FUNDAMENTAL OF NURSING PROCEDURE MANUAL for PCL ...

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40 Fundamental of Nursing Procedure Manual Fig.24 Stethoscope Astethoscope consists of : ear pieces, tubing, two heads such as the bell and the diaphragm. Fig.25 The bell of head of stethoscope The bell has cup-shaped and is used to correct low-frequency sounds, such as abnormal heart sounds. Fig. 26 The diaphragm of head of stethoscope The diaphragm is flat side of the head and is used to test high-frequency sounds: breath, normal breath, and bowel sounds. Fig. 27 Aneroid manometer Aneroid manometer is a kind of sphygmomanometer. Sphygmomanometer consists of: an inflatable bladder, attached to a bulb and a diameter, enclosed in a cuff, with a deflating mechanism
41 Fundamental of Nursing Procedure Manual a. Taking axillary temperature by glass thermometer Definition: Measuring/ monitoring patient’s body temperature using clinical thermometer Purpose: 1. To determine body temperature 2. To assist in diagnosis 3. To evaluate patient’s recovery from illness 4. To determine if immediate measures should be implemented to reduce dangerously elevated body temperature or converse body heat when body temperature is dangerous low 5. To evaluate patient’s response once heat conserving or heal reducing measures have been implemented Procedure: Care Action Rationale 1. Wash your hands. Handwashing prevents the spread of infection 2. Prepare all required equipments Organization performance. facilitates accurate skill 3. Check the client’s identification. To confirm the necessity 4. Explain the purpose and the procedure to the Providing information fasters cooperation and client. understanding 5. Close doors and/or use a screen. Maintains client’s privacy and minimize 6. Take the thermometer and wipe it with cotton embarrassment. Wipe from the area where few organisms are swab from bulb towards the tube. present to the area where more organisms are present to limit spread of infection 7.Shake the thermometer with strong wrist Lower the mercury level within the stem so movements until the mercury line falls to at least that it is less than the client’s potential body 95 ℉ (35 ℃). temperature 8. Assist the client to a supine or sitting position. To provide easy access to axilla. 9. Move clothing away from shoulder and arm To expose axilla for correct thermometer bulb placement 10. Be sure the client’s axilla is dry. If it is moist, pat it dry gently before inserting the thermometer. 11. Place the bulb of thermometer in hollow of axilla at anteriorinferior with 45 degree or horizontally. (Fig.28) 12. Keep the arm flexed across the chest, close to the side of the body ( Fig. 29) 13.Hold the glass thermometer in place for 3 minutes. Moisture will alter the reading. Under the condition moistening, temperature is generally measured lower than the real. To maintain proper position of bulb against blood vessels in axilla. Close contact of the bulb of the thermometer with the superficial blood vessels in the axilla ensures a more accurate temperature registration. To ensure an accurate reading
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Page 3 and 4: 3 Fundamental of Nursing Procedure
Page 5 and 6: III. Specimen collection 1.Collecti
Page 9 and 10: Bed making a. Making an Un-occupied
Page 11 and 12: Fig.3 Tuck the bottom sheet under t
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 29 and 30: Care Action Action 18.Back and butt
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: 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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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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