Nursing skills 1

Applying an Extremity Restraint: Evaluation

1. After application, assess the patient for signs of injury every 15 minutes or according to facility policy and should include: a. The placement of restraint, neurovascular assessment of affected extremity, and skin integrity. b. Assess for signs of sensory deprivation, such as increased sleeping, daydreaming, anxiety, panic, and hallucinations. c. Readiness for discontinuation 2. Release restraint at least every 2 hours, or according to agency policy and for patient need for toileting, nutrition, hygiene. Assess extremity and fingers/toes perform ROM as needed. 3. Evaluate patient for continued need of restraint. Reapply restraint only if continued need is evident and order is still valid. 4. Reassure patient at regular intervals. Provide continued explanation of rationale for interventions and reorientation if necessary. Keep call bell within easy reach. 5. Document restraint alternatives attempted, patient's behavior prior to application, type of restraint applied, location of restraint, time, and assessments.

Hand Hygiene Using Alcohol-Based Hand rub

1. Push watch and sleeves above wrists, remove any rings. 2. Dispense ample amount of product to palm of one hand, using about 1-3 mL. 3. Rub hands together, making sure to cover all surfaces of the palms, back of hands, thumb and wrists, fingers, and fingertips. 4. Continue rubbing hands for several seconds until alcohol is completely dry. ( at least 15 seconds)

Collecting a Urine Specimen from an Indwelling Urinary Catheter for a Culture & Sensitivity (C & S): Equipment Needed

Alcohol wipe, 10mL sterile syringe, non-sterile gloves, sterile specimen container, biohazard bag and label.

Hand Hygiene Using Alcohol-Based Hand rub: Equipment Needed

Alcohol-based Hand rub

Hand Hygiene using Soap and Water: Equipment Needed

Antimicrobial soap, paper towels, running water.

Ear Care and Care of Hearing Aids: Equipment Needed

Bath basin, Clean gloves, Bath towels and washcloths

Shaving a Male Patient: Equipment Needed

Bath basin, Disposable razor, Clean gloves, Bath towels and washcloths, shaving cream.

Assisting Patient On and Off of a Bedpan: Equipment Needed

Bedpan, toilet tissue, non-sterile gloves

Assisting With On and Off of a Bedside Commode: Equipment Needed

Bedside commode, toilet tissue, non-sterile gloves

Assisting a Patient from Bed to a Chair: Equipment Needed

Chair or wheelchair, gait belt, non-skid shoes or slippers, cover sheet or Blanket. If unable to move patient without assistance, use of additional caregivers, stand-assist device, and/or mechanical device lift etc. should be used.

Applying an Extremity Restraint: Equipment Needed

Cloth restraint, padding for bony prominences if necessary

When do you offer Ear Care and Care of Hearing Aids?

Usually offer to provide ear care as you wash the patients face.

Oral Care: Oral Care for the Patient with Dentures

1. Apply gloves. 2. Apply gentle pressure with gauze or cloth to grasp upper denture and remove it. Place immediately in denture cup or basin. Lift lower dentures with gauze or cloth, using rocking motion. Place in denture cup or basin to carry to the sink. Never remove dentures with gloves only without a cloth to reduce the risk of slipping and damage to the dentures. 3. Line sink with cloth or paper towels while brushing. Using toothbrush, brush all areas of dentures. 4. Rinse dentures thoroughly with tepid water. Place in cup or basin to carry back to patient. 5. Use gauze, clean washcloth, or toothette to gently clean gums, mucus membranes, and tongue. Offer mouthwash or allow rinsing mouth. 6. Insert upper denture in mouth and press firmly. Insert lower denture. Check that the dentures are secure in mouth. 7. If patient desires, dentures can be left in denture cup in cold water. Label container, not the lid, with patient's ID information and leave at bedside.

Collecting a Urine Specimen (Clean Catch, Midstream) Urinalysis & Culture & Sensitivity (C&S)

1. Apply non-sterile gloves 2. If patient can get out of bed, assist to the bathroom or onto the bedside commode. If on bedrest assist on bedpan. Instruct patient not to defecate or discard toilet paper into the urine, which may contaminate the specimen. 3. Females: Instruct the female patient to separate the labia for cleaning of the area and during Collection of urine. Female patients should use the towelettes or wet washcloth to clean each side of the urinary meatus, then the center over the meatus, from front to back, using a new wipe for each stroke. 4. Males: Instruct to use a toilette to clean the tip of the penis, wiping in a circular motion away from the urethra. Instruct male patient who is not circumcised to retract foreskin before cleaning and during collection. 5. Have patient void about 25 mL into toilet, bedpan, or commode. The patient should then stop urinating briefly, then void into collection container. Collect specimen (10-20 mL is enough), and then finish voiding. Do not touch the inside of the container or the lid. 6. Place lid on container. If necessary, transfer specimen to appropriate containers for ordered test, according to facility policy. 7. Assist the patient from the bathroom, off the commode, or off the bedpan. Provide perineal care if necessary. 8. Remove gloves. Perform hand hygiene. 9. Check the specimen label matches the patient's identification bracelet. Label specimen container with patient's name, MR#, time, date and your initials. Place in biohazard bag. Ensure specimen is sent to lab immediately. 10. Document as directed or per facility policy.

Collecting Stool for an Occult Blood called a Hemoccult Test

1. Apply non-sterile gloves 2. Place the specimen hat in the toilet or bedside commode, if applicable. Assist the patient to the bathroom or onto the bedside commode, or assist the patient onto the bedpan. Instruct patient not to urinate or discard toilet paper with the stool, which may contaminate the specimen. Allow the patient to defecate. 3. After the patient defecates, assist the patient out of the bathroom, off the commode, or remove the bedpan. Perform hand hygiene and put on disposable gloves. 4. With wooden applicator, obtain small amount of stool from the center of the bowel movement and apply onto one window of Hemoccult testing card. With opposite end of wooden applicator, obtain another sample of stool from another area and apply a small amount of stool onto second window of Hemoccult card. 5. Close flap over stool samples. 6. If testing specimen at bedside: Turn card over and open flap on opposite side of card and place two drops of developer over each window and control panel. Wait the time stated in the Manufacturer's instructions. Observe card for results. Blue coloring represents positive results (blood present). Discard Hemoccult card, remove gloves and perform hand hygiene. 7. If sending specimen to laboratory: Check the specimen label matches the patient's identification bracelet. Label specimen container with patient's name, MR#, time, date and your initials. Place in biohazard bag. Ensure specimen is sent to lab immediately. 8. Document as directed or per facility policy.

Making an Unoccupied Bed

1. Arrange equipment on a clean bedside table in the following order from bottom to top: a. pillow case b. blanket c. top sheet d. waterproof protective pad e. draw sheet f. bottom sheet 2. Assist the patient to transfer from bed to chair if appropriate 3. Put on gloves. Detach all tubes and equipment from bed and inspect bed for loose personal items, such as pens, eyeglasses. 4. Remove unsoiled bedspread for reuse and place on back of chair or other clean site. If soiled, remove and use clean spread. 5. Snugly roll all other linen with the soiled side inward making a small bundle which can be carried without touching the floor or uniform and deposit soiled linen in bag. 6. Remove gloves, unless indicated for transmission precautions. Center and unfold bottom sheet, with corner seams inside, Pull bottom sheet over corners at the head and foot of the mattress. 7. Apply waterproof sheet or draw sheet, if needed. 8. Move to the opposite side of bed and secures the bottom linens. 9. Center and unfold the top sheet with hem side up at head of the mattress. 10. Unfold and place the bedspread at the edge of the top of the bed, rough edges out. 11. Secure the top sheet, and spread under the foot of the mattress on each side. Miter the corners. Fanfolds the upper linen to the foot of the bed so bed is ready when patient ready to get back in bed. 12. Apply a clean pillow case without shaking or touching the pillow to the uniform. (Open the pillow case; gather the pillow case over one hand toward closed end. Grasp pillow with the hand inside pillow case. Keep a firm hold on top of pillow and pull the cover on to the pillow. Place pillow at the head of the bed). Put bed lowest position, raise side rail on opposite side of bed, leaving side rail down close to patient.

Making an Occupied Bed

1. Arrange equipment on a clean bedside table in the following order from bottom to top: a. pillow case b. blanket c. top sheet d. waterproof protective pad e. draw sheet f. bottom sheet 2. Put on gloves. Detach all tubes and equipment from bed and inspect bed for loose personal items, such as pens, eyeglasses. 3. Remove unsoiled bedspread for reuse and place on back of chair or other clean site. If soiled, remove and use clean spread. 4. Loosen top sheet and leave to cover the patient. 5. Assist patient to turn toward opposite side of bed and reposition pillow. 6. Loosen all bottom linen on the near side. 7. Roll soiled bottom linen as close to the patient as possible with soiled side inward. 8. Apply clean bottom linen and draw sheet to near side of bed with other folded in the middle. 9. Raise side rail on near side and assist patient to roll over all linen in center of bed toward you. Reposition pillow and top sheet, move to other side of the bed, lower the side rail. 10. Snugly roll all linen from under patient with the soiled side inward making a small bundle which can be carried without touching the floor or uniform and deposit soiled linen in bag. 11. Remove glove, unless indicated for transmission precautions.. Ease clean linen from under patient. Pull bottom sheet taut and secure corners. Pull draw sheet tight and smooth and tuck securely under the mattress. 12. Reposition patient to the center of the bed or in position of comfort 13. Apply top sheet so that it is centered. Asks patient to grasp clean top sheet while you withdraw soiled linen from underneath. Apply bedspread. 14. Tuck the top sheet and bedspread together beneath the mattress. Miter the corners. 15. Make toe pleat - provide adequate room for the patient's toes 16. Apply a clean pillow case without shaking or touching the pillow to the uniform. (Open the pillow case; gather the pillow case over one hand toward closed end. Grasp pillow with the hand inside pillow case. Keep a firm hold on top of pillow and pull the cover on to the pillow. Place pillow at the head of the bed). Put bed lowest position, raise side rail. 17. Fold the hem of the top sheet to form a cuff over the spread.

Assisting a Patient with Eating

1. Assess level of consciousness, for any physical limitations, decreased hearing or visual acuity or swallowing impairment. If patient uses a hearing aid or wears glasses or dentures, provide as needed. Ask if the patient has any cultural or religious preferences and food likes and dislikes, if possible. 2. Assess the abdomen. Ask the patient there is any difficulty swallowing, nausea or pain and administer medication as needed. 3. Offer to assist the patient with any elimination needs. 4. Provide patient with hand hygiene and mouth care as needed. 5. Remove any bedpans or odors if possible from the vicinity where meal will be eaten. 6. Assist to or position the patient in a high Fowler's or sitting position in the bed or chair. Position the bed in the low position, if the patient remains in bed. 7. Place protective covering or towel over the patient if desired. 8. Ensure tray is the correct diet before serving. Open cover by the door of the room to prevent overwhelming smell of the food. 9. Place tray on the over-bed table so patient can see food if able. Ensure that hot foods are hot and cold foods are cold. Use caution with hot beverages, allowing sufficient time for cooling if needed. Ask the patient for his/her preference related to what foods are desired first. Cut food into small pieces as needed. Observe swallowing ability throughout the meal. 10. If possible, sit facing the patient while feeding is taking place. If patient is able, encourage them to hold finger foods and feed self as much as possible. Converse with patient during the meal as appropriate. If, however, the patient has dysphagia, limit questioning or conversation that would require patient response during eating. Play relaxation music if patient desires. 11. Allow enough time for the patient to adequately chew and swallow the food. The patient may need to rest for short periods during eating. 12. When the meal is completed or the patient is unable to eat any more, remove the tray from the room. Write down the amount food consumed and the volume of liquid consumed. 13. Reposition the over-bed table, remove the protective covering, offer hand hygiene as needed, and offer the bedpan. Assist the patient to a position of comfort and relaxation. 14. Document as directed or per facility policy.

Pursed Lip Breathing Procedure

1. Assess pain level prior to beginning exercises and medicate if necessary. 2. Instruct the patient to practice "Purse lips" by positioning lips as if sucking through a straw or whistling. 3. While sitting up the patient inhales through the nose while counting to three and then exhales slowly and evenly against pursed lips while tightening the abdominal muscles. 4. During exhalation, have the patient count to seven. 5. Document as directed or per facility policy.

Effective Deep Breathing, Coughing & Splinting Procedure

1. Assess pain level prior to beginning exercises and medicate if necessary. 2. Place patient in a semi-Fowler's position, leaning forward to ventilate the lobes of the lungs. 3. Instruct the patient to: a. Inhale and exhale deeply and slowly through the nose two times. (In 2-3-4; out 2-3-4) b. Then on third exhale, have the patient cough fully for two or three consecutive coughs without inhaling between coughs. 4. Repeat the exercise 2 or 3 times every 2 hours while awake. 5. Document as directed or per facility policy.

Applying a Warm or Cold Compress

1. Assess the patient for possible need for non-pharmacologic pain-reducing interventions or analgesic medication before beginning the procedure. Administer appropriate analgesic, consulting HCP's orders, and allow enough time for analgesic to achieve its effectiveness before beginning procedure. 2. Assess the skin area where application going for inflammation, skin color, and/or ecchymosis. 3. Cover the device with a towel or wash cloth, unless the device has a cloth exterior. 4. Monitor the time the compress is in place to prevent burns and skin/tissue damage. Monitor the condition of the patient's skin and the patient's response. 5. After the prescribed time for the treatment (up to 30 minutes), remove device. Or, remove at anytime the patient complains of discomfort. 6. Assess the skin condition around the site and note any changes in the application area. 7. Document the patient's response to the warm or cold compression.

Incentive Spirometer Procedure

1. Assist patient to an upright position. 2. Nurse to administer ordered pain medication if needed. If patient has recently undergone abdominal or chest surgery, place a pillow for incision for splinting. 3. Demonstrate how to hold mouthpiece with one hand, and steady device with other hand. 4. Instruct the patient to exhale normally, place lips securely around mouthpiece, inhale slowly, and as deeply as possible through mouthpiece, hold breath, count to three and then exhale. 5. Check position of gauge to determine progress. Repeat x 3. 6. Document as directed or per facility policy.

Assisting With On and Off of a Bedside Commode: Assisting Patient Off Commode

1. Assist the patient to stand. If patient needs assistance with hygiene, wrap toilet tissue around your hand several times, and wipe patient clean, using one stroke from the pubic area toward the anal area. Discard tissue in receptacle and continue with additional tissue until patient is clean. 2. Do not place toilet tissue in commode if a specimen is required or if output is being recorded. Lower the seat cover. 3. Remove your gloves. Return the patient to the bed or chair. If the patient returns to the bed, raise side rails, as appropriate. Ensure that the patient is covered and call bell is readily within reach. 4. Offer patient supplies to wash and dry his or her hands, assisting as necessary. 5. Put on clean gloves. Empty and clean the commode, measuring urine in graduated container. 6. Remove gloves and additional PPE, if used. Perform hand hygiene.

Administering Oxygen by a Mask

1. Attach face mask to oxygen source with humidification, if needed. Start the flow of oxygen at the specified rate. For a mask with a reservoir, allow oxygen to fill the bag. 2. Position face mask over the patient's nose and mouth. Adjust the elastic strap to fit snugly but comfortably on the face. Adjust the flow rate as ordered. 3. Reassess respiratory rate, effort, and lung sounds. Note any signs of respiratory distress, such as tachypnea, nasal flaring, use of accessory muscles, or dyspnea. 4. Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously. Do not use powder around the mask. 5. Document as directed or per facility policy.

Applying an Extremity Restraint: Implementation

1. Be sure patient is in a comfortable position and in proper body alignment. 2. Inspect area where restraint is to be placed. (nearby equipment, tubing, condition of patients skin) 3. 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 if needed. c. Wrap the restraint around the extremity with the soft part in contact with the skin. d. Secure restraint with the Velcro® straps or quick release buckle or knot at the extremity, ensuring that it does not tighten around the extremity upon movement. 4. Ensure that two fingers can be inserted between the restraint and patient's wrist or ankle. 5. Maintain restrained extremity in normal anatomic position. Use a quick-release knot to tie the restraint strap to the bed frame, not side rail. The restraint strap may be attached to chair frame. The site should not be accessible to patient. 6. If appropriate, demonstrate use of call button and make sure patient can access.

Oral Care: Oral Care for Patient who is Independent or Needs Assistance

1. Brush and rinse the teeth appropriately if the patient cannot perform independently. 2. Offer mouthwash and dental floss, if the patient desires. 3. Apply lubricant to lips, if needed.

Collecting a Urine Specimen from an Indwelling Urinary Catheter for a Culture & Sensitivity (C & S)

1. Clamp the catheter drainage tubing or bend it back on itself distal to the port. If an insufficient amount of urine is present in the tubing, allow tubing to remain clamped up to 30 minutes, to collect sufficient amount of urine, unless contraindicated. 2. Remove lid from specimen container, keeping the inside of the container and lid free from contamination. 3. Cleanse aspiration port with alcohol wipe for 15 seconds and allow port to air dry. 4. Attach the syringe to the needleless port. Slowly aspirate 10 mL of urine. Remove syringe from port. Unclamp drainage tubing. 5. Slowly inject urine into specimen container being careful not to spray or splash contents. Place lid on container. Dispose of syringe in proper waste container. 6. Remove gloves. Perform hand hygiene. 7. Check the specimen label matches the patient's identification bracelet. Label specimen container with patient's name, MR#, time, date and your initials. Place in biohazard bag. Ensure specimen is sent to lab immediately. 8. Document as directed or per facility policy.

Administering Oxygen by Nasal Cannula

1. Connect nasal cannula to oxygen setup with humidification, if needed. Adjust flow rate as ordered. Check that oxygen is flowing out of prongs. 2. Place prongs in patient's nostrils. Place tubing over and behind each ear with adjuster comfortably under chin. Ensure protection pad on tubing in place over ear. 3. Tubing should be snug but not tight against the skin. Adjust as necessary. 4. Encourage patient to breathe through the nose, with the mouth closed. 5. Reassess respiratory rate, effort, and lung sounds. Note any signs of respiratory distress, such as tachypnea, nasal flaring, use of accessory muscles, or dyspnea. 6. Document as directed or per facility policy.

Exit Measures

1. Verbalize to patient that you are leaving. 2. 4 P's (Pain, Potty, Possessions and Position). 3. Bed in lowest position. 4. Two side rails up. 5. Call bell within reach. 6. Perform hand hygiene as exit room.

Assessing Brachial Artery Blood Pressure - One Step Method

1. Evaluate the size and accessibility of the arm for use. Select best site to use. For example, if the patient is receiving intravenous fluids in the left arm, use the right arm to take the blood pressure. 2. Place the patient in comfortable lying or sitting position, extend arm with the forearm supported at the level of the heart and the palm of the hand upward. ● Supine position, support arm with a pillow, legs uncrossed. ● Sitting position, support arm yourself or by using the bedside table. ● Sitting in a chair, have the patient sit to supports back with legs uncrossed. 3. Expose the brachial artery by removing garments, or move a sleeve, if it is not too tight, above the area where the cuff will be placed. 4. Palpate the location of the brachial artery. 5. Center the artery arrow over the brachial artery, about midway on the arm, so that the lower edge of the cuff is about 1 -2 inches (two fingerbreadths) above the antecubital area. The tubing should extend from the edge of the cuff nearer the patient's elbow. 6. Wrap the cuff around the arm smoothly and snugly, and fasten it. Do not allow any clothing to interfere with the proper placement of the cuff. 7. Place the stethoscope earpieces in your ears. Direct the earpieces forward into the canal (toward nose). 8. Place the bell or diaphragm of the stethoscope firmly but with as little pressure as possible over the brachial artery. Do not allow the stethoscope to touch clothing or the cuff. 9. Ask the patient their recent B/P reading. Then pump 30 mm Hg above recent systolic reading. Open the valve on the manometer and allow air to escape slowly (allowing gauge to drop 2-3 mm per heartbeat). 10. Note the point on the gauge at which the first faint, but clear, sound appears that slowly increases in intensity. Note this number as the systolic pressure. Read the pressure to the closest even number. 11. Do not re-inflate the cuff once the air is being released to recheck the systolic pressure reading. 12. Note the point on the gauge at which the sound disappears completely. Note this number as diastolic reading. Read the pressure to the closest even number. 13. Allow the remaining air to escape quickly and write down the readings. Repeat any suspicious reading, but wait one minute to allow normal circulation to return in the limb. Deflate the cuff completely between attempts to check the blood pressure. 14. Remove the cuff, clean the diaphragm of the stethoscope with the alcohol wipe and store according to facility policy. 15. Document as directed or per facility policy.

Collecting a 24-Hour Urine Specimen

1. Explain to the patient that you will need to collect ALL urine for a 24 hour period. 2. Prepare the equipment: a. Place the urine hat collector in the toilet in the patient's bathroom. b. Label the collection bottle with the patient identifying information, the date, and time the collection begins and ends. c. Bath basin with ice chips - place in the bathroom floor by the toilet. Place the collection bottle in the bath basin on the ice chips. Add ice chips as needed in order to keep the urine chilled. 3. To start the test, Instruct the patient to urinate in the urine hat and then dump that urine specimen down the toilet. **Note the time - this is the beginning of the 24 hours. 4. After the first void and dump, tell the patient to collect the rest of their urine in the Urine hat collector. The urine is to be poured from the cap to the collection bottle (by the nurse or patient). Impress on the patient, the importance that every drop of urine that they pass should go into the container. 5. Place signs on the patients door and in the bathroom indicating the patient is on "24-Hours Urine Collection" 6. Instruct the patient to drink adequate fluids during the collection period. 7. Emphasize proper hand hygiene before and after each collection 8. Exactly 24-hours after beginning the collection, ask the patient to void. This will complete the specimen collection. 9. Ensure specimen is sent to lab immediately. 10.Document as directed or per facility policy.

Ear Care and Care of Hearing Aids: Replacing the hearing aids

1. Gently replace into ear canal. 2. Turn hearing aids on and ask patient if they need any adjustment. 3. Continue the bath

Applying Pneumatic Compression Devices

1. Hang the compression pump at foot of the bed, plug it & attach tubing to the pump. 2. Lay the unfolded sleeves on the bed with the cotton lining facing up. Note the markings indicating the correct placement for the ankle and popliteal areas. 3. Apply antiembolism stockings, if ordered. Place a sleeve under the patient's leg with the tubing toward the heel. For total leg sleeves, place the behind-the-knee opening at the popliteal space to prevent pressure there. For knee-high sleeves, make sure the back of the ankle is over the ankle marking. 4. Wrap the sleeve snugly around the patient's leg so that two fingers fit between the leg and the sleeve. Secure the sleeve with the Velcro fasteners. Repeat for the second leg, if bilateral therapy is ordered. Connect each sleeve to the tubing, following manufacturer's recommendations. 5. Set the pump to the prescribed maximal pressure (usually 35 to 55 mm Hg). Make sure the tubing is free from kinks. Check that the patient can move about without interrupting the airflow. Turn on the pump. Initiate cooling setting, if available. 6. Observe the patient and the device during the first cycle. Check the audible alarms. 7. Perform hand hygiene. 8. Assess the extremities for peripheral pulses, edema, changes in sensation, and movement. Remove the sleeves and assess and document skin integrity every 8 hours.

Assisting Patient On and Off of a Bedpan: Removing the Bedpan

1. Have a receptacle, such as plastic trash bag, handy for discarding tissue. 2. Lower the head of the bed 30°. 3. Help the patient roll onto his or her side, moving toward the opposite side rail and off of the bedpan. 4. To prevent spillage, hold the bedpan flat and steady as the patient rolls off of it. 5. Place the bedpan on the draped bedside chair, and cover the bedpan with a cover or towel. 6. If you need to cleanse the patient's perineal area, use several layers of toilet tissue first, then clean with washcloths. 7. Deposit contaminated tissues in the bedpan if no specimen or intake and output measurements (I&O) are needed. If necessary, place the contaminated tissue or washcloths in appropriate container. Allow the patient to perform hand hygiene. 8. Do not place toilet tissue in the bedpan if a specimen is required or if output is being recorded. Place toilet tissue in appropriate receptacle. 9. Make sure the linens under the patient are dry. Remove your gloves and ensure that the patient is covered. 10. Remove additional PPE, if used. Perform hand hygiene.

Assisting Patient On and Off of a Bedpan

1. If not contraindicated, place the patient in a supine position, with the head of the bed elevated 30° 2. Fold top linen back to allow placement of bedpan. If not present, apply waterproof pad. 3. Lower the side rail. Help the patient roll onto his or her side, moving toward the opposite side rail, with the patient's back toward you. Place the bedpan firmly against the patient's buttocks and push it down into the mattress. Be sure that the open rim of the bedpan is facing the foot of the bed. 4. Use one of your hands to keep the bedpan centered under the patient, and place the other hand around the patient's far hip. Ask the patient to roll back onto the bedpan, flat in bed. Do not force the pan under the patient. 5. Place a small pillow or a towel under the lumbar curve of the patient's back to reduce back strain while the patient sits on the bedpan. 3. Ensure that bedpan is in proper position and patient's buttocks are resting on the rounded shelf of the regular bedpan or the shallow rim of the fracture bedpan. 4. Unless contraindicated, raise head of bed to sitting position. Cover patient with bed linens. 5. Place call bell and toilet tissue within easy reach. Place the bed in the lowest position. Leave patient if it is safe to do so. Use side rails appropriately. 6. Remove gloves and additional PPE, if used. Perform hand hygiene.

Assisting a Patient with Ambulation: Prevention of a fall when ambulating

1. If the patient begins to fall, gently ease him or her to the floor by holding firmly onto the gait belt, standing with your feet apart to provide a broad base of support, extending your leg, and letting the patient gently slide to the floor. 2. As the patient slides, bend your knees to lower his or her body. Protect the patients head.

Assisting a Patient with Ambulation

1. Lower the bed, lock the wheels on the bed, lower side rail, raise patient to fowler's position. 2. Encourage the patient to make use of a stand-assist aid, either freestanding or attached to the side of the bed, if available, to move to the side of the bed. Assist the patient to the side of the bed, if necessary. 3. Have the patient dangle with feet touching the floor. Sit on the side of the bed for several minutes to prevent orthostatic hypotension. Assess for dizziness or lightheadedness. Have the patient take several deep breaths until balance is obtained. Stay sitting on side of bed until he or she feels secure. 4. Ask the patient to move feet in circles, and then put on non-skid footwear and a robe, if desired. 5. Wrap the gait belt around the patient's waist, based on assessed need and facility policy. 6. Encourage the patient to make use of the stand-assist device. Assist the patient to stand, using the gait belt, if necessary. Assess the patient's balance and leg strength. If the patient is weak or unsteady, return the patient to the bed or assist to a chair. 7. If you are the only nurse assisting, position yourself to the side and slightly behind the patient. Support the patient by one hand on the patient's waist or transfer belt, and the other hand on the patient's upper arm (bicep). Be sure you have good support of the patient's body, not just holding the patient's gown. a. When two nurses assist, position yourself to the side and slightly behind the patient, supporting the patient by the waist or gait belt and upper arm. Have the other nurse carry or manage equipment or provide additional support from the other side. b. Alternatively, when two nurses assist, stand at the patient's sides (one nurse on each side) with near hands grasping the gait belt and far hands holding the patient's upper arm 8. Take several steps forward with the patient. Continue to assess the patient's strength and balance. Remind the patient to stand erect and to look up. 9. Continue with ambulation for the planned distance and time. Return the patient to the bed or chair based on the patient's tolerance and condition. 10. Remove gait belts. Clean transfer aids per facility policy, if not indicated for single patient use.

Administration of High Volume or Cleansing Enema

1. Open package, clamp is tubing then open top of bag and fill bag with warm water. 2. Release clamp and allow fluid to progress through tube until air is removed and water is to the end. Reclamp tubing. 3. Position the patient on the left side in side lying or Sim's position. Fold top linen back just enough to allow access to the patient's rectal area. Place a waterproof pad under hip. 4. Put on non-sterile gloves. 5. Elevate solution so that it is no higher than 18 inches above level of anus. Plan to give the solution slowly over a period of 5 to 10 minutes. The container may be hung on an IV pole or held in the nurse's hands at the proper height. 6. Generously lubricate end of rectal tube 2 to 3 inches. A disposable enema set may have a pre-lubricated rectal tube. 7. Lift buttock to expose anus. Slowly and gently insert the enema tube 3 to 4 inches for an adult. Direct it at an angle pointing toward the umbilicus, not bladder. Ask patient to take several deep breaths. 8. If resistance is met while inserting tube, permit a small amount of solution to enter, withdraw tube slightly, and then continue to insert it. Do not force entry of the tube. 9. Introduce warm solution slowly over a period of 5 to 10 minutes. Hold tubing all the time that solution is being instilled. 10. Clamp tubing or lower container if patient has desire to defecate or cramping occurs. Patient also may be instructed to take small, fast breaths or to pant. 11. After solution has been given, clamp tubing and remove tube. Have paper towel or towel ready to receive tube as it is withdrawn. 12. Encourage the patient to hold the solution as long as possible. Once the urge to defecate is strong, usually immediately with high volume enema, assist patient on bedpan and off bedpan when finished eliminating solution. Bring bedpan to bathroom. 13. Prior to flushing results into commode, assess color, consistency, amount, and odor of feces. Wash hands with soap and water. 14. Put on gloves and assist patient, if necessary, with cleaning of anal area. Offer washcloths, soap, and water for hand washing. 15. Document as directed or per facility policy.

Oral Care: Oral Care for the Unconscious Patient

1. Organize equipment, obtains suction equipment and suction catheter if needed. 2. Place the patient in a lateral or Sim's position and turn head to the side or downward position to promote drainage of oral secretions to prevent aspiration. Have head of bed as low as possible. 3. Place towel or absorbent pad under head, curved basin under chin. 4. Apply gloves. 5. Gently open the patient's mouth by applying pressure to lower jaw at the front of the mouth. Remove dentures, if present. Brush the teeth and gums carefully with toothbrush and paste. Lightly brush the tongue. 6. Use toothette dipped in water to rinse the oral cavity. If desired, insert the rubber tip of the irrigating syringe into patient's mouth and rinse gently with a small amount of water. Position patient's head to allow for return of water or use suction apparatus to remove the water from oral cavity. 7. Clean the dentures before replacing. 8. Apply lubricant to patient's lips. 9. Remove gloves / Perform hand hygiene. 10. Remove equipment and return patient to a position of comfort. Raise side rail and lower bed. 11. Remove additional PPE, if used. Perform hand hygiene.

Perineal Care: Male

1. Place a protective pad or towel under the patient. 2. May position patient on bedpan or supine position. Drape appropriately. 3. Retract foreskin of penis if uncircumcised. 4. Clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward, using clean surface of washcloth for each stroke. 5. Replace foreskin, if appropriate. 6. Wash down shaft of penis, using clean surface of washcloth for each stroke. 7. Wash scrotum. 8. If patient has an indwelling catheter is in place, cleanse the catheter by hold the catheter between finger and thumb near the urethral opening and wiping gently from the meatus outward with cloth in the other hand. 9. Wash inner thighs from proximal to distal, toward feet. 10. Rinse and dry with clean towel in the same sequence. 11. Turn patient to side facing away from you and wash the buttocks starting with the outer area then between the gluteal folds, and finishing with the anal area (Cleanest to dirtiest). Wash anal area from front to back, rinse and dry. 12. Remove gloves / Perform hand hygiene.

Collecting a Sputum Specimen for Culture

1. Place patient in semi-Fowler's position. 2. Instruct patient to take four deep breaths at end of fourth breath cough deeply mobilizing secretions. If patient has had abdominal surgery, assist patient to splint abdomen. 3. If patient produces sputum, open the lid to the container and have patient expectorate the specimen into container. Ensure specimen is sputum and NOT saliva. Have patient continue to collect sputum until have ~15ml. 4. Place lid on container. Offer oral hygiene to patient after collection. 5. Remove PPE. Perform hand hygiene. 6. Check the specimen label matches the patient's identification bracelet. Label specimen container with patient's name, MR#, time, date and your initials. Place in biohazard bag. Ensure specimen is sent to lab immediately. 7. Document as directed or per facility policy.

Perineal Care: Female

1. Place protective pad or towel under the patient. 2. May position patient in supine position or on bedpan. Drape for privacy. 3. Separate labia with one hand to expose urethral and vaginal openings. 4. Wipe labia majora (outer) from front to back in downward motion using clean surface of wash cloth for each swipe. Rinse cloth. 5. Wipe labia minora (inner) from front to back in downward motion using clean surface of wash cloth for each swipe. Rinse cloth. 6. Wipe down the center of the meatus from front to back. 7. If using a bedpan, rinse perineal area with warm to tepid water using peri-bottle, then remove bedpan. 8. If patient has an indwelling catheter is in place, cleanse the catheter by hold the catheter between finger and thumb near the urethral opening and wiping gently from the meatus outward with cloth in the other hand. 9. Wash inner thighs from proximal to distal, toward feet. 10. Pat dry using clean towel in same order as wash. 11. Turn patient to side facing away from you and wash the buttocks starting with the outer area then between the gluteal folds, and finishing with the anal area (Cleanest to dirtiest). Wash anal area from front to back, rinse and dry. 12. Remove gloves / Perform hand hygiene.

Assisting With On and Off of a Bedside Commode

1. Place the commode close to, and parallel with, the bed. Raise or remove the seat cover. 2. Assist the patient to stand and then help patient pivot to the commode. While bracing one commode leg with your foot, ask the patient to place his or her hands one at a time on the arm rests. Assist the patient to lower himself/herself slowly onto the commode seat. 3. Cover the patient with blanket if desires. Place call bell & tissue within reach. Leave patient if it is safe.

Collecting a Stool Specimen for Culture

1. Place the specimen hat in the toilet or bedside commode, if applicable. Assist the patient to the bathroom or onto the bedside commode, or assist the patient onto the bedpan. Instruct patient not to urinate or discard toilet paper with the stool, which may contaminate the specimen. Allow the patient to defecate. 2. After the patient defecates, assist the patient out of the bathroom, off the commode, or remove the bedpan. Perform hand hygiene and put on disposable gloves. 3. Use the tongue blades to obtain a sample of the stool from two different sites, free of blood or urine, and place in clean specimen container. 4. Place lid on container. Remove gloves and perform hand hygiene. 5. Check the specimen label matches the patient's identification bracelet. Label specimen container with patient's name, MR#, time, date and your initials. Place in biohazard bag. Ensure specimen is sent to lab immediately. 6. Document as directed or per facility policy.

Administrating a Low Volume or Retention Enema

1. Position the patient on the left side (Sims' position), as dictated by patient comfort, ability and condition. Fold top linen back just enough to allow access to the patient's rectal area. Place a waterproof pad under the patient's hip. 2. Put on non- sterile gloves 3. Remove the cap and add generously lubricate to the end of rectal tube 2" to 3". 4. Lift buttock to expose anus. Slowly and gently insert the enema tube 3" to 4" for an adult. Direct it at an angle pointing toward the umbilicus, not bladder. Ask patient to take several deep breaths during insertion. 5. Compress the container slowly with your hands. Roll the end up on itself, toward the rectal tip. Administer all the solution in the container. 6. If resistance is met while inserting tube, permit a small amount of solution to enter, withdraw tube slightly, and then continue to insert it. Do not force entry of the tube. Ask patient to take several deep breaths and relax. 7. After solution has been given, remove tube, keeping the container compressed. Have paper towel ready to receive tube as it is withdrawn. 8. Encourage the patient to hold the solution until the urge to defecate is strong, usually in about 5 to 15 minutes. 9. Implement safety exit measure and instruct patient to use call light wen patient has a strong urge to defecate. 10. When patient calls with a strong urge to defecate, place him or her in a sitting position on a bedpan or assist to commode or bathroom. Stay with patient or have call light readily accessible. 11. Remind patient not to flush commode (if uses bathroom) before nurse inspects results of enema. 12. Prior to flushing results assess color, consistency, amount, and odor of feces. Wash hands with soap and water. 13. Put on gloves and assist patient if necessary with cleaning of anal area. Offer washcloths, soap, and water for hand washing. Remove gloves. 14. Document as directed or per facility policy.

Applying an External Condom Catheter

1. Prepare urinary drainage setup or reusable leg bag for attachment to condom sheath. Make sure the patient does not have any latex allergies if using a catheter made of latex. 2. Position patient on back with thighs slightly apart. Drape so only the penis is exposed. Slide waterproof pad under patient. 3. Put on disposable gloves. Trim any long pubic hair that is in contact with penis. 4. Make sure area is dry following perineal care. 5. Roll condom sheath outward onto itself. Grasp penis firmly with non-dominant hand. Apply condom sheath by rolling it onto penis with dominant hand. Leave 1 to 2 inches (2.5 to 5 cm) of space between tip of penis and end of condom sheath. 6. Apply pressure to sheath at the base of penis for 10 to 15 seconds. 7. If you are using a condom catheter with an outer securing strip, use the spiral wrap technique to allow the elastic adhesive to expand, so that blood flow to the penis is not compromised. 8. Connect condom sheath to drainage setup. Ensure the condom is not twisted and that urine flow is unobstructed. 9. Put on clean gloves. Secure drainage tubing to the patient's inner thigh with Velcro leg strap or tape. Leave some slack in tubing for leg movement. 10. Secure drainage bag below the level of the bladder. Check that drainage tubing is not kinked and that movement of side rails does not interfere with the drainage bag. 11. Remove equipment. Remove gloves and additional PPE, if used. Perform hand hygiene. 12. Re-assess the penis within 15 to 30 minutes of application of condom catheter. Check for swelling or discoloration. Ask the patient if he is experiencing any discomfort.

Assisting Patient with the Use & Removal of a Urinal: Removing the Urinal

1. Pull back the linens and remove the urinal. Cover the open end of the urinal. Place on the bedside chair. If patient needs assistance with hygiene, wrap tissue around the hand several times, and wipe patient clean. Place tissue in receptacle. 2. Make sure the linens under the patient are dry. Remove your gloves and ensure that the patient is covered. 3. Offer patient supplies to wash and dry his hands, assisting as necessary. 4. Put on clean gloves. Empty and clean urinal, measuring urine. 5. Remove additional PPE, if used. Perform hand hygiene.

Hand Hygiene using Soap and Water

1. Push watch and sleeves above wrists, remove any rings. 2. Stand in front of sink without hands or clothing touching the sink during washing. 3. Turn on water, adjust water force (avoid splashing water against uniform), and regulate temperature until water warm. Wet the hands and wrist area keep hands lower than elbows; allow flow water to drain downward toward the fingertips. 4. Apply soap using about 3-5 mL of liquid antiseptic soap from dispenser. Lather your hands by rubbing together with the soap being sure to cover all areas of hands with soap product. 5. Wash hands using mechanical friction and circular motions to lather the soap going from clean to dirty, for at least 15 seconds. a. Wrist b. Back of hands / Palms/ Fingers c. In between fingers- web areas d. Fingertips and Nails 6. Rinse hands under clean running water so that the soap drains from the forearm to the fingertips (clean to dirty). 7. Using a fresh dry paper towel, pat hands dry wiping from forearms to wrists to fingers. Dry hands thoroughly. (May use another dry paper towel if needed to ensure hands get dry). 8. Dispose wet paper towels into proper waste container. 9. Use another dry paper towel to turn off the faucet. Dispose in proper waste container.

Assisting Patient with the Use & Removal of a Urinal

1. Put on gloves. 2. Assist to an appropriate position: standing at bedside, lying on side or back, sitting in bed with the head elevated, or sitting on the side of the bed. 3. If the patient remains in the bed, fold the linens to allow for proper placement of the urinal. 4. If the patient is not standing, have him spread his legs slightly. Hold the urinal close to the penis and position the penis completely within the urinal. Keep the bottom of the urinal lower than the penis. If necessary, assist the patient to hold the urinal in place. 5. Cover the patient with linen. Place call bell & tissue within reach. Leave patient if it is safe. 6. Remove gloves and additional PPE, if used. Perform hand hygiene.

Hygiene - Giving a Bath

1. Put on gloves. Lower side rail on one side. Move the patient to the edge of bed nearest you. 2. Loosen top covers. Remove the bedspread, if unsoiled, place on a clean area for reuse. Leave on top sheet which you will use to drape you patient during the bath. 3. Loosen gown by removing arms from patient gown and leave the gown as a drape over the patient. If patient has an IV - remove the gown from the arm without the IV first and then remove the gown from the IV arm by lowering the IV container and pass gown over the tubing and the container. Rehang the IV bag. 4. Raise side rails. Fill basin with warm water, add cleaner when appropriate. Change water as necessary throughout the bath. Lower side rail closer to you when you return to the bedside to begin the bath. 5. Put on gloves, if necessary. Fold the washcloth like a mitt on your hand so that there are no loose ends. Lay a towel across patient's chest. Face: 6. With no cleanser on the washcloth, wipe one eye from the inner part of the eye, near the nose, to the outer part. Rinse or turn the cloth before washing the other eye. Bathe the neck and ears. Dry the face and neck. Apply appropriate emollient. Arms and Hands: 7. Move towel, lengthwise under arm. Wash, rinse, and dry hand, arm, and axilla, distal to proximal. Repeat for opposite upper extremity. Apply appropriate emollient. If unable to reach bathe one side and then move to opposite side of bed to bathe opposite extremity). Chest and abdomen: 8. Spread another towel over chest and a second towel over the abdominal area. Lift chest towel and wash, rinse, and dry chest being sure to pay special attention to the folds under the breasts. Cover chest and now lift lower towel and wash, rinse, and dry the abdomen. Remove gown and put on clean gown. If the patient has an IV, put the gown on the IV arm first. Put the IV bag and tubing through the armhole from the back side of gown and follow with hand and arm. Then put the gown on the non-IV arm and tie at neck. Legs: 9. Place dry towel lengthwise under leg. Wash rinse, and dry lower extremities (excluding feet) distal to proximal. (If unable to reach bathe one side and then move to opposite side of bed to bathe opposite extremity). Apply appropriate emollient. Feet: 10. Wash, rinse, and dry feet paying attention to areas between toes. Apply appropriate emollient. CHANGE THE WATER and GLOVES. Perineal Care 11. See separate checklist for either male or female CHANGE THE WATER AND GLOVES. Back and buttocks: 12. Turn patient to side-lying position, place towel lengthwise along back. Wash back and buttocks area. Pay particular attention to cleansing between gluteal folds, and observe for any redness or skin breakdown in the sacral area. If not contraindicated, give patient a backrub. 13. Clean buttocks last - going from clean to dirty/ front to back. 13. Dispose of linens and other equipment used in bath in proper containers. 14. OPTION: with patient on their side, make the occupied bed. 15. Remove gloves / Perform hand hygiene. 16. Verbalize hair care, feet and nail care, eye and ear care, elimination care

Applying Elastic Anti-embolism Stockings (TED Hose): Removal

1. Remove daily (usually best time is during bath). 2. Grasp top of stocking with your thumb and fingers and smoothly pull stockings off inside-out to heel. Support foot and ease stocking over it.

Personal Protective Equipment (PPE): Removing PPE

1. Remove gloves: a. Free your Wrists - Grasp gown near cuff area and pull up exposing about an inch of skin, do this on both sides. b. Glove to glove - Pinch palm area (stay away from cuff), with opposite gloved hand and pulls off glove turning glove inside out holding dirty glove in palm of gloved hand. (dirty to dirty) c. Finger to skin - Slide clean finger of ungloved hand under cuff of dirty glove and remove turning inside out, taking care not to touch the outer surface. (clean to clean) d. Dispose in proper waste container. 2. Remove goggles/face shield (only if appropriate): a. Grasp goggles/face shield by head band or earpieces b. Lift away from face c. Dispose in proper waste container. 3. Remove gown: a. Unfasten ties of waist and then tie at neck. Pull gown off shoulders by just holding ties and then let go. b. Slide clean finger under gown cuff, pull gown down over hand making a mitt. (clean to clean) c. With mitt hand, grasps opposite gown sleeve and pull gown down, (dirty to dirty) allowing gown to fall away from shoulder, making a mitt. d. Keeping hands on inner surface of gown pull from arms and remove gown without touching outside surface. e. Turn gown inside out f. Fold or roll gown into a bundle, stopping about 12 inches before the bottom edge and discard in proper waste container. 4. Remove mask: a. For elastic - grasp elastic loops and pull off, being careful to touch only the elastic. b. For tie mask - Grasp the neck ties first and then the head ties and remove. Take care to avoid touching front of mask. c. Discard in proper waste container. 5. Perform hand hygiene immediately after removing PPE.

Assisting a Patient With Turning in Bed:

1. Remove positioning devices, such as pillows. 2. Loosen top sheet and leave to cover the patient. 3. If not already in place, position a friction-reducing sheet or draw sheet under the patient. 4. Using the friction-reducing sheet or draw sheet, move the patient to the edge of the bed, opposite the side to which he or she will be turned. Raise the side rails. 5. If able, have patient grasp side rail on the side of the bed toward which he or she is turning. Alternately, place patient's arms across their chest and cross their far leg over the leg nearest you. 6. Stand with feet spread about shoulder width, tighten gluteal and abdominal muscles and flex knees. Use leg muscles to do the pulling. Place a hand on the patient's shoulder and the other on the patient's hip and turn the patient over toward you. Instruct the patient if able to pull on the bed rail at the same time. Use the friction-reducing sheet to gently turn the patient over on his or her side. 7. Place pillows behind the patients back and between knees. 8. Pull the shoulder blade forward and out from under the patient. 9. Ensure patient is comfortable, covered, and in proper body alignment.

Assessing Axillary Temperature

1. Remove the electronic unit from the charging unit, and remove the probe from within the recording unit. 2. Cover thermometer probe with disposable probe cover and slide it on until it snaps into place. 3. Move the patient's clothing to expose only the axilla. 4. 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. 5. Place the end of the probe in the center of the axilla. Have the patient bring the arm down and close to the body. 6. Hold the probe in place until it beeps, remove the probe and write down reading. 7. Dispose of the probe cover by holding the probe over an appropriate waste receptacle and pressing the release button. 8. Return the electronic unit to the charging unit, if appropriate. 9. Document as directed or per facility policy.

Assessing Rectal Temperature

1. Remove the electronic unit from the charging unit, and remove the probe from within the recording unit. 2. Cover thermometer probe with disposable probe cover and slide it on until it snaps into place. 3. Place the patient in a Sim's position with upper knee flexed. Drape the patient to expose only anal area 4. Apply disposable gloves 5. Slide disposable probe cover over thermometer and then lubricate about 1" -1 ½" of probe cover with a water-soluble lubricant. 6. Reassure the patient. Separate the buttocks until the anal sphincter is clearly visible. 7. Insert the probe gently into anus about 1½ inches in an adult, 1 inch in a child. ½ inch for infant. 8. Hold the probe in place until it beeps, remove the probe and write down reading. 9. Dispose of the probe cover by holding the probe over an appropriate waste receptacle and pressing the release button. 10. Return the electronic unit to the charging unit, if appropriate. 11. Using a cleaning wipe or toilet tissue wipe the anus of any feces or excess lubricant and discard. 12. Write down your results so you can later document as directed or per facility policy.

Assessing Oral Temperature

1. Remove the electronic unit from the charging unit, and remove the probe from within the recording 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. Ask the patient to close his or her lips around the probe. 4. Continue to hold the probe until you hear a beep. 5. Remove the probe from the patient's mouth and writing down reading. 6. Dispose of the probe cover by holding the probe over an appropriate receptacle and pressing the probe release button. Return the thermometer probe to the storage within the unit. Return the electronic unit to the charging unit, if appropriate. 7. Document as directed or per facility policy.

Moving a Patient Up in Bed with Assistance from another Staff Member

1. Review the medical record for conditions that may influence the patient's ability to move or be positioned. Assess for any tubes, IV lines, or equipment that may alter the positioning procedure. 2. Seek the assistance of other personnel, if needed (Patient Ergonomics) 3. Remove pillow from patient and place at head of bed in upright position so it pads the headboard 4. Position at least one nurse on either side of the bed, and lower both side rails. 5. If a friction-reducing sheet (or device) is not in place under the patient, place one under the patient's midsection. 6. Ask the patient (if able) to bend his or her legs and put his or her feet flat on the bed to assist with the movement. 7. Have the patient fold the arms across the chest. 8. Have the patient (if able) lift the head with chin on chest. 9. Grasp the friction-reducing sheet or draw sheet securely, close to the patient's body. 10. Flex your knees and hips. Tighten your abdominal and gluteal muscles and keep your back straight. 11. Shift your weight back and forth from your back leg to your front leg and point feet in direction of movement. Count to three. On the count of three, move the patient up in bed. If possible, the patient can assist with the move by pushing with the legs. Repeat the process, if necessary, to get the patient to the right position. 12. Assist the patient to a comfortable position and readjust the pillows and supports, as needed. Ensure patient is covered, and in proper body alignment.

Assessing the Apical Pulse by Auscultation

1. Use alcohol swab to clean the diaphragm of the stethoscope. Use another swab to clean the earpieces, if necessary. 2. Assist patient to a semi-fowlers or reclining position and expose chest area. 3. Move the patient's clothing to expose only the apical site. 4. Warm the diaphragm with the palm of the hand before placement . 5. Find Landmark: Palpate the space between the fifth and sixth ribs (fifth intercostal space), and move to the left midclavicular line. Place the diaphragm over the apex of the heart. Verbalize site. 6. Listen for heart sounds ("lub-dub"). Each "lub-dub" counts as one beat. 7. Using a watch with a second hand, count the heartbeat: ● If apical pulse is regular, count rate for 30 seconds. Multiply this number by 2 to calculate the rate for 1 minute. ● If apical pulse is irregular in rate, rhythm, or amplitude, count the pulse for 1 minute (60 seconds). 8. Clean the diaphragm of the stethoscope with an alcohol swab. 9. Document as directed or per facility policy.

Assisting a Patient from Bed to a Chair

1. Review the medical record for conditions that may influence the patient's ability to move. Assess for any tubes, IV lines, or equipment that may alter moving the patient. 2. Assess patient mobility status. Seeks the assistance of other personnel, if needed. 3. Move any equipment to make room for the chair and a clear path to the chair. 4. Make sure the bed brakes are locked. Place chair at 45˚-90˚ angle to the bed. If available, lock the brakes of the chair. If the chair does not have brakes, brace the chair against a secure object. 5. Place the bed in lowest position. Raise the head of the bed to a Fowler's position (sitting). 6. Ask patient to move to the side of the bed and push self-up from a side-lying position or assist patient to pivot around by placing your hands across patient knees and swing around. Keep your back straight; avoid twisting. 7. Dangle patient on the side of the bed by ensuring both feet touch the floor (patient might have to slide buttock to edge of bed for feet to touch floor) and arms on bed at each side. 8. Allow the patient's legs to dangle a few minutes before continuing to prevent orthostatic hypotension. While patient is dangling, assess for any balance problems or complaints of dizziness or nausea. If dizzy or nauseated, do not get the patient up, assist patient back in bed. If not dizzy, assist patient with putting on a robe and non-skid footwear. 9. Wrap the gait belt around the patient's waist, based on assessed need and facility policy. 10. Lower the side rail, if necessary, and stand in front of patient with knees flexed and feet shoulder width apart. Position yourself close to patient. 11. Have patient hands on your upper arms, NOT around your neck. 12. Place your arms on patient's waist or grasp gait belt from underneath. 13. Rock back and forth while counting to three. On the count of three, have patient look up while use your legs (not your back) to help raise the patient to a standing position. If indicated, brace your front knee against the patient's weak extremity as he or she stands. Assess the patient's balance and leg strength. If the patient is weak or unsteady, return the patient to bed. 14. Pivot on your back foot and assist the patient to turn until the patient feels the chair against his or her legs. 15. Instruct the patient to use the armrests for support and assist the patient to sit. (If no arm rest have patient feel back of chair against legs than assist the patient to sit in chair). 16. Assess the patient's alignment in the chair. Remove gait belt and cover with sheet if needed.

Using a Pulse Oximeter

1. Select adequate site for application of sensor - usually use patients index, middle or ring finger 2. Check proximal pulse and capillary refill at the pulse closest to the site. If circulation is inadequate, consider using earlobe, forehead, bridge of nose, or toe. 3. Prepare monitoring site. a. Cleanse the selected area with alcohol wipe or disposable cleaning cloth. b. Allow area to dry. c. If necessary remove nail polish and artificial nails after checking pulse ox manufacturer's instructions. 4. Apply probe securely to area .Make sure light emitting sensor and light receiving sensor are aligned opposite each other 5. Connect sensor probe to pulse oximeter and turn on the oximeter, & check operation of equipment. 6. Set alarms on pulse oximeter. 7. Assess Oxygen saturation every 4 hours as part of VS or as ordered. 8. Remove sensor every 4 hours and assess skin for irritation. 9. Document as directed or per facility policy.

Assessing a Radial / Peripheral Pulse by Palpation

1. Select the appropriate peripheral site based on assessment data. 2. Move the patient's clothing to expose only the site chosen. 3. Place your first, second, and third fingers over the artery. Lightly compress the artery so pulsations can be felt and counted. 4. Using a watch with a second hand, count the number of pulsations: ● If radial pulse is regular, count rate for 30 seconds. Multiply this number by 2 to calculate the rate for 1 minute. ● If radial pulse is irregular in rate, rhythm, or amplitude - take an apical pulse for 1 minute (60 seconds). 5. Write down the rate, rhythm and amplitude of the pulse. 6. Document as directed or per facility policy.

Applying Elastic Anti-embolism Stockings (TED Hose): Application

1. Stand at the foot of the bed. Place hand inside stocking and grasp heel area securely. Turn stocking inside-out to the heel area, leaving the foot inside the stocking leg. 2. With the heel pocket down, ease the foot of stocking over foot and heel. Check that patient's heel is centered in heel pocket of stocking. 3. Using your fingers and thumbs, carefully grasp edge of stocking and pull it up smoothly over ankle and calf, toward the knee. Make sure it is distributed evenly. 4. Pull forward slightly on toe section. If the stocking has a toe window, ensure it is properly positioned. Adjust if necessary to ensure material is smooth. 5. If the stockings are knee-length, make sure each stocking top is 1"-2" below the patella. Make sure the stocking does not roll down. 6. If applying thigh-length stocking, continue the application. Flex the patient's leg. Stretches the stocking over the knee. 7. Pull the stocking over the thigh until the top is 1-3 inches below the gluteal fold. 8. Adjust the stocking as necessary to distribute the fabric evenly. Make sure the stocking does not roll down. 9. Perform hand hygiene. 10. Return and assess the neurovascular status of feet and toes every shift or according to facility policy: Neuro assessment = tingling, numbness, can they wiggle their toes. Vascular assessment = is skin warm to touch, pink in color, and good capillary refill of <2-3 seconds.

Ear Care and Care of Hearing Aids: Removal of hearing aids and cleaning the external ear

1. Turn off the hearing aids. 2. Gently remove the aid from the ear. 3. Wipe with clean dry cloth. Do not get them wet. 4. Clean the outer ear with damp washcloth.

Assessing Respirations

1. While your fingers are still in place for the pulse measurement, after counting the pulse rate, observe the patient's respirations noting the rise and fall of the patient's chest. 2. Using a watch with a second hand, count the number of respirations for 30 seconds. 3. Multiply this number by 2 to calculate the respiratory rate per minute. If respirations are abnormal in any way, count the respirations for at least 1 full minute. 4. Write down the rate, depth and rhythm of the respirations. 5. Document as directed or per facility policy.

Assisting a Patient with Ambulation: Equipment Needed

Gait belt, non-skid shoes or slippers. If unable to ambulate patient without assistance, use of additional caregivers, stand-assist device, and/or mechanical device lift etc. should be used.

Applying Pneumatic Compression Devices: Equipment Needed

Compression sleeves, inflation punt with connecting tubing.

Applying an External Condom Catheter: Equipment Needed

Condom sheath appropriate size, skin protectant, top sheet, urinary drainage system, waterproof pad, non-sterile gloves, scissors,

Oral Care: Equipment Needed

Denture cup or emesis basin, towel, washcloth or gauze, toothbrush, toothpaste, dental floss, towels, toothettes, denture care products, suction set up and yanker if patient on aspiration precautions. 1. Position the patient to facilitate oral care (high fowlers, semi-fowlers, side-lying). 2. Place towel across the chest.

Assessing Vital Signs - Temperature, Apical Pulse, Radial Pulse, Respiratory Rate, Blood Pressure: Equipment Needed

Digital or electronic thermometer, disposable probe covers, water soluble lubricant for rectal temperature, pencil, paper, or flow sheet, computerized records, blood pressure cuff of appropriate size, alcohol swab, stethoscope, sphygmomanometer, watch.

Administration of High Volume or Cleansing Enema

Disposable enema set, water-soluble lubricant, IV pole, bedpan, bedside commode, or nearby bathroom ready for use with tissue paper, waterproof pad, basin, wash cloth, towels and soap, and non- sterile gloves.

Applying Elastic Anti-embolism Stockings (TED Hose): Equipment Needed

Elastic embolic stockings (correct size), measuring tape. 1. Assist the patient to a supine position. If the patient has been sitting or walking, have patient lie down with legs and feet elevated for at least 15 minutes before applying the stockings. 2. Read manufacturer's directions for measurement and use, measure and get appropriate size 3. stockings 4. Assess skin integrity of the thigh and legs bilaterally.

Assisting a Patient With Turning in Bed: Equipment Needed

Friction-reducing sheet or draw sheet, pillows to help the patient maintain the desired position after turning and to maintain proper body alignment. Additional caregivers to assist based on assessment. If unable to turn patient with assistance, a mechanical device lift should be used.

Administering Oxygen by Nasal Cannula: Equipment Needed

Flow meter, humidifier with sterile distilled water, nasal cannula and tubing

Administering Oxygen by a Mask: Equipment Needed

Flow meter, humidifier with sterile distilled water, nasal cannula and tubing

Personal Protective Equipment (PPE): Prechecks and putting on PPE

I. Verify HCP orders to determine which PPE are to be used. II. Equipment Needed: Gloves, masks, impervious gown, protective eyewear (when appropriate). Putting on PPE 1. Gown: Put on gown, with opening in the back taking care to cover the entire front and back of uniform. Tie gown securely at back of gown (tie neck first and then waist). 2. Mask: Put on mask, with blue facing outward and wire on top. Secure it over the nose, mouth and chin. If mask has ties - tie head first then at neck. If elastic, pull around ears. Press wire around nose. 3. Goggles: Put on goggles or face shield when appropriate. 4. Gloves: Pull cuffs of gown down over part of hands prior to applying gloves. Apply gloves, making sure extending gloves to cover the cuff of the gown sleeve. No exposed skin!

Entry Measures

I. Verify Health Care Provider's (HCP's) orders and/or hospital policy. II. Gather all needed equipment and supplies. Check expiration dates as needed. Entry Measures: 1. Perform hand hygiene, put on PPE, if indicated. 2. Provide privacy - close door or close curtain 3. Greet patient and introduce self (Name, ACC Nursing Student) 4. Identify patient using two acceptable identifiers (ask patient their name & assess MR#) 5. Ask patient if they have any allergies. 6. Explain the procedure to the patient and why this intervention is needed. Answer any questions as needed. 7. Raise bed to a working height and put down side rail.

Collecting a Sputum Specimen for Culture: Preparation

If patient may have pain with coughing, administer pain medication if ordered. If patient can perform task without assistance after instruction, leave container at bedside with instructions to call nurse as soon as specimen is produced. Instruct patient that sputum is needed, NOT saliva. Should collect specimen first thing in the morning before a meal. Confirm that the patient has not recently completed oral hygiene or mouthwash.

Incentive Spirometer Procedure: Equipment Needed

Incentive Spirometer, pillow

Administrating a Low Volume or Retention Enema

Low volume enema bottle (oil retention enema, fleets enema), water-soluble lubricant, bedpan, bedside commode, or nearby bathroom ready for use with tissue paper, waterproof pad, basin, wash cloth, towels and soap, and non- sterile gloves.

When is handwashing with alcohol-based hand rub used?

Mainly when entering a patient's room and anytime that hands have not been working with contaminated items.

Collecting a Urine Specimen (Clean Catch, Midstream) Urinalysis & Culture & Sensitivity (C&S): Equipment Needed

Moist cleansing towelettes or soap, water & washcloth, non-sterile gloves, sterile specimen container, biohazard bag, and label.

Collecting a Sputum Specimen for Culture: Equipment Needed

Non-sterile gloves, sterile sputum specimen container, goggles, biohazard bag, and Label.

Collecting Stool for an Occult Blood called a Hemoccult Test: Equipment Needed

Non-sterile gloves, wooden applicator, Hemoccult card and developer, bio-hazard bag, bedpan, specimen hat, commode, or nearby bathroom ready for use.

Pursed Lip Breathing Procedure: Equipment Needed

None

Making an Occupied Bed: Equipment Needed

One of each of the following: pillow case, large flat sheet, draw sheet, fitted sheet, bedspread, linen hamper/bag, bedspread, waterproof protective pad, bedside chair. Place on clean area in room.If unable to move patient without assistance use of additional caregivers, stand-assist device, and/or mechanical device lift etc. should be used.

Making an Unoccupied Bed: Equipment Needed

One of each of the following: pillow case, large flat sheet, draw sheet, fitted sheet, bedspread, linen hamper/bag, bedspread, waterproof protective pad, bedside chair. Place on clean area in room.

Assisting a Patient with Eating: Equipment Needed

Pencil, paper, or flow sheet, computerized records, suction set up and Yanker if patient on aspiration precautions

Effective Deep Breathing, Coughing & Splinting Procedure

Pillow

Moving a Patient Up in Bed with Assistance from another Staff Member: Equipment Needed

Pillows, friction-reducing sheet or draw sheet. If unable to move patient without assistance, use of additional caregivers, stand-assist device, and/or mechanical device lift etc. should be used.

Applying an Extremity Restraint: Prior to Application

Prior to Application: 1. Determine need for restraints. Assess patient's physical condition, behavior, and mental status. (e.g., confusion, disorientation, agitation, repeated removing of tubing or dressings) 2. Make sure that all alternatives have been tried prior to use of restraints and determine failure of the alternative measures. 3. Confirm agency policy for application of restraints. Secure a health care provider's order or validate that the order has been obtained within the past 4 hours. 4. Explain reason for use to patient and family. Explain that it is a temporary measure. Determine if a signed consent for use of restraint is necessary.

Using a Pulse Oximeter: Equipment Needed

Pulse oximeter, nail polish remover (if needed), ETOH wipes

When do you remove the PPE? What is the exception?

Remove all PPE BEFORE exiting the patients room. ONLY exception is N95 mask in an airborne precaution: Remove mask after leaving patient room, closing the door, and AFTER entering anteroom

Shaving a Male Patient: Before Shaving

Usually offer to shave the male patient prior to starting the bath. Before shaving: 1. Review the patient's medical history, medications, and laboratory values, such as platelet count and anticoagulation studies. Use an electric razor on patients who take anticoagulant medications, have bleeding disorders, or diabetes. Grooming tools and safety razors with razor blades increase the risk of skin injury and bleeding. 2. Assess the patient's hair on face and skin for any broken skin or reddened areas.

Collecting a 24-Hour Urine Specimen: Equipment Needed

Urine hat specimen collector, Large, clean amber bottle with cap or stopper (usually obtain this from the lab); bath basin, gloves, signs related to a 24-hour urine collection. (Bedpan or urinal if patient is unable to get out of bed).

Applying a Warm or Cold Compress: Equipment Needed

Warm or cold pack, washcloth or towel.

Perineal Care: Female: Equipment Needed

Wash basin, personal hygiene equipment, skin cleaning agent, wash cloths, and towels.

Perineal Care: Male: Equipment Needed

Wash basin, personal hygiene equipment, skin cleaning agent, wash cloths, and towels.

Hygiene - Giving a Bath: Equipment Needed

Wash basin, personal hygiene equipment, skin cleaning agent, wash cloths, towels, gown, laundry bag, non-sterile gloves. Note: may just need to gather several disposable bathwipe packets.

Shaving a Male Patient: Shaving with a Disposable Safety Razor

Shaving with a Disposable Safety Razor: 1. Apply clean gloves. 2. Test the water to ensure that it is not too hot. 3. Place a washcloth in the basin. 4. Place a bath towel over the patient's chest and shoulders. 5. Wring out the washcloth thoroughly. Apply the warm, moist washcloth over the patient's facial hair for several seconds. 6. Apply approximately 1/4-inch layer of shaving cream or soap to the patient's face. Smooth the cream evenly over the sides of the patient's face, over his chin, and under his nose. 7. Hold the razor in your dominant hand at a 45-degree angle to the patient's skin. Use your non-dominant hand to gently pull the skin taut while shaving. 8. Begin by shaving across one side of the patient's face, using short, firm strokes in the direction in which the hair grows. 9. Check with the patient, and ask him if he feels comfortable. 10. Dip the razor in the water as shaving cream accumulates on the blade. 11. After the patient has been shaved, change the water in the basin and cleanse his face thoroughly with another warm, moist washcloth. 12. Dry the face thoroughly, and apply aftershave lotion if the patient wishes. 13. Help the patient into a comfortable position. 14. Return the used equipment to its proper place. Discard soiled linen in the linen bag, and perform hand hygiene.

Collecting a Stool Specimen for Culture: Equipment Needed

Tongue blade (x2), clean specimen container, biohazard bag, non-sterile gloves, and label.