Fundamentals of Nursing Skills Manual Fall 2024 PDF

Fall 2024 Fundamentals of Nursing/Clinical Fundamentals and Administration Department Skills Manual and Procedure Checklists and Forms 0 ...

Fall 2024 Fundamentals of Nursing/Clinical Fundamentals and Administration Department Skills Manual and Procedure Checklists and Forms 0  Fall 2024 Fundamentals of Nursing Skills Manual and Procedure Checklists and Forms Fundamentals and Administration Department 1 TABLE OF CONTENTS PAGE PAGE # # PATIENT PATIENT IDENTIFICATION 3 SURGICAL ASEPSIS HAND WASHING PRIOR TO 229 IDENTIFICATION AND WOUND CARE STERILE PROCEDURE MEDICAL ASEPSIS HAND HYGIENE 7 DONNING A STERILE GOWN AND 230 GLOVES (CLOSED) APPLYING AND REMOVING PERSONAL 14 DONNING AND REMOVING 232 PROTECTIVE EQUIPMENT STERILE GLOVES (OPEN) VITAL SIGNS VITAL SIGNS 23 STERILE GLOVING 233 ACTIVITY, RANGE OF MOTION EXERCISES 56 ESTABLISHING AND 235 EXERCISE AND MAINTAINING A STERILE FIELD POSITIONS POSITIONING CLIENTS (MOVING A CLIENT 62 CLEANING A SUTURED WOUND 237 UP IN BED) AND APPLYING A STERILE DRESSING LOGROLLING A CLIENT 68 WOUND DRESSING 240 TURNING A CLIENT TO THE LATERAL OR 74 BANDAGES AND BINDERS 243 PRONE POSITION IN BED DANGLING 85 SUTURE REMOVAL 249 TRANSFERRING BETWEEN BED AND 87 URINARY URINARY CATHETERIZATION 256 STRETCHER CATHETERIZATION PROCEDURE TRANSFERRING BETWEEN BED AND 92 ADMINISTRING AN ENEMA ADMINISTRATION 265 CHAIR ENEMA PROCEDURE DIAGNOSTIC OBTAINING A CAPILLARY BLOOD SAMPLE 102 HYGIENE AND BATHING AN ADULT OR 272 TESTS FOR BLOOD GLUCOSE TESTING COMFORT PEDIATRIC CLIENT OBTAINING A CLEAN-CATCH OR 111 PROVIDING A BACK MASSAGE 282 MIDSTREAM URINE SPECIMEN URIE TESTING 115 SHAMPOOING THE HAIR OF A 286 CLIENT CONFINED TO BED MEDICATION ORAL MEDICATION 118 FOOT CARE 293 ADMINISTRATION ADMINISTERING OPHTHALMIC (EYE) 128 PERINEAL CARE-GENITAL CARE 298 INSTALLATIONS ADMINISTERING OTIC (EAR) 134 ORAL CARE 304 INSTALLATIONS ADMINISTERING NASAL INSTALLATIONS 138 PROVIDING SPECIAL ORAL CARE 308 FOR THE UNCONSCIOUS CLIENT ADMINISTRATION OF MEDICATION 142 CHANGING AN OCCUPIED BED 314 THROUGH INHALERS ADMINISTERING RECTAL MEDICATIONS 144 CHANGING UNOCCUPIED BED 321 APPLICATION OF SKIN PREPARATION 146 APPROVED NANDA 334 NURSING DIAGNOSIS LIST 2018-2020 REFERENCES PREPARING MEDICATIONS FROM 149 AMPULE PREPARING MEDICATIONS FROM VIAL 153 PREPARING AND USING MULTIDOSE 160 VIALS ADMINISTERING AN INTRAMUSCULAR 160 INJECTION ADMINISTERING A SUBCUTANEOUS INJECTION 170 ADMINISTERING AN INTRADERMAL 182 INJECTION STARTING AN INTRAVENOUS INFUSION 188 MONITORING AN INTRAVENOUS INFUSIO 192 OXYGEN ADMINISTERING OXYGEN THERAPY 197 ADMINISTRATION NEBULIZATION 204 BREATHING EXERCISES 210 NASOGASTRIC NASOGASTRIC TUBE INSERTION 212 TUBE INSERTION , NASOGASTRIC TUBE FEEDING 218 REMOVAL OF NASO- GASTRIC TUBE 224 2  FEEDING AND REMOVAL OBJECTIVES: On the completion of practical session, students will be able to: Identify the importance of patient identification Identify when to perform the patient identification Demonstrate the use of 3Vs for patient identification Skill 1.1 Patient Identification PURPOSE _____________________________________________________________________________ To identify the patient correctly and practice safety procedures using the 3 Vs: verbalization, visualization, and verification. PROCEDURE STEPS _____________________________________________________________________________ 1. Verbalization - refers to verbalization of the full four names by patient when asked by the staff. The staff performing procedure on the patient must ask the patient to verbally state their full four names. 2. Visualization - refers to visualization of full four names verbally stated by the patient along with the patients’ MRN on the ID band. 3. Verification - refers to comparison of patient identifiers (name and MRN) against orders/procedures/chart. 3  Patient Identification Skill 1.1 Patient Identification Checklist Student Name : _________________________________ Score Levels of Performance 0 Missed step/procedure Student ID : __________________________________ 1 Unacceptable performance Performance acceptable with major Station No : __________________________________ 2 Modification Date : __________________________________ Performance acceptable with minor 3 modification 4 Satisfactory performance 5 Excellent performance Indicators/ Procedure 5 4 3 2 1 0 Remarks Purpose To identify the patient correctly and practice safety procedures using the 3 Vs Patient Preparation Maintains client’s confidentiality and privacy Observes universal precautions in providing care to clients (hand washing, use of gloves) Introduces self to client Identify the patient using the 3Vs [verbalization, visualization, verification] Pre–Assessment Bring doctor’s order and other documents (e.g. MAR, chart, procedure order) 4 Prepares supplies and equipment (e.q. hand rub gel) Preparing Equipment ✔ No equipment required Procedure Steps Verbalization - ask the patient to verbally state their full four names. If client is comatose or unable to comprehend or unable to speak, ask the attendant/ significant others to provide identification card of the patient (any identifier such as resident card/ passport/ or any valid document) Visualization – while the patient or attendant is stating the full name, visualize full four names verbally stated by the patient / attendant along with the patients’ MRN on the ID band. Verification - compare ID band (name and MRN) against orders/procedures/chart Post- assessment Observes universal precautions in providing care to clients (hand washing, use of gloves). Total Marks Remarks: Evaluator: 5  Sample of patient identification SQUH SQUH 012345 SQUH 012345 Mohammad Ali Mohammad Ali Mohammad Ali Mohammad Ali DOB 07/03/1985 AGE 32 DOB 07/03/1985 AGE 32 Male Omani Male Omani SQUH 012345 SQUH 012345 Mohammad Ali Mohammad Ali Mohammad Ali Mohammad Ali DOB 07/03/1985 AGE 32 DOB 07/03/1985 AGE 32 Male Omani Male Omani SQUH 012345 SQUH 012345 Mohammad Ali Mohammad Ali Mohammad Ali Mohammad Ali DOB 07/03/1985 AGE 32 DOB 07/03/1985 AGE 32 Male Omani Male Omani SQUH 012345 SQUH 012345 Mohammad Ali Mohammad Ali Mohammad Ali Mohammad Ali DOB 07/03/1985 AGE 32 DOB 07/03/1985 AGE 32 Male Omani Male Omani 6  2. MEDICAL ASEPSIS SQUH 012345 SQUH 012345 Mohammad Ali Mohammad Ali Mohammad Ali Mohammad Ali DOB 07/03/1985 AGE 32 DOB 07/03/1985 AGE 32 Male Omani Male Omani OBJECTIVES: On the completion of practical session, students will be able to: Identify the importance of medical asepsis in controlling infection. Identify when to perform the medical hand washing. Demonstrate techniques of hand washing. Understand the consequences of lack of proper hand hygiene. Skill 2.1 HAND HYGIENE PURPOSE _____________________________________________________________________________ To reduce the number of microorganisms on the hands. To reduce the risk of transmission of microorganisms to clients To reduce the risk of cross contamination among clients To reduce the risk of transmission of infectious organisms to oneself PRE-ASSESSMENT _____________________________________________________________________________ My 5 Moments for Hand Hygiene. These include: Moment 1—Before touching a patient Moment 2—Before a clean or aseptic procedure Moment 3—After a body fluid exposure or risk of exposure Moment 4—After touching a patient 7  Moment 5—After touching patient surroundings Assess the hands: Nails should be kept short. Remove all jewelry. Check the hands for breaks in the skin, such as hangnails or cuts. Assess the patient for : Presence of factors increasing susceptibility to infection and possibility of undiagnosed infection. Whether the client uses immunosuppressive medications. Recent diagnostic procedures or treatments that penetrated the skin or a body cavity. Current nutritional status. Signs and symptoms indicating the presence of an infection: Localized signs : swelling; redness; pain or tenderness with palpation or movement; palpable heat at site; loss of function of affected body part; or presence of exudates. Systemic indications : fever; increased pulse and respiratory rates; lack of energy, anorexia or enlarged lymph nodes. PREPARING EQUIPMENTS _____________________________________________________________________________ Determine the location of running water (sink) Antimicrobial or non-antimicrobial soap (if in bar form, soap must be placed on a soap rack) Paper towels Moisturizing hand lotion or cream approved by health care facility (optional) PROCEDURE STEPS _____________________________________________________________________________ 1. Gather the necessary supplies. Stand in front of the sink. Do not allow your clothing to touch the sink during the washing procedure (Figure 1). (Rational: The sink is considered contaminated. Clothing may carry organisms from place to place) 2. Remove jewelry prior to patient contact, if possible, and secure in a safe place. A plain band may remain in place, based on facility policy. (Rational: Microorganisms may accumulate in settings of jewelry and underneath rings (CDC, 2019b), so it should not be worn during patient care. If jewelry was worn during care, it should be left on during handwashing. 3. Turn on water and adjust force (Figure 2). Regulate the temperature until the water is warm. (Rational: Water splashed from the contaminated sink will contaminate clothing. Warm water is more comfortable and is less likely to open pores and remove oils from the skin. Organisms can lodge in roughened and broken areas of chapped skin. 8  Figure 1. Standing in front of sink. Figure 2. Turning on the water at the sink 4. Wet the hands and wrist area. Keep hands lower than elbows to allow water to flow toward fingertips (Figure 3).(Rational: Water should flow from the cleaner area toward the more contaminated area. Hands are more contaminated than forearms. 5. Use about 1 teaspoon liquid soap from dispenser or rinse bar of soap and lather thoroughly, using a firm circular motion (Figure 4). Alternatively, use the amount of product recommended by the manufacturer. Cover all areas of hands with the soap product. If using bar soap, rinse soap bar again and return to soap rack without touching the rack. (Rational: Rinsing the soap before and after use removes the lather, which may contain microorganisms. Figure 3. Wetting hands to the wrist. Figure 4. Lathering hands with soap and Rubbing with firm circular motion. 6. Continuing with firm rubbing and circular motions. Wash the palms and backs of the hands; each finger; the areas between the fingers (Figure 5); and the knuckles, wrists, and forearms. Wash at least 1 inch above area of contamination. If hands are not visibly soiled, wash to 1 inch above the wrists (Figure 6). (Rational: Friction caused by firm rubbing and circular motions helps to loosen dirt and organisms that can lodge between the fingers, in skin crevices of knuckles, on the palms and backs of the hands, and on the wrists and forearms. Cleaning less contaminated areas (forearms and wrists) after hands are clean prevents spreading microorganisms from the hands to the forearms and wrists. 9 Figure 5. Washing areas between fingers. Figure 6. Washing to 1 inch above the wrist. 7. Continue this friction motion for at least 15 to 20 seconds. (Rational: Effective handwashing requires at least a 15- to 20-second scrub with plain soap or disinfectant and warm water (CDC, 2019b). Hands that are visibly soiled need a longer scrub. 8. Use fingernails of the opposite hand to clean under fingernails (Figure 7). (Rational: The area under nails has a high microorganism count, and organisms may remain under the nails, where they can grow and be spread to other people. 9. Rinse hands thoroughly under running water with water flowing toward fingertips (Figure 8). (Rational: Running water rinses microorganisms and dirt into the sink. Figure 7. Using fingernails to clean under Figure 8. Rinsing hands under running water nails of opposite with water flowing toward fingertips hand.. 10. Pat hands dry with a paper towel, beginning with the fingers and moving upward toward forearms, and discard it immediately. Use another clean towel to turn off the faucet. Discard towel immediately without touching other clean hand. (Rational: Patting the skin dry prevents chapping. Dry hands first because they are considered the cleanest and least contaminated area. Turning the faucet off with a clean paper towel protects the clean hands from contact with a soiled surface. 11. Use moisturizing hand lotion or cream, as approved by facility policy. (Rational: Moisturizing hand lotion or cream helps to increase skin hydration to keep the skin soft and prevents dermatitis. It is best applied after patient care is complete, from a small, personal container, 10 according to facility policy. Avoid use of unapproved lotions or creams because they can cause deterioration of gloves or decrease the efficacy of some interventions, providers should educate patients, family Follow facility policy. 12. Documentation: The performance of handwashing is not generally documented. POST ASSESSMENT _____________________________________________________________________________ Ensure hands are dry before gloves are donned to decrease risk of dermatitis Educate patient, family, and nonfamily visitors on the importance of hand hygiene. 11  Skill 2.1 Hand Hygiene Student Name : _________________________________ Score Levels of Performance 0 Missed step/procedure Student ID : __________________________________ 1 Unacceptable performance Performance acceptable with major Station No : __________________________________ 2 Modification Date : __________________________________ Performance acceptable with minor 3 modification 4 Satisfactory performance 5 Excellent performance Indicators/ Procedure 5 4 3 2 1 0 Remarks Purpose To reduce: ✔ The number of microorganisms on the hands. ✔ The risk of transmission of microorganisms to clients ✔ The risk of cross contamination among clients ✔ The risk of transmission of infectious organisms to oneself Patient Preparation Maintains client’s confidentiality and privacy Observes universal precautions in providing care to clients (hand washing, use of gloves) Introduces self to client Identify the patient using the 3Vs [verbalization, visualization, verification] Prepares client and explains the procedure Pre–Assessment My 5 Moments for Hand Hygiene 12  Assess the hands: ✔ Nails should be kept short. ✔ Remove all jewelry. ✔ Check the hands for breaks in the skin, such as hangnails or cuts. Assess the patient for : ✔ Presence of factors increasing susceptibility to infection ✔ Recent diagnostic procedures or treatments that penetrate the skin or a body cavity. ✔ Current nutritional status. ✔ Signs and symptoms indicate the presence of infection Preparing Equipment ✔ Determine the location of running water (sink) ✔ Antimicrobial or no antimicrobial soap (if in bar form, soap must be placed on a soap rack) ✔ Paper towels ✔ Moisturizing hand lotion or cream approved by health care facility (optional) Procedure Steps Gather the necessary supplies. Stand in front of the sink. Do not allow your clothing to touch the sink during the washing procedure Remove jewelry prior to patient contact, if possible, and secure in a safe place. A plain band may remain in place, based on facility policy Turn on water and adjust force Wet the hands and wrist area. Keep hands lower than elbows to allow water to flow toward fingertips Use about 1 teaspoon liquid soap from dispenser or rinse bar of soap and lather thoroughly, using a firm circular motion Continuing with firm rubbing and circular motions. Wash the palms and backs of the hands; each finger; the areas between the fingers and the knuckles, wrists, and forearms. Wash at least 1 inch above area of contamination. If hands are not visibly soiled, wash to 1 inch above the wrists Continue this friction motion for at least 15 to 20 seconds. Use fingernails of the opposite hand to clean under fingernails Rinse hands thoroughly under running water with water flowing toward fingertips 13 Skill 2.2 APPLYING AND REMOVING PERSONAL PROTECTIVE EQUIPMENT Pat hands dry with a paper towel, beginning with the fingers and moving upward toward forearms, and discard it immediately. Use another clean towel to turn off the faucet. Discard towel immediately without touching other clean hand Use moisturizing hand lotion or cream, as approved by facility policy Post- assessment Ensure hands are dry before gloves are donned to decrease risk of dermatitis Educate patient, family, and nonfamily visitors on the importance of hand hygiene. Total Marks Remarks: Evaluator: PURPOSE _____________________________________________________________________________ To protect health care workers and client from transmission of infection PRE-ASSESSMENT _________________________________________________________________________ Assess the patient: ⮚ Immunity level ⮚ Medical history for presence of infectious disease Consider which activities will be performed, this will determine which equipment is required. PREPARING EQUIPMENT _____________________________________________________________________________ Arranging for the care of your clients, if necessary. Consider if special handling is indicated for removal of any specimens or other materials from the room. Determine which supplies are present within the client’s room and which must be brought with you. Gloves Mask (surgical or particulate respirator) Impervious gown 14  Goggles or face shield (protective eye wear; does not include eyeglasses) Note: Equipment for PPE may vary depending on level of precautions required and facility policy PROCEDURE STEPS _____________________________________________________________________________ 1. Check medical record and plan of care for type of precautions and review precautions in infection control manual. (Rational: Mode of transmission of organism determines type of precautions required) 2. Plan nursing activities before entering patient’s room. (Rational: Organization facilitates performance of task and adherence to precautions) 3. Provide instruction about precautions and use of PPE to patient, family members, caregivers, and visitors. (Rational: Explanation encourages cooperation of patient, family, and caregivers and reduces apprehension about precaution procedures) 4. Perform hand hygiene. (Rational: Hand hygiene prevents the spread of microorganisms) 5. Put on gown, mask (surgical or particulate respirator), protective eyewear, and gloves based on the type of exposure anticipated and category of isolation precautions. (Rational: Use of PPE interrupts chain of infection and protects patient and nurse. Gown should protect all clothing and exposed skin on upper extremities. Gloves protect hands and wrists from microorganisms. Masks and particulate respirators protect wearer from direct contact with body fluids that may spray or splash; masks protect wearer from exposure to large-particle aerosols and particulate respirators protect wearer from inhalation of airborne droplet nuclei, and small-particle aerosols. Eyewear protects mucous membranes in the eye from splashes) a. Put on the gown, with the opening in the back. Tie gown securely at neck and waist (Figure 1). (Rational: Gown should fully cover the torso from the neck to knees, arms to the end of wrists, and wrap around the back) b. Put on the mask or respirator over your nose, mouth, and chin (Figure 2). Secure ties or elastic bands at the middle of the head and neck. Fit mask snug to face and below chin. Fit flexible band to nose bridge. If respirator is used, perform a fit check. Inhale: The respirator should collapse. Exhale: Air should not leak out. (Rational: Masks protect nurse or patient from droplet nuclei and large-particle aerosols. A mask must fit securely to provide protection) 15 Figure 1. Tying gown at neck and waist. Figure 2. Applying mask over nose, mouth, and chin. c. Put on goggles (Figure 3). Place over eyes and adjust to fit. Alternatively, a face shield could be used (Figure 4). (Rational: Eyewear protects mucous membranes in the eye from splashes; it must fit securely to provide protection) Figure 3. Putting on goggles. Figure 4. Putting on face shield. d. Put on clean disposable gloves. Extend gloves to cover the wrist of the gown (Figure 5). (Rational: Gloves protect hands and wrists from microorganisms) Figure 5. Putting on gloves, ensuring gloves cover gown cuffs. 16 6. Identify the patient. Explain the procedure to the patient. Continue with patient care as appropriate. (Rational: Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect Remove PPE There are a variety of ways to remove PPE to achieve the goal of safe removal without contamination of clothes, skin, or mucous membranes. One methods is outlined here, based on CDC recommendations. 7. Remove PPE: Except for respirator, if worn, remove PPE before exiting the patient room or in an anteroom. Remove respirator after leaving the patient’s room and closing the door. (Rational: Proper removal prevents contact with and the spread of microorganisms. Removing respirator outside the patient’s room prevents contact with airborne microorganisms. a. Outside of gloves are contaminated. If hands are contaminated during gown or glove removal, immediately perform hand hygiene. (Rational: Outside front of equipment is considered contaminated. Hand hygiene prevents transmission of microorganisms. (Rational: The inside, outside back, and ties on head and back are considered clean, which are areas of PPE that are not likely to have been in contact with infectious organisms) b. Grasp the palm area of one gloved hand with the opposite gloved hand and peel off first glove, turning the glove inside out as you pull it off (Figure 6). Hold the removed glove in the remaining gloved hand. (Rational: Outside of gloves are contaminated. This process contains the contaminated areas) c. Slide fingers of ungloved hand under the remaining glove at the wrist, taking care not to touch the outer surface of the glove (Figure 7). (Rational: Ungloved hand is clean and should not touch contaminated areas) Figure 6. Grasping the palm area of one glove Figure 7. Sliding fingers of ungloved hand under 17 and peeling off. the remaining glove at the wrist d. Peel off the second glove over the first glove, containing the first glove inside the other (Figure 8). Discard in appropriate container. (Rational: This process contains the outside, contaminated areas of gloves. Proper disposal prevents transmission of microorganisms) e. To remove the goggles or face shield: Outside of goggles or face shield is contaminated—do not touch. If hands are contaminated during goggle or face shield removal, immediately perform hand hygiene. Handle by the headband or earpieces and remove from the back (Figure 9). Lift away from the face. Do not touch the front of goggles or face shield. Place in designated receptacle for reprocessing or in an appropriate waste container. Outside of goggles or face shield is contaminated; do not touch. Hand hygiene prevents transmission of microorganisms. (Rational: Handling by headband or earpieces and lifting away from face prevents transmission of microorganisms. Proper disposal prevents transmission of microorganisms) Figure 8. Peeling off the second glove, containing Figure 9. Removing goggles by grasping the first glove inside the other. earpieces. f. To remove gown: Gown front and sleeves are contaminated. If hands are contaminated during gown removal, immediately perform hand hygiene. Unfasten ties, if at the neck and back, taking care that sleeves of gown do not contact the body. Allow the gown to fall away from shoulders. Touching only the inside of the gown, pull away from the neck and shoulders (Figure 10). Keeping hands on the inner surface of the gown pull gown from arms (Figure 11). Turn gown inside out. Fold or roll into a bundle (Figure 12) and discard in an appropriate waste container. (Rational: Gown front and sleeves are contaminated. Hand hygiene prevents transmission of microorganisms. Touching only, the inside of the gown and pulling it away from the torso prevents transmission of microorganisms. This process contains the outside, contaminated areas of gown. The proper disposal prevents transmission of microorganisms) g. To remove mask or respirator: Front of mask/respirator is contaminated—do not touch. If hands are contaminated during mask/respirator removal, immediately perform hand hygiene. Grasp the bottom ties or elastic of the mask/respirator, then top ties or elastic and remove. Do not touch the front of mask or respirator (Figure 13). Discard in an appropriate waste container. If using a reusable respirator, save for future use in the designated area. (Rational: Front of mask or 18 respirator is contaminated; do not touch. Not touching the front of the mask and proper disposal of the mask prevent transmission of microorganisms) Figure 10. Touching only the inside of the gown, Figure 11. Keeping hands on the inner surface pull away from the neck and shoulders. of the gown, pull gown from arms Figure 12. Turning gown inside out, rolling Figure 13. Removing mask or respirator, into a bundle. grasping the neck ties or elastic, taking care to avoid touching the front 8.Perform hand hygiene. (Rational: Hand hygiene prevents the spread of microorganisms) Documentation: It is not usually necessary to document the use of specific articles of PPE or each application of PPE. However, document the implementation and continuation of specific transmission-based precautions as part of the patient’s care. POST-ASSESSMENT _____________________________________________________________________________ Ensure hands after hand hygiene are clean and all used items are disposed correctly Educate patient, family, and nonfamily visitors on the importance of PPE. 19  Skill 2.2 APPLYING AND REMOVING PERSONAL PROTECTIVE EQUIPMENT Student Name : _________________________________ Score Levels of Performance 0 Missed step/procedure Student ID : __________________________________ 1 Unacceptable performance Performance acceptable with major Station No : __________________________________ 2 Modification Date : __________________________________ Performance acceptable with minor 3 modification 4 Satisfactory performance 5 Excellent performance Indicators/ Procedure 5 4 3 2 1 0 Remarks Purpose To protect health care workers and client from transmission of infection Patient Preparation Maintains client’s confidentiality and privacy Observes universal precautions in providing care to clients (hand washing, use of gloves) Introduces self to client 20  Identify the patient using the 3Vs [verbalization, visualization, verification] Prepares client and explains the procedure Pre–Assessment Assess the patient: ✔ Immunity level ✔ Medical history for presence of infectious disease Consider which activities will be performed, this will determine which equipment is required. Preparing Equipment ✔ Gloves ✔ Mask (surgical or particulate respirator) ✔ Impervious gown ✔ Goggles or face shield (protective eye wear; does not include eyeglasses) ✔ Procedure Steps Check medical record and plan of care for type of precautions and review precautions in infection control manual Plan nursing activities before entering patient’s room. Provide instruction about precautions and use of PPE to patient, family members, caregivers, and visitors. Perform hand hygiene Put on gown, mask (surgical or particulate respirator), protective eyewear, and gloves based on the type of exposure anticipated and category of isolation precautions a. Put on the gown, with the opening in the back. Tie gown securely at neck and waist b. Put on the mask or respirator over your nose, mouth, and chin. Secure ties or elastic bands at the middle of the head and neck. Fit mask snug to face and below chin. Fit flexible band to nose bridge. If respirator is used, perform a fit check. Inhale: The respirator should collapse. Exhale: Air should not leak out. c. Put on goggles.Place over eyes and adjust to fit. Alternatively, a face shield could be used. d. Put on clean disposable gloves. Extend gloves to cover the wrist of the gown. e. To remove the goggles or face shield: Outside of goggles or face shield is contaminated—do not touch. If hands are contaminated during goggle or face shield removal, immediately perform hand hygiene. Handle by the headband 21  or earpieces and remove from the back. Lift away from the face. Do not touch the front of goggles or face shield. Place in designated receptacle for reprocessing or in an appropriate waste container. Outside of goggles or face shield is contaminated; do not touch. Hand hygiene prevents transmission of microorganisms. Remove PPE: Except for respirator, if worn, remove PPE before exiting the patient room or in an anteroom. Remove respirator after leaving the patient’s room and closing the door. a. Outside of gloves are contaminated. If hands are contaminated during gown or glove removal, immediately perform hand hygiene b. Grasp the palm area of one gloved hand with the opposite gloved hand and peel off first glove, turning the glove inside out as you pull it off c. Slide fingers of ungloved hand under the remaining glove at the wrist, taking care not to touch the outer surface of the glove d. Peel off the second glove over the first glove, containing the first glove inside the other e. To remove the goggles or face shield: Outside of goggles or face shield is contaminated—do not touch. If hands are contaminated during goggle or face shield removal, immediately perform hand hygiene. Handle by the headband or earpieces and remove from the back. Lift away from the face. Do not touch the front of goggles or face shield. Place in designated receptacle for reprocessing or in an appropriate waste container. Outside of goggles or face shield is contaminated; do not touch. Hand hygiene prevents transmission of microorganisms f. To remove gown: Gown front and sleeves are contaminated. If hands are contaminated during gown removal, immediately perform hand hygiene. Unfasten ties, if at the neck and back, taking care that sleeves of gown do not contact the body. Allow the gown to fall away from shoulders. Touching only the inside of the gown, pull away from the neck and shoulders. Keeping hands on the inner surface of the gown pull gown from arms. Turn gown inside out. Fold or roll into a bundle and discard in an appropriate waste container. g. To remove mask or respirator: Front of mask/respirator is contaminated—do not touch. If hands are contaminated during mask/respirator removal, immediately perform hand hygiene. Grasp the bottom ties or elastic of 22  the mask/respirator, then top ties or elastic and remove. Do not touch the front of mask or respirator. Discard in an appropriate waste container. If using a reusable respirator, save for future use in the designated area Perform hand hygiene. Document the implementation and continuation of specific transmission-based precautions as part of the patient’s care. Post- assessment Ensure hands after hand hygiene are clean and all used items are disposed correctly Educate patient, family, and nonfamily visitors on the importance of PPE. Total Marks Remarks: Evaluator: 3. VITAL SIGNS OBJECTIVES: On the completion of practical session, students will be able to: Identify the variations in normal body temperature, pulse, respirations and blood pressure among individuals Identify the sites for measurement of the vital signs Demonstrate the steps of assessing the body temperature, pulse from different site, respiration, blood pressure, oxygen saturation and pain assessment Document and report abnormal findings BRIEF DESCRIPTION Vital Signs includes body temperature, pulse, respiration and blood pressure. Oxygen saturation is also measured at the same time Skill 3.1 VITAL SIGNS 23 PURPOSE _____________________________________________________________________________ Vital signs reflect the changes in body function PATIENT PREPERATION _____________________________________________________________________________ Maintains client’s confidentiality and privacy Observes universal precautions in providing care to clients (hand washing, use of gloves) Introduces self to client Identify the patient using the 3Vs [verbalization, visualization, verification] Prepares client and explains the procedure Place the client in the appropriate position PRE-ASSESSMENT _____________________________________________________________________________ Clinical signs of fever. Temperature Clinical signs of hypothermia. Site most appropriate for measurement. Factors that might alter core body temperature Clinical signs of cardiovascular alterations. Pulse Factors that might alter pulse rate. Site most appropriate Skin and mucous membrane color. Position assumed for breathing. Respiration 24  Signs of cerebral anoxia. Chest movements. Activity tolerance. Chest pain. Dyspnea. Medications affecting respiratory rate Signs and symptoms of hypertension. Blood Pressure Signs and symptoms of hypotension. Factors affecting blood pressure. The best location for a pulse oximeter sensor based on the client’s age and physical condition. Oxygen Saturation The client’s overall condition, including risk factors for development of hypoxemia and hemoglobin level. Vital signs, skin color and temperature, nail bed color, and tissue perfusion of extremities as baseline data. PREPARING EQUIPMENT _____________________________________________________________________________ Digital or electronic thermometer, appropriate for site to be used Disposable probe covers Water-soluble lubricant for rectal temperature measurement Temperature Nonsterile gloves, if appropriate Additional personal protective equipment (PPE), as indicated Toilet tissue, if needed Electronic record or pen and paper or flow sheet Pulse Watch with a second hand or indicator Respiration Watch with a second hand or indicator Assessing Blood Pressure Using an Automated, Electronic Oscillometric Device 25  Blood Pressure Blood pressure cuff of appropriate size Automated, electronic oscillometric blood pressure device Electronic record or pen and paper or flow sheet PPE, as indicated Assessing Blood Pressure by Auscultation Stethoscope Sphygmomanometer Blood pressure cuff of appropriate size Electronic record or pen and paper or flow sheet Alcohol swab PPE, as indicated Oxygen Nail polish remover, as needed Saturation Alcohol wipe Sheet or towel Pulse oximeter PROCEDURE STEPS _____________________________________________________________________________ 1. Check the prescribed interventions or plan of care for frequency of measurement and route. (Rational: Assessment and measurement of vital signs at appropriate intervals provide important data about the patient’s health status) 2. Perform hand hygiene and put on PPE, if indicated. ((Rational: Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions) 3. Identify the patient. (Rational: Identifying the patient ensures that the right patient receives the intervention and helps prevent errors) 4. Close the curtains around the bed and close the door to the room, if possible. Discuss the procedure with the patient and assess the patient’s ability to assist with the procedure. (Rational: This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. Dialogue encourages patient participation and allows for individualized nursing care) 5. Assemble equipment on the overbed table within reach. (Rational: Organization facilitates performance of task) 26  Assessing Body Temperature 6. Ensure that the electronic or digital thermometer is in working condition. (Rational: Improperly functioning thermometer may not give an accurate reading) 7. Put on gloves, if indicated. (Rational: Gloves prevent contact with blood and body fluids. Gloves are usually not required for an oral, axillary, or tympanic temperature measurement, unless contact with blood or body fluids is anticipated. Gloves should be worn for rectal temperature measurement) 8. Select the appropriate site based on assessment data. (Rational: This ensures safety and accuracy of measurement) 9. Follow the steps as outlined below for the appropriate type of thermometer. 10. When measurement is completed, remove gloves, if worn. Remove additional PPE, if used. Perform hand hygiene. (Rational: Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms) Measuring an Oral Temperature 11. Remove the electronic unit from the charging unit and remove the probe from within the recording unit. (Rational: Electronic unit must be taken into the patient’s room to assess the patient’s temperature. On some models, the machine is turned on when the probe is removed) 12. Cover thermometer probe with disposable probe cover, sliding it on until it snaps into place (Figure 1). (Rational: Using a cover prevents contamination of the thermometer probe) 13. Place the probe beneath the patient’s tongue in the posterior sublingual pocket (Figure 2). Ask the patient to close their lips around the probe. (Rational: When the probe rests deep in the posterior sublingual pocket, it is in contact with blood vessels lying close to the surface) 14. Continue to hold the probe until you hear a beep (Figure 3). Note the temperature reading. (Rational: If left unsupported, the weight of the probe tends to pull it away from the correct location. The probe must remain in the sublingual pocket for the full period of measurement to ensure accurate measurement. The signal indicates that the measurement is completed. The electronic thermometer provides a digital display of the measured temperature) 15. Remove the probe from the patient’s mouth. Dispose of the probe cover by holding the probe over an appropriate receptacle and pressing the probe-release button (Figure 4). (Rational: Disposing of the probe 27 cover ensures that it will not be reused accidentally on another patient. Proper disposal prevents spread of microorganisms) 16. Return the thermometer probe to the storage place within the unit. Return the electronic unit to the charging unit, if appropriate. ((Rational: The thermometer needs to be recharged for future use. If necessary, the thermometer should stay on the charger so that it is ready to use at all times) Figure1. Putting probe cover on the Figure 2. Placing thermometer under the tongue in thermometer. the posterior sublingual pocket. Figure 3. Holding probe in the patient’s Figure 4. Pushing button to dispose of cover. mouth. Measuring Axillary Temperature 28 17. 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. (Rational: Using a cover prevents contamination of the thermometer probe) 18. Move the patient’s clothing to expose only the axilla (Figure 5).The axilla must be exposed for placement of the thermometer. (Rational: Exposing only the axilla keeps the patient warm and maintains their dignity) 19. Place the end of the probe in the center of the axilla (Figure 6). Have the patient bring the arm down and close to the body. Hold the patient’s arm by the patient’s side until the measurement is complete. (Rational: The deepest area of the axilla provides the most accurate measurement; surrounding the bulb with skin surface provides a more reliable measurement) Figure 5. Exposing axilla to assess Figure 6. Placing thermometer in the center temperature. of the axilla. 20. Hold the probe in place until you hear a beep, and then carefully remove the probe. Note the temperature reading. (Rational: Axillary thermometers must be held in place to obtain an accurate temperature) 21. Cover the patient and help them to a position of comfort. (Rational: This ensures patient comfort) 22. Dispose of the probe cover by holding the probe over an appropriate waste receptacle and pushing the release button. (Rational: Discarding the probe cover ensures that it will not be reused accidentally on another patient) 29 23. Place the bed in the lowest position and elevate rails, as needed. Leave the patient clean and comfortable. (Rational: Low bed position and elevated side rails provide for patient safety) 24. Return the electronic thermometer to the charging unit. (Rational: The thermometer needs to be recharged for future use) 25. Document temperature in the electronic record or flow sheet. Communicate abnormal findings to the appropriate person. Identify the site of assessment used if other than oral. Assessing a Peripheral Pulse by Palpation 26. Select the appropriate peripheral site based on assessment data. (Rational: This ensures safety and accuracy of measurement) 27. Move the patient’s clothing to expose only the site chosen. (Rational: The site must be exposed for pulse assessment. Exposing only the site keeps the patient warm and maintains their dignity) 28. Place your first, second, and third fingers over the artery (Figure 7). Place your fingers over the artery so that the ends of your fingers are flat against the patient’s skin when palpating peripheral pulses. Do not press with the tip of the fingers only. Lightly compress the artery so pulsations can be felt and counted. (Rational: The sensitive fingertips can feel the pulsation of the artery) 29. Using a watch with a second hand, count the number of pulsations felt for 30 seconds (Figure 8). Multiply this number by 2 to calculate the rate for 1 minute. If the rate, rhythm, or amplitude of the pulse is abnormal in any way, palpate and count the pulse for 1 minute. (Rational: Ensures accuracy of measurement and assessment) 30  Figure 7. Placing fingers over the artery Figure 8. Counting the pulse. 30. Note the rhythm and amplitude of the pulse, as well as the elasticity of the blood vessel. (Rational: This provides additional assessment data regarding the patient’s cardiovascular status) 31. When measurement is completed, remove gloves, if worn. Perform hand hygiene. Cover the patient and help them to a position of comfort. (Rational: Proper removal of gloves reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. Covering and positioning the patient ensures patient comfort) 32. Document pulse rate, strength, rhythm and elasticity in the electronic record or flow sheet. Identify site of assessment. Communicate abnormal findings to the primary care provider. Assessing Respiration 33. While your fingers are still in place for the pulse measurement, after counting the pulse rate, observe the patient’s respirations (Figure 1). (Rational: The patient may alter the rate of respirations if they are aware they are being counted) 31  Figure 9. Assessing respirations. 34. Note the rise and fall of the patient’s chest. (Rational: A complete cycle of an inspiration and an expiration composes one respiration) 35. Using a watch with a second hand, count the number of respirations for 30 seconds. Multiply this number by 2 to calculate the respiratory rate per minute. Avoid counting for a 15-second interval. (Rational: Sufficient time is necessary to observe the rate, depth, and other characteristics. Use of a 15- second interval and multiplying by 4 can result in a respiratory count that is significantly incorrect. Some literature suggests 60-second counts should be implemented whenever possible to ensure accuracy) 36. If respirations are abnormal in any way, count the respirations for at least 1 full minute. (Rational: Increased time allows the detection of unequal timing between respirations) 37. Note the depth and rhythm of the respirations. (Rational: This provides additional assessment data regarding the patient’s respiratory status) 38. Document respiratory rate, depth, and rhythm on electronic record or flow sheet. Communicate any abnormal findings to the appropriate person. Assessing Blood Pressure Assessing Blood Pressure Using an Automated, Electronic Oscillometric Device 39. Select the appropriate arm (or alternate site) for measurement and blood pressure cuff. 32 (Rational: Decision on measurement site and cuff size is based on nurse’s assessment of individual patient circumstances. Incorrect cuff size contributes to the most frequent error in measurement in nonacute care settings) 40. Have the patient assume a comfortable lying or sitting position with the forearm supported at the level of the heart and the palm of the hand upward (Figure 10). If the measurement is taken in the supine position, support the arm with a pillow. In the sitting position, support the arm yourself or by using the bedside table. If the patient is sitting, have the patient sit back in the chair so that the chair supports their back. In addition, make sure the patient keeps the legs uncrossed. (Rational: The position of the arm can have a major influence when the blood pressure is measured; if the upper arm is below the level of the right atrium, the readings will be too high. If the arm is above the level of the heart, the readings will be too low. This position places the brachial artery on the inner aspect of the elbow so that the bell or diaphragm of the stethoscope can rest on it easily. Support for the patient’s arm prevents isometric exercise that will affect the blood pressure level. If the back is not supported, the diastolic pressure may be elevated falsely; if the legs are crossed, the systolic pressure may be elevated falsely) Figure. 10 Proper positioning for blood pressure assessment using brachial artery 41. 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. (Rational: Clothing over the artery interferes with the ability to hear sounds and can cause inaccurate blood pressure readings. A tight sleeve would cause congestion of blood and possibly inaccurate readings) 42. Palpate the location of the brachial artery. Center the bladder of the cuff over the brachial artery, about midway on the upper arm, so that the lower edge of the cuff is about 2.5 to 5 cm (1 to 2 inches) above the inner aspect of the elbow (Figure 11). Line up the artery marking on the cuff with the patient’s brachial artery. The tubing should extend from the edge of the cuff nearer the patient’s elbow (Figure 12). (Rational: Pressure in the cuff applied directly to the artery provides the most accurate readings. If the cuff gets in the way of the stethoscope, readings are likely to be inaccurate. A cuff placed upside down with the tubing toward the patient’s head may give a false reading. 33 43. Wrap the cuff around the arm smoothly and snugly, and fasten it (Figure 13). Do not allow any clothing to interfere with the proper placement of the cuff. (Rational: A smooth cuff and snug wrapping produce equal pressure and help promote an accurate measurement. A cuff wrapped too loosely results in an inaccurate reading) 44. Turn on the machine. If the machine has different settings for infants, children, and adults, select the appropriate setting. Push the start button. Instruct the patient to hold the limb still and refrain from speaking. (Rational: Keeping the limb still and refraining from talking provide for accurate measurement of blood pressure levels (Muntner et al., 2019). 45. Wait until the machine beeps and the blood pressure reading appears. Note the reading (Figure 14). (Rational: Beep signals completion of reading) FIGURE 11. Centering the bladder of the FIGURE 12. Cuff tubing extending from cuff over the brachial artery the edge of the cuff nearer the patient’s elbow FIGURE 13. Wrapping the cuff around the FIGURE 14. Noting the blood pressure arm smoothly and snugly reading. 34 46. Remove the cuff from the patient’s limb and clean and store the equipment. (Rational: Cleaning of equipment prevents transmission of microorganisms and prepares equipment for future use. 47. Record the findings on the electronic record or flow sheet. Communicate abnormal findings to the primary health care provider. Identify arm used or site of assessment if other than brachial. Assessing Blood Pressure by Auscultation 48. Select the appropriate arm (or alternate site) for measurement and blood pressure cuff. (Rational: Decision on measurement site and cuff size is based on nurse’s assessment of individual patient circumstances. Incorrect cuff size contributes to the most frequent error in measurement in nonacute care settings (Muntner et al., 2019). 49. Have the patient assume a comfortable lying or sitting position with the forearm supported at the level of the heart and the palm of the hand upward (Fig. 15). If the measurement is taken in the supine position, support the arm with a pillow. In the sitting position, support the arm yourself or by using the bedside table. If the patient is sitting, have the patient sit back in the chair so that the chair supports their back. In addition, make sure the patient keeps the legs uncrossed. (Rational: The position of the arm can have a major influence when the blood pressure is measured; if the upper arm is below the level of the right atrium, the readings will be too high. If the arm is above the level of the heart, the readings will be too low (Muntner et al., 2019; Pickering et al., 2005). This position places the brachial artery on the inner aspect of the elbow so that the bell or diaphragm of the stethoscope can rest on it easily. Support for the patient’s arm prevents isometric exercise that will affect the BP level (Muntner et al., 2019). If the back is not supported, the diastolic pressure may be elevated falsely; if the legs are crossed, the systolic pressure may be elevated falsely (Muntner et al., 2019; Pickering et al., 2005). 50. 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. (Rational: Clothing over the artery interferes with the ability to hear sounds and can cause inaccurate blood pressure readings. A tight sleeve would cause congestion of blood and possibly inaccurate readings (Muntner et al., 2019). 51. Palpate the location of the brachial artery. Center the bladder of the cuff over the brachial artery, about midway on the upper arm, so that the lower edge of the cuff is about 2.5 to 5 cm (1 to 2 inches) above the inner aspect of the elbow. Line up the artery marking on the cuff with the patient’s brachial artery. The tubing should extend from the edge of the cuff nearer the patient’s elbow (Fig. 16). (Rational: Pressure in the cuff applied directly to the artery provides the most accurate readings. If the cuff gets in the way of the stethoscope, readings are likely to be inaccurate. A cuff placed upside down with the tubing toward the patient’s head may give a false reading. 35 FIGURE 15. Positioning for blood pressure assessment using brachial artery. (Source: Used with permission from Shutterstock. Photo by B. Proud.) FIGURE 16. Placing the blood pressure cuff on the upper arm. (Source: Used with permission from Shutterstock. Photo by B. Proud.) 52. 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. (Rational: A smooth cuff and snug wrapping produce equal pressure and help promote an accurate measurement. A cuff wrapped too loosely results in an inaccurate reading) 53. Check that the needle on the aneroid gauge is within the zero mark (Figure 17). (Rational: If the needle is not in the zero area, the blood pressure reading may not be accurate) 36  FIGURE 17. Ensuring gauge starts at zero. (Source: Used with permission from Shutterstock. Photo by B. Proud.) Estimating Systolic Pressure 54. Palpate the pulse at the brachial or radial artery by pressing gently with the fingertips (Figure 18). (Rational: To identify the first Korotkoff sound accurately, the cuff must be inflated 20 to 30 mm Hg above the point at which the pulse can no longer be felt (Muntner et al., 2019). FIGURE 18. Palpating the brachial pulse. (Source: Used with permission from Shutterstock. Photo by B. Proud.) 55. Tighten the screw valve on the air pump. (Rational: The bladder within the cuff will not inflate with the valve open) 56. Inflate the cuff while continuing to palpate the artery. Note the point on the gauge where the pulse disappears. (Rational: The point where the pulse disappears provides an estimate of the systolic pressure. 37 To identify the first Korotkoff sound accurately, the cuff must be inflated to a pressure above the point at which the pulse can no longer be felt. 57. Deflate the cuff and wait 1 minute. (Rational: Allowing a brief pause before continuing permits the blood to refill and circulate through the arm. Obtaining Blood Pressure Measurement 58. Assume a position that is no more than 3 ft away from the gauge. (Rational: A distance of more than about 3 ft can interfere with accurate reading of the numbers on the gauge. 59. Place the stethoscope earpieces in your ears. Direct the earpieces forward into the canal and not against the ear itself. (Rational: Proper placement blocks extraneous noise and allows sound to travel more clearly. 60. Place the bell or diaphragm of the stethoscope firmly but with as little pressure as possible over the brachial artery (Figure 19). Do not allow the stethoscope to touch clothing or the cuff. (Rational: Having the bell or diaphragm directly over the artery allows more accurate readings. Heavy pressure on the brachial artery distorts the shape of the artery and the sound. Placing the bell or diaphragm away from clothing and the cuff prevents noise, which would distract from the sounds made by blood flowing through the artery. FIGURE 19. Placement of diaphragm of stethoscope. (Source: Used with permission from Shutterstock. Photo by B. Proud.) 61. Pump the pressure 20 to 30 mm Hg above the point at which the systolic pressure was palpated and estimated. Open the valve on the manometer and allow air to escape slowly (allowing the gauge to drop 2 mm Hg per second) (Muntner et al., 2019). (Rational: Increasing the pressure above the point where the pulse disappeared ensures a period before hearing the first sound that corresponds with the systolic pressure. It prevents misinterpreting phase II sounds as phase I sounds) 38 62. Note the point on the gauge at which the first of at least two consecutive beats appears (Figure 20). Read the pressure to the closest 2 mm Hg. Note this number as the systolic pressure. (Rational: Systolic pressure is the point at which the blood in the artery is first able to force its way through the vessel at a similar pressure exerted by the air bladder in the cuff. The first sound is phase I of Korotkoff sounds. 63. Do not reinflate the cuff once the air is being released to recheck the systolic pressure reading. (Rational: Reinflating the cuff while obtaining the blood pressure is uncomfortable for the patient and can cause an inaccurate reading. Reinflating the cuff causes congestion of blood in the lower arm, which lessens the loudness of Korotkoff sounds. 64. Note the point at which the sound completely disappears (Figure 21). Read the pressure to the closest 2 mm Hg. Note this number as the diastolic pressure. (Rational: The point at which the sound disappears corresponds to the beginning of phase V Korotkoff sounds and is generally considered the diastolic pressure reading (Muntner et al., 2019; Pickering et al., 2005). 65. Allow the remaining air to escape quickly. Repeat any suspicious reading, but wait at least 1 to 2 minutes. Deflate the cuff completely between attempts to check the blood pressure.. (Rational: False readings are likely to occur if there is congestion of blood in the limb while obtaining repeated readings. FIGURE 20. Noting the point on the gauge at which the first of at least two consecutive beats appears. (Source: Used with permission from Shutterstock. Photo by B. Proud.) 39  FIGURE 21. Noting the point at which the sound completely disappears. (Source: Used with permission from Shutterstock. Photo by B. Proud.) 66. When measurement is completed, remove the cuff. Remove gloves, if worn. Perform hand hygiene. Cover the patient and help them to a position of comfort.. (Rational: Removing gloves properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. Covering and positioning the patient ensures patient comfort. 67. Clean the bell or diaphragm of the stethoscope with the alcohol wipe. Clean and store the sphygmomanometer, according to facility policy.. (Rational: Appropriate cleaning deters the spread of microorganisms. Equipment should be left ready for use. 68. Remove additional PPE, if used. Perform hand hygiene.. (Rational: Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene deters the spread of microorganisms. 69.. Record the findings on the electronic record or flow sheet. Communicate abnormal findings to the primary health care provider. Identify arm used or site of assessment if other than brachial. ASSESSING OXYGEN SATURATION 40  0. Select an appropriate site for application of the sensor. (Rational Inadequate circulation can interfere with the oxygen saturation (SpO2) reading.. Use the patient’s index, middle, or ring finger (Figure 22). (Rational: Fingers are easily accessible) a. Check the proximal pulse (Figure 23) and capillary refill (Figure 24) closest to the site. (Rational: Brisk capillary refill and a strong pulse indicate adequate circulation to the site. b. If circulation to the site is inadequate, consider using the earlobe or forehead. Use the appropriate oximetry sensor for the chosen site. (Rational: These alternative sites are highly vascular. Correct use of appropriate equipment is vital for accurate results) c. Use a toe only if lower extremity circulation is not compromised. (Rational: Peripheral vascular disease is common in lower extremities) FIGURE 22. Selecting an appropriate finger. FIGURE 23. Assessing pulse. FIGURE 24. Assessing capillary refill. 71. Select the proper equipment:. If one finger is too large for the probe, use a smaller finger. (Rational: Inaccurate readings can result if the probe or sensor is not attached correctly) a. Use probes appropriate for the patient’s age and size. Use a pediatric probe for a small adult, if necessary. (Rational: Probes come in adult, pediatric, and infant sizes) 41  b. Check if the patient is allergic to the adhesive. A nonadhesive finger clip or reflectance sensor is available. (Rational: A reaction may occur if the patient is allergic to an adhesive substance. 72. Prepare the monitoring site. Cleanse the selected area with a disposable cleansing cloth, as necessary; alternatively, have the patient wash their hands. Allow the area to dry. If necessary, remove any nail polish and artificial nails after checking the pulse oximeter’s manufacturer’s instructions. (Rational: Skin oils, dirt, or grime on the site can interfere with the passage of light waves. Research is conflicting regarding the effect of dark color nail polish and artificial nails. However, it is prudent to remove the nail polish (American Thoracic Society, 2021; USFDA, 2021; World Health Organization [WHO], 2011; Yönt et al., 2014). Refer to facility policy and the pulse oximeter’s manufacturer’s instructions regarding nail polish and artificial nails for additional information) 73. Attach the probe securely to the skin (Figure 25). Make sure that the light-emitting sensor and the light-receiving sensor are aligned opposite each other (not necessary to check if placed on the forehead). (Rational: Secure attachment and proper alignment promote satisfactory operation of the equipment and an accurate recording of the SpO2) 74. Connect the sensor probe to the pulse oximeter (Figure 26), turn the oximeter on, and check operation of the equipment (audible beep and fluctuation of the bar of light or waveform on the face of the oximeter). (Rational: An audible beep represents the arterial pulse, and a fluctuating waveform or light bar indicates the strength of the pulse. A weak signal will produce an inaccurate recording of the SpO2. The tone of the beep reflects the SpO2 reading. If SpO2 drops, the tone becomes lower in pitch) 75. Set alarms on the pulse oximeter. Check the manufacturer’s alarm limits for high and low pulse rate settings (Figure 27). (Rational: The alarm provides an additional safeguard and signals when high or low limits have been surpassed. FIGURE 25. Attaching probe to patient’s finger. FIGURE 26. Connecting sensor probe to unit. 42  FIGURE 27. Checking alarms. 76. Check oxygen saturation at regular intervals, as prescribed, as per nursing assessment, and as signaled by alarms. Monitor the hemoglobin level. (Rational: Monitoring SpO2 provides ongoing assessment of the patient’s condition. A low hemoglobin level may be satisfactorily saturated yet inadequate to meet a patient’s oxygen needs) 78. Remove the sensor on a regular basis and check for skin irritation or signs of pressure (every 2 hours for a spring-tension sensor and every 4 hours for an adhesive finger or toe sensor). (Rational: Prolonged pressure may lead to tissue necrosis. An adhesive sensor may cause skin irritation) 79. Clean nondisposable sensors according to the manufacturer’s directions. Remove PPE, if used. Perform hand hygiene. (Rational: Cleaning equipment between each patient use reduces the spread of microorganisms. Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms) Skill 3.1 PAIN ASSESSMENT 43 PURPOSE _____________________________________________________________________________ Pain Assessment is recommended to be part of regular care making it the fifth vital sign. A comprehensive assessment provides a basis for optimal pain control. PRE-ASSESSMENT _____________________________________________________________________________ Check patient history Check patient current complaint Check medication patient is receiving PREPARING EQUIPMENT _____________________________________________________________________________ Pain assessment scale (Figure 28) FIGURE 28. Pain assessment scale PROCEDURE STEPS _____________________________________________________________________________ Pain assessment consist of two components: 44 (a) Pain history to obtain facts from the client (b) Direct observation of behaviors , physical signs of tissue damage and secondary physiological responses of the client Pain History Assessment: Location: Where is your discomfort? Quality: Tell me what your discomfort feels like. Intensity: On a scale of 0-10, With "0" representing no pain(Substitute the term client uses, e.g., "no burning" ) and "10" representing the worst possible pain (e.g., " burning sensation"). How would you rate the degree of discomfort you are having right now? Pattern:. Time of onset: When did or does the pain start? a. Duration: How long have you had it, or how long does it usually last? b. Constancy: Do you have pain-free periods? When? And for how long? Precipitating factors: What triggers the pain or makes it worse? Alleviating factors: What measures or methods have you found helpful in lessening or relieving the pain? What pain medications do you use? Associated symptoms: Do you have any other symptoms (e.g., nausea, dizziness, blurred vision, shortness of breath) before, during, or after your pain? Effects on ADLs: How does the pain affect your daily life (e.g., eating, working, sleeping, and social and recreational activities)? Past pain experiences: Tell me about past pain experiences you have had and what was done to relieve the pain. Meaning of pain: What does having this pain mean to you? Does it signal something about the future or past? What worries or scares you the most about your pain? Coping resources: What do you usually do to help you deal with pain? Affective response: How does the pain make you feel? Anxious? Depressed? Frightened? Tired? Burdensome? Document the intensity of pain in a scale of 0-10 in the vital signs chart and report as required. POST ASSESSMENT _____________________________________________________________________________ Follow up the period in appropriate intervals to assess response to pain management measures and report it as required 45  DOCUMENTATION SHEET VITAL SIGNS RECORD – KOZIER AND INTERNATIONAL STANDARD Name of the Patient: _________________________ Hospital ID:_______________ Ward: _____________________________________ Bed No: __________________ 46  Observation item Value Low range High range Systolic BP 100 140 Diastolic BP 60 90 BP Mean 65 110 Pulse rate 60 100 Respiration 12 20 Oxygen saturation 95 100 Body Temperature 36.00C 37.50C Pain score Signature Date and Time VITAL SIGNS RECORD - SQUH Name of the Patient: _________________________ Hospital ID:_______________ Ward: _____________________________________ Bed No: __________________ 47  Observation item Value Low range High range Systolic BP 115 139 Diastolic BP 80 88 BP Mean Pulse rate 60 80 Respiration 11 15 Oxygen saturation 90 100 Body Temperature 36.00C 37.70C Pain score Signature Date and Time Vital Signs- Normal Range and Variation Body Temperature: 36.0° C- 37.5° C - Average / Normal temperature 37.5-40.9°C- Pyrexia 41° C & above – Hyperpyrexia Below 36° C – Hypothermia An axillary temperature is considered one degree lower than oral temperature Rectal temperature is considered one degree higher temperature. Variation of Pulse and Respiration by Age 48  AGE PULSE AVERAGE AND RANGES RESPIRATION AVE. AND RANGES New Born 130 (80-180) 35 (30-60) 1 year 120 (80 – 140) 30 (20 – 40) 5 – 8 years 100 (75 – 120) 20 ( 15 – 25) 10 years 70 ( 50 – 90) 19 (15 – 25) Teen 75 (50 – 90) 18 (15 – 20) Adult 80 (60 – 100) 16 (12 – 20) Older adult 70 (60 – 100) 16 (15 – 20) Classification of Blood Pressure: Category Systolic BP Diastolic BP (MMHG) (MMHG) Normal 100 Oxygen Saturation (SaO2) Value is the percent of all hemoglobin binding sites that are occupied by oxygen; normal is 95% to 100%, below 70% is life-threatening 49  Skill 3.1 VITAL SIGNS Student Name : _________________________________ Score Levels of Performance 0 Missed step/procedure Student ID : __________________________________ 1 Unacceptable performance Performance acceptable with major Station No : __________________________________ 2 Modification Date : __________________________________ Performance acceptable with minor 3 modification 4 Satisfactory performance 5 Excellent performance Indicators/ Procedure 5 4 3 2 1 0 Remarks Purpose Vital signs reflect the changes in body function Patient Preparation Maintains client’s confidentiality and privacy Observes universal precautions in providing care to clients (hand washing, use of gloves) Introduces self to client Identify the patient using the 3Vs [verbalization, visualization, verification] Prepares client and explains the procedure Pre–Assessment Food and fluid intake (time) Activity and exercise Medications being taken Presence of any diseases Preparing Equipment Temprature: Digital or electronic thermometer Disposable probe covers Nonsterile gloves Additional personal protective equipment (PPE), as indicated 50  Pulse and respiration Watch with a second hand or indicator Blood Pressure Using an Automated, Electronic Oscillometric Device Blood pressure cuff Automated, electronic oscillometric blood pressure device Blood Pressure by Auscultation Stethoscope Sphygmomanometer Pain Assessment Pain scale Procedure Steps Assessing Oral Body Temperature Ensure that the electronic or digital thermometer is in working condition. Put on gloves, if indicated. Remove the electronic unit from the charging unit and remove the probe from within the recording unit. Cover thermometer probe with disposable probe cover, sliding it on until it snaps into place Place the probe beneath the patient’s tongue in the posterior sublingual pocket Ask the patient to close their lips around the probe. Continue to hold the probe until you hear a beep Note the temperature reading Remove the probe from the patient’s mouth. Dispose of the probe cover by holding the probe over an appropriate receptacle and pressing the probe-release button Return the thermometer probe to the storage place within the unit. Return the electronic unit to the charging unit, if appropriate. When measurement is completed, remove gloves, if worn. Remove additional PPE, if used. Perform hand hygiene. Assessing a Peripheral Pulse by Palpation 51  Select the appropriate peripheral site based on assessment data. Move the patient’s clothing to expose only the site chosen. Place your first, second, and third fingers over the artery Place your fingers over the artery so that the ends of your fingers are flat against the patient’s skin when palpating peripheral pulses. Do not press with the tip of the fingers only. Lightly compress the artery so pulsations can be felt and counted Using a watch with a second hand, count the number of pulsations felt for 30 seconds Multiply this number by 2 to calculate the rate for 1 minute. If the rate, rhythm, or amplitude of the pulse is abnormal in any way, palpate and count the pulse for 1 minute. Note the rhythm and amplitude of the pulse, as well as the elasticity of the blood vessel. When measurement is completed, remove gloves, if worn. Perform hand hygiene. Cover the patient and help them to a position of comfort. Document pulse rate, strength, rhythm and elasticity in the electronic record or flow sheet. Identify site of assessment. Communicate abnormal findings to the primary care provider. Assessing Respiration While your fingers are still in place for the pulse measurement, after counting the pulse rate, observe the patient’s respirations Note the rise and fall of the patient’s chest. Using a watch with a second hand, count the number of respirations for 30 seconds. Multiply this number by 2 to calculate the respiratory rate per minute. Avoid counting for a 15-second interval. If respirations are abnormal in any way, count the respirations for at least 1 full minute. Note the depth and rhythm of the respirations. Document respiratory rate, depth, and rhythm on electronic record or flow sheet. Communicate any abnormal findings to the appropriate person. 52  Assessing Blood Pressure Assessing Blood Pressure Using an Automated, Electronic Oscillometric Device Select the appropriate arm (or alternate site) for measurement and blood pressure cuff. Have the patient assume a comfortable lying or sitting position 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. Palpate the location of the brachial artery. Center the bladder of the cuff over the brachial artery, about midway on the upper arm, so that the lower edge of the cuff is about 2.5 to 5 cm (1 to 2 inches) above the inner aspect of the elbow Line up the artery marking on the cuff with the patient’s brachial artery. The tubing should extend from the edge of the cuff nearer the patient’s elbow 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. Turn on the machine. If the machine has different settings for infants, children, and adults, select the appropriate setting. Push the start button. Instruct the patient to hold the limb still and refrain from speaking. Wait until the machine beeps and the blood pressure reading appears. Note the reading Assessing Blood Pressure by Auscultation Select the appropriate arm (or alternate site) for measurement and blood pressure cuff. Have the patient assume a comfortable lying or sitting position with the forearm supported at the level of the heart and the palm of the hand upward. If the measurement is taken in the supine position, support the arm with a pillow. In the sitting position, support the arm yourself or by using the bedside table. If the patient is sitting, have the patient sit back in the chair so that the chair supports their back. In addition, make sure the patient keeps the legs uncrossed. 53  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. Palpate the location of the brachial artery. Center the bladder of the cuff over the brachial artery, about midway on the upper arm, so that the lower edge of the cuff is about 2.5 to 5 cm (1 to 2 inches) above the inner aspect of the elbow. Line up the artery marking on the cuff with the patient’s brachial artery. The tubing should extend from the edge of the cuff nearer the patient’s elbow. 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. (Rational: A smooth cuff and snug wrapping produce equal pressure and help promote an accurate measurement. A cuff wrapped too loosely results in an inaccurate reading) Check that the needle on the aneroid gauge is within the zero mark Estimating Systolic Pressure Palpate the pulse at the brachial or radial artery by pressing gently with the fingertips Tighten the screw valve on the air pump. Inflate the cuff while continuing to palpate the artery. Note the point on the gauge where the pulse disappears. Deflate the cuff and wait 1 minute. Obtaining Blood Pressure Measurement Assume a position that is no more than 3 ft away from the gauge. Place the stethoscope earpieces in your ears. Direct the earpieces forward into the canal and not against the ear itself. 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. Pump the pressure 20 to 30 mm Hg above the point at which the systolic pressure was palpated and estimated. Open the valve on the manometer and allow air to escape slowly (allowing the gauge to drop 2 mm Hg per second) 54  Note the point on the gauge at which the first of at least two consecutive beats appears Read the pressure to the closest 2 mm Hg. Note this number as the systolic pressure. Do not reinflate the cuff once the air is being released to recheck the systolic pressure reading. Note the point at which the sound completely disappears. Read the pressure to the closest 2 mm Hg. Note this number as the diastolic pressure. Allow the remaining air to escape quickly. Repeat any suspicious reading, but wait at least 1 to 2 minutes. Deflate the cuff completely between attempts to check the blood pressure. When measurement is completed, remove the cuff. Remove gloves, if worn. Perform hand hygiene. Cover the patient and help them to a position of comfort. Clean the bell or diaphragm of the stethoscope with the alcohol wipe. Clean and store the sphygmomanometer, according to facility policy. Remove additional PPE, if used. Perform hand hygiene. Record the findings on the electronic record or flow sheet. Communicate abnormal findings to the primary health care provider. Identify arm used or site of assessment if other than brachial. ASSESSING OXYGEN SATURATION Select an appropriate site for application of the sensor. Use the patient’s index, middle, or ring finger Check the proximal pulse and capillary refill closest to the site. Select the proper equipment: Prepare the monitoring site. Cleanse the selected area with a disposable cleansing cloth, as necessary Attach the probe securely to the skin Check oxygen saturation Clean no disposable sensors according to the manufacturer’s directions Record the findings on the electronic record or flow sheet. Communicate abnormal findings to the primary health care provider 55  Assess the pain P = provocative/palliative factors Q = quality R = region/radiation S = severity T = timing Record the findings on the electronic record or flow sheet. Communicate abnormal findings to the primary health care provider Post–Assessment Reposition the patient comfortably. Interpret the obtained values. Replace articles and dispose used supplies. Total Marks Remarks: Evaluator: 56  4. ACTIVITY, EXERCISE AND POSITIONS OBJECTIVES: On the completion of the practical session, students will be able to: Explain and demonstrate different positions used for providing comfort to patients Identify clients who require log rolling, breathing exercises and range of motion exercises Demonstrate steps in log rolling a client Explain to clients the rationale for performing the breathing exercises Demonstrate steps of breathing exercises Demonstrate the steps of moving the patient up in the Bed, Transferring a patient from bed to wheel chair Document and report abnormal findings Skill 4.1 RANGE OF MOTION EXERCISES Range of motion ROM of a joint is the maximum movement that is possible for that joint. Joint Range of motion varies from individual to individual and is determined by genetic makeup, developmental patterns, the presence or absence of disease, and the amount of physical activity in which the person normally engages. PURPOSE _____________________________________________________________________________ To maintain the size, shape , tone and strength of the muscles and flexibilities of the joints and range of motion INDICATIONS _____________________________________________________________________________ Clients with mobility problems TYPES _____________________________________________________________________________ Active ROM and Passive ROM POST ASSESSMENT _____________________________________________________________________________ Assess the response of the client and the outcome of the plan of ROM activities