FUNDAMENTAL OF NURSING PROCEDURE MANUAL for PCL ...

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50 Fundamental of Nursing Procedure Manual 4. Auscultation Auscultation means listening the sounds transmitted by a stethoscope which is used to listen to the heart , lungs and bowel sounds. Equipments required: 1. Tray (1) 2. Watch with a seconds hand (1) 3. Height scale (1) 4. Weight scale (1) 5. Thermometer (1) 6.. Stethoscope (1) 7. Sphygmomanometer (1) 8. Measuring tape (1) 9. Scale (1) 10.Tourch light or penlight (1) 11. Spatula (1) 12 Reflex hammer (1) 13. Otoscope if available (1 set) 14. Disposable gloves (1 pair) 15. Cotton swabs and cotton gauze pad 16. Examination table 17. Record form 18. Ballpoint pen, pencils Procedure: Action (✽Rationale) Normal findings Abnormal findings/ Changes from normal 1. Explain the purpose and procedure ( ✽ Providing information fosters his/her cooperation and allays anxiety) 2. Close doors and put screen.(✽ To provide privacy) 3. Encourage the client to empty bladder( ✽ A full bladder makes him/her uncomfortable) 4.Perform physical examination A. General examination Assess overall body appearance and mental status Inspection Observe the client’s ability to respond to verbal commands.( ✽ Responses indicate the client’s speech and cognitive function.) The client responds appropriately to commands The client confused, disoriented, or inappropriate responses
51 Fundamental of Nursing Procedure Manual Action (✽Rationale) Normal findings Abnormal findings/ Changes from normal Observe the client’s level of The client is fully awake and Client has lowered LOC and consciousness( ; LOC) and alert: eyes are open and follow shows irritability, short orientation. Ask the client to state people or objects. The client is attention span, or dulled his/her own name, current location, attentive to questions and perceptions. and approximate day, month, or responds promptly and He/she is uncooperative or year.(✽Responses indicate the client’s accurately to commands. unable to follow simple brain function. LOC is the degree of If he/she is sleeping, he/she commands or answer simple awareness of environmental stimuli. responds readily to verbal or questions. It varies from full wakefulness and physical stimuli and At a lowered LOC, he/she alertness to coma. Orientation is a demonstrates wakefulness may respond to physical measure of cognitive function or the and alertness. stimuli only. The lowest ability to think and reason. ) The client is aware of who extreme is coma, when the he/she is( orientation to eyes are closed and the client person), where he/she is fails to respond to verbal or ( orientation to place), and physical stimuli, when no when it is( orientation to voluntary movement. time). If LOC is between full awareness and coma, objectively note the client’s eye movement: voluntary, withdrawal to stimuli or withdrawal to noxious Observe the client’s ability to think, The client is able to follow stimuli( pain) only. Dysphasia remember, process information, and commands and repeat and Dysarthria communicate.( ✽ These processes remember information. Memory loss indicate cognitive functioning.) Disorientation Hallucinations Inspect articulation on speech, style smooth/ appropriate native not clear/ not smooth/ and contents of speacking language inappropriate contents Observe the client’s ability to see, hear, smell and distinguish tactile sensations. Observe signs of distress(✽ Alert the examiner to immediate concerns. If you note distress, the client may require healthcare interventions before you continue the exam. ) The client can hear even though the speaker turns away. He/she can identify objects or reads a clock in the room and distinguish between sharp and soft objects. The client cannnot hear low tones and must look directly at the speaker. He/she cannot read a clock or distinguish sharp from soft. The client shows labored breathing, wheezing, coughing, wincing, sweating, guarding of body part (suggests pain), anxious facial expression, of fidgety movements.
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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
Page 19 and 20: Performing Oral Care Definition: Mo
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 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
Page 49: Definition: Performing Physical Exa
Page 67 and 68: Normal adult thorax Barrel thorax F
Page 81 and 82: Umbilicus Observe its contour, loca
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Procedure: b. Removal a Nasal-Gastr
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Procedure: 103 Fundamental of Nursi
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105 Fundamental of Nursing Procedur
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Fundamental of Nursing Procedure Ma
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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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Fundamental of Nursing Procedure Ma
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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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FUNDAMENTAL OF NURSING PROCEDURE MANUAL for PCL ...

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