Active ROM exercise PDF

Active ROM exercise Steps 1 2 3 4 5 Neck pivot joint Flexion: Move the heads from the upright midline position forward, so that the chin rest on the chest. (45 degree from Midline) Extension:...

Active ROM exercise Steps 1 2 3 4 5 Neck pivot joint Flexion: Move the heads from the upright midline position forward, so that the chin rest on the chest. (45 degree from Midline) Extension: move the headfrom the flexion position to upright position. (45 degree from Midline) Hyperextension: move the head from the upright position back as far as possible.. (45 degree) Lateral flexion: move the head laterally to the right and the left shoulders, while facing front. (40 degree from Midline) Rotation: turn the face as far as possible to right and left.(70 degree Midline) shoulder –ball-and socket joint. Arms: 41 Flexion: raise each arm froma position by the side forward and upward to a position beside the head.( 180 degree from the side) Extension: move each armfrom a vertical position beside the head for word and down to arresting position at the side of the body.( 180 degree from vertical position beside the head) Hyperextension: move eacharm from arresting side position to behind the body.(50 degree from side position) Abduction: move each armlaterally from arresting position at the side to a side position above the head, palm of the hand away from the head.(180 degree) Adduction:(anterior) Move each arm from apposition beside the head down ward laterally and across front of the body as far as possible.(50 degree) 42 Horizontal flexion: extend each arm laterally at shoulderheight and move it through a horizontal plan across thefront of the body as far aspossible. (135 degree) Horizontal extension: extend each arm laterally at shoulder height and move it through a horizontal plan across the behind the body as far as possible. (45 degree) Circumduction: move each arm forward up, back and down in a full circle (360 degree) Externalrotation: with each arm held out to the side at the shoulder level and theelbow bent to a right angle,finger point down move the arm upward so that the fingers point up.(90 degree) Internalrotation: with each arm held out to the side at shoulder level and the elbow bent to a right angle, finger point up bring the arm forward and down that the finger point down.(90 degree) 43  Elbow-hinge joint Flexion: bring each lower arm forward and upward so that the hand is at the shoulder.(150 degree) Extension: bring each lower arm forward and down ward, straightening the arm.(150 degree) Rotationsupination :turn each hand facing forearm so that the palm is facing upward.(70-90 degree) Rotationpronation: turn each hand and forearm so that the palm is facing downward.(70-90 degree) 44 Flexion: bring the finger of each hand toward the inner aspect of the forearm.(80-90 degree) Extension: straighten each hand toward the inner aspectof the forearm. Extension: straighten the finger of each hand. (80-90 degree.) thumb side with hand Hyperextension: bend the finger of each hand back asfar as possible.(70-90 degree) Radialflexion(ulnarhyperextension): (Abduction): bend each wrist laterally toward the supinated.( 0-20 degree) Ulnarflexion (adduction):bend each wrist laterally to word the fifth finger with the hand supinated, the behind the body as far as possible (30-50 degree) 45  Hand and finger Metacarpophalangeal Joint-condyloid: interphalanggeal joins –hinge Flexion: make a first with each hand.( 90 degree) Extension: straighten the fingers of each hand. ( 90 degree) Hyperextension: bend the fingers of each hand back as far as possible.(30 degree) Abduction: spread the finger of each hand apart. (20 degree) Adduction: bring the fingers of each hand together.(20 degree) Thumb-saddle joint Flexion: move each thumb across the palmer surface of the hand toward the fifth finger. (90 degree) Extension: move each thumb away from the hand. (90 degree) Abduction: extend each thumb laterally.(30 degree) 46 Abduction: extend eachthumb laterally.(30 degree) Adduction: move each thumb back to the hand. Opposition: touch each thumb to the tip of each fingers of the same hand.(70 degree) Hip –ball and socket joint flexion: move each leg forward and upward, the knee may be extended or flexed. (90 degree) Extension: move each legback beside the other leg. (90-120 degree) Hyperextension: move eachleg back behind the body. (30-50degree) Abduction: move each legout to the side (45- 50 degree) Adduction: move each leg back to the other leg andbeyond in front of it. (20-30 degree) Circumduction: move each leg forward, lateral, backward , to the side and downin a circle. (360 degree) 47 Internalrotation: turn each foot and leg In ward that thetoes point as far as possible to ward the other leg. (40 degree) Externalrotation: turn each foot and leg out ward that the toes point as far as possible to ward the other leg. (45 degree) Knee- hinge joint Flexion; bend each legs bringing the heel toward the back of the thigh. (120-130 degree) Extension: straighten each leg returning the foot to its position beside the other foot. (120-130 degree) Ankle –hinge joint 48 Extension:( planter flexion)point the toes of each footdown word. (20 degree) Flexion :(dorsiflexion)Toes of each foot upward. (45-50 degree) Foot Eversion: turn the sole of each foot laterally. (5 degree) Inversion: turn the sole of each foot medially. (5 degree) Toes Interphalangael Joint king: Metatarsophalangeal. Joint hinge: intertarsel joint–gliding Flexion: curve the toes joint of each foot down ward. (35-60 degree) Extension: straighten the toes of each foot. (35- 60 degree)Abduction: spread the toes of each foot apart. Adduction: bring the toes of each foot to gather. 49  Trunk –gliding joint flexion: bend the trunk toward the toes. (70-90 degree) Extension: straighten the trunk from a flexed position. (70-90 degree) Hyperextension: bend the trunk back ward. (20- 30 degree) Lateral flexion: bend the trunk to the right and to the left. (35 degree) Rotation: turn the upper part of the body from side to side.(30-45 degree) 50 Passive ROM Exercises The nurse performs these exercises. Procedure: 1- Assist the patient to supine position near the nurse , and expose the body parts requiring exercise ,place the client feet together ,place the arms at the sides , and leave space around the head and the feet. Rational: positioning the client close to the nurse prevents excessive reaching. 2-Return to the starting position after each motion, repeat each motion three times. 3-Throughout the exercise assess: a - ability to tolerate the exercise. b - range of motion of an affected joint. Upper Extremity Passive ROM Exercises Upper extremity, passive ROM exercises teach someone else how to stretch your arms if you are unable to move your arms by yourself. These exercises should be done slowly and gently, and can be done with the person sitting in a chair or lying down. Do each exercise ten times. 51 Steps 1 2 3 4 5 Neck Rotation and laterally: Turn head slowly to look over left shoulder then turn to look over right shoulder, touching the chin to the Shoulder if possible. Place the heels of the hands on each side of the client checks. Move the top of the head to the right and left. Neck Flexion and extension: place the palm of one hand under the client head and the palm of the other hand on the client chin. Move the head forward until the chin rest on the chest , then back to the resting supine position without the head pillow Shoulder Flexion and Extension Hold the upper arm with one hand and forearm with the other hand. Bend the arm at the elbow so that the hand touches the shoulder. Then straighten the arm all the way out. 52 Move Shoulder Internal and External Rotation Place one hand under the Elbow. With your other Hand, hold the forearm. Bring arm out to the side to shoulder level. Turn arm so that the hand points to the Ceiling. Then turn arm back down so that hand points to floor and the upper arm is twisting in the shoulder joint. Horizontal Shoulder Abduction Place hands behind or Above head. Gently touch elbows to bed and hold as Tolerated. Stretch felt in Chest.Pull arm across chest. Stretch is felt in back of arm and shoulder. Elbow Flexion and Extension Hold the wrist with one hand. With the other hand, grasp the elbow joint to Stabilize it. Turn the palm inward, facing the body, and keep the elbow relatively straight 53 Finger and Wrist Flexion and Extension Hold the forearm above the wrist with one hand and grasp the fingers with your other hand. Holding the hand in this way, bend the wrist back, about 90 degrees, while straightening the fingers Out. Then bend the wrist the opposite direction, about 90 degrees, while curling the fingers into a Fist. Thumb Flexion and Extension Move thumb to little Finger. Then bend and straighten the thumb out to the side to stretch the "web space" hip and leg 54 flexion and extension supporting the lower leg.flex the leg toward the chest and then extend the leg internal and external rotation supporting the lower leg angle the foot inward and outward knee flexion and extension supporting the lower leg ,flex and extend the knee Ankle 55 flexion and extension supporting the lower leg ,flex and extend the ankle Foot adduction and abduction supporting the ankle ,spread the toes apart and then bring them close together flexion and extension supporting the extend the toes upward and then extend the toes downward 56 Lower Extremity Passive ROM Exercises 1. Wash your hands. 2. Explain what you are going to do. 3. Provide privacy. Make sure client is wearing adequate clothing. 4. Raise bed to a comfortable working height if possible. 5. Assist client into supine position. Lower Extremity Passive ROM Exercises Lower extremity passive exercises are for someone else to stretch your hips, legs, and Knees if you are unable to do this yourself. These exercises should be done slowly and gently while you are lying on your back. Each exercise should be done ten times on each leg each day. Steps 1 2 3 4 5 Hip and Knee Flexion Cradle the leg by placing one hand under the bent Knee. With the other hand, grasp the heel for Stabilization. Lift the knee and bend it toward the chest, with the kneecap Pointed toward the ceiling. Do not allow the hip to twist during this Movement. The foot should stay in a straight line with the hip and not swing in or out. The leg is then lowered to the starting position. 57 Hip Rotation Place one hand on the thigh and other hand just below the knee. Bend the knee halfway to the chest so that there is a 90 degree angle at the hip and knee. Pull the foot toward you and then push it away. Remember; do not go beyond the point of resistance or pain. lower leg to starting position. 1. Support the leg under the knee and heel. 2. Bend the knee halfway to the chest so that there is a 90 degree angle at the hip and knee. 3. Push the foot away from you. 4.Pull the foot toward you Hip Abduction 58 Cradle the leg by placing your hand under the knee and holding it. Place the other hand under the heel to stabilize the hip joint. Keeping the knees straight, move the leg along the surface of the bed, toward you and away from the other leg, approximately 45 degrees. Then bring the leg back to the other leg Ankle Rotation With the knee straight and one hand holding the ankle steady, place the hand around the foot and turn foot inward, then outward Toe Flexion and Extension With one hand, stabilize the foot just below the toes. With the other hand, gently move each or all of the toes forward and backward 59 Heel-Cord Stretching Cups or cradle the heel with your hand and place your forearm against the ball of the foot. Push the ball of the foot forward, bending the foot toward the knee and stretching the muscles in the back of the leg Cup the heel of the foot into the palm of your hand. Gently push the foot down to “point the toes.” Do this with knee bent, then repeat with knee straight 60 Lumbar Rotation Bend knees up and keeping them together, lower than to one side as far as they comfortably go. Repeat to the other side. Hamstring Stretch With the knee and heel supported slowly raise the leg up, keeping the knee straight. Return to starting position 61 Procedure 1 2 3 4 5 Hand washing and wearing gloves. To prevent infection Prepare equipment to save time and effort Maintain patient privacy To reduce embarrassment Place the patient on back with pillow under the head, arms and hands in the sides ,knees flexed and separated. To pressure on skin, increase comfort and prevent bed sores Place air ring under the hips and cotton or foam pads under the heels to reduce pressure. To promote circulation and prevent bed sores Place footboard under the bottom of feet. To maintain dorsiflexion of the foot and prevent foot drop. If the patient is paralyzed place hand roll in hand. To keep hand in functional position and prevent finger contracture. Put tronchonter roll lf needed. To prevent external rotation of legs. Align the patient‘s body in good position Record procedure and response of patient. Reassure patient ,remove gloves and hand washing Prone position: 69 Indication: 1.Patient with pressure sores, burns, operation on back 2. To relieve abdominal distention. 3. Renal biopsy. 4. Examination of back. 5. in postoperative patient Procedure 1 2 3 4 5 Hand washing and wearing gloves. To prevent infection Prepare equipment to save time and effort Maintain patient privacy To reduce embarrassment Explain the Procedure to the patient. Place the patient flat on abdomen with one pillow under the head to promote comfort and relaxation Turn the patients head to one side and align the body in good position. Place both arm at the side of the head and support the arm in a flexed position at level of the shoulder. Support lower legs with pillow to elevate toes and decrease pressure. -reassure the patient, removing gloves and hand washing. Side-Lying or lateral Position: 70 Indication: 1. Patient require position changes 2. Immediate postoperative care. 3. used for examination of the perineum. 4. Inserting suppositories. 5. Taking rectal temperature. 6. Giving back care. 7. Giving enema and colonic irrigation. Procedure 1 2 3 4 5 Hand washing and wearing gloves. To prevent infection Prepare equipment to save time and effort Maintain patient privacy To reduce embarrassment -place the patient on his side with both arms forward and his knees flexed To maintain comfort and relaxation -The upper leg is flexed more than the lower leg -The upper knee and hip should be at the same level -Put small pillow between knees To reduce pressure and promote comfort -Put small pillow under head and neck, one hand rested on bed and put pillow under other Hand that rested on chest -put air rings under the patient and hand roll lf needed To prevent finger contracture and prevent bed sores Raise side rails to prevent falling -Reassure the patient, remove the gloves and hand washing. -record the procedure and response of patient. 72 Knee-Chest or Genu-Pectoral:  The patient rests on the knees and the chest.  The body is at 90◦ angle to the hip with back straight, the arm above the head and head turned to one side.  The abdomen remains un supported. Indication : 1. To examine the bladder. 2. To help correct retroversion of the uterus. 3. To administer caudal and sacral anesthesia. 4. Vaginal and rectal examinations. 5. Operative procedures on the vagina, rectum and perineum. Operative deliveries 6.. Dorsal lithotomy Procedure: Steps 1 2 3 4 5 Hand washing and wearing gloves. To prevent infection Prepare equipment to save time and effort Maintain patient privacy To reduce embarrassment -Make the patient on bed and rest on the knees and chest. To allow for examination to bladder, vagina or rectal. -The head is turned to one side with cheek on pillow -The body at90 angle to the hip and back straight. To maintain a correct position for examination. 73  -The arms should be extended on the bed at the elbow to support the patient partially -The abdomen remains un supported Fowlers and Semi-Fowler’s Position: It is a sitting position in which the head is elevated at45◦ to 60◦ and the client knees are slightly elevated, avoiding pressure on popliteal vessels. Indication: 1. To relieve dyspnea. 2. To improve circulation. 3. To relax the muscle of the abdomen back and thigh. 4. To relieve tension on the abdominal suture. 5. To facilitate breathing in patients with cardiac or respiratory embarrassment. Procedure : Steps 1 2 3 4 5 -Hand washing and wearing gloves. To prevent infection -Prepare equipment to save time and effort -Maintain patient privacy To reduce embarrassment -Elevate The head of the bed to 45angle to semi fowler, 60angle for high fowler -Rest the patient against mattress or small pillow. To maintain comfort and relaxation. 74  -put pillows under the arms, put hand roll if needed, put small pillow under lower back. -Place foot board at the bottom of the foot To prevent foot drop. -Place pillow under knees. -Place trochanterroll if needed. To prevent external rotation of legs. -Raise side rails To prevent falling. -Reassure the patient, remove gloves and hand washing. -Record procedure and response of patient. Orthopedic position High Fowler’s Position with over bed table to be placed across the front of the patient to rest both hands over bed table /on pillow placed in it and lean forward Leaning forward facilitate respiration allowing maximum chest expansion by reducing pressure of abdominal organs on the diaphragm. 75 Indication: 1. Patient with sever dyspnea. 2. Cardiac patient. 3. Position for thoracocentesis. 4. Patient with chest drainage tube. Procedure Steps 1 2 3 4 5 -Hand washing and wearing gloves. To prevent infection -Prepare equipment to save time and effort -Maintain patient privacy To reduce embarrassment -Raise the head of bed to 90angle, Place over bed table in front of the patient To rest his hands over it. -Place Pillow over the bed table abd ask patient to lean forwardon pillows To facilitate breathing to patient. Raise side rails of bed to prevent falling. -Reassure the patient, remove gloves and hand washing. -Record procedure and response of patient. Semis position or semi prone position: Indication: 1. Vaginal and rectal examination. 2. Administration of enema and suppository. 3. For relaxation in antenatal exercises 4. Position for sigmoidoscopy and protoscopy 76 procedure Steps 1 2 3 4 5 -Hand washing and wearing gloves, To prevent infection -Prepare equipment to save time and effort -Maintain patient privacy, To reduce embarrassment -Place the patient on left or right side. -the lower arm behind the body and upper arm is bent and rest on bed. To Maintain comfort and relaxation -The knees are both flexed with upper knee more flexed. -Place pillow under the upper arm. To support arm level with shoulder. -Place Pillow under upper knee. To support leg with hip -place sand bags parallel to planter surface. -Raise side rails of bed to prevent falling. -reassure the patient, remove gloves and Hand washing. -Record procedure and response of patient. Trendelenburg Position:. 77 Indication: 1. Gynecological surgery and supra-pubic prostatectomy cases. 2. To prevent shocks. 3. To prevent or relieve post-partum hemorrhage. steps 1 2 3 4 5 -Hand washing and wearing gloves, To prevent infection -Prepare equipment to save time and effort -Maintain patient privacy, To reduce embarrassment Place the patient I horizontal recumbent position,well padded shoulder braces and knees. Raise the foot of the bed at45angle. To prevent shocks and post partumhemorrage. -If on operating table, adjust the table so the patient's head is low and the knee is flexed. -Apply pillow under knees -apply restraints to arms and legs. Lithotomy position Indication: 1. For delivery of the baby. 2. For rectal examination and surgeries. 3. For vaginal examination and hysterectomy. 78 Procedure: Steps 1 2 3 4 5 -Hand washing and wearing gloves, To prevent infection -Prepare equipment to save time and effort -Maintain patient privacy, To reduce embarrassment Explain the Procedure to the patient. Position the patient on his back with a pillow under the head. Keep the leg well separated and the thigh flexed on the abdomen and the legs on the thighs buttocks are kept on the edge of the table and the legs are supported with stirrups Lumbar puncture position  Is a medical procedure in which a needle is inserted into the spinal canal, most commonly to collect cerebrospinal fluid (CSF) for diagnostic testing. The main reason for a lumbar puncture is to help diagnose diseases of the central nervous system, including the brain and spine. Examples of these conditions include meningitis  The patient should be positioned in a left lateral (for a right handed physician) or right lateral position (for a left handed physician) for LP or be in sitting position. This will in turn create the greatest interspinous distance (opens the gap) through which to access the intrathecal space and put a pillow under the head will provide comfort and keep the spine in a horizontal plane. 79  1-Moving a patient in bed toward you: Purpose: 1- To change patient's position. 2- To make an occupied bed. Steps 1 2 3 4 5 Stand at the side of the bed toward which you wish to move the patient. Consider the patient's body is divided into 3 segments upper, middle and lower Place one arm under the shoulder and neck of the patient and the other arm under the waist. move the patient toward you: a) Move the upper part of the patient's body toward you to the side of bed. b) Move the middle part of the patient's body toward you by placing one arm under patient back and arm under the thighs. c) Move the lower part of the patient's body toward you by placing one arm under the thighs and other under the feet. Moving a patient in bed toward you 85 Log rolling a Client Logrolling the Client : Logrolling is a technique for moving a client whose body must remain in straight alignment. Situations requiring total alignment of the spine include spinal injury or recovery from spinal surgery Logrolling is accomplished by two or three nurses working in a coordinated fashion. Equipment - Hospital bed with side rails -Turn sheet or draw sheet - Pillows Steps 1 2 3 4 5 Inform client of reason forthe move and how to assist(if able) Rationale Reduces anxiety; helps increase comprehension cooperation; Promotes client autonomy. Elevate hospital bed to highposition. Rationale A voids strain on nurses backmuscles. Using one or more staffmembers; place a turn /draw sheet under the clients back and head Rationale Reduces shearing force whichcan precipitate pressure ulcerformation. The lead nurse tells theclient and other personnelthe direction of the move. Rationale Cooperation and coordinationplace less strain on client andpersonnel. One person stands on eachside of bed. The lead nursegives the signal for themove. The staff member onside of the bed in thedirection of the move holdsthe turn\draw sheet to guidethe move pressure on clients bake toward the direction ofthe move , assisting client toroll. 86  Rationale Two persons give moresupport to client than oneperson could and are betterable tomaintain properalignment of clients spine andneck. Tuck pillows at clients back and abdomen Rationale Maintains side- lyingposition. Assess the client for comfortand proper alignment. Rationale Comfort is subjective Elevate side rails and lowerthe bed height. Rationale Promotes client safety. This procedure can bereversed to a position clientson their backs. Rationale Repositioning can preventdevelopment of pressuresores and promote circulation 2-Raising the patient's shoulders: Objective: - To arrange pillow. - To help the patient change his gown. - To assist the patient in a sitting position. Steps 1 2 3 4 5 Stand facing head of bed. Place hand of patient under your armpit and around your near shoulder. Place your hand under patient shoulder. Place free hand under patient shoulder and neck. Raise patient from pillow and support with locked arms. Remove pillow with free hand and move patient. 87  Raising the person's head and shoulders with assistance. A, two nursing assistantslock arms with the person. B, the nursing assistants have their arms under theperson's head and neck. C, the nursing assistants raise the person to a semi-sittingposition. D, one nursing assistant supports the person in the semi-sitting positionwhile the other gives care. 3-Moving the patient up in bed Objective: To promote the client’s comfort. Steps 1 2 3 4 5 1. Explain procedure to patient. 2. Lower the head of the bed and remove pillow from under the head to reduce resistance as possible. Place the pillow against the bed frame to protect the patients head. (N.B): If patient has trouble breathing, raise the head of the bed. Ask the patient to flex the knees & brace the feet on bed. Stand with one-foot in front of other & face head of bed. Place one arm under patient neck & shoulder, the other arm under his thighs & bend your knees. If the patient can assist: a) Using a headboard: Have the patient grasp the headboard and bend his knees,Place your forearms under his shoulders and knees, Lift at the count of three. b) Using a trapeze: if the patient has a trapeze on the bed have the patient graspthe trapeze and bend at the knees. Instruct patient to pull the bars at the head of bed with arms and pushes with feet while you at the same time move patient by shifting your weight from the back to front foot. 89  c) Using a lift sheet to moving patient up in the bed: a lift sheet makes liftingeasier helps prevent friction against the patient’s skin takes two persons to lift if patient can help him bend his knees. Turning the patient away from you Objective : - -To change patient's position. -To make an occupied bed. - To make back care. Steps 1 2 3 4 5 -Explain to the patient what you are going to do -Help the patient to move the near side and assist him to flex the near knee - Arm under patient shoulder a- place the patient's arm across her chestand the leg that is farther from you over the other leg b- turn the patient toward you onto her side - Pull lower buttock toward you 90 Turning the patient toward you Objective : - -To change patient's position. -To make an occupied bed. Steps 1 2 3 4 5 -Explain to the patient what you are going to do -Move patient to far side to allow enough space to turn the patient -Assist patient to flex the far knee -Firmly but gently , grasp the shoulder with one hand and the hip with other hand. -Turn patient and smoothly toward you. if the patient has , any drainage be sure that it is in correct place and position - Move pillow to a comfortable position under head and shoulder - Flex the patient upper leg and support it with a pillow , leave the lower leg extends on the bed. - Side rails for unconscious patient to prevent falling 91  Transferring Definition of transferring: Moving a patient from place refer to moving a patient from bed to a chair or stretcher, or wheelchair with maximum comfort and safety for patient and nurse Purpose for transferring: - Improvement of the patient’s condition (from ICU to medicine unit. - The need for surgery or X ray. - Transfers at the patient’s request. Methods of transferring: - By wheel chair - By stretcher - By a movable bed 6-Transferring patient between a bed and stretcher: Objective: - To transfer supine client from one location to another. Equipment: - Stretcher - Sliding board: Optional Steps 1 2 3 4 5 Lower the head of the bed until it is flat. Raise the bed so that it is slightly higher than the surface of the stretcher. Ensure that the wheels on the bed are locked. Pull the draw sheet out from both sides of the bed and roll it as close the patient sides as possible. Move the client to the edge of the bed, and position the stretcher. Transfer the client securely to thestretcher ensure client comfort and safety. Cover the patient with a sheet or both blanket. 93 Place the stretcher parallel to the bed and lock its wheels. Fill the gap that exist between the bed and the stretcher loosely with bath blankets. Two nurses press their bodies tightly against the stretcher to prevent its movement. Roll the pull sheet tightly against the client. The nurses flex their hips and pull the client on the pull sheet directly toward themselves and into the stretcher. Ask the patient to flex the neck during the transferring if possible and place the arms across the chest to prevent injury to these body parts. Make the patient comfortable. Unlock the stretcher wheels and move the stretcher away from the bed. Immediately raise the stretcher side rails to prevent falling, as the stretcher is high and narrow. 94 7-Lifting patient into wheel chair: Objective: - To put patient in sitting position. - To transfer patient from bed. Steps 1 2 3 4 5 Wash your hands Explain the procedure to the patient Position the wheelchair next to the bed and prepare it with blanket and top sheet. Lock the wheel brakes and remove the food rests or move them to the “up” position. Prepare to move the client: a. Assist the client with patting on robe and slippers. b. Obtain help from another person if the client is immobile, heavy, or connected to multiple pieces of equipment. Raise the head of the bed so that the client is in the sitting position. Assist the client to sit on the side of the bed a. Support the head and neck with one arm. b. Use your other arm to move the client’s leg over the side of the bed. c. Allow the client’s feet to rest on the floor. d. Maintain the client in this position for a short time Prepare to raise the client to a standing position a. Apply a transfer belt if necessary. b. Spread the client’s feet and brace your knees against client’s knees. c. Place your arms around client’s waist. Cover with top sheet and blanket if necessary 95  - To turn patient to bed place chair in original position and reverse step of procedure. 8-Transferring patient from bed to a chair using a hydraulic lift : Purpose: Safely transfer a patient from a bed to a chair when safe transfer is not possible without using a hydraulic lift. Procedure: Steps 1 2 3 4 5 Identify client and any mobility restrictions. Explain procedure andpurpose to patient. Place the sling evenly under the patient. Position the hydraulic lift so the frame can centered over the patient.Attach the sling to the frame. Have a nurse on each side of the hydraulic lift. Engage the hydraulicsystem to raise the patient from the bed. Carefully wheel the patient in hydraulic lift away from the bed,supporting limbs as needed. Position patient over chair and gentlylower to chair using the hydraulic lift. The sling remains in place under the patient and reattached to the frame when the patient is moved back to bed. 99 Assisting a client with Ambulation Steps Rationale 1 2 3 4 5 Inform client of the purposes Reduces client anxiety and and distance of the walking increase cooperation. exercise. Elevate the head of the bed Prevents orthostatic and wait several minutes. hypotension Lower the bed height, Legs , Reduces distance client has move the client into to step …….. thus the dangling position. decreasing risk of injury Encourage client to dangle at Prevents orthostatic side of bed for several hypotension. Allows for minutes. assessing tolerance for the sitting position. Stand in front of client with Prevents client from sliding your knees touching clients forward if dizziness or knees faintness occurs. Place arms under clients Axillae Supports clients trunk Assist client to a standing position allowing client time to balance Reduces risk of fall. Assist the client from a Help the client move into supine to a seated position A. the Place one arm under theclients dangling position back and one arm under the clients legs. Help client ambulate desired Provides assistance in distance or distance of achieving ambulatory tolerance by placing your goals. hand under the clients forearm and ambulating close to the client. 101 Assisting a client with Crutch walking Equipment:  One pair of crutches  Measuring tape  Gait belt (optional) Steps Rationale 1 2 3 4 5 Inform client that youwill Reduces anxiety ; help increase be assist withambulation comprehension and cooperation using promotes client autonomy. crutches. Assess client forstrength, Helps determine the mobility, rangeof motion , capabilities of client andamount visual acuity,perceptual of assistance required. difficulties,and balance. Adjust crutches to fit Provides broad base of theclient. With the supportfor client Space between clientsupine, measure the from the crutch pad and the heel to the axillae. axillaeprevents pressure on Withthe client standing, radialnerves. The elbow setthe crutch position at a flexionallows for space between point 4 to 5 in. lateral the tothe client and 4 to 6in crutch pad and axillae. front of the client. The crutch pad axillae. Thehand grip should beadjusted to allow for the client to have elbowsbent at 30 flexion. Lower the height of Allows client to sit with feet on thebed floor for stability. Dangle the client at Allows for stabilization of blood theside of bed for pressure , thus severalminutes. Assess preventingorhostatichypotension for vertigo Instruct client on Increase client methodto hold the comprehensionand cooperation crutches; thatis , with elbows bent 30and pad 1.5 102 to 2 in.below the axillae.instruct client to position crutches lateral to and forward of feet.Demonstrate correctpositioning. Apply the gait beltaround Provides support; the clients waistif balance Promotesclient safety and positionwith crutches. preventing orthostatic Support asneeded hypotension Four-point Gait Position the crutches 4.5to The four- point gait (used 6 in to the side and infront fourpartial on full weight of each foot. Movethe bearing) right crutch forward 4 provides greater stability to 6 in. and move the Weight bearing is on threepoint leftfoot forward ,even (two crutches and one withthe left crutch. Move foot on two feet and one theleft crutch forward 4 to crutch)at all times the client 6 and move the must beable to bear weight with rightcrutch. Repeat the bothlegs. four-point gait Three- Point Gait Advance both crutchesand The three-point gait (used the weaker legforward forpartial or non- Weight together 4 to 6 in Move bearing)Provides a strong the stronger legforward, baseof support. This gait can even with thecrutches. beused the client has a weak Repeat thethree- point gait ornon- weight bearing leg. Two- Point Gait Move the left crutch The two- point gait (used andright leg forward 4 to forpartial ….. weight bearing) 6in. Move the right provides a strong base of crutchand left leg forward support 4 to6 in Repeat the two- The client must be able point gait. bearweight on both legs. This gait faster than the four- point gait. Swing- Through Gait Move both The swing- through gaitpermits crutchesforward together a faster pace. This gait requires 4 to 6 in 103  Move both legs weight bearing on bothlegs , forwardtogether in a greater balance. And swingingmotion , even more strength with thecrutches. Repeat theswing- through gait Set realistic goals Crutch walking takes up to andopportunities 10times the energy required for forprogressive unassisted ambulation ambulationusing crutches Consult with a The physical therapist is physicaltherapist for theexpert on the health care clientlearning to walk teamfor crutch-walking withcrutches. techniques References: Graven,F.Rand HIRNLE,J.C92003).fundamentals of nursing.Ch37 4TH – ED.LONDON awotters company. Craven.R.&hirnle.c. (2008):fundmental of nursing human health and function ,3rd edition ,Lippincott company ,new yourk ,22,371-375. Rosdable,C.(2008):basic nursing,Lippincott company7th ed.pp470-80. Follow up activities: 1- Define turning , moving and transferring 2 - Enumerate guidelines before turning and moving 3- Discuss technique of Log rolling 4- List purpose of transferring 5- Discuss methods of transferring 104 Equipment: Thermometer tray consists of: - 1. Clean tray. 2. Clean thermometer with probe cover. 3. Dry cotton. 4. Cotton soaked with alcohol in labeled container. 5. Pen. 6. Watch with seconds. 7. Gloves. 8. Nursing record or vital signs chart. Steps of oral temperature 1 2 3 4 5 1- Hand washing before &after procedure&take personal protection. Rational : To reduce spread ofmicroorganisms. 2-Prepare equipment. Rational: - To save time and effort. 3-Identify and greeting the patient. 4- Explain procedure to the patient and puthim in comfortable position. Rational:To reduce apprehension&promote comfort andcooperation. 5- Wear gloves. 6-- Take a clean thermometer and check mercury level by holding the thermometer horizontally at eye level&rotate it until see the mercury clear. Rational: - Holding at eye level facilitatesreading 7- If mercury level above 35c hold it and firmly with thumb &four finger and shake it down until well see the mercury less than 35c. 129 Rational: - shaking moves the mercury backinto the bulb &keep yourself awayof any barrier (table, chair, bed) tovoid breaking. 7- Wipe the thermometerwith dry cotton start from bulb to end. Rational :To prevent transmission of micro-organism 8- Ask the patient to open his mouth &placethe bulb under left or right sublingualpocket and instruct him to close with hislips not teeth. Rational :- Sublingual pocket is rich withblood vessels, to avoid breaking on his mouth. 9- Leave the thermometer in place for (3-5)minutes.use this time to measure other vital signs. Rational :- To allow sufficient time formercury to extend which ensure accurate measures. 10- Remove the thermometer and wipe anysaliva with dry cotton from end to bulbusing firm rotating motion in one direction. Rational :-To decrease transmission ofmicroorganisms. 11- Read the thermometer. 12- Wash it in soapy water &rinse in coolwater, dry and disinfect it with cottonsoaked with alcohol replace it after shakingit again. Rational: - To remove microorganisms and prepare for reuse. 13- Record temperature& report anyabnormalities to physician. 130 Steps 1 2 3 4 5 1-Greet the patient. Rationale To gain his co-operation 2- Prepare equipment. Rationale To save time and effort. 3- Hand washing before& after and wear gloves Rationale To reduce spread of microorganisms. 5-Take a clean thermometer &wipe it with dry cotton from bulb toend then check mercury level if itabove 35c shaking it down under35c Rationale Away from furniture to avoid breaking. 6- Expose the patient’s axilla if itmoist dry it with wash cloth Rationale To reduce microorganisms& to ensure accurate measures. 7- Place the bulb into the center ofthe axilla and ask the patient toplace his arm tightly across hisChest 8- Leave it (5-10)minutes 9- Remove the thermometer & wipe it from end to bulb with dry cotton. 10- read it , Add 0.5 degree to the reading. 11-Wash the thermometer with Soapy water then disinfect withcotton soaked with alcohol Rationale To reuse it. 12-Record in vital signs chart. 132 Rectal temperature Contra-indication of rectal temperature 1-patient have heart disease especially myocardial infarction because thermometer can stimulate vagal nerve 2-Patient has rectal diseases or surgery or diarrhea 3-Anal fissure & rectal bleeding Equipment: -Thermometer tray consists of: Clean tray Dry cotton. Cotton soaked with alcohol. Clean thermometer -Watch with seconds. Paraffin oil, gel, lubricant. -Gloves. Wash cloth -Nursing record. pen Steps 1 2 3 4 5 1- Identify and greeting patient. Rationale To gain cooperation 2- Explain the procedure. Rationale To reduce apprehension. 3- Prepare equipment &hand washing Rationale To save time & effort, to prevent microorganisms 4- Take a clean thermometer & wipe it with dry cotton from bulb to end 5- Check level of mercury if it above 35cholds it firmly with thumb and fourfinger and shake it down. 6- Assist patient to sim’s position withupper leg flexed expose only anal area,or prone or knee-chest position. Rationale Maintain privacy reduce embarrassment from exposingbuttocks. 133 7- Clean anal area with wash cloth from any feces (stool). 8- Lubricant the bulb and area above itapproximately 2.5cm with gauze. Rationale To reduce friction, facilitateinsertion, minimize discomfort &injury. 9- Separate patient’s buttocks Rationale To ensure visualization for accurate placement. 10- Ask patient to take deep , slow breathing, insert the thermometer into anus 1.5inch for adult , don’t force.nomore 1 inch for infant 11-Permit the buttocks to fall in placewhile holding the thermometer for 1minute or 2. Rationale To relax external sphincters. 12- Remove it & wipe any stool with dry cotton from end to bulb. 13- Read itDecrease or minus 0.5 degreefrom reading. 14- Wash the thermometer with soapywater then rinse and disinfect with cottonsoaked alcohol. Replace it after shakingIt Rationale to reuse it 15- Recording and reporting anyAbnormalities 134 Obtaining a radial pulse Action 1 2 3 4 5 1- Wash hands, identify the patient and explain the procedure. Rationale provide safety and increase the compliance. 2-Position patient comfortably with forearm across chest or at side with wrist extended. Rationale To allows easier arterypalpation. 3-Place fingertips of your three fingers along the groove at the base of thumb, on patient wrist. Rationale Fingertips are most sensitive part of the hand for palpating pulses. 4- Press against radial artery to obliterate pulse, and then gradually release pressure until you feel pulsation. Rationale don’t use the thumb to palpate, it has a strong pulse that you may confuse with the patient. 5- Assess pulse for regularity and strength. Rationale To accurately assess the pulse rate and regularity. 6- If pulse is not easily palpable ,use Doppler: *Apply conducting gel to end of probe or to radial sit **Reposition slightly, using firm pressure until, using firm pressure until you hear pulsating sound. 7-If pulse is regular, count pulse for 30 seconds, and multiply by two. If pulse irregular, count for one minute. Normal pulse from 60-100 beats per minute. Rationale To prevent overestimation of pulse. If pulse irregular, a longer counting period ensures a more accurate pulse rate determination. 138 8- Age normal growth from infancy to adulthood result in larger lung capacity. as lung capacity increase , lower respiratory rate. 9- Fever heat can be lost from lungs ,so respiratory rate increased. 10- Sex Men normally have a larger lung capacity than women Characteristics of respiration 1- Rate:  Bradypnea: decrease than 14 cycle/ minute  Normal: 14-24 cycle/ minute  Tachypnea: more than 24 cycle/ minute 2- Rhythm : regular & irregular 3- Depth : deep , normal , shallow. Procedure Steps 1 2 3 4 5 1-Wash hands. Rationale provides for patient safety 2- After assessment of pulse , keep your fingers resting on patient’s wristand observe or feel the rising andfalling of chest with respiration , anddon’t explain procedure to the patient Rationale To prevent self-control to alter respiratory pattern. 3- When you have observed onecomplete cycle of inspiration andexpiration, look at second hand of watch and count the number ofcomplete cycles. If the rate is irregularcount for 1 full minute. 4- Note depth and rhythm ofrespiration report any abnormalitiesfindings. Rationale To provide accuratedocumentation. 140 How to measure blood pressure: A- Palpatory method. B- Auscultatory method. Remember to:- 1-check the efficiency of equipment: a) Sphygmomanometer: control valve should be clear and freely adjustable, rubber tube connecting bladder to manometer. b) Stethoscope: clear ear tips and diaphragm before and after use with cotton swab soaked with alcohol. 2-select the best site for obtaining blood pressure and avoid taking blood pressure in case of mastectomy from the nearest armto operative site. 3-Encourage client to avoid caffeine and smoking for 30 minutes before assessment. Steps 1 2 3 4 5 Identify yourself& greeting the patient Hand washing Rationale :to reduce microorganisms Explain procedure Rationale: to reduce apprehension Put the patient in suitable position (lying or sitting) Rationale: to maintain accurate measuring Position client’s upper arm at heart level with palm turned up. Expose upper arm Place sphygmomanometer at patient heart level Palpate brachial artery with fully deflate wrap cuff smoothly and snugly around upper arm Hold rubber pump in hand catching the screw of valve with thumb and forefingers. Tighten the screw valve on the air pump Be sure manometer is positioned vertically at eye level. Palpate radial artery with finger tips of one hand while inflating cuff (pumping air into cuff Look at the column of mercury or needle until you do not feel the pulse anymore and record the reading (to 144 identify palpatory systolic pressure without under pressure) Deflate (releasing air from cuff) cuff fully rapidly by opening the valve (continuous pressure over arm interferes with blood flow). Wear the stethoscope and be sure sounds are clear by stethoscope. Palpate brachial artery and place the diaphragm on it. Close valve and inflate (quickly) the cuff to 30 mm/hg above note point in which pulse disappear or stop (palpated systolic pressure). Slowly release valve and allow mercury to fall at rate of 2-3 mm/hg/sec. Listen for the first clear sound.(to detect systolic pressure Continue cuff deflation slowly, noting point on manometer to nearest 2mm/hg at which sound changes or disappears. (To detect diastolic pressure). Deflate cuff rapidly and completely and remove Stethoscope.(continuous cuff inflation causes arterial occlusion , resulting in numbness of arm Unfold cuff and remove apparatus.close the apparatus safety and restore. Record systolic and diastolic pressure. If this is the first assessment of client; repeat the procedure on other arm Comfort client and cover upper arm. Inform client of reading 145  Steps from 1 to 7 stable Steps 1 2 3 4 5 1- Identify the patient, greeting and explain the procedure to him. Rational: to his gain his cooperation and relieve fears 2- Check the patient's chart for any doctors' order. Prepare necessary equipment and supplies near the patient. Rational: to save time and effort. 3-Close door or bed curtains around Patient Rational: to prevent air draft and patient's privacy 4-Hand washing Rational: to prevent transition of microorganisms 5-Apply apron and gloves Rationale: to prevent transition of microorganisms -help patient to use bed pan, urinal if needed Rationale : to prevent interruption during procedure 6- raise bed to high level.lock up side rail on opposite side of bed from your work Rationale: to reduce strain in nurses' back 7- check vital signs Rationale: To know patient's condition before and aftter procedure 8- loosen and remove top sheet and bed spread, then place bath blanket on patient. Help patient move closer to you. If top linen is to reused, placed it in laundry bag. Rationale: To provide easy movement, prevent soiling of bed linen. bath blanket provides warmth and privacy 9- lay towel across client's chest. Rationale: To prevent water from dripping on client's chest. 10-wet cotton sponge with warm water. 11- cleans eyes with water only, from inner to outer. Start cleaning of the eye. should be kept moist and protected from air liquid tear solution as saline can be instilled in eye to prevent dryness. Rationale: from inner to outer canthus to prevent secretion from entering and irritating nasal cranial ducts. 153 Cleaning of eyeglasses: Steps 1 2 3 4 5 1- Clean eye glasses on a basin with warm water and soft towel. Rationale: to prevent falling and breaking of glasses 2- If there is dried substance on theglass wash it with little soap. 3- Rinse glasses. 4- Dry it with a clean tissue paper. Care of the ears: Steps 1 2 3 4 5 1-Remove hearing aids if present &Keep. Rationale: to avoid injury of ears 2-Clean the outer ears with cotton ballmoist with water and start cleansingfrom inside toward outside andbehind ears. 3-Dry ears with cotton ball or a softtowel. 4-Avoid using any sharp object toremove wax. Care of the nose: Steps 1 2 3 4 5 1- Place towel under patient' chin Rationale: to aid in softening and removing crusts. avoid using soap inside prevent irritation 2- Ask the patient to blow his nosegently, give him paper tissue toclean it. 3- If there are crusts in the externalnares, apply mineral oil. 4- If the patient unable to removenasal secretion, use a wetwashcloth to remove secretion. 5- If the patient has Ryle(nasogastric tube) & here isdried secretion on the nose orRyle, wash it with soap & warmwater. 154 Steps 1 2 3 4 5 4- Gather equipment. Rationale: to save time and effort 2- Place client in aside lying positionwith head of bed lowered. Rationale:saliva runs out of mouth by gravity and prevent aspiration 3-Place towel or water proof padunder client's chin 4-Place emesis basin against client'smouth. 5-Use padded tongue to open teethgently. Leave in place between theback molars. 156 Procedure for mouth care for the conscious patient: Equipment of mouth care: -Toothbrush - toothpaste -Glass with clean water - denture container -Hygienic aids as lubricant or ointment - sodium bicarbonate -Sodium chloride (normal saline 0.9) Steps 1 2 3 4 5 1. Place equipment on bedsidetable. Rational: to facilitate the work 2. Provide patient privacy. Rational: to avoid embarrassment 3. Help the patient to sit up ifpossible not raise the head ofbed. Rational: to help in expulsion of fluid 4. Place towel around thepatient's neck and chest. 5. Place the kidney basin is held under the person’s chin 6. Wear gloves. 7. Moisten the bristles to thetoothbrush with water and putsmall amount of toothpaste. 157  8. hand the tooth brush to the patient or brush his teeth asthe following: a) Hold the brush against theteeth with bristles at 45 to gum line and brush fromgum line to crown - Brush outer and innersurfaces. - Brush back and fourthlyacross. - Biting surfaces of teeth. b) brush tongue gently with tooth brush A, The brush is held at a 45-degree angle to the gums. B, The brush is at a 45-degree angle against the inside of the front teeth. C, The brush is held horizontally against the inner surfaces of the teeth. D, The brush is positioned on the biting surfaces of the teeth. 9. hand the patient the water cup or mouth wash solution to rinse his mouth and ask him to spit into kidney basin 10.remove the basin and wipe the patient's lips 11.use lubricant for lips to avoid dryness 12.clean and return equipment to its place 13.change soiled linen 14.wash your hands and remove gloves 158 Dentures care: Dentures should be given the same careful cleansing as the natural teeth. The conscious patient normally wears his teeth. The patient normally cleans his mouth and natural teeth while dentures Equipment: (1) Tissues. (3) Toothbrush or denture brush. (2) Washbasin. (4) Denture container. Cleaning dentures: Steps 1 2 3 4 5 – Wash your hands. – Put on disposable gloves. – Identify the patient by checking his/her name band. – Inform the patient that you will be cleaning his/her dentures. – Remove the patient’s dentures or have the patient remove them. Remove the upper denture by grasping it with the thumb and index finger of one hand. Use a piece of gauze to grasp the slippery denture. – Place the dentures in an emesis basin that is lined with a paper towel. – Carry the dentures to the sink. Place a towel in the sink; if the dentures aredropped, they will not break. – Use toothpaste or denture cleaner and clean all of the surfaces of thedentures. – Rinse the dentures with cool running water. – Fill the denture cup with water, mouthwash or a denture solution and placethe dentures in the cup. – Return the dentures to the patient or place them in an appropriate place. 159  Steps 1 2 3 4 5 Identify the patient, greeting and explain the procedure to him. Rationale: To gain his cooperation and relive fear. Prepare necessary equipment beside to patient and check the patient's chart for any doctors' order. Rationale: To save time and effort. Check vital signs Rationale: To know patient condition before and after procedure. Apply apron and gloves. Rationale: to prevent transmission of microorganisms Close door or bed curtains. Help patient use bed pan, urinal if needed. Rationale: bedpan to prevent interruption during procedure. Close window and door. Rationale: to prevent air draft and maintain privacy Hand washing Rationale: to prevent transmission of microorganisms Raise bed to high position, lock up side rail on opposite side of bed from your work Rationale: To reduce strain in nurses' back. Loosen and remove top sheet and bedspread, then place bath blanket on patient, Help patient move closer to you. If top linen is to be reused place it on back of chair; otherwise, place it in laundry bag. Rationale:to provide easy movement and prevent soiling of bed linen.bath blanket provides warmth and privacy. Lower side rails, remove all pillows from under the patient head, and put one under patient shoulder. Rationale: to raise shoulder and keep head below body level preventing water from returning to patient. Position patient supine with head and shoulder at side of bed (obligue position) Rationale:to keep head in reach. 162 Place waterproof pad under patient‘s shoulders, neck, and head Rationale:to prevent soiling of linens Place towel around patient shoulder and cotton ball in ear. Rationale:to protect patient clothes and ear. Place large basin in floor on newspaper. Rationale:to receive water. Roll sides and upper end of the rubber sheet from through place rolled end of the sheet under the head. drop free end of rubber sheet in basin. Remove any pins or comb hair result in more cleansing Obtain warm water and fill pitcher. Check temperature by bath thermometer or inner aspect of forearm. Rationale:to prevent burn face and scalp. Apply gloves if client has lesion of scalp or presence of lice Rationale:to prevent transmission of microorganisms Protect patient eye by either using wash cloth or using free hand over forehead. Rationale:to prevent shampoo or water from entering eyes. With water pitcher ,pour water over hair untile it wet. Rationale:to aid in distribution of shampoo. Use hydrogen peroxide if hair contaminated with both hand, start at hair line and wok toward back of head. Left head with one hand to wash back of head. Shampoo sides of head massage scalp by applying pressure with fingertips. Rinse hair with water thoroughly. Rationale: retained shampoo cause scalp irritation. Repeat applying shampoo, washing and rinsing as required. Rationale: to ensure cleansing Squeeze excess moisture from hair , Wrap patient‘s head in bath towel, dry off any moisture along neck or shoulders Dry hair and scalp use second towel from bed. 163  Remove equipment and wet towel from bed , place dry towel around shoulder. Comb hair to remove tangles and dry with dryer or remaining towel and complete styling of hair according patient hair prefer. Assist patient to comfortable position Bed making and soiled linens Rationale: to promote physical and psychological well being Clean equipment and store it Wash hand Rationale:to prevent transmission of microorganisms Chart date, time shampoo patient reaction participation usual condition of hair and signature. Bathing Purpose of Bathing: 1. Removes perspiration (sweating) dirt and microorganisms. 2. Stimulates circulation. 3. Exercises body parts. 4. Refreshes, relaxes and promotes physical comfort. 5. Removes odors. 6. Allows for evaluation of skin condition. Methods of Bathing: *Partial bath: The person is bathing himself while sitting on the side of the bed.Necessary equipment is within his reach. 164 Equipment of bed bath: -Equipment of vital signs. -Two large basin. -Bed linen. -Top spreadsheets -Small water pitcher. -Bath blanket. - Clean gown or pajamas. - Shampoo or soap and soap dish. - Comb or brush. - Apron & disposable gloves - Nursing record -Two bath towels. -Bath thermometer. -Bedpan or urinal. -Two wash towels. - Cotton balls in small basin. Complete bed bath: Steps 1 2 3 4 5 1-Identify the patient, greeting and explain the procedure to him Rational: -To gain his cooperation 2-Prepare necessary equipment and supplies near the patient. Check the patient's chart for any doctors' order Rational: -To save time and effort. Check vital signs. Rational: - To know patient condition before and after procedure. Apply apron and gloves. Rational: Apply apron and gloves to reduce transmission of microorganisms. Close door or bed curtains, help patient use bedpan, urinal if needed during procedure. Rational:- Offer bedpan to prevent interruption during procedure. Close window and door. Rational:To prevent air draft & maintain patient 166 Privacy Hand washing Rational:To prevent transmission ofmicroorganisms. Raise bed to high position. Rational:To reduce strain in nurses' back. Lock up side rail on opposite side of bed from your work Loosen and remove top sheet and bedspread, then place bath blanket on patient. Help patient move closer to you. If top linen is to be reused, place it on back of chair; otherwise, place it in laundry bag Rational: Provide easy movement & prevent soiling of the bed linen. Bath blanket provides warmth & privacy. Lay towel across patient's Chest Rational:Prevent soiling of the bed linen. Wet washcloth and fold around your finger to make a mitt. a. Fold washcloth into thirds. b. Straighten washcloth to take out wrinkles. c. Fold washcloth over to fit hand. d. Tuck loose ends under edge of washcloth on palm. Mitten washcloth Cleanse eyes with water only, wiping from inner to outer canthus. Use separate corner of mitt for each eye. Rational: From inner to outer canthus prevents secretions from entering &irritation nasal cranial ducts Determine if patient would like soap used on face.washface, neck, and ears rinseand dry well. 167 Fold bath blanket off arm away from you. Place towel engthwise under arm. Wash, rinse, and dry the arm using long, firm strokes from the fingers Toward the axilla. Wash axilla. Place folded towel and water basin on patient's bed. Soak patient's hand, then wash and rinse. Rational: Prevents soiling of the bed linen. To facilitates removal of debris, bacteria & to stimulate circulation Raise side rail, repeat for hand and arm nearest you Place bath towel over chest Fold bath blanket down to below umbilicus. Rational: To prevent chilling & maintain patient privacy With one hand lift edge of bath towel off chest, and bathe chest and abdomen with cloth using long, firm strokes. Give special attention to skin under the breasts and any other skin folds if patient is overweight. Rinse and dry well. Rational: For proper cleanliness, that prevents skin irritation Bath abdomen, give attention to bathing umbilicus & abdominal folds then rinse and dry. After that, wash other arm as the same steps. Expose leg away from you by folding over bath blanket. 168 Lift leg by positioning your arm under leg, elevate leg from matters slightly, and place bath towel lengthwise under leg &Be careful to keep perineumcovered. Place basin on towel on bed. Wash, rinse, and dry leg using long, firm strokes from ankle toknee & from knee to thigh. Wash feet. Rinse and dry well. Repeat for other leg and foot. Assess bath water for warmth. Change water if necessary. Assist patient to side-lying position. Place bath towel alongside of back and buttocks to protect linen. Wash, rinse, and dry back and buttocks. Give a backrub with lotion. The person lies in the prone position for a back massage.Stroke upward from thebuttocks to the shoulder, downover the upperarms, back up the upper arms, across the shoulders, and down the back tothe buttocks. Assist patient to supine position. Assess if patient can washgenitals and perineal areaindependently. If patient needs help, drape with blanket so thatonly genitals are exposed. Don disposable, clean gloves. Using fresh water and a new cloth, wash,rinse, and dry genitalia and perineum. The foreskin of theuncircumcised male is pulledback for perineal care. It is returned to the 169 normal position immediately after cleaning and rinsing. -The penis is cleaned with circularmotions starting at the meatus. Separate the labia with one hand. Use a mitted washcloth to cleansebetween the labia with downwardstrokes.- The rectal area is cleaned by wipingfrom the vagina to the anus. The side lying position allows the anal area to be cleaned more thoroughly. Complete care according to patient's preference. Apply lotion. Assist With hair and mouth care. Assist patient's indressing. Make bed with clean linen.-Rational: Maintains patient body image & provides clean environment. Clean equipment and return to appropriate storage area. Rational: To reduces transmission of microorganism. Perform hand hygiene. Check vital signs. 170