to take a deep breath & hold it. – This closes the glottis, thereby preventing
accidental aspirations of any gastric contents.
- Pinch the tube. – Pinching prevents any contents inside the tube from draining into the clients
throat.
- Quickly & smoothly withdraw the tube. Place the tube in the plastic bag. – Prevents the
transfer of microorganisms from the tube.

4. Ensure client’s comfort. Assist the client as required to blow the nose. – Excessive secretions
may have accumulated in the nasal passages. Provide mouthwash. Thank the client for
cooperation.

5. Dispose all the equipment appropriately. Place the pad, bag with the tube & gloves in the
receptacle designated by the agency. – Correct disposal prevents the transmission of

14
microorganisms.

6. Do handwashing & document relevant information. Record the removal of the tube & any
relevant assessment of the client.

Intravenous Infusion

- Intravenous Infusion is an efficient & effective method of supplying fluids directly into the
intravascular fluid compartment.

Purposes
1. To supply fluid when client are unable to take in an adequate volume of fluids by mouth.
2. To provide salts needed to maintain electrolyte balance
3. To provide water-soluble vitamins & medications
4. To provide glucose the main fuel of metabolism
5. To establish a lifeline for rapidly needed medications.

Classifications
1. Isotonic – same concentration of solute to your blood plasma.
2. Hypertonic – greater concentration of solute to your blood plasma
3. Hypertonic – lesser concentration of solute to your blood plasma

Category of Solutions According to their Purpose

1. Nutrient Solutions – rich in calorie, carbo etc.
2. Electrolyte Solution – ions/cations
3. Alkalizing Solutions – To counter act metabolic acidosis
4. Acidifying Solutions – To counter act metabolic alkalosis
5. Blood Volume Expanders – use to increase the volume of blood following severe blood loss.

Intravenous Equipment
1. Solution Container – available in various sizes
2. Infusion set:

Insertion Spike – kept sterile & inserted into the solution container when the equipment is set up
& ready to start

Chamber – Permits a predictable amount of fluid to be delivered.

Micro drip Chamber Set – has a needle

Roller Valve/Screw Champ – which compresses the lumen of the tubing , controls the rate of the
flow

Protective Cap Over the Needle Adapter – Maintains the sterility of the end of the tubing so that
it can be attached to a sterile needle inserted in the clients vein

IV Port – required to administer secondary infusions/medications

3. IV Pole/rod – needed to hang the solution container also called as IV stand.

For Demo
1. Confirm the physicians order or check the patients chart
-To check the right procedure to the right patient

2. Do handwashing

3. Prepare the needed materials

15
-dry cotton balls
-wet cotton balls
-bandage scissor
-plaster 3-5 inches long #3 pieces
-receptacle
-sterile cap for KSS (keep set sterile)
-new bottle of solution (for the termination/disposable)

4. Go to the patients room.

-Knock on the door; greet the patient; introduce yourself & verify the clients identity by asking
the patients complete name.
-Explain to the patient what you are going to do and why it is necessary.
-Assist the patient to a comfortable position.

Termination/Discontinue IVF
5. First I am going to demonstrate how to terminate IVF & we do this whenever patient no longer
need any solution or if the patient is going to be charge. We actually throw all the materials
used.

6. Make the patient comfortable. Close the roller valve in order not to be messy.

7. if the patient has splint, cut the plaster & remove the splint.

8. Get wet cotton balls soaked in an alcohol, start removing the plaster by applying wet cotton
balls on the plaster starting from the peripheral side of the IV. Then lastly, on the needle side.
Then inform the patient that you are going to pull the needle, pull the needle slowly. Apply
pressure on the area & get a dry cotton balls on the needle site and put a plaster on it to prevent
bleeding.

For KSS (Keep Set Sterile)-client not to be discharge or there might be possible complication

1. Remove the needle from the insertion point then cover the needle adapter w/ sterile cap.
2. Then return the tubing & hang it on the IV stand.
3. Instruct the patient that someone will go to her to insert an IV needle on the other part or
area.
4. Do after care, handwashing & document.

Follow-up IV (needs another solution)

1. Enter patient room w/ a new bottle
2. Close roller bulb
3. Get the IV bottle
4. Kink
5. Hold the IV solution in upright position using the non-dominant hand then remove the
insertion spike from the IV solution using your dominant hand.
6. Get new bottle
7. Open bottle-insert-release
8. Place on IV pole
9. Open roller valve
10. Do after care, handwashing & document such as any sign of inflammation, edema, redness
& pain.

DEMO ON VITAL SIGNS

Definition: Vital signs or cardinal signs are body temperature, pulse, respirations & blood
pressure, fifth is pain.

Times to Assess Vital Signs:

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- On admission to a health care agency to obtain baseline data.
- When a client has a change in health status or reports symptoms
- Before & after surgery/invasive procedures
- Before & after administration of medications
- Before & after any intervention that could affect the vital signs

1. Check for the patients chart

- In order to check the condition of the patient & to check the last BP if there is any.
2. Do handwashing.

3. Prepare the needed materials.

- Stethoscope
- Sphygmomanometer
- Thermometer/Axillary & Digital
- Tissue Paper
- Wet Cotton Balls soaked in an alcohol
- Dry cotton balls
- Receptacle
- Ballpen
-Watch w/ second hand
- Paper
- Ballpen

*Patients Info*
- Name
-Age
- Sex
- Date
- Time
- Chief complaint
- Physician
- Temperature
- Radial Pulse
- Respiratory Rate
- Blood Pressure

4. Check the equipments if they are working properly in order to save time .

- Hold the thermometer in an eye level & check if there is any breaks, if there is none clean it
with a wet cotton balls soaked an alcohol then dry it with the use of dry cotton balls. Then shake
it away from the patient or any object because thermometer is very sensitive it could easily
break, this is in order to lower the temperature to at least below 35 Degree Celsius.

- Check also the stethoscope, tap your finger lightly on the diaphragm if you can hear sound.

- Then check the sphygmomanometer for leaks. Pump up the cuff then deflate in order to
determine if there is any leaks.

5. Go to patients room, knock on the door, greet the patient & introduce yourself & verify the
patients identity by asking his/her complete name. Explain to the client what you are going to do
& why it is necessary & how he/she can cooperate. Discuss how the result will be used in
planning for further care or treatments.

- Also ask for the food, fluid intake as well as the activities done prior to getting the vital signs
because it can elevate the results.

6. Provide for clients privacy.

7. Place the client in an appropriate position (lateral or sim’s position)

17
8. Start getting the vital signs.
- First I am going to get the body temperature w/ the use of an axillary thermometer. Firstly, get
a tissue & pat dry the axillae. Do not rub it because it can elevate the result. Then place the
thermometer appropriately, and then wait for 8-10 minutes for the result.

- While waiting for the body temperature result, I am going to get the radial pulse. Palpate and
count the pulse for one full minute. Place two or three fingers lightly & squarely over the pulse
point. Do not use the thumb because it has pulse that could be mistaken for the clients pulse.
Assess pulse rate, rhythm & volume. Bear in mind that when you write the result it must include
the units of measure which is beats per minute or bmp

Assessing an Apical Pulse

- This is in order to check the discrepancy of the result in the radial pulse. The units of measure
is beats per minute or bmp Place client in a comfortable supine position or sitting position.
Locate the apical pulse.
Adult (left side of the chest, 3 inches to the left of the sternum & at the 4th, 5th or 6th inter-
coastal space)

Child 7-9 years old (4th or 5th inter-coastal space).

4 Years old (left of the mid-clavicular line)

- Auscultate & Count Heartbeats. Use antiseptic wipes to clean the earpieces & diaphragm of
the stethoscope if their cleanliness is doubt. – The diaphragm needs to be cleaned & disinfected
if soiled w/ body substances.

- Warm the diaphragm (flat-disc) of the stethoscope by holding it in the palm of the hand for a
moment. – The metal of the diaphragm is usually cold & can startle the client when placed
immediately on the chest. Tap your finger lightly on the diaphragm to be sure it is the active side
of the head. Place the diaphragm of the stethoscope over the apical impulse & listen for the
normal S1 & S2 heart sounds, which is heard as “lub-dub”. – The heartbeat is normally loudest
over the apex of the heart. Each lub-dub is counted as one heartbeat. S1 (lub) occurs when the
atrioventicular valves close after the ventricles have been sufficiently filled. S2 (dub) occurs
when the semilunar valves close after the ventricles empty. If you have difficulty hearing the
apical pulse ask the supine client to roll onto his/her left side or sitting client to lean slightly
forward. – This positioning moves apex of the heart close to the chest wall. Count for 1 full
minute. – A second count provides a more accurate assessment of an irregular pulse than 1 30
second count. Assess the rhythm & strength of the heartbeat.

After getting the apical pulse, get also the body temperature w/ the use of the digital
thermometer. (Note: show the result to your Clinical Instructor before turning it off).

Assessing Respirations
- Then get the respiratory rate (note: do not mention this because you’ll get minus point from
your clinical instructor) why? Because, patient can control his/her RR if you’re going to mention
it. Unit of measure for RR is cycle per minute or cpm

- Observe or palpate & count the respiratory rate. Client’s awareness when counting the
respiration rate could cause the client to purposely alter the respiratory pattern. If you anticipate
this, place a hand against the client chest to feel the chest movements w/ breathing or place the
client’s arm across the chest & observe the chest movements while supposedly taking the radial
pulse. Count for 1 full minute. An inhalation & an exhalation count as one respiration. Observe
the depth, rhythm & character of respirations. Depth by watching the movement of the chest. –
During deep respiration, a large volume of air is exchanged, shallow, small volume of air is
exchanged. Regular or irregular rhythm. – Normally, respirations are evenly spaced. Character
of respirations – sound they produced & the effort they require. – silent & effortless.

Assessing Blood Pressure

Preparation:
- Make sure that the client has not smoked or ingested caffeine w/ in 30 minutes prior to
measurement. – Smoking constricts blood vessels & caffeine increases the pulse rate. Both of

18
these cause a temporary increase in blood pressure.

- Position the client appropriately. The adult should be sitting unless otherwise specified. Both
feet should be flat on the floor. – Legs crossed at the knee result in elevated systolic & diastolic
blood pressure.

- The elbow should be slightly flexed w/ the palm of the hand facing up & the forearm supported
at heart level. – The blood pressure increases when the arm is below the heart level &
decreases when the arm is above the heart level.

- Wrap the deflated cuff evenly around the upper arm. Then locate the brachial artery. Apply the
center of the bladder directly over the artery. – The bladder inside the cuff must be directly over
the artery to be compressed if reading is to be accurate. Approximately 2.5 cm (1 inch) above
the antecubital space.

- If this is the client’s initial examination, perform a preliminary palpatory determination of

systolic pressure. – The initial estimate tells the nurse the maximal pressure to which the
manometer needs to be elevated in subsequent determination. It also prevents under estimation
of the systolic pressure or over estimation of the diastolic pressure should an auscultatory gap
occur.

- Palpate the brachial artery c/ the fingertips.

- Close the valve on the bulb.
- Pump up the cuff until you no longer feel the brachial pulse. At that pressure the blood cannot
flow throw the artery. Note the pressure on the sphygmomanometer at which pulse is no longer
felt. – This gives an estimate of systolic pressure (+30).

- Release the pressure completely in the cuff & wait 1 to 2 minutes before making further
measurements. – A waiting period gives the blood trapped in the veins time to be released.
Otherwise, false high systolic readings will occur.

- Position the stethoscope appropriately. Cleanse the earpieces w/ antiseptic wipes. Insert the
ear attachments of the stethoscope in your ear so they tilt slightly forward. – Sound are heard
more clearly when the ear attachments follow the direction of the ear canal.

- Ensure that the stethoscope hangs freely from the ears to the diaphragm. – If the stethoscope
tubing rubs against an object, the noise can block the sounds of the blood w/ in the artery.

- Place the bell side of the amplifier to the stethoscope over the brachial pulse site. – Because
blood pressure is a low-frequency sound, it is best heard w/ the bell-shaped diaphragm.

- Place the stethoscope directly on the skin, not on clothing over the site. – This is to avoid noise
made from rubbing the amplifier against cloth.

- Hold the diaphragm w/ the thumb & index finger.

- Auscultate the client’s blood pressure. Pump up the cuff until the sphygmomanometer reads
30 mmHg above the point where the brachial pulse disappeared.

- Release the valve on the cuff carefully so that the pressure decreases at the rate of 2 to 3
mmHg per second. – If the rate is faster or slower, an error in measurement may occur.

- Deflate the cuff rapidly & completely. Wait 1 to 2 minutes before making further
determinations.- This permits blood trapped in the veins to be released.

- Repeat the above steps to confirm the accuracy of the reading especially if it falls outside the
normal range. If there is 75mmHg difference between the two readings, additional
measurements may be taken & the result averaged.

- If this is the client’s initial examination repeat the procedure on the other arm. There should be
no more than 10 mmHg difference between the arms. Arm with higher BP should be used for

19
subsequent examinations.

- Remove the cuff & wipe w/ an approved disinfectant. – Cuffs can become significantly
contaminated.

- Document & report pertinent assessment & data.

- Read the result of the axillary thermometer (let your clinical instructor see the result before
putting it down.

10. Write the results.

11. Inform the patient of the result because they have the right to know.
12. Do after care.
13. Don’t forget to say thank you to the patient before the leaving the room.

Note: Sequence
1. Body temperature (Axillary thermometer 5. Body Temperature (digital thermometer)
2. Radial Pulse 6. Blood Pressure
3. Respiratory Rate
4. Apical Pulse

Donning & Removing Personal Protective Equipment (Gloves) OPEN METHOD

Definition: Protective equipment worn during many procedure to maintain the sterility of
equipment & to protect from contact w/ blood & body fluids

Purpose:
- To enable the nurse to handle or touch sterile objects freely and contaminating them.
- To prevent transmission of potentially infective organisms from the nurses hands to clients at
high risk for infection
Equipment:
- Packages of sterile gloves

Procedure:
1. Prior to performing the procedure introduce self & verify the clients identity using agency
protocol. Explain to the client what you are going to do & why it is necessary & how he/she can
cooperate. Discuss how the results will be used in planning further care or treatments.
2. Observe appropriate infection control procedures.
3. Provide for client privacy
4. Open the packages of sterile gloves
- Place the package of gloves on a clean dry surface – Any moisture on the surface could
contaminate the gloves

- Some gloves are packed in an inner as well as outer package. Open the outer packages
without contaminating the gloves or the inner package.

- Remove the inner package from the outer package.

- Open the inner package according to the manufacturer’s directions. Some manufacturer’s
provide a numbered sequence for opening the flaps & folded tabs to grasp for opening the flaps.
If no tabs are provided, pluck the flap so that the fingers do not touch the inner surfaces – The
inner surfaces which are next to the sterile gloves will remain sterile.

5. Put the first glove on the dominant hand.

- If the gloves are packaged so that they lie side by side, grasp the gloves for the dominant
hand. Touch only the inside of the cuff – The hands are not sterile. By touching only the inside
of the glove, the nurse avoids contaminating the outside.

20
- If the gloves are packaged one on top of the other, grasp the cuff of the top glove as above,
using the opposite hand.

- Insert the dominant hand into the glove & pull the glove on. Keep the thumb of the inserted
hand against the palm of the hand during the insertion. – If the thumb is kept against the palm, it
is likely to contaminate the outside of the glove.

- Leave the cuff in place once the unsterile hand releases the glove. – Attempting to further
unfold the cuff is likely to contaminate the glove.

6. Put the second glove on the non-dominant hand.

- Pick up the other glove w/ the sterile gloved hand inserting the gloved fingers under the cuff &
holding thumb close to the gloved palm. – This helps prevent accidental contamination of the
glove by bare hand.

- 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 touch the arm & become
contaminated.

- Adjust each glove so that it fits smoothly & carefully pull the cuffs up by sliding the fingers
under the cuffs.

Removing:
1. Remove the first glove by grasping it on its palmar surface taking care to touch only glove to
glove. – This keeps the soiled parts of the used gloves from touching the skin of the wrist or
hand.

- Pull the first glove completely off by inverting or rolling the glove inside out.

- Continue to hold the inverted removed glove by the fingers of the remaining gloved hand.
Place the first two fingers of the bare hand inside the cuff of the second glove. – Touching the
outside of the second soiled glove with the bare hand is avoided.

- Pull the second glove off to the fingers by turning it inside out. This pulls the first glove inside
the second glove. – The soiled part of the glove is folded to the inside to reduce the chance of
transferring any microorganisms by direct contact.

- Using the bare hand, continue to remove the gloves which are now inside out & dispose them
in the garbage container.

2. Perform proper hand hygiene.

HANDWASHING

Definition: The most effective infection control measure.

Purpose:
1. To reduce the number of microorganism on the hand.
2. To reduce the risk of transmission of microorganisms to clients
3. To reduce the risk of cross-contamination among clients
4. To reduce the risk of transmission of infectious organisms to oneself.

Equipment:
- Soap
- Warm running water
- Disposable or sanitized towels

21
Implementation/Rationale:
Assess Hands:
1. Nails should be kept short
- Short natural nails are less likely to harbor microorganisms, scratch a client or puncture
gloves.

2. Remove all jewelry

- Microorganisms can lodge in the settings of jewelry & under rings.

3. Check hands for break in the skin

- A nurse who has open sores may require a work assignment w/ decreased risk for
transmission of infectious organisms.

4. Explain to the client what are you going to do and why it is necessary.

5. Turn on the water and adjust the flow - Warm water removes less of the protective oil of the
skin than hot water.

6. Wet your hands & wrist w/ warm water & apply soapfrom a dispenser. Don’t use bar soap, it
allows cross-contamination.

7. Wet hands thoroughly holding the hands lower than the elbow under running water so that
the water flows from the arms to the fingertips & to prevent water from running up your arms &
back down, thus contaminating clean areas, then apply soap.
- The water should flow from the least contaminated to the most contaminated area; the hands
are considered more contaminated than the lower arms.

8. Use firm rubbing & circular movements.

- The circular action helps remove the microorganisms mechanically.
Work up a generous lather for at least 10 seconds. Soap & warm water loosen surface
microorganisms, which wash away in lather.
Palm to palm
Palm to dorsal
Dorsal to dorsal
Interlace fingers
Sides of the fingers
Inside of the nails
Knuckles
- Interlacing the fingers & thumbs cleans the inter-digital spaces. The nails & finger tips are
commonly missed during handwashing.

9. Avoid splashing water on yourself or on the floor, microorganisms spread more easily on wet
surfaces & slippery floors are dangerous.

10. Avoid splashing water on yourself or the floor, microorganisms spread more easily on wet
surfaces & slippery floors are dangerous.

11. Don’t touch the sink or faucets; they are considered contaminated.
12. Rinse hands & wrists well, so running water flushes suds, soil & microorganisms away.

13. Pat hands & wrists dry with paper towels. Avoid rubbing, which can cause abrasion &
chopping.
- Moist skin becomes chapped readily, chapping produces lesions.

14. Use a new paper towels to grasp a hand operated control.

- This prevents the nurse from picking upmicroorganisms from the faucet handles.

15. Use a new towel to dry the other hand & arm.
- A Clean towel prevents the transfer of microorganisms from one elbow to the other hand.

22
16. After Care- wash, clean & dry all the re-usable equipments. Discard all the disposables.
Return the re-usable equipments on their designated places.

Bathing an Adult or Pediatric Client

Definition: Removing accumulated oil, perspiration, dead skin cells & some bacteria

Purposes:
- To remove transient microorganisms, body secretions & dead skin cells
- To stimulate circulation to the skin
- To promote a sense of well being
- To produce a relaxation & comfort
- To prevent & eliminate unpleasant body odors

Assess:
- Condition of the skin
- Physical or emotional factors
- Presence of pain & need for adjunctive measures before the bath
- Range of motion of the joints
- Any other aspect of health that may affect the clients bathing process
- Need for use of clean gloves during the bath

Equipment:
- Basin or sink w/ warm water
- Soap & soap dish
- Linens: bath blanket, two bath towels, wash cloth, clean gowns or pajamas or clothes
- Gloves if appropriate
- Personal hygiene articles
- Shaving equipment
- Table for bathing equipment
- Laundry hamper

Preparation:
- Purpose & type of bath the client needs
- Self-care ability of the client
- Any movement or positioning precautions specific to the client
- Other care the client may be receiving such as physical therapy or x-rays, in order to
coordinate all aspects of health care and prevent unnecessary fatigue.
- The client’s comfort level w/ being bathed by someone else
- Necessary bath equipment & linens.

Procedure:
1. Introduce self..
2. Perform hand hygiene & other appropriate infection control procedure.
3. Provide privacy. – Hygiene is a personal matter
4. Prepare the client & the environment. Invite a family member or significant other to participate
if desired.
- Close windows & doors to ensure the room is in a comfortable temperature. – Air current
increases loss of heat from the body by convection.

- Offer the client a bedpan or urinal or ask whether the client wishes to use the toilet or
commode. – Warm water & activity can stimulate the need to void. The client will be more
comfortable after voiding & voiding before cleaning the perineum is advisable.

- Encourage the client to perform as much personal care as possible. – This promotes
independence & self-esteem

- During the bath, assess each area of the skin carefully.

23
5. Prepare the client & position the client appropriately.
- Position the bed at a comfortable working level. Lower the side rail on the side close to you.
Keep the other side rail up. Assist the client to move near you. – This avoids undue reaching &
Straining & promotes good body mechanics.

- Place a bath blanket over the top sheet. Remove the top sheet from under the bath blanket by
starting at the client’s shoulders & moving linen down toward the client’s feet. – The bath
blanket provides comfort, warmth & privacy. If linen is to be re used put it in the bed side chair, if
it is to be changed put in the hamper not on the floor.

- Remove client’s gown while keeping the client covered with the bath blanket. Place gown in
linen hamper.

6. Make a bath mitt w/ the wash cloth. – A bath mitt retains water & heat better than a close
loosely held & prevents ends of wash cloth from dragging across the skin.
7. Wash the face. – Begin the bath at the cleanest area & work downward toward the feet.

- Place towel under the client’s head.

- Wash the client’s eyes w/ water only & dry them well. Use a separate corner of the wash cloth
for each eye. – Using separate corners prevents transmitting microorganisms from one eye to
the other. Wipe from the inner canthus to the outer canthus. – This prevents secretions from
entering the nasolacrimal ducts.

- Ask the client if he/she want soap on the face. – Soap has a drying effect on the face which is
exposed to the air more than other body parts tend to be drier.

- Wash, rinse & dry the client’s face, ears & neck.

- Remove the towel from under the client’s head.

8. Wash the arms & hands. (Omit the arms in partial bath). Place a towel lengthwise under the
arms away from you. – It protects the bed from becoming wet.

- Wash, rinse & dry the arm by elevating the client’s arm & supporting the client’s wrist & elbow.
Use long firm strokes from wrist to shoulders, including the axillary area. – Firm strokes from
distal to proximal areas promote circulation by increasing venous blood return.

- Apply deodorant or powder if desired.

- Place a towel on the bed & put a washcloth on it. Place the client’s hands in the basin. – Many
clients enjoy immersing their hands in the basin & washing themselves. Soaking loosens dirt
under the nails. Assist the client as needed to wash, rinse & dry the hands, paying particular
attention to the spaces between the fingers.

- Repeat for hand and arm nearest you. Exercise caution if IV is present & check its flow after
moving the arm.

9. Wash the chest & abdomen. (Omit in partial bath).

- Place the bath towel lengthwise over the chest. For the bath blanket down to the client’s pubic
area. – This keeps the client warm while preventing unnecessary exposure of the chest.
- Lift the bath towel off the chest & bath the chest & abdomen w/ your mitted hand using long
firm strokes. Give especial attention to the skin under the breasts & any other skin folds
particularly if the client is overweight. Rinse & dry well.

10. Wash the legs & feet.

- Expose the legs farthest from you by folding the bath blanket toward the other leg being
careful to keep the perineum covered. – Covering the perineum promotes privacy & maintains

24
the client’s dignity.

- Lift leg & place the bath towel lengthwise under the leg. Wash, rinse & dry the leg using long,
smooth firm strokes from the ankle to the knee and to the thigh. – Washing from the distal to
proximal areas promotes circulation by stimulating venous blood flow.

- Reverse the coverings & repeat for the other leg.

- Wash the feet by placing them in a basin of water.

- Dry each foot. Paying particular attention to the spaces between the toes.

- Obtain fresh warm bath water now or when necessary. – Water may become dirty & cold.
Because surface skin cells are removed w/ washing, the bathwater from dark skinned client
maybe dark, however this does not mean the client is dirty. Lowe the bed when refilling the
basin. – This ensures the safety of the client.

11. Wash the back & then the perineum.

- Assist the client into a prone or side-lying position facing away from you. Place the bath towel
lengthwise alongside the back & buttocks while keeping the client covered with the bath blanket
as much as possible. – This provides warmth & prevents undue exposure.

- Wash & dry client’s back, moving from shoulders to the buttocks & upper thighs, paying
attention to the gluteal folds.

- Perform back massage now or after completion of bath.

- Assist the client to the supine position & determine whether the client can wash the perineal
area independently. If the client cannot do so drape the client.

12. Assist the client w/ grooming aids such as powder, lotion or deodorant.
- Use powder sparingly. Release as little as possible into the atmosphere. – This will avoid
irritation of the respiratory tract by powder inhalation. Excessive powder can cause caking which
leads to skin irritation.

- Help the client put on clean gown or pajama.

- Assist the client to care for hair, mouth & nails.
FOR A TUB BATH OR SHOWER
13. Prepare the client & the tub
- Fill the tub about 1/3 to ½ full of water at 43 degree Celcius to 46 degree Celsius. – Sufficient
water is needed to cover the perineal area.
- Cover all intravenous catheters or wound dressings with plastic coverings & instruct the client
to prevent wetting these areas.
- Put a rubber bath mat or towel on the floor of the tub if safety strips are not on the tub floor. –
These prevents slippage of the client during the bath or shower.

14. Assist the client into the shower or tub.

- Assist the client taking a standing shower w/ the initial adjustment of the water temperature &
water flow pressure as needed. Some clients need a chair to sit on in the shower because of
weakness. Hot water can cause elderly people to feel faint.

- If the client requires considerable assistance w/ a tub bath, a hydraulic bath tub chair maybe
required.

- Explain how the client can signal for help, leave the client for 2 to 5 minutes & place an
occupied sign on the door. For safety reasons do not leave a clients who may be at risk.

15. Assist client w/ washing & getting out of the tub.

- Wash the client’s back, lower legs & feet if necessary.
- Assist the client out of the tub. If the client is unsteady, place a bath towel over the client’s

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shoulders & drain the tub w/ water before the client attempts to get out of it. – Draining the water
first lessens the likelihood of a fall. The towel prevents chilling.

16. Dry the client and assist w/ follow-up care

- Follow step 12

- Assist the client back to his/her bed

- Clean the tub or shower in accordance w/ agency practice, discard the used linen in the
laundry hamper & place the unoccupied sign on the door.

17. Document
- Type of bath given
- Skin assessment such as excoriation, erythema, exudates, rashes, drainage or skin
breakdown.

Return Demo on Using Mechanical Aids for Ambulation

Last, August 29, 2011 we had a retun demo on how to use mechanical aids for ambulation
which includes canes, walkers & crutches. This devices are used for ambulatory purposes. It
was just really funny coz I was able to memorize all the steps as well as the procedure on how
to do each steps. But then, when it was my turn to have my demo, I did the first step right and
got confused when i repeat the steps..so it was a minus points..in all i had 6 minus points..thats
why in a score of 50 i only got 44 score..This steps are really important to remember coz it will
be part in our TESDA Assessment examination in order to have a certificate as a Professional
Caregiver after taking the course. All caregiver students or even nurses that take NC II for
Professional Caregiver should remember this steps...and in order for me not to forget this steps,
i decided to write it her in my blog..

CANES

****When Maximum Support is Required*****

1. Position the cane on the stronger side of the body. Then do the tripod position (6 inches to
the side and 6 inches to the front).
2. Move the cane forward about 30 cm, or a distance that is comfortable while the body weight
is borne by both legs,
3. Then move the affected (weak) leg forward to the cane while the weight is borne by the cane
& stronger leg.
4. Then move the unaffected (stronger) leg forward ahead of the cane & weak leg while the
weight is borne by the cane & weak leg.
5. Repeat 2, 3 & 4 steps.

****As You Become Stronger & Require Less Support****

1. Position the cane on the stronger side of the body. Then do the tripod position (6 inches to
the side and 6 inches to the front.)
2.Move the cane & weak leg forward at the same time, while the weight is borne by the
stronger leg.
3. Move the stronger leg forward, while the weight is borne by the cane & the weak leg.

CRUTCH USE

When using crutches the weight of your body should be borne by the arms rather than the
axillae. Continual pressure on the axillae can injure the radial nerve and eventually cause crutch
palsy, a weakness of the muscles of the forearm, wrist and hand.

Maintain an erect posture as much as possible to prevent strain on muscles & joint & to

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maintain balance.

****Four-Point Alternate Gait****

1. Tripod position.
2. Move the right crutch ahead a suitable distance such as 10-15 cm.
3. Move the left foot forward, preferably to the level of the left crutch.
4. Move the left crutch forward.
5. Move the right foot forward.
6. Repeat steps 2, 3, 4 & 5.

****Three-Point Gait****

-To use this gait, the client must be able to bear the entire body weight on the unaffected leg.
1. Tripod position (6 inches to the side & 6 inches to the front.
2. Move both crutches & the weaker leg forward.
3. Move the stronger leg forward.

****Two-Point Alternate Gait****

-This gait Is faster than the four-point gait. It requires more balance because only two points
support the body at one time.

1. Tripod position (6 inches to the side & 6 inches to the front).

2. Move the left crutch & the right foot forward together.
3. Move the right crutch & the left foot ahead together.

****Swing-To Gait****

-The swing gaits are used by clients w/ paralysis of the legs & hips. Prolonged use of this gaits
result in atrophy of the unused muscles.

1. Tripod position (6 inches to the side & 6 inches to the front).

2. Move both crutches ahead together.

3. Lift body weight by the arms & swing to the crutches.

****Swing-Through Gait****

-This gait requires considerable skill, strength & coordination.

1. Tripod position (6 inches to the side & 6 inches to the front).

2. Move both crutches forward together
3. Lift body weight by the arms & swing through & beyond the crutch.

****Going Up Stairs****

1. Tripod position at the bottom of the stairs.

2. Move the unaffected leg onto the step.
3. Move the crutches & affected leg up to the step.
4. Repeat steps 2 & 3.

****Going Down Stairs****

1. Assume the tripod position at the top of the stairs.

2. Move the crutches & the affected leg down to the next step.

WALKERS

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****When Maximum Support is Required****

1. Move the walker 6 inches to the front.

2. Then move the walker ahead about 15 cm while your body weight is borne by both legs.
3. Then move the right foot up to the walker while your body weight is borne by the left leg.
4. Next, move the left foot up to the right foot while you body weight is borne by the right leg &
both arms.

****If one leg is Weaker than the Other****

1. Move the walker 6 inches to the front.

2. Move the walker & the weak leg ahead together about 15 cm while your weight is borne by
the stronger leg.
3. Then move the stronger leg ahead while your weight is borne by the affected leg & both
arms.

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