FUNDAMENTAL OF NURSING PROCEDURE MANUAL for PCL

182 Pages·2010·1.87 MB·English

FUNDAMENTAL OF NURSING
PROCEDURE MANUAL
for PCL course
Nursing Department,
Khwopa Poly-Technic Institute ＆
Japan International CooperationAgency (JICA)
FundamentalofNursingProcedureManual
Publishedby:
JapanInternationalCooperationAgency(JICA)NepalOffice
BlockB,KarmachariSanshayaKoshBuilding
Hariharbhavan,Lalitpur,NEPAL
(P.O.Box450,Kathmandu,NEPAL)
Tel:[phone]
Fax:[phone]
AllcopyrightreservedbyJICA
FirstEdition: March,2008
Re-print: November,2008
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FundamentalofNursingProcedureManual
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Contributor: SanjitaKhadka
DurgeshoriKisi
PadmaRaya
SaphaltaShrestha
EditedbyKeiMiyamoto(NursingEducation,SeniorVolunteer,JICA)
✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽
Khwopapolytechnicinstitute,Nursingdepartment
Principle: Dr.RajanSuwal
FacultymembersofNursingDepartment
HeadofDepartment:SharmilaShrestha
Lecturer: SanjitaKhadka(1styearcoordinator)
ChitraKalaSharma(2ndyearcoordinator)
MerinaGiri(3rdyearcoordinator)
BishnuUprety
Assistantlecturer: DurgeshoriKisi
PadmaRaya
SushilaChaudhari
SunitaBatas
Instructor: Saphalta Shrestha
Sumitra Budhathoki
SabitraKhadka
Thankforcontributingyourprofessionalknowledgeandexperience.Wewouldliketoappreciate
toallourteachersandtheformerteachers,Ms.JunelyKoju,Ms.UttamTara,andMs.Rashmi
Joshi.
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FundamentalofNursingProcedureManual
TableofContents
I. BasicNursingCare/Skill 7
1. Bedmaking
a.MakinganUn-occupiedbed 9
b.ChanginganOccupiedbed 13
c.MakingaPost-operativebed 16
2. Performingoralcare 19
a.Assistingtheclientwithoralcare 21
b.Providingoralcarefordependentclient 23
3. Performingbedbath 26
4. Performingbackcare 30
5. Performinghairwashing 32
6. Careforfingernails/toenails 35
7. Performingperinealcare 37
8. Takingvitalsigns 39
a.Takingaxillarytemperaturebyglassthermometer 41
b.Measuringradialpulse 43
c.Countingrespiration 45
d.Measuringbloodpressure 46
9. Performingphysicalexamination 49
10. CareforNasal-gastricTube 98
a.InsertingaNasal-GastricTube 98
b.RemovalaNasal-GastricTube 101
11.AdministeringNasal-Gastrictubefeeding 102
12. CleaningawoundandApplyingasteriledressing 106
13. Supplyingoxygeninhalation 109
a.NasalCannulaMethod 111
b.MaskMethod:Simplefacemask 113
II. AdministrationofMedications 115
1. Administeringoralmedications 117
2. AdministeringoralmedicationsthroughaNasal-GastricTube 120
3. Removingmedicationsfromanampoule 123
4. Removingmedicationsfromavial 126
5. Preventionoftheneedle-stickinjuries 129
6. GivinganIntra-muscularinjection 130
7. StartinganIntra-venousinfusion 135
8. MaintenanceofI.V.system 140
9. AdministeringmedicationsbyHeparinLock 144
10. PerformingNebulizerTherapy 147
a.Inhaler 148
b.Ultrasonicnebulizer 149
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FundamentalofNursingProcedureManual
III. Specimencollection 151
1.Collectingbloodspecimen 153
a. Performingvenipuncture 153
b. Assistinginobtainingbloodforculture 157
2.Collectingurinespecimen 159
a. Collectingasinglevoidedspecimen 160
b. Collectinga24-hoururinespecimen 161
c. Collectingaurinespecimenfromaretentioncatheter 163
d. Collectingaurineculture 164
3.Collectingastoolspecimen 166
4.Collectingasputumspecimen 168
a. Routinetest 168
b. Collectingasputumculture 169
Appendix 171
References 181
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I.BasicNursingCare/Skill
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FundamentalofNursingProcedureManual
Bed making
a. Making an Un-occupied Bed
Definition:
Abedpreparedtoreceiveanewpatientisanun-occupiedbed.
Fig.1.Un-occupiedbed
Purpose
1. Toprovidecleanandcomfortablebedforthepatient
2. Toreducetheriskofinfectionbymaintainingacleanenvironment
3. Topreventbedsoresbyensuringtherearenowrinklestocausepressurepoints
Equipmentrequired:
1. Mattress(1)
2. Bedsheets(2): Bottomsheet(1)
Topsheet (1)
3. Pillow (1)
4. Pillowcover (1)
5. Mackintosh (1)
6. Drawsheet (1)
7. Blanket (1)
8. SavlonwaterorDettolwaterinbasin
9. Spongecloth(4):towipewithsolution(1)
todry (1)
✽ Whenbedmakeisdonebytwonurses,
spongeclothisneededtwoeach.
10. Kidneytrayorpaperbag(1)
11. LaundrybagorBucket (1)
12. Trolley(1)
Fig.2.Equipmentrequiredonatrolley
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FundamentalofNursingProcedureManual
Procedure:byonenurse
CareAction Rationale
1.Explainthepurposeandproceduretotheclient.  Providinginformationfosterscooperation.
2.Performhandhygiene.  Topreventthespreadofinfection.
3. Prepare all required equipments and bring the  Organization facilitates accurate skill
articlestothebedside. performance
4. Movethechairandbedsidelocker  Itmakesspaceforbedmakingandhelpseffective
action.
5.CleanBed-sidelocker:  Tomaintainthecleanliness
Wipewithwetanddry.
6.Cleanthemattress:  Topreventthespreadofinfection
1)Standinrightside.
2) Start wet wiping from top to center and from
centertobottominrightsideofmattress.
3)Gatherthedustanddebristothebottom.
4)Collectthemintokidneytray.
5)Givedrywipingassameasprocedure2).
6)Movetoleftside.
7)Wipewithwetanddrytheleftside.
7.Movetorightside.
Bottomsheet:
1)Place andslidethebottomsheetupwardover Unfolding the sheet in this manner allows you to
thetopofthebedleavingthebottomedgeofthe makethebedononeside.
sheet.
2)Openitlengthwisewiththecenterfoldalongthe
bedcenter.
3)Foldbacktheupperlayerofthesheettowardthe
oppositesideofthebed.
4)Tuckthebottomsheetsecurelyundertheheadof
themattress(approximately20-30cm).(Fig.3)
Makeamiteredcorner. Amiteredcornerhasaneatappearanceandkeeps
thesheetsecurelyunderthemattress.
➀Pick up the selvage edge with your hand
nearestthehandofthebed.
➁Layatriangleoverthesideofthebed(Fig.4)
➂Tuck the hanging part of the sheet under the  Tucking the bottom sheet will be done by turn,
mattress.(Fig.5) the corner of top firstly and the corner of the
➃Dropthetriangleoverthesideofthebed. bottomlater.
(Fig.6ⓐ→ 6ⓑ)
⑤Tuckthesheetundertheentiresideofbed.(Fig.  Tosecurethebottomsheetononesideofthebed.
7)
5) Repeat the same procedure at the end of the
cornerofthebed
6)Tucktheremainderinalongtheside
8.Mackintoshanddrawsheet:  Mackintosh and draw sheet are additional
1)Placeamackintoshatthemiddleofthebed(if protectionforthebedandservesasaliftingor
used),foldedhalf,withthefoldinthecenterof turningsheetforanimmobileclient.
thebed.used),foldedhalf,withthefoldinthe
centerofthebed.
2)Lifttherighthalfandspreaditforwardthenear
Side.
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