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FUNDAMENTAL OF NURSINGPROCEDURE MANUALfor PCL courseNursing Department,Khwopa Poly-Technic Institute &Japan International Cooperation Agency (JICA)

Fundamental of Nursing Procedure ManualPublished by:Japan International Cooperation Agency (JICA) Nepal OfficeBlock B, Karmachari Sanshaya Kosh BuildingHariharbhavan, Lalitpur, NEPAL(P.O. Box 450, Kathmandu, NEPAL)Tel:(977-1) 5010310Fax:(977-1) 5010284All copyright reserved by JICAFirst Edition: March, 2008Re - print:November, 20082

Fundamental of Nursing Procedure Manual Contributor:Sanjita KhadkaDurgeshori KisiPadma RayaSaphalta ShresthaEdited by Kei Miyamoto( Nursing Education, Senior Volunteer, JICA) Khwopa polytechnic institute, Nursing departmentPrinciple:Dr. Rajan SuwalFaculty members of Nursing DepartmentHead of Department : Sharmila ShresthaLecturer:Sanjita Khadka(1st year coordinator)Chitra Kala Sharma(2nd year coordinator)Merina Giri(3rd year coordinator)Bishnu UpretyAssistant lecturer:Durgeshori KisiPadma RayaSushila ChaudhariSunita BatasInstructor:Saphalta ShresthaSumitra BudhathokiSabitra KhadkaThank for contributing your professional knowledge and experience. We would like to appreciateto all our teachers and the former teachers, Ms. Junely Koju, Ms.Uttam Tara, and Ms. RashmiJoshi.3

Fundamental of Nursing Procedure ManualTable of ContentsI. Basic Nursing Care/ Skill7Bed makinga. Making an Un-occupied bedb. Changing an Occupied bedc. Making a Post-operative bed2. Performing oral carea. Assisting the client with oral careb. Providing oral care for dependent client3. Performing bed bath4. Performing back care5. Performing hair washing6. Care for fingernails/ toenails7. Performing perineal care8. Taking vital signsa. Taking axillary temperature by glass thermometerb. Measuring radial pulsec. Counting respirationd. Measuring blood pressure9. Performing physical examination10. Care for Nasal-gastric Tubea. Inserting a Nasal-Gastric Tubeb. Removal a Nasal-Gastric Tube11. Administering Nasal-Gastric tube feeding12. Cleaning a wound and Applying a sterile dressing13. Supplying oxygen inhalationa. Nasal Cannula Methodb. Mask Method: Simple face mask1.II. Administration of Medications1.2.3.4.5.6.7.8.9.10.Administering oral medicationsAdministering oral medications through a Nasal-Gastric TubeRemoving medications from an ampouleRemoving medications from a vialPrevention of the needle-stick injuriesGiving an Intra-muscular injectionStarting an Intra-venous infusionMaintenance of I.V. systemAdministering medications by Heparin LockPerforming Nebulizer Therapya. Inhalerb. Ultrasonic 8149

Fundamental of Nursing Procedure ManualIII. Specimen collection1.Collecting blood specimena. Performing venipunctureb. Assisting in obtaining blood for culture2.Collecting urine specimena. Collecting a single voided specimenb. Collecting a 24-hour urine specimenc. Collecting a urine specimen from a retention catheterd. Collecting a urine culture3. Collecting a stool specimen4. Collecting a sputum specimena. Routine testb. Collecting a sputum ndix171References1815

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Fundamental of Nursing Procedure ManualI. Basic Nursing Care/ Skill7

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Fundamental of Nursing Procedure ManualBed makinga. Making an Un-occupied BedDefinition:A bed prepared to receive a new patient is an un-occupied bed.Fig.1. Un-occupied bedPurpose1. To provide clean and comfortable bed for the patient2. To reduce the risk of infection by maintaining a clean environment3. To prevent bed sores by ensuring there are no wrinkles to cause pressure pointsEquipment required:1. Mattress (1)2. Bed sheets(2): Bottom sheet (1)Top sheet(1)3. Pillow(1)4. Pillow cover (1)5. Mackintosh (1)6. Draw sheet (1)7. Blanket(1)8. Savlon water or Dettol water in basin9. Sponge cloth (4): to wipe with solution (1)to dry(1) When bed make is done by two nurses,sponge cloth is needed two each.10. Kidney tray or paper bag (1)11. Laundry bag or Bucket (1)12. Trolley(1)Fig. 2. Equipment required on a trolley9

Fundamental of Nursing Procedure ManualProcedure: by one nurseCare Action1. Explain the purpose and procedure to the client.2. Perform hand hygiene.3. Prepare all required equipments and bring thearticles to the bedside.4. Move the chair and bed side locker5. Clean Bed-side locker:Wipe with wet and dry.Rationale Providing information fosters cooperation. To prevent the spread of infection. Organizationfacilitatesaccurateskillperformance It makes space for bed making and helps effectiveaction. To maintain the cleanliness6. Clean the mattress: To prevent the spread of infection1) Stand in right side.2) Start wet wiping from top to center and fromcenter to bottom in right side of mattress.3) Gather the dust and debris to the bottom.4) Collect them into kidney tray.5) Give dry wiping as same as procedure 2).6) Move to left side.7) Wipe with wet and dry the left side.7. Move to right side.Bottom sheet:1) Place and slide the bottom sheet upward over Unfolding the sheet in this manner allows you tothe top of the bed leaving the bottom edge of themake the bed on one side.sheet.2) Open it lengthwise with the center fold along thebed center.3) Fold back the upper layer of the sheet toward theopposite side of the bed.4) Tuck the bottom sheet securely under the head ofthe mattress(approximately 20-30cm). (Fig.3)Make a mitered corner. A mitered corner has a neat appearance and keepsthe sheet securely under the mattress.➀Pick up the selvage edge with your handnearest the hand of the bed.➁Lay a triangle over the side of the bed (Fig.4 )➂Tuck the hanging part of the sheet under the Tucking the bottom sheet will be done by turn,the corner of top firstly and the corner of themattress.( Fig. 5)bottom later.➃ Drop the triangle over the side of the bed.( Fig. 6 6 )⑤Tuck the sheet under the entire side of bed.(Fig. To secure the bottom sheet on one side of the bed.7)5) Repeat the same procedure at the end of thecorner of the bed6) Tuck the remainder in along the side8. Mackintosh and draw sheet: Mackintosh and draw sheet are additional1) Place a mackintosh at the middle of the bed ( ifprotection for the bed and serves as a lifting orused), folded half, with the fold in the center ofturning sheet for an immobile client.the bed. used), folded half, with the fold in thecenter of the bed.2) Lift the right half and spread it forward the nearSide.10

Fundamental of Nursing Procedure ManualFig.3 Tuck the bottom sheet under the mattressFig.6a Putting and holding the sheet bedside themattress at the level of topFig.4 Picking the selvage and laying a triangle onthe bedFig.6b Dropping the triangle over the side of the bedFig.5 Tucking the hanging part of the sheet underthe mattressFig.7 Tucking the sheet under the entire side of thebed11

Fundamental of Nursing Procedure ManualCare Action3) Tuck the mackintosh under the mattress.4) Place the draw sheet on the mackintosh. Spreadand tuck as same as procedure 1)-3).9.Move to the left side of the bed.Bottom sheet , mackintosh and draw sheet:1) Fold and tuck the bottom sheet as in the aboveprocedure 7.2) Fold and tuck both the mackintosh and the drawsheet under the mattress as in the aboveprocedure 8.10. Return to the right side.Top sheet and blanket:1) Place the top sheet evenly on the bed, centeringit in the below 20-30cm from the top of themattress.2) Spread it downward.3) Cover the top sheet with blanket in the below 1feet from the top of the mattress and spreaddownward.4) Fold the cuff (approximately 1 feet) in the neckpart5) Tuck all these together under the bottom ofmattress. Miter the corner.6) Tuck the remainder in along the side11. Repeat the same as in the above procedure 10 inleft side.12. Return to the right side.Pillow and pillow cover:1) Put a clean pillow cover on the pillow.Rationale Secure the bottom sheet, mackintosh and drawsheet on one side of the bed A blanket provides warmth. Making the cuff at the neck part preventsirritation from blanket edge. Tucking all these pieces together saves time andprovides a neat appearance. To save time in this manner A pillow is a comfortable measure. Pillow cover keeps cleanliness of the pillow andneat.2) Place a pillow at the top of the bed in the center The open end may collect dust or organisms.with the open end away from the door. The open end away from the door also makesneat.13. Return the bed, the chair and bed-side table to Bedside necessities will be within easy reach fortheir proper place.the client .14. Replace all equipments in proper place. It makes well-setting for the next.Discard lines appropriately. Proper line disposal prevents the spread ofinfection.15. Perform hand hygiene To prevent the spread of infection. Nursing Alert Do not let your uniform touch the bed and the floor not to contaminate yourself. Never throw soiled lines on the floor not to contaminate the floor. Staying one side of the bed until one step completely made saves steps and time to do effectively andsave the time.12

Fundamental of Nursing Procedure ManualBed makingb. Changing an Occupied BedDefinitionThe procedure that used lines are changed to a hospitalized patient is an occupied bed.Fig. 8 Occupied bedPurpose:1. To provide clean and comfortable bed for the patient2. T reduce the risk of infection by maintaining a clean environment3. To prevent bed sores by ensuring there are no wrinkles to cause pressure pointsEquipment required:1. Bed sheets(2) : Bottom sheet( or bed cover) (1)Top sheet(1)2. Draw sheet (1)3. Mackintosh (1) (if contaminated or needed to change)4. Blanket(1) ( if contaminated or needed to change)5. Pillow cover (1)6. Savlon water or Dettol water in bucket7. Sponge cloth (2): to wipe with solution (1)to dry(1) When the procedure is done by two nurses, sponge cloth is needed two each.8. Kidney tray or paper bag (1)9. Laundry bag or bucket (1)10. Trolley(1)13

Fundamental of Nursing Procedure ManualProcedure: by one nurseCare Action1. Check the client’s identification and condition.2. Explain the purpose and procedure to the client3. Perform hand hygiene4. Prepare all required equipments and bring thearticles to the bedside.5. Close the curtain or door to the room. Put screen.6. Remove the client’s personal belongings frombed-side and put then into the bed-side locker orsafe place.7. Lift the client’s head and move pillow from centerto the left side.8. Assist the client to turn toward left side of thebed. Adjust the pillow. Leaves top sheet in place.Rationale To assess necessity and sufficient condition Providing information fosters cooperation To prevent the spread of infection. Organization facilitates accurate skill performance To maintain the client’s privacy. To prevent personal belongings from damage andloss. The pillow is comfortable measure for the client. Moving the client as close to the other side of thebed as possible gives you more room to make thebed. Top sheet keeps the client warm and protect his orher privacy.9.Stand in right side: Placing folded (or rolled) soiled linen close to theLoose bottom bed linens. Fanfold (or roll) soiled client allows more space to place the clean bottomlinens from the side of the bed and wedge them sheets.close to the client.10. Wipe the surface of mattress by sponge cloth To prevent the spread of infection.with wet and dry.11. Bottom sheet, mackintosh and draw sheet: Soiled linens can easily be removed and clean1) Place the clean bottom sheet evenly on the bed linens are positioned to make the other side of thefolded lengthwise with the center fold as close to bed.the client’s back as possible.2) Adjust and tuck the sheet tightly under the headof the mattress, making mitered the uppercorner.3) Tighten the sheet under the end of the mattressand make mitered the lower corner.4) Tuck in along side.5) Place the mackintosh and the draw sheet on thebottom sheet and tuck in them together.12. Assist the client to roll over the folded (rolled) Moving the client to the bed’s other side allows youlinen to right side of the bed. Readjust the pillow to make the bed on that side.and top sheet.13. Move to left side:Discard the soiled linens appropriately. Hold Soiled linens can contaminate your uniform,them away from your uniform. Place them in the which may come into contact with other clients.laundry bag (or bucket).14. Wipe the surface of the mattress by sponge cloth To prevent the spread of infection.with wet and dry.15. Bottom sheet, mackintosh and draw sheet:1) Grasp clean linens and gently pull them out from Wrinkled linens can cause skin irritation.under the client.2) Spread them over the bed’s unmade side. Pull thelinens taut14

Fundamental of Nursing Procedure ManualCare Action3) Tuck the bottom sheet tightly under the head ofthe mattress and miter the corner.4) Tighten the sheet under the end of the mattressand make mitered the lower corner.5) Tuck in along side.6) Tuck the mackintosh and the draw sheet underthe mattress.16. Assist the client back to the center of the bed.Adjust the pillow.17. Return to right side:Clean top sheet, blanket:1) Place the clean top sheet at the top side of thesoiled top sheet.2) Ask the client to hold the upper edge of the cleantop sheet.3) Hold both the top of the soiled sheet and the endof the clean sheet with right hand and withdrawto downward. Remove the soiled top sheet andput it into a laundry bag (or a bucket).4) Place the blanket over the top sheet. Fold topsheet back over the blanket over the client.5) Tuck the lower ends securely under the mattress.Miter corners.6) After finishing the right side, repeat the left side.18. Remove the pillow and replace the pillow coverwith clean one and reposition the pillow to thebed under the client’