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Wash patient’s hands by soaking them in the basin or with
29.
a washcloth. Clean the nails.
Cover the chest with towel, then wash, rinse and
30. thoroughly dry patient’s chest, (especially under the
breasts.
Bathe patient’s abdomen.
- Cover body areas with towel and expose part
31.
that need to clean.
- Wash, rinse and dry abdomen and umbilicus.
Bathe patient’s legs and feet.
- Place towel under the leg.
32. - Start from the leg away from you then to the closest.
- Drape other leg, hip and genitalia with the bath
blanket
33. Carefully place bath basin on the towel the patient’s foot.
With one arm under the patient’s leg, grasp the patient’s
34.
foot and bend knee. Place foot in basin of water.
Bathe patient’s leg, moving toward hip.
35.
Rinses and dry patient’s leg.
Wash patient’s foot with wash cloth. Rinse and dry foot
36.
and area between toes thoroughly.
Move basin to other side of bed, and repeat
37.
procedure for patient’s other leg and foot.
Change bath water.
38. - Raise side rail before leaving patient.
- Check the water temperature.
39. Assess the patient’s condition throughout the procedure.
Put patient to lateral position.
40. - Place towel under area to be bathed.
- Cover patient with a bath blanket
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Wash, rinse, and dry patient’s back, moving from shoulders
41.
to the buttocks
42. Give back massage while cleaning the patient’s back
Clean patient’s genital area. Placed tower under patient’s
43.
hips (refer checklist 2.7.4)
For a female patient:
- Bathe from front to back to prevent contamination
from the rectal area.
- Use a different section of the washcloth for each stroke.
- Wash, rinse and dry thoroughly between skin folds.
44.
For a male patient:
- Carefully retract the foreskin for uncircumcised
penis.
- Wash, rinse and dry gently and replace foreskin to its
original position.
- Continue to wash, rinse and dry penis, scrotum and
remaining skin folds.
45. Remove gloves.
46. Assist patient to dress in a clean hospital gown.
Put patient in comfortable position and place side rail up
47.
position.
Clean and store bath equipment. Dispose soiled linen
48.
accordingly.
49. Wash your hands.
50. Document and report.
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PROCEDURE CHECKLIST 28
Nursing Interventions in Meeting Patient’s Comfort
Oral Care
NO. PROCEDURE REMARKS
Establish rapport.
1. - Greet & maintain eye contact.
- Introduce yourself.
2. Explain purpose of procedure and provide privacy.
3. Prepare equipment.
4. Wash hands and wear disposable gloves
Assess for patient’s gag reflex by placing
tongue blade on back half of tongue.
- Reveal whether patient is at risk for aspiration and the
need of suction machine.
5. - Turn on suction machine and connect tubing to suction
catheter. (if needed)
6. Raise bed to its highest horizontal level: lower side rail.
Position patient close to side of bed; turn patient’s head
7. toward mattress.
Place towel under patient’s head and
8. kidney dish under chin.
Separate upper and lower teeth carefully with padded tongue
9. blade by inserting blade and insert when client is relaxed.
Clean mouth with brush or sponge toot Hettes moistened with
10. peroxide and water.
11. Clean chewing and inner teeth surfaces.
Swab roof of mouth, gums and inside
12. cheeks.
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Gently swab or brush tongue, avoid stimulate gag reflex (if
13. present).
Moisten clean swab or toothette with water to rinse several
14. times.
15. Suck secretions as they accumulate, if necessary.
16. Apply thin layer of water-soluble jelly to lips.
17. Inform patient that procedure is completed.
18. Remove gloves and dispose in clinical waste.
19. Make patient comfortable and raise side rails as appropriate.
20. Clean equipment and dispose soiled linen.
21. Wash hands.
22. Document and report.
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Nursing Interventions in Meeting Patient’s
Comfort: Perianal-Genital Care
NO. PROCEDURE REMARKS
Establish rapport.
1. - greet patient & maintain eye contact.
- introduce yourself.
Explain purpose of procedure and provide
2.
privacy
Assess patient’s ability to perform self-care and determines
3.
level of assistance required.
4. Prepare equipment as required.
Raise bed to comfortable working position and lower side
5. rail.
6. Wash hand. Apply disposable gloves.
7. Put patient in lateral position.
8. Place disposable pad under patient’s buttocks.
If fecal material is present, remove fecal debris with toilet
9. tissue or disposable wipes.
- clean buttock and anus from front to back.
Clean, rinse and dry area thoroughly.
10. - remove and discard disposable pad and replace with
clean one.
11. Change glove when they are soiled.
Fold top bed linen down towards foot of bed and raise
12.
patient gown above genital area.
‘Diamond” drape patient by placing bath blanket with one
corner between patient’slegs, one corner pointing towards
13.
each side of bed and one corner over client’s chest.
- tuck side corner around patient’s leg and under hips
14. Raise side rail. Fill wash basin with warm water.
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Place wash basin and toilet tissue on trolley.
15.
- place wash cloths in basin.
16. Provide perineal care.
Female perineal care.
17.1 put patient to dorsal recumbent position.
17.2 flex knees and spread legs.
17.3 wash and dry patient’s upper thighs.
clean labia majora.
• use non dominant hand to gently retract labia
rom thigh.
• wash skinfolds carefully in with dominant hand.
17.4 • wipe in direction from perineum to rectum (front
17.
to back).
• repeat on opposite side using separate section of
washcloth.
• rinse and dry area thoroughly.
Separate labia with non-dominant hand to expose
urethral meatus and vaginal orifice.
17.5 - using dominant hand, wash downward from
pubic area
- toward rectum in one smooth stroke.
- use separate section of cloth for
- each stroke.
Pour warm water over perineal area. (if patient uses
clean thoroughly around labia minora, clitoris and
17.6 vaginal orifice.
bedpan)
• dry perineal area thoroughly, using front to back
method.
For Male Perineal care
• lower side rail and assist patient to supine
17.1
position.
• fold lower corner of bath blankets up between
17.2 patient’s legs and onto abdomen. wash and dry
patient’s upper thighs
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• gently raise penis and place bath towel
17.3
underneath.
• gently grasp shaft of penis. if patient is
uncircumcised, retract foreskin.
17.4 • wash tip of penis at urethral meatus first.
• using circular motion, cleanse from meatus
outward. discard washcloth and repeat with
clean cloth until penis is clean.
• rinse and dry gently.
• wash shaft of penis with gentle but firm
17.5
downward strokes.
• rinse and dry penis thoroughly.
17.6 • gently clean scrotum.
• lift carefully and wash underlying skinfolds.
17.7 • rinse and dry.
18. Assist patient to lateral position.
19. Apply thin layer of skin barrier over anal and perineal skin.
20. Remove and dispose gloves.
21. Make patient comfortable.
22. Remove and dispose soiled linen.
23. Keep equipment to storage area.
24. Document and report
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PROCEDURE CHECKLIST 30
NURSING INTERVENTIONS IN MEETING PATIENT’S COMFORT:
HAIR CARE
NO. PROCEDURE REMARKS
Establish rapport.
1. - Greet patient & maintain eye contact.
- Introduce yourself.
2. Explain purpose of procedure and provide privacy.
3. Assess condition and type of hair care products needed.
Lower head of the bed; removes pillow from under patient’s
4. neck, and places it under her shoulders.
Place waterproof pad or plastic trash bag under patient’s
5. shoulders and covers with towels.
Place shampoo tray under patient’s shoulders (or head,
depending on how it is made). If using a hard-plastic tray,
liberally pads with towels. An inflatable shampoo tray needs
6. minimal padding. Ensures that the tray will drain into the
washbasin or other receptacle.
Fold the top linens down to the patient’s waist and cover her
7. upper body with a bath blanket.
8. Use gloves if lesions or infestation are present.
9. Remove tangles with comb or fingers.
Wet the hair using warm water then apply shampoo and lather
10. well.
Work from the scalp out and from the front to the back of the
11. head.
12. Gently lift the patient’s head to rub the back of the head.
13. Rinse thoroughly.
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14. Apply conditioner to the hair and rinse. (if needed)
Remove the tray and blot dry hair with towel.
15. Do not use circular motion to dry the hair.
Comb or brush hair to remove tangles, starting at the ends and
16. working toward the scalp.
17. Dry hair with bath towel.
18. Variation: Shampooing the Hair Using Rinse-Free Shampoo
18.1 Place bath towel under patient’s shoulders.
18.2 Repeat step 8 -9
18.3 Apply rinse-free shampoo to thoroughly wet the hair.
18.4 Work through hair, from scalp down to end.
18.5 Dry hair accordingly.
Variation: Shampooing the Hair Using Rinse-Free Shampoo
19.
Cap
Warm the shampoo cap using a water bath or
19.1
microwave, according to package instructions.
19.2 Check temperature before placing on patient’s head.
19.3 Place cap on patient’s hair and massage gently.
19.4 Remove cap and towel dry the patient’s hair.
20. Make patient comfortable.
21. Document and report.
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PROCEDURE CHECKLIST 31
Nursing Interventions in Meeting Patient’s Oxygenation
Insertion Oropharyngeal Airway
NO. PROCEDURE REMARKS
1. Identify need to insert oral airway.
Determine factors that may contribute to upper airway
2. obstruction.
3. Ensure patient does not have dentures.
4. Position unconscious patient appropriately.
5. Perform hand hygiene, wear clean gloves and PPE.
Get correct size of oral airway, by measuring from tip of the
6. mouth to tip of the ear lobe.
Use padded tongue blade to open patient’s mouth, use thumb
7. and forefingers as necessary.
Hold oral airway gently slide the airway over the tongue
o
towards the throat, rotate the airway180 over and follow
natural curve of tongue. The tip of the airway should point
8. down as it approached the posterior wall of the pharynx.
9. Suck secretions as needed.
10. Reassess patient’s respiratory status, auscultate lungs.
11. Clean patient’s face with tissue or washcloth.
Discard tissue into appropriate receptacle, place washcloth in
12. soiled linen bag, remove and discard gloves and PPE.
13. Wash hands.
14. Administer mouth care frequently.
Observe patient’s respiratory status and compare respiratory
15. assessments before and after insertion.
16. Documentation and report
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PROCEDURE CHECKLIST 32
Nursing Interventions in Meeting Patient’s Oxygenation
Suctioning Oropharyngeal and Nasopharyngeal cavities
NO. PROCEDURE REMARKS
Positions the patient:
a. For oropharyngeal suctioning: Semi- Fowler’s position
with his head turned towards the nurse.
1.
b. Nasopharyngeal suctioning: Semi- Fowler’s position with
his head hyperextended (unless contraindicated).
2. Place the disposable pad on the patient’s chest.
3. Put on a face shield or goggles.
Turn on the suction machine and adjust the pressure regulator
4. according to policy (usually 100 to 120 mm Hg for adults, 95 to
110 mm Hg for children, and 50 to 95 mm Hg for infants).
5. Test the suction equipment by occluding the connection tubing.
Don sterile gloves; keep the dominant hand sterile; consider
6.
non dominant hand nonsterile.
Pour sterile saline into the sterile container, using the non-
7.
dominant hand.
Pick up the suction catheter with the dominant hand and attach
8.
it to the connection tubing (to suction).
Put the tip of the suction catheter into the sterile container of
normal saline solution and suck a small amount of normal
9. saline solution through the suction catheter.
Apply suction by placing a finger over the suction control port.
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10. Estimate the depth to insert the suction
catheter:
a. Oropharyngeal suctioning: Measure the distance
between the edge of the patient’s mouth and the tip of
the patient’s ear lobe.
b. Nasopharyngeal suctioning: Measure the distance
between the tip of the patient’s nose and the tip of the
patient’s ear lobe.
11. Using the non-dominant hand, remove the oxygen delivery
device, if present. Allow patient to take several slow deep
breaths. If the oxygen saturation is < 95%, or if patient is in any
distress, administer oxygen before, during, and after
suctioning.
12. a. Oropharyngeal suctioning
- Lubricate the catheter tip with normal saline.
Using the dominant hand, gently but quickly insert the suction
- catheter along the side of the patient’s mouth into the
oropharynx.
Advance the suction catheter quickly to the premeasured
- distance (usually 7 to 10 cm in the adult), being careful not to
force the catheter.
13. b. Nasopharyngeal suctioning
- Lubricate the catheter tip with the water-soluble
lubricant.
- Using the dominant hand, gently but quickly insert the
-
suction catheter into the nares.
- Advance the suction catheter quickly to the premeasured
distance (13 to 15 cm in the adult), being careful not to force
the catheter.
- If resistance is met, try using the other nares.
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Place a finger (thumb) over the suction control port of the
suction catheter and start suctioning the patient.
14. Apply suction while withdrawing the catheter in a
continuous rotating motion.
15. Limit suctioning to 5 to 10 seconds.
After the catheter is withdrawn, clear it by placing the tip of
16. the catheter into the container of sterile saline and applying
suction.
Lubricate the catheter and repeat suctioning as needed,
allowing at least 20- second intervals between suctioning.
17.
For nasopharyngeal suctioning, alternate nares each time
suction is repeated
Coil the suction catheter in the dominant hand.
Pull the sterile glove off over the coiled catheter.
18.
(Alternatively, wrap the catheter around the dominant gloved
hand and hold the catheter while removing the glove over it.)
19. Discard catheter and gloves.
20. Wash hand.
21. Document and report.
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PROCEDURE CHECKLIST 33
Nursing Interventions in Meeting Patient’s Oxygenation: Coughing and Deep
Breathing Exercise
NO. PROCEDURE REMARKS
Check the patient’s chart for the type of surgery and medical
1.
orders.
2. Gather the necessary equipment and bring to the bedside.
3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
Establish rapport.
5. - Greet patient & maintain eye contact.
- Introduce yourself.
6. Explain the purpose and provide privacy to patient.
Assess level of knowledge on deep breathing exercises,
7.
coughing, and splinting of the incision.
Explain the rationale of performing deep
8.
breathing exercises, coughing, and splinting of the incision.
Assist the patient to sit up (semi- or High-Fowler’s position.
9. Instruct patient to place palms of both hands along the lower
anterior rib cage.
10. Instruct the patient to exhale gently up to the maximum.
Instruct the patient to breathe in through the nose as deeply
11.
as possible and hold breath for 3 seconds.
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Instruct the patient to exhale through the mouth, pursing the
12.
lips as if patient is whistling.
Observe the patient practicing breathing exercise for three
13.
times and guide when necessary.
Emphasize that this exercise should be performed every 1 to
14.
2 hours for the first 24 hours after surgery.
Inform the importance of coughing and splinting (providing
15.
support to the incision).
Ask the patient to sit up (semi-Fowler’s position). Show how
16. to apply a folded towel or small pillow against the part of body
where the incision will be (e.g., abdomen or chest).
Instruct the patient to inhale and exhale through the nose
17.
three times.
Ask the patient to take a deep breath and hold it for 3
18.
seconds and then cough out three short breaths.
Ask the patient to take a breath through the mouth and cough
19.
strongly twice.
Inform patient to perform this exercise every 2 hours after
20.
waking up from surgery.
Validate patient’s understanding:
- Ask the patient to give a return demonstration.
21.
- Encourage patient to ask questions.
- Instruct patient to practice the exercise.
22. Remove PPE, if used. Perform hand hygiene.
23. Document and report.
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PROCEDURE CHECKLIST 34
Nursing Interventions in Meeting Patient’s Elimination and Specimens
Collection
Collecting Urine Specimen (Culture & Sensitivity)
NO. PROCEDURE Remarks
Identify and establish rapport with patient.
1. - Greet patient & maintain eye contact.
- Introduce yourself.
2. Explain procedure to patient and make sure patient
understand how to perform procedure. Provide privacy.
3. Bring necessary equipment to patient’s bedside.
4. Perform hand hygiene and put on PPE, if indicated.
5. Instruct patient perform hand hygiene, if performing self-
collection.
Assist the patient to the bathroom, or onto the bedside
6.
bedpan.
7. Collection of MSU
Female Patient
- Instruct to separate the labia before cleaning the
area.
- Clean each side of the urinary meatus, the centre over
the meatus, from front to back, using a new wipe for
each stroke with towelettes or wet tissues to.
Male Patient Check the
specimen label
- Clean tip of the penis, wiping in a circular motion away with the patient’s
from the urethra using towelette / wet tissue. identification
- Instruct the uncircumcised male patient to retract the bracelet.
foreskin before cleaning and during collection.
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NO. PROCEDURE REMARKS
Explain how to void a small amount of urine into the
8. toilet/bedpan or commode, stop urinating briefly, then void
into collection container.
Collect specimen (10 to 20 mL is sufficient), into sterile
9. appropriate container, then finish voiding. Place lid on
container.
10. Assist the patient from the bathroom, commode/bedpan.
11. Remove gloves and perform hand hygiene.
Label and place container in plastic, sealable biohazard
12.
bag.
13. Perform hand hygiene.
Send specimen together with requisition form to the
14.
laboratory immediately.
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PROCEDURE CHECKLIST 35
Nursing Interventions in Meeting Patient’s Elimination and Specimens
Collection
Collecting Stool Specimen
NO. PROCEDURE REMARKS
Identify and establish rapport with patient.
1. - Greet patient & maintain eye contact.
- Introduce yourself.
2. Explain procedure to patient and provide privacy.
3. Gather all necessary equipment.
4. Wash hands and wear gloves.
5. Ask patient to void and discard urine.
6. Assist patient to use bedpan.
7. Help the patient to clean perineum if necessary.
Use wooden spatula to obtain and place a small portion (2
8. teaspoons) of the formed stools in plastic container.
9. Discard remaining stool and clean bedpan.
10. Label container and place it in biohazard bag.
11. Remove gloves and wash hands.
Send specimen together with requisition form to the
12. laboratory immediately.
13. Documentation and report.
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PROCEDURE CHECKLIST 36
Nursing Interventions in Meeting Patient’s Elimination and Specimens
Collection
Collecting Sputum Specimen
NO. PROCEDURE REMARKS
1. Identify and establish rapport with patient.
- Greet patient & maintain eye contact.
- Introduce yourself.
2. Explain procedure to patient.
3. Perform hand hygiene and put on PPE, if indicated.
4. Ask patient to rinse mouth with water before collecting
specimen.
5. Position the patient in an upright position (high Fowler’s
position).
6. Ask the patient to take several deep breaths
– breathing in through the nose and exhaling though the
mouth – to help loosen secretions.
7. Ask the patient to force a deep cough to get an adequate
sample.
8. Remove gloves, apron and facemask then decontaminate
hands.
9. Label the specimen and ensure requisition forms is
completed.
10. Send specimen together with requisition form to the
laboratory immediately.
11. Documentation and report.
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PROCEDURE CHECKLIST 37
Nursing Interventions in Meeting Patient’s Elimination and Specimens
Collection
Collecting Throat Swab
NO. PROCEDURE REMARKS
Identify and establish rapport with patient.
1. - Greet patient & maintain eye contact.
- Introduce yourself.
2. Explain procedure to patient.
3. Bring necessary equipment to patient’s bedside.
4. Perform hand hygiene and put on PPE, if indicated.
5. Prepare a sterile swab for use by loosening the top container.
Ask patient to sit upright, tilt head backwards, open the mouth
6.
and stick the tongue out and say “äh”
7. Depress anterior 1/3 of the tongue with spatula for visualization.
8. Insert the swab without touching the cheek, lips, teeth or tongue.
Swab the tonsillar area from side to side in a quick, gentle
9.
motion.
Withdraw swab carefully without touching other areas of the
10.
mouth.
Remove the top of the transport medium container. Take the
11.
swab appropriately for the type required
Insert the used swab in the transport medium ensuring it has
12.
securely clicked into place.
13. Remove PPE and dispose.
14. Documentation and report.
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PROCEDURE CHECKLIST 38
BANDAGING SIMPLE SPIRAL
NO. PROCEDURE REMARKS
1. Gather necessary roller bandages.
Identify and establish rapport with patient.
2. - Greet patient & maintain eye contact.
- Introduce yourself.
Explain the use of the bandage to the patient and provide
3. privacy.
4. Elevate the extremity.
5. Begin to wrap the extremity at the distal end.
6. Anchor the bandage with two circular turns.
Apply moderate amount of tension to maintain on the
7. bandage.
Continue to unroll the bandage and overlap the previous
8.
circle until the designated area is covered.
9. Secure the bandage with tape/safety pin or metal clip.
Observe for even, tight fit of the bandage, and ensure the
10.
bandage not occluding circulation.
Assess distal area of the extremity after 20 minutes, then
11.
every 2- 4 hours.
12. Ensure bandage is wrinkle-free.
13. Document and report
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UNIT 3
PROCEDURE CHECKLIST 39
Nursing interventions for Client with Infections and Inflammations: Wound
dressing
REMARKS
NO. PROCEDURE
1. Ensure physician’s order
2. Identify and inform the patient
3. Check present dressing with non-sterile gloves.
4. Perform hand hygiene and put on mask
5. Gather necessary equipment.
Prepare environment, position patient, adjust height of bed, and
6. turn on lights.
7. Prepare patient and loose the tape around the wound
8. Cut pieces of paper tape and have them within reach
9. Perform hand hygiene
10. Prepare sterile field.
11. Add necessary sterile supplies.
12. Pour cleansing solution.
13. Perform hand hygiene
Apply sterile gloves and use dressing forceps prepare enough
14. swab for dressing. Depending on the amount of cleaning
needed.
Use dissecting forceps remove outer and inner dressing and
15. discard as per agency policy
Assess the soiled dressing and note the type, colour, odour and
16. presence of discharge.
17. Discard dissecting forceps according to agency policy
Inspect the wound site for size, appearance, and drainage.
18. Assess if any pain is present. Note any problems to include in
your documentation.
Clean wound using one sterile swab per stroke using dressing
19. forceps. Strokes should be:
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- From clean to dirty (incision, then outer edges)
- From top to bottom
20. Discard the soiled dressing forceps
Apply inner dressing (4 x 4 gauze) with forceps to incision
21.
site.
Apply outer dressing, keeping the inside of the sterile
22. dressing touching the wound.
23. Discard the forceps or sterile gloves if they were used
To complete dressing change:
- Assist patient to comfortable position.
24. - Lower patient’s bed.
- Discard used equipment appropriately.
- Perform hand hygiene.
25. Documentation and report.
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UNIT 3
PROCEDURE CHECKLIST 40
Nursing interventions for Client with Infections and Inflammations: Removal
of suture / clip
NO. PROCEDURE REMARKS
1. Review the medical orders or the nursing plan for wound care.
2. Identify and inform the patient
3. Check present dressing with non-sterile gloves.
4. Perform hand hygiene and put on mask
5. Gather necessary equipment.
Prepare environment, position patient, adjust height of bed and
6. turn on lights.
7. Prepare patient and expose dressed wound
8. Cut pieces of paper tape and have them within reach
9. Perform hand hygiene
10. Prepare sterile field.
Add necessary sterile supplies such as scissors / Michelle’s
11. clip remover.
12. Pour cleansing solution.
Apply sterile gloves and use dressing forceps prepare enough
13. swab for dressing.
14. Use dissecting forceps remove soiled dressing.
15. Discard the dissecting forceps
Clean the incision site using the alcohol swabs or according to
facility policies and procedures
16.1 From clean to dirty (incision, then outer edges)
16.
16.2 From far to near
16.3 From top to bottom
17. Discard the soiled dressing forceps
Use the forceps, grasp the knot of the first suture and gently lift
18.
the knot up off the skin.
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NO. PROCEDURE REMARKS
Slide the tip of stitch scissors around the suture, cut one side of
19. the suture below the knot, close to the skin.
Grasp the knot with the forceps and pull the cut suture through
the skin.
20. Avoid pulling the visible portion of the suture through the
underlying tissue
Place the remove sutures on a piece of gauze and discard the
21.
sutures into clinical waste or according to facility policy.
Remove every other suture (alternately) to be sure the wound
edges are healed.
22. If they are, remove the remaining sutures as ordered.
(Repeat step 19 - 22)
Removal of clip
Position the staple remover so that the lower
18.
jaw is on the bottom
Ensure the staple is perpendicular to the plane of the skin. If
19.
not, reposition the staple with the tips of the lower jaw
Lift slightly on the staple, ensuring that it stay perpendicular to
20. the skin.
Continue to lift slightly while gently squeezing the handles
21.
together to close
22. Lift the reformed staple straight up from the skin
Remove every other (alternately) staple, and check the tension
23.
on the wound
If there is no significant pull on the wound, remove the remaining
24. staples.
Place the remove staples on a piece of gauze and discard the
25.
staples into sharp bin.
26. Assist patient to comfortable position.
27. Discard used equipment appropriately.
28. Perform hand hygiene.
29. Documentation and reporting
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UNIT 3
PROCEDURE CHECKLIST 41
Nursing interventions for Client with Infections and Inflammations: Removal
of drain
NO. PROCEDURE REMARKS
Confirm that the physician order correlates with amount of
1. drainage in the past 24 hours
Explain procedure to patient: offer analgesia and bathroom as
2. required
3. Prepare necessary equipment.
Apply a waterproof drape/ pad for depositing the drain once it
4. has been removed. This provides a place to put the drain once it
is removed.
5. Perform hand hygiene
Apply non-sterile gloves and face shield according to agency
6. policy
Release suction on reservoir; measure and record drainage if
7. >10mls.
8. Remove tape and dressing from drain insertion site
9. *Clean site according to simple dressing change procedure.
Carefully cut and remove suture anchoring drain with sterile
10.
suture scissors.
Snip beneath the suture knot to ensure contaminated suture is
11. not brought into the tissue. Pull suture out. Snip or cut knot away
from yourself.
12. Stabilize skin with non-dominant hand by using sterile gauze.
Ask patient to take a deep breath and exhale slowly: remove the
13. drain as the patient exhales using sterile forceps
Firmly grasp drainage tube close to skin with dominant hand,
14. and with a swift and steady motion withdraw the drain and place
it on the waterproof drape/pad.
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NO. PROCEDURE REMARKS
Place drain and tube on waterproof pad or in clinical waste to
15.
be disposed of after procedure is complete.
Clean old drain site using aseptic technique according to
16. simple dressing change procedure
17. Cover drain site with sterile dressing
18. Assist patient back to comfortable position and lower bed
19. Discard drain in biohazard waste as per hospital policy
20. Perform hand hygiene
Assess dressing 30 minutes after drain removal. Monitor for
21. excessive drainage from the drainage site.
22. Documentation and report.
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UNIT 3
PROCEDURE CHECKLIST 42
Nursing interventions for Client with Infections and Inflammations: Incision
and drainage
NO. PROCEDURE REMARKS
1. Greet patient
2. Identify and prepare right patient
3. Explain and inform patient
4. Hand hygiene
5. Prepare equipment
6. Prepare of the area of abscess and surrounding skin
7. Give psychological support throughout the procedure.
Assist the procedure:
8.1 In preparing the area with povidone-iodine and alcohol
8.2 Drape the area
8. Infiltrate 0.5% or 1% lidocaine into the incision site
8.3 over the abscess to anesthetize the area well before
the procedure
8.4 Preparing scalpel blade to incise the abscess
8.5 Obtain cultures form the drainage
9. Following exploration, clean the cavity with hydrogen peroxide
10. Observe for bleeding or any complication.
Perform loose packed dressing using one-fourth or one-half inch
11.
iodoform or plain gauze packing.
Apply a sterile gauze dressing and secure the dressing with no
12.
allergenic adhesive tape
13. Documentation and reporting.
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UNIT 3
PROCEDURE CHECKLIST 43
Nursing interventions for Client with Infections and Inflammations: Insertion
of the peripheral line and setup intravenous infusion
NO. PROCEDURE REMARKS
Review physician’s order for type and amount of IV fluid and
1. rate of fluid administration.
2. Identify and inform the patient
3. Prepare equipment
4. Open sterile packages using aseptic technique
5. Prepare IV infusion tubing and solution
Check IV solution, using rights principle of drugs
5.1
administration.
Open infusion set, maintaining sterility of both
5.2 ends of tubing.
Place roller clamp (see illustration) about 2 to 5 cm
5.3 (1 to 2 inches) below drip chamber and move roller
clamp to ‘off’ position
Remove protective sheath over IV
5.4
tubing port on plastic IV solution bag
Clean rubber stopper on bottled solution with
5.5 antiseptic and insert spike into black rubber stopper
of IV bottle.
5.6 Insert infusion set into fluid bag or bottle
Prime infusion tubing by filling with IV solution:
5.7 Compress drip chamber and release, allowing it to fill
one-third to one-half full.
Remove protector cap on end of tubing and slowly
release roller clamp to allow fluid to travel from drip
5.8 chamber through tubing to needle adapter.
Return roller clamp to ‘off’ position after tubing is
primed (filled with fluid)
5.9 Be certain tubing is clear of air and air bubbles.
5.10 Replace cap protector on end of infusion tubing
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NO. PROCEDURE REMARKS
6. Apply disposable gloves.
7. Identify accessible vein for placement of IV catheter or needle.
8. Apply flat tourniquet around arm, above antecubital fossa or 4
to 6 in (10 – 15cm) above proposed insertion site.
9. Select the vein for IV insertion. The cephalic, basilic, and
median cubital are preferred in adults
10. Palpate the vein by pressing downward and noting the resilient,
soft, bouncy feeling as the pressure is released. Always use
the same finger to palpate.
11. If possible, place extremity in dependent position
12. Place needle adapter end of infusion set nearby on sterile
gauze or sterile towel
13. Then clean insertion site using firm, circular motion (middle to
outward) with 70% alcohol. Allow the site to dry for at least 2
minutes.
14. Perform venapuncture. Anchor vein by placing thumb over vein
and by stretching the skin against the direction of insertion 2 to
3 in (5 – 7.5cm) distal to the site.
15. Look for blood return through flashback chamber of catheter
indicating that needle has entered vein. Advance catheter
another ¼ inch into vein and then loosens stylet.
Do not reinsert the stylet once it is loosened.
16. Stabilize catheter with one hand and release tourniquet with
index finger of non-dominant hand 1 ¼ inches above the
insertion site
17. Connect needle adapter of infusion tubing set.
Do not touch point of entry of needle adapter.
18. Begin infusion by slowly opening the slide clap or adjusting the
roller clamp of the IV tubing
19. Tape or secure catheter. Slide tape under catheter hub
- Cross tape ends over hub
- Secure loop of tubing with tape
- Apply transparent dressing over IV site and catheter
20. Recheck flow rate to correct drops per minute
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21. Dispose used stylet or other sharps in sharps bin. Discard
supplies
22.
Remove gloves and wash hand
23. Instruct client on how to move about in and out of bed without
dislodging IV catheter
24.
Documentation and report
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UNIT 3
PROCEDURE CHECKLIST 44
Nursing interventions for Client with Infections and Inflammations:
Insertion central venous line (assisting)
NO. PROCEDURE REMARKS
1. Greet patient
2. Identify right patient
3. Verify the purpose of prescription
4. Explain the procedure and purpose to patient
5. Prepare equipment
6. Position patient appropriately (supine position)
7. Flush IV infusion set and manometer
8. Place ECG monitoring
9. The CVP site is surgically cleaned
10. Assist the patient to remaining motionless during insertion
Monitor for dysrhythmias, tachypnoea, tachycardia as
11.
catheter is threaded to great veins
Connect primed IV tubing to catheter and allow IV solution to
12.
flow
13. Assist in suturing the catheter
14. Place a sterile transparent dressing over site
15. Obtain a chest x-ray
16. Documentation and report.
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UNIT 3
PROCEDURE CHECKLIST 45
Nursing interventions for Client with Infections and Inflammations:
Measuring central venous pressure
NO. PROCEDURE REMARKS
1. Greet patient
2. Explain the procedure and purpose to patient
3. Place the patient in supine position
4. Perform hand hygiene
Position the zero point of the manometer should be on level
5. with the patient right atrium.
Turn the stopcock so the IV solution flow into manometer, to
6. about 20 – 25 cmH2O level.
Then turn stopcock so the solution in manometer flow to the
7. patient
Record the level at which the solution stabilizes.
8.
This is CVP reading
9. Assess patient conditions
Turn the stopcock again to allow IV solution to flow to patient
10. veins and should monitor infusion hourly
11. Perform hand hygiene
12. Documentation and report
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UNIT 3
PROCEDURE CHECKLIST 46
Nursing interventions for Client with Infections and Inflammations:
Obtaining blood specimen
NO. PROCEDURE REMARKS
1. Review physician’s order for type of blood specimen.
2. Identify and inform the patient
3. Obtained informed consent
Prepare necessary equipment to obtain blood sample for
analysis and label specimen bottles accordingly (name, RN,
4. type of specimen, date)
Perform hand hygiene and don non-sterile gloves and other
5. necessary PPE
Position the patient to permit easy access to the selected
6. venipuncture site
Identify an appropriate venipuncture site.
7. (Note for any limb restrictions)
Apply the tourniquet 3 – 4 inches/ 7.5-10cm proximal to the
8.
insertion site using a quick- release knot
Using aseptic no touch technique, prepare the skin site for
9. percutaneous venipuncture
Scrub site with 70% alcohol using a circular motion from
10. puncture site outward.
Anchor vein by holding skin taut 1-2 inches below puncture
11. site
12. Explain patient not to move
13. Insert needle bevel up into vein at 15 – 30-degree angle
Observe for a ‘flash’ of blood once needle properly enters
14.
vein
Allow the blood to flow till the amount that needed in the
15. syringe
Release the tourniquet before the needle is removed from the
16. vein to reduce the risk of developing a hematoma at the
puncture site
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NO. PROCEDURE REMARKS
Remove the syringe of blood and place it in a sterile kidney
17. dish
Remove needle from vein, immediately place a folded square
18. of gauze over the site and apply firm pressure over the gauze,
maintain pressure until the venipuncture site stops bleeding.
Fill the specimen bottle tube with the blood, allow the syringe
19.
to fill the tube till the required amount.
Following the correct order of draw, continue filling all the
20. specimen tubes until all necessary specimens have been
collected.
After each tube is drawn, gently invert the tube to mix the
21. additive to prevent clotting. To prevent hemolysis, DO NOT
shake.
Discard needles in the sharps / biohazard container and
22.
dispose of used materials in proper receptacles
Correctly packages specimen in biohazard bag for transport
23.
to lab.
Recheck venipuncture site to ensure bleeding has stopped
24. before leaving patient.
25. Discard PPE and perform had hygiene
26. Documentation and report.
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