CLINICAL NURSING MANUAL.

"Empower your passion for care, become a nurse and make a

difference everywhere."
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Nursing skills are the foundation of quality patient care. Competent and
confident nurses are essential for promoting patient safety and achieving
positive clinical outcomes. The nursing profession requires a wide range of
clinical competencies, including medication administration, wound care, vital
sign measurement, patient education, and emotional support. A
comprehensive manual detailing nursing skills is an invaluable resource for
nurses, especially those in clinical settings, as it provides a quick reference
guide for essential procedures. This manual highlights the essential nursing
skills required to deliver quality patient care and provides step-by-step
instructions for each procedure. It is intended to serve as a practical guide
for all nursing students, as they continue to provide outstanding patient care.
With love:

BRIDGE “Paving the Road for Success.”

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CONTENTS:

Skill 1 Performing hand hygiene.

Skill 2 Using personal protective equipment and isolation
precautions.
Skill 3 Assisting with a tub bath or shower.
Skill 4 Assisting with Perineal care for a female
patient.
Skill 5 Perineal care for a male patient.
Skill 6 Assisting with a Partial bed bath.
Skill 7 Assisting with a complete bed
bath.
Skill 8 Making an unoccupied bed.
Skill 9 Making an occupied
bed.
Skill 10 Making a surgical bed.
Skill 11 Applying elastic stockings.
Skill 12 Assisting with positioning a patient in
bed.
Skill 13 Moving a patient in bed.
Skill 14 Performing passive range-of-motion
exercises.
Skill 15 Transferring a patient from a bed to a
stretcher.
Skill 16 Transferring a patient from a bed to a wheelchair using a
transfer belt.
Skill 17 Using a hydraulic lift.
Skill 18 Using a sequential compression
device.
Skill 19 Assisting with a bedpan.
Skill 20 Assisting with a urinal.
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Skill 21 Providing catheter
care.
Skill 22 Applying a condom catheter.
Skill 23 Administering a cleansing
enema.
Skill 24 Assisting with meals.
Skill 25 Measuring intake and output.
Skill 26 Taking aspiration
precautions.
Skill 27 Assisting with a gown change for
patients.
Skill 28 Cleaning dentures.
Skill 29 Performing hair care and shampooing in bed for patients who
cannot get out of bed.
Skill 30 Performing nail and foot care for patients.
Skill 31 Performing Oral Hygiene for an Unconscious
Patient.
Skill 32 Shaving a male patient.
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Skill 33 Measuring blood pressure.

Skill 34 Taking Heart rate (radial pulse).
Skill 35 Taking Oxygen saturation.
Skill 37 Taking Temperature.
Skill 38 Application of
Restrain.
Skill 39 Using restraint alternatives.
Skill 40 Adding items to a sterile
field.
Skill 41 Establishing and maintaining a sterile
field.
Skill 42 Performing sterile gloving.
Skill 43 Pouring a sterile solution.
Skill 44 Using a prepackaged sterile kit.
Skill 45 Inserting a Nasogastric (NG)
tube.
Skill 46 Removing a feeding tube.
Skill 47 Providing Enteral
feedings.
Skill 48 Pouching a colostomy.
Skill 49 Pouching a Urostomy.
Skill 50 Applying a nasal cannula or face
mask.
Skill 51 Ensuring oxygen safety.
Skill 52 Maintain an airway.
Skill 53 Performing Oropharyngeal suctioning.
Skill 54 Performing Nasotracheal and nasopharyngeal
suctioning.
Skill 55 Provide tracheostomy care.
Skill 56 Setting oxygen flow rates.
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Skill 57 Performing a preoperative
assessment.
Skill 58 Preparing a patient for surgery.
Skill 59 Promoting family support and participation in preoperative
care.
Skill 60 Providing postoperative care.
Skill 61 Teaching postoperative exercises.
Skill 62 Managing a nasogastric tube
postoperatively.
Skill 63 Managing pain postoperatively.
Skill 64 Providing post operative care to
patients.
Skill 65 Collecting a sputum specimen.
Skill 66 Collecting a midstream urine
specimen.
Skill 67 Collecting a specimen for wound
culture.
Skill 69 Performing fecal occult blood testing.
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Skill 70 Performing gastric occult blood

testing.
Skill 71 Screening urine for chemical
properties.
Skill 72 Caring for a suprapubic catheter.
Skill 73 Inserting an indwelling urinary catheter in a female
patient.
Skill 74 Inserting an indwelling urinary catheter in a male
patient.
Skill 75 Irrigating a urinary catheter.
Skill 76 Obtaining a Specimen from an Indwelling Urinary
Catheter.
Skill 77 Performing intermittent straight catheterization.
Skill 78 Removing an indwelling urinary
catheter.
Skill 79 Assessing wounds.
Skill 80 Caring for pressure
ulcers.
Skill 81 Changing a dressing.
Skill 82 Irrigating wounds.
Skill 83 Using wound drainage
systems.
Skill 84 Administering oral
medications.
Skill 85 Documenting medication
administration.
Skill 86 Handling medication variations.
Skill 87 The Six Rights of Medication Administration.
Skill 88 Using automated medication dispensing
systems.
Skill 89 Administering Ear medications.
Skill 90 Administering eye medications.
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Skill 91 Applying an estrogen patch and nitroglycerin
ointment.
Skill 92 Applying topical medications.
Skill 93 Inserting a rectal
suppository.
Skill 94 Using a dry powder inhaler.
Skill 95 Using a metered-dose inhaler.
Skill 96 Administering intradermal injections.
Skill 97 Administering intramuscular
injections.
Skill 98 Administering subcutaneous
injection.
Skill 99 Drawing up more than one type of
insulin.
Skill 100 Preparing and administering insulin.
Skill 101 Preparing injections from a vial.
Skill 102 Preparing injections from an
ampule.
Skill 103 Dressing the infusion site.
Skill 104 Performing venipuncture.
Skill 105 Preparing an infusion
site.
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Skill 106 Assessing Troubleshooting intravenous

infusions.
Skill 107 Changing intravenous dressing.
Skill 108 Changing intravenous tubing and
fluids:
Skill 109 Regulating intravenous infusion.
Skill 110 Using an infusion pump.
Skill 111 Initiating a transfusion.
Skill 112 Monitoring for adverse reactions to a
transfusion.
Skill 113 Drawing blood and administering fluid.
Skill 114 Performing Dressing Care for a Central Venous Access
Device (CVAD).
Skill 115 Troubleshooting vascular access devices.
Skill 116 Administering parenteral nutrition through a central
line.
Skill 117 Administering PPN with lipid infusion.
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Skill 1 Performing hand hygiene:

1. Remove any jewelry on your hands and wrists and roll up your
sleeves to ensure that there is no obstruction that could interfere
with handwashing.
2. Turn on the faucet and wet your hands with running water.
3. Apply soap to your hands, and rub them together to create a lather.
Be sure to use enough soap to cover all surfaces of your hands.
4. Scrub your hands together for at least 20 seconds. Make sure to
clean all parts of your hands, including the backs, palms, fingers,
and nails.
5. Use a scrubber to clean under your nails and to scrub your fingertips.
6. Rinse your hands thoroughly under running water.
7. Dry your hands with a clean towel or air dryer.
8. Use the towel to turn off the faucet to avoid contamination.
9. If you use a hand sanitizer, make sure to follow the manufacturer's
instructions carefully. Apply a dime-sized amount of sanitizer to the
palm of one hand and rub it all over the surfaces of both hands until
they are dry.
10. Repeat hand hygiene as often as necessary to maintain good hand
hygiene.

Skill 2 Using personal protective equipment and isolation precautions:

1. Identify the type of isolation precautions required for the patient
(e.g., contact, droplet, airborne).
2. Verify the appropriate personal protective equipment (PPE) required
for the specific isolation precautions.
3. Wash hands thoroughly with soap and water or use an alcohol-
based hand rub before donning PPE.
4. Don the appropriate PPE in the following order, ensuring a tight fit:
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a. Gown: put on the gown and fasten ties at the neck and waist or use Velcro.
b. Mask or Respirator: put on the mask or respirator, making sure it covers
the nose and mouth or nose, mouth, and chin. Fit the nose clip around the
bridge of the nose and ensure it is adjusted correctly to minimize the gap
between the skin and mask or respirator. If the mask has earloops, secure
them behind the ears. If the mask has ties, tie the top ties first, then the
bottom ties, and adjust the mask to fit snugly.
c. Eye Protection: put on eye protection, such as goggles or a face shield,
over the mask or respirator. If wearing goggles, adjust the strap to fit
snugly around the head.
d. Gloves: put on gloves, ensuring they cover the cuff of the gown. If the
gloves are too tight or too loose, adjust or change them out.
5. Perform the necessary tasks while in isolation precautions.
6. Remove the gloves first, pulling them from the cuff, and discard
them in the appropriate container.
7. Remove the gown by untying or using Velcro at the neck and
waist and rolling it inside out, then discard it in the appropriate
container.
8. Remove the eye protection by grasping the earpieces or headband
and lifting away from the face, then discard it in the appropriate
container.
9. Remove the mask or respirator by untying strings or unhooking
earloops, then discard it in the appropriate container.
10. Wash hands thoroughly with soap and warm water or use an
alcohol-based hand rub after removing PPE.
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Skill 3 Assisting with a tub bath or shower:

1. Determine the patient’s ability to participate – Before starting the tub

bath or shower, assess the patient's ability to participate and ensure
that it is safe for them to do so.
2. Gather necessary supplies – Before starting the tub bath or shower,
ensure that all necessary supplies are readily available such as
towels, soap, shampoo, and gloves.
3. Assist the patient to the bathroom – If the patient is mobile, assist
them to the bathroom. If they are bedridden, use a transfer bench,
or a portable shower device and the bed as the bath area.
4. Temperature adjustment – Make sure that the water temperature is
suitable for the patient, their preference, is not too hot, and is safe to
use.
5. Provide privacy – Ensure the patient has the utmost privacy as
much as possible, and close the bathroom door.
6. Assist with getting undressed – Assist the patient with removing
clothing as needed, or in some cases, the patient may be able to
undress by themselves.
7. Steady the patient – Help slide the patient into the tub or shower
seat or hoyer lift to make it comfortable for them to take a bath,
ensuring that the patient is safe and secure.
8. Wash the patient – Using soap, shampoo, washcloth, and towel, wash
the patient's entire body while they sit or stand, beginning with the
face, chest, abdomen, arms, legs, back, and buttocks. When
shampooing, tilt the patient's head back to avoid getting water in their
eyes.
9. Rinse the patient – Use running water to rinse the areas washed,
taking care not to splash water all around.
10. Assist patient in drying – Help the patient in drying themselves
with a clean towel
11. Assist the patient out – Assist the patient out of the tub or
shower seat or hoyer lift, ensuring that they are safe and secure.
12. Provide fresh clothing – Provide the patient with fresh and clean
clothing.
13. Document procedure – Document the steps of the procedure
taken, observation made, and any changes in the skin condition in
the patient's medical record.
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Skill 4 Assisting with Perineal care for a female patient:

1. Gather necessary supplies – Before starting perineal care, ensure
that all necessary supplies are readily available such as gloves, a
basin with lukewarm water, soap, a washcloth, towels, and
disposable wipes.
2. Introduce and explain the procedure to the patient – Introduce yourself
to the patient, explain the process to them, and obtain their consent.
3. Provide privacy – Close the curtains or door to ensure that the
patient is comfortable and has privacy.
4. Assist with positioning – Assist the patient into a comfortable position
with knees bent and feet flat, you can also use a bedpan or
waterproof pad under the buttocks to avoid soiling the bed.
5. Put on gloves – Wear gloves to prevent the transmission of
microorganisms from patient to nurse.
6. Cleanse the labia – Using a clean washcloth wet with water, clean the
labia gently from front to back to avoid contamination.
7. Cleanse the perineum area – Use another washcloth or disposable
wipes to clean the perineum area thoroughly wiping from front to
back to prevent the spread of bacteria from the rectum.
8. Rinse with water – Use another washcloth damp with water to rinse the
soap or cleansing agent from the perineal and labia area.
9. Pat dry – Use a clean and dry towel to gently pat the area dry, avoid
rubbing or applying any pressure to the sensitive tissues as it can
cause irritation.
10. Assist the patient to their preferred position – Help the patient to
reposition her body to a comfortable position.
11. Discard gloves and cleansing supplies – discard gloves,
washcloths, and disposables in a biohazard bag or a waste bin.
12. Document the procedure – Document the steps of the
procedure taken, observation made, and any changes in the skin
condition into the patient's medical record.
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Skill 5 Perineal care for a male patient:

1. Gather necessary supplies – Before starting perineal care, ensure

that all necessary supplies are readily available such as gloves, a
basin with lukewarm water, soap, a washcloth, towels, and
disposable wipes.
2. Introduce and explain the procedure to the patient – Introduce yourself
to the patient, explain the process to them, and obtain their consent.
3. Provide privacy – Close the curtains or door to ensure that the
patient is comfortable and has privacy.
4. Assist with positioning – Assist the patient into a comfortable position,
either lying down or in a semi-reclined position.
5. Put on gloves – Wear gloves to prevent the transmission of
microorganisms from patient to nurse.
6. Cleanse the penis – Using a clean washcloth wet with water, clean
around the penis, including the underside of the penis, the tip, and
the foreskin (depending on the patient's anatomical condition).
7. Cleanse the scrotum – Use another washcloth or disposable wipes to
clean the scrotal area thoroughly, and wipe the skin folds to remove
sweat and dirt to prevent infections.
8. Rinse with water – Use another washcloth damp with water to rinse the
soap or cleansing agent from the area.
9. Pat dry – Use a clean towel to gently pat the area dry, avoid
rubbing or applying any pressure to the sensitive tissues as it
can cause irritation.
10. Assist the patient to their preferred position – Help the patient to
reposition himself and make them comfortable.
11. Discard gloves and cleansing supplies – Discard gloves,
washcloths, and disposables in a biohazard bag or a waste bin.
12. Document the procedure – Document the steps of the
procedure taken, observation made, and any changes in the skin
condition into the patient's medical record.
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Skill 6 Assisting with a Partial bed bath:

1. Gather necessary supplies – Before starting the partial bed bath,

ensure that all necessary supplies are readily available such as a basin
with lukewarm water, soap, a washcloth, towels, and gloves.
2. Introduce and explain the procedure to the patient – Introduce yourself
to the patient and explain the purpose, process, and benefits to them.
Obtain their consent to perform the procedure.
3. Provide privacy – Close the curtains or door to ensure that the
patient is comfortable and has privacy.
4. Assist with turning the patient – Assist the patient in turning on their
side/stomach to begin cleaning the back and buttocks area or the
front of the body.
5. Clean the area – Using a washcloth and soap or a no-rinse cleansing
agent, wash the patient in the areas that need cleaning.
6. Rinse the area – Rinse the area with a clean, damp washcloth or towel.
7. Pat dry – Use a clean towel to pat the area dry.
8. Apply lotion – If necessary, apply lotion to dry skin areas to
promote skin health.
9. Assess the patient’s skin – While providing care, inspect the patient’s
skin for any sores or any abnormalities.
10. Redress the patient – Assist the patient in getting dressed or in
bed-clothing they prefer.
11. Document procedure – Document the steps of the procedure
taken, observation made, and any changes in the skin condition in
the patient's medical record.
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Skill 7 Assisting with a complete bed bath:

1. Gather necessary supplies – Before starting the bed bath, ensure
that all necessary supplies are readily available such as a basin
with lukewarm water, soap, a washcloth, towels, and gloves.
2. Introduce and explain the procedure to the patient – Introduce yourself
to the patient, explain the process to them, outline each step of the
procedure, and obtain their consent.
3. Provide privacy – Close the curtains or door to ensure that the
patient is comfortable and has privacy.
4. Assist with turning the patient – Assist the patient in turning on
their side/stomach to begin cleaning the back and buttocks
areas.
5. Wash the face – Using a washcloth and water, wash the patient’s
face, being careful not to splash the water around.
6. Shampoo the hair – Place a towel under the head to avoid getting
water on the bed. Wet the hair with warm water, apply shampoo, and
gently massage the scalp. Then rinse out the shampoo with clean
water.
7. Clean the top half of the body – Wash the top half of the patient's
body; the chest, arms, and abdomen with a washcloth and soap
thoroughly.
8. Clean the bottom half of the body – Return the patient to their back
and wash their legs, feet, and genital area, remembering to change
the water and washcloth once on this step.
9. Rinse and dry – Use a clean washcloth and water to rinse soap
from the patient’s skin, and then pat dry.
10. Apply lotion – If necessary or if a medical order, apply lotion
to dry skin areas.
11. Assess the patient’s skin – While providing care, inspect the
patient’s skin for any sores or any abnormalities.
12. Redress the patient – Assist the patient in getting dressed or in
bed-clothing they prefer.
13. Document procedure – Document the steps of the procedure
taken, observation made, and any changes in the skin condition in
the patient's medical record.
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Skill 8 Making an unoccupied bed:

1. Gather all the necessary supplies like clean sheets, pillowcases,

pillow, bedspread, blanket, etc.
2. Make sure to wash your hands and put on gloves before handling any
of the bedding.
3. Loosen the old bedding by removing any pillows, cushions, or soft items.
4. Strip the old bedding off the bed, removing it carefully and folding it
into a bundle.
5. Check the mattress and wipe clean if necessary and cover it with a
mattress pad if needed.
6. Hold the fitted sheet at the corners, shake it out to straighten it, and
place the corners over the mattress's top corners. Tuck the sheet in at
the head and foot of the bed and ensure that it is pulled taut so that
there are no wrinkles or bumps.
7. Place the flat sheet over the fitted sheet, making sure that it is
centered and even on both sides. Tuck the foot of the flat sheet on
the bed and fold the top sheet down at the head of the bed.
8. Put the pillowcases on the pillows and then stack the pillows
against the headboard.
9. Cover the bed with a bedspread or comforter.
10. Fold the top sheet down neatly over the blanket or bedspread.
11. Tuck in the sides of the sheet at the foot of the bed and tuck in
the bedspread or comforter under the foot of the bed.
12. Smooth out any wrinkles in the bedding you notice and in case of
any soiling, remove the gloves and dispose of them safely and wash
your hands correctly.
13. Dispose of the used bedding by putting it in a hamper or
plastic bag for laundry.
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Skill 9 Making an occupied bed:

1. Introduce yourself to the patient and explain the process you will be
doing.
2. Check the electronic chart or consult with other healthcare
professionals to know the level of the patient's mobility.
3. Assess any devices and equipment in use, and remove them if
necessary, consulting with other healthcare professionals if
necessary.
4. Lower the bed to a comfortable working height and then place it
in the Trendelenburg position if the patient has been instructed to
do so by the healthcare professional.
5. Ask the patient to shift his weight towards one side, grasp the far
edge of the bottom sheet, and roll the bottom sheet toward the
patient's head to expose the mattress.
6. Clean any wet or soiled areas of the mattress and pat dry as necessary.
7. Put a clean bottom sheet over the mattress. Adjust and tuck it in
around the sides of the mattress.
8. Roll the patient back onto the freshly made side of the bed and
repeat step 5 for the other side of the bed.
9. Adjust the patient's clothes, pillows, and any other materials that
were removed during the cleaning process.
10. Put a clean top sheet over the patient and tuck it in around the
sides of the bed.
11. Place the blanket or comforter over the top sheet and fold it down.
12. Adjust the pillow under the patient's head in a comfortable position.
13. Assist the patient to roll back slowly towards the center of the bed.
14. Ask the patient if he is comfortable and have them adjust any
materials if needed.
15. Raise the bed to a comfortable height for the patient.
16. Dispose of any used linens in the appropriate container.
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Skill 10 Making a surgical bed:

1. Verify the surgical booking and ensure the patient's chart is

appropriately labeled.
2. Invite the patient and caregivers to verify the right patient and
surgical site as per the hospital process and provide privacy.
3. Remove any extra equipment or devices from the bed surface,
except for the patient's TED hose if applied pre-operatively.
4. Review the surgical site with the surgical team and position the
bed to accommodate the surgical site, if possible.
5. Remove rolled sheets and place under the mattress to reserve for use
later.
6. Loosen the bed sheet from the head of the bed and untuck it from
the food part of the bed.
7. Wrap the bed sheet around the patient using an overlapping
technique, with the top part of the sheet just above the patient's
arms.
8. Tuck in the bottom of the sheet under the foot of the bed and bring
the top edges of the sheet together to create a tight seal.
9. Place the draw sheet over the fitted sheet, tucking in the sides and
the side closest to the patient over the side tuck, ensuring that no
wrinkles are present.
10. Place a waterproof pad over the draw sheet or mat to safeguard
the bed from any excess fluids during surgery.
11. Make sure that the pillow is double cased with a protective
case and a pillowcase and place it at the top of the bed.
12. Fold a light, warm blanket in thirds and place it over the bed,
covering the patient up to the shoulders.
13. Reposition the bed to accommodate the safety and
accessibility for the surgical team.
14. Hand any other necessary equipment for the patient or the surgical
team.
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Skill 11 Applying elastic stockings:

1. Begin by introducing yourself to the patient and explaining what you

need to do.
2. Assess the patient's condition and their medical history, as well
as any allergies, skin conditions or other concerns that could
impact the use of elastic stockings.
3. Measure the patient's leg to determine the appropriate size and
length of the stocking, making sure to measure at various points to
ensure an accurate fit.
4. Help the patient remove any existing stockings or footwear.
5. Instruct the patient to lie down on their back, with their legs lifted
slightly off the bed.
6. Put on clean gloves, if required.
7. Gather the elastic stocking and gather the top of the stocking up to the
heel.
8. Slip your hand into the stocking, taking care to hold the heel section
of the stocking in your palm.
9. Reach down to the patient's toes while keeping the heel of the
stocking in your palm.
10. Guide the patient's toes through the foot section of the stocking.
11. Slowly pull the stocking up over the patient's foot and ankle,
ensuring that the heel of the stocking is sitting in the correct position
and that there are no visible creases, wrinkles or twists.
12. Continue pulling the stocking up over the patient's calf,
maintaining a consistent tension to ensure a snug but
comfortable fit.
13. Once the stocking is in the correct position, make sure the
foot and heel section of the stocking are also correctly
positioned.
14. Repeat the process for the other leg if necessary.
15. Check the stockings regularly to ensure they remain properly
positioned.
16. Instruct the patient to remove the stockings at regular intervals
to evaluate and monitor their skin.
17. Document the details of the elastic stocking application in
the patient's medical record.
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Skill 12 Assisting with positioning a patient in bed:

1. Begin by introducing yourself to the patient and explaining what you

need to do.
2. Assess the patient's condition before attempting to reposition them.
Identify any medical conditions or injuries that may affect how you
position the patient.
3. Evaluate the patient's bed, making sure the bed is in a low position,
with the brakes on, and the side rails are up before you start.
4. Position yourself on the side of the bed where you want the patient
to move to.
5. Explain to the patient what you are about to do and how you will
need their help.
6. Ask the patient to bend their knees and place their feet flat on the bed.
7. Place one arm under the patient's neck and the other arm under their
back.
8. Ask the patient to roll towards you.
9. Slowly and gently move the patient into the desired position,
making sure their head, shoulders, hips, and legs are aligned.
10. Place pillows or other support devices under their head,
lower back, and between their legs to ensure their comfort.
11. Always communicate with the patient throughout the process,
asking them about any pain, discomfort or dizziness.
12. Ensure that the patient is comfortable, with their call bell within
reach.
13. Document the details of the repositioning in the patient's medical
record.
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Skill 13 Moving a patient in bed:

1. Begin by introducing yourself to the patient and explaining what you

need to do.
2. Assess the patient's condition before attempting to move them.
Identify any medical conditions or injuries that may affect how you
move the patient.
3. Make sure the bed is in a low position, with the brakes on, and the
side rails are up before you start.
4. Position yourself on the side of the bed where you want the patient
to move to.
5. Ask the patient to cross their arms over their chest, and to bend their
knees slightly.
6. Place one arm under the patient's neck and the other under their knees.
7. Ask the patient to roll towards you, while you help to guide them.
8. Make sure the patient's head, shoulders, and hips remain aligned.
9. Once the patient is in the desired position, adjust the pillows or other
support devices to ensure their comfort.
10. Always communicate with the patient throughout the process,
asking them about any pain, discomfort, or dizziness.
11. Be patient – this process should be slow and gentle to avoid any
injury to the patient.
12. Once the patient is settled in their new position, make sure
their call bell is within reach so they can alert you if they need
assistance.
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Skill 14 Performing passive range-of- motion exercises:

1. Begin by introducing yourself to the patient and explaining what you
need to do.
2. Assess the patient's condition and review their medical record
regarding any limitations or precautions.
3. Position the patient comfortably, either sitting or lying down.
4. Identify the joints you wish to exercise, such as the shoulders, elbows,
knees, ankles, wrists, and fingers.
5. Place your hands on the joint, supporting it gently but firmly.
6. Move the joint slowly and gently through its full range of motion,
paying attention to any signs of pain or discomfort.
7. Move the joint in one direction, then return it to its starting position.
8. Repeat this movement, gradually increasing the range of
motion, but avoiding any movement that causes pain or
discomfort.
9. Perform the same exercise on the opposite limb.
10. Continue through the various joints, checking for the patient's
comfort level throughout the exercise.
11. If the patient is experiencing discomfort, reduce the range of
motion, stop the exercise or adjust the position of the affected limb.
12. Remind the patient to take deep breaths and relax throughout the
process.
13. Document the details of the range-of-motion exercises in the
patient's medical record.
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Skill 15 Transferring a patient from a bed to a stretcher:

1. Begin by introducing yourself to the patient and explaining what you

need to do.
2. Assess the patient's condition before attempting to transfer them.
Identify any medical conditions or injuries that may affect how you
transfer the patient.
3. Verify that the stretcher is in good condition, with the brakes on
and the railings raised. Make sure the stretcher is at the same
height as the bed.
4. Position yourself on the side of the bed where you want the
patient to be moved to.
5. Place the stretcher alongside the bed, making sure it is at an
appropriate height.
6. Place a transfer board, if available, alongside the patient, bridging
the gap between the bed and the stretcher.
7. Ask the patient to move towards the edge of the bed, and to shift their
weight onto the side closer to you.
8. Assess whether the patient is able to assist and instruct them to use
their arms or legs to help with the transfer as you lift them.
9. Place one arm under the patient's shoulders and the other arm
under their hips.
10. Assist the patient to slowly roll onto their side, towards you.
11. Slide the transfer board gently under the patient's hips,
ensuring that their back is straight, and their head is supported.
12. Instruct the patient to hold onto the transfer board, if they can do
so.
13. On the count of three, you and another nurse can lift the
patient onto the stretcher, ensuring that their head, back, and legs
are properly positioned.
14. Ensure that the patient is comfortable and properly
positioned on the stretcher. Secure the patient with stretcher
straps.
15. Verify that the stretcher is locked, and the patient's call bell is
within reach.
16. Document the details of the transfer in the patient's medical record.
 .

Skill 16 Transferring a patient from a bed to a wheelchair using a transfer

belt:

1. Begin by introducing yourself to the patient and explaining what you

need to do.
2. Assess the patient's condition before attempting to transfer them.
Identify any medical conditions or injuries that may affect how you
transfer the patient.
3. Check the wheelchair for any damage or issues that could affect the
transfer. Verify that the brakes are on and the footrests are out of the
way.
4. Position the wheelchair sideways next to the bed, with the armrest
closest to the patient.
5. Position yourself on the opposite side of the bed from the wheelchair.
6. Place the transfer belt around the patient's waist, making sure it is
snug but not too tight.
7. If the patient is able to assist, instruct them to place their feet flat
on the floor.
8. Help the patient to sit up at the edge of the bed, with their feet flat
on the floor.
9. Ensure that the patient is stable and comfortable before proceeding.
10. Instruct the patient to hold onto the armrest of the
wheelchair, while you stand behind them and grasp the transfer
belt handles.
11. Instruct the patient to stand up, using your support and the
armrest of the wheelchair.
12. Slowly pivot the patient around, so that they are facing the
wheelchair.
13. Guide the patient to the wheelchair, making sure their feet
are properly positioned on the footrests.
14. Help the patient to sit back in the wheelchair, while
maintaining a secure grip on the transfer belt.
15. Remove the transfer belt and ensure the patient is comfortable
and stable in the wheelchair.
16. Verify that the wheelchair is locked, and the patient's call
bell is within reach.
17. Document the details of the transfer in the patient's medical record.
 .

Skill 17 Using a hydraulic lift:

1. Begin by introducing yourself to the patient and explaining what you

need to do.
2. Assess the patient's condition before lifting them. Identify any
medical conditions or injuries that may affect how you lift the
patient.
3. Check the hydraulic lift for any defects or malfunctions before use.
4. Make sure the patient is positioned properly and wearing any
necessary equipment or garments for transfer.
5. Move the hydraulic lift close to the patient, making sure that the lift
is on a level surface.
6. Position the sling beneath the patient, making certain that the
sling is properly aligned, and the patient's weight will be
distributed evenly.
7. Gently guide the individual onto the sling, ensuring that they are
securely in place, with the sling around their back.
8. Verify that the sling is attached properly to the hydraulic lift.
9. Confirm that the brakes are engaged on the lift, and the wheels are
locked.
 .

10. Use the controls to gradually elevate the patient to the desired
height.
11. Move the lift to the desired location, taking care to avoid
any hazards, obstacles, or uneven ground.
12. Use the controls to gently lower the patient onto the new bed,
wheelchair, or other destination.
13. Remove the sling, making sure that the patient is comfortable
and correctly positioned.
14. Document the details of the patient lift and transfer in the
patient's medical record.

Remember to move slowly and safely, paying attention to the patient's

comfort level and safety throughout the entire process. Communicate with
the patient regularly throughout the lift, and ensure that they are
comfortable and secure at all times.

Skill 18 Using a sequential compression device:

1. Begin by introducing yourself to the patient and explaining what you

need to do.
2. Assess the patient's condition and review their medical history to
ensure that they are suitable to use a sequential compression device.
3. Verify that the device is properly maintained, well-connected, and
ready to be used.
4. Position the patient in a comfortable and safe manner, whether
sitting or lying down.
5. Make sure the compression device is unplugged and turned off before
placing it on the patient.
6. Insert the patient's feet or calf into the compression boots, ensuring
that the boots are tightly wrapped but not too tight.
 .

7. Turn on the device, ensuring that it is programmed correctly to

meet the patient's requirements.
8. Monitor the patient closely during the device's operation, ensuring
that there are no signs of discomfort, pain or other issues.
9. If the patient experiences any discomfort or pain, reduce the pressure
or stop the device immediately.
10. Make sure that the patient is wearing appropriate clothing
and that the compression device does not interfere with their
circulation.
11. The treatment may last as little as 30 minutes or as long as two
hours. Use the device accordingly.
12. Turn off the device and remove the boots.
13. Document the details of the sequential compression device
application in the patient's medical record.

Remember to follow the device's user manual and other guidelines, being
attentive to the patient's condition throughout the process. Never leave the
patient unattended while the device is operating. Ensure that the patient is
aware of the treatment process and is comfortable before, during, and after
the procedure.

Skill 19 Assisting with a bedpan:

1. Begin by introducing yourself to the patient and explaining what you

need to do.
2. Ensure that the patient's privacy is maintained during the process by
closing curtains or doors as needed.
3. Assess the patient's condition and determine whether a bedpan is
necessary for them.
4. Verify that the bedpan is clean and sanitary before use.
 .

5. Assist the patient into a comfortable position, either lying down or

sitting.
6. Provide clear instructions to the patient on how to use the
bedpan, if necessary.
7. Place the bedpan under the patient's buttocks, ensuring that it is
correctly positioned and secure.
8. Offer assistance as needed to ensure that the patient is
comfortable and stable.
9. If necessary, you can use a towel or tissue to cover the patient's
genitals for privacy.
10. Monitor the patient closely to ensure that the bedpan is being
used properly and safely.
11. Once the patient is finished, gently remove the bedpan, taking
care not to spill any contents.
12. Assist the patient in cleaning themselves if needed,
and help with repositioning or bedding if necessary.
13. Ensure that the bedpan is emptied, cleaned, and stored
appropriately.
14. Document the details of the bedpan assistance in the
patient's medical record.

Remember to promote hygiene and cleanliness, and ensure that the

patient's privacy is respected during the process. Also, ensure that you and
the patient are safe and protected from any spills or other accidents that
could happen.

Skill 20 Assisting with a urinal:

1. Begin by introducing yourself to the patient and explaining what you

need to do.
2. Ensure that the patient's privacy is maintained during the process by
closing curtains or doors as needed.
 .

3. Assess the patient's condition and determine whether they require

assistance with using the urinal.
4. Verify that the urinal is clean and sanitary before use.
5. Assist the patient to a sitting position, either at the edge of the bed
or in a chair.
6. Make sure the patient's clothing is appropriately adjusted to allow
access to the perineal area.
7. Provide clear instructions to the patient on how to use the
urinal, if necessary.
8. Hold the urinal in place and help the patient to position themselves
properly, ensuring that the urinal is correctly aligned.
9. If necessary, you can use a towel or tissue to cover the patient's
genitals for privacy.
10. Prevent the patient from spilling the urinal or injuring
themselves by providing necessary assistance, as well as
observing the process closely.
11. Once the patient is finished, gently remove the urinal, taking care
not to spill any contents.
12. Assist the patient in cleaning themselves if needed,
and help with repositioning or bedding if necessary.
13. Ensure that the urinal is emptied, cleaned and stored properly.
14. Document the details of the urinal-assistance in the patient's
medical record.

Remember to promote hygiene and cleanliness, and ensure that the

patient's privacy is respected throughout the process. Also, ensure that you
and the patient are safe and protected from any spills or other accidents
that could happen.
 .

Skill 21 Providing catheter care:

1. First, wash your hands thoroughly with soap and warm water.
2. Gather all necessary equipment, including sterile gloves, antiseptic
solution, clean gauze, and a catheter bag cover.
3. Verify the patient's identity and explain the procedure to him/her.
4. Position the patient comfortably and make sure the bed
covers are appropriately arranged for privacy.
5. Start by pre-cleaning the catheter tube with antiseptic solution using
gentle motions. Use separate pieces of gauze to clean each side of
the tube.
6. Put on sterile gloves to avoid contamination, and continue to clean
the area around the catheter insertion site with an antiseptic
solution, using circular motions. Clean a three to four-inch area
around the insertion site with each swab.
7. Use clean gauze to pat the area around the catheter dry after cleaning.
8. Check the drainage bag and tubing for kinks or twisting. Make sure
the bag is securely attached to the bed or leg and is below the level
of the bladder.
9. Use the catheter bag cover to help prevent infection, ensuring it's
closed securely.
10. Remove the sterile gloves carefully, being careful not to touch
your skin with the gloves.
11. Wash your hands again thoroughly with soap and warm water.
12. Reassess the patient's comfort level, documentation and report
changes to the healthcare provider if necessary.
It's essential to follow the specific instructions or protocols of the healthcare
facility regarding the care of catheters, including any specific cleansing
solution or equipment.
 .

Skill 22 Applying a condom catheter:

1. Begin by introducing yourself to the patient and explaining what you

need to do.
2. Assess the patient's condition and review their medical records
for any allergies or conditions that may affect catheter use.
3. Gather the necessary materials, which may include the condom
catheter, adhesive, alcohol prep pads, and sterile gloves.
4. Help the patient to lie flat on their back with their legs spread apart.
5. Clean the patient’s penis gently with a wet washcloth.
6. Dry the area thoroughly.
7. Open the condom package using sterile technique, taking care not
to touch the tip of the condom.
8. Unroll the condom onto the patient’s penis, making sure it is
positioned correctly and snugly.
9. Apply adhesive tape or strips to keep the condom in place, ensuring
that it is not too tight but snug enough not to slip.
10. Attach the catheter tubing to the drainage bag, ensuring that it
is properly connected.
11. Monitor the patient to ensure that the condom catheter is
working properly, and that the patient is comfortable.
12. Monitor and record the urine output.
13. Help the patient to reposition in a comfortable position.
14. Document the details of the condom catheter application .
 .

Skill 23 Administering a cleansing enema:

1. Start by explaining the procedure to the patient, including the reason

for the enema and what to expect during and after the procedure.
2. Gather all necessary supplies, including a pre-packaged enema kit,
gloves, a bedpan or commode, and disposable pads or towels.
3. Ask the patient to lie on their left side with their knees bent and their
right leg pulled up toward their chest.
4. Put on gloves and open the enema kit. Follow the kit instructions to
prepare the enema solution, typically by filling a bag with warm
water and adding the appropriate amount of enema solution.
5. Lubricate the enema tip with a water-soluble lubricant.
6. Insert the enema tip gently into the patient's rectum, aiming
toward the navel. You may need to ask the patient to take deep
breaths to aid in relaxation.
7. Slowly and gently squeeze the bag to administer the enema
solution. Encourage the patient to take deep breaths and
remain relaxed.
8. Once the bag is empty, remove the enema tip and assist the patient
in holding the solution for several minutes or until they feel the urge
to have a bowel movement.
9. Provide a bedpan or commode and assist the patient in moving to a
sitting position or standing near the toilet.
10. Allow the patient to evacuate their bowels and provide
them with any necessary support or assistance.
11. Discard all disposable supplies, clean any reusable equipment,
and document the procedure in the patient's medical record.
 .

12. Monitor the patient for any adverse reactions or complications,

and provide appropriate care and follow-up as needed.

Remember, always follow the specific instructions provided by your

healthcare provider and use caution when administering an enema.

Skill 24 Assisting with meals:

1. Start by washing your hands with soap and warm water.

2. Verify the patient's identity and ask them if they have any food
allergies or restrictions.
3. Make sure the patient is positioned comfortably at a table or bed
for the meal.
4. If necessary, assist the patient with putting on a bib or clothing protector.
5. Help the patient to open any packaging or containers and arrange the
food on the plate or bowl to their liking. If they are unable to feed
themselves, you may need to assist them with feeding.
6. Provide any necessary utensils, such as spoons, forks, or knives.
7. Ensure the patient has appropriate beverages, such as water or juice.
8. Encourage the patient to eat their food and drink their beverage,
providing any assistance needed.
9. Observe the patient for any signs of difficulty chewing or swallowing.
10. Monitor the patient's food intake and document it accurately.
11. After the meal, help the patient with wiping their face and hands
clean, and dispose of any used containers or food waste.
12. Wash your hands again thoroughly with soap and warm water.
 .

Remember to take precautions for infection control, including wearing gloves

and maintaining appropriate hygiene. Also, consult with the healthcare
facility for any specific mealtime protocols.

Skill 25 Measuring intake and output:

1. Explain the procedure to the patient and make them comfortable.

2. Obtain all necessary equipment, including a graduated measuring
container, paper to record the measurements, and gloves.
3. Wash hands thoroughly and put on clean gloves.
4. Measure the patient’s intake by recording the amount of fluids they
drink and eat, including water, juice, and any other liquid or dietary
intake.
5. Measure the patient’s output by recording the amount of urine, stool,
and any other body fluids or drainage, such as vomit or wound
drainage.
6. Use a graduated container to measure fluid output accurately. For
urine output, ask the patient to urinate in the container or attach a
urine collection bag if the patient is unable to walk to the restroom.
7. Record the output measurement, along with the color, odor, and
consistency of the urine or other fluids.
8. Assess the intake and output measurements and report any
discrepancies or abnormalities.
9. Document the intake and output measurements in the patient’s
medical record.
10. Remove gloves and wash hands
thoroughly. 11.
By following these steps, you can accurately measure a patient’s intake and
output. Remember to maintain confidentiality, respect the patient’s privacy,
and provide gentle care throughout the procedure.
 .

Skill 26 Taking aspiration precautions:

1. Begin by washing your hands with soap and warm water.

2. Verify the patient's identity and explain the aspiration precautions to
them.
3. Elevate the head of the patient's bed to at least 30 degrees
unless contraindicated by the medical condition.
4. Check the patient's ability to swallow or cough and ask them if they
have any history of choking or aspiration.
5. Make sure the patient is sitting upright during meals and remains in
an elevated position for at least 30 minutes after eating. If the patient
has difficulty sitting up, consider using a recliner or a wedge pillow to
help them maintain an upright position.
6. Make sure the patient's food and drinks are thickened per
healthcare provider orders, if necessary.
7. Monitor the patient during meals, looking for signs of distress,
such as coughing, choking, or difficulty swallowing.
8. Educate the patient on how to take small bites and to chew
the food thoroughly before swallowing.
9. Encourage the patient to sip fluids instead of gulping them down.
10. If the patient is obese or has a large amount of gastric
content, inform the healthcare provider immediately.
11. Document your observations about the patient's swallowing and
fluid intake carefully.
12. Reinforce education for the patient, their family, and caregivers
about the importance of aspiration precautions and the potential risk
and consequences of aspiration.

Remember, aspiration precautions can vary depending on the patient's

medical condition, age, and nutritional status, so always follow your
healthcare provider's instructions closely.
 .

Skill 27 Assisting with a gown change for patients:

1. Explain the procedure to the patient and make sure they are
comfortable.
2. Gather all necessary equipment, including a new gown, a blanket or
sheet, gloves, and any other clothing items the patient may need.
3. Close any curtains or doors to provide privacy for the patient.
4. Help the patient sit up or assist them to the edge of the bed.
5. Put on gloves to maintain hygiene and safety.
6. Remove the patient’s old gown from one arm and then the other. Be
careful, especially if the patient has an IV line.
7. Help the patient to hold the blanket or sheet around themselves for
privacy, and wrap the blanket or sheet around the patient.
8. Remove the old gown, being careful to avoid exposing the patient's
body.
9. Assist the patient to put on the new gown. Put the opening in the
back if the patient is bedridden or partially bedridden, or otherwise
depending on the patient's position.
10. Make sure the gown is comfortable, and adjust if necessary.
11. Assist the patient to remove the blanket or sheet.
12. Help the patient to relax back into a comfortable position and
cover them with a clean blanket or sheet.
13. Remove your gloves and dispose of them safely.
14. Document the procedure, any observations, and the patient's
response in their healthcare record.
 .

By following these steps, you can assist patients with a gown change while
maintaining their comfort, privacy, and dignity. Always use appropriate
equipment, maintain hygiene and safety measures, and communicate
clearly with the patient to ensure they are comfortable throughout the
procedure.

Skill 28 Cleaning dentures:

1. Gather all necessary equipment, including a denture brush, a

container or sink with warm water, and denture cleaning paste.
2. Explain the procedure to the patient and make them comfortable.
3. Put on gloves and remove the dentures from the patient's mouth.
4. Rinse the dentures with warm water to remove any debris or food
particles.
5. Apply denture cleaning paste to the denture brush, and then gently
brush the dentures. Be sure to clean all the surfaces of the dentures,
including the clasps and metal parts.
6. Rinse the dentures thoroughly with warm water to remove any
cleaning paste.
7. Fill a container or sink with warm water and add denture cleaning
tablets or a cleaning solution recommended by the denture
manufacturer.
8. Soak the dentures in the cleaning solution for the amount
of time recommended by the manufacturer.
9. After soaking, remove the dentures from the solution and rinse
them thoroughly with warm water.
10. Inspect the dentures to ensure they are clean and free of debris.
11. If necessary, apply a denture adhesive to the denture
surface before reinserting them into the patient's mouth.
12. Place the dentures back into the patient's mouth, ensuring they
are properly aligned.
 .

13. Remove your gloves and wash your hands.

14. Document the procedure and any observations in the
patient’s healthcare record.

By following these steps, you can effectively clean dentures for a patient. It's
essential to be gentle, use appropriate cleaning materials, and follow the
manufacturer's recommendations to ensure the dentures are cleaned
correctly and avoid any potential damage or injury to the patient's oral
cavity.

Skill 29 Performing hair care and shampooing in bed for patients who
cannot get out of bed:
1. Gather all necessary equipment, including a basin, towels,
shampoo, a hairbrush or comb, gloves, and a waterproof apron.
2. Explain the procedure to the patient and make sure they are
comfortable.
3. Prepare the patient by placing a waterproof apron around their
neck and covering their shoulders with a towel.
4. Put on gloves to begin the hair care process.
5. Hold the basin against the patient's head, ensuring a snug fit to avoid
spills.
6. Wet the patient's hair using warm water, ensuring the water does
not get into their ears.
7. Apply a small amount of shampoo to the patient's hair, depending
on the length of their hair.
8. Use your fingertips to massage the shampoo into the patient's scalp
gently.
9. Rinse the patient's hair thoroughly with warm water, being sure to
remove any remaining shampoo.
 .

10. Use a clean, dry towel to pat the patient's hair dry and remove
any excess water.
11. Use a hairbrush or comb to style the patient's hair as desired.
12. Remove the waterproof apron carefully to avoid spilling any
remaining water.
13. Remove your gloves and dispose of them safely.
14. Clean up the area by disposing of any excess water and equipment.
15. Document the procedure, any observations, and the patient's
response in their healthcare record.

By following these steps, you can perform hair care and shampooing for a
patient who cannot get out of bed. It's crucial to use appropriate equipment,
be gentle with the patient's hair and scalp, and pay attention to their comfort
during the procedure.

Skill 30 Performing nail and foot care for patients:

1. Explain the procedure to the patient and make sure they are
comfortable.
2. Gather all necessary equipment, including a basin of warm water,
soap, a towel, a nail cutter, a foot file, lotion, and gloves.
3. Put on gloves to maintain safety and hygiene.
4. Soak the patient's feet in warm, soapy water for several minutes to
soften the skin and nails.
5. Use a nail cutter to cut the patient's nails straight across, rounding the
corners slightly to prevent ingrown nails. Be careful not to cut too
close to the skin, which can cause injury or infection.
6. Use a foot file to smooth rough edges, calluses, or rough patches
on the patient's feet. Be careful not to cause pain or irritate the
patient's skin.
7. Apply lotion to the patient's feet to soothe and moisturize the skin.
 .

8. Dry the patient's feet using a clean towel, paying special attention to
be dry between the toes to prevent infections.
9. Check for any signs of infection or abnormalities, such as open sores,
blisters, or rashes.
10. Document the procedure, any observations, and the patient's
response in their healthcare record.
11. Clean and disinfect all equipment thoroughly.

By following these steps, you can provide safe and effective nail and foot care
for patients. Always use appropriate equipment, maintain hygiene and safety
measures, and be gentle and mindful of the patient's comfort during the
procedure.

Skill 31 Performing Oral Hygiene for an Unconscious Patient:

1. Ensure your safety by washing your hands and putting on gloves.
2. Tilt the patient’s head to the side to allow for drainage of saliva or
other fluids.
3. Use a suction machine to remove any accumulated secretions in the
mouth or throat.
4. Carefully pull out the patient’s upper lip to check for any visible
sores or lesions.
5. Use a soft-bristled toothbrush or sponge moistened with water or a
mouth rinse to brush the patient’s teeth, gums, and tongue.
6. If the patient has a breathing tube in place, brush around it gently to
remove any accumulated secretions.
 .

7. If the patient has dentures, remove them and clean them

according to the manufacturer’s instructions.
8. Use a clean, moistened washcloth or sponge to clean the patient’s lips
and the inside of their mouth.
9. Rinse the patient’s mouth thoroughly with a mouthwash or water.
10. Position the patient on their side and use a suction machine to
remove any remaining fluids.
11. Remove your gloves and wash your hands.
12. Document the procedure and any observations in the
patient’s healthcare record.

Performing oral hygiene for an unconscious patient requires precision,

patience, and care. Be sure to use appropriate techniques and equipment,
such as suction machines and soft-bristled brushes, to avoid injuring the
patient's mouth. Always be gentle, compassionate, and respectful to ensure
the patient's comfort and safety.

Skill 32 Shaving a male patient:

1. Explain the procedure to the patient and make sure they are
comfortable.
2. Wash your hands thoroughly and put on gloves.
3. Gather all necessary equipment, including a basin of warm water,
shaving cream, a razor, a towel, and aftershave lotion.
4. Place a towel around the patient's neck to protect clothing.
5. Wet the patient's face with a warm, moist towel to soften the hair
follicles and make shaving easier.
6. Apply shaving cream or gel to the patient's face using a brush,
making sure to cover all areas to be shaved.
7. Hold the razor at a 30-degree angle and start shaving in the direction
of the hair growth. Shave with slow, light strokes, and rinse the razor
frequently.
 .

8. If necessary, pull the skin taut with one hand to make the shaving
surface smooth and prevent cutting.
9. Continue shaving all areas of the face, taking care around sensitive
areas such as the chin and upper lip.
10. Rinse the patient's face with warm water and pat dry with a clean
towel.
11. Apply aftershave lotion to soothe irritations and provide a fresh
fragrance.
12. Remove your gloves and dispose of them safely.
13. Help the patient clean up any remaining shaving cream or
water on their face.
14. Document the procedure, any observations, and the patient's
response in their healthcare record.

By following these steps, you can perform a safe and effective shaving
procedure for a male patient. Remember to be gentle and take care around
sensitive areas, rinse the razor frequently, and provide aftershave lotion for
care after shaving.

Skill 33 Measuring blood pressure.

Definition: The pressure of the blood in the circulatory system, often

measured for diagnosis since it is closely related to the force and rate of the
heartbeat and the diameter and elasticity of the arterial walls
 If patient has been active, wait 5 to 10 minutes before
assessing blood pressure.
 If patient has been smoking or ingesting caffeine, wait 15
minutes before assessing blood pressure.
 Have the patient assume a comfortable lying or sitting position
with the forearm supported at the level of the heart and the
palm of the hand upward.
 .

 If the measurement is taken in the supine position, support the

arm with a pillow. In the sitting position, support the arm yourself
or by using the bedside table.
 If the patient is sitting, have the patient sit back in the chair so
that the chair supports his or her back.
 Make sure the patient keeps the legs uncrossed.

Procedure: Assessing Blood Pressure- non electronic device.

1. Wash your hands.

2. Explain procedure to the patient.
3. Assess patient’s medical condition and current medication list.
4. Determine correct sized cuf for the individual.
5. Determine the estimated systolic pressure
6. Inflate the cuff 30 mmHg above the estimated blood pressure .
7. Deflate cuff in a slow and steady manner.
8. Obtain correct systolic pressure within + 4mm of mercury.
9. Obtain correct diastolic pressure within + 4mm of mercury.
10. Clean stethoscope with alcohol after listening.
11. Compare findings with previous baseline and acceptable range for
patient.
12. Document vital signs as per facility policy.

Estimating Systolic Pressure

 Palpate the pulse at the brachial or radial artery by pressing

gently with the fingertips.
 Tighten the screw valve on the air pump.
 .

 Inflate the cuff while continuing to palpate the artery.

 Note the point on the gauge where the pulse disappears.
 Deflate the cuff and wait 1 minute.

Common mistakes when assessing Blood Pressure:

Error Effect

Cuff too wide False low reading.

Cuff too narrow or False-high reading.

too
short

Deflating cuff too False-high diastolic reading.

slowly

Deflating cuff too False-low systolic and

quickly.
false-high diastolic reading.

Arm below heart False-high reading.

level

Arm above heart False low reading.

level

Inflating too slowly False-high diastolic reading

Repeating False-high systolic reading.

assessments too
quickly
 .

Procedure: Assessing Blood Pressure- electronic device.

1. Wash your hands.

2. Explain procedure to the patient.
3. Assess patient’s medical condition and current medication list.
4. Determine the best site for cuff placement.
5. Determine correct sized cuf for the individual.
6. Assist patient in a comfortable position.
7. Set the parameter for manual and or automatic B/P.
8. Compare findings with previous baseline and acceptable range for
patient.
9. Document vital sign as per policy.

Special Considerations: Blood Pressure

 During and after menopause women often have higher blood

pressures than men of same age.
 Blood pressure varies throughout day; pressure is highest during
the day between 10:00 am and 6:00 pm and lowest in early
morning.
 Pain, anxiety, or fear stimulates the sympathetic nervous system,
causing blood pressure to rise.
 Assessing Blood Pressure electronically has limitations: Requires
source of electricity, Sensitive to outside motion interference and
cannot be used in patients with seizures, tremors, or shivers or
patients unable to cooperate, Not accurate for patients with irregular
heart rate or hypotension or in conditions with reduced blood flow
(e.g., hypothermia).
 .

Skill 34 Taking Heart rate (radial pulse).

Definition: The rate at which the heart beats per minute, usually
measured to obtain a quick evaluation of a person’s health.
 If patient has been active, wait 5 to 10 minutes before assessing
pulse.
 If patient has been smoking or ingesting caffeine, wait 15
minutes before assessing pulse.
 If patient is supine, place his or her forearm straight alongside or
across lower chest or upper abdomen with wrist extended
straight.
 If patient sitting, bend patient’s elbow 90 degrees and support lower
arm on chair or on nurse’s arm.

Procedure: Assessing Radial Pulse.

1. Wash your hands.

2. Explain procedure to the patient.
3. Assess patient’s medical condition and current medication list.
4. Determine baseline pulse for comparison.
5. Assess patient’s best location to take the pulse.
6. If the pulse is regular, count rate for 30 seconds and multiply total by
two.
7. If the pulse is irregular, count for 1 full minute.
8. Note pulse rhythm and quality.

Special Considerations: Radial Pulse.

 Radial artery is difficult to assess in an infant. Apical, femoral, or

brachial pulse is best site for assessing pediatric heart rate and
rhythm until 2 years of age.
 .
 Radial pulse should be used to detect side effects of
cardiovascular medications and patient should be trained
on that purpose.
 Breath holding in a child affects pulse rate.

Special Considerations: Peripheral Pulses.

 The integrity of peripheral pulses indicates the status of blood

perfusion to the area distributed by the pulse.

Pulse sites:

Pulse site Location

Temporal Over temporal bone of head, above and lateral to

the eyebrow

Carotid Along medial edge of sternocleidomastoid

muscle in neck

Apical Fourth to fifth intercostal space at left

midclavicular line

Brachial Groove between biceps and triceps muscles at

antecubital fossa

Radial Radial or thumb side of forearm at wrist

Ulnar Ulnar side of forearm at the wrist

Femoral Below inguinal ligament, midway between

symphysis pubis and anterior superior iliac spine

Popliteal Behind knee in popliteal fossa

Posterior Inner side of each ankle, below medial malleolus

Tibial

Dorsali Pedis Along top of foot between extension tendons of

great and first toe
 .

Skill 35 Taking Oxygen saturation.

Definition: Pulse oximetry is the noninvasive measurement of arterial blood

oxygen saturation, the percent to which hemoglobin is filled with Oxygen.

 A finger free of polish or acrylic nail is preferred

 If patient has tremors or is likely to move, use earlobe or forehead.
 Site must have adequate local circulation and be free of moisture.
 For patients with decreased peripheral perfusion, you can apply a
forehead sensor.

Procedure: Assessing Oxygen Saturation.

1. Wash your hands.

2. Explain procedure to the patient.
3. Assess patient’s medical condition and current medication list.
4. Determine previous baseline measurement if available.
5. Determine most appropriate patient-specific site (e.g., finger, earlobe,
bridge of nose, forehead) for sensor probe placement by measuring
capillary refill. If capillary refill is less than 2 seconds, select
alternative site.
6. Position patient comfortably. Instruct him or her to breathe normally.

Attach sensor to monitoring site. Leave sensor in place 10 to 30 seconds

or
until oximeter readout reaches constant value and pulse display reaches full
strength during each cardiac cycle.

7. Document vital signs as per facility policy.

 .

Probes and Sites: Characteristics of Pulse Oximetry.

Probes Characteristics

Digit Probe Easy to apply, conforms to various sizes.

Earlobe Probe Clip-on smaller and lighter, although more

positional than digit probe
• Yields strong correlation with
oxygen saturation

• Good when uncontrollable or rhythmic

movements (e.g., hand tremors during
exercise) are present

• Vascular bed least affected by decreased

blood flow.

Forehead Sensor . Reliable for patients on vasoactive

medications

• Detects desaturation quicker than other

sites

• Does not require a pulsatile vascular bed

• Good when uncontrollable or

rhythmic movements (e.g., hand
tremors) are present

• Requires headband to secure sensor

 .
Disposable Sensor Can be applied to a variety of sites: earlobe
Pad. of adult, nose bridge, palm or sole of infant

• Less restrictive for continuous

oxygen saturation monitoring
• Expensive

• Contains latex

• Possible that skin under adhesive

becomes moist and harbors pathogens.

• Available in variety of sizes; pad

can be matched to infant weight.

Skill 36 Assessing respirations.

Definition: The rate at which a person inhales and exhales, usually measured
to obtain a quick evaluation of a person’s health.
 If patient has been active, wait 5 to 10 minutes before
assessing respirations.
 Assess respirations after pulse measurement in adult.
 Be sure that patient is in comfortable position, preferably sitting
or lying with the head of the bed elevated 45 to 60 degrees.

Procedure: Assessing Respirations.

1. Wash your hands.

2. Assess patient’s medical condition and current medication list.
3. Asses for signs and symptoms of alter respiratory function.
4. Identify the patient is in a comfortable position.
5. If rhythm is regular, count number of respirations in 30 seconds and
multiply by two. If rhythm is irregular, count number of respirations for
one full minute.
6. Determine respirations within + 2 breaths/minute.
7. Compare findings with previous baseline and acceptable range for
patient.
8. Document vital signs as per facility policy.
 .

Special Considerations: Respirations.

 Exercise increases respiratory rate and depth.

 Anxiety causes increase in respiration rate and depth because of
sympathetic nervous system stimulation.
 Pain alters rate and rhythm of respirations; breathing becomes shallow.
 Chronic smoking changes pulmonary airways, resulting in an
increased respiratory rate at rest when not smoking.
 Narcotic analgesics, general anesthetics, and sedative hypnotics
depress rate and depth.
 Amphetamines and cocaine increase rate and depth;
bronchodilators cause dilation of airways, which ultimately slows
respiratory rate.
 Decreased hemoglobin levels lower amount of oxygen carried in
blood, which results in increased respiratory rate to increase oxygen
delivery.
 Depth of respirations tends to decrease with aging.
 Kyphosis and scoliosis, frequent in older adults, may also
restrict chest expansion.
 Children up to age 7 breathe abdominally; thus respirations are
observed by abdominal movement.

Alterations in Breathing Patterns:

Alteration Description

Hyperpnea Respirations are increased in depth.

Hyperventilatio Rate and depth of respirations increase.

n
Hypoventilation Respiratory rate is abnormally low; depth of
ventilation may be depressed.

Tachypnea Rate of breathing is regular but abnormally rapid

(more than 20 breaths/min).

Apnea Respirations cease for several seconds.

Persistent cessation results in respiratory arrest.

Bradypnea Rate of breathing is regular but abnormally slow

(fewer than 12 breaths/min).
 .
Biot’s Irregular respirations vary in depth and are
respiration interrupted by periods of apnea.

Cheyne-Stokes Respiratory rate and depth are irregular,

respiration characterized by alternating periods of apnea
and hyperventilation.

Kussmaul’s Respirations are abnormally rapid and deep but

respiration regular; common in diabetic ketoacidosis.

Skill 37 Taking Temperature.

Procedure: Oral Temperature non electronic thermometer.

1. Wash your hands.

2. Gather appropriate equipment.
3. Verify working conditions of the equipment ( eg Clean, Shake
thermometer down prior to taking the temperature if mercury
thermometer).
4. Place tip of thermometer under the patient’s tongue.
5. Leave thermometer in place for the designated time.
6. Determine correct temperature within + 0.2 of a degree.
7. Use non-sterile gloves for removal of thermometer and discard cover
shield.
8. Use non-sterile gloves for removal of thermometer and discard cover.
9. Document vital signs as per facility policy.
 .

Procedure: Oral Temperature electronic thermometer.

1. Remove the electronic unit from the charging unit.

2. Cover thermometer probe with disposable probe cover and slide it on
until it snaps into place.
3. Place the probe beneath the patient’s tongue in the posterior
sublingual pocket.
4. Ask the patient to close his or her lips around the probe.
5. Continue to hold the probe until you hear a beep. Note the
temperature reading.
6. Remove the probe from the patient’s mouth. Dispose of the probe
cover by holding the probe over an appropriate receptacle and
pressing the probe release button.
7. Return the thermometer probe to the storage place within the unit.
Return the electronic unit to the charging unit, if appropriate.

Special Considerations: Oral Temperature.

 It can not be used in patients who have had oral surgery ,facial
trauma or seizures.
 Avoid using it in infant or small children.
 Avoid using it in uncooperative or unconciouss patients.
 Risk for body fluid exposure.
 Delay if ingestion of cold or hot temperature liquids occurred
before the proceduce. Smoking and used of gums should be
also avoided.
 .

Procedure: Axillary Temperature.

1. Expose patient’s axilla.

2. Remove the probe from the recording unit of the electronic
thermometer. Place a disposable probe cover on by sliding it on and
snapping it securely.
3. Place the end of the probe in the center of the axilla. Have the
patient bring the arm down and close to the body.
4. Hold the probe in place until you hear a beep, and then carefully
remove the probe. Note the temperature reading.
5. Cover the patient.
6. Dispose of the probe cover by holding the probe over an
appropriate waste receptacle and pushing the release button.
7. Place the bed in the lowest position and elevate rails, as needed.
Leave the patient clean and comfortable.
8. Return the electronic thermometer to the charging unit.

Special Considerations: Axillary Temperature.

 Not recommended for detecting fever in infants and young children.

 Requires exposure of thorax, which can result in
temperature loss, especially in newborns

Procedure: Tympanic Temperature.

1. Remove the electronic unit from the charging unit.

2. Perform hand hygiene.
3. Place a probe filter on the device.
4. Turn on the device.
5. Pull the pinna of the ear up and back. (But for children less than 12
months pull the pinna of the ear down and back )
6. Insert the device inside the ear.
 .

7. Press the button on device to take the temperature. ( 2

seconds to be displayed).
8. Remove device and read temperature measurement.
9. Dispose of probe filer and clean the thermometer per facilities protocol.
10. Perform hand hygiene.
11. Chart reading (include the
route taken). 12.
Special Considerations: Tympanic Temperature.

 Not used with patients who have had surgery of the ear or
tympanic membrane.
 Anatomy of ear canal makes it difficult to correctly position in
neonates, infants, and children younger than 3 years of age.
Procedure: Temporal Artery Temperature.

1. Perform hand hygiene.

2. Remove probe cover (some models have this) and place a probe
cover on the device, if it requires one. Some devices don’t have probe
filters, but require a thorough cleaning after use.
3. Turn on the thermometer.
4. Start on the center of the forehead and sweep the thermometer
across the forehead to the hairline.
5. If the patient is very sweaty, start on the center of the forehead and
sweep the thermometer across the forehead to the hairline and
THEN behind the base of the ear.
6. Read temperature measurement.
7. Clean thermometer per facilities protocol.
8. Perform hand hygiene.
9. Chart reading (include the route taken).

Special Considerations: Temporal Artery Temperature.

 Inaccurate with head covering or hair on forehead.

 Affected by skin moisture such as diaphoresis or sweating.
 .

Skill 38 Application of Restrain:

Definition: Any manual method, physical or mechanical device, material, or

equipment that immobilizes or reduces the ability of a patient to move his or
her extremities, body, or head freely.
 Restraints are a temporary means to maintain patient safety.
 The order must be current, specifying the type of restraint and the
duration and circumstances or patient behaviors under which the
restraint is to be used.
 The use of restraints is associated with serious complications,
including pressure ulcers, hypostatic pneumonia, constipation,
incontinence, and death.
Procedure: Application of Restrains.

1. Determine need for restraints.

2. Assess patient’s physical condition, behavior, and mental status.
3. Confirm agency policy for application of restraints. Secure an
order from the primary care provider, or validate that the
order has been obtained within the past 24 hours.
4. Perform hand hygiene and put on PPE, if indicated.
5. Identify the patient.
6. Explain reason for restraint use to patient and family.Clarify how care
will be given and how needs will be met. Explain that restraint is a
temporary measure.
7. Include the patient’s family and/or significant others in the plan of care.
8. Apply restraint according to manufacturer’s directions:
a. Choose the least restrictive type of device that allows the greatest
possible degree of mobility.
b. Pad bony prominences.
9. Ensure that two fingers can be inserted between the restraint and
patient’s wrist or ankle.
10. Maintain restrained extremity in normal anatomic position, tied
to the bed frame or a chair frame, never to the side rail.
11. Remove PPE, if used. Perform hand hygiene.
12. Assess the patient at least every hour or according to facility
policy. Remove restraint at least every 2 hours, or according
to agency policy and patient need. Perform range-of-motion
exercises.
13.Evaluate patient for continued need of restraint. Reapply restraint
only if continued need is evident and order is still valid.
 .
14.Reassure patient at regular intervals. Provide continued
explanation of rationale for interventions, reorientation if
necessary, and plan of care.
15.Document for Agency Protocol.
Special Considerations: Application of Restrains.

 Assessment should include the placement of the restraint,

neurovascular assessment of the affected extremity, skin integrity,
peripheral circulation.
 When a child needs to be restrained for a procedure, it is best if
the person applying the restraint is not the child’s parent or
guardian.
 Consider the risks associated with restraints.
 Restrained older adults often respond with anger, fear,
depression, humiliation, demoralization, discomfort, and
resignation.
 .

Skill 39 Using restraint alternatives:

1. Assess the Patient: Determine the patient’s needs, behaviors, and

potential risks to identify the best restraint alternatives.
2. Communicate with the Patient and Family: Discuss the patient's
needs and comfort level, and educate them on the use of restraint
alternatives. Involve family members in the decision-making process
when possible.
3. Provide Environmental Modifications: Adjust the patient’s room to
provide comfort and safety. Place pillows around them, lower the
bed to the lowest position to prevent injury from falling, and provide
soft restraints, such as padded side rails.
4. Provide Diversions: Distractions can help soothe the patient and
reduce their need for restraint. Engage them in activities that are
calming, comforting, and of interest to them.
5. Use Behavioral Strategies: Cognitive behavioral therapies,
redirection, and validation techniques can help reduce anxiety and
depression, which are often the causes of aggressive or disruptive
behaviors.
6. Promote Relaxation: Encourage deep breathing, stretching,
relaxation exercises, or music therapy to help the patient remain
calm and relaxed
7. Involve the Healthcare Team: Assess the patient’s response to
restraint alternatives regularly, and involve the healthcare team to
help monitor and adjust strategies when necessary.
8. Document Everything: Record the patient's response to the restraint
alternatives, including any successes or failures, and update the
treatment plan accordingly.
 .

Skill 40 Adding items to a sterile field:

1. Inform the healthcare team present that you are leaving the sterile
field to get additional supplies.
2. Remove the sterile gloves and gown carefully, and then wash your
hands thoroughly.
3. Use the correct type of personal protective equipment (PPE) such as
sterile gloves or gown, mask, and hat.
4. Use a fresh solution of sterile antiseptic or sanitizer solution to
clean your hands before going towards the sterile field.
5. Gather all necessary additional items, such as sterile dressings,
swabs, or medications. Be sure to keep the items in their sterile
package.
6. Check the expiration date of the new sterile items before taking them
to the sterile field.
7. Avoid touching non-sterile surfaces or areas when carrying the
additional items.
8. Wipe your hands and the new sterile package with an antiseptic
solution before breaking the seal.
9. Open the package using the correct technique, maintaining sterile
handling of the new items. Do not place the sterile items on a
contaminated surface area.
10. Hold the sterile package in a way that does not contaminate the
items.
11. Place the new sterile items onto the sterile field quickly and
carefully. Do not let the sterile items face downward.
12. Return to the sterile field, and use sterile gloves and other
PPE to safely handle the new sterile items.
13. Continue with the surgical or medical procedure, following the
established protocols for cleanliness and sterility.
 .

Skill 41 Establishing and maintaining a sterile field:

1. Gather all necessary materials and equipment, including sterile gown,
gloves, masks, drapes, sterile instruments or tools, and a surgical tray.
2. Wash your hands thoroughly and put on sterile gloves, mask, hat, and
gown.
3. Open the surgical tray and place it on a sterile field.
4. Open the sterile drapes, and drape them over the patient. Be sure
to place the drapes in a way that only exposes the surgical site.
5. Set up a sterile table or shelf where instruments and materials will be
laid.
6. Establish boundaries for the sterile field by marking the area with
unsterile tape or by using the edges of the sterile drapes.
7. Open the sterile instruments and place them on a sterile surgical
tray or on the sterile part of the surgical field.
8. Clean any necessary parts of the patient's body with an antiseptic
solution.
9. Move within the sterile field as little as possible to avoid contamination.
10. Keep any talking to a minimum near the sterile field to avoid
the spread of microorganisms.
11. Avoid reaching over the sterile field to avoid cross-contamination.
12. If a non-sterile item touches the sterile field, remove it
immediately and replace it with a new sterile item.
13. Monitor the sterile field regularly and replace any
contaminated items as needed.
14. Dispose of all contaminated materials safely and appropriately.
15. Remove gloves and gown correctly to avoid contamination,
and then wash hands thoroughly.
 .

Skill 42 Performing sterile gloving:

1. Perform Hand Hygiene: The very first step is to perform hand hygiene
using soap and warm water. Dry your hands completely before
putting on gloves.
2. Open Sterile Gloves Package: Open the sterile gloves package using
aseptic technique. This means that you should avoid touching any
non-sterile items, including the outer packaging of the gloves
3. Pick Up First Glove: With the package open, pick up one of the gloves
by the cuff with your non-dominant hand.
4. Slip First Glove Onto Dominant Hand: Using your dominant hand,
carefully slide your fingers into the glove to cover your hand
completely. Avoid touching the outer surface of the glove with your
bare skin.
5. Hold First Glove with Teeth: Hold the first glove with your teeth,
then use your gloved hand to pick up the second glove by the cuff.
6. Slip Second Glove onto Non-Dominant Hand: Using only your gloved
hand, carefully slide your fingers into the second glove to cover your
hand completely. Again, avoid touching the outer surface of the
glove with your bare skin.
7. Adjust Gloves: Carefully adjust each glove to ensure that they fit
comfortably and are secure around your wrist.
8. Test Gloves for Tears or Holes: To ensure the integrity of the gloves,
inspect them for any holes or tears. If any are present, discard the
gloves and start again with a new pair.
 .

Skill 43 Pouring a sterile solution:

1. Gather all necessary materials and equipment, including a sterile

solution, sterile container or bottle, sterile applicator, and gloves.
2. Wash your hands thoroughly and put on sterile gloves.
3. Open the sterile container or bottle and hold it with the label and cap
facing upward.
4. Hold the sterile applicator in your other hand, ready for use.
5. Use the non-dominant hand to hold the sterile bottle or container in
place, while the dominant hand opens the cap of the container.
6. Tilt the container or bottle between 45 and 90 degrees and pour the
sterile solution onto the sterile applicator or surface.
7. Be careful not to let the solution touch any non-sterile surfaces or items.
8. Pour enough solution to saturate the sterile applicator or surface
without leaving a pool of liquid.
9. Recap the sterile container or bottle.
10. Pass the sterile applicator to the person conducting the
procedure, avoiding any contamination.
11. Discard any unused sterile solution or dispose of the
container or bottle correctly.
12. Remove the sterile gloves and dispose of them correctly.
13. Wash your hands thoroughly after removing the gloves.
 .

Skill 44 Using a prepackaged sterile kit:

1. Wash Your Hands: The first step before using any sterile supplies is to
wash your hands thoroughly with soap and water. Scrub your hands
for at least 20 seconds and use warm water to rinse them off.
2. Open the Pack: Locate the prepackaged sterile kit and carefully open
it. Take care not to touch the sterility packaging inside the kit.
3. Lay Out Supplies: Take the sterile supplies out of the package and lay
them on a sterile field or tray. Generally, the sterile supplies should be
arranged in a specific order of use from left to right.
4. Put on Sterile Gloves: Put on a pair of sterile gloves to protect the
patient from any germs that may be on your hands.
5. Prepare the Site: Use an antiseptic solution to clean the area where
you will be performing the procedure. Depending on the procedure,
you may need to use more than one antiseptic solution.
6. Use the Supplies: Use the supplies from the sterile kit as needed to
perform the procedure.
7. Dispose of Supplies: After completing the procedure, dispose of
the used supplies in a biohazard waste container.
8. Remove Gloves: Carefully and slowly remove your sterile gloves to
avoid any contamination, and dispose of them properly.
9. Document the Procedure: Document the procedure and any
relevant information in the patient's medical record, including the
date and time of the procedure, any supplies used, and how the
patient tolerated the procedure.
 .

Skill 45 Inserting a Nasogastric (NG) tube:

1. Gather Supplies: Before starting, gather all the necessary supplies,

such as the NG tube, water-soluble lubricating jelly, a syringe, a glass
of water, and a emesis basin or towel.
2. Explain the Procedure: Explain the procedure to the patient,
ensuring that their questions are answered, and obtain informed
consent.
3. Position Patient: Assist the patient to sit upright in a comfortable
position. If possible, tilt their head back to straighten the nasal
passage.
4. Measure the Tube: Measure the length of the tubing needed by
placing the end of the tubing at the tip of the patient's nose and
extend it down and back to the ear lobe and then down to the xiphoid
process.
5. Lubricate the Tube: Lubricate the tip of the tubing with water-
soluble lubricating jelly.
6. Insert the Tube: Gently insert the tubing through one nostril with the
bevel facing downward along the floor of the nasal cavity. Direct the
tube posteriorly and towards the opposite ear as you advance the
tube.
7. Check for Placement: Ask the patient to swallow as you advance the
tube. If resistance is encountered, withdraw the tube and try again.
Continue to advance the tube until it is in the correct position in the
stomach or until you reach the desired measurement from step 4.
8. Confirm Placement: Use a syringe to aspirate the stomach contents
and check the pH to help confirm the placement of the tube. A pH of
less than 5 indicates proper placement.
9. Secure the Tube: Once you have confirmed proper placement, secure
the tube using tape or an NG tube holder designed to secure the tube
to the nose.
10. Document the Procedure: Document the procedure, including
the location of the final tube placement, the patient's tolerance to
the procedure, and the patient's response to the NG tube
 .

Skill 46 Removing a feeding tube:

1. Check Physician's Orders: Before removing the feeding tube, check the
physician's orders to make sure it is safe to remove the tube and to
determine whether or not a replacement tube is needed.
2. Gather Supplies: Gather all necessary supplies, including gloves, a
syringe, saline solution, and a clean towel.
3. Wash Hands: Before handling any feeding supplies, wash your
hands thoroughly using soap and water.
4. Verify Placement: Verify the placement of the feeding tube by
checking the tube placement using an x-ray, aspirating stomach
contents or asking the patient to speak.
5. Administer Saline Solution: Administer saline solution through the
feeding tube by flushing the tube with approximately 30 mL of saline
using a syringe.
6. Close Clamp or Stop Pump: Close the clamp or stop the pump to
prevent any formula from running into the tube.
7. Remove Tube: Gently but steadily remove the feeding tube by pulling
it out slowly and smoothly, holding onto the external portion of the
tube with your free hand.
8. Clean the Site: Once the tube has been removed, clean the site
gently with a clean towel or gauze and inspect for any signs of
redness or irritation.
9. Offer Support to the Patient: Provide emotional support and comfort
to the patient as they may feel discomfort after the feeding tube is
removed.
10. Document the Procedure: Document the removal of the feeding
tube, including the reason for removal, the date and time, the
patient's tolerance of the procedure, and any observations about the
condition of the patient's skin at the tube site.
 .

Skill 47 Providing Enteral feedings:

1. Check Physician's Orders: First, check the physician's orders for the
feeding route, type of formula, amount, and timing of the feeding.
2. Assemble Supplies: Assemble all necessary supplies, including the
enteral feeding formula, feeding pump, feeding bag, tubing, and
syringes.
3. Wash Hands: Before handling any feeding supplies, wash your
hands thoroughly using soap and water.
4. Prepare the Formula: Prepare the formula according to the
manufacturer's instructions or as specified by the physician's orders.
5. Prime the Tubing: Prime the feeding tubing by completely filling the
tubing with the enteral formula using a syringe.
6. Connect the Tubing: Connect the tubing to the feeding bag and the
feeding pump.
7. Check the Flow Rate: Set the pump to the prescribed flow rate and
adjust it as needed.
8. Verify Placement: Verify the placement of the feeding tube before
starting the feeding by checking the tube placement using an x-ray,
aspirating stomach contents, or asking the patient to speak.
9. Start the Feeding: Once you have verified the tube placement and
checked the flow rate, start the feeding by turning on the pump.
10. Monitor the Patient: While the patient is being fed, monitor them
closely for any signs of discomfort, intolerance, or complications such
as aspiration.
11. Monitor the Feeding: Monitor the feeding to make sure the
pump is functioning correctly and the formula is being delivered
as prescribed.
12. Flush the Tubing: After completing the feeding, flush the
tubing and the feeding bag with water as per manufacturer's
directions.
13. Dispose of Supplies: Once you have completed cleaning,
dispose of the used supplies and discard them in the designated
biohazard waste container.
14. Document the Feeding: Record the feeding time, amount,
type of formula, flow rate, and patient tolerance in the patient's
medical record
 .

Skill 48 Pouching a colostomy:

1. Wash Hands: Before beginning, wash your hands with soap and warm
water thoroughly.
2. Gather Supplies: Gather all necessary supplies, including the
colostomy bag, a powder and a skin barrier wafer.
3. Cleanse the Site: Remove the existing colostomy bag and cleanse
the stoma site with warm water and mild soap. Pat dry with a towel.
4. Apply Powder: Apply powder to the stoma site generously to
absorb any excess moisture.
5. Apply Skin Barrier Wafer: Apply a skin barrier wafer around the
stoma, making sure that the stoma is at the center of the
opening.
6. Prepare Bag: Cut the colostomy bag to fit the stoma's size and shape,
leaving the wafer flange exposed to surround the stoma.
7. Attach the Bag: Remove the backing from the wafer and attach the
colostomy bag to the wafer flange securely.
8. Smooth the Bag: Smooth the colostomy bag's sides to ensure that it
adheres to the skin and cover the hole that exposes the stoma using a
protective filter.
9. Clean the Supplies: Clean and dispose of used materials and products.
Do not flush the colostomy bag — dispose of it in a proper biohazard
waste container.
10. Document the Procedure: Document any observations such as
skin integrity, date and time of the change, changes in stoma size or
appearance, and any pertinent patient instruction.
 .

Skill 49 Pouching a Urostomy:

1. Wash Hands: Before beginning, wash your hands with soap and warm
water thoroughly.
2. Gather Supplies: Gather all necessary supplies, including the
urostomy bag, a skin barrier wafer, scissors, adhesive remover, and a
towel.
3. Cleanse the Site: Remove the existing urostomy bag and cleanse
the stoma site with warm water and mild soap. Pat dry with a towel.
4. Apply Skin Barrier Wafer: Apply a skin barrier wafer around the
stoma, making sure that the stoma is at the center of the
opening.
5. Prepare Bag: Cut the urostomy bag to fit the stoma's size and shape,
leaving the wafer flange exposed to surround the stoma.
6. Attach the Bag: Remove the backing from the wafer and attach the
urostomy bag to the wafer flange securely.
7. Prepare the Drainage Tube: Connect the drainage tube to the
urostomy bag's spout.
8. Secure the Tube: Secure the drainage tube to the patient's leg
using a drainage bag holder or a leg strap.
9. Smooth the Bag: Smooth the edges of the urostomy bag's flange
to ensure that it adheres to the skin.
10. Check the Position of the Bag: Check that the urostomy bag is
in the right position to avoid pressure, which can cause skin
irritation.
11. Clean the Supplies: Clean and dispose of used materials and
products. Do not flush the urostomy bag; it is considered medical
waste and must be properly disposed of in a biohazard waste
container.
12. Document the Procedure: Document any observations, such as
skin integrity, the date and time of the change, changes in stoma size
or appearance, and any pertinent patient instructions.
 .

Skill 50 Applying a nasal cannula or face mask:

Nasal Cannula:

1. Wash your hands thoroughly with soap and water or use hand
sanitizer before starting the procedure.
2. Explain the procedure to the patient.
3. Check the oxygen level of the patient and make sure it is within the
desired range.
4. Select the appropriate size nasal cannula that fits snugly in the
patient's nostrils.
5. Insert the prongs of the nasal cannula into the nostrils and adjust the
tubing over the patient's ears.
6. Connect the tubing to the oxygen source and adjust the flow
rate as prescribed by the doctor.
7. Observe the patient carefully for any signs of discomfort or skin irritation.
8. Advise the patient to breathe through their nose and to avoid
blocking the tubing at any time.
9. Secure the tubing behind the patient's head using clips or adhesive tape.
10. Reassess the patient's oxygen level periodically and adjust
the flow rate accordingly.

Face Mask:

1. Wash your hands thoroughly with soap and water or use hand
sanitizer before starting the procedure.
2. Explain the procedure to the patient.
3. Check the oxygen level of the patient and make sure it is within the
desired range.
4. Select the appropriate size mask that fits snugly over the patient's
nose and mouth.
5. Place the mask over the patient's nose and mouth, making sure it fits
snugly and covers the chin.
6. Secure the mask to the patient's face using elastic bands or straps.
7. Connect the tubing to the oxygen source and adjust the flow
rate as prescribed by the doctor.
8. Observe the patient carefully for any signs of discomfort or skin irritation.
9. Advise the patient to breathe normally and to avoid removing the
mask at any time.
10. Reassess the patient's oxygen level periodically and adjust
the flow rate accordingly.
 .

Skill 51 Ensuring oxygen safety:

1. Educate Patients: Educate patients and their families about the

proper use and maintenance of oxygen equipment and have written
instructions available as a reminder.
2. Keep a Safe Distance: Keep all sources of open flames, such as
cigarettes, candles, or stoves, at least ten feet away from oxygen
equipment.
3. Post Oxygen Safety Signs: Display signs indicating the presence of
oxygen if the patient is in a multi-patient area.
4. Avoid Using Oxygen Near Heat Sources: Keep oxygen equipment
away from sources of heat, such as space heaters, direct sunlight,
and radiators, which can cause oxygen tanks to overheat or ignite.
5. Flow Rate and Humidity: Make sure the flow rate is adequate
and the humidity of the gas is appropriate as prescribed by the
physician.
6. Leaks and Malfunction: Check for any potential leaks or malfunctions of
the oxygen equipment, such as tubing or buttons that are dislodged, or
cracked or damaged oxygen tanks.
7. Smoking Ban around Oxygen Equipment: Prohibit smoking in areas
where oxygen is being used since it is a potential ignition source.
8. Remove Flammable Materials: Remove any flammable materials from
the patient's room, such as alcohol-based hand sanitizers, aerosol
sprays, and oil- based lotions.
9. Properly Store Tanks: Store oxygen tanks in a secure upright
position to minimize the risk of tipping, falling, or tumbling.
10. Emergency Procedures: Learn and be familiar with the
hospital's specific emergency procedures for oxygen use in the
event of a fire or equipment malfunction.
 .

Skill 52 Maintain an airway:

1. Before beginning the procedure, ensure the patient is in a stable

condition, and call for assistance if needed.
2. Position the patient in a supine position, with the head and neck
slightly extended.
3. Check for any obstructed airway, including secretions, foreign
objects, or swelling in the throat.
4. Use suction or a suction catheter to clear any secretions or foreign
objects in the airway.
5. If necessary, insert an oral or nasal airway to maintain patency.
Choose the appropriate size based on the patient's age and size.
6. Gently lift the patient's jaw using the head tilt-chin lift method or use
the jaw thrust technique to ensure the airway is open.
7. Observe the patient's breathing and airway patency at all times, and
monitor their oxygen saturation levels.
8. If the patient requires supplemental oxygen, use appropriate oxygen
equipment, such as a nasal cannula or face mask, connected to a
flow meter.
9. Reassess the patient's airway and breathing regularly and
adjust your interventions as needed.
10. Document the procedure, including the time, the interventions
used and any observations made during the procedure.
 .

Skill 53 Performing Oropharyngeal suctioning:

1. Wash your hands thoroughly with soap and water or use a hand
sanitizer before starting the procedure.
2. Explain the procedure to the patient and provide reassurance
throughout the process.
3. Gather all necessary equipment for the procedure, including clean
gloves, suction catheter, suction machine or wall suction, and a
clean towel or disposable underpad to protect the patient's
clothing.
4. Position the patient in a semi-Fowler’s position with the neck
slightly extended, or in a lateral recovery position if the patient
is unconscious.
5. Put on clean gloves and prepare the suction catheter to ensure it is
sterile.
6. Turn on the suction machine or wall suction, and adjust the
pressure to a level appropriate for the patient.
7. Insert the suction catheter through the mouth and into the pharynx.
8. Use a circular motion while applying negative pressure to remove
secretions or mucus from the back of the throat and avoid stimulating
the gag reflex.
9. Suction the catheter intermittently by releasing the suction pressure
while rocking the catheter tip back and forth.
10. Observe the color, consistency, and amount of secretions and
suction until clear, and perform suctioning for no more than 10
seconds at a time.
11. Remove the suction catheter and turn off the suction machine or
wall suction.
12. Dispose of all used supplies in the appropriate manner and
remove your gloves.
13. Reassess the patient's breathing and airway patency.
14. Document the procedure, including the time, interventions used,
and observations made during the procedure
 .

Skill 54 Performing Nasotracheal and nasopharyngeal suctioning:

1. Wash your hands thoroughly with soap and water or use a hand
sanitizer before starting the procedure.
2. Explain the procedure to the patient and provide reassurance
throughout the process.
3. Gather all necessary equipment for the procedure, including clean
gloves, suction catheter, suction machine or wall suction, and a
clean towel or disposable underpad to protect the patient's
clothing.
4. Position the patient in a semi-Fowler’s position with the neck
slightly extended.
5. Put on clean gloves and prepare the suction catheter to ensure it is
sterile.
6. Choose the appropriate size suction catheter based on the age and
size of the patient.
7. Apply nasal decongestant spray to one nostril and wait for a few
minutes to allow the medication to take effect.
8. Insert the suction catheter through the nostril where the
decongestant was applied and into the trachea or pharynx.
9. Advance the catheter without applying suction until resistance is
met, then applying negative pressure, withdraw the catheter while
rotating it gently, suctioning for no more than 10 seconds at a time.
10. Suction the catheter intermittently by releasing the suction
pressure while rocking the catheter tip back and forth.
11. Observe the color, consistency, and amount of secretions and
suction until clear.
12. Repeat the above process for the other nostril.
13. Remove the suction catheter and turn off the suction machine or
wall suction.
14. Dispose of all used supplies in the appropriate manner and
remove your gloves.
15. Reassess the patient's breathing and airway patency.
16. Document the procedure, including the time,
interventions used, and observations made during the
procedure.
 .

Skill 55 Provide tracheostomy care:

1. Wash your hands thoroughly with soap and water or use a hand
sanitizer before starting the procedure.
2. Explain the procedure to the patient and provide reassurance
throughout the process.
3. Gather all necessary equipment for the procedure, including clean
gloves, suction catheter, clean tracheostomy tube, clean water, sterile
saline solution, and a clean cloth or gauze.
4. Position the patient in a semi-Fowler’s position with the neck
slightly extended.
5. Put on clean gloves and remove the old dressing or ties from
around the tracheostomy tube.
6. Clean the tracheostomy site with sterile saline solution and a clean
cloth or gauze, using a circular motion from the outer edge towards
the center of the site.
7. Use a suction catheter to suction any secretions or mucus from the
tracheostomy tube and the airway. Ensure the suction catheter is
sterile.
8. Remove the old tracheostomy tube and carefully insert a new, clean
tracheostomy tube into the stoma. Ensure that the new tracheostomy
tube is the appropriate size.
9. Secure the tracheostomy tube in place with new sterile ties or Velcro
straps.
10. Change the dressing around the tracheostomy tube with
a clean, dry dressing.
11. Dispose of all used supplies in the appropriate manner and
remove your gloves.
12. Reassess the patient's breathing and the appearance of the
tracheostomy site.
13. Document the procedure, including the time, the interventions
used, and any observations made during the procedure.
 .

Skill 56 Setting oxygen flow rates:

1. Check the Physician's Orders: Before starting, check the physician's

orders for the flow rate of oxygen, the percentage of oxygen in the
gas, and the type of oxygen delivery device to be used.
2. Wash Hands: Before handling any oxygen equipment, wash your
hands with soap and warm water thoroughly.
3. Attach Equipment: Attach the oxygen delivery device to the oxygen
source, such as an oxygen tank, oxygen concentrator, or wall outlet.
4. Review the Device Settings: Review the device settings to ensure
that the appropriate flow rate and oxygen concentration settings
are selected.
5. Adjust Settings as Required: Use the flow meter to adjust the
flow rate according to the physician's orders or as required.
6. Check Oxygen Saturation Levels: Check the patient's oxygen
saturation levels using a pulse oximeter or arterial blood gas (ABG)
analysis to ensure the proper amount of oxygen is being delivered.
7. Monitor the Patient: Monitor the patient closely for any signs of
discomfort, intolerance, or complications such as difficulty breathing
or skin irritation.
8. Adjust Flow Rate: Adjust the flow rate as needed based on the
patient's condition, oxygen saturation levels, and physician's
orders.
9. Document the Procedure: Document the procedure, including the
prescribed flow rate, the oxygen concentration, the type of device
used, and the patient's tolerance and response to the oxygen therapy.
 .

Skill 57 Performing a preoperative assessment:

1. Review the patient's medical history, including allergies, chronic

illness, medications, and previous surgeries.
2. Assess the patient's physical status, including vital signs, heart
and lung sounds, and mobility range.
3. Collect any necessary laboratory results, such as blood
tests, electrocardiograms, and imaging studies.
4. Assess the patient's readiness and ability to follow post-
operative instructions.
5. Perform a comprehensive physical examination of the patient,
including the airway, respiratory system, cardiovascular system,
abdomen, and extremities.
6. Assess the patient's nutritional status and potential risk for malnutrition.
7. Verify that the patient has signed a surgical consent form,
understands the risks and benefits of the procedure, and has had
their questions answered.
8. Ensure that the patient has followed the preoperative fasting
guidelines, including avoiding solid foods for a specified period
before surgery and only consuming clear liquids no less than 2 hours
before surgery.
9. Assess the patient's emotional and mental state, providing emotional
support and addressing any anxiety or concerns they may have.
10. Document the assessment findings, including vital signs,
laboratory results, medical history, and physical examination.
 .

Skill 58 Preparing a patient for surgery:

1. Collecting patient information: Before any surgical procedure, it is

important for the nurse to obtain the patient's complete medical
history, including any allergies, medications or pre-existing medical
conditions that may require special attention during or after the
procedure.
2. Confirm surgical order: It is important for the nurse to confirm the
surgical order with the medical team and verify all necessary pre-
operative testing and diagnostic procedures have been completed.
3. Review pre-op instructions: The nurse should review pre-operative
instructions with the patient so they understand what to expect
before and after the surgical procedure. This includes fasting and
medication restrictions.
4. Consent form: The nurse must ensure the patient signs a consent form
before the procedure. The nurse should explain the procedure,
associated risks, benefits, and alternative treatments before obtaining
the patient's signature.
5. Administer pre-operative medications: The nurse must administer
pre- operative medications as prescribed, including antibiotics,
sedatives, and pain medication.
6. Removal of jewelry and other items: All jewelry, watches, hairpins, and
other personal items should be removed before the patient enters the
operating room.
7. Prepare the surgical site: The nurse may be required to shave and
sterilize the surgical site to minimize the risk of infection.
8. Outfit patient in operating room attire: The nurse should ensure the
patient is dressed in operating room attire, including a gown and cap.
9. Secure IV access: The nurse should ensure IV access is established,
and the patient is hydrated before surgery.
10. Transporting the patient: Prior to transporting the patient to the
operating room, the nurse must verify that all necessary equipment
and supplies are ready, including any required medical devices such
as oxygen or monitoring equipment.
 .

Skill 59 Promoting family support and participation in preoperative care:

1. Introduce yourself to the patient's family and explain your role in their
loved one's care.
2. Ask the family about their concerns, questions, and expectations
regarding the patient's surgery.
3. Explain the surgical procedure and its potential risks and
benefits in a language they can understand.
4. Provide education to the family about their role in the patient's
preoperative care, such as helping to transport the patient to the
hospital, supporting them during the preoperative fasting period, and
arranging for transportation after surgery.
5. Encourage the family to be present during the preoperative
assessment, where they can ask questions and provide valuable
information about the patient's medical history, allergies, and
medications.
6. Discuss pain management options with the family and explain how
they can help their loved one manage pain and discomfort after
surgery.
7. Provide emotional support to the family by addressing any anxiety,
fears, or uncertainties they may have.
8. Encourage the family to participate in the patient's care during their
hospital stay, encouraging them to visit, and providing information
about the patient's condition and progress.
9. Arrange for follow-up care and post-operative advice to the family,
including providing information about emergency contact numbers
and instructions for care at home.
10. Document all communication with the patient's family,
including their concerns and questions as well as any education
provided.
 .

Skill 60 Providing postoperative care:

1. Monitor Vital Signs: After the patient returns from surgery, the nurse
must check the patient's vital signs (blood pressure, heart rate,
respiratory rate, and temperature) regularly. Any significant changes
should be reported to the physician.
2. Administer Medications: Postoperative medications should be
administered as prescribed, including pain relief medication and
antibiotics.
3. Manage Pain: It is important to manage postoperative pain through
regular monitoring and medication administration. The nurse may
also recommend non-pharmacological methods such as positioning
and relaxation techniques to ease discomfort.
4. Fluid Management: The nurse must monitor the patient's fluid
intake and output to ensure adequate hydration, especially if the
patient has an IV or Foley catheter in place.
5. Wound Care: Postoperative wound care is vital to minimize the risk of
infection. The nurse should check the surgical site regularly and
change dressings as needed. Any drainage, redness, or swelling
should be reported to the physician.
6. Monitor for Infection: Signs of infection include fever, chills, increased
redness, swelling or drainage from the wound, and should be
reported to the physician immediately.
7. Assist with Ambulation: The patient may experience weakness or
dizziness after surgery, so it is important to assist with ambulation
and encourage regular movement as tolerated.
8. Provide Nutritional Support: The nurse should provide appropriate
nutritional support depending on the patient's postoperative status,
such as clear fluids or a soft diet.
9. Educate the Patient: The nurse should educate the patient on
postoperative care instructions, including wound care, pain
management, and activity restrictions.
10. Collaborate with the Multidisciplinary Team: The nurse should
collaborate with the physician and other members of the
multidisciplinary team to ensure optimal postoperative care.
 .

Skill 61 Teaching postoperative exercises:

1. Introduce yourself to the patient and explain the benefits and

importance of postoperative exercises.
2. Assess the patient's overall physical condition, including their mobility,
range of motion, strength, and coordination.
3. Instruct the patient to perform gentle range-of-motion exercises, such
as ankle pumps, leg lifts, and shoulder rolls, to promote circulation
and prevent blood clots.
4. Teach the patient deep breathing and coughing exercises to
prevent pneumonia and other respiratory complications.
Recommend the use of an incentive spirometer to help the patient
achieve this.
5. Teach the patient to perform ambulation exercises such as sitting at
the edge of the bed, standing up, and walking, to improve strength
and mobility gradually.
6. Instruct the patient to perform strengthening exercises specific to
their surgical site, such as arm and leg curls, biking, and squats. This
should only be done after approval by the surgical team.
7. Advise the patient to maintain proper posture during exercises,
especially those done while sitting or standing.
8. Encourage the patient to take breaks and rest when needed and to
listen to their body's signals to avoid overexertion.
9. Schedule follow-up appointments to assess the patient's progress,
reinforce instruction or modify their regimen as required
10. Provide written instructions and diagrams to help
support their understanding of the exercises.
 .

Skill 62 Managing a nasogastric tube postoperatively:

1. Check Physician Orders: Check the physician's orders regarding the
use of a nasogastric tube, the type and size of the tube, and the rate
of feeding, suction or medication administration.
2. Gather Equipment: Gather all the necessary equipment – gloves, clean
water, a clean measuring cup or cylinder for checking aspirate, pH test
strips, and tape or dressing for securing the tube.
3. Wash Hands: Wash your hands with soap and water or use an alcohol-
based hand sanitizer.
4. Position the Patient: Position the patient in semi or high-Fowler's
position for feeding, but turn the patient to the side when suction is
needed.
5. Assist with Insertion: Assist with inserting the nasogastric tube
according to the physician's orders to prevent dislodging, coiling or
kinking.
6. Check Placement: Check the tube placement by aspirating gastric
contents and inspecting the fluid for color, consistency or pH; confirm
the tube position with an X-ray or a point-of-care ultrasound.
7. Begin Feedings: Begin feeding or medication administration
according to physician orders; monitor the rate, volume and
appearance of the aspirate, residual volume and patient's response
to feeding.
8. Manage Suction: Manage suction as per physician orders; ensure the
suction device is working correctly, monitor the amount of aspirate
and check the patient's tolerance to the suction.
9. Monitor Comfort: Monitor the patient's comfort level; ensure the
nasal and oral areas around the tube are clean, lubricated, and not
irritated.
10. Document: Document the insertion, placement verification,
medication administration, feedings, aspirate, and suction in the
patient's medical record.
 .

Skill 63 Managing pain postoperatively:

1. Assess the Patient: After surgery, assess the patient's pain level and
document it along with vital signs. Use a pain scale to measure the
intensity of pain from 0-10.
2. Administer Medication: Administer pain medication as prescribed
by the physician. The medication may be oral or IV.
3. Monitor for Side Effects: Some medication might cause side effects
such as nausea, vomiting or respiratory depression; monitor for these
side effects and report to the physician.
4. Encourage Use of Non-Pharmacological Methods: Encourage the
patient to use non-pharmacological methods to manage their pain
such as deep breathing, relaxation techniques, music therapy or
massage.
5. Educate the Patient: Educate the patient about their pain medications,
when to take them, the expected pain relief, and possible side effects
to anticipate.
6. Reassess and Adjust Medication: Reassess the patient's pain level
regularly and adjust the medication dose as needed.
7. Coordinate Discharge Care: Coordinate the patient's discharge plan
with the physician, pharmacist and family members to ensure that
they continue to get pain relief at home.
8. Document and Report: Document all medication administration,
pain assessment, interventions and the patient's response to them.
Report any concerns or significant changes to the physician.
 .

Skill 64 Providing post operative care to patients.

1. Assess the patient's vital signs and level of consciousness: After the
patient comes from the surgery, assess their vital signs, including
blood pressure, pulse, respiratory rate, and temperature. Also, check
the patient's level of consciousness to determine if they are alert
enough to respond to questions or commands.
2. Monitor the patient for any signs of complications: Watch out for any
signs of complications, such as bleeding, fever, or signs of infection.
Check the wound site for any drainage, bleeding, or redness.
3. Administer medication as prescribed: Provide medication to the
patient as prescribed by the physician. This might include
painkillers, antibiotics, or other medication to manage specific
symptoms.
4. Encourage the patient to take deep breaths and move around:
Encourage the patient to take deep breaths and cough to prevent
lung issues. Also, assist the patient in moving around frequently to
increase blood flow and prevent the formation of blood clots.
5. Assist with wound care: Depending on the type of surgery, help the
patient take care of their wound site. This could involve changing
dressings, cleaning the wound, or applying medication.
6. Offer emotional support: Recovering from surgery can be stressful
and challenging for patients. Offer emotional support and
reassurance, remind the patient that everything is going to be OK,
keep them engaged in positive conversations, and provide comfort as
needed.
7. Educate the patient on postoperative care: Educate the patient about
what to expect during the recovery process. This could include tips for
pain management, instructions on caring for the wound, when to seek
medical attention, and other specifics that will help ensure a smooth
recovery.
 .

Skill 65 Collecting a sputum specimen:

1. Review Patient's Medical Records: Review the patient's medical

record to understand why the test is needed.
2. Gather Supplies: Gather all the necessary supplies, such as gloves,
sterile container, sputum cup, tissue, mask, and a disposable bag.
3. Provide Instructions: Provide clear instructions to the patient on
how to produce sputum, including deep breathing and coughing
techniques.
4. Ensure Proper Hygiene: Instruct the patient to rinse their mouth and
brush their teeth before collecting the sputum.
5. Wear Protective Gear: Wear protective gear such as gloves, a surgical
mask, and an apron to prevent infections.
6. Assist Patient: Assist the patient in a comfortable position, either
sitting or lying, with their head slightly inclined forward.
7. Collect the Specimen: Ask the patient to take a deep breath and cough
deeply to bring up sputum from the lungs into their mouth; collect the
sputum in the sterile container or sputum cup.
8. Label the Specimen: Label the specimen with the patient's name,
time and date of collection, and any other information required by
the lab.
9. Transport the Specimen: Transport the specimen to the lab
immediately, following proper handling procedures to avoid
contamination.
10. Document: Document the sputum collection in the patient's
medical record, including the date, time, and any other relevant
information.
 .

Skill 66 Collecting a midstream urine specimen:

1. Explain Procedure: Explain the procedure to the patient, including

why the urine specimen is necessary and how it will be collected.
2. Wash Hands: Wash your hands and put on gloves.
3. Provide Privacy: Provide privacy for the patient by closing the
patient's room or drawing the curtain around the bed.
4. Assist with Positioning: Assist the patient in the proper positioning -
explain that the patient should sit on the toilet or bed with legs apart
and lean forward slightly.
5. Cleanse with Antiseptic: Cleanse the urethral area with an antiseptic
solution; females should wipe from front to back to avoid
contamination, and males should retract foreskin to get to the
urethra.
6. Collect Specimen: Ask the patient to begin urinating into the toilet or
bedpan and then collect 20-30 mL of urine in a sterile specimen
container.
7. Label and Transport Specimen: Label the specimen container with the
patient's name, date, time of collection and transport the specimen to
the laboratory within 30 minutes. If this is not possible, refrigerate the
specimen to mitigate bacterial growth.
8. Document: Document the specimen collection in the patient's medical
record, including date, time, the volume of the specimen, and any
difficulties encountered in the collection process.
9. Wash Hands and Dispose: Thoroughly wash your hands; discard
gloves and dispose of all used materials per facility protocol.
 .

Skill 67 Collecting a specimen for wound culture:

1. Review Patient's Medical Record: Review the patient's medical

record to understand why the test is needed.
2. Gather Supplies: Gather all the necessary supplies, such as gloves,
sterile container, saline solution, chlorhexidine, sterile gauze, and a
waste receptacle.
3. Explain Procedure to Patient: Explain the procedure to the
patient thoroughly, including why the wound culture is
necessary.
4. Wash Hands and Wear Protective Gear: Wash your hands and
wear protective gear, including gloves and a surgical mask.
5. Prepare and Clean the Site: Clean the wound site using sterile water
or saline solution, using a circular motion, and dry the site with
sterile gauze. Use chlorhexidine in cases of significant wound
exudate.
6. Collect the Specimen: Using sterile technique, collect the specimen
from the deepest part of the wound, avoiding contamination from the
surrounding skin. The swab should be inserted and twisted at the
wound site to ensure the contact surface area has a chance to
acquire the bacteria from the site.
7. Label the Specimen: Label the specimen with the patient's name,
time, date, and any other information necessary by the lab.
8. Transport the Specimen: Transport the specimen to the lab
immediately using proper transportation procedures to avoid
contamination.
9. Educate Patient: Instruct the patient that they may experience
mild to moderate pain while collecting the specimen.
10. Document: Document the wound culture collection process,
including any complications or discomfort experienced by the
patient, and the transport procedure, in the patient's medical
record.
 .

Skill 68 Performing blood glucose testing:

1. Review Patient's Medical Records: Review the patient's medical
records and understand the reason for the test.
2. Gather Supplies: Gather all the necessary supplies such as gloves,
clean alcohol swab, lancet device, blood glucose monitoring system,
and test strips.
3. Explain the Procedure: Explain the procedure to the patient,
including why the test is being performed and how it will be done.
4. Wash Hands and Wear Protective Gear: Wash your hands and wear
gloves.
5. Choose the Site: Choose the site for the puncture, most commonly
on the fingertips or the side of the hand.
6. Cleanse the Site: Cleanse the selected site with an alcohol swab and
let the area dry completely.
7. Prepare the Lancing Device: Prepare the lancing device and adjust
to the desired depth of penetration as per manufacturer's
instructions
8. Collect Blood: Pierce the skin with the lancet device and collect a
small drop of blood by applying slight pressure to the site. Be sure to
discard the first drop, as it can be contaminated.
9. Apply Blood to the Test Strip: Apply the blood to the test strip by
following the device's instructions.
10. Get Results: Wait for the device to display the results, usually
within a few seconds. If the result is too high or too low, notify the
physician and follow their ordered protocol.
11. Dispose of Supplies and Educate the Patient: Dispose of all
supplies as per facility protocol and educate the patient on their
glucose range.
12. Document: Document the test result, date, time, and the patient's
response to the intervention in the medical record.
 .

Skill 69 Performing fecal occult blood testing:

1. Review Patient's Medical Record: Review the patient's medical

record and understand why the test is needed.
2. Provide Instructions: Provide clear instructions to the patient about
the test, including the preparation needed, such as avoiding certain
foods that may affect the test's accuracy.
3. Gather Supplies: Gather all the necessary supplies such as gloves,
fecal occult blood test kit, disposable gloves, clean container, and
applicator stick from the lab.
4. Explain the Collection Process: Explain the collection process to the
patient, including asking them to defecate in a clean container and not
mix urine with the sample.
5. Collect Fecal Sample: Collect a small sample of the stool using the
provided applicator stick and place it in the designated area of the
test card.
6. Develop the Test: Follow the manufacturer's instructions to
prepare and develop the test strip.
7. Interpret the Results: Read and interpret the test results according to
the manufacturer's instructions. If test results are positive, notify the
physician to order further testing.
8. Dispose of Supplies and Educate the Patient: Dispose of all supplies
per facility protocol and educate the patient about future testing,
including how often they will need to be tested.
9. Document: Document the test's result in the patient's medical
record, including the time, date, and the test's result.
 .

Skill 70 Performing gastric occult blood testing:

1. Review Patient's Medical Record: Review the patient's medical

record and understand why the test is needed.
2. Collect Equipment: Collect all required equipment such as gloves,
gastric occult blood test kit, pH testing strips, sterile container or
vial, and emesis basin.
3. Explain the Procedure to the Patient: Explain the process to the
patient, inform them that the procedure will likely cause nausea
and vomiting.
4. Cleanse the Mouth: Cleanse the patient's mouth with water and
ensure that they do not eat or drink anything for at least 30 minutes
before the test.
5. Collect the Specimen: Collect the gastric aspirate specimen after
inserting the nasogastric tube according to the physician's orders.
Approximately 5-10 mL of gastric fluid is required.
6. Apply the Specimen to the Test: Apply the collected gastric
contents to the filter paper strip or test area on the kit as per the
manufacturer's instructions.
7. Perform pH Level Test: Check the pH of the sample with pH testing
strips to ensure the sample is from the stomach.
8. Develop the Test and Interpret Results: Follow the
manufacturer's instructions and let the test develop. Interpret
the results; if the test is positive, report to the physician.
9. Dispose of Supplies and Educate the Patient: Dispose of all
supplies per facility protocol and educate the patient about the
next steps per the physician's order.
10. Document: Document the test's results, including time, date, test
results, and any further steps taken in the patient's medical record.
 .

Skill 71 Screening urine for chemical properties:

1. Review Patient's Medical Records: Review the patient's medical
records to understand the reason for the test.
2. Gather Supplies: Gather all necessary supplies, such as gloves, a
clean container or vial, an automatic urine analyzer and urine
test strips.
3. Wash Hands: Wash your hands and wear gloves to maintain medical
hygiene.
4. Collect the Urine Specimen: Ask the patient to provide a clean-
catch midstream urine specimen, following appropriate
instructions to avoid contamination.
5. Test the Urine Sample: Dip the test strip into the urine specimen,
according to the manufacturer's instructions, and wait for the
designated time as per the instructions.
6. Analyze the Results: Observe the color changes of the test pad on
the strip, compare to the color chart provided by the manufacturer
to interpret the results.
7. Interpret the Results: Match the results with the expected
concentration ranges; the expected ranges for each chemical
property may vary depending on the test strip used.
8. Document the Results: Document the results in the patient's medical
record, including the date and time of the test, the chemical
properties tested, and the results.
9. Dispose of Supplies and Educate the Patient: Dispose of all used
supplies according to facility protocol, educate the patient about
their results and what they mean.
 .

Skill 72 Caring for a suprapubic catheter:

Step 1: Gather Supplies and Prepare the Patient

 Gather appropriate supplies including a clean dressing, sterile saline,

sterile gloves, and antiseptic wipes.
 Explain the suprapubic catheter care procedure to the patient or
caregiver.
 Position the patient in a comfortable position, if possible in a seated
position or on their back, with the catheter and tubing within reach.
 .

Skill 73 Inserting an indwelling urinary catheter in a female patient:

Step 1: Prepare the patient

 Explain the procedure to the patient, reassuring her that it

might be uncomfortable but will be done as gently as possible
to avoid harm.
 Allow the patient to empty her bladder beforehand.
 Place the patient in a lithotomy position (lying on her back, knees
bent, and legs spread apart).

Step 2: Prepare the equipment

 Collect all necessary supplies, such as a urinary catheter, sterile

gloves, antiseptic solution, sterile drapes, a drainage bag, a lubricant,
and a syringe.
 Open and place all supplies within reach.
 Don sterile gloves and other aseptic attire if
required. Step 3: Sterilize the insertion site
 Clean the genital area with soap and water first before wiping it
down with antiseptic. Use gentle back-and-forth strokes from
anterior to posterior.
 Hold the labia apart with one hand and use the other hand to
spread the antiseptic solution over the urethral meatus with small
circular motions.

Step 4: Insert the catheter

 Take the catheter with your dominant hand and lubricate its tip
using a sterile lubricant.
 Using your non-dominant hand, carefully separate the labia.
 Use your dominant hand to slowly insert the catheter into the
urethral meatus. Advance the catheter up into the bladder. When
you observe urine flow into the tubing, continue advancing the
catheter an extra inch to guarantee that it's deeply into the bladder.
 Inflate the balloon as per the manufacturer's instructions once it's
inside the bladder, which will keep it from slipping out.

Step 5: Secure the catheter and check for proper placement

 Connect the tubing to the drainage bag.

 Secure the catheter in place by taping it to the patient's leg, paying
particular attention to prevent any tension on the catheter itself.
 .
 Assess the urine color and flow rate, ensuring that the urine is free
of blood clots or other contaminants.
Step 6: Document the procedure

 Document the catheterization procedure, such as the date and time

the catheter was inserted, the catheter size, the volume of sterile
water used to inflate the balloon, and the appearance of the urine.
 Skill 74 Inserting an indwelling urinary catheter in a male patient:
Step 1: Explain the procedure to the patient

 Explain the procedure to the patient, reassuring him that it

might be uncomfortable but will be done as gently as possible
to avoid harm.
 Allow the patient to empty his bladder beforehand.
 Position the patient on his back with his legs spread
apart. Step 2: Gather the necessary supplies
 Collect all necessary supplies, such as a urinary catheter, sterile
gloves, antiseptic solution, sterile drapes, a drainage bag, a lubricant,
and a syringe.
 Open and place all supplies within reach.
 Don sterile gloves and other aseptic attire if
required. Step 3: Sterilize the urinary meatus
 Clean the genital area with soap and water first before wiping it
down with antiseptic. Use gentle back-and-forth strokes from
anterior to posterior.
 Hold the penis with your non-dominant hand and use the other
hand to spread the antiseptic solution over the urinary meatus with
small circular motions.
Step 4: Insert the catheter

 Take the catheter with your dominant hand and lubricate its tip
using a sterile lubricant.
 Take the penis with your non-dominant hand and hold it at a 60- to 90-
degree angle from the patient's body.
 Using your dominant hand, gently insert the catheter into the
urinary meatus.
 Guide the catheter into the urethra until urine begins to flow into the
tubing. Advance the catheter another 1-2 inches to make sure it
enters the bladder.
 Inflate the balloon per the manufacturer's instructions to keep the
catheter securely in place.

Step 5: Secure the catheter and confirm proper placement

 Connect the tubing to the drainage bag.

 Secure the catheter in place by tapping it to the patient's leg, paying
particular attention to prevent any tension on the catheter itself.
 Assess the urine color and flow rate, ensuring that the urine is free
of blood clots or other contaminants.

100 | P a
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Step 6: Document the procedure

 Document the catheterization procedure, such as the date and time

the catheter was inserted, the catheter size, the volume of sterile
water used to inflate the balloon, and the appearance of the urine

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 .

Skill 75 Irrigating a urinary catheter:

Step 1: Gather Supplies

 Sterile gloves
 Sterile catheter irrigation kit (if available)
 Syringe (30 mL)
 Sterile water or normal saline (prescribed
volume) Step 2: Step 2: Prepare the Patient
 Explain the procedure to the patient.
 Place a bedpan or urinal if
necessary. Step Step 3: Don Sterile
Gloves
 Start by washing your hands and then wearing your sterile
gloves. Step 4: Step 4 :Draw up Sterile Water/Saline
 Use the syringe to draw up the prescribed volume of sterile water or
normal saline.
Step 5: Position Tubing

 Position the tubing of the urinary catheter so that it can hang freely
into the bedpan or urinal.

Step 6: Prepare Catheter Site

 Cleanse periurethral area with antiseptic in a circular motion, working

from the meatus outward.

Step 7: Insert Syringe

 Insert the syringe filled with sterile water or saline into the catheter
port. Step 8: Step 8: Flush System
 Slowly and gently inject the saline or sterile water into the catheter.
 Wait for the saline solution to start to return to the
syringe. Step 9: Step 9: Remove Syringe
 Withdraw the syringe from the catheter
port. Step Step 10: Drain Fluid
 Encourage the patient to relax for 30-60 seconds while the saline or
sterile water drains.

Step 11: Repeat Procedure

 Repeat the procedure and document as needed or as prescribed by

physician or by facility protocol.
 .
Step 12: Document

 Document the date and time of the procedure, volume of sterile

water or saline used, and the patient’s response to the procedure.
.
 .

Skill 76 Obtaining a Specimen from an Indwelling Urinary Catheter:

Step 1: Prepare the Patient and Equipment

 Explain the procedure to the patient.

 Ensure the patient is comfortable and positioned appropriately,
with the drainage bag within reach.
 Gather necessary equipment, including sterile gloves, a sterile
specimen container, antiseptic solution, and sterile syringe and
needle (if needed).

Step 2: Don Sterile Gloves and Cleanse the Injection Port

 Put on sterile gloves.

 Use antiseptic solution to cleanse the injection port of the urinary
catheter, scrubbing with gentle back-and-forth motion.
 Allow the injection port to air
dry. Step 3: Aspirate the Specimen
 Using sterile syringe and needle, puncture the injection port to
aspirate the urine to the syringe.
 Obtain the prescribed urine volume.
Step 4: Transfer the Specimen to the
Container
 Remove the needle from the syringe, place it in the appropriate
sharps container.
 Transfer the urine from the syringe to the sterile specimen container.
 Label the container with the patient’s identification information and
time of collection.
 .

Skill 77 Performing intermittent straight catheterization:

Step 1: Prepare the Patient

 Explain the procedure to the patient.

 Assist the patient into a comfortable position (sitting, lying
down, or standing).
 Provide privacy as well as adequate
coverage. Step 2: Step 2: Gather Supplies:
 Sterile gloves
 Sterile drape
 Sterile intermittent catheter
 Lubricant
 Antiseptic solution
 Cotton balls or sterile gauze
 Container for urine
collection Step 3: Don Sterile
Gloves
 Start by washing your hands before putting on sterile
gloves. Step 4: Step 4: Prepare the Catheter
 Open the sterile catheter package and drop it on the sterile drape.
 Apply sterile lubricant onto the catheter
tip. Step 5: Step 5: Cleanse the Urinary
Meatus
 Locate and cleanse the urethra with antiseptic solution, with clean
cotton balls or sterile gauze using a circular motion.

Step 6: Insert the Catheter

 Using your dominant hand, grasp the penis or spread the labia and
hold the catheter with your non-dominant hand.
 Insert the catheter gently into the urethra, advancing it up to the
point where urine flows through the catheter and into the urine
container.
 Advance the catheter an extra inch or two further to ensure bladder
drainage completely.

Step 7: Collect Sample & Check for Complications

 Collect the urine sample in the container for further testing.

 Assess for the absence or presence of blood, debris, and change in
the urine color.

Step 8: Withdraw the Catheter

 .
 Once complete, slowly and steadily withdraw the catheter while
gently applying pressure to the penis near the urethra.
Step 9: Discard Equipment and Document

 Committee any supplies or equipment that cannot be reused.

 Document the procedure, including the date and time of
collection, the volume of urine obtained, and the patient's
response to the process.
 .

Skill 78 Removing an indwelling urinary catheter:

Step 1: Prepare the Patient and Equipment

 Explain the procedure to the patient.

 Ensure the patient is comfortable and positioned appropriately.
 Gather all necessary equipment, including gloves, sterile gauze,
antiseptic solution, a specimen container for output, and a towel or
pad to absorb any accidental leakage.
Step 2: Don Sterile Gloves

 Start by washing your hands before putting on sterile

gloves. Step 3: Step 3: Deflate the Balloon
 Remove any adhesive from the catheter that fastens it to the patient's
leg.
 Using a syringe, withdraw the prescribed volume of sterile water or
saline that was used to inflate the balloon.
Step 4: Remove the Catheter

 Now that the balloon is deflated, gently but steadily pull the
catheter out with controlled pressure from its insertion site.
 Ensure that the urethra does not collapse around the catheter, which
could cause discomfort or harm. Use sterile gauze if needed to hold
pressure on the urethra while removing the catheter.

Step 5: Check for Complications

 Inspect the catheter and observe for any side effects such as
discomfort, blood, or discharge from within the urethra or around the
catheter insertion point.
 Check for signs of
infection. Step 6: Document
 Document the procedure, including the date and time of removal,
duration of catheter use, and the patient's response to removal.
Step 7: Provide Appropriate Care

 Assist the patient in using the bathroom and provide appropriate

care to ensure patient hygiene and comfort.
 Ensure the patient does not experience any sequelae or symptoms
after the catheterization removal.
.
.
 .

Skill 79 Assessing wounds:

Step 1: Review the Patient's Medical History

 Review the patient's medical history, including their previous wound

history, chronic diseases or other comorbidities, medications, and
relevant surgical interventions.

Step 2: Assess the Wound Location and Size

 Identify the location and size of the wound and take note of the
depth and edges, and measure the length, width, and depth in
centimeters.

Step 3: Evaluate the Wound Bed

 Examine the wound bed for the presence or absence of granulation

tissue, necrotic tissues or exudates, and slough, and note the
percentage areas that are affected.

Step 4: Assess the Wound Exudate

 Check for the type and volume of exudate, including serous,

purulent, sanguineous, and serosanguineous.

Step 5: Determine the Wound Margins

 Assess the wound margins for evidence of maceration,

hyperkeratosis, undermining, and tunneling.

Step 6: Evaluate for Signs of Infection

 Look for signs of inflammation, such as erythema, edema, warmth,

and tenderness around the wound. And note check for signs of odor
or increased pain.

Step 7: Assess Tissue and Skin Integrity

 Evaluate the surrounding tissue and skin for signs of dryness,

irritation, cracking, or rash.

Step 8: Document Wound Characteristics

 .

 Record wound characteristics, including location, size, depth, exudate

type and amount, wound margins, tissue and skin damage, and any
other signs of abnormalities.

Step 9: Monitor and Adjust the Care Plan

 Monitor the wound regularly to evaluate healing progress,

development or progress of any infection, and adjust the care plan
as necessary.

Remember effective wound assessment is essential in promoting positive

healing outcomes. Make sure to follow standard protocols including regional
guidelines and institution policies to provide quality care.

Skill 80 Caring for pressure ulcers:

1. Before beginning, wash your hands thoroughly and put on

appropriate PPE, such as sterile gloves.
2. Introduce yourself to the patient and explain the procedure for
pressure ulcer care.
 .
3. Assess the pressure ulcer's size, location, stage of healing, and the
presence of exudate, odor, or signs of infection. Document the findings
in the patient's medical record.
4. Cleanse the wound using sterile saline and a gentle back-and-forth
motion. For larger ulcers, use syringe irrigation to ensure all areas of
the wound are thoroughly cleaned.
5. Pat the wound dry using sterile gauze, being careful not to
contaminate the surrounding skin.
6. Apply an appropriate wound dressing as per the healthcare
provider's instructions. Dressings could be primary or secondary, and
antimicrobial or non-antimicrobial, depending on the severity of the
ulcer.
7. Reposition the patient to relieve pressure on the ulcer site, ensuring
that the patient's positioning is changed at least every 2 hours.
8. Administer pain medication and antibiotic therapy, if prescribed.
9. Evaluate the patient's nutrition and hydration status, and consult
with the healthcare provider or dietician, if required.
10. When necessary, consult with other healthcare professionals,
such as physical therapists or wound care specialists, for additional
interventions.
11. Encourage the patient to participate in their care by
assisting with repositioning or applying topical medication, if
possible.
12. Reassess the ulcer regularly and document any changes in
the patient's medical record.
13. Provide education to the patient and their caregivers on
wound care, prevention, and self-management.
14. Dispose of all used equipment, including dressing, gloves and so
on, and wash your hands again.
 .

Skill 81 Changing a dressing:

1. Before beginning, wash your hands thoroughly and put on sterile gloves.
2. Introduce yourself to the patient and explain the dressing change
procedure.
3. Position the patient comfortably, ensuring adequate lighting and privacy.
4. Remove the existing dressing carefully, pulling it away from the
wound, and discard it into a biohazard container.
5. Observe the wound and surrounding skin for any signs of
inflammation, infection, or drainage. Document any observations or
changes in the patient's medical records.
6. Cleanse the wound using sterile saline or as per the healthcare
facility protocol. Use a gentle back-and-forth motion, starting
from the wound's
center and moving outward in circles. Avoid going over the same area
twice with the same used swab or cotton ball.
7. Pat the wound dry using sterile gauze, being careful not to
contaminate the surrounding skin.
8. Apply any topical medication, as directed by the healthcare provider.
9. If the wound requires dressing, select the appropriate dressing as per
the facility protocols and patient's condition. Ensure that the size of
the dressing covers the wound completely.
10. Place the dressing over the wound, securing it by using adhesive
tapes, gauze roll, or wound dressings as prescribed by the healthcare
provider.
11. If a secondary dressing is required, cover the primary dressing
with gauze roll, adhesive tape, or stretch wrap. Ensure that the
dressing and tape are not too tight or too loose, causing discomfort
or impeding circulation.
12. Dispose of all used equipment and wash your hands again.
13. Record the dressing change procedure in the patient's
medical records, including the dressing type, date, and time.
 .

Skill 82 Irrigating wounds:

1. Before beginning, wash your hands thoroughly and put on sterile gloves.
2. Position the patient comfortably and ensure adequate lighting
for the procedure.
3. Remove any dressings or bandages covering the wound area.
4. Prepare the irrigation solution. This may vary depending on the
type of wound and healthcare facility protocols. Normal saline
(0.9%) solution is commonly used.
5. Attach a sterile irrigation syringe or a sterile solution delivery system
to the solution container and fill it with the predetermined amount of
solution.
6. Place a sterile drape under the affected area to prevent contamination.
7. Holding the syringe or delivery system about 1-2 inches above the
wound surface or down into the wound bed, apply gentle pressure to
allow the solution to flow into the area. Use a back-and-forth, up-
and-down motion to ensure that all areas of the wound receive
adequate irrigation.
8. Repeat the irrigation process until the wound is thoroughly cleaned.
The amount of solution and number of repetitions may vary based on
the wound size and severity.
9. Pat the wound dry gently with sterile gauze.
10. Apply any necessary wound dressing or medication as
directed by the healthcare provider.
11. Dispose of all used equipment and wash your hands again.
12. Document the irrigation procedure in the patient's medical
records, including any observations or concerns about the wound's
healing progress.
 .

Skill 83 Using wound drainage systems:

1. Before beginning, wash your hands thoroughly and put on sterile gloves.
2. Verify the patient's identity and ensure that the wound drainage
system is prescribed by the healthcare provider and correctly
labeled.
3. Position the patient comfortably, ensuring adequate lighting and privacy.
4. Select the appropriate drainage system as per the healthcare facility
protocol and patient's condition. Common types of wound drainage
systems include Jackson-Pratt (JP) Drain, Hemovac Drain, and Penrose
Drain.
5. Prepare the wound and surrounding area by cleansing it with sterile
saline solution or as per the healthcare facility protocol.
6. Remove the protective cover from the drainage system, exposing the
catheter or the tube.
7. Insert the catheter or tube into the appropriate depth into the
wound, ensuring that it is secured in place with sutures or
adhesive tape.
8. Connect the tubing to the drainage reservoir, making sure all
connections are secure.
9. Place a dressing over the site to ensure that the wound drainage
system is adequately protected.
10. Observe the patient frequently for any signs of bleeding,
inflammation, or infection, documenting the amount and
appearance of drainage in the patient's medical record.
11. Ensure that the drainage system is functioning correctly, and
the reservoir does not overfill. Empty the reservoir as directed by the
healthcare provider or the drainage system's instructions.
 .

12. Dispose of all used equipment and wash your hands again.

Note: Wound drainage systems are used in patients who have undergone
surgery or have an injury or wound that produces large amounts of
drainage. These systems help maintain a sterile and dry environment to
promote healing and prevent infection.

Always adhere to infection control protocols and appropriate PPE when using
wound drainage systems. Document the drainage system's type, date, and
time in the patient's medical record, along with any observed changes or
complications.

Skill 84 Administering oral medications:

1. Obtain the medication order from the healthcare provider and

verify the patient’s identity using two unique identifiers, such as
their name, date of birth, medical record number, ID bracelet, or
photo identification.
2. Wash your hands thoroughly and prepare the medication as
per the healthcare provider’s instructions.
3. Check the medication label, dosage, and expiration date. Ensure
that the medication is not expired, correct medication, and correct
dosage.
 .
4. Explain the procedure to the patient and obtain their consent for
taking the medication.
5. Provide the patient with water, juice or as instructed by the
healthcare provider.
6. With one hand, hold the medication cup or syringe containing the
medication towards the patient’s mouth.
7. Verify the correct medication is in the mouth and have the patient
swallow it.
8. Offer the patient with more water or juice or other fluids as
necessary. For patients who have difficulty swallowing solid forms,
provide the medication in the appropriate liquid form.
9. Observe the patient for any adverse reactions such as vomiting,
nausea, or difficulty swallowing.
10. Document the medication administration, including the
name of the medication, dosage, and the time of
administration.
11. Dispose of any used equipment, including medication cups,
and wash your hands.
 .

Skill 85 Documenting medication administration:

1. Verify the patient's identity using two unique identifiers, such as their
name, date of birth, medical record number, ID bracelet, or photo
identification.
2. Review the medication order to ensure that it is correct and not expired.
3. Administer the medication as per the medication administration protocol.
4. Immediately following the medication administration, thoroughly
document the administration of the medication in the patient's
medical record or electronic medical record. Document the
following:
 The name of the medication
 The dose, route, and time of administration
 Any adverse reactions observed
 Instructions or additional notes provided to the patient
5. If the medication administration was refused by the patient,
document the conversation and reason for refusing.
6. If any medication errors occurred, document the error and report it to
the healthcare/provider and supervisor in accordance with facility
protocols and policies.
7. Ensure that medication administration documentation is
completed in a timely and appropriate manner.
8. Help resolve discrepancies or inconsistencies in medication
administration by consulting with the healthcare provider, pharmacist
or other nursing staff as necessary.
9. Always accurately and thoroughly document medication
administration to ensure that the care provided to patients is
consistent, effective, and safe
 .

Skill 86 Handling medication variations:

1. Verify the patient's identity using two unique identifiers, such as their
name, date of birth, medical record number, ID bracelet, or photo
identification.
2. Check the medication order and medication label and compare
them, ensuring that the medication name, dose, and route are
the same.
3. Contact the healthcare provider or pharmacist for any
clarification or discrepancy in the medication order or label.
4. If the medication is different from the original medication order or
label, confirm with the healthcare provider or pharmacist if the change
is due to the change in the patient’s condition or an error in the
previous medication order.
5. If the medication variation is due to a change in the patient’s
condition or a proper medication substitution, follow the new
medication administration protocols provided by the healthcare
provider or pharmacist.
6. If the medication variation is due to a medication error, report the
error immediately to the healthcare provider, charge nurse, and
document the medication error according to facility policy and
procedures.
7. Educate the patient about the medication variation, and provide
them/list them with the correct medication name, dose, and any
changes in medication schedule.
8. If applicable Explain the patient that drugs often come in different
physical forms, depending on the manufacturer.
9. Document the medication variation, including the medication name,
dose, route, and any instructions or notes provided to the patient, and
any changes made to the medication order.

Note: Handling medication variations is an important nursing

responsibility to ensure that medication errors are prevented and the
patients receive the correct medications in the correct doses.

Always verify the medication name, dose, and route with the medication
order and label for each medication administered to avoid medication errors.
Follow the
 .

medication administration protocols provided by the healthcare provider or

pharmacist to ensure that the patient receives the correct medication in the
correct dose. If there is any discrepancy, seek clarifications from the
healthcare provider or pharmacist. Report any medication error to the
appropriate personnel if an error exists.

 Record the medication, dose, route, and time of administration on the

MAR or computer printout immediately after administration. Include
your initials or signature.
 If a narcotic is refused and discarded, document the narcotic waste
according to facility policy, and include the signature of the nurse who
witnessed the waste.
 If a medication is refused, document that it was not given, the
patient’s reason for refusal, and the time at which the health care
provider was notified.
 If a medication is held because of a contraindication, follow facility
policy for documenting the withheld dose. Notify the health care
provider if indicated, and record the time of notification and reason
for withholding.
 For PRN medications, document the time, dose and route of
administration in the MAR. Include the indication for giving the PRN
medication. After waiting the appropriate amount of time, reassess the
patient for response to the PRN medication and document the
response.

Skill 87 The Six Rights of Medication Administration:

1. Right Patient: Verify the patient's identity using two unique identifiers,
such as their name, date of birth, medical record number, ID bracelet,
or photo identification.
 .
2. Right Medication: Check the medication order against the
medication label and packaging to verify that the right medication is
being administered. Check the medication expiration date.
3. Right Dosage: Confirm the prescribed dosage and ensure that it is
within the safe dosage range for the patient's age, weight, and
medical condition. Confirm laboratory values, if relevant.
4. Right Time: Administer the medication at the prescribed time or
within the prescribed timeframe, ensure that the frequency of
administration matches the order.
5. Right Route: Check the medication order to confirm the prescribed
route of administration, such as oral, intravenous, subcutaneous,
intramuscular, transdermal, inhalation, or another appropriate
route. Ensure that the administration method is safe and
appropriate.
6. Right Documentation: Document the medication administration in the
patient's medical record, including the medication name, dosage,
route, time of administration, and any adverse reactions or concerns.

Note: Ensuring the Six Rights of Medication Administration is an important

nursing responsibility that involves verifying that the right patient receives the
right medication, at the right dosage, at the right time, using the right route of
administration, and documenting the right information.

Along with the Six Rights of Medication Administration, follow the Five Rules
of Medication Administration - right medication, with the right patient, at the
right time, by the right route, and the right documentation – for a safe
medication administration process. Always adhere to infection control
protocols, ensure proper storage of medications, monitor the patient for any
adverse reactions, and provide education to the patient about their
medications.
.
 .

Skill 88 Using automated medication dispensing systems:

1. Access the automated medication dispensing system using the

unique identification code or login credentials assigned by the
healthcare facility.
2. Enter the patient's information, such as the name, date of birth, or
medical record number, into the system to access their medication
orders.
3. Verify the medication order and dosage, ensuring that they match
the patient's medical history, allergies, and other medications to
identify any potential drug interactions or allergies.
4. Follow the prompts to select the correct medication from the system,
ensuring that the medication label matches the medication order.
5. Verify the correct medication by scanning the barcode on the
medication label or using other automated medication verification
methods, such as radio- frequency identification (RFID) technology.
6. Follow the prompts to select the correct dose and route of
medication administration, as per the healthcare provider's
instructions.
7. Administer the medication to the patient as per the
medication administration protocol.
8. Immediately document the medication administration in the
patient's medical records or electronic records system.
9. Dispose of any unused or expired medication according to the
healthcare facility's policies and procedures.
10. If there are any issues with the automated medication
dispensing system, such as a malfunction or error message,
promptly notify the appropriate personnel for troubleshooting.
11. Participate in staff education sessions and review the facility's
policies and procedures for using automated medication dispensing
systems regularly.
 12. Adhere to infection control protocols while using the automated
medication dispensing systems.

Note: Automated medication dispensing systems are commonly used in

healthcare facilities to ensure accurate medication administration and reduce
medication errors

Automated medication dispensing systems are highly effective in preventing

medication errors, but it is essential to follow proper procedures and
protocols to use them correctly. Be familiar with the system's technology
and functions to avoid any malfunctions, and promptly notify the
appropriate personnel if there are any issues. Accurately document
medication administration in the patients’ medical records.

Skill 89 Administering Ear medications:

Step 1: Check the medication order

Before administering any medication, always check the medication order in

the chart to verify the patient's name, medication, dose, and frequency.
Ensure that you are administering the correct medication as prescribed by
the healthcare provider.
Step 2: Wash your hands Wash your hands thoroughly with soap and warm
water. Dry your hands with a clean towel or paper towel. This will help
prevent the spread of bacteria and infection.

Step 3: Prepare the medication Shake the medication bottle well to ensure
that the medication is mixed properly. Use a dropper or syringe to draw the
prescribed amount of medication into the applicator.

Step 4: Position the patient Position the patient in a comfortable position, lying
on their side with the affected ear facing up. Make sure that the patient's head
is supported with a pillow or cushion.

Step 5: Administer the medication Slowly insert the applicator into the
patient's ear canal, being careful not to touch the ear with the dropper or
syringe. Gently squeeze the applicator to administer the medication into the
ear canal. If necessary, you can gently massage the ear to help distribute
the medication.
Step 6: Allow the patient to remain in position Allow the patient to remain in
the same position for a few minutes to allow the medication to flow into the
ear canal. If the patient needs to turn over to administer medication in the
other ear, assist the patient in repositioning and ensure that the head is
supported.

Step 7: Discard the applicator Discard the applicator as per institutional

policies.

Step 8: Document the medication administration Document the medication

administration in the patient's medical record. Record the date, time,
medication, dose, and route of administration.
Skill 90 Administering eye medications:

1. Verify the medication order: Before administering any eye

medication, the nurse must first verify the medication order with
the physician or the pharmacist.
2. Identify the patient: Confirm the patient's identity using two
patient identifiers, such as their name and date of birth.
3. Wash hands and wear gloves: Wash hands with soap and water
and wear gloves to prevent the spread of infection.
4. Explain the procedure: Explain the procedure to the patient, including
what medication will be given and how it will be administered.
5. Position the patient: Position the patient in an upright or supine
position with their head tilted back unless otherwise instructed.
6. Cleanse the eye: Using a clean and moistened cotton ball, cleanse
the eye from the inner to the outer canthus to remove any
discharge or debris.
7. Administer the medication: Hold the medication dropper over the eye,
avoiding contact with the eye, lashes, or eyelids. Gently pull the lower
eyelid down to create a pouch, and instruct the patient to look up at
the ceiling.
8. Instill the correct number of drops into the eye, as ordered by the
physician, and release the lower eyelid.
9. Close the eye: Instruct the patient to close their eye gently, without
squeezing. Ask them to apply gentle pressure to the inner corner of
the eye for a few minutes with a clean tissue or cotton ball to prevent
the medication from draining into the nasolacrimal duct.
10. Remove gloves and wash hands: Carefully remove gloves and
wash hands with soap and water.
11. Document the administration: Record the medication name,
dosage, route, time, and any observations made during the
procedure in the patient's medical record.
12. Instruct the patient: Instruct the patient on any post-
administration care or adverse reactions to be aware of.
Skill 91 Applying an estrogen patch and nitroglycerin ointment:

Applying an Estrogen Patch:

1. Verify the medication order: Before applying an estrogen patch or

any other medication, the nurse must first verify the medication
order with the physician or the pharmacist.
2. Identify the application site: Identify the site where the estrogen
patch will be applied. The site should be clean, dry, and free from
hair.
3. Clean the area: Clean the area with soap and water or an alcohol
swab. Dry the area thoroughly before applying the patch.

4. Prepare the patch: Remove the patch from the packaging and remove
the protective liner. Hold the patch by the edges and avoid touching
the adhesive surface.
5. Apply the patch: Apply the patch to the cleaned and dried area and
press it firmly for a few seconds to ensure proper adhesion.
6. Dispose of the supplies: After applying the patch, dispose of
any used supplies, such as gloves or applicators.
7. Document the administration: Document the medication
administration in the patient's medical record, which should include
the medication name, dosage, route, time, and any observations
made during the procedure.
8. Instruct the patient: Instruct the patient on the placement and
duration of the patch, and advise them to avoid activities that may
cause the patch to come off, such as swimming or showering.

Applying Nitroglycerin Ointment:

1. Verify the medication order: Before applying nitroglycerin ointment

or any other medication, the nurse must first verify the medication
order with the physician or the pharmacist.
2. Identify the application site: Identify the site where the
nitroglycerin ointment will be applied. The site should be clean,
dry, and hairless.
3. Clean the area: Clean the area with soap and water or an alcohol
swab. Dry the area thoroughly before applying the ointment.
4. Prepare the ointment: Measure the appropriate amount of nitroglycerin
ointment using the supplied measuring strip or depending on the
instructions from the physician.
5. Apply the ointment: Apply the measured dose of ointment to the
cleaned and dried area, and smooth it evenly over the skin.
6. Cover the area: If appropriate, cover the area loosely with
gauze or a dressing.
7. Dispose of the supplies: After applying the ointment, dispose of
any used supplies, such as gloves or applicators.
8. Document the administration: Document the medication
administration in the patient's medical record, which should include
the medication name, dosage, route, time, and any observations
made during the procedure.
9. Instruct the patient: Instruct the patient on the placement and
frequency of the ointment and advise them to consult the healthcare
provider if they experience any adverse reactions or side effects.
Skill 92 Applying topical medications:

1. Verify the medication order: Before applying any topical

medication, the nurse must first verify the medication order with
the physician or the pharmacist.
2. Wash hands: It is important to maintain strict hand hygiene by
washing hands with soap and water before administering any
topical medication.
3. Clean the area: Clean the area where the medication will be applied
with a clean, moist towel. If the area is already contaminated or has
debris, the nurse should clean it more thoroughly.
4. Prepare the medication: Prepare the medication as per the prescription
or the medication package instruction. Wear gloves if necessary or as
per the facility's policy, especially while handling any ointments or
creams.
5. Apply the medication: Using a sterile applicator, apply the medication
to the affected area, spreading it evenly. Use gentle pressure to make
sure the medication is absorbed.
6. Dispose of the supplies: After applying the medication, dispose of
any used supplies, such as gloves, applicators, or gauze, as per the
facility's infection control policy.
7. Document the administration: Document the medication
administration in the medical record, which should include the
medication name, dosage, route, time, and any observations made
during the procedure.
8. Monitor the patient: Monitor the patient's response to the medication
closely, observing for any adverse reactions or side effects. Instruct
the patient to report any concerns, and inform the healthcare provider
if necessary.
Skill 93 Inserting a rectal suppository:

Step 1: Check the medication order

Before administering any medication, always check the medication order in

the chart to verify the patient's name, medication, dose, and frequency.
Ensure that you are administering the correct medication as prescribed by
the healthcare provider.

Step 2: Wash your hands Wash your hands thoroughly with soap and warm
water. Dry your hands with a clean towel or paper towel. This will help
prevent the spread of bacteria and infection.

Step 3: Prepare the suppository

Remove the suppository from the packaging and check for any
abnormalities or damage. If the suppository is too soft or has melted, keep it
in the fridge for some time to make it hard enough for insertion. If
necessary, use gloves to handle the suppository.

Step 4: Position the patient

Position the patient in a comfortable position, preferably lying on their left

side with their knees bent towards their chest. You can use a pillow to
support their head and neck.
Step 5: Lubricate the suppository

Apply a small amount of a water-based lubricant, such as KY jelly or

petroleum jelly, to the rounded end of the suppository.

Step 6: Insert the suppository

Gently spread the patient's buttocks to expose the rectal opening. With one
hand, hold the suppository near the rounded end, and with the other hand,
separate the patient's buttocks. Gently insert the suppository into the
rectum, pointed end first, about an inch into the rectum. You may ask the
patient to bear down like a bowel movement to make it easier to insert the
suppository.

Step 7: Advise the patient

Advise the patient to remain in the same position for a few minutes and
avoid using the bathroom for at least 30 minutes to allow the suppository to
dissolve and provide the desired effect.
Step 8: Discard the packaging Discard the packaging and any used materials
as per institutional policies.

Step 9: Wash your hands Wash your hands thoroughly with soap and warm
water after the procedure.

Step 10: Document the medication administration

Document the medication administration in the patient's medical record.

Record the date, time, medication, dose, and route of administration
Skill 94 Using a dry powder inhaler:

Step 1: Check the medication order

Before administering any medication, always check the medication order in

the chart to verify the patient's name, medication, dose, and frequency.
Ensure that you are administering the correct medication as prescribed by
the healthcare provider.

Step 2: Wash your hands

Wash your hands thoroughly with soap and warm water. Dry your hands with
a clean towel or paper towel. This will help prevent the spread of bacteria
and infection.

Step 3: Explain the procedure to the patient

Explain the procedure to the patient and ensure that they understand how
to use the dry powder inhaler correctly.

Step 4: Check the expiration date of the inhaler

Check the expiration date of the inhaler to ensure that it is not

expired. Step 5: Load the dose
Load the dose of medicine into the inhaler according to the
manufacturer's instructions.

Step 6: Position the patient

Position the patient in a comfortable and upright position, and ensure that the
patient's mouth and throat are free from any food or fluid.

Step 7: Instruct the patient to exhale Instruct the patient to exhale fully
through their mouth to empty their lungs before inhaling the medication.

Step 8: Instruct the patient to inhale Instruct the patient to inhale deeply and
forcefully through their mouth to breathe in the medication.
Step 9: Instruct the patient to hold their breath

Instruct the patient to hold their breath for about 10 seconds to allow
the medication to settle in their lungs.

Step 10: Teach the patient correct use of the inhaler

Instruct the patient to close their lips tightly around the mouthpiece of the
inhaler to ensure that the medication is inhaled properly.

Step 11: Clean the inhaler

Clean the inhaler as per institutional policies.

Step 12: Document the medication

administration
Document the medication administration in the patient's medical record.
Record the date, time, medication, dose, and route of administration.

Skill 95 Using a metered-dose inhaler:

Step 1: Check the medication order: Before administering any medication,

always check the medication order in the chart to verify the patient's name,
medication, dose, and frequency. Ensure that you are administering the
correct medication as prescribed by the healthcare provider.

Step 2: Wash your hands: Wash your hands thoroughly with soap and warm
water. Dry your hands with a clean towel or paper towel. This will help
prevent the spread of bacteria and infection.
Step 3: Explain the procedure to the patient: Explain the procedure to the
patient and ensure that they understand how to use the metered-dose
inhaler correctly.

Step 4: Check the expiration date of the inhaler: Check the expiration date of
the inhaler to ensure that it is not expired.
Step 5: Prepare the medication: Remove the cap from the inhaler and shake
the inhaler well to ensure that the medication is mixed properly.

Step 6: Attach the spacer: Attach the spacer to the inhaler if instructed by the
healthcare provider.

Step 7: Position the patient: Position the patient in a comfortable and upright
position, and ensure that the patient's mouth and throat are free from any
food or fluid.

Step 8: Instruct the patient to exhale: Instruct the patient to exhale fully
through their mouth to empty their lungs before inhaling the medication.

Step 9: Instruct the patient to inhale: Instruct the patient to inhale deeply
and slowly through their mouth while pressing down on the inhaler to
release the medication.
Step 10: Instruct the patient to hold their breath: Instruct the patient to hold
their breath for about 10 seconds to allow the medication to settle in their
lungs.

Step 11: Instruct the patient to exhale: Instruct the patient to exhale slowly
through their mouth to empty their lungs.

Step 12: Clean the inhaler: Replace the cap on the inhaler and clean the
inhaler as per institutional policies.

Step 13: Document the medication administration: Document the

medication administration in the patient's medical record. Record the date,
time, medication, dose, and route of administration.
Skill 96 Administering intradermal injections:
1. Wash hands and gather equipment: Before starting, wash your
hands with soap and water. Gather all the necessary equipment,
including the medication, an insulin syringe, a small needle, alcohol
wipes, a gauze pad, and adhesive bandage.
2. Prepare the injection site: Identify the injection site on the patient's
arm, usually on the inner forearm. Clean the area with an alcohol wipe,
starting from the center and moving outwards in a circular motion.
Allow it to air dry.
3. Hold the skin taut: Hold the patient's skin taut with the non-dominant
hand to create a tight surface for the injection.
4. Insert the needle: With the other hand, gently insert the needle at a
10–15-degree angle, with the bevel up, just under the epidermis. The
needle should only enter the top layer of skin, not the muscle.
5. Inject the medication: Slowly inject the medication under the skin,
making sure the medication forms a wheal, a small, raised bump on
the skin.
6. Remove the needle: Remove the needle from the skin at the same
angle you inserted it, being careful not to touch the needle or the
injection site.
7. Apply pressure and bandage: Using a gauze pad, apply pressure to
the injection site for a few seconds to stop any bleeding. Then, cover
the site with an adhesive bandage.
8. Discard the equipment: Since the needles are single use only, you
should discard them in a sharps container immediately after
administering the injection.
9. Document the administration: Document the administration
of the intradermal injection in the patient's medical record,
including the medication used, the dosage, the time, and any
adverse reactions or symptoms.
Skill 97 Administering intramuscular injections:

1. Verify the patient’s identity by checking their name and medical record
number.
2. Explain the injection procedure to the patient, including the potential side
effects and the benefits.
3. Select the appropriate needle and medication for the patient’s condition.
4. Wash your hands and put on gloves.
5. Choose the injection site based on the patient’s age and medical
condition. Common injection sites for adults include the deltoid muscle in
the upper arm, the vastus lateralis muscle in the thigh, and the gluteus
Medius muscle in the buttock.
6. Clean the injection site with an antiseptic pad and allow it to dry.
7. Remove the needle cap from the syringe, ensuring that the needle
doesn’t touch anything.
8. Hold the needle at a 90-degree angle to the skin and quickly insert it
into the muscle.
9. Aspirate, or pull back on the plunger, to check for blood. If you see
blood in the syringe, remove the needle and start again.
10.Inject the medication slowly and steadily.
11.Remove the needle and place a dry cotton ball or gauze pad over the
injection site.
12.Apply light pressure to the injection site to prevent bleeding.
13.Dispose of the used needle and syringe in a sharp container.
14.Document the injection in the patient’s medical record, including the
medication name, dosage, injection site, and any adverse reactions.
15.Provide any necessary aftercare instructions to the patient, such as
applying heat or ice to the injection site or monitoring for side effects.
Skill 98 Administering subcutaneous injection:

1. Wash hands and gather equipment: Before starting, wash your

hands with soap and water. Gather all the necessary equipment,
including the medication, an insulin syringe or pen, alcohol wipes, a
gauze pad, and an adhesive bandage.
2. Prepare the injection site: Identify the injection site on the patient's
abdomen, thigh, upper arm, or buttocks. Clean the area with an
alcohol wipe, starting from the center and moving outwards in a
circular motion. Allow it to air dry.
3. Pinch the skin: Depending on the injection site, use your non-
dominant hand to pinch the skin at the injection site to create a small
fold. This will help ensure the medication is injected into
subcutaneous fat.
4. Insert the needle: With the other hand, gently insert the needle at a
45- degree angle for an insulin syringe or 90-degree angle for an
insulin pen, into the skin fold. The needle should be inserted quickly
and smoothly, with one swift motion.
5. Inject the medication: Slowly inject the medication into the
subcutaneous fat, being careful not to inject into muscle. Inject the
medication at a steady pace in order to reduce pain and minimize
tissue trauma.
6. Remove the needle: Once the medication is fully administered,
quickly remove the needle from the skin. Do not rub the injection site
after removing the needle.
7. Apply pressure and bandage: Using a gauze pad, apply pressure to
the injection site for a few seconds to stop any bleeding. Then, cover
the site with an adhesive bandage.
8. Discard the equipment: Since the needles are single-use only, you
should discard them in a sharps container immediately after
administering the injection.
9. Document the administration: Document the administration of
the subcutaneous injection in the patient's medical record,
including the medication used, the dosage, the time, and any
adverse reactions or symptoms.
Skill 99 Drawing up more than one type of insulin:

1. Wash hands and gather equipment: Before starting, wash your hands
with soap and water. Gather all the necessary equipment, including
the two types of insulin, two insulin syringes, alcohol wipes, and a
sharps container.
2. Check the insulin: Check both vials of insulin for any abnormalities,
such as clumps or discoloration. If you notice anything unusual, do
not use insulin and notify the healthcare provider.
3. Withdraw air into the syringes: Pull air into the syringe for the long-
acting insulin equal to the desired dose. Then, do the same for the
short-acting insulin vial.
4. Draw up the long-acting insulin: Inject the needle into the long-acting
insulin vial and inject the air into it. Flip the vial and draw up the
insulin dose, making sure to remove any air bubbles. Then, remove
the needle from the vial.
5. Draw up the short-acting insulin: Inject the needle into the short-
acting insulin vial and inject the air into it. Flip the vial and draw up
the insulin dose, making sure to remove any air bubbles.
6. Check the dosage: Double-check the dosage for both types of insulin
to ensure that you have drawn up the correct amount.
7. Administer the insulin: Choose the injection site and administer the
long- acting insulin first. Then, administer the short-acting insulin.
Make sure to rotate injection sites to avoid developing
lipohypertrophy, which is a buildup of fat tissue under the skin.
8. Discard the needles: Since the needles are single-use only, you should
discard them in a sharps container immediately after administering
the insulin.
9. Document the administration: Document the administration of both
types of insulin in the patient's medical record, including the time and
the dosage given.
Skill 100 Preparing and administering insulin:
Step 1: Check the medication order Before preparing or administering any
insulin, always check the medication order in the chart to verify the patient's
name, medication, dose, and frequency. Ensure that you are administering
the correct insulin as prescribed by the healthcare provider.
Step 2: Wash your hands thoroughly with soap and warm water. Dry your
hands with a clean towel or paper towel. This will help prevent the spread of
bacteria and infection.

Step 3: Gather supplies Gather all the supplies you need, including alcohol
swabs, insulin vial, syringe, and needle.

Step 4: Inspect the insulin and vial Inspect the insulin and vial visually to
ensure that they are intact and free of any debris or particles. If they appear
discolored or questionable in any way, discard them and use new ones.

Step 5: Wash the rubber top of the insulin vial. Use an alcohol swab to clean
the rubber top of the insulin vial. Do not touch the top with your fingers
after cleaning to maintain cleanliness.

Step 6: Draw up air into the syringe Pull back the plunger to draw up the
amount of air equal to the dosage of insulin prescribed by the health care
provider.

Step 7: Inject the air into the insulin vial. Insert the needle into the rubber top
of the insulin vial and inject the air into the vial before removing the needle.

Step 8: Turn the vial over, and gently draw up the prescribed amount of insulin
into the syringe with the needle.

Step 9: Expel any air bubbles Check for air bubbles, and if any are seen,
gently tap the syringe while holding it with the needle pointing up to cause
the bubbles to rise to the top. Then, gently push the plunger to expel the air
bubbles, and readjust the dose as needed.

Step 10: Prepare the injection site Choose the injection site by rotating the
sites on the body. Wipe the site with an alcohol swab and wait for it to dry.

Step 11: Administer the insulin Insert the needle into the injection site at a
90- degree angle, and slowly push the plunger to inject the insulin. Wait for
10 seconds to allow the insulin to be absorbed before removing the needle.

Step 12: Discard the needle and syringe

Safely dispose of the needle and syringe as per institutional policies.

Step 13: Document the medication administration

Record the date, time, medication, dose, and route of administration in

the patient's medical record.
Skill 101 Preparing injections from a vial:
Step 1: Check the medication order Before preparing any medication, always
check the medication order in the chart to verify the patient's name,
medication, dose, and frequency. Ensure that you are preparing the correct
medication as prescribed by the healthcare provider.

Step 2: Wash your hands Wash your hands thoroughly with soap and warm
water. Dry your hands with a clean towel or paper towel. This will help
prevent the spread of bacteria and infection.

Step 3: Gather supplies Gather all the supplies you need, including alcohol
swabs, sterile syringe, and needle.

Step 4: Inspect the vial Inspect the vial visually to ensure that it is intact
and free of any cracks or chips. If it is damaged, discard it and use a new
vial.

Step 5: Clean the top of the vial Clean the top of the vial with an alcohol swab
to remove any dirt or debris. Wait for the alcohol to dry.

Step 6: Assemble the syringe and needle Assemble the syringe and needle,
and remove the needle cap.

Step 7: Draw air into the syringe Pull back on the plunger to draw air into the
syringe equal to the amount of medication that is to be administered.
Step 8: Inject the air into the vial Insert the needle into the center of the
rubber top of the vial and inject the air into the vial. This equalizes the
pressure in the vial and makes it easier to draw the medication.

Step 9: Invert the vial and draw up the medication Invert the vial with the
needle still in the medication, and draw up the medication slowly into the
syringe to the desired amount.

Step 10: Expel any air bubbles Hold the syringe with the needle pointing
upwards, push the plunger slightly until a small drop of medication or air
comes out the tip. This expels any air bubbles to ensure accurate dosage of
medication.
Step 11: Discard the needle Remove the needle from the vial, and dispose of
it safely as per institutional policies.

Step 12: Clean the injection site Clean the injection site with an alcohol swab
and allow it to dry.

Step 13: Administer the injection Administer the injection using proper
technique while carefully monitoring the patient.

Step 14: Discard used materials Dispose of all used materials safely
and appropriately as per institutional policies.

Step 15: Document the medication administration Record the date,

time, medication, dose, and route of administration in the patient's
medical record.

That's it. Remember to always check the medication order and follow strict
infection control protocols while preparing injections.

Skill 102 Preparing injections from an ampule:

Step 1: Check the medication order.
Before preparing any medication, always check the medication order in the
chart to verify the patient's name, medication, dose, and frequency. Ensure
that you are preparing the correct medication as prescribed by the
healthcare provider.
Step 2: Wash your hands
Wash your hands thoroughly with soap and warm water. Dry your hands
with a clean towel or paper towel. This will help prevent the spread of
bacteria and infection.

Step 3: Gather supplies

Gather all the supplies you need, including alcohol swabs, sterile syringe
and needle, and the ampule.

Step 4: Inspect the ampule

Inspect the ampule visually to ensure that it is intact and free of any cracks
or chips. If it is damaged, discard it and use a new ampule.
Step 5: Clean the top of the ampule
Clean the top of the ampule with an alcohol swab to remove any dirt or
debris. Wait for the alcohol to dry.

Step 6: Snap the top of the ampule

Hold the ampule upright between your fingers and snap off the top of the
ampule quickly and firmly. Use a sterile gauze or tissue to avoid cuts from
the broken glass.

Step 7: Remove any excess solution Hold the ampule vertically and tap it
gently to remove any excess solution that may be clinging to the sides.
Step 8: Aspirate the solution into the syringe

Insert the needle into the center of the open ampule and aspirate the
solution into the syringe slowly.

Step 9: Expel any air bubbles Hold the syringe with the needle pointing
upwards, push the plunger slightly until a small drop of medication or air
comes out the tip. This expels any air bubbles to ensure accurate dosage of
medication.
Step 10: Discard the needle
Remove the needle from the ampule, and dispose of it safely as per
institutional policies.

Step 11: Clean the injection site

Clean the injection site with an alcohol swab and allow it to dry.

Step 12: Administer the injection

Administer the injection using proper technique while carefully monitoring the
patient.

Step 13: Discard used materials

Dispose of all used materials safely and appropriately as per

institutional policies.

Step 14: Document the medication administration

Record the date, time, medication, dose, and route of administration in

the patient's medical record.
Skill 103 Dressing the infusion site:

1. Verify the patient’s identity by checking their name and medical record
number.

2. Explain the dressing procedure to the patient and inform them of

any post- procedure care.
3. Gather all the necessary equipment, including gauze pads, adhesive tape,
and an antiseptic solution or alcohol swab.
4. Wash your hands thoroughly with soap and water, and put on gloves.

5. Check the infusion site for any signs of redness, swelling, or irritation.
If any issues are present, notify the clinician in charge of the patient.
6. Clean the area around the infusion site with an antiseptic solution or
alcohol swab. If the site is particularly dirty or heavily contaminated, cover
the entire area with an antiseptic-dampened gauze pad and clean from the
inside out.

7. Gently remove the old dressing, taking care not to dislodge the
catheter or any other tubing connected to the infusion site.
8. Place a new gauze pad over the infusion site, making sure to cover
the entire area.
9. Secure the gauze pad with adhesive tape, ensuring that it is not too tight
or too loose. The tape should be long enough to extend several centimeters
past the gauze pad on all sides.
10.Check the infusion site frequently for any signs of irritation, such as
redness, swelling, or pus discharge. Notify the clinician in charge of the
patient immediately if any issues arise.
11.Remove the dressing if it becomes saturated with fluid, dislodged,
or if the catheter is removed.
12.Document the dressing change in the patient's medical record,
including any observed issues with the infusion site and the type of
dressing used.

Remember to always follow appropriate safety measures and

guidelines when dressing an infusion site.
Skill 104 Performing venipuncture:

1. Verify the patient’s identity by checking their name and medical record
number.

2. Explain the venipuncture procedure to the patient, including the

potential side effects and the benefits.
3. Gather all necessary equipment, including the blood collection tube,
needle or butterfly catheter, antiseptic pad or alcohol swab, tourniquet or
band, and adhesive bandage or cotton ball.

4. Wash your hands and put on gloves.

5. Choose an appropriate vein for the venipuncture. Common sites
include the inside of the elbow, the back of the hand, and the wrist.
6. Apply a tourniquet or band to the patient's arm above the intended
insertion site to create venous stasis.

7. Clean the insertion site with an antiseptic pad or alcohol swab, using
back-and- forth motions starting from the center of the insertion site and
moving outward to clean a two-inch circle.
8. Allow the area to dry for at least 10-15 seconds.
9. Make a fist to further increase the visibility and accessibility of the veins.

10.Insert the needle or butterfly catheter into the vein at a 15- to 30-
degree angle with the bevel facing upward.
11.Once you notice the flashback of blood in the hub of the needle,
advance the needle further into the vein while holding the catheter to
avoid possible displacement.

12.Release the tourniquet or band before releasing the needle.

13.Make sure to fill the blood collection tube according to the required
volume and multiple tubes should be taken if necessary.
14.Steadily withdraw the needle or catheter and apply pressure on the
insertion site with a cotton ball for a few minutes until the bleeding stops.
 15.Apply an adhesive bandage over the collection site or cotton ball.

16.Properly dispose of the used needles, tubes, and medical waste in an

appropriate biohazard container.

17.Document the venipuncture procedure in detail in the patient's medical

record, including the type of test, the volume of blood collected, and any
adverse reactions.

Remember to always follow appropriate safety measures and guidelines when

performing venipuncture.

Skill 105 Preparing an infusion site:

1. Verify the patient’s identity by checking their name and medical record
number.
2. Explain the infusion procedure to the patient, including the potential side
effects and the benefits.
3. Gather all necessary equipment, including the infusion bag, tubing, and
needle or catheter.
4. Wash your hands and put on gloves.
5. Choose a suitable site for the infusion, typically the back of the patient's
hand or the inner forearm.
6. Clean the infusion site with an antiseptic pad and allow it to dry.
7. Put on a sterile drape or towel to cover the surrounding area around the
infusion site.
8. Apply a tourniquet above the infusion site to help increase venous pressure.

9. Ask the patient to make a fist to further enhance the visibility of veins.
10.Insert the catheter or needle into the vein, taking care to avoid
penetrating through the back wall of the vein.
11.Once the needle or catheter is in place, release the tourniquet and
adjust the catheter or needle position, if required.

12.Remove the needle and attach the tubing to the catheter or needle.
13.Start the infusion at the prescribed rate based on the type of medication
and the patient's medical condition.
14.Monitor the patient and the infusion site during the procedure,
checking for discomfort, swelling, or signs of infection.

15.When the infusion is complete, remove the needle or catheter and

clean the infusion site with an antiseptic pad.
16.Dispose of all used needles, catheters, and tubing in a sharps container.

Skill 106 Assessing Troubleshooting intravenous infusions:

1. Verify the patient’s identity by checking their name and medical record
number.
2. Assess the patient’s condition to determine if there are any issues that
need your immediate intervention.
3. Check the IV tubing for any kinks or bends that may be limiting the flow
of the infusion.
4. Check the IV catheter for signs of infiltration or phlebitis, such as
redness, swelling or pain.

5. Check the IV site for signs of infection, such as warmth, redness or drainage.
6. Check the IV bag for any leaks or damage that may compromise the
integrity of the solution.
7. Check the IV pump to ensure it is properly calibrated and programmed.
8. Check the patient's vital signs, such as blood pressure and heart rate, to
ensure they are stable and within normal range.
9. Confirm the prescribed medications or fluids, as well as the rate of flow
and the route of administration

10.Adjust the position of the patient's arm, wrist, or hand to help increase
venous pressure.
11.Adjust the position of the tubing or the IV bag to prevent any
obstructions, such as air bubbles.
12.Try flushing the IV with a saline solution or slowly adjusting the infusion
rate to clear any obstructions.
13.Notify the clinician in charge of the patient of any issues or adverse
reactions.
14.If necessary, remove the IV catheter and restart the infusion at a
different site or using a different catheter.
15.Document any interventions or changes in the patient's medical
record and communicate them to the clinician in charge of the patient.

Remember to always follow appropriate safety measures and guidelines when

troubleshooting intravenous infusions.

Skill 107 Changing intravenous dressing:

1. Verify physician’s orders: Before changing the intravenous

dressing, it is essential to double-check if there are any physician’s
orders that need to be followed. Ensure that it's safe to change the
dressing.
2. Gather supplies: Gather all of the supplies you will need for the
procedure, including disposable gloves, sterile gauze, antiseptic wipes,
and a transparent dressing.

3. Wash or sanitize your hands: Before starting, wash or sanitize your

hands thoroughly.
4. Explain the process to the patient: Tell the patient what you’ll be doing
and what they may experience. Reassure them that the process should be
quick and painless.
5. Prepare the patient: Make sure the patient is comfortable and
properly positioned, with the arm extended and slightly bent at the
elbow.
6. Remove the old dressing: Gently remove the old dressing that covers the
insertion site. Pull the dressing back slowly and avoid pulling it violently as
this may be painful for the patient.
7. Clean the site: Clean the catheter site with the antiseptic wipe and
make sure that it’s cleaned thoroughly. Allow it enough time to air dry.
8. Apply sterile gauze: Apply a sterile gauze pad around the catheter site,
pressing it gently but firmly to absorb any fluid leakage.
9. Apply a new dressing: Place a new transparent dressing over the sterile
gauze. Ensure that the dressing is secure but not too tight that it may
cause discomfort.
10.Document: Document the date and time of the procedure, the
condition of the site, and any complications (if any).

Following these steps will ensure that the catheter site is clean and free of
infection. This will also help in preventing infiltration or dislodgement of the
catheter while maintaining patient comfort.

Skill 108 Changing intravenous tubing and fluids:

1. Verify physician’s orders: Before changing the intravenous tubing and

fluids, it is essential to double-check if there are any physician’s orders that
need to be followed. Make sure you have the correct type and dosage of
fluid prescribed.
2. Gather supplies: Gather all of the supplies you will need for the
procedure, including a new IV bag or bottle, a new IV tubing, an alcohol
swab, and gloves.

3. Wash or sanitize your hands: Before starting, wash or sanitize your

hands thoroughly.
4. Explain the process to the patient clearly: Tell the patient what you’ll be
doing and what they may experience. Reassure them that the process
should be quick and painless.
5. Stop the current IV flow and clamp it: Stop the current IV flow by
closing the clamp on the IV tubing.
6. Remove the existing tubing: Remove the existing tubing from the
catheter and dispose of it safely.
7. Remove the old IV solution bag: Disconnect the current IV bag or
bottle and safely get rid of it. Be sure to review the contents before
disposing of it.

8. Prepare the new IV tubing: Open the packaging of the new IV tubing and
ensure that the priming fluid is appropriately marked.
9. Prime the new tubing: Open the stopcock or roller clamp, hang the new
IV bag, and make sure it is properly secured. Prime the IV tubing by
running the priming fluid through it until the fluid reaches the end of the
tubing. Make sure that there are no air bubbles in the tubing.

10.Connect the new tubing and start the flow: Connect the new IV tubing
to the catheter and start the flow slowly. The flow rate should not exceed
the recommended infusion rate.
11.Observe the site and observe the patient: Observe the IV site and the
patient for signs of inflammation or infection. Take note of any side effects
to ensure correct response.

12.Document: Document the date and time of procedure, the type and
dosage of fluid used (when it was discontinued and replaced), and any
complications.

Following these steps can help maintain proper intravenous hydration

and medication delivery for patients while avoiding infections,
inflammations or contamination of the fluids.
Skill 109 Regulating intravenous infusion:

1. Verify physician’s orders: Before regulating the IV infusion, it is

essential to double-check if there are any physician’s orders that need to
be followed. Ensure that the medication and dosage are correct.
2. Gather supplies: Gather all of the supplies you will need based on the
type of medication and device being used, including a saline flush, sterile
gloves, alcohol swabs, and an infusion pump.
3. Wash or sanitize your hands: Before starting, wash or sanitize your
hands thoroughly.
4. Prepare the patient: Position the patient in a comfortable position, and
connect them to the infusion device. Explain the process to the patient, and
make sure they know what to expect.
5. Inspect the IV site: Examine the IV site for any signs of redness,
swelling, or infection. Check to make sure the catheter is still in the
vein.
6. Adjust the infusion rate: Use the infusion pump to regulate the rate of
infusion, as prescribed by the physician. Be sure to adjust the rate slowly.

7. Check the medication dosage: Calculate the dosage of the medication

against the prescribed concentration, and adjust accordingly via the pump.
8. Flush the line: Use the saline flush to clear the IV line and ensure that
medication is correctly being delivered to the patient. Allow the saline
flush to complete before adjusting the infusion pump again.
9. Check the infusion site regularly: Monitor the patient’s IV site regularly
for any sign of discomfort or potential complications.
10.Document: Document the date and time of IV infusion, the medication
used, the dosage and any adjustments made to the infusion rate, and
patient response.

Following these steps will ensure an easy and smooth regulation of

intravenous infusion for nurses. Ensure to insert the right dosage and
monitor the patient carefully to prevent potential complications.
Skill 110 Using an infusion pump:

1. Verify physician’s orders: Before using the infusion pump, it is essential

to double-check if there are any physician’s orders that need to be
followed. Ensure that the medication and dosage are correct.
2. Gather supplies: Gather all of the necessary supplies you will need
for the procedure, including disposable gloves, alcohol swabs, an IV
cannula, and an infusion pump.
3. Wash or sanitize your hands: Before starting, wash or sanitize your
hands thoroughly.
4. Prepare the patient: Explain the procedure to the patient clearly and
make sure they are comfortable. Position their arm and disinfect the IV site
with an alcohol swab.
5. Insert the IV cannula: Insert the IV cannula into the patient's vein, ensuring
that it is properly in place. Secure it with a transparent dressing.
6. Connect the IV tubing to the infusion pump: Connect the free end of the IV
tubing to the infusion pump, taking care to avoid any air bubbles.
7. Set the infusion parameters: Set the parameters of the infusion pump
according to the physician's orders. Set the rate of infusion, the total
volume to be infused, and any additional parameters as applicable.

8. Prime the IV tubing: Prime the IV tubing to ensure that the medication
is properly delivered. The infusion pump will automatically remove any air
bubbles from the tubing.
9. Start the infusion pump: Start the infusion pump and monitor the
patient’s response. Check the pump frequently to ensure that it is infusing
at the correct rate, that there are no air bubbles or kinks in the tubing, and
that it is functioning appropriately.

10.Document: Document the date and time of the infusion pump

procedure, the medication used, the dosage, and any adjustments made
to the infusion rate.
 11.Monitor the patient frequently: Monitor the patient frequently for signs of
complications or adverse reactions. Observe for any signs of infiltration,
phlebitis, or infection.

Following these steps will ensure that the infusion pump is correctly and
safely used by nurses, ensuring that patients receive the intended
medication and in the right dosage.

Skill 111 Initiating a transfusion:

1. Verify physician’s orders: Before initiating a transfusion, it is essential to

double- check if there are any physician’s orders that need to be followed,
including the specific type and amount of blood product and the rate of
administration.
2. Verify patient identification: Verify the patient’s identification and
confirm that the correct blood product is being administered by double-
checking the blood product label with the patient’s medical record.
3. Explain the procedure to the patient: Explain the process to the patient,
and make sure they understand what to expect. Ensure the patient is
comfortable and informed.
4. Gather supplies: Gather all of the necessary supplies you will need
for the procedure, including gloves, alcohol swabs, blood product
administration set, transfusion pump, and a blood product cooler.
5. Inspect the blood product: Inspect the blood product before using it,
checking for expiration dates or signs of clotting or contamination.
6. Clean the administration site: Clean the site of administration with an
alcohol wipe, and ensure that it is cleaned thoroughly. Allow it enough
time to air dry.
7. Set up the blood product: Set up the blood product, administration set,
and transfusion pump to the appropriate delivery rate and ensure that it's
appropriately connected to the patient's IV line.
8. Start the transfusion: Start the transfusion slowly and monitor the
patient frequently for any signs of adverse reactions or transfusion-related
reactions, such as chills, fever, or hives.
9. Monitor the infusion rate: Ensure that the infusion rate is appropriate to
prevent unnecessary complications or reactions. The rate may be decreased
or stopped altogether upon physician's order or when signs of reactions are
identified.
10.Monitor the patient: Monitor the patient for any signs of transfusion
reactions or complications that may arise. Inform the physician if any
immediate intervention is necessary.
11.Document: Document the date and time of the transfusion, the blood
product used, the amount administered, and any adverse reactions.
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Following these steps will ensure that blood transfusions are safely initiated
with minimal complications while ensuring patient comfort and ease.

Skill 112 Monitoring for adverse reactions to a transfusion:

1. Verify physician’s orders: Before monitoring for adverse reactions, it is

essential to double-check if there are any physician’s orders that need to
be followed, including the specific type and amount of blood product and
the rate of administration.
2. Monitor the patient closely: Monitor the patient frequently for any
signs of transfusion reactions, such as fever, chills, nausea, vomiting,
or skin rash.
3. Stop the transfusion: If any signs of transfusion reactions are detected,
stop the transfusion immediately and notify the physician or charge nurse.
4. Assess the patient: Assess the patient for any symptoms such as
shortness of breath, chest pain, or changes in blood pressure.

5. Inform the patient: Inform the patient of any signs of transfusion

reactions and provide reassurance and safety measures to them.
6. Administer medication: Administer medication as prescribed by the
physician to treat any transfusion reactions or complications.
7. Notify the physician: Inform the physician immediately of any adverse
reactions and follow their advice.

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8. Re-start the transfusion: Depending on the physician's instructions and

how the patient responds, the transfusion can be re-started after appropriate
measures have been taken.
9. Document: Document any transfusion reactions or complications, actions
taken, and any drugs administered.

Following these steps will ensure that adverse reactions to transfusions are
quickly detected, managed, and documented for appropriate follow-up actions.
This will also ensure patient safety and comfort during the transfusion process.

Skill 113 Drawing blood and administering fluid:

Drawing Blood:

1. Wash your hands thoroughly before approaching the patient.

2. Verify the patient’s identity and explain the procedure to them.
3. Gather all the necessary supplies such as a tourniquet, alcohol swabs,
gauze, a needle, and a blood collection tube.
4. Select an appropriate site for venipuncture, usually at the
antecubital fossa (inner elbow) or the back of the hand.
5. Apply a tourniquet above the selected site and ask the patient to
make a fist to facilitate venous engorgement.
6. Clean the selected site with an alcohol swab and allow the area to dry.
7. Insert the needle into the vein at a 30-degree angle and
release the tourniquet.
8. Collect the required amount of blood into the blood collection tube.
9. Once the blood is collected, remove the needle from the patient
and apply pressure to the site with gauze.

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10. Dispose of the needle and blood collection tube in a sharps

container and document the procedure in the patient’s chart,
including the date, time, supplies used, and any observations.

Administering Fluid:

1. Wash your hands thoroughly before approaching the patient.

2. Verify the patient’s identity and explain the procedure to them.
3. Gather all the necessary supplies such as an IV bag and tubing,
alcohol swabs, and a catheter.
4. Select an appropriate site for catheter insertion, usually at the lower
arm or hand.
5. Clean the selected site with an alcohol swab and allow the area to dry.
6. Insert the catheter into the vein and secure it in place with adhesive.
7. Connect the IV tubing to the catheter and open the flow regulator.
8. Adjust the flow rate to the prescribed rate indicated by the physician’s
orders.
9. Monitor the patient for any adverse reactions or complications,
such as infiltration or infection.
10. Once the bag is empty, remove the catheter from the patient,
dispose of all supplies, and document the procedure in the patient’s
chart, including the date, time, supplies used, and any
observations.

Skill 114 Performing Dressing Care for a Central Venous Access Device (CVAD):
1. Wash your hands thoroughly before approaching the patient.
2. Gather all the necessary supplies such as sterile gloves, sterile
dressing, cleaning solution, and transparent film dressing.

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3. Verify the patient’s identity and explain the procedure to them.

4. Put on sterile gloves and remove the old dressing using a clean
technique. Make sure you dispose of the old dressing appropriately.
5. Inspect the site for redness, swelling, or pus drainage. If you notice
any of these, notify the physician or the charge nurse.
6. Clean the skin around the insertion site using a cleaning solution
recommended by your facility. Use a back and forth motion and start
from the center of the site, moving outward. Repeat this process three
times, using a new swab for each pass.
7. Allow the skin to dry completely before applying the new dressing.
8. Apply a transparent film dressing over the insertion site, making
sure it is secure and centered over the insertion site.
9. If needed, secure the Tubing of CVAD with a sterile dressing or
securement device.
10. Document the procedure in the patient’s chart, including the
date, time, supplies used, and any observations.

Skill 115 Troubleshooting vascular access devices:

Step 1: Assess the Patient.

The first step in troubleshooting vascular access devices is to assess the

patient. Take a thorough medical history to understand the patient's current
state of health, past vascular access experience, and any associated issues.
Conduct a physical examination to assess the patient's overall health status,
including vital signs, appearance, and skin integrity.

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Step 2: Evaluate the Vascular Access Device

After assessing the patient, evaluate the vascular access device. Check for
any signs of infection, dislodgement, damage, or clotting. Examine the
catheter insertion site for any redness, swelling, or drainage. Ensure that the
catheter is patent and freely flowing by aspirating blood or flushing with
saline.

Step 3: Identify the Problem

To identify the problem, ask the patient if they have any pain, discomfort,
or unusual sensations around the catheter insertion site. Check for any signs
and symptoms of infection, including fever, chills, and malaise. Look closely
at the catheter's tip to see if it is broken, fractured, or disconnected. Check
the catheter's position to see if it has migrated or become dislodged.

Step 4: Implement Interventions

Based on the assessment, implement interventions to address the problem.

For instance, if the catheter is positioned incorrectly, reposition it to the
correct location. If there is a clot in the catheter, try to flush it with an anti-
coagulant. If there is an infection present, start the patient on antibiotic
therapy as per the hospital
protocol.

Step 5: Monitor the Patient's Recovery After implementing interventions,

monitor the patient's recovery closely. Check the patient's vital signs
frequently and keep an eye on the catheter insertion site. Refer the patient
to a physician if any complications arise.

In summary, troubleshooting vascular access devices require thorough

clinical skills, judgement, and critical thinking. By following these steps,
nurses can identify potential problems, initiate timely interventions, and
monitor patients' recovery effectively.

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Skill 116 Administering parenteral nutrition through a central line:

Step 1: Verify the Prescription and Gather Supplies Before administering

parenteral nutrition, verify the prescription with the healthcare provider to
ensure the correct formulation, rate of infusion, and duration. Gather
appropriate supplies, including parenteral nutrition solution, IV bags, tubing,
and dressing change kit.

Step 2: Prepare the Parenteral Nutrition Solution Prepare the parenteral

nutrition solution according to the instructions provided. Check the solution for
clarity, completeness, and pH level.

Step 3: Assemble the Equipment Assemble the equipment necessary for

administering parenteral nutrition through a central line. Ensure that the
tubing is primed with the parenteral nutrition solution and there are no air
bubbles present.

Step 4: Verify the Line Placement Verify the placement of the central line
using the hospital's protocol. Confirm that the catheter tip is in the correct
position, and there is no air in the line.

Step 5: Prepare the Patient Prepare the patient by explaining the

procedure and ensuring that they are comfortable. Position the patient in
a lying or semi-sitting position.

Step 6: Administer the Parenteral Nutrition Solution Attach the tubing to the
central line and start the infusion at the prescribed rate. Check the patient's
vital signs frequently and monitor for any signs of complications such as
fever, chills or shortness of breath.

Step 7: Monitor the Patient Monitor the patient's progress closely to identify
any complications, such as catheter obstruction, dislodgment or infection.
Document all procedures and findings accurately.

Step 8: Clean and Dress the Central Line Exit Site Clean and dress the
central line exit site using sterile technique to prevent infection. Ensure that
the dressing is secure and dry.

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In summary, administering parenteral nutrition through a central line

requires careful attention to detail, extensive training, and sterile
technique. By following these steps, nurses can ensure the safe and
effective administration of parenteral nutrition to patients.

Skill 117 Administering PPN with lipid infusion:

Step 1: Verify the Prescription Before administering PPN with lipid infusion,
verify the order with the healthcare provider to ensure the correct
formulation, rate of infusion, and duration. Check the compatibility of the
different components of the solution.

Step 2: Gather the Supplies Gather the necessary supplies, including

the PPN solution, lipid emulsion, IV tubing, infusion pump, gloves,
alcohol swabs, and dressing change kit.

Step 3: Prepare the Patient Prepare the patient by explaining the

procedure and ensuring that they are comfortable. Position the patient in
a lying or semi-sitting position.

Step 4: Assemble the Equipment Assemble the equipment necessary

for administering PPN with lipid infusion. Attach the lipid emulsion to
the PPN solution using a Y-connector, and prime the tubing with the
solution.

Step 5: Check the Patient's Vital Signs Check the patient's vital signs,
including blood pressure, heart rate, temperature, and oxygen saturation
levels.

Step 6: Start the Infusion and Adjust the Rate Start the infusion at the
prescribed rate, usually starting at a low rate and gradually increased as per
the hospital's protocol. Monitor the patient's condition to identify any
adverse signs, reactions, symptoms or discomforts. Adjust the rate of the
infusion based on the patient's tolerance level and vital signs.

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Step 7: Monitor the Patient's Progress Monitor the patient closely for
signs of complications, such as fluid overload, hyperlipidemia, and
catheter-related infections. Document all procedures and findings
accurately.

Step 8: Clean and Dress the Exit Site Clean and dress the exit site using a
sterile technique to prevent infections. Ensure that the dressing is secure
and dry.

In summary, administering PPN with lipid infusion requires attention to

detail, specialized knowledge, and sterile technique as there is a risk of
infections, lipid overload, and other complications. By following these steps,
nurses can ensure the safe and effective administration of PPN with lipid
infusion to patients.

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