CLINICAL PRACTICE I PROFESSIONAL NURSING AND HEALTH UPDATED

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CLINICAL PRACTICE I




PROFESSIONAL NURSING




AND HEALTH



NSCP 2192

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NURSING PROCESS





NO. PROCEDURE

1. Greet patient and introduce self

2. Perform hand hygiene


3. Get the subjective data through interview of the patient:

3.1 Personal data

3.2 History of medical illness


3.3 History of surgery

3.4 History of allergic

3.5 Elimination

3.6 Social history


6. Perform nursing diagnosis (gather all the subjective and objective data


7. Perform nursing intervention based on nursing diagnosis


8. Perform the evaluation based on nursing intervention

9. Document and report














1

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MEETING SAFETY NEEDS: HAND WASHING



NO. PROCEDURE

1. Prepare requirements


2. Remove accessories

3. Turn on the tap and control the flow of the water

4. Wet hands till forearm

5. Apply enough soap to cover all hand surfaces



6. Rub hands palm to palm


7. Rub palm over left dorsum with interlaced fingers and vice versa


8. Rub palm to palm with fingers interlaced



9. Rub with back of fingers to opposing palms with fingers interlocked


10. Rotational rubbing of left thumb clasped in right palm and vice versa



Rotational rubbing, backwards and forwards with clasped fingers of right hand in
11.
left palm and vice versa


12. Rotational rubbing of right wrist clasped in left palm and vice versa




13. Using elbow to turn off tap



14. Dry hands and forearm thoroughly with a single-use towel


15. Hand washing should take 40-60 seconds






2

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MEETING SAFETY NEEDS: HAND RUB





NO. PROCEDURE



1. Pour hand rub solution onto left palm. Dip all fingers of the right hand into solution


2. Rub hands – palm to palm


3. Rub right palm over left dorsum with interlaced fingers and vice versa


4. Rub palm to palm with fingers interlaced.


5. Rub back of fingers to opposing palms with fingerinterlocked.


Clasp right thumb in left palm and rub using rotational movements. Repeat for
6.
another thumb.

Clasp fingers of the left hand in right palm and perform rotational rubbing. Repeat
7.
for another hand.

8. Once dry, the hands are safe for use

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LIFTING AND MOVING PATIENT: LATERAL




NO. PROCEDURE


1. Greet patient and introduce self


2. Explain procedure


3. Confirm the position required (right or left lateral) and provide privacy
Cross patient’s arms on the chest and cross right leg over left leg (if left
4. lateral)
Stand to face the patient (on the right side) with one leg in front and the other
5. leg behind and flex both knees

Move patient edge of the bed


6.1 Place left hand under patient’s shoulder and hold the opposite shoulder

6. Place a right hand under patient's chest and move head and chest close
6.2
to the edge of right side of the bed
Place left hand under patient's waist and the other hand under patient's
6.3 knees and move patient's trunk and legs to the edge of right side of the
bed
Place left a hand on the patient right shoulder and right hand on the buttocks
7. and turn patient to the left side.

8. Place a pillow under the head.

Flex the upper knee and straighten the lower leg. Place a pillow between the
9. legs

10. Flex the arms and place a pillow between them.


11. Make patient comfortable


12. Document and report

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LIFTING AND MOVING PATIENT: FOWLER’S


NO. PROCEDURE


1. Position patient in supported fowlers position

1.1 Greet client and introduce self
1.2 Explain the purpose of the procedure

1.3 Perform hand hygiene
1.4 Prepare equipment

1.5 Lock the bed wheels.

1.6 Elevate the head of bed 45 to 60 degrees if not contraindicated
1.7 Rest head against mattress on the pillow.

Use a pillow to support arms and hands if the patient does not have
1.8
voluntary control or use of hands and arms
1.9 Position pillow at lower back

1.10 Place pillow or roll under thigh
1.11 Support calves with pillows

1.12 Make the patient comfortable
1.13 Document and report

2.0 Hemiplegic in supported fowler’s position (if applicable)
2.1 Greet client and introduce self

2.2 Explain the purpose of the procedure
2.3 Perform hand hygiene

2.4 Prepare equipment
2.5 Lock the bed wheels.

2.6 Position patient in supine position Elevate head of bed 45° to 60°
2.7 Position patient in straight alignment

Position head on a small pillow with chin slightly forward. If the patient is
2.8
totally unable to control head movement, avoid hyperextension of the neck.

Provide support for involved arm and hand by placing arm away from
2.9
patient's side and supporting elbow with a pillow
2.10 Make the patient comfortable

2.11 Document and report

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LIFTING AND MOVING PATIENT: PRONE




NO. PROCEDURE




1. Greet client and introduce self

2. Explain the purpose of the procedure


3. Perform hand hygiene

4. Prepare equipment

5. Lock the bed wheels and provide privacy

6. Raise the bed to a comfortable working height


7. Remove the pillow lie patient flat

8. Cross the patient’s arm’s over the chest. Cross the legs.

9. Shift the patient to the edge of the bed

10. Straighten both arms, tuck in the further arm under the patient’s body

11. Hold patient’s shoulders and hip turn patient.

12. Turn the patient to lie on the abdomen with head turned to one side

13. Flex both arms of the patient at the side of his head


14. Position patient’s limb in correct alignment

15. Place a pillow under patient’s legs

16. Make patient comfortable.

17. Document and report

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LIFTING AND MOVING PATIENT: SEMI PRONE





NO. PROCEDURE



1. Greet client and introduce self


2. Explain the purpose of the procedure

3. Perform hand hygiene


4. Prepare equipment

5. Lock the bed wheels and provide privacy


6. Raise the bed to a comfortable working height


7. Remove pillow and turn patient on to his / her back

8. Cross the patient’s arm over the chest. Cross the legs

9. Shift the patient to the edge of the bed

10. Straighten both arms, tuck in the further arm under the patient’s body

11. Place pillow alongside patient’s abdomen


12. Hols patients shoulder and hips and turn the patient

13. Straighten the arm and leg nearer to the nurse


14. Flex the other arm and leg

15. Place a pillow under patient's head. Ensure patient is in normal body alignment.

16. Make patient comfortable.


17. Document and report

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LIFTING AND MOVING PATIENT: TRANSFERRING CLIENT BETWEEN
BED AND STRETCHER




NO. PROCEDURE



1. Greet client and introduce self

2. Explain the purpose of the procedure


3. Perform hand hygiene

4. Prepare equipment


5. Lock the bed wheels.


6. Lower head of the bed completely or to a position as low as the client can tolerate
Place chair at the head of the bed.
7.
If using wheelchair or commode, lock brake and elevate foot pedal.

8. Move client to the edge of the bed and instruct the client to bend the knee.

Turn client onto the side, keeping knees flexed, or place the bed in Fowler's
9.
position (head elevated at 45° angle)
Stand at client hip level. Assume broad base support with the forward foot
10.
closest to the client. Flex your knee hip and ankles.
11. Dangle client until he/she stable. Give client shoes or slippers.


12. Move client to the side of bed using galt belt for support.

13. Place your foot closest to chair within client's feet.


14. Rock client and count of three, assist the client to stand position.

Grasp galt belt firmly for safe transfer, while using leg muscles to pivot client to
15.
the chair.
16. Slowly lower client into a chair. Position client in the chair.


17. Make patient comfortable.

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LIFTING AND MOVING PATIENT: TRANSFERRING
CLIENT FROM CHAIR TO BED




NO. PROCEDURE


1. Greet client and introduce self


2. Explain the purpose of the procedure


3. Perform hand hygiene

4. Prepare equipment


5. Lock the bed wheels and provide privacy


6. Assist the patient to stand

6.1 Stand in front of the patient with knees bent


6.2 Instruct patient to place both arms on nurse’s shoulders

6.3 Support patient arms


6.4 Lift patient to a standing position

7. Instruct patient to turn his back towards the head of the bed

8. Assist patient to sit (in the centre) at the side of the bed


9. Assist patient to lie and lift his leg onto the bed
Assist/lift patient's head and chest to the centre of the bed followed by the trunk and
10. legs

11. Make patient comfortable


12. Place patient’s personal items and call bell within reach

13. Put up bed railings as necessary

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LIFTING AND MOVING PATIENT: TRANSFERRING CLIENT FROM BED TO
CHAIR/WHEELCHAIR/COMMODE





NO PROCEDURE

1 Greet client and introduce self

2 Explain the purpose of the procedure

3 Perform hand hygiene

4 Prepare equipment

5 Lock the bed wheels.


6 Lower head of the bed completely or to a position as low as the client can tolerate

Place chair at the head of the bed.
7
If using wheelchair or commode, lock brake and elevate foot pedal.

8 Move client to the edge of the bed and instruct the client to bend the knee.


Turn client onto the side, keeping knees flexed, or place the bed in Fowler's position
9
(head elevated at 45° angle)

Stand at client hip level. Assume broad base support with the forward foot closest to
10
the client. Flex your knee hip and ankles.

11 Dangle client until he/she stable. Give client shoes or slippers.

12 Move client to the side of bed using gait belt for support.

13 Place your foot closest to chair within client's feet.


14 Rock client and count of three, assist the client to stand position.

Grasp gait belt firmly for safe transfer, while using leg muscles to pivot client to the
8
chair.

9 Slowly lower client into a chair. Position client in the chair.


10 Make patient comfortable.