FUNDAMENTAL OF NURSING PROCEDURE MANUAL for PCL ...

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22 Fundamental of Nursing Procedure Manual Care Action Rationale 10. Instruct the client to brush teeth Points of instruction 1) Client places a soft toothbrush at a 45 °angle to the teeth. 2) Client brushes in direction of the tips of the bristles under the gum line with tooth paste. Rotate the bristles using vibrating or jiggling motion until all outer and inner surfaces of the teeth and gums are clean. 3) Client brushes biting surfaces of the teeth 4) Client clean tongue from inner to outer and avoid posterior direction. 11. If the client cannot tolerate toothbrush (or cannot be available toothbrush), form swabs or cotton balls can be used 12. Rinse oral cavity 1) Ask the client to rinse with fresh water and void contents into the kidney tray. 2) Advise him/her not to swallow water. If needed, suction equipment is used to remove any excess. Effective in dislodging debris and dental plaque from teeth and gingival margin Cleansing posterior direction of the tongue may cause the gag reflex When the client is prone to bleeding and/or pain, tooth brush is not advisable To make comfort and not to remain any fluid and debris To reduce potential for infection and 13. Ask the client to wipe mouth and around it. To make comfort and provide the well-appearance 14. Confirm the condition of client’s teeth, gums and tongue. Apply lubricant to lips. To moisturize lips and reduce risk for cracking 15. Rinse and dry tooth brush thoroughly. Return the proper place for personal belongings after drying up. To prevent the growth of microorganisms 16. Replace all instruments To prepare equipments for the next procedure 17. Discard dirt properly and safety To maintain standard precautions 18. Remove gloves and wash your hands To prevent the spread of infection 19. Document the care and sign on the records. Documentation provides and coordination of care ongoing data collection Giving signature maintains professional 20. Report any findings to senior staffs accountability To provide continuity of care
23 Fundamental of Nursing Procedure Manual b. Providing oral care for dependent client Fig. 17 Equipments required for oral care in depending client Procedure: The procedure with cotton balls soaked sodium bicarbonate is showed here. Care Action Rationale 1. Check client’s identification and condition Providing nursing care for the correct client with appropriate way. 2. Explain the purpose and procedure to the client Providing information fosters cooperation and understanding 3.Perform hand hygiene and wear disposable gloves To prevent the spread of infection. 4. Prepare equipments: 1) Collect all required equipments and bring the articles to the bedside. 2) Prepare sodium bicarbonate solutions in gallipot. ❖Nursing Alert❖ If the client is unconscious, use plain tap water. 3) Soak the cotton ball in sodium bicarbonates solution(3 pinches / 2/3 water in gallipot) with artery forceps. 4) Squeeze all cotton balls excess solution by artery forceps and dissecting forceps and put into another gallipot Organization facilitates accurate skill performance Solutions must be prepared each time before use to maximize their efficacy To reduce potential infection Cleaning solutions aids in removing residue on the client’s teeth and softening encrusted areas. To avoid inspiration of the solution 5. Close the curtain or door to the room. Put screen. It maintains the client’s privacy 6. Keep the client in a side lying or in comfortable position. Proper positioning prevents back strain Tilting the head downward encourages fluid to drain out of the client’s mort and it prevents aspiration.
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Page 3 and 4: 3 Fundamental of Nursing Procedure
Page 5 and 6: III. Specimen collection 1.Collecti
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Page 13 and 14: Bed making b. Changing an Occupied
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Page 29 and 30: Care Action Action 18.Back and butt
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Page 35 and 36: Caring for fingernails and toenails
Page 37 and 38: Performing Perineal Care 37 Fundame
Page 39 and 40: Taking Vital Signs: 39 Fundamental
Page 43 and 44: . Measuring a Radial Pulse Definiti
Page 45 and 46: c. Counting Respiration 45 Fundamen
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Umbilicus Observe its contour, loca
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Procedure: Care Action Rationale 1.
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Procedure: b. Removal a Nasal-Gastr
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Procedure: 103 Fundamental of Nursi
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Supplying Oxygen Inhalation 109 Fun
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Administering Oral Medications Defi
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Removing Medications from an Ampoul
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Prevention of the Needle-Stick Inju
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❖Nursing Alert❖ Selection of ap
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Starting an Intra-Venous Infusion 1
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Performing Nebulizer Therapy 147 Fu
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Equipments required: 1. Dr.’s ord
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III. Specimen Collection 151 Fundam
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Definition: Collecting Blood Specim
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Collecting Urine Specimen 159 Funda
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. Collecting a 24-hour Urine Specim
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. Collecting a sputum culture 169 F
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Appendix 1 Checklist for Taking Vit
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Appendix 2 Checklist for Bedmaking:
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Appendix 3 Checklist for Changing o
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General Comments: 179 Fundamental o
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References: 181 Fundamental of Nurs
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