FUNDAMENTAL OF NURSING PROCEDURE MANUAL for PCL ...

Fundamental of Nursing Procedure Manual
Procedure: by one nurse
Care Action Rationale
1. Check the client’s identification and condition. To assess necessity and sufficient condition
2. Explain the purpose and procedure to the client Providing information fosters cooperation
3. Perform hand hygiene To prevent the spread of infection.
4. Prepare all required equipments and bring the
articles to the bedside.
Organization facilitates accurate skill performance
5. Close the curtain or door to the room. Put screen. To maintain the client’s privacy.
6. Remove the client’s personal belongings from To prevent personal belongings from damage and
bed-side and put then into the bed-side locker or
safe place.
loss.
7. Lift the client’s head and move pillow from center
to the left side.
The pillow is comfortable measure for the client.
8. Assist the client to turn toward left side of the Moving the client as close to the other side of the
bed. Adjust the pillow. Leaves top sheet in place. bed as possible gives you more room to make the
bed.
Top sheet keeps the client warm and protect his or
her privacy.
9.Stand in right side:
Placing folded (or rolled) soiled linen close to the
Loose bottom bed linens. Fanfold (or roll) soiled client allows more space to place the clean bottom
linens from the side of the bed and wedge them
close to the client.
sheets.
10. Wipe the surface of mattress by sponge cloth
with wet and dry.
To prevent the spread of infection.
11. Bottom sheet, mackintosh and draw sheet:
1) Place the clean bottom sheet evenly on the bed
folded lengthwise with the center fold as close to
the client’s back as possible.
2) Adjust and tuck the sheet tightly under the head
of the mattress, making mitered the upper
corner.
3) Tighten the sheet under the end of the mattress
and make mitered the lower corner.
4) Tuck in along side.
5) Place the mackintosh and the draw sheet on the
bottom sheet and tuck in them together.
12. Assist the client to roll over the folded (rolled)
linen to right side of the bed. Readjust the pillow
and top sheet.
13. Move to left side:
Discard the soiled linens appropriately. Hold
them away from your uniform. Place them in the
laundry bag (or bucket).
14. Wipe the surface of the mattress by sponge cloth
with wet and dry.
15. Bottom sheet, mackintosh and draw sheet:
1) Grasp clean linens and gently pull them out from
under the client.
2) Spread them over the bed’s unmade side. Pull the
linens taut
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Soiled linens can easily be removed and clean
linens are positioned to make the other side of the
bed.
Moving the client to the bed’s other side allows you
to make the bed on that side.
Soiled linens can contaminate your uniform,
which may come into contact with other clients.
To prevent the spread of infection.
Wrinkled linens can cause skin irritation.