CLINICAL PRACTICE II

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CLINICAL PRACTICE II






HEALTH ASSESSMENT AND
NURSING PRACTICE



NSCP 2203










TRAINING MANAGEMENT DIVISION


MINISTRY OF HEALTH


MALAYSIA


2019

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BIL PERKARA MUKASURAT

1 Feeding Helpless Patients 4

2 Measure and Record of Intake Output Chart 5

3 Administration Oral Medication and Documentation: Enteral 6
/ Oral
4 Administration Parenteral Medication and Documentation: 8
Intradermal

5 Administering A Subcutaneous 10

6 Administering an Intramuscular 12

7 Administering an Intravenous 14


8 Administering Medication Per Rectum: Suppository 16

9 Administering Medication Per Rectum: Enema 18

10 Health Assessment and Nursing Practice Perform 19
Procedures: Admission
11 Perform Procedures: Discharge 21

12 Perform Procedures: Transfer 22

13 Health assessment and physical examination 24


14 Perform health assessment and physical examination: 26
Braden scale

15 Perform health assessment and physical examination: 31
Morse Fall scale
16 Perform observation: Temperature (Via Tympanic 33
Membrane)
17 Perform Observation: Pulse 34

18 Perform Observation: Respiration 35

19 Perform Observation: Blood Pressure 36


20 Perform Observation: Pain Score 38

21 Nursing Intervention for Heat and Cold Therapies: Cold 39
Compress
22 Nursing Intervention for Heat and Cold Therapies: Tepid 40
Sponge








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BIL PERKARA MUKASURAT

23 Universal Precaution. Donning and Removing Personal 41
Protective
24 Donning and Removing Personal Protective 42


25 Changing an Unoccupied Bed 44

26 Changing an Occupied Bed 47

27 Bed Bathing 49


28 Oral Care 53

29 Perianal-Genital Care 55

30 Hair Care 58

31 Insertion Oropharyngeal Airway 60

32 Suctioning Oropharyngeal and Nasopharyngeal cavities 61


33 Coughing and Deep Breathing Exercise 64

34 Collecting Urine Specimen (Culture & Sensitivity) 66

35 Collecting Stool Specimen 68


36 Collecting Sputum Specimen 69

37 Collecting Throat Swab 79

38 Bandaging Simple Spiral 71

39 Wound dressing 72

40 Removal of suture / clip 74


41 Removal of drain 76

42 Incision and drainage 78

43 Insertion of the peripheral line and setup intravenous 79
infusion
44 Insertion central venous line (assisting) 82

45 Measuring central venous pressure 83

46 Obtaining blood specimen 84








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PROCEDURE CHECKLIST 1
NUTRITION: FEEDING HELPLESS PATIENTS



NO. PROCEDURE REMARKS


1. Greet patients and introduce self

2. Informed procedure to the patient

Assess patient
– remove denture
3. - Gag reflects
- Ability to swallow
- Elimination needs

4. Greet patients and introduce self

5. Assist patients to sit up / upright position

6. Assist patients to wash hands before feeding

7. Apply bib


8. Prepare food:

8.1 Suitable temperature

8.2 Remove bone

8.3 Cut the dish to small pieces


9. Use spoon to feed
Offer fluids to drink throughout feeding; at least every 2-3
10.
bites of food
Give time to patient to chew and to swallow before feeding the
11.
next bite
12. Observed amount of food taken and his appetite

13. Communicate with patient during meal (e.g., encourage intake)

14. Give patient water to clean and rinse mouth


15. Make patient comfortable

16. Document in intake output chart and report


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PROCEDURE CHECKLIST 2
NUTRITION: MEASURE AND RECORD OF INTAKE OUTPUT
CHART



NO. PROCEDURE REMARKS



1. Check patients note to assess patient intake requirement

2. Greet patient and introduce self


3. Explain the importance of recording intake and output chart


Fill up patient details on the chart
i. Name
4.
ii. Registered number
iii. Ward and bed number

Label the drink container (mug or glass) to measure all oral
5.
fluids
Prepared measuring jug (to measure urine and vomit) at patient
6.
bedside
Prepare and inform patient the amount of fluid to be taken per
7.
shift

8. Ask / measure every intake and output


Record every intake and output in appropriate column:
9.1. Intake
- Date
9.
- time
- type of drink
- amount


9.2. Output
- Date
- time
- type of output/ characteristic
- amount

10. Total the intake and output every shift


11. Documentation and report


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PROCEDURE CHECKLIST 3
THERAPEUTIC
Administration oral medication and documentation:
Enteral / Oral



NO. PROCEDURE Remarks


1.
Wash and dry hands

2. Check prescription in patient notes and in the medication
chart.
3.
Using the 6R principles of drug administration:
check:
- patient’s name
- registration number
- type of medication
- dose
- route
- time

4. Check the medication with medication chart. (with trained
staff)

5. Prepare the medication (tablet /capsule)

Check name and dose at the medication
5.1
container with medication chart

5.2 Calculate the correct dosage

6.
Perform second medication check:

- Take required dose of medication and
- Place in the medication cup in tray.

7.
Prepare Medication in Liquid form

Perform second medication check

- Shake the medication bottle if necessary
7.1 - Hold the bottle with label against the palm.
- Open bottle cover hold cup at eye level in non-
dominant hand and pour out the required amount.
- Place the medication in the tray.



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NO. PROCEDURE Remarks


- Close the medication bottle with the cap.


Perform third medication check
- Take the medication and the medication chart to
7.2 patient’s bed side.
- Ask patient’s name. Check patient’s ID tag with
the medication chart


Explain to patient ‘s
8. - Type of medication
- Action and effects of medication.

9. Give medication to patient with adequate water.

10. Ensure patient swallows the medication
11. Give medication one by one if many

- Document administration of medication:
- Date and time

- Name of Std. who administers the medication
- RN (witness) countersigns in medication chart.

12. Leave patients comfortable. Tidy up the unit

Clean equipment.
13. Keep medication in its proper storage place.




























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PROCEDURE CHECKLIST 4
THERAPEUTIC
Administration parenteral medication and documentation: Administration parenteral
medication and documentation: Intradermal





NO. PROCEDURE REMARKS



1. Check the prescription in the patient’s medication record.


2. Wash hands


3. Greet patient and introduce self

Prepare equipment and medication (refer preparing
4. medication from ampoule or vial)


5. Follow the Right principle of drug administration
Check patient’s identification band and ask patient to state
6.
name
Explain the

- type of medication,
7.
- route and location of injection
- action of the medication to the patient.

8. Place patient in comfortable position, provide privacy

9. Wash hand and don sterile gloves

Select the site of injection using appropriate anatomical
10.
landmarks where skin is not damaged or discoloured.

Clean area with an alcohol wipe. Using a circular motion,
11.
cleanse from inside to outside. Wait for alcohol to dry

Prepare the syringe for injection
- remove the needle guard
12.
- express air bubble
- check the amount as prescribe





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NO. PROCEDURE REMARKS


13. Inject the medication:

Grasp the patient’s forearm and gently pull the
13.1
skin taut.

o
13.2 Insert needle at a 10-15 angle with the bevel of
the needle facing up. Do not aspirate.


Inject medication slowly.
13.3 Observe for signs of wheal formation and blanching
at the site.


Withdraw needle.
13.4 Pat area gently with a dry cotton swab.
Do not massage area.

14. Return patient to a comfortable position


15. Discard supplies in appropriate area.


16. Documentation and report




































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PROCEDURE CHECKLIST 5
THERAPEUTIC
Administration parenteral medication and documentation: Administering a
subcutaneous



NO. PROCEDURE Remarks

1. Ensure physician’s order.


2. Greet patient and introduce self


3. Wash and dry hands

4. Using the Right principles of drug administration.


Prepare equipment and medication prescribe (refer
5. preparing medication from ampoule or vial). Perform third
medication check


Take the injection tray with:
- Alcohol swabs
6. - medication ampoule or vial
- Prepared medication in syringe
- Medication chart to patient’s bed side.

Ask patient’s name and check ID tag with the
7.
medication chart.


Inform and explain to patient
- type of medication
8.
- route and location of injection
- medication action


Position the patient to a comfortable position and provide
9. privacy


Select and expose the correct site for the injection.
- Abdomen
10. - Lateral and anterior aspect of upper arm and thigh
- Scapula area
- Upper ventro gluteal area


11. Administer the subcutaneous injection;


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NO. PROCEDURE Remarks


11.1. Swab the selected site for injection

Pinch the subcutaneous tissue at the injection site
11.2
using thumb and forefinger

Hold the needle and the syringe at an angle of 45º or
11.3
90 º

Inject the needle, aspirate to ensure that is not in the
11.4
blood vessel.

11.5 If no inject the medication slowly

11.6 remove needle and syringe swiftly


Apply pressure to the injection site with dry swab,
11.7
do not massage

Place syringe and needle in the sharp bin without
12.
recapping

13. Make patient comfortable.

Document administration of medication:

− Date and time
14.
− Name of Std. who administers the medication.
− RN (witness) countersigns in medication chart.

Observed the patient for any side or adverse effect and
15.
asses the effectiveness of the medication


16. Wash and dry hands

17. Documentation and report















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PROCEDURE CHECKLIST 6
THERAPEUTIC
Administration parenteral medication and documentation: Administering an
Intramuscular


NO. PROCEDURE REMARKS


1. Ensure physician’s order

2. Greet patient and introduce self


3. Wash and dry hands


4.
Using the Right principles of drug administration.
5. Prepare equipment and medication prescribe (refer

preparing medication from ampoule or vial). Perform third
medication check

6.
Take the injection tray/ trolley with:
- alcohol swabs
- medication ampoule or vial
- prepared medication in syringe
- medication chart to patient’s bed side.

7. Ask patient’s name and check ID tag with the medication
chart.

8.
Inform and explain to patient
- type of medication
- route and location of injection
- medication action
9. Position the patient to a comfortable position and provide
privacy
10.
Select and expose the correct site for the injection.
- Deltoid muscle: 2 or 3 fingers away from the acromion
process of the arm
- Vastus lateralis: anterolateral aspect of the thigh
- Ventrogluteal site (gluteal medius muscle)
- Dorso gluteal (gluteal maximus musle: Upper outer
quadrant of buttocks





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NO. PROCEDURE REMARKS


11. Administer the intramuscular injection
11.1
Swab the selected site for injection

11.2
Pull /stretch the skin at the injection site

11.3
Hold the needle and the syringe at an angle of 90º

11.4
Inject the needle into the muscle, aspirate to
ensure that is not in the blood vessel

11.5 If no blood, inject the medication slowly about 10
sec

11.6 Remove needle and syringe swiftly
11.7 Apply gentle pressure to the injection site with dry
swab

12. Place syringe and needle in sharp bin without
recapping

13. Make patient comfortable.

14. Document administration of medication:
- Date and time
- Name of Std. who administers the medication.
- RN (witness) countersigns in medication chart.
15. Wash and dry hands

16. Document and report

























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PROCEDURE CHECKLIST 7
THERAPEUTIC
Administration parenteral medication and documentation; Administering an
Intravenous




NO. PROCEDURE REMARKS

1. Ensure physician’s order
2. Gather equipment

3. Wash hand and don gloves
Prepare medications according to directions on vial or
4. medication insert sheet.

5. Check medication according to seven right

6. Take medication to patient’s bedside
Check the patient is not allergic to the IV bolus drug he or she
7. will receive

8. Check patient’s identity band and ask him or her to state.
name
9. Double check drug level

10. Clean injection port closest to needle or catheter with an
alcohol swab
11. Close clamp on IV tubing or pinch off tubing
12. Insert needle into port

13. Pull back on plunger and observe for blood flashback

14. Inject medication slowly or according to directions

15. Time the length of injection by dividing total amount of
medication by prescribed time to inject. Use your watch and
administer the medication at the prescribed time
16. Reopen clamp and readjust flow rate as ordered

17. Withdraw needle when medication is infused

18. Type and amount of medication administered

19. Rate medication administered





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NO. PROCEDURE REMARKS
20. Patient’s response to medication


21. Documentation and reporting




































































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PROCEDURE CHECKLIST 8
THERAPEUTIC
Administering medication per rectum: Suppository



NO. PROCEDURE REMARKS


1. Ensure physician’s order
2. Greet patient and introduce self

3. Wash hands. Prepare requirements equipment
4. Explain procedure to patient

5. Provide privacy
6. Don non-sterile gloves

7. Place waterproof sheath under patient’s
buttocks
8. Position patient in left lateral / Sim’s position
with upper leg flexed.
9. Expose the rectum
10. Insert the rectal suppositories

10.1 Open suppository foil and lubricate tip of suppository.

Apply a small amount of lubricant to the smooth round
10.2
end of the suppository

Instruct patient to take deep breaths and breathe
10.3
through the mouth, to relax the anal sphincter.


10.4 Insert suppository gently with pointed end facing inwards


Insert suppository into rectal canal beyond the internal
10.5
sphincter, abou10 cm for adult and 5 cm for child

Withdraw the fingers and wipe the anal area with
10.6
tissue









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NO. PROCEDURE REMARKS


11. Advice patient to stay in lateral position for about 10-15
minutes.

12. Assist patient to sit on bedpan or commode
13. Remove gloves and wash hands.
14. Document and report the results of suppository
insertion.






























































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PROCEDURE CHECKLIST 9
THERAPEUTIC
Administering medication per rectum: Enema



NO. PROCEDURE REMARKS

1. Ensure physician’s order

2. Greet patient and introduce self
3. Wash hands. Prepare requirements equipment

4. Explain procedure to patient

5. Provide privacy
6. Don non-sterile gloves

7. Place waterproof sheath under patient’s
buttocks

8. Position patient in left lateral / Sim’s position
with upper leg flexed.
9. Expose the rectum

10. Insert the enema:
Lubricate tip of fleet enema tube with water soluble
10.1
lubricant

Instruct patient to take deep breaths, insert fleet enema tip
10.2
about 5 cm into the anal canal


Squeeze tube gently and empty entire amount of
10.3
solution into the canal

11. Instruct patient to hold and maintain lateral position for about
10 minutes.
12.
Assist patient to sit on bedpan, commode or go to the toilet
13.
Clean and dry perianal area.
14. Remove gloves. Wash hands.


15. Documentation and reporting







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PROCEDURE CHECKLIST 10
HEALTH ASSESSMENT AND NURSING PRACTICE Perform Procedures: Admission





NO. PROCEDURE REMARKS


1. Introduces self to patient and family.

Do ward registration.
2. Assists patient into hospital gown.

3. If possible, measures weight while standing on a scale.


4. Take patient to the bed.

Checks patient’s identification band to
5. ensure information, including allergies, is correct. Verifies this
information with the patient or family.

6. Measures patient’s vital signs.


Explains equipment, including how to use call system and
7. location of personal care items.



Explains hospital routines, including use of side rails,
8. mealtimes, etc., and answers patient’s and family’s questions.

Obtains nursing admission assessment
9. - Health history
- Physical assessment
Completes inventory of patient’s
belongings.
10. - Encourages family to take home valuable items.
- If that is not possible, arranges to have valuables placed
in the hospital safe

11. Ensures that all admission orders have been completed









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NO. PROCEDURE REMARKS

12. Initiates care plan or clinical pathway according to
assessment


13. Documents all findings and report

































































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PROCEDURE CHECKLIST 11
HEALTH ASSESSMENT AND NURSING PRACTICE
Perform Procedures: Discharge


NO. PROCEDURE REMARKS

1. Check patient notes to confirm


2. Inform patient
- Review details of discharge with patient
- inform relative if necessary
- take medication from pharmacy
(according to hospital protocol)
- date for follow up

3. Assist patient with hygiene, dressing, packing


4. Give health education on
- medication
- physical care
- follow up


5. Follow your hospital’s prescribed procedure for patient
discharge, i.e, discharge time and method of leaving
hospital unit


6. Document the patient’s discharge on the chart
and census





























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PROCEDURE CHECKLIST 12
HEALTH ASSESSMENT AND NURSING PRACTICE
Perform Procedures: Transfer



NO. PROCEDURE REMARKS


1. Ensure physician’s order

2. Contact admitting office to arrange for transfer


3. Communicate with transfer unit to determine the best time for
moving the patient
Inform and talk to patient of impending transfer
4.

5. Gather equipment, belongings, and records
Wash hand to prevent transfer of microorganism to
6. new unit
Obtain necessary staff assistance for smooth transfer
7.
Transfer patient to wheelchair unless patient is remaining in
8.
bed for transfer
Cover patient to provide warmth and to avoid exposure
9. during transfer
Notify head nurse when you arrive on the new unit
10.
Introduce and acquaint patient with new roommates
11.

Introduce patient to new staff, especially the nurse who will
12. be caring for the patient that day


13. Give a complete report to staff, using the patient Care
Plan.
- Give information concerning individualized care needs,
- patient problems, progress
- next medications or treatments are due


14. Hand over to staff accordingly with the written transfer
slip







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NO. PROCEDURE REMARKS

15. Notify physician and admitting office when patient’s transfer is
completed





































































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PROCEDURE CHECKLIST 13
HEALTH ASSESSMENT AND NURSING PRACTICE
Health assessment and physical examination




NO. PROCEDURE REMARKS


1. Greet client
2. Self-introduction and establish rapport

3. Provide privacy
4. Explain the procedure

5. Use therapeutic communication techniques
6. Get consent from patient

7. Observe general appearance: -
- Physical appearance,
- nutrition status,
- hygiene
- personality

8. Observe facial expression
- pain,
- fear
- happy

9. Taking vital sign
- blood pressure
- pulse
- respiratory

10. Take patient
- weight
- height
11. Performed physical examination

11.1 Skin, hair and nail
11.2 Head, neck and cervical lymph nodes
11.3 Mouth, throat, nose and sinuses

11.4 Eyes and ears










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NO. PROCEDURE REMARKS

11.5 thorax and lungs

11.6 heart and abdomen
11.7 genitalia, anus and rectum

11.8 extremities
11.9 musculoskeletal
- posture, Gait,
- joint and muscle

12. Documentation and Record
























































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PROCEDURE CHECKLIST 14
HEALTH ASSESSMENT AND NURSING PRACTICE

Perform health assessment and physical examination: Braden scale





NO. PROCEDURE REMARKS
1. Greet patient


2. Explain to patient the procedure


3. Assess patient using Braden Scale (refer to appendix 1-Braden
scale)
3.1
Sensory perception

3.2
Moisture degree to skin
3.3 Activity degree of physical activity


3.4 Mobility ability to change and control body position


3.5 Nutrition - usual food intake pattern

3.6 Friction and shear


4.
Documentation and report




























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Appendix 1

BRADEN SCALE – For Predicting Pressure Sore Risk
Use the form only for the approved purpose. Any use of the form in publications (other
than internal policy manuals and training material) or for profit-making ventures
requires additional permission and/or negotiation.

SEVERE RISK: Total score 9 HIGH RISK: Total score 10-12
MODERATE RISK: Total score 13-14 MILD RISK: Total score 15-18 DATE OF ASSESS:

RISK SCORE/
FACTOR 1 2 DESCRIPTION 3 4

SENSORY 1. COMPLETELY 2. VERY LIMITED – 3. SLIGHTLY 4. NO IMPAIRMENT
PERCEPTION LIMITED – Responds only to LIMITED – – Responds to
Ability to Unresponsive painful verbal
respond (does not moan, stimuli. Cannot Responds to commands. Has
meaningfully flinch, or communicate verbal commands no sensory deficit
to grasp) to painful discomfort except by but cannot always which would limit
pressure- stimuli, moaning discomfort or ability to feel or
related due to diminished or restlessness, OR has need to be turned, OR voice pain or
discomfort level of a discomfort
consciousness or limits the ability to feel has some sensory
sedation, impairment which limits
pain ability to feel pain or
OR limited ability or discomfort over ½ of discomfort in 1 or
to feel pain over body. 2 extremities.
most of body
surface.


MOISTURE 1. CONSTANTLY 2. OFTEN MOIST – 3. 4. RARELY MOIST
Degree to MOIST– Skin is kept Skin is often but not OCCASIONAL – Skin is usually
which moist almost always moist. Linen LY MOIST – dry; linen only
skin is constantly by must be changed at Skin is requires changing
exposed to perspiration, urine, least once a shift. occasionally at routine intervals.
moisture etc. moist, requiring
Dampness is an extra linen
detected change
every time patient is approximately once
moved or turned. a day.


ACTIVITY 1. BEDFAST – 2. CHAIRFAST – 3. WALKS 4. WALKS
Degree of Confined to bed. Ability to walk severely OCCASIONALLY – FREQUENTLY–
physical limited or non-existent. Walks occasionally Walks outside the
activity Cannot bear own during day, but room
weight and/or must be for very short at least twice a day
assisted into chair or distances, with or and

wheelchair. without assistance. inside room at least
Spends majority of once every 2 hours
during waking hours.
each shift in bed or
chair.



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MOBILITY 1. COMPLETELY 2. VERY LIMITED – 3. SLIGHTLY 4. NO
Ability to IMMOBILE – Does Makes occasional LIMITED – Makes LIMITATIONS –
change and not make even slight slight changes in body frequent Makes major and
control body changes in body or or extremity position though slight changes frequent changes in
position extremity position but unable to make in body position without
without frequent or significant or extremity position assistance.
assistance. changes independently.
independently.


SENSORY 1. COMPLETELY 2. VERY LIMITED – 3. SLIGHTLY 4. NO IMPAIRMENT
PERCEPTION LIMITED – Responds only to LIMITED –Responds to – Responds to
Ability to Unresponsive painful stimuli. Cannot verbal commands but verbal commands.
respond (does not moan, communicate cannot always Has no sensory
meaningfully flinch, or discomfort except by discomfort or need to be deficit which would
to grasp) to painful moaning or turned OR has some limit ability to feel or
pressure- stimuli, restlessness OR has a sensory impairment voice pain or
related due to diminished limit the ability to feel which limits ability to discomfort?
discomfort level of pain or discomfort over feel pain or discomfort
consciousness or ½ of body. in 1 or 2 extremities.
sedation, OR limited
ability to feel pain
over most of body
surface.



MOISTURE 1. CONSTANTLY 2. OFTEN MOIST – 3. OCCASIONALLY 4. RARELY MOIST
Degree to MOIST– Skin is kept Skin is often but not MOIST – – Skin is usually dry;
which moist almost always moist. Linen Skin is occasionally linen only requires
skin is constantly by must be changed at moist, requiring an extra changing at routine
exposed to perspiration, urine, least once a shift. linen change intervals.
moisture etc. approximately once a
Dampness is day.
detected every time
patient is moved or
turned.


























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NUTRITION 1. VERY POOR 2. PROBABLY 3. ADEQUATE – 4.
Usual food – Never eats a INADEQUATE – Eats over half of EXCELLENT –
intake complete meal. Rarely eats a most meals. Eats Eats most of
pattern Rarely eats more complete meal a total of 4 every meal.
1NPO: than 1/3 of any and generally servings of Never refuses
Nothing by food offered. eats only about ½ protein (meat, a meal.
mouth. Eats 2 servings of any food dairy products) Usually eats a
2IV: or less of protein offered. Protein each day. total of 4 or
Intravenously. (meat or dairy intake includes Occasionally more servings
3TPN: Total products) per only 3 servings of refuses a meal, of meat and
parenteral day. Takes fluids meat or dairy but will usually dairy products.
nutrition. poorly. Does not products per day. take a Occasionally
take a liquid Occasionally will supplement if eats between
offered,
dietary take a dietary meals. Does
supplement, supplement OR is on a tube not require
feeding or TPN3 supplementati
OR is NPO1 OR receives less regimen, which on.
and/or than optimum probably meets
maintained on amount of liquid most of
clear liquids or diet or tube nutritional needs.
IV2 for more than feeding.
5 days.


1. PROBLEM- Requires moderate to 2. POTENTIAL 3. NO
FRICTION maximum assistance in moving. PROBLEM– APPARENT
AND SHEAR PROBLEM –
Complete lifting without sliding Moves feebly or Moves in bed
against sheets is impossible. requires and in chair
Frequently slides down in bed or minimum independently
chair, requiring frequent repositioning assistance. and has
sufficient
with maximum assistance. Spasticity, During a move, muscle strength
contractures, or agitation leads to skin probably to lift up
almost constant friction. slides to some completely
extent against during move.
sheets, chair, Maintains good
position in bed
restraints, or or chair at all
other devices. times.
Maintains
relatively good
position in chair
or bed most of
the time but
occasionally
slides down.




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TOTAL SCORE Total score of 12 or less represents
HIGH RISK

D
EVALUATOR A EVALUATOR
ASSESS DATE SIGNATURE / ASSESS
TITLE T SIGNATURE /
E TITLE

1 / / 3 / /

2 / / 4 / /
R
Attending
NAME-Last First Middle e Room/Bed
Physician
c
or
d
N
o.




















































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PROCEDURE CHECKLIST 15
HEALTH ASSESSMENT AND NURSING PRACTICE

Perform health assessment and physical examination: Morse Fall scale


NO. PROCEDURE REMARKS


1. Greet patient


2. Explain to patient the procedure

Assess patient using Morse Fall Scale (refer appendix 2-
3. Morse fall Scale). Check for: -

3.1 History of Falling


3.2 Secondary Diagnosis

3.3 Ambulatory Aid


3.4 IV or IV access

3.5 Gait


3.6 Mental Status



4. Documentation and reporting































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Appendix 2
Morse Fall Scale
Fall Risk is based upon Fall Risk Factors and it is more than a Total Score. Determine Fall
Risk
Factors and Target Interventions to Reduce Risks. Complete on admission, at change of
condition, transfer to a new unit, and after a fall.

Admission Review Review
Variables Score
Date Date Date
History of NO 0
Falling YES 25
Secondary NO 0
Diagnosis YES 15
Ambulatory None/bedrest/nurse assist 0
Aid Crutches/cane/walker 15
Furniture 30
IV or IV NO 0
access YES 20
Gait Normal/bedrest/wheelchair 0
Weak 10
Impaired 20
Mental Knows own limits 0
Status
Overestimates or forgets 15
limits Total
Signature &
Status
To obtain the Morse Fall Score add the score from each category.
Morse Fall
High Risk Score 45 and higher
Moderate Risk 25 – 44
Low Risk 0 - 24



Note: Complete checklist for resident assessed based on level of risk.



















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PROCEDURE CHECKLIST 16
HEALTH ASSESSMENT AND NURSING PRACTICE

Perform observation: Temperature (Via Tympanic Membrane)



NO. PROCEDURE REMARKS


1.
Greet patient and introduce self

2.
Explain procedure to patient.

3.
Perform hand washing and dry hands

4.
Provide privacy

5. Assist patient in comfortable position with head turned
towards side, away from nurse.

6. Attach disposable cover over centre of the lens and press
firmly till secure.
7.
Insert speculum of thermometer into ear canal.

8. Pull pinna:
- upwards and backwards for adult

- downwards and backwards for child.

9. Gently advance probe into ear canal towards tympanic
membrane.

10. Hold thermometer’s button until green light
flashes.
11.
Remove gently and read the temperature.

12.
Discard the probe cover

13.
Return thermometer to home base.

14.
Perform hand washing.

15. Document into the observation chart
Compare with previous data.

16. Document any abnormalities and inform doctor.


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PROCEDURE CHECKLIST 17
HEALTH ASSESSMENT AND NURSING PRACTICE

Perform Observation: Pulse


NO. PROCEDURE REMARKS


1. Greet patient and introduce self

2. Explain procedure to patient.

3. Perform hand washing and dry hands

Ensure that the patient has rested 15 minutes before
4. taking pulse.

5. Place patient in comfortable position.

Place 3 fingers on patient’s wrist at lateral aspect to
6. locate pulsation.


Count pulse rate for 1 minute and assess:


7. - Rhythm

- Volume


8. Perform hand washing.

Document pulse rate in clinical observation chart.
9.
Compare with previous data.

10. Report and document any abnormalities.



















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PROCEDURE CHECKLIST 18
HEALTH ASSESSMENT AND NURSING PRACTICE

Perform Observation: Respiration



NO. PROCEDURE REMARKS


1. Greet patient and introduce self


2. Explain procedure to patient.


3. Perform hand washing and dry hands


4. Provide privacy.


5. Place patient in comfortable position. Expose chest.

Place 3 fingers on patient’s wrist, while observing the chest
6. movements


7. Count rise and fall of patient’s chest for one minute.

8. Perform hand washing.


9. Documentation and reporting Compare with previous data.






























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PROCEDURE CHECKLIST 19
HEALTH ASSESSMENT AND NURSING PRACTICE

Perform Observation: Blood Pressure




NO. PROCEDURE REMARKS


1. Greet patient and introduce self


2. Perform hand washing and dry hands

3. Inform and explain the procedure to patient


4. Position patient in sitting or lying position
Position forearm at heart level with palm facing up (lying
5. position).
Instruct patient to keep feet flat on floor
6. (sitting position)

7. Expose upper arm fully.

8. Palpate brachial pulse in the antecubital space.
Ensure cuff is fully deflated.
9. Locate middle of inflatable bladder and position cuff 1 inch
above antecubital space.
Apply cuff evenly and snugly around arm. Position
10.
sphygmomanometer at heart level.

11. Locate radial pulse.

Inflate cuff until pulse is not felt and note the mercury level.
12. Deflate cuff completely

Clean earpiece and diaphragm of stethoscope.
13. Place diaphragm over brachial artery. Place
stethoscope earpiece in ears.

Inflate the cuff 20-30mmHg of mercury above the point
14.
where radial pulsation stopped.

At eye level, release the valve slowly so that pressure
15. decreases at 2-3 mmHg


16. Note the mercury reading where first sound is heard.

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NO. PROCEDURE REMARKS


Continue to deflate cuff gradually and note point at
17.
which the last sound is heard.
Deflate the cuff rapidly and completely. Remove the
18.
cuff.
19. Leave patient comfortable.
20. Inform patient of the blood pressure reading.

Documentation and reporting.
21. Compare with previous data.


























































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PROCEDURE CHECKLIST 20
HEALTH ASSESSMENT AND NURSING PRACTICE

Perform Observation: Pain Score



NO. PROCEDURE REMARKS

1. Greet patient

2. Explain to patient the procedure

3. Show the pain score ruler to the patient (refer appendix 3)

Ask patients to rate their pain on a scale from 0 to 10, with
4. 10 being the worst possible pain and 0 being no pain.

5. Documentation and report



Appendix 3

Sample








































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PROCEDURE CHECKLIST 21
HEALTH ASSESSMENT AND NURSING PRACTICE

Nursing Intervention for Heat and Cold Therapies: Cold Compress



NO. PROCEDURE Remarks

1. Prepare equipment and take to patient’s room.


2. Greet patient and Introduce self.

3. Explain purpose of procedure. Provide privacy

4. Perform hand washing


5. Immerse all flannels in water and squeeze lightly.

6. Place 1 flannel on forehead


7. Change flannels at forehead

8. Minimize procedure to 20 minutes duration
Check patient’s temperature after 20 minutes
9.
and document.

10. Clear equipment. Perform hand washing.


11. Documentation and reporting



























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PROCEDURE CHECKLIST 22
HEALTH ASSESSMENT AND NURSING PRACTICE

Nursing Intervention for Heat and Cold Therapies: Tepid Sponge




NO. PROCEDURE REMARKS


1. Prepare equipment and take to patient’s room.

2. Greet patient Introduce self.
3. Explain purpose of procedure.

4. Provide privacy
5. Perform hand washing.
Cover patient with bath blanket and remove all clothing
6. and blanket.

7. Take patient’s temperature before sponging.

8. Immerse all flannels in water and squeeze lightly.
Place 1 flannel on forehead, back of neck, both axilla and
9. groins (6 flannels)

10. Use 7 th flannel to sponge the upper and lower body.

11. Dab dry the patient’s skin.

Change flannels at forehead, neck, groins and axilla every 5
12.
min. (Soak in water and squeeze)

13. Minimize procedure to 20 minutes duration.

14. Dry skin gently, dress and provide warmth.
Check patient’s temperature after 20 minutes and document
15.
in temperature chart.
16. Clear equipment. Perform hand washing.
17. Documentation and reporting













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PROCEDURE CHECKLIST 23
HEALTH ASSESSMENT AND NURSING PRACTICE

Universal Precaution. Donning and Removing Personal Protective
Equipment-
1. Wearing Mask
2. Removing Mask



NO. PROCEDURE REMARKS


1. Wearing Mask

1.1 Wash and dry hands.

Take a mask from box. Hold mask by top two
1.2
strings.

1.3 Tie top strings over the ears.

Tie bottom string around the neck to secure mask
1.4
over the mouth

Gently pinch upper metal band in the mask around
1.5
bridge of nose.

1.6 Pull down the lower edge to widen the mask.

2. Removing Mask

Untie the lower strings and then untie the top
2.1
strings.

Pull mask away from face by holding strings
2.2 only.


Fold mask with inner layer facing inwards and tie
2.3
the mask with the strings.


2.4 Discard mask into biohazard container.


2.5 Wash and dry hands.









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PROCEDURE CHECKLIST 24
Universal Precaution. Donning and Removing Personal Protective
Equipment: Gloves





NO. PROCEDURE REMARKS


1. Donning Gloves

1.1 Perform hand wash and dry hands.
Check sterile pack:
1.2 i. expiry date
ii. packing dry and intact

1.3 Peel apart sides of outer package of glove wrapper.

Lay i n n e r p a c k a g e o n clean, flat surface just
1.4
above waist level.
1.5 Perform surgical hand wash.

Open glove package by holding corner of package to
1.6
expose the gloves

Hold folded cuff of right glove with right hand using
1.7
thumb and index finger.
Make right hand smaller by crossing right thumb in
1.8 front of palm and
other fingers close together.

Insert right hand into glove until fingertips are at
1.9
base of fingers of glove
Pull cuff of glove while inserting right hand into
1.10
glove.
Let go of cuff of right glove. Hold right hand in front
1.11
away from body

Slip right fingers only under fold of left cuff.
1.12
Lift left cuff












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NO. PROCEDURE REMARKS



1.13 Make left hand smaller by crossing left thumb front
of palm and other fingers close together

Put left glove on in same way as putting on the
1.14
right glove

Let go of left cuff without touching skin of left arm.
1.15
Tidy both gloves

Maintain hands donned with sterile gloves above
1.16
waist level.

2.0 Dispose of gloves:

2.1 Without touching wrist, grasp outside of one cuff with
other gloved hand.

Pull glove off, turning it inside out. Discard in
2.2
receptacle.

Tuck fingers of bare hand inside remaining glove cuff.
2.3
Peel glove off, inside out.

2.4 Dispose the gloves in ‘biohazard’ bin


2.5 Wash and dry hands.





























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PROCEDURE CHECKLIST 25
NURSING INTERVENTIONS IN MEETING PATIENT’S COMFORT:
MAKING BEDS: CHANGING AN UNOCCUPIED BED


NO. PROCEDURE REMARKS


1. Prepare equipment and bring to bedside.
Perform hands rub and apply clean gloves. (gloves are worn
2. only if linen is soiled or there is risk for contact with body
secretions)
Move any furniture away from the bed to provide ample working
3.
space.
4. Locked the bed.

Position beds: flat, lower side rails on both sides of bed and
5.
adjust bed to a comfortable working position.

Check mattress and reposition mattress. Wipe of any moisture
6. using a washcloth moistened in antiseptic solution. Dry
thoroughly.
Removes gloves, perform hands rub and apply second pair of
7.
clean gloves. (if appropriate)

Apply all bottom linen on one side of bed before moving to
8.
opposite side.
To apply a flat unfitted sheet, allow about 25 cm (10 in) to hang
9.
over mattress edge.

Position yourself diagonally toward the head of the bed. Lift the
10. top of the mattress corner with the hand closest to the bed,
then smoothly tuck the sheet under the mattress.


11. Mitre top corner of bottom sheet (see 1.12 -1.13)

Move to opposite side of bed and spread bottom sheet
12.
smoothly over edge of mattress from head to foot of bed.















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NO. PROCEDURE REMARKS


Miter top corner of the bottom sheet making sure corner is
13.
taut.

Grasp remaining edge of unfitted bottom sheet and tuck tightly
under mattress while moving from head to foot of bed. Smooth
14.
folded draw sheet over bottom sheet and tuck under mattress,
first at middle, then at top, and then at bottom.


15. If needed apply waterproof pad over draw sheet.

Then place blanket over bed with top edge parallel to top edge
16.
of sheet, down from edge to sheet (2-time fold).

17. Place the folded blanket at the bottom of the mattress.


18. Fanfolds top of the blanket to the foot of the bed on each side.

Apply a clean pillowcase on each pillow.

- With one hand, grasp the closed end of the
pillowcase.
- Gather the pillowcase and turn it inside out overhand.
19.
- With the same hand, grasp the middle of one end of
the pillow.
- With the other hand, pull the case over the length of the
pillow.

Lower the bed and lock its wheels to ensure patient
20.
safety.

21. Return furniture to its proper place.
Assist patient back into beds and place the call
22.
button within the patient.
23. Remove gloves and wash hands.











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How to make a mitered corner: 1-Laying a triangular fold of 2- Tucking the end of the
sheet 3- Pulling the triangular fold over the side Sheet on the bed. Under the mattress
the mattress


















1. 2. 3.


















































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PROCEDURE CHECKLIST 26
NURSING INTERVENTIONS IN MEETING PATIENT’S COMFORT
CHANGING AN OCCUPIED BED




NO. PROCEDURE REMARKS


Establish rapport.
1. - Greet patient & maintain eye contact.
- Introduce yourself.

2. Explain purpose of procedure and provide privacy

Assess condition of blanket / bedsheet / pillowcase and
3.
prepare equipment.
4. Bring clean linens to patient’s bedside.

Perform hands rub and apply gloves (gloves are worn only
5. if linen is soiled or there is risk for contact with body
secretions)

Remove unnecessary equipment such as a dietary tray or
6.
items used for hygiene

7. Give patient privacy

8. Adjust bed height to comfortable working position.


9. Loosen top linen at foot of bed


10. Remove blanket. Keep soiled linen away from uniform.


11. Checks that no tubes are entangled in the bed linens

Slides patient to far side of the bed, places in left lateral
12.
position facing the side rail
Places pillow under patient’s head: if needed, places a
13.
pillow between patient and side rail.

Rolls or tightly fanfolds the soiled linens toward patient’s
14.
back: tucks the roll slightly under the patient.








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NO. PROCEDURE REMARKS


Covers any moist areas of the soiled linens with a waterproof
15.
pad.
Places clean bottom sheet and draw sheet on near side of the
16.
mattress, with the center vertical fold at the center of the bed
Fanfolds the half of the clean linen that is to be used on the far
17. side, folding it as close to the patient as possible and tucking it
under the dirty linen.
Tucks the lower edges of clean linen under the mattress.
18.
Smooth out all wrinkles

19. Explain to patient that he will be rolling over a “lump”

Rolls patient over dirty linen and gently pulls patient toward her
20.
so the patient rolls onto the clean linen
21. Raises side rail on “clean” side of the bed

Moves pillows to the clean side of the bed: Position patient
22.
right lateral near the bed rail on the clean side
23. Moves to opposite side of bed; lowers the bed rail

Pull soiled linen away from patient and placed in laundry bag
24.
accordingly
Pull clean linens through to the unmade side of the bed, and
25.
tuck them in

26. Miter corners neatly
27. Tuck the side of the linen under the mattress neatly

28. Change pillowcases

29. Return bed to low position, raise side rails
Position bedside table and over-bed table within patient’s
30.
reach.

31. Remove gloves and wash hands.











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PROCEDURE CHECKLIST 27
NURSING INTERVENTIONS IN MEETING PATIENT’S COMFORT:
BED BATHING




NO. PROCEDURE REMARKS


Establish rapport.
1. - Greet patient & maintain eye contact.
- Introduce yourself.

2. Explain purpose of procedure and provide privacy

Assess patient’s condition to determine patient’s ability to
3. perform bathing and level of assistance and type of bath
needed.

4. Prepare equipment as required.


5. Offer bedpan or urinal and assist patient as needed.

Wash hand. Apply gloves if there is an actual or a risk for
6.
drainage or secretions on patient’s skin.
Move bed to comfortable working height, lower side rail
7. and assist patient to comfortable position - semi fowler’s or
fowler’s position.

8. Put the equipment trolley within reach.


9. Wash patient’s face and hands or assist as needed.

10. Dry face and hands.


11. Offer oral hygiene.

Reposition bed and assist patient in comfortable supine
12.
position.

Place bath blanket over patient and over top linen. Loosen
13.
top linen at edges and foot of bed.









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NO. PROCEDURE REMARKS


Remove dirty top linen from under bath blanket, starting at
14. patient’s shoulders and rolling linen down toward patient’s
feet.

15. Place dirty linen in laundry bag


16. Help patient to the side of the bed closest to you.

Remove patient’s gown. Keep patient covered with bath
17.
blanket. Place gown in laundry bag.

18. Remove pillow if patient can tolerate.

19. Place towel under patient ’s head

Begin bath from cleanest area and work downward toward
20.
feet. Use flannel or wash cloth fold around the hand.

Wash patient’s eyes.

- With one edge of face cloth, wipe from the inner
21.
canthus toward the outer canthus.
- Use different section of the washcloth, repeat
procedure on another eye.
Wash, rinse, and dry patient’s forehead, cheeks, nose and
22.
area around lips. Use soap with patient’s permission
Wash, rinse and dry area behind and around the patient’s
23.
ears.
24. Wash, rinse and dry patient’s neck.

25. Remove towel from under patient’s head

Bathe patient’s upper body and extremities.
26.
Place towel under area to be bath.
Wash both arms by elevating patient’s arm and holding
patient’s wrist.
- Start from the arm away from you to the closest to
27.
you.
- Use gentle strokes from the wrist toward the
shoulder, including the axillary area.

Wash, rinse and dry patient’s axillae.
28.
Apply powder if desired.

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