FLEET ENEMA

Name: Quezilyn Mae K. Quezon Grade: __________________________

Year and Section: 2-A Date: ___________________________

Legend:
1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
PLANNING
To prevent
1. Before administering enema, determine that there is complications and
a primary care provider’s order demonstrate proper
enema administration.
2. Equipment:
2.1 Fleet Enema Ensure the availability
2.2 Disposable linen-saver pad/incontinent pad of necessary materials
2.3 bath blanket for a smooth and
2.4 clean gloves efficient procedure.
2.5 bedpan or commode
2.6 water-soluble lubricant
2.7 paper towel
IMPLEMENTATION
To establish rapport,
ensure that you’re
3. Prior to performing the procedure, introduce
handling the correct
yourself and verify the client’s identity.
patient, and to foster
cooperation.
To avoid transmission
of microorganism and
4. Perform hand hygiene. Wear clean gloves and
infections and to
observe appropriate infection control procedure.
protect hands from
exposure to feces.
To promote patient
5. Provide privacy comfort and preserve
their dignity.
6. Place the bedpan or commode in position for patient
To promote patient
who can’t ambulate to the toilet or have difficulty with
safety and comfort.
sphincter control.
7. Assist the client to the left lateral position with the To expose the anus and
right leg as acutely flexed as possible. facilitate the flow of
 solution into the
rectum and colon.

To minimize trauma to
8. Lubricate about 5cm (2inches) of the rectal tube. the anal sphincter
Some commercially prepared enema set already have during the insertion of
lubricated nozzle. the rectal tube.

To facilitate for the

9. Separate the buttocks and locate the rectum.
insertion of the tube.
To foster cooperation
10. Instruct the patient that you will insert the nozzle
and prevent patient
and to take a slow deep breath.
discomfort.
11. Insert the tube smoothly and slowly administer the
To alleviate discomfort
solution into the rectum directing towards the
of inserting the tube.
umbilicus.
To prevent any liquids
12. Roll up the plastic container as the fluid is instilled.
from splashing.
To maintain cleanliness
13. Do after care.
and sterility of the area.
To avoid transmission
14. Wash hands.
of microorganisms.
To provide a record of
results for legal basis
15. Document the procedure.
and for the on-going
data collection.
ATTITUDE
For an improved
16. Accepts constructive suggestions and criticisms
performance.
To remain ethical in our
17. Assume responsibility of his or her actions.
actions.

Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________

5x ____________ = __________

Total divided by no. of items = __________

Comments:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________________

_______________________________________ _______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over Printed name
 PERINEAL CARE

Name: Quezilyn Mae K. Quezon Grade: __________________________

Year and Section: 2-A Date: ___________________________

Legend:
1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
To develop trust, foster
1. Introduce yourself and explain the procedure to the
cooperation, and reduce
patient.
anxiety.
To provide comfort and
2. Provide privacy.
preserve patient’s dignity.
3. Bring equipment and supplies to the bedside. Bring the
tray with lining containing the following:
a. pitcher with warm irrigating fluid (300-500 ml) at
40.5°C-43.3°C)
b. sterile balls
c. bath blanket
d. betadine cleanser Ensures availability of the
e. absorbent pad/cotton draw sheet materials and promotes easy
f. clean gloves access to equipment to be used.
g. waste receptacle
h. screen for ward use
i. rubber sheet
j. pail
k. kidney
l. bed pan
To prevent contaminating the
4. Protect the bed with an absorbent pad.
bed.
To allow easy access to the
5. Place the client on the bed pan in a dorsal recumbent
perineal region and to promote
position.
patient comfort.
6. Drape the client with a bath blanket to permit exposing To provide patient privacy and
just the perineal area. reduce anxiety.
To prevent the spread of
7. Wash your hands.
microorganisms.
To reduce the possibility of
8. Don on clean gloves.
potential contamination and to
 prevent contact from any
secretions.
9. Wash upper and inner thighs with lukewarm water. To promote muscle relaxation.
To improve cleaning and
10. Separate labia with non-dominant hand. Pour warm
prevent rectal microbes from
irrigating solution gently over the vulva.
going to the vaginal canal.
11. Cleanse the perineal area with cherry balls soaked in
betadine cleanser held by a dressing forceps. Cleansing
should be done from the vagina outward. Follow the figure
below which shows the typical pattern for cleansing the
perineal area, using 8 strokes.

The betadine cleanser’s

antiseptic property destroys
pathogens.

To eradicate microorganisms
12. Rinse the scrubbed areas well. Remove the client from
and to provide assistance to the
the bed pan.
client.
13. Dry the perineal area using dry cherry balls in the same To inhibit the growth of
fashion as in cleaning (step 11). microorganisms.
14. Help client to a side lying position and adjust the bath
To promote patient comfort.
blanket.
To maximize cleansing while
15. Wash, rinse, and dry the anal area. Wipe from front to
minimizing the transmission of
back.
microorganisms.
16. Discard the soiled water, clean the equipment, dispose To prevent the spread of
soiled gloves and remove absorbent pad. microorganisms.
17. Help client to a comfortable position and remove the
To promote patient comfort.
bath blanket.
To reduce the transmission of
18. Wash hands.
microorganism.
DOCUMENTATION
1. Record any significant problem such as; redness, To build a bases for further
excoriation, swelling. Episiotomy should be noted for nursing assessment and care
edema, inflammation, separation or presence of and to provide for the on-going
hematoma. data collection.
To note for any deviations from
2. Note the amount, color, and odor of any discharge.
the previous outcome.
To account for the patient’s
3. Document the client’s tolerance of the procedure. tolerance to the treatment
rendered.

Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________

5x ____________ = __________

Total divided by no. of items = __________

Comments:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________________

_______________________________________ _______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over Printed name
 PERILITE EXPOSURE

Name: Quezilyn Mae K. Quezon Grade: __________________________

Year and Section: 2-A Date: ___________________________

DEFINITION: Application of dry heat to perineal area in order to provide comfort and increase blood
circulation and hasten wound healing.

PURPOSE: 1. To dilate blood vessels of surrounding tissues thus promote circulation

2. To keep area dry thus promote healing.
3. To promote diaphoresis.
Legend:
MATERIALS: 1. Perilite lamp/ gooseneck lamp/heat lamp 1- Excellent
2. Blanket 2- Very Satisfactory
3. Perineal flushing set 3- Satisfactory
4. Incontinent pad 4- Needs Improvement
5. Clean hand towel 5- Poor

PROCEDURE RATIONALE 1 2 3 4 5

To verify the treatment to be

1. Review physician's order. rendered and to minimize
errors.
2. Gather equipment and check it for safety To ensure the availability and
Factors. the quality of the materials to
be used.
To promote an easy access to
3. Bring equipment to patient’s room. the materials for a smooth
procedure.
4. Explain procedure to the patient. To foster cooperation and
minimize anxiety.
To avoid procedure
5. After getting the approval, let patient void first. interruption since heat
stimulates urine, especially
when the bladder is full.
6. Wash hands. To reduce the transmission of
microorganisms.
7. Provide bed screen and arrange beddings to
expose only the body part to which treatment is To maintain patient’s privacy
to be given. and minimize anxiety.

To facilitate visualization of the

8. Assist patient into a dorsal recumbent position. area and to gain an optimum
result of the procedure.
9. Check and assess the condition of the To facilitate a proper
perineum. Remove any ointment or dressings if observation and to reduce
 present. contamination.

To assist client for urination

10. Provide bedpan and render perineal flushing. and defecation, if deemed
necessary and to prevent
infection, odors, and irritation.
11. Dry perineum thoroughly with clean hand To inhibit the growth of
towel/dry cotton balls and remove bedpan. microorganisms.
12. Place incontinent pad under patient’s To prevent contaminating the
perineum. bed.
13. Place heat lamp under the blanket about 18 - 24 Observing the correct distance
inches from the perineum and connect prevents injury or burning
electricity. sensation to the perineum
since it is highly sensitive.
14. Leave the lamp according to the prescribed To ensure that the client can
duration and check patient twice during the manage the heat and also
treatment procedure is administered for any promote client’s safety and
discomfort, burning reaction or untoward comfort with the optimum
reaction. result.
PROCEDURE RATIONALE 1 2 3 4 5
15. Instruct patient not to change position nor To foster patient cooperation
touch lamp during the entire procedure. and to provide an optimum
result.
16. Disconnect electricity and remove lamp after To prevent skin burn and to
15 minutes or as ordered by the physician. lessen the chance of making
errors.
To note if there’s an unusual
17. Assess the surrounding area that receives the reaction and other anomalies
treatment and reposition patient comfortably. such as skin burn and to ensure
patient comfort.
18. Do after care.

 Disinfect the lamp by wiping it with alcohol.

 Return equipment to store room. To keep the area clean and
sanitized for the prevention
 Dispose soiled dressings to infectious waste
from contamination.
Bin

19. Do documentation: To provide for the on-going

data collection and to note for
 Time treatment done. further nursing assessment and
 Part exposed. care.
  Duration of treatment.
 Condition of part or of patient.
 Amount and character of drainage if any.
 Signature of nurse.
ATTITUDE OF THE STUDENT:

20. Accept constructive suggestions and criticisms. For an improved performance.

21. Assumes accountability. To remain ethical in our
actions.

Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________

5x ____________ = __________

Total divided by no. of items = __________

Comments:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________________

_______________________________________ _______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over Printed name
 HOT SITZ BATH

Name: Quezilyn Mae K. Quezon Grade: __________________________

Year and Section: 2-A Date: ___________________________

DEFINITION: A prolonged immersion of buttocks and lower trunk in water with an initial temperature of
98◦F to 110◦F, gradually increased to temperature of 110◦F-120◦F (43.5◦C-48.7◦C) or as hot as the
patient can tolerate.

PURPOSE: 1. To relieve muscle spasm

2. To soften exudates
3. To hasten the suppuration process
4. To hasten healing
5. To reduce congestion and provide comfort in the perineal area

MATERIALS:

• Sitz tub half filled with water 110F-120F

• Empty pitcher (may be small)
• Pitcher with hot water
• Bath thermometer
• Fresh camisa/patient’s clean clothes
• Bath towael
• 2-3 Blankets
• 1 Bath robe and slippers (from bedside)
• newspaper

Legend:

1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor

PROCEDURE RATIONALE 1 2 3 4 5

To verify the treatment to be

1. Check physician’s order for sitz bath
rendered and to minimize
patient.
errors.
To ensure the availability of the
2. Prepare the materials needed and bring materials to be used and for an
materials at bedside. easy access for a smooth
procedure.
 To develop trust, foster
3. Introduce self and check patient’s identity cooperation, and reduce
anxiety.
4. Explain procedure to patient. To foster patient cooperation.
To avoid procedure interruption
since heat stimulates urine,
5. Make patient void before procedure.
especially when the bladder is
full.
6. Place bathmat on floor beside tub. You
To provide an anti-slip surface
may use newspaper if bathmat is not
to step on to avoid accidents.
available.
To prepare the water and adjust
7. Fill in tub one-fourth full of water –
temperature according to the
temperature 98◦F to 100◦F.
required level.
To facilitate bath, provide
8. Remove patient’s bath robe and place on
patient comfort, and to prevent
back of chair.
the robe from getting wet.
9. Wrap patient with bath blanket and pin at To protect the patient from
back. feeling chilly and from exposure.
To facilitate bath, promotes
easy demonstration while sitting
10. Remove patient’s gown.
in the tub, and to prevent the
gown from being wet.
11. Ask and help patient to sit squarely on To promote patient safety and
tub. comfort.
12. Prevent blanket (about patient) from
To provide privacy, promote
getting wet by arranging it over shoulders
patient comfort and safety. and
and tucking it at feet and sides of tub. Adjust
to reduce the spread of
hot water bag about patient’s feet. Bring
microbes in the area.
second blanket up to knees.
13. Increase temperature of water gradually
To assess patient’s maximum
to 110◦F-120◦F or as hot as patient can
tolerance with the temperature
tolerate by holding your hand between
to promote their comfort and
patient’s body and stream of water being
ensure their safety.
poured.
14. Let patient stay in tub for the prescribed
To ensure optimum result.
period of time.
To facilitate cleansing and to
15. Assist patient out of tub then dry him
minimize the spread of
thoroughly with bath towel.
microorganisms.
16. Assist patient while he puts on his gown To render support and patient
and bath robe. comfort.
17. Take patient back to bed and keep him To ensure patient safety and
warm. promote comfort.
 To promote patient comfort and
18. Make patient comfortable and give him
safety and to provide an easy
something to drink. Place buzzer or intercom
access to the buzzer in case the
within patient’s reach.
patient needs anything.
19. Do after care:
 Bring all materials except sitz tub to
utility room. Cleanse thoroughly and To maintain cleanliness and
return to their proper places. Return sterility of the area to prevent
chair to its place. contamination.
 Wash tub with soap and running
water for non-communicable cases.
20. Do documentation:
To provide for the on-going data
 Type of treatment
collection and to note for
 Length of time of application
further nursing assessment and
 Type of heat application
care.
 Comfort of patient
 Signature of nurse.
ATTITUDE OF THE STUDENT:
24. Accept constructive suggestions and
For an improved performance.
criticisms.
25. Assumes accountability. To remain ethical in our actions.

Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________

5x ____________ = __________

Total divided by no. of items = __________

Comments:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________________
_______________________________________ _______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over Printed name
 IMMEDIATE NEWBORN CARE

Name: Quezilyn Mae K. Quezon Grade: __________________________

Year and Section: 2-A Date: ___________________________

Legend:
1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
PLANNING
1. Prepare all equipment.
To save time and effort for a
smooth and efficient
procedure.
1.1 Cebu Puericulture Center and
Maternity Inc. (CPCMHI) To promote easy access to
Cord clamp equipment for a smooth and
Sterile OC (3-4 pcs) efficient procedure.
Sterile cotton balls (2-3 pcs)
Mayo Scissors
Bulb Syringe
Tape measure
Vitamin K ampule
Terramycin eye ointment tube
ICC Syringe
Baby diaper
ID band – Blue (male), Pink (female)
Receiving blanket
Digital Thermometer
Baby’s cap
Weighing scale
Goose neck lamp

1.2 Vicente Sotto Memorial Medical

Center (VSMMC)
Cord Clamp To promote easy access to
Sterile OS (3-4 pcs) equipment for a smooth and
Sterile Cotton balls (2-3 pcs) efficient procedure.
Cord cuter
Tape measure
Vitamin K ampule
 Terramycin eye ointment tube
ICC Syringe
Baby diaper
ID band – Blue (male), Pink (female)
Receiving blanket
Digital Thermometer
Baby’s clothes
Baby’s blanket
Weighing scale and goose neck lamp
IMPLEMENTATION
To prevent newborn from
acquiring hypothermia by
utilizing the goose neck
2. Prepare the room temperature of the delivery
lamp and to render thermo
room. Room temperature should be 25-28 C.
regulated environment for
both the mother and the
newborn.
To reduce the chance of
3. Notify appropriate staff.
committing errors.
To promote easy access and
4. Arrange needed supplies in linear fashion. a smooth and efficient
procedure.
5. Check resuscitation equipment. To promote efficiency.
To avoid unintended
6. Wear face mask and bonnet properly.
contamination.
To reduce the transmission
7. Wash hands with clean water and soap.
of microorganisms.
To avoid the possibility and
8. Don’t double glove just before delivery. the risk of having torn
gloves.

To keep the baby warm
9. Within first 30 second;
and reduce
9.1 Dry the newborn thoroughly for at
evaporation.
least 30 seconds. 
To locate a possible
9.2 Do a quick check of breathing while
airway obstruction.
drying. (do not suction unless the 
To dispose bodily fluid.
mouth/nose are blocked with secretions
Keeping the vernix
or other materials)
caseosa protects the
9.3 Wipe the eyes, face, head, front and
baby from skin
back, arms and legs. (DO NOT wipe off the
infection.
vernix caseosa) 
To prevent the infant
9.4 Remove the wet cloth.
from shivering.
10. After 30 seconds, if newborn is breathing and 
To allow bonding time
crying, between the mother
 10.1 Position the newborn prone on the and the newborn while
mother’s abdomen or chest. ensuring the baby’s
10.2 Cover the newborn’s back with a dry comfort.
blanket. 
To prevent the baby
10.3 Cover the newborn’s head with a from acquiring
bonnet/cap. hypothermia.

To keep the baby warm
to prevent
hypothermia.
11. After 1-3 minutes, properly time cord 
To prevent the spread
clamping. of microorganisms.
11.1 Remove the first set of gloves. 
To provide about 2cm
11.2 After the umbilical pulsations have of space to allow the
stopped, lamp the cord using a sterile umbilicus to bleed.
plastic clamp at 2cm from the base. 
To avoid back flow of
11.3 Do not milk the cord towards the blood to the newborn.
baby. 
To stop blood supply at
11.4 Clamp again at 5 cm using Kelly the midpoint of the 2
forceps from the base. clamps.
11.5 Cut the cord close to the plastic 
To keep blood from
clamp. gushing.
12. Place the identification band on ankle (not
To provide for the proper
wrist) of corresponding gender.
identification of the baby
12.1 CPCMHI – left ankle
and prevention of injuries.
12.2 VSMMC – both ankles

To encourage the baby
to locate the mother’s
areola.
13. Leave the newborn in skin-to-skin contact. 
To allow the mother to
determine when to
13.1 Observe for feeding cues, including feed the baby.
tonguing, licking, rooting.
13.2 Point these out to the mother and 
To urge the infant to
encourage her to nudge. seek out and suck on
the areola of the
mother.

14. After 90 minutes, remove the newborn from To allow the baby to adjust
mother’s abdomen. towards a new environment.
To conduct a thorough
15. Transfer the newborn to the work table
physical examination.
To gather an accurate data
16. Weigh the newborn to the work table.
documentation.
17. Perform physical assessment of the newborn To identify and avoid
and do APGAR scoring. suspected diseases and to
 look for any anomalies.

To determine whether
the measurement is
normal or
18. Perform Anthropometric measurement hydrocephalic.
18.1 Head circumference 
To identify irregular
18.2 Chest circumference conditions.
18.3 Mid arm
18.4 Body length

To examine any defects.

To determine regular
measurements.
To assess the temperature
19. Take the rectal temperature of the baby as well as the
condition of the anus.
20. Inject Vitamin K
To facilitate the production
20.1 CPCMHI – left thigh
of prothrombin in
20.2 VSMMC – right thigh
accordance with the
institutional protocols.
To prevent the baby from
21. Apply eye prophylaxis.
acquiring eye infection.
To prevent heat loss and
22. Put on baby’s clothes.
hypothermia.
To keep the baby warm and
23. Wrap the baby with baby’s blanket safe from hypothermia and
cold.
To gather baseline data and
24. Obtain heart rate and respiratory rate.
to test for anomalies.
To foster bonding between
25. Show the baby to the mothers. Latch on the the baby and the mother so
baby to the mother’s breast. as to relieve the mother’s
anxiety.
To provide for the on-going
26. Documentation immediately after cord care data collection and to note
and latch on. for further nursing
assessment and care.
To maintain cleanliness and
27. Do after care. sterility of the area to
prevent contamination.
ATTITUDE
For an improved
28. Accept constructive suggestions and criticism.
performance.
To remain ethical in our
29. Assume responsibility of his/her action.
actions.
Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________

5x ____________ = __________

Total divided by no. of items = __________

Comments:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________________

_______________________________________ _______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over Printed name