FUNDAMENTAL OF NURSING PROCEDURE MANUAL for PCL ...

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28 Fundamental of Nursing Procedure Manual Care Action Rationale 13. Upper extremities: 1) Move the mackintosh and big towel ○A to under the client’s far arm. 2) Uncover the far arm. 3) Fold the sponge cloth and moisten. 4) Wash the far arm with soap and rinse. Use long strokes: wrist to elbow→ elbow to shoulder→ axilla→ hand 5) Dry by face towel 6) Move the mackintosh and big towel ○A to under the near arm and uncover it 7) Wash, rise, and dry the near arm as same as procedure 4). 14. Chest and abdomen: 1) Move the mackintosh and bath towel ○A to under the upper trunk 2) Put another bath towel ○B to over the chest 3) Fold the sponge towel and moisten 4) Wash breasts with soap and rinse. Dry by the big towel covering. 5) Move the bath towel ○B covering the chest to abdomen. 6)Fold the sponge cloth and moisten. 7) Wash abdomen with soap, rinse and dry 8) Cover the trunk with top sheet and remove the bath towel ○B from the abdomen. To prevent sheet from making wet Washing the far side first prevents dripping bath water onto a clean area. Long strokes improve circulation be facilitating venous return Mackintosh and bath towel ○A prevent sheet from wetting Bath towel ○B provides warmth and privacy 15. Exchange the warm water. Cool bath water is uncomfortable. The water is probably unclean. You may change water earlier if necessary to maintain the proper temperature. 16. Lower extremities: 1) Move the mackintosh and bath towel ○A to under the far leg. Put pillow or cushion under the bending knee. Cover the near legg with bath towel ○B . 2) Fold the sponge cloth and moisten. 3) Wash with soap, rinse and dry. Direction to wash: from foot joint to knee→ from knee to hip joint 4) Repeat the same procedure as 16.1)- 3) on the near side. 5) Cover the lower extremities with top sheet Remove the cushion, mackintosh and big towel ○A . 17. Turn the client on left lateral position with back towards you. Pillow or cushion can support the lower leg and makes the client comfort. To provide clear visualization and easier contact to back and buttocks care
Care Action Action 18.Back and buttocks: 1) Move the mackintosh and big towel ○A under the trunk. 2) Cover the back with big towel ○B . 3) Fold the towel and moisten. Uncover the back. 4) Wash with soap and rinse. Dry with big towel ○B . 5) Back rub if needed ✽ See our nursing manual “Back Care” 6) Remove the mackintosh and big towel ○A 29 Fundamental of Nursing Procedure Manual Skin breakdown usually occurs over bony prominences. Carefully observe the sacral area and back for any indications. 19. Return the client to the supine position. To make sustainable position for perineal care 20. Perineal care: ✽See our nursing manual “Perineal care” Clean the perineal area to prevent skin irritation and breakdown and to decrease the potential odor. 21. Assist the client to wear clean cloth. 22. After bed bath: To provide for warmth and comfort 1) Make the bed tidy and keep the client in comfortable position. These measures provide for comfort and safety 2) Check the IV flow and maintain it with the speed prescribed if the client is given IV. To confirm IV system is going properly and safely 23. Document on the chart with your signature and Documentation provides coordination of care report any findings to senior staff. Giving signature maintains professional accountability
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Page 5 and 6: III. Specimen collection 1.Collecti
Page 9 and 10: Bed making a. Making an Un-occupied
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Page 13 and 14: Bed making b. Changing an Occupied
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Page 21 and 22: a. Assisting the client with Oral c
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Page 31 and 32: 2) Turn the client to her/ his side
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
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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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