FUNDAMENTAL OF NURSING PROCEDURE MANUAL for PCL ...

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42 Fundamental of Nursing Procedure Manual Care Action Rationale 14.Remove and read the level of mercury of thermometer at eye level. To ensure an accurate reading 15. Shake mercury down carefully and wipe the thermometer from the stem to bulb with spirit swab. To prevent the spread of infection 16. Explain the result and instruct him/her if he/she To share his/her data and provide care needed has fever or hypothermia. immediately 17. Dispose of the equipment properly. Wash your hands. To prevent the spread of infection 18. Replace all equipments in proper place. To prepare for the next procedure 19. Record in the client’s chart and give signature Axillary temperature readings usually are lower on the chart. than oral readings. Giving signature maintains professional 20. Report an abnormal reading to the senior staff. accountability Documentation provides ongoing data collection Fig.28 Placing the glass thermometer into the axilla Fig. 29 Keeping the forearm across the chest
. Measuring a Radial Pulse Definition: Checking presence, rate, rhythm and volume of throbbing of artery. 43 Fundamental of Nursing Procedure Manual Purpose: 1. To determine number of heart beats occurring per minute( rate) 2. To gather information about heart rhythm and pattern of beats 3. To evaluate strength of pulse 4. To assess heart's ability to deliver blood to distant areas of the blood viz. fingers and lower extremities 5. To assess response of heart to cardiac medications, activity, blood volume and gas exchange 6. To assess vascular status of limbs Procedure: Care Action Rationale 1. Wash hands. Handwashing prevents the spread of infection 2. Prepare all equipments required on tray. Organization facilitates accurate skill problems 3. Check the client’s identification To confirm the necessity 4. Explain the procedure and purpose to the client. Providing information fosters cooperation and understanding 5. Assist the client in assuming a supine or sitting position. 1) If supine, place client’s forearm straight alongside body with extended straight (Fig.30ⓐ) or upper abdomen with extended straight( Fig.30ⓑ) 2) If sitting, bend client’s elbow 90 degrees and support lower arm on chair (Fig.31ⓐ) or on nurse’s arm slightly flex the wrist (Fig. 31ⓑ) 6. Count and examine the pulse 1) Place the tips of your first, index, and third finger over the client's radial artery on the inside of the wrist on the thumb side. To provide easy access to pulse sites Relaxed position of forearm and slight flexion of wrist promotes exposure of artery to palpation without restriction. The fingertips are sensitive and better able to feel the pulse. Do not use your thumb because it has a strong pulse of its own. 2) Apply only enough pressure to radial pulse Moderate pressure facilitates palpation of the pulsations. Too much pressure obliterates the pulse, whereas the pulse is imperceptible with too little pressure 3) Using watch, count the pulse beats for a full minute. 4) Examine the rhythm and the strength of the pulse. 7.Record the rate on the client’s chart. Sign on the chart. Counting a full minute permits a more accurate reading and allows assessment of pulse strength and rhythm. Strength reflects volume of blood ejected against arterial wall with each heart contraction. Documentation provides ongoing data collection To maintain professional accountability 8. Wash your hands. Handwashing prevents the spread of infection 9. Report to the senior staff if you find any abnormalities. To provide nursing care and medication properly and continuously
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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 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 and 40: Taking Vital Signs: 39 Fundamental
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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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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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