checklist - nursing procedures

8/14/2019 Checklist - Nursing Procedures

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Name: _________________________________ Date: _____________ Section/Group:________

Hand washing

CHECKLIST

Legend:

3-Very Satisfactory 0- Did not perform the procedure2- Satisfactory 1- Needs Improvement

PROCEDURES 3 2 1 0

1. Determine:

Presence in client of factors increasing susceptibility to infection. Whether client uses immunosuppressives. Clients medications Recent diagnostic procedures of treatments that penetrated the clients

skin or a body cavity.

Clients current nutritional status. Signs and symptoms indicating the presence of an infection; Localized signsswelling, redness, pain or tenderness with palpation or

movement, palpable heat at site, loss of function with affected body part,

presence of exudates Systemic indicationsfever, increased pulse and respiratory rates, lack ofenergy, anorexia and enlarged lymph nodes.

Determine:

The location of running water and soap or soap substitutesAssemble the equipment:

Soap Warm, running water Disposable or sanitized towels

Assess the hands:

Nails should be kept short. Remove all jewelry Check hands for breaks in the skin, such as hangnails or cuts.

Procedure

If you are washing your hands where the client can observe you, explain to the

client can observe you, explain to the client what you are going to do and why is itnecessary.

Turn on the water, and adjust the flow:

For knee levers, move with the knee to regulate flow and temperature. For foot pedals, press with the foot to regulate flow and temperature. For elbow controls, move the elbows instead of the hands. For infrared control, motion in front of the sensor causes water to start

and stop flowing automatically.

Be sure to adjust the flow so that water is warm.

Wet the hands thoroughly by holding them under the running water, and apply

soap to the hands.

Hold the hands lower than the elbows, so that the water flows from thearms to the fingertips.

If the soap is liquid, apply 2-4 ml (1 tsp). if it is bar soap, granules, orsheets, rub them firmly between the hands

Thoroughly wash and rinse the hands.Use firm, rubbing and circular movements to wash the palm, back and wrist ofeach hand. Interlace the fingers and thumbs, and move the hands back and forth.Continue this motion for 10 seconds.

Rub the fingertips against the palm of the opposite hand.


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Rinse the hands.

Thoroughly dry the hands and arms

Dry hands and arms thoroughly with a paper towel.

Discard the paper towel in the appropriate container.

Turn off the water.

Use a new paper towel to grasp a hand operated control.

Variation : Handwashing Before Sterile Technique

Procedure

Apply the soap and wash as described in Step 4, but hold the hands higher thanthe elbows during this hand wash. Wet the hands and forearms under the runningwater, letting it run from the fingertips to the elbows so that the hands become

cleaner than the elbows.

Apply the soap and wash as described earlier in Step 6, maintaining the handsuppermost.

After washing and rinsing, use a towel to dry one hand thoroughly in a rotatingmotion, from the fingers to the elbows. Use a new towel to dry the other hand and

arm.

For the next items, evaluate the students in general according to the criteria. (5 as the

highest score)

5 4 3 2 1

Mastery

Orderliness

Proper attitude in assessing the client followed.

Ability to answer questionsProper reporting observed.

Students signature: __________________Evaluators Signature: __________________

Comments:___________________________________________________________________________________________________________________________________________________


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Donning and Removing Sterile Gloves (Open Method)

CHECKLIST

Legend:


PROCEDURES 3 2 1 0Assess client for latex allergies.

Assemble equipments and supplies.

Sterile glovesEnsures sterility of the package of gloves.

Procedure

Explain to the client what you are going to do, why is it necessary, and how he cancooperate.

Wash hands and observe other appropriate infection control procedures.

Provide for client privacy.

Open the package of the sterile gloves.

Place the package of gloves on a clean dry surface.If the gloves are packed in both an inner and an outer package, open the outer packagewithout contaminating the gloves or the inner package.

Remove the inner package from the outer package.

Open the inner package as in Step 4 of procedure 29-3, or according to the

manufacturers direction. If no tabs are provided, pluck the flap so that the fingers donot touch the inner surfaces.

Put the first glove on the dominant hand.

If the gloves are packaged so that they lie side by side, grasp the glove for thedominant hand by its folded cuff edge (on the palmar side) with the thumb and the first

finger of the non dominant hand. Touch only the inside of the cuff; or ,

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 and pull the glove on. Keep the thumb of theinserted hand against the palm of the hand during insertion.

Leave the cuff turned down.

Put the second glove on the non dominant hand.

Pick up the other glove with the sterile-gloved hand, inserting the gloved fingers underthe cuff and holding the gloved thumb close to the gloved palm.

Pull on the second glove carefully. Hold the thumb of the gloved first hand as far aspossible from the palm.

Adjust each glove so that it fits smoothly, and carefully pull the cuffs up by sliding thefingers under the cuffs.

Remove and dispose of used gloves.There is no special technique for removing sterile gloves. If they are soiled with

secretions, remove them by turning them inside out.

Document that sterile technique was used in the performance of the procedure.


highest score)

5 4 3 2 1

Mastery

Orderliness


Ability to answer questions

Proper reporting observed.


Comments:_____________________________________________________________________

______________________________________________________________________________


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Measuring Body Temperature

CHECKLIST

Legend:


PROCEDURES 3 2 1 0

1. Review medical record for baseline factors that influence vital signs.

2. Explain to the client that vital signs will be assessed. Encourage client to remain

still and refrain from drinking, eating, and smoking to avoid mouth breathing, ifpossible.

3. Assess clients toileting needs and proceed as appropriate.

4. Gather equipment.

5. Provide for privacy.

6. Wash hands/hand hygiene and apply gloves, when appropriate.

Oral temperature:

7. Repeat Actions 1-6.

8. Grasp top of probes stem.

9. Place tip of thermometer under the clients tongue and along gum line toposteriorsublingual pocket lateral to lower jaw.

10. Instruct client to keep mouth closed around thermometer.

11. Thermometer will signal (beep) when a constant temperature registers.

12. Read measurement on digital display of electronic thermometer.

13. Inform client of temperature reading.

14. Remove gloves and perform hand hygiene.

Rectal temperature. Repeat actions 1-6

Place client in Sims position with upper knee flexed. Adjust sheet to expose only

anal area.Place tissues in easy reach. Apply gloves.

Lubricate rectal probe tip.

With dominant hand, grasp top of the probes stem. With other hand, separatebuttocks to expose anus.

Instruct client to take deep breath. Insert probe gently into anus.

Repeat actions 11-14.

Axillay temperature.Repeat actions 1-6

Remove clients arm and shoulder from one sleeve of gown. Avoid exposing chest.

Make sure axillay skin is dry, if necessary, pat dry.

Place probe into center of axilla. Fold clients upper arm straight down, and place

arm across clients chest.Repeat actions 11-14


highest score)

5 4 3 2 1

Mastery

Orderliness





Comments:___________________________________________________________________________________________________________________________________________________


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Assessing Pulse rate

CHECKLIST

Legend:


PROCEDURES 3 2 1 0

1. Wash hands/hand hygiene.

2. inform client of site(s) where pulse will be measures.

3. Flex clients elbow and place lower part of arm across chest.

4. Support clients wrist by grasping outer aspect of thumb.

5. Place index and middle fingers on inner aspect of clients wrist over the radialartery, and apply light but firm pressure until pulse is palpated.

6. Identify pulse rhythm.

7. Determine pulse volume.

8. Count pulse rate by using second hand of watch.

Taking apical pulse.


10. Raise clients gown to expose sternum and left side of chest.

11. Cleanse earpiece and stethoscope diaphragm with an alcohol swab.

12. Put stethoscope around the neck.

13. locate the apex of the heart.

With the client lying on left side, locate suprasternal notch. Palpate second intercostal space to left sternum. Place index finger in intercostal space, counting downward until fifth

intercostal space is located.

Move index finger along fourth intercostals left of sternal border and tofifth intercostals space, left of midclavicular line to palpate the point of

maximal impulse (PMI) Keep index finger of nondominant hand on PMI.

14. Inform client that clients heart will be listened to. Instruct client to remain

silent.

15. With dominant hand, put earpiece of the stethoscope in ears and grasp

diaphragm of stethoscope in palm of the hand for 5-10 seconds.

16. Place diaphragm of stethoscope over PMI and auscultate for sounds S1 and S2to hear lubdub sound.

17. Note the regularity of the rhythm.

18. Start to count while looking at second hand of watch. Count lub-dub sound as

one beat.

19. Share findings with patient.

20. Record by site, rate,rhythm, and, if applicable, number of irregular beats.



highest score)

5 4 3 2 1

Mastery

Orderliness




Students signature: __________________

Evaluators Signature: __________________

Comments:___________________________________________________________________________________________________________________________________________________


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Assessing Respiratory Rate

CHECKLIST

Legend:


PROCEDURES 3 2 1 0


2. be sure chest movement is visible. Remove clothing, if necessary.

3. Observe one complete respiratory cycle.

4. Start counting with first inspiration while looking at the second hand of watch.

5. Observe character of respiration.

6. Replace clients gown, if needed.

7. Record rate and character of respiration.

8. Was hands/hand hygiene.

For the next items, evaluate the students in general according to the criteria. (5 as thehighest score)

5 4 3 2 1

Mastery

Orderliness






Comments:_____________________________________________________________________

______________________________________________________________________________


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Assessing Blood Pressure

CHECKLIST

Legend:


PROCEDURES 3 2 1 0

1. Wash hands/ hand hygiene.

2. determine which extremity is most appropriate for reading.

3. Select a cuff size appropriate for the client.

4. Rest clients bare arm on a support so the midpoint of the upper arm is at thelevel of the heart. Extend elbow with palm turn upward.

5. Make sure bladder cuff is fully deflated and pump valve moves freely. Placemanometer at eye level and easily visible.

6. palpate brachial artery in antecubital space, and place cuff so that midline ofbladder is over arterial pulsation. Wrap and secure off snugly around the clientsbare upper arm. Lower edge of cuff should be 1 inch above antecubital fossa where

head of stethoscope is to be placed.7. Inflate cuff rapidly to 70 mmHg and increase by 10 mm increments while

palpating radial pulse. Note level of pressure at which pulse disappears and

subsequently reappears during deflation.

8. Insert stethoscope earpieces into ear canals.

9. Relocate brachial artery with nondominat hand, and place stethoscope bell over

brachial artery pulsation.

10. With dominant hand, turn valve clockwise to close. Compress pump to inflate

cuff rapidly and steadily until manometer registers 20-30 mmHg above the levelpreviously determined by palpation.

11. Partially unscrew (open) valve counter clockwise to deflate bladder at 2mm/secwhile listening for the 5 phases of the Korotkoff sounds. Note manometer reading

for these sounds.12. After the last Korotkoffs sound is heard, deflate cuff slowly for at least another

10 mmHg then deflate rapidly and completely.

13. Allow client to rest for at least 30 seconds and remove cuff.

14. Inform client of reading.

15. Record the BP reading.

16. if appropriate, lower bed, raise side rails, and place call light in easy reach.

17. Put all equipment in proper place.



highest score)

5 4 3 2 1Mastery

Orderliness





Comments:___________________________________________________________________________________________________________________________________________________


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Proper Body Mechanics, Safe Lifting, and Transferring

CHECKLIST

Legend:


PROCEDURES 3 2 1 0


2. Assess for obstacles, heavy clients, poor handholds, equipment or object.Assess for tubing or equipment connected to client.

3. Assess for slippery surfaces, including wet floors; slippery surface beforelifting the client or object.

4. Assess for slippery surfaces, including client confusion, combativeness,orthostatic hypotension, drug effects, pain, or fear.

5. Maintain low center of gravity by bending at hips and knees. Squat downrather than bend over to lift and lower the client.

6. Establish a wide support base with feet spread apart.

7. Use feet to move, not a twisting or bending motion from the waist.8. When pushing and pulling:

Stand near object Stagger one foot partially ahead of the other

9. When pushing:

Lean into the client or object and apply continuous light pressure. Lean away and grasp with light pressure. Never jerk or twist your body to force a weight to move.

10. When stopping to move an object:

Maintain a wide base support with feet. Flex knees to lower body. Maintain straight upper body.

11. When lifting or carrying an object:

Bend the knees in front of the object. Take a firm hold, and assume a standing position by using leg muscles

and keeping back straight.

12. When rising up from a squatting position:

Arch your back slightly. Keep the buttocks and abdomen tucked in. Rise up with your head first.

13. When lifting or carrying heavy objects, keep weight as close to your center ofgravity as possible.

14. When reaching for a client or an object:

Keep the back straight. If client or object is heavy, do not try to lift without repositioningyourself closer to the weight.

15. Use safety aids and equipment.

Use gait belts, lifts, draw sheets, and other transfer assistance devices. Encourage clients to use handrails and grab bars. Wheelchair, cart and stretcher wheels should be locked when they are not

being moved.



highest score)

5 4 3 2 1

Mastery

Orderliness




Students signature:__________________ Evaluators Signature:__________________

Comments:_____________________________________________________________________


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Turning and Positioning a Client

CHECKLIST

Legend:


PROCEDURES 3 2 1 0


2. Explain procedure to client. Elicit client cooperation and participation.

3. Gather all necessary equipment. Provide for client privacy.

4. Secure adequate assistance to complete task safely.

5. Adjust bed to comfortable working height. Lower side rail on side of bed closest toyou.

6. Follow proper body mechanics guidelines:

When moving a client in bed, position bed so that your legs are slightly bent atknees and hips.

Maintain natural curves in your back while lifting. Position one foot slightly in front of other and spread feet apart to create a wide

base for balance.

When arms are placed under client, slowly lean backward onto your back legusing your body weight to help you lift client to one side of bed.

Do not extend to rotate your back to move a client in bed. If you cannot move client easily, always ask for and obtain assistance for the

safety of both you and the client.

Be sure floor is not slippery and that bed is locked. Always use a turning sheet when rolling a client because this gives you better

support and control of client.

7. Position drains tubes and IVs to accommodate clients new position.

8. Place or assist client into appropriate starting position. Monitor client status, andprovide adequate rest breaks or support as necessary.

Moving from Supine to Side-Lying Position

9. Move client from supine to sidelying position:

Slide your hands underneath client. Move client to one side of bed by lifting clients toward you in stages:

First the upper trunk; Then the lower trunk; Finally, the legs

Lift clients body; do not drag client across sheets. Roll client to side-lying position by placing clients inside arm next to clients

body with palm of hand against hip.

Cross clients outside arm and leg toward midline and logroll client toward you. Use clients outside shoulder and hip for leverage while maintaining stability and

control of top arm and leg.

Maintaining Side-Lying Position

10. Repeat Action 1-8.

11. Use pillows to support client:

Place to support clients head and arms. Can be used topside leg, thigh, knee, ankle, and foot. Move lower arm forward slightly at shoulder and bend elbow for comfort. If client in unstable, placing a pillow against the back will provide additional

support and keep the client from rolling supine.

Moving from Side-Lying to Prone Position


13. To move to Prone position:

Remove positioning towels, pillows, or others support devices. Assess if clients position needs to be adjusted to accommodate continued

movement into prone position.

Move clients inside arm next to clients body with palm against hip. Roll client onto stomach using shoulder and hip as key points of control.


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Place the head in a comfortable position to one side without excessive pressureto sensitive areas.

Place pillows under trunk, as needed, to relieve pressure and increase comfort. Place arms comfortably at clients side and uncross legs with feet approximately

a foot apart.

Maintaining Prone Position

14. To maintain prone:

Use a shallow pillow or folded towel to support clients heat comfortably. Place pillow under abdomen to support back. Place an additional pillow under lower leg to reduce pressure of toes and

forefoot against bed.

Moving from Prone to Supine Position


16. To move from prone to supine:

Remove positioning towers or pillows. Slide your hands underneath client. Move client segmentally to one side of the bed to accommodate the new

position. Position inside arm next to clients body with clients palm next to hip. Roll client to supine position by logrolling the client toward you using the

clients outside shoulder and hip for leverage.

Position client away from direction of roll to prevent undue pressure. When client reaches supine, uncross, the arms and legs and place into anatomic

positions.

Maintaining Supine Position

17. To maintain supine position:

Use a footboard to support the foot. Use heel protectors or place a pillow between the heel and gastrocnemuis

muscle to reduce the pressure on the heels. Assess and compare warmth, sensation, color, and movement of feet. Use a trochanter roll to prevent excessive external rotation of the lower

extremity.

For comport, place additional pillows to support clients head, arms, or lowerback.

18. Place side rails in upright position. Return bed to low position.

19. Please call light within reach.

20. Move bedside table close. Place items of frequent use within reach.



highest score)5 4 3 2 1

Mastery

Orderliness





Evaluators Signature: __________________Comments:_____________________________________________________________________

______________________________________________________________________________


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Moving a Client in Bed

CHECKLIST

Legend:


PROCEDURES 3 2 1 0

Moving a Client up in Bed with One Nurse


2. Inform client of reason for the move and how to assist.

3. Elevate bed to just below waist height. Lower head of bed, if tolerated. Lowerside rails on your side.

4. Remove the pillow. Place against headboard.

5. Have client fold arms across chest.

6. Have client hold on to overhead trapeze, if available.

7. Have client bend knees and place feet flat on bed.

8. Stand at an angle to head of bed with feet apart, facing head of bed, and knees

bent.9. Slide one hand and arm under clients shoulder, the other underclients thigh.

10. Rock forward toward head of bed, lifting client with you. Have client push

with legs.

11. If client has trapeze, have client pull up holding onto trapeze as you move

client upward.

12. Repeat these steps until client is moved up high enough in bed.

13. Returns clients pillow under the bed.

14. Elevate head of bed, if tolerated by client.

15. Assess client for comfort.

16. Adjust the clients bedclothes as needed for comfort.

17. Lower bed and elevate side rails.18. Hand hygiene.

Moving a Client up in Bed with Two or More Nurses

19. Hand hygiene.

20. Inform client of reason for the move and how to assist.

21. Elevate bed to just below waist height. Lower head of bed if tolerated byclient. Lower side rails.

22. With two nurses, place turn or draw sheet under clients back and head.

23. Roll up draw sheet on each side until it is next to client.

24. Follow Actions 4-7.

25. The nurses stand on either side of bed, at an angle to head of bed, with knees

flexed and feet apart in wide stance.26. The nurses hold their elbows as close as possible to their bodies.

27. The lead nurse will give signal to move: 1-2-3 go. The nurses will lift up (offof bed) on turn or draw sheet and forward (toward head of bed) in one smoothmotion. The move is coordinated to transfer client toward head of bed.Simultaneously, have client push with legs or pull using trapeze.

28. Repeat until client is moved upright enough in bed to be comfortable.

29. Return clients pillow under head.

30. Elevate head of bed, if tolerated by client.

31. Assess client for comfort.

32. Adjust clients bedclothes for comfort.

33. Lower bed and elevate side rails.34. Wash hands/hand hygiene.


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highest score)

5 4 3 2 1

Mastery

Orderliness

Proper attitude in assessing the client followed.Ability to answer questions



Comments:___________________________________________________________________________________________________________________________________________________


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Assisting from Bed to Wheelchair, Commode, or Chair

CHECKLIST

Legend:


PROCEDURES 3 2 1 0

1. Inform client about desired purpose and destination.

2. Assess client for ability to assist with transfer and presence of cognitive orsensory deficits.

3. Lock bed in position. Hand hygiene.

4. Place any splints, braces, or other devices on client.

5. Place shoes or slippers on clients feet.

6. Lower height of bed to lowest possible position.

7. Slowly raise head of bed if not contraindicated by clients condition.

8. Place one arm under clients legs and one arm behind clients back. Slowly pivot

client so clients legs are dangling over edge of bed and client is in a sitting

position on edge of bed.9. Allow client to dangle for 2 to 5 minutes. Help support client, if necessary.

10. Bring chair or wheelchair close to side of bed. Place at 45 angle to bed. Ifclient has a weaker side, place chair or wheelchair on clients strong side.

11. Lock wheelchair brakes and elevate foot pedals. For chairs, lock brakes, ifavailable.

12. If using a gait belt to assist client, place it around clients waist.

13. Assist client to side of bed until feet are firmly on floor and slightly apart.

14. Grasp sides of gait belt or place your hands just below clients axilla. Using a

wide stance, bend your knees and assist client to standing position.

15. Stand close to client, pivot until clients back is toward chair.

16. Instruct client to place hands on arm supports or place clients hand on armsupports of chair.

17. Bend at knees and ease client into a sitting position.

18. Assist client to maintain proper posture. Support weak side with pillow, ifneeded.

19. Secure safety belt, place clients feet on feet pedals, and release brakes ifmoving client immediately. Make sure tubes and lines, arms and hands are not

pinched or caught between client and chair. If client is sitting in chair, offer afootstool, if available.



highest score)

5 4 3 2 1Mastery

Orderliness





Comments:___________________________________________________________________________________________________________________________________________________


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Assisting from Bed to Stretcher

CHECKLIST

Legend:


PROCEDURES 3 2 1 0

Transferring a Client with Minimum Assistance1. Inform client about desired purpose and destination. Hand hygiene.

2. Raise the height of bed to 1 inch higher than the stretcher and lock brakes of bed.

3. Instruct client to move to side of bed close to stretcher. Lower side rails of bedand stretcher. Leave side rails on opposite side up.

4. Stand at outer side of stretcher and push it toward bed.

5. Instruct client to move onto stretcher providing assistance, as needed.

6. Cover client with sheet or bath blanket.

7. Elevate side rails on stretcher and secure safety belts about client. Release brakesof stretcher

8. Stand at head of stretcher to guide it when pushing.9. Hand hygiene.

Transferring a Client with Maximum Assistance

10. Repeat Actions 1 and 2.

11. Assess amount of assistance required for transfer. Usually 2 to 4 staff members

are required for maximally assisted transfer.

12. Lock wheels of bed and stretcher.

13. Have one nurse stand close to clients head.

14. Logroll client (keep in straight alignment) and place a lift sheet under clientsback, trunk and upper legs. The lift sheet can extend under head if client lacks head

control abilities.

15. Empty all drainage bags (e.g., T-tube, Hemo Vac, Jackson-Pratt). Recordamounts. Secure drainage system to clients gown before transfer.

16. Move client to edge of bed near stretcher. Lift client up and over to avoid

dragging.

17. Because client is now on side of bed with side rail down, the nurse on

nonstretcher side of bed holds stretcher side of lift sheet up ( by reaching across theclients chest) to prevent client from falling onto stretcher or off bed.

18. Place pillow or slider board to overlap bed and stretcher.

19. Have staff members grasp edges of lift sheet. Be sure to use good bodymechanics.

20. On count of 3, have staff members pull lift sheet and client onto stretcher.

21. Position client on stretcher, place pillow under head, and cover with a sheet.

22. Secure safety belts and elevate side rails of stretcher.23. If IV pole is present, move it from bed IV pole to stretcher IV pole after clienttransfer.


For the next items, evaluate the students in general according to t2he criteria. (5 as the

highest score)

5 4 3 2 1

Mastery

Orderliness



Proper reporting observed.Students signature: __________________


Comments:_____________________________________________________________________

______________________________________________________________________________


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Changing an Unoccupied Bed

CHECKLIST

Legend:


PROCEDURES 3 2 1 0

1. Assess:

The clients health status, to determine that the person can safely getout of the bed

The clients pulse and respirations, if indicated Note all the tubes and equipment connected The clients pulse and

respirations, if indicated

Note all the tubes and equipment connected to the client.2.Assemble equipment

And supplies:

Two flat sheets, or one Fitted and one flat sheet, Cloth drawsheet,One blanket, One bedspread, Waterproof drawsheet, Or waterproofpads

(optional), Pillowcases for the head Pillows, Plastic laundry bag or Portable linen

hamper, If available.

Procedure

1. Explain to the client what you are going to do, why it is necessary, and howshe can cooperate

2. Wash hands and observe other appropriate infection control procedures

3. Provide for client privacy

4. Place the fresh linen on the clients chair or overbed table, do not use anotherclients bed.

5. Assess and assist the client out of bed. Make sure that this is an appropriate

and convenient time for the client to be out of bed. Assist the client to acomfortable chair

6. Strip the bed. Check bed linens for any items belonging to the client, and

detach the call bell or any drainage tubes from the bed linen. Loosen all beddingsystematically, starting at the head of the bed on the far side and moving aroundthe bed up to the head of the bed on the near side. Remove the pillowcases, ifSoiled and place the pillows on the bedside chair near the foot of the bed. Foldreusable linens, such as the bedspread and top sheet of the bed, into fourths. First,

fold the linen in half by bringing the top edge even with the bottom edge, thengrasp it at the center of the middle fold and bottom edges. Remove the waterproof

pad and discard it, if soiled. Roll all soiled linen inside the bottom sheet, hold itaway from your uniform, and place it directly in the linen hamper. Grasp the

mattress securely, using the lugs, if present, and move the mattress up to the headof the bed.

7. Apply the bottom sheet and drawsheet. Place the folded bottom sheet with itscenter fold on the center of the bed. Make sure the sheet is hem-side down for asmooth foundation. Spread the sheet out over the mattress and allow a sufficient

amount of sheet at the top to tuck under the mattress. Miter the sheet at the topcorner on the near side and tuck the sheet under the mattress, working from thehead of the bed to the foot.

If a waterproof drawsheet is used, place it over the bottom sheet so thatthe center fold is at the center line of the bed and the top and bottomedges extend from the middle of the clients back to the area of the mid -

thigh or knee. Fanfold the upper-most half of the folded drawsheet at the

center or far edge of the bed, and tuck in the near edge. Lay the clothdrawsheet over the waterproof sheet in the same manner.

Optional: Before moving to the other side of the bed, place the top linenson the bed hem-side up, unfold them, tuck them in, and miter the bottomcorners.

8. Move to the other side and secure the bottom linens. Tuck in the bottom sheetunder the head of the mattress, pull the sheet firmly, and miter the corner of thesheet. Pull the remainder of the sheet firmly so that there are no wrinkles.


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Complete this same process for the drawsheet(s).

9.Apply or complete the top sheet, blanket, and spread. Place the top sheet, hem-side up, on the bed so that its center fold is at the center of the bed and the top

edge is even with the top edge of the mattress.

Unfold the sheet over the bed. Optional: Make a fold in the sheet toprovide additional room forthe clients feet.

vertical toe pleat: make a fold in the sheet 5-10 cm (2-4in) perpendicularto the foot of the bed.

Horizontal toe pleat: Make a fold in the sheet 5-10 cm (2-4 in) across thebed near the foot.

Follow the same procedure for blanket and the spread, but place the topedges about 15 cm (6in) from the head of the bed to allow a cuff of sheet

to be folded over them. Tuck in the sheet, blanket, and spread at the foot of the

bed, and miter the corner using all three layers of linen. Leave the sides of thetop sheet, blanket, and spread hanging freely, unless toe pleats were provided.

Fold the top of the top sheet down over the spread, providing a cuff.Move to the other side of the bed, and secure the top bedding in the same manner.

10.Put clean pillowcases On the pillows as required. Grasp the closed end of the

pillowcase at the center with one hand. Gather up the sides of the Pillowcase andplace them over the hand grasping the case. Then grasp the center of one shortside of the pillow through the pillowcase. With the free hand, pull the pillowcase

over the pillow. Adjust the pillowcase so that the pillow fits into the corners ofthe case and the seams are straight. Place the pillows appropriately at the head of

the bed.

11.Provide for client comfort and safety. Attach the signal cord so that the client

can conveniently use it. If the bed is currently being used by a client, either foldback the top covers at one side or fanfold them down to the center of the bed.

Place the bedside table and the overbed table so that they are available tothe patient. Leave the bed in the high Position if the client is returning bystretcher, or place in the low Position if the client is returning to bed after

being up.

12. Document and report pertinent data.

Variation : Surgical Bed

Strip the bed.

Place and leave the pillows on the bedside chair.

Apply the bottom linens as for an unoccupied bed. Place a bath blanket on thefoundation of the bed, if this is agency practice.

Place the top covers on the bed as you would for an unoccupied bed. Do not tuckthem in, miters the corners, or make a toe pleat.

Make a cuff at the top of the bed as you would for an unoccupied bed. Fold thetop linens up from the bottom.

On the side of the bed where the client will be transferred, fold up the two outercorners of the top linens so they meet in the middle of the bed forming a triangle.

Pick up the apex of the triangle, and fanfold the top linens lengthwise to the other

side of the bed.

Leave the bed in high position with the side rails down.

Lock the wheels of the bed if the bed is not to be moved.


highest score)

5 4 3 2 1

Mastery

Orderliness

Proper attitude in assessing the client followed.Ability to answer questions




Comments:___________________________________________________________________________________________________________________________________________________


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17


Changing an Occupied Bed

CHECKLIST

Legend:


PROCEDURES 3 2 1 0

1. Assess: Note specific orders or precautions for moving and positioning the client. Determine presence of incontinence or excessive drainage from other

sources indicating the need for protective waterproof pad.

Assess skin condition and need for special mattress, footboard, or heelprotectors.

2. Assemble equipment and supplies: Two flat sheets, or one fitted and one flat sheet. Cloth drawsheet (optional) One blanket One bedspread Waterproof drawsheet or waterproof pads (optional) Pillowcases for the head pillows Plastic laundry bag or portable linen hamper, if available.

Procedure

1. Explain to the client what you are going to do, why is it necessary and howshe can cooperate.

2. Wash hands and observe other appropriate infection control procedures3. Provide for client privacy.4. Remove the top bedding. Remove any equipment attached to the bed linen, such as a signal light.

Loosen all the top linen at the foot of the bed, and remove the spread andthe blanket.

Leave the top sheet over the client, or replace it with a bath blanket asfollows:

Spread the bath blanket over the top sheet. Ask the client to hold the top edge of the blanket. Reaching under the blanket from the side, grasp the top edge of the sheet

and draw it down to the foot of the bed, leaving the blanket in place. Remove the sheet from the bed and place it in the soiled linen hamper. 5. Change the bottom sheet and drawsheet Assist the client to turn on the side facing away from the side where the

clean linen is.

Raise the side rail nearest the client. If there is no side rail, have anothernurse support the client at the edge of the bed. Loosen the foundation of the linen on the side of the bed near the linen

supply.

Fanfold the drawsheet and the bottom sheet at the center of the bed, asclose to the patient as possible.

Place the new bottom sheet on the bed, and vertically fanfold the half to beused on the far side of the bed as close to the patient as possible. Tuck the

sheet under the near half of the bed, and miter the corner if a contour sheetis not being used.

Place the clean drawsheet on the bed with the center fold at the center ofthe bed. Fanfold the uppermost half vertically at the center of the bed, and

tuck the near side edge under the side of the mattress. Assist the client to roll over toward you onto the clean side of the bed.

Have the client roll over the fanfolded linen at the center of the bed.

Move the pillows to the clean side for the patients use. Raise the side railbefore leaving the side of the bed.

Move to the other side of the bed, and lower the side rail. Remove the used linen and place it in the portable hamper. Unfold and fanfold bottom sheet from the center of the bed.


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Facing the side of the bed, use both hands to pull the bottom sheet so that itis smooth, and tuck excess under the side of the mattress.

Unfold the drawsheet fanfolded at the center of the bed and pull it tightlywith both hands. Pull the sheet in three sections:

Face the side of the bed to pull the middle section. Face the far top corner to pull the bottom section. Face the far bottom corner to pull the top section. Tuck the excess drawsheet under the side of the mattress.6. Reposition the client in the center of the bed. Reposition the pillows at the center of the bed. Assist the client to the center of the bed. Determine what position the client

requires or prefers, and assist the client to that position.

7. Apply or complete the top bedding. Spread the top sheet over the client, and either ask the client to hold the top

edge of the sheet or tuck it under the shoulders, the sheet should remainover the client when the bath blanket or used sheet is removed.

Complete the top of the bed.8.

Ensure the continued safety of the client.

Raise the side rails. Place the bed in the low position before leaving thebedside.

Attach the signal cord to the bed linen within the clients reach. Put items used by the client within easy reach. Bed making is not normally recorded.


highest score)

5 4 3 2 1

Mastery

Orderliness


Ability to answer questionsProper reporting observed.



Comments:_____________________________________________________________________

______________________________________________________________________________


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Brushing and Flossing the Teeth

CHECKLIST

Legend:


PROCEDURES 3 2 1 0

Assess:

The extent of the clients self care abilities The clients usual mouth care practices Inspect lips, gums, oral mucosa, and tongue for deviation from normal. For presence of oral problems such as tooth carries, halitosis, gingivitis, or

lose or broken teeth.

The client for bridge work or dentures.Assemble equipment and supplies:Brushing and flossing:

Towel Disposable gloves Curved basin or emesis basin Tooth brush Cup of tepid water Toothpaste Mouthwash Dental floss (at least two pieces, 20cm or 8 inches in length) Floss holder (optional)

Cleaning artificial dentures:

Disposable gloves Tissue or piece of gauze

Denture container Clean wash cloth Toothbrush or stiff brittle brush Toothpaste Tepid water Container of mouth wash Curved basin Towel

Procedure

Explain to the client what you are going to do, why it is necessary, and how she

can cooperate.



Prepare the client and the environment.

Assist the client to a sitting position in bed, if health permits. If not assist the client

is a side lying position with the head turned.

Prepare the equipment

Place the towel under the clients chin.

Put on clean gloves

Moisten the bristles of the toothbrush with tepid water and apply the toothpaste to

the toothbrush.Use a soft toothbrush and the clients choice of toothpaste.

For the client who must remain in bed, place of hold the curved basin under theclients chin, fitting the small curve around the chin or neck.

Inspect the mouth and teeth.

Brush the teeth.


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Hand the toothbrush to the client, or brush the clients teeth as follows:

Hold the brush against the teeth with the bristles at a 45 degree angle. Thetips of the outer bristles should rest against and penetrate against thegingival.

Move the bristle up and down, using a vibrating or jiggling motion fromthe sulcus to the crowns of the teeth.

Repeat until all outer and inner surfaces of the teeth and sulci of the gumsare cleaned.

Clean the biting surfaces by moving the brush back and forth over them inshort strokes.

If the tongue is open, brush it gently with a toothbrush.Hand the client the water cap or mouthwash to rinse the mouth vigorously. Thenask the client and spit the water and excess toothpaste into the basin.

Repeat the preceding steps until the mouth is free of toothpaste and food particles.

Remove the curved basin and help the client wipe her/his mouth.

Floss the teeth.

Assist the client to floss independently, or floss the teeth as follows: Wrap one end of the cloth around the third finger of each hand. To floss the upper teeth, use your thumb and index finger to starch the

floss. Move the floss up and down between the teeth from the tops of thecrown to the gum and along the gum lines as far as possible. Make a C

with the floss around the tooth edge being flossed. Star at the back on theright side and work around to the back of the left side, or work from the

center teeth to the back of the jaw on either side.

To floss the lower teeth, use your index fingers to stretch the floss andfollow instructions as above.

Give the client tepid water of mouth wash to rinse the mouth and a curved basin inwhich to spit the water.

Assist the client in wiping the mouth

Remove and dispose of equipment appropriately.

Remove and clean the curved basin.

Remove and discard the gloves.

Document assessment of the teeth, tongue, gums, and oral mucosa.


highest score)

5 4 3 2 1

Mastery

Orderliness





Comments:___________________________________________________________________________________________________________________________________________________


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21


Providing Special Oral Care

CHECKLIST

Legend:


PROCEDURES 3 2 1 0

Assess:

Inspect lips, gums, oral mucosa, and tongue from deviations form normal Identify presence of oral problems such as tooth carries, halitosis,

gingivitis, lose or broken teeth.

Asses for gag reflex when appropriateAssemble equipment and supplies:

Towel Tissue or piece of gauze to remove denture (optional) Denture container Rubber tipped bulb syringe Suction catheter with suction apparatus (optional) Foam swabs and clean solution for cleaning the mucus membranes Petroleum jelly Bite block to hold the mouth open and teeth apart (optionl) Disposable gloves Curved basin or emesis basin Tooth brush Cup of tepid water Toothpaste Mouthwash

Procedure

Explain to the client what you are going to do, why it is necessary, and how shecan cooperate.




Position the unconscious client in a side lying position, with the head of the bedlowered.

Place the towel under the clients chin

Place the curved basin against the clients chin and lower cheek to receive the

fluid form the mouth

Put on gloves

Clean the teeth and rinse the mouth

If the client has natural teeth, brush the teeth. If the client has artificial teeth,

clean them as prescribe in the variation component*****

Rinse the clients by drawing about 10 ml of water or alcohol free mouth wash

into the syringe and injecting it gently into each side of the mouth.

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

into the basin. If not, suction the fluid from the mouth

Repeat rinsing until the mouth is free form tooth paste if used.

Inspect and clean the oral tissues

If the tissues appear dry or unclean, clean them with the foam swabs or gauze andcleaning solution, following agency policy.

Picking up moistened foam swab, wipe the mucous membrane of one cheek. If no

foam swabs are available, wrap a small gauze square around a tongue blade andmoisten it. Discard the swab or tongue blade in a waste container and, with afresh one, clean the next area.

Clean all the mouth tissues in an orderly progression, using separate applicators:the cheeks, roof of the mouth, base of the mouth, and tongue.

Observe the tissues closely for inflammation and dryness.

Rinse the clients mouth as prescribed in step 5.


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Remove and discard gloves

Ensure the client comfort.

Remove the basin, and dry around the clients mouth with the towels. Replaceartificial dentures if indicated

Lubricate the clients lips with petroleum jelly. If the client is on oxygen therapy,do not use petroleum jelly because it can cause burns to the clients mouth. Use

another mouth care product that does not have petroleum in it.

Document:

Assessment of the teeth tongue, gums, and oral mucosa Any problems such as sores or inflammations or swelling of the gums.


highest score)

5 4 3 2 1

Mastery

Orderliness





Comments:___________________________________________________________________________________________________________________________________________________


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23


Providing Perineal and Genital Care

CHECKLIST

Legend:


PROCEDURES 3 2 1 0

Assess for presence of:

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 Whether the client is experiencing any discomfort in the perineal genital

area.

Assemble equipments and supplies:Perineal genital care provided in conjunction with a bed bath

Bath towel Bath blanket Clean gloves Bath basin with water 4346 degrees Celsius (110115 Fahrenheit) Soap Wash cloth

Special perineal genital care

Bath towel Bath blanket Clean gloves Cotton balls or swabs Solution bottle, pitcher, or container filled with warm water or a

prescribe solution.

Bed pan to receive rinse water. Moisture resistant bag or receptacle for used cotton swabs Perineal pad

Procedure


can cooperate.




Fold the top bed linen to the foot of the bed and fold the gown up to exposedgenital area.

Place a bath towel under the clients hips.

Position and drape the client and clean the upper and inner thighs

For females

Position in a back lying position with the knees flexed and spread well apart.

Cover her body and legs with a bath blanket. Drape the legs by tucking thebottom corners of the bath blanket under the inner sides of the legs. Bring the

middle portion of the base of the blanket up over the pubic area.

Put on gloves, and wash and dry the upper inner thighs.


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For males

Position the male client in a supine position with knees slightly flexed and hipsslightly externally rotated.

Put on gloves, and wash and dry the upper inner thighs

Inspect the perineal area

Note particular areas of inflammation, excoriation, or swelling, especiallybetween the labia in females or the scrotal folds in males.

Also note excessive discharge or secretion from the orifices, and the presence ofodors.

Wash and dry the perennial genital area.

For females

Clean the labia majora. Then spread the labia to wash the folds between the labiamajora and minora.

Use separate quarters of the wash cloths for each stroke, and wipe from the pubisto the rectum. For menstruating women and clients with clients with indwelling

catheters, use clean wipes, cotton balls, or gauze. Take a clean ball for eachstroke.

Rinse the area well.

Dry the perineum thoroughly.

For males

Wash and dry the penis, using firm strokes.

If the client is uncircumcised, retract the prepuce to expose the glans penis for

cleaning. Replace the fore skin after cleaning the glans penis.

Wash and dry the scrotum. The posterior folds of the scrotum may need to be

clean in step 9 with the buttocks.

Inspect the perineal orifices intactnessInspect particularly around the urethra in clients with indwelling catheter.

Clean between the buttocks.

Assist the client to turn on to the side facing away from you.

Pay particular attention to the anal area and posterior folds in the scrotum inmales. Clean the anus with toilet tissue before washing it, if necessary.

Dry the area well.

For post delivery or menstruating females, apply a perineal pad as needed, fromfront to back.

Document:

Any unusual findings such as redness excoriation, skin break down,discharge, or drainage.

Any localized area of tenderness.For the next items, evaluate the students in general according to the criteria. (5 as the

highest score)

5 4 3 2 1

Mastery

Orderliness





Comments:_____________________________________________________________________

______________________________________________________________________________


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Bathing an Adult or Pediatric Client

CHECKLIST

Legend:

3-Very Satisfactory 0- Did not perform the procedure

2- Satisfactory 1- Needs ImprovementPROCEDURES 3 2 1 0

Assess:

Condition of the skin Fatigue Presence of pain and 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

Assemble equipment and supplies:

Basin or sink with warm water Soap and soap dish Linens: bath blanket, two bath towels, washcloth, clean gown, orpajamas or clothes as needed, additional bed linen and towels, if

required

Gloves, if appropriate Personal hygiene articles Shaving equipment for male clients Table for bathing equipment Laundry hamper

Determine:

The purpose and 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 Clients comfort level with being bathed by someone else

Procedure


can cooperate.




Invite a family member or significant other to participate, if desired

Close windows and doors to ensure the room is a comfortable temperature.

Offer the client a bedpan or urinal, or ask whether the client wishes to use thetoilet or commode.

Encourage the client to perform as much personal self-care as possible.

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

For a Bed Bath

Prepare the bed and position the client appropriately.

Position the bed at a comfortable working height. Lower side rail on the sideclose to you. Keep the other side rail UP. Assist the client to move near you.

Place bath blanket over top sheet. Remove the top sheet from under the bathblanket by starting at clients shoulders and movinglinen down towards clients

feet. Ask the client to grasp and hold the top of the bath blanket while pullinglinen to the foot of the bed.

Note: If the bed linen is to be reused, place it over the bedside chair. If it is to bechanged, place it in the linen hamper.

Make a bath mitt with the washcloth.

Wash the face.

Place towel under the clients head.


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Wash the clients eyes with water only, and dry them well. Use a separate

corner of the washcloth for each eye. Wipe from the inner to the outer canthus.

Ask whether the client wants soap used on her face.

Wash, rinse, and dry the clients face, ears and neck.

Remove the towel from under the clients head.

Wash the arms and hands.Place a towel lengthwise under the arm away from you.

Wash, rinse and dry the arm by elevating the clients arm and supporting theclients wrist and elbow.

Apply deodorant or powder if desired.

Optional: place a towel on the bed and put a washbasin on it. Place the clientshands in the basin. Assist the client as needed to wash, rinse and dry her hands,

paying particular attention to the spaces between her fingers.

Repeat for hand and arm nearest you.

Wash the chest and the abdomen.

Place bath towel lengthwise over chest. Fold bath blanket down to the clients

pubic area.Lift the bath towel off her chest, and bathe her chest and abdomen with your

mitted hand, using long, firm strokes. Rinse and dry well.

Replace the bath blanket when the areas have been dried.

Wash the legs and feet.

Expose the leg farthest from you by folding the bath blanket towards the other

leg, being careful to keep the perineum covered.

Lift leg and place the bath towel lengthwise under the leg. Wash, rinse and dry

the leg, using long, smooth, firm strokes from the ankle to the knee to the thigh.

Reverse the coverings and repeat for the other leg.

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

Dry each foot.

Obtain fresh, warm, bathwater now or when necessary.

Wash the back and then the perineum.

Assist the client into a prone or side-lying position facing away from you. Placethe bath towel lengthwise alongside the back and buttocks while keeping theclient covered with the bath blanket as much as possible.

Wash and dry the clients back, moving from the shoulders to the buttocks, andupper thighs, paying attention to the gluteal folds.

Perform a back massage now or after completion of bath.

Assist the client to the supine position and determine whether the client can

wash the perineal area independently. If she can not do so, drape the client andwash the area.

Assist the client with grooming aids such as powder, lotion or deodorant.

Use powder sparingly. Release as little as possible into the atmosphere.

Help the client put on a clean gown or pajamas.

Assist the client to care for hair, mouth and nails.


highest score)

5 4 3 2 1

Mastery

Orderliness





Comments:___________________________________________________________________________________________________________________________________________________


27/53

27


Administering an Intradermal Injection

CHECKLIST

Legend:


PROCEDURES 3 2 1 0

Assess:

Appearance of injection site Specific drug action and expected response Clients knowledge of drug action and response


Vial or ampule of the correct medication Sterile 1ml syringe calibrated into hundredths of a milliliter (i.e.

tuberculin syringe) and a 25to 27gauge needle hat is to 5/8 inch long

Alcohol swabs 2 x 2 sterile gauze square (optional) Nonsterile gloves (according to agency protocol) Band Aid (optional) Epinephrine (a bronchodilator and antihistamine) on hand

Check the MAR

Check the label on the medication carefully against the MAR to make sure that thecorrect medication is being prepared.

Follow the three checks for administering medications. Read the label on themedication:

When it is taken from the medication cart Before withdrawing the medication After withdrawing the medication

Organize the equipment.

Procedure


Prepare the medication from the vial or ampule for drug withdrawal.

See Procedure 332 and 333.

Prepare the client

Check the clients identification band

Explain to the client that he medication will produce a small wheal, sometimes

called a bleb.

Provide for client privacy

Select and clean the site

Select a site.Avoid using sites hat are tender, inflammed, or swollen, and those that have lesions

Put on gloves.

Cleanse the skin at the site using a firm circular motion, starting at the center andwidening he circle outward. Allow the area to dry thoroughly.

Prepare the syringe for he injection

Remove he needle cap while waiting for the antiseptic to dry.

Expel any air bubbles from the syringe.

Grasp the syringe in your dominant hand, holding it between thumb and forefinger.Hold the needle almost parallel to the skin surface with the bevel of the needle up.

Inject the fluid.

With the nondominant hand, pull the skin at the site until it is taut.Insert the tip of the needle far enough to place the bevel through the epidermis intothe dermis. The outline of the bevel should be visible under the skin surface.

Stabilize the syringe and needle, and inject the medication carefully and slowly, so

that it produces a small wheal on the skin.

Withdraw the needle quickly at the same angle that it was inserted. Apply a Band

Aid, if indicated.

Do not massage the area.


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Dispose of the syringe and needle safely.

Remove gloves.

Circle the injection site with ink to observe for redness or induration per agency

policy.

Document all relevant information.

Record the testing material given, the time, dosage, route, site and nursingassessments.


highest score)

5 4 3 2 1

Mastery

Orderliness





Comments:_____________________________________________________________________

______________________________________________________________________________


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Administering an Subcutaneous Injection

CHECKLIST

Legend:


PROCEDURES 3 2 1 0

Assess:

Allergies to medication Specific drug action, side effects, and adverse reactions Clients knowledge and learning needs about the medication Status and appearance of subcutaneous site for lesions, erythema,

swelling, ecchymosis, inflammation, and tissue damage from previousinjections.

Ability of client to cooperate during the injection Previous injection sites used


MAR or computer printout Vial or ampule of the correct sterile medication Syringe and needle Antiseptic swabs Dry sterile gauze for opening an ampule (optional) Disposable gloves

Check the MAR.

Check the label on the medication carefully against the MAR to make sure that

the correct medications is being prepared.

Follow the three checks for administering medications. Read the label on the

medication:


Organize the equipment.

Procedure


Prepare the medication from the ampule or vial for drug withdrawal.

See procedure 332 (ampule) or 333 (vial)


Prepare the client.

Check the clients identification band.

Assist the client to a position in which the arm, leg, or abdomen can be relaxed,depending on the site to be used.

Obtain assistance in holding an uncooperative client.

Explain the purpose of the medication and how it will help, using language

that the client can understand. Include relevant information about effects

of the medication

Select and clean the site.

Select a site free of tenderness, hardness, swelling, scarring, itching, burning,and localized inflammation.

Select a site that has not been used frequently

Put on gloves

As agency protocol indicates, clean the site with an antiseptic swab. Start at thecenter of the site and clean in a widening circle to about 5cm (2in). Allow the

area to dry thoroughly

Place and hold the swab between the third and fourth fingers of thenondominant hand, or position the swab on the clients skin above the intended

site.

Prepare the syringe for injection

Remove the needle cap while waiting for the antiseptic to dry.


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Inject the medication.

Grasp the syringe in your dominant hand by holding it between your thumb andfingers. With palm facing to the side or upward for a 45degree angle insertion,

or with the palm downward for a 90degree angle insertion, prepare to inject.

Using the nondominant hand, pinch or spread the skin at the site, and insert the

needle, using the dominant hand and a firm steady push.

When the needle is inserted, move your nondominant hand to the end of the

plunger.

Aspirate by pulling back on he plunger. If blood appears in the syringe,

withdraw the needle, discard the syringe, and prepare a new injection. If blooddoes not appear, continue to administer the medication.

Inject the medication by holding the syringe steady and depressing the plunger

with slow, even pressure.

Remove the needle

Remove the needle slowly and smoothly, pulling along the line of insertionwhile depressing the skin with your nondominant hand.

If bleeding occurs, apply pressure to the site with dry sterile gauze until it stops.

Dispose of supplies appropriately.Discard the uncapped needle and attached syringe into designated receptacles

Remove gloves. Wash hands.

Document all relevant information.

Document the medication given, dosage, time route, and any assessments.

Many agencies prefer that medication administration be recorded on themedication record.

Assess the effectiveness of the medication at the time it is expected to act.

Variation: Administering a Heparin Injection

Procedure

Select a site o the abdomen away from the umbilicus and above the level of the

iliac crests.Use a 3/8inch, 25or 26gauge needle, and insert it at a 90degree angle. If a

client is very lean or wasted, use a needle longer than 3/8inch, and insert it at a45degree angle. The arms or highs may be used as alternate sites.

Do not aspirate when giving heparin by subcutaneous injection.

Do not massage the site after the injection.

Alternate the sites of subsequent injections.


highest score)

5 4 3 2 1

Mastery

OrderlinessProper attitude in assessing the client followed.




Comments:___________________________________________________________________________________________________________________________________________________


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31


Administering an Intramuscular Injection

CHECKLIST

Legend:


PROCEDURES 3 2 1 0

Assess:

Client allergies to medication(s) Specific drug action, side effects, and adverse reactions Clients knowledge of and learning needs about the medication. Tissue integrity of the selected site Clients age and weight, to determine site and needle size Clients ability or willingness to cooperate

Determine:

Whether the size of the muscle is appropriate to the amount of medicationto be injected.

Assemble equipment and supplies: MAR or computer printout Sterile medication (usually provided in an ampule or vial) Syringe and needle of a size appropriate for the amount of solution to be

administered

Antiseptic swabs. Disposable gloves

Check the MAR.

Check the label on the medication carefully against the MAR to make sure that the

correct medication is being prepared.

Follow the three checks for administering the medication and dose. Read the

label on the medication:


Confirm that the dose is correct.

Procedure


Prepare the medication from the ampule or vial for drug withdrawal.

See Procedure 332 (ampule) or 333 (vial)

Whenever feasible, change the needle on the syringe before the injection.

Invert the syringe needle uppermost, and expel all excess air.

Provide for client privacy.Prepare the client.

Check the clients identification band.

Assist the client to a supine, lateral, prone, or sitting position, depending on thechosen site.

Obtain assistance in holding an uncooperative client.

Explain the purpose of the medication and how it will help, using language

that the client can understand. Include relevant information about effects of

the medication.

Select, locate ad clean the site

Select a site free of skin lesions, tenderness, swelling, hardness, or localized

inflammation, and one that has not been used frequently.If injections are to be frequent, alternate sites. Avoid using the same site twice in a

row

Locate the exact site for the injection.

Put on clean gloves.

Clean the site with an antiseptic swab. Using a circular motion, start at the centerand move outward about 5 cm (2in).

Transfer and hold the swab between the third and fourth fingers of your


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nondominant hand in readiness for needle withdrawal, or position the swab on the

Clients skin above the intended site. Allow skin to dry prior to injectingmedication.

Prepare the syringe for injection

Remove the needle cover without contaminating the needle.

If using a prefilled unitdose medication, take caution to avoid dripping medicationon the needle prior to injection. If this does occur, wipe the medication off theneedle with sterile gauze.

Inject the medication using a Ztrack technique.

Use the ulnar side of the nondominant hand to pull the skin approximately 2.5 cm(1inch) to the side.

Holding the syringe between the thumb and forefinger, pierce the skin quickly andsmoothly at a 90degree angle, and insert the needle into the muscle.

Hold the barrel of the syringe steady with your nondominant hand, and aspirate by

pulling back on the plunger with your dominant hand. Aspirate for 5 to 10 seconds.If blood appears in the syringe, withdraw the needle, discard the syringe, and

prepare a new injection.

If blood does not appear, inject the medication steadily an slowly (approximately10 seconds per milliliter) while holding the syringe steady.

After injection, wait 10 seconds.

Withdraw the needle.

Withdraw the needle smoothly at the same angle of insertion.

Apply gentle pressure at the site with a dry sponge. Do not massage the site.

If bleeding occurs, apply pressure with dry sterile gauze until it stops.

Discard the uncapped needle and attached syringe into the proper receptacle.

Remove gloves. Wash hands.

Document all relevant information

Include the time of administration, drug name, dose, route, and the clients

reactions.Assess effectiveness of the medication at the time it is expected to act.


highest score)

5 4 3 2 1

Mastery

Orderliness





Comments:_____________________________________________________________________

______________________________________________________________________________


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33


Administering Cardiopulmonary Resuscitation [CPR]

CHECKLIST

Legend:


PROCEDURES 3 2 1 0

CPR: One Rescuer- Adult, Adolescent

1. Assess responsiveness by tapping or gently shaking client while shouting, Areyou OK?

2. Activate emergency medical system

(EMS):

In clinical setting, follow institutional protocol. In community or home environment, activate local emergency response

system.

3. Position client in a supine position on hard, flat surface.

4. Apply gloves or face shield, if available.

5. Position self. Face client on knees parallel to client, next to head, to begin toassess airway and breathing status.

6. Open airway.

If head or neck injury suspected, use jaw thrust method.7. Assess for respirations. Look, listen, and feel for air movement (3-5 seconds).

8. If respiration is absent:

Occlude nostrils with thumb and index finger of hand on forehead that istilling head back.

Form a seal over the clients mouth using either your mouth or theappropriate respiratory assist device (e.g., Ambu (r) - Bag and mask) and

give two full breaths of approximately 0.5-2 seconds, allowing time forboth inspiration and expiration.

In serious mouth or jaw injury that prevents mouth-to-mouth ventilation,uses mouth-to-nose ventilation

9. Assess for rises and fall of chest:

If chest rises and falls, continue to Action 10. If chest does not move, assess for excessive oral secretions, vomit,

airway obstruction, or improper positioning.

10. Palpate carotid pulse (5-10 seconds):

If present, continue rescue breathing at rate of 12 breaths/min. If absent, begin external cardiac compressions.

11. Perform cardiac compressions as follows:

Maintain position on knees parallel to sternum.

Position hands for compressions.a. With hand nearest to legs, use index finger to locate lower rib marginand quickly move fingers up to location where ribs connect to

sternum.b. Place middle finger of this hand on notch where ribs meet sternum

and index finger next to it.c. Place heel of opposite hand next to index finger on sternum.d. Remove first hand from notch and place on top of hand that is on

sternum so that they are on top of each other.e. Extend or interface fingers and do not allow them to touch chest.f. Keep arms straight with shoulders directly over hands on sternum

and lock elbows.

g.

Compress adult chest 3.89 5.0 cm (1/2-2 inches) at the rate ofapproximately 100.h. Heel of hand must completely release pressure between

compressions, but should remain in constant contact with clientsskin.

i. Use the mnemonic one and, two and three and to keep rhythmand timing.

j. Ventilates client as described in Action 8.


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12. Maintain compression rate for approximately 100 times/min, interjecting 2

ventilations after every 15 compressions. (compression: ventilation rate 15:2).

13. Reassess client after 4 cycles.

CPR: Two RescuersAdult, Adolescent14. Follow steps above, with the following changes:

One rescuer is positioned facing client parallel to head while otherrescuer is positioned on opposite side facing client parallel to sternumnext to trunk.

Rescuer positioned at clients trunk is responsible for performing cardiaccompressions and maintaining verbal mnemonic count. This is rescuer 1.

Rescuer 2 positioned at clients head is responsible for monitoringrespirations, assessing carotid pulse, establishing an open airway, and

performing rescue breathing.

Maintain compression rate for approximately 100 times/min, interjecting2 ventilations after every 15 compressions (15:2 ratio)

Rescuer 2 palpates carotid pulse with each chest compression duringfirst full minute.

Rescuer 2 is responsible for calling for a change when fatigued,following this protocol.

Rescuer 1 calls for a change and completes 15 chest compressions. Rescuer 2 administers 2 breaths and then moves to a position parallel to

clients sternum and assumes proper hand position.

Rescuer 1 moves to rescue breathing position and checks carotid pulsefor 5 seconds. If cardiac arrest persists, rescuer 1 says, continue CPR

and delivers one breath. Rescuer 2 resumes cardiac compressionsimmediately after breath.

CPR: One RescuerChild (1-7 years)

15. Assess responsiveness, activate emergency medical system, position

isolation, position child, apply appropriate body substance isolation, position self,

open airway, and assess for respirations as described in Action 1 -7.16. If respirations are absent, begin rescue breathing:

Give two slow breaths (11 sec/ breath), pausing to take a breathin between.

Use only amount of air needed to make chest rise.17. Palpate carotid pulse (5 10 seconds). If present, ventilate at a rate of onceevery 4 seconds or 15 times/min. If absent, begin cardiac compressions.

18. Cardiac compressions (child 17 years):

Maintain positions on knees parallel to childs sternum Position hands for compressions.

a. Locate lower margin of rib cage using hand closest to feet andfind notch where ribs and sternum meet.

b. Pace middle finger of this hand on notch and then place indexfinger next to middle finger.

c. Place heel of other hand next to index finger of first hand onsternum with heel parallel to sternum (1 cm above the xiphoid

process).

d. Keeping elbows locked and shoulders over child, compresssternum 2.53.8 cm (1 -1 inches) at appropriate rate of 100

times/min.e. Keep other hand on childs forehead.f. At end of every fifth compression, administer a ventilation (1

1 seconds).g. Reevaluate child after 20 cycles.h. A 1minute CPR should be performed for infants and children

up to age 8 before calling 911. In institutions, follow hospitalprotocol.

CPR: One RescuerInfant ( 112 months )

19. Assess responsiveness, activate emergency medical system, position child,apply appropriate body substance isolation, position self, open airway, and assessfor respirations as described in Action 1- 7.

20. If respirations are absent, begin rescue breathing:


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Avoid overextension of infants neck. Place a small towel or diaper under infants shoulders or use a hand

to support neck.

Make a tight seal over both infants nose and mouth and gentlyadminister artificial respirations.

Give two slow breaths (1 1 1/2 sec/breath), pausing to take abreath in between.

Use only amount of air needed to make chest rise.21. Assess circulatory status using brachial pulse:

Locate brachial pulse on inside of upper arm between elbow andshoulder by placing thumb on outside of arm and palpating proximalside of arm with index finger and middle fingers.

If pulse is palpated, continue rescue breathing 20times/min or onceevery 3 seconds.

If pulse is absent, begin cardiac compressions.22. cardiac compressions ( infant 112 months:

Maintain position parallel to infant. Place small towel or other support under infants shoulders and neck. Position hands for compressions:

a. Using hand closest to infants feet, locate intermammary linewhere it intersects sternum

b. Place index finger 1 cm blow this location on sternum and placemiddle finger next to index finger.

c. Using these two fingers, compress in a downward motion 1.3-2.5cm (1/2-1 inch) at rate 100 times/min.

d. Keep other hand on infants forehead.e. At end of every fifth compression, administer a ventilation (1-1

seconds).f. Reevaluate infant after 20 cycles.g. A 1-minute CPR should be performed for infants and childr

checklist - nursing procedures

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