Nursing Skill Procedures 1

Nursing Skills Procedure Manual

Gulf College of Nursing DGK

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Contributor:
Sonia Khalid (Instructor)

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Principal: Muhammad Hussain

 Nursing Skill Procedures 2

Table of Contents
Sr. No Contents Page No.

1 Vital Signs 03

2 1.Body Temperature 06
a. Taking oral Temperature 04
b. Taking axillary Temperature 07
c. Taking rectal Temperature 9
3 2.Pulse 12
a.Taking radial pulse
4 3.Respiration 15

5 4.Blood pressure 19

6 Bed making 22

7 Performing Oral Care 25

8 Application of Restrains 28

9 Measuring of Height and Weight 36

10 Bathing of the Patient on bed 31

11 Admission of pt in hospital 41

12 Discharge of pt from hospital 45

 Nursing Skill Procedures 3

I. Basic Nursing Care/ Skill

Taking Vital Signs
Temperature, Pulse, Respiration, Blood pressure
Definition:
Taking vital signs are defined as the procedure that takes the sign of basic physiology that
includes temperature, pulse, respiration and blood pressure. If any abnormality occurs in the
body, vital signs change immediately.

Purpose:
1) To assess the client’s condition
2) To determine the baseline values for future comparisons
3) To detect changes and abnormalities in the condition of the client

Equipment’s required:

1 Oral/ axilla / rectal thermometer 1

2 Stethoscope 1
3 Sphygmomanometer with appropriate cuff size 1
4 Watch with a second hand 1
5 Spirit swab or cotton 1
6 Sponge towel 1
7 Paper bag 1
8 Record form
9 Ball- point pen: 3
blue 1
black 1
red 1
1 Steel tray: to set all materials 1
0
 Nursing Skill Procedures 4

a. Taking Oral Temperature by Glass Thermometer

Definition:
Measuring/monitoring patient’s body temperature using clinical thermometer

Purpose:
1) To determine body temperature
2) To assist in diagnosis
3) To evaluate patient’s recovery from illness
4) To determine if immediate measures should be implemented to reduce dangerous
elevated body temperature or converse body heat when body temperature is
dangerous low
5) To evaluate patient’s response once heat conserving or heal reducing measures have
been implemented.

No. Procedure Rationale

1 Place the patient in a comfortable To ensure comfort and accuracy of
position temperature reading
2 Wash hands To reduces transmission of micro
organisms
3 Hold the stem end of the glass To reduce contamination of thermometer
thermometer with finger tips bulb
4 Rinse the thermometer in cold water if it To remove solution irritating to oral
is in a disinfectant solution mucosa
5 Take wet swabs and wipe thermometer To reduce contamination of bulb end
toward fingers in rotating fashion.
Dispose of the swab
6 Read mercury level while holding Thermometer reading must be below
thermometer at eye level and gently body temperature before use
rotating it
7 If mercury is above the desired level,
securely grasp tip and stand away from
solid objects. Sharply flick wrist
downward as through cracking a whip.
Continue shaking until reading is below
35.5°C or 96°F
8 Ask the patient to open mouth, and gently Heat from blood vessels in sublingual
place thermometer under tongue in pocket produces temperature reading
posterior or sublingual pocket, lateral to
the centre of the lower jaw
9 Ask the patient to hold thermometer To ensure safety. Breaking of
under tongue with lips closed. Caution thermometer causes mercury poisoning
against biting it.
10 Leave the thermometer inside for To allow time for expansion of mercury
2-3 minutes
 Nursing Skill Procedures 5

11 Carefully remove the thermometer and To ensure accuracy

read at eye level.
12 Inform the patient about this temperature To promote patient participation
reading
13 Wipe the thermometer with wet cotton From the least area of contamination to
swab. Wipe in rotating fashion from the most contaminated area
fingers, toward bulb
14 Wash the thermometer in cold water, dry To prevent infection.
and put it , after disinfection , in storage To prevent breakage
container
15 Wash hands To reduce transmission of infection
16 Remove and replace the other articles, For easy availability for next use
after use, in their proper places
17 Record the temperature in the TPR chart To detect disease condition earlier
and inform the abnormalities to ward
sister
 Nursing Skill Procedures 6

Procedure Checklist:
a. Taking Oral Temperature by Glass Thermometer
Check (􀀹) Yes or No
No Procedure Yes No Comments
1 Place the patient in a comfortable position
2 Wash hands
3 Hold the stem end of the glass
thermometer with finger tips
4 Rinse the thermometer in cold water if it
is in a disinfectant solution
5 Take wet swabs and wipe thermometer
toward fingers in rotating fashion.
Dispose of the swab
6 Read mercury level while holding
thermometer at eye level and gently
rotating it
7 If mercury is above the desired level,
securely grasp tip and stand away from
solid objects. Sharply flick wrist
downward as through cracking a whip.
Continue shaking until reading is below
35.5°C or 96°F
8 Ask the patient to open mouth, and gently
place thermometer under tongue in
posterior or sublingual pocket, lateral to
the Centre of the lower jaw
9 Ask the patient to hold thermometer under
tongue with lips closed. Caution against
biting it.
10 Leave the thermometer inside for
2-3 minutes
11 Carefully remove the thermometer and
read at eye level.
12 Inform the patient about this temperature
reading
13 Wipe the thermometer with wet cotton
swab. Wipe in rotating fashion from
fingers, toward bulb
14 Wash the thermometer in cold water, dry
and put it , after disinfection , in storage
container
15 Wash hands
16 Remove and replace the other articles,
after use, in their proper places
17 Record the temperature in the TPR chart
and inform the abnormalities to ward
sister

Recommendation: Pass ____________ needs more practice __________________________

 Nursing Skill Procedures 7

Student: ________________________ Date: _____________________________________

Instructor:_______________________ Date: _____________________________________
b. Taking Axillary Temperature by Glass Thermometer

Definition:
Measuring/monitoring patient’s body temperature using clinical thermometer

Purpose:
1) To determine body temperature
2) To assist in diagnosis
3) To evaluate patient’s recovery from illness
4) To determine if immediate measures should be implemented to reduce dangerously elevated
body temperature or converse body heat when body temperature is dangerous low
5) To evaluate patient’s response once heat conserving or heat reducing measures have been
implemented

No. Procedure Rationale

1 Bring the articles to the bed side. These For easy availability
are the same as the ones used for oral
temperature
2 Screen the bed or close the door To provide privacy.
Embarrassment is minimized
3 Make the patient lying in supine To provide easy access to axilla
position or sitting
4 Move clothing away from shoulder or For easy exposure of axilla
arm
5 Repeat steps 2 to 6 used in taking oral
temperature
6 Insert thermometer into the center of Maintains proper position
axilla, lower arm over thermometer and
place it across patient’s chest
7 Hold the thermometer for 5 minutes in To ensure accuracy of reading
axilla
8 Remove the thermometer and swab it To avoid contact with microorganisms
with a wet swab, from fingers towards
bulb. Dispose of the swab in paper bag
9 Read the thermometer at eye level To ensure accuracy
10 Inform the patient about this To give him awareness about his condition
temperature reading
11 Wash the thermometer with soap or To assure cleanliness
soapy swab and rinse it in cold water
12 Disinfect , dry and keep it in storage To prevent breakage
container
13 Assist the patient in putting on his To ensure comfort
clothes and put him in a comfortable
position
14 Record it in the chart and report, if any For early detection of disease condition and
abnormality is noticed, to ward sister for prompt treatment
15 Wash hands To prevent transmission of micro organisms
 Nursing Skill Procedures 8

Procedure Checklist:
b. Taking Axillary Temperature by Glass Thermometer
Check (􀀹) Yes or No

No Steps of procedure Yes No Comments

1 Bring the articles to the bed side. These
are the same as the ones used for oral
temperature
2 Screen the bed or close the door
3 Make the patient lying in supine
position or sitting
4 Move clothing away from shoulder or
arm
5 Repeat steps 2 to 6 used in taking oral
temperature
6 Insert thermometer into the center of
axilla, lower arm over thermometer and
place it across patient’s chest
7 Hold the thermometer for 5 minutes in
axilla
8 Remove the thermometer and swab it
with a wet swab, from fingers towards
bulb. Dispose of the swab in paper bag
9 Read the thermometer at eye level
10 Inform the patient about this
temperature reading
11 Wash the thermometer with soap or
soapy swab and rinse it in cold water
12 Disinfect , dry and keep it in storage
container
13 Assist the patient in putting on his
clothes and put him in a comfortable
position
14 Record it in the chart and report, if any
abnormality is noticed, to ward sister
15 Wash hands

Recommendation: Pass ____________ Needs more practice __________________________

Student: ________________________ Date: _____________________________________

Instructor:_______________________ Date: _____________________________________

 Nursing Skill Procedures 9

c. Taking Rectal Temperature by Glass Thermometer

Definition:
Measuring/monitoring patient’s body temperature using clinical thermometer

Purpose:
1) To determine body temperature
2) To assist in diagnosis
3) To evaluate patient’s recovery from illness
4) To determine if immediate measures should be implemented to reduce dangerously elevated
body temperature or converse body heat when body temperature is dangerous low
5) To evaluate patient’s response once heat conserving or heal reducing measures have been
implemented

No. Procedure Rationale

1 Screen the patient To provide privacy
2 Upper body and lower extremities To prevent unnecessary exposure
should be covered with a sheet
3 Put the patient in left lateral-position. To expose area for placing rectal
It exposes only anal area thermometer
4 Repeat steps 2-6 of oral temperature To have minimum exposure
measurement
5 Separate buttocks to expose anus and To ensure proper exposure of anus
clean it if needed
6 Ask the patient to breathe slowly and To relax anal sphincter
relax
7 Lubricate the rectal thermometer For easy insertion and to prevent trauma to
rectal mucosa
8 Insert thermometer bulb 0.5 inch for Ensures adequate exposure against blood
infant and 1.5 inch for adults into vessels in rectal wall
rectum
 Nursing Skill Procedures 10

9 Keep the thermometer inside for two To ensure accuracy of reading

minutes
10 Carefully remove thermometer and To ensure cleanliness
wipe it with wet cotton swabs to
remove faecal matter and Vaseline
11 Put the swabs into paper bag To prevent transmission of micro organisms
12 Read temperature, holding the To ensure accuracy in reading
thermometer at the eye level
13 Record the temperature in the chart For easy management of patient
and report to ward sister if any
abnormalities are detected
14 Take the articles to the utility room, For easy availability at any time.
clean and keep them in their respective To prevent breakage
storage containers and places
15 Make the patient comfortable and let To ensure comfort
him know about this temperature To gain patient’s cooperation
 Nursing Skill Procedures 11

Procedure Checklist
c. Taking Rectal Temperature by Glass Thermometer
Check (􀀹) Yes or No

No Steps of Procedure Yes No Comments

1 Screen the patient
2 Upper body and lower extremities
should be covered with a sheet
3 Put the patient in left lateral-position. It
exposes only anal area
4 Repeat steps 2-6 of oral temperature
measurement
5 Separate buttocks to expose anus and
clean it if needed
6 Ask the patient to breathe slowly and
relax
7 Lubricate the rectal thermometer
8 Insert thermometer bulb 0.5 inch for
infant and 1.5 inch for adults into
rectum
9 Keep the thermometer inside for two
minutes
10 Carefully remove thermometer and
wipe it with wet cotton swabs to remove
faecal matter and Vaseline
11 Put the swabs into paper bag
12 Read temperature, holding the
thermometer at the eye level
13 Record the temperature in the chart and
report to ward sister if any
abnormalities are detected
14 Take the articles to the utility room,
clean and keep them in their respective
storage containers and places
15 Make the patient comfortable and let
him know about this temperature

Recommendation: Pass ____________ Needs more practice __________________________

Student: ________________________ Date: _____________________________________

Instructor:_______________________ Date: ____________________________________

 Nursing Skill Procedures 12

d. Measuring a Radial Pulse

Definition:
Checking presence, rate, rhythm and volume of throbbing of artery

Purpose:
1) To determine number of heart beats occurring per minute (rate)
2) To gather information about heart rhythm and pattern of beats
3) To evaluate strength of pulse
4) To assess heart's ability to deliver blood to distant areas of the blood viz. fingers and lower
extremities
5) To assess response of heart to cardiac medications, activity, blood volume and gas exchange
6) To assess vascular status of limbs
General instructions for taking pulse:

1) Pulse should not be taken immediately after exercise, in emotional stress or during or
after a painful treatment.
2) Count pulse for one full minute, especially when there is irregularity.
3) Observe rate, rhythm, volume and tension of pulse
4) Record pulse immediately
5) Choose suitable site for taking pulse
 Nursing Skill Procedures 13

No Procedure Rationale
1 Before taking pulse, consider factors To have accurate assessment of pulse
that normally influence pulse
character, e.g., age, exercise
2 Explain the procedure to the patient To reduce anxiety and activity
and courage him to relax.
3 Prepare the needed articles pen, pencil, To avoid delay
wrist watch with seconds hand, chart
4 Wash hands To prevent transmission of micro organisms
5 Place the patient in supine position. To have proper exposure of artery for
Place forearm across the chest, with palpation
wrist extended and palm down
6 Place tips of first two fingers of your Finger tips are more sensitive for palpation.
hand over groove, along radial or Thumb has pulsation that may interfere with
thumb side of patient’s inner wrist accuracy
7 Lightly compress against radius
8 After pulse is felt regularly, look at To count only after timing
watch’s seconds hand and begin to
count rate. Start counting with zero,
one and so on.
9 Count pulse for full one minute, if To ensure accuracy 30 seconds check is most
irregular, otherwise, 30 seconds, and accurate
multiply total by 2.
10 Determine strength of pulse, note Strength reflects volume
thrust of vessel against finger tips
11 Palpate with two fingers, along course To have an idea about peripheral vascular
of artery, to ward wrist, to determine system
elasticity of arterial wall
12 Put the patient in a comfortable To ensure a sense of well-being
position
13 Write down the result immediately To avoid errors
14 Remove the articles and keep them For easy availability next time
their respective places
 Nursing Skill Procedures 14

Procedure Checklist
d. Measuring a Radial Pulse
Check (􀀹) Yes or No

No Step of procedure Yes No Comments

1 Before taking pulse, consider factors
that normally influence pulse
character, e.g., age, exercise
2 Explain the procedure to the patient
and courage him to relax.
3 Prepare the needed articles pen, pencil,
wrist watch with seconds hand, chart
4 Wash hands
5 Place the patient in supine position.
Place forearm across the chest, with
wrist extended and palm down
6 Place tips of first two fingers of your
hand over groove, along radial or
thumb side of patient’s inner wrist
7 Lightly compress against radius
8 After pulse is felt regularly, look at
watch’s seconds hand and begin to
count rate. Start counting with zero,
one and so on.
9 Count pulse for full one minute, if
irregular, otherwise, 30 seconds, and
multiply total by 2.
10 Determine strength of pulse, note
thrust of vessel against finger tips
11 Palpate with two fingers, along course
of artery, to ward wrist, to determine
elasticity of arterial wall
12 Put the patient in a comfortable
position
13 Write down the result immediately
14 Remove the articles and keep them
their respective places

Recommendation: Pass ____________ Needs more practice __________________________

Student: ________________________ Date: _____________________________________

Instructor:_______________________ Date: _____________________________________

 Nursing Skill Procedures 15

e. Counting Respiration

Definition:
Monitoring the involuntary process of inspiration and expiration in a patient

Purposes:
1) To determine number of respiration occurring per minute
2) To gather information about rhythm and depth
3) To assess response of patient to any related therapy/medication

No. Procedure Rationale

1 If the patient has been active, wait 5- Activity increases respiratory rate and depth
10 mints.
2 Make the patient comfortable in the An erect, sitting position promotes easy
bed in fowlers or sitting position respiration
3 Prepare the articles; watch having
seconds hand, pen and chart.
4 Provide privacy and wash hands To prevent transmission of micro organisms

5 Expose the chest of patient To ensure proper exposure to observe the

movements of the chest and abdominal wall
6 Place the patient’s arm across lower Hand rises and falls during respiration
chest and your hand over his upper
abdomen
7 Observe completely, one inspiration To ensure rate
and expiration
8 Then, look at the watch and count the To ensure accuracy
respiration for one full minute.
9 Note the depth of respiration by To assess disease condition
observing chest wall movement while
counting rate.
10 Note rhythm of inspiration and Alteration shows disease condition
expiration
11 Redress the patient and cover him with To provide comfort
bed linen
12 Wash hands Reduces transmission of micro organisms
13 Inform the patient against his To ensure understanding of his health- status
respiration
14 Record it in the chart and report to the To ensure accuracy and to give proper
ward sister if any abnormalities are treatment
detected
 Nursing Skill Procedures 16

Procedure Checklist
e. Counting Respiration
Check (􀀹) Yes or No

No Procedure Yes No Comments

1 If the patient has been active, wait 5-10
mints.
2 Make the patient comfortable in the
bed in fowlers or sitting position
3 Prepare the articles; watch having
seconds hand, pen and chart.
4 Provide privacy and wash hands
5 Expose the chest of patient
6 Place the patient’s arm across lower
chest and your hand over his upper
abdomen
7 Observe completely, one inspiration
and expiration
8 Then, look at the watch and count the
respiration for one full minute.
9 Note the depth of respiration by
observing chest wall movement while
counting rate.
10 Note rhythm of inspiration and
expiration
11 Redress the patient and cover him with
bed linen
12 Wash hands
13 Inform the patient against his
respiration
14 Record it in the chart and report to the
ward sister if any abnormalities are
detected

Recommendation: Pass ____________ Needs more practice __________________________

Student: ________________________ Date: _____________________________________

Instructor:_______________________ Date: _____________________________________

 Nursing Skill Procedures 17

f. Measuring Blood Pressure

Definition:
Monitoring blood pressure using palpation and/or sphygmomanometer

Purpose:
1) To obtain baseline data for diagnosis and treatment
2) To compare with subsequent changes that may occur during care of patient
3) To assist in evaluating status of patient’s blood volume, cardiac output and vascular system
4) To evaluate patient’s response to changes in physical condition as a result of treatment with
fluids or medications
 Nursing Skill Procedures 18

No. Procedure Rationale

1 Explain the procedure to the patient To ensure comfort
and put him in a comfortable position, To ensure accurate reading
either lying down with the arm resting To gain cooperation
on the bed or sitting with the arm
supported on the table at heart-level.
2 Determine the best site for applying Inappropriate selection will not give accurate
the cuff. Don’t use bandaged arm or reading and will cause pain and discomfort to
arm with I.V. infusion or an injured patient
arm
3 Bladder and cuff bladder should To ensure proper reading of blood pressure
completely encircle arm without
overlapping
4 Place the patient in a sitting or lying To ensure comfort
position
5 Wash hands To reduce transmission of micro-organisms
6 Place the patient’s base upper arm at To ensure proper reading
heart level with palm turned up.
7 Expose the upper arm by removing To ensure proper application of cuff
clothing
8 Palpate brachial artery, place the To ensure application of pressure
central bladder above the artery

9 Wrap the cuff evenly around upper Loose filling cuff shows false readings
arm; see step 3.
 Nursing Skill Procedures 19

10 Place the manometer vertically at eye To ensure accurate reading

level
11 Close the valve, deflate the cuff and To identify approximate systolic pressure
palpate the radial artery. Pump up air
in the cuff until the
sphygmomanometer at which the
radial pulsation
12 Place the stethoscope earpieces in ears To ensure proper hearing
and place its bell over brachial artery
in cubital fossa
13 Close valve of pressure bulb clockwise To prevent air leak during inflation
until tight
14 Slowly release valve and allow First sound indicates systolic pressure
mercury to fall. Note the point on
manometer when first clear sound is
heard
15 Continue to deflate the cuff gradually It indicates diastolic pressure
when the sound becomes the muffled
and disappears
16 Deflate the cuff rapidly and Continuous inflation causes arterial
completely occlusion

17 Place the patient in a comfortable To ensure comfort

position
18 Tell him about his blood pressure To give him information about his condition
19 Wash hands To reduce transmission of micro-organisms
20 Record blood pressure in nurse’s notes To ensure accuracy and proper treatment
and, if any abnormalities are there,
report them to ward sister.
21 Keep the stethoscope To ensure safety of the instrument
Sphygmomanometer at proper place in
the box
 Nursing Skill Procedures 20

Procedure Checklist
f. Measuring Blood Pressure
Check (􀀹) Yes or No

No Steps of Procedure Yes No Comments

1 Explain the procedure to the patient
and put him in a comfortable position,
either lying down with the arm resting
on the bed or sitting with the arm
supported on the table at heart-level.
2 Determine the best site for applying
the cuff. Don’t use bandaged arm or
arm with I.V. infusion or an injured
arm
3 Bladder and cuff bladder should
completely encircle arm without
overlapping
4 Place the patient in a sitting or lying
position
5 Wash hands
6 Place the patient’s base upper arm at
heart level with palm turned up.
7 Expose the upper arm by removing
clothing
8 Palpate brachial artery, place the
central bladder above the artery
9 Wrap the cuff evenly around upper
arm; see step 3
10 Place the manometer vertically at eye
level
11 Close the valve, deflate the cuff and
palpate the radial artery. Pump up air
in the cuff until the
sphygmomanometer at which the
radial pulsation
12 Place the stethoscope earpieces in ears
and place its bell over brachial artery
in cubital fossa
13 Close valve of pressure bulb
clockwise until tight
14 Slowly release valve and allow
mercury to fall. Note the point on
manometer when first clear sound is
heard
15 Continue to deflate the cuff gradually
when the sound becomes the muffled
and disappears
16 Deflate the cuff rapidly and
 Nursing Skill Procedures 21

completely
17 Place the patient in a comfortable
position
Tell him about his blood pressure
19 Wash hands
20 Record blood pressure in nurse’s notes
and, if any abnormalities are there,
report them to ward sister.
21 Keep the stethoscope
Sphygmomanometer at proper place in
the box

Recommendation: Pass ____________ Needs more practice __________________________

Student: ________________________ Date: _____________________________________

Instructor:_______________________ Date: _____________________________________

 Nursing Skill Procedures 22

Bed Making
Definition:

It is a technique which provides enough area to patient on which he can be comfortable and
perform his activities of daily living and also to facilitate therapeutic care.

Purpose:

1) To provide, rest, comfort and safety to the patient

2) To help him have a good relaxed sleep
3) To give the room a neat and tidy appearance
4) To provide an opportunity to the nurse for observation and assessment of the nursing
needs of the patient
5) To give active and passive exercises to the patient and to promote cleanliness
6) To keep it ready for an emergency in order to economize time and energy.
7) To establish a good nurse patient relationship and to teach the relatives bed-making to
take care of the patient in home situations

Equipments:
For an ambulatory patient

1 Chair / stool / trolley – hamper

2 Duster 2
3 Basin with water/lotion savlon, 1:100
4 Mattress protector
5 Mattress with cover
6 Long mackintosh
7 Bed sheets 2
8 Pillow with covers 2
9 Draw sheet with mackintosh
10 Blankets (if required)
11 Bed spread (counter pane)
 Nursing Skill Procedures 23

No. Procedure Rationale

1 The nurse should wash her hands To reduce infection by reducing micro-
organisms
2 Collect all needed articles on a chair,
stool or trolley
3 Explain to the patient the entire To establish a good nurse patient
procedure relationship
4 Take off bed clothes, by folding one To prevent the spread of micro-organisms
by one, and place them on a
stool/chair/trolley.
Shake them gently
5 Discard the soiled linen into the To prevent the spread of micro-organisms
hamper or bucket.
6 Clean and draw the mackintosh, roll it Folding causes creases
and take it off
7 Take pillows off, shake and change
covers
8 Discard dirty linen into the hamper To prevent infection
9 Clean the long mackintosh, roll and
keep it on the chair/trolley
10 Dust mattress and Dari with a dry Damp dusting will stain the mattress
duster
11 Clean bed with wet duster To prevent cross infection
12 Replace the long mackintosh on the To protect it from soiling
mattress
13 Spread bed sheet (bottom) and make Saves many steps
box corners on your side of the bed
14 Spread and draw mackintosh, draw- Draw sheets protect the bottom sheet from
sheet and tuck them on your side soiling
15 Go to the other side of the bed
16 Make the box corner of the sheet at the To have a neat appearance and for the
head –end and the foot-end of the bed. comfort of the patients
Tuck draw-mackintosh and draw-sheet
neatly without wrinkles on the side
17 Spread top sheet to the full length of
the mattress
18 Spread blankets over the top sheet
19 Tuck at the foot end by making To have a neat appearance and also for
corners fixing the sheet in bed
20 Spread counter pane to the full length
by making corners
21 Put the pillow case and place the
pillow at the head-end, the open end
away from entrance
 Nursing Skill Procedures 24

Procedure Checklist
Bed Making
Check (􀀹) Yes or No

No Steps of Procedure Yes No Comments

1 The nurse should wash her hands
2 Collect all needed articles on a chair, stool or
trolley
3 Explain to the patient the entire procedure
4 Take off bed clothes, by folding one by one,
and place them on a stool/chair/trolley.
Shake them gently
5 Discard the soiled linen into the hamper or
bucket.
6 Clean and draw the mackintosh, roll it and
take it off
7 Take pillows off, shake and change covers
8 Discard dirty linen into the hamper
9 Clean the long mackintosh, roll and keep it on
the chair/trolley
10 Dust mattress and Dari with a dry duster
11 Clean bed with wet duster
12 Replace the long mackintosh on the mattress
13 Spread bed sheet (bottom) and make box
corners on your side of the bed
14 Spread and draw mackintosh, draw-sheet and
tuck them on your side
15 Go to the other side of the bed
16 Make the box corner of the sheet at the head –
end and the foot-end of the bed. Tuck draw-
mackintosh and draw-sheet neatly without
wrinkles on the side
17 Spread top sheet to the full length of the
mattress
18 Spread blankets over the top sheet
19 Tuck at the foot end by making corners
20 Spread counter pane to the full length by
making corners
21 Put the pillow case and place the pillow at the
head-end, the open end away from entrance

Recommendation: Pass ____________ Needs more practice __________________________

Student: ________________________ Date: _____________________________________

 Nursing Skill Procedures 25

Instructor:_______________________ Date: _____________________________________

Performing Oral Care

Oral Hygiene:

Oral hygiene is important because mouth is the portal of entry of food and digestion starts
from mouth. So, the condition of mouth directly affects health.

Purpose:

1) To prevent dental carries and tooth decay

2) To feel fresh, clean and socially acceptable
3) To stimulate salivation
4) To prevent inflammation of gums and salivary glands
5) To prevent complications such as stomatitis, glossitis, pyorrhea, parotitis, etc.

Equipments Required:

1 A tray containing
2 Artery forceps 1
3 Dissecting forceps 1
4 Small mackintosh 1
5 Cotton swabs in a bowl
6 Tongue depressor – solution as ordered 1
7 Feeding cup 1
8 Gauge pieces in a bowl
9 Paper beg 1
1 kidney tray 1
0
1 Face towel 1
1
1 A bowl with clean water
2

Solutions used for oral care:

1) Potassium permanganate 1: 5000 solution
2) Hydrogen peroxide 1:8
3) Sodium chloride 1 teaspoon to 500ml of water
4) Sodium chloride and lime juice mixture

No Procedure Rational
1 Explain the procedure to the patient To allay anxiety if not unconscious
2 Provide Privacy To give security
3 Position the patient in side-lying To prevent aspiration of secretions and to
position toward the dependent side help in drainage
 Nursing Skill Procedures 26

4 Arrange the articles conveniently To save time and energy

5 Wash hands To prevent cross infection
6 Place the mackintosh and towel beneath To prevent soiling bed linen
the patient’s chin
7 Place the kidney tray close to the cheek To prevent soiling bed linen
8 Use any dentifrice to clean teeth To ensure through
Cleanliness
9 Do not pour water into mouth if the Due to poor gag reflex, the fluid will go
patient is unconscious into lungs
10 Wrap a swab around the forceps, It removes secretions and encrustations
covering the tips completely, and clean
the mouth systematically. Clean the
mouth in the following order:
Inside cheeks
Gums
Teeth
Roof of mouth
Lips
11 Use tongue depressor, if needed, and It helps in proper visualization of tongue,
wipe the tongue from side to side gums
12 For a conscious patient, tooth brush and Ensure proper cleanliness
paste can be used; the patient can spit,
and water can be poured for washing his
mouth
13 Use as many swabs as required till the
mouth is clean
14 Repeat the entire procedure with swabs
dipped in fresh water
15 When the teeth and tongue are cleaned To give a sense of freshness
well, stop the procedure, wipe the lips
and face with towel
16 Apply glycerin borax on the cracked
lips
 Nursing Skill Procedures 27

Procedure Checklist
Giving Mouth Care
Check (􀀹) Yes or No

No Steps of procedure Yes No Comments

1 Explain the procedure to the patient
2 Provide Privacy
3 Position the patient in side-lying
position toward the dependent side
4 Arrange the articles conveniently
5 Wash hands
6 Place the mackintosh and towel beneath
the patient’s chin
7 Place the kidney tray close to the cheek
8 Use any dentifrice to clean teeth
9 Do not pour water into mouth if the
patient is unconscious
10 Wrap a swab around the forceps,
covering the tips completely, and clean
the mouth systematically. Clean the
mouth in the following order:
Inside cheeks
Gums
Teeth
Roof of mouth
Lips
11 Use tongue depressor, if needed, and
wipe the tongue from side to side
12 For a conscious patient, tooth brush and
paste can be used; the patient can spit,
and water can be poured for washing
his mouth
13 Use as many swabs as required till the
mouth is clean
14 Repeat the entire procedure with swabs
dipped in fresh water
15 When the teeth and tongue are cleaned
well, stop the procedure, wipe the lips
and face with towel
16 Apply glycerin borax on the cracked
lips
 Nursing Skill Procedures 28

Recommendation: Pass ____________ Needs more practice __________________________

Student: ________________________ Date: _____________________________________

Instructor:_______________________ Date: _____________________________

Application of Restraints
Definition

Restraints are protective devices used to limit the physical activity of a client or to
immobilize a client or extremity.
Purpose:
1) Restraints are used to protect the client.
2) Allow for treatment in a safe environment.
3) Reduce the risk of injury to others.
Equipment:
Restraint
Types of Physical Restraints

A. Jacket B. Belt C. Mitten or Hand

 Nursing Skill Procedures 29

E. Limb or Extremity D. Elbow F. Mummy

Procedure:
No Action Rationale
1 Explain rationale for application of Explanations facilitate cooperation.
restraint. Repeatedly reinforce
rationale.
2 Select the proper type of restraint. Least restrictive restraint that does not
interfere with client’s health status but
provides safety should be selected.
3 Assess skin for irritation. Provides baseline skin assessment.
4 Apply restraint to client assuring some Maintains adequate circulation and mobility.
movement of body part. One to two Prevents skin breakdown. Restraint should
fingers should slide between restraint be easy to release.
and client’s skin. Tie straps securely
with clove hitch knot To make a clove
hitch: make a figure-eight; pick up the
loops; put the limb through the loops
and secure. Pad bony
Prominences.
5 Secure restraint to bed frame; do not Prevents accidental injury to client from
tie the straps to the side rail. moving side rails and decreases client’s
ability to untie restraints.
6 Assess restraints and skin integrity Permits muscle exercise. Promotes
every 30 minutes. Release restraints at circulation.
least every 2 hours.
7 Continually assess the need for Assist in evaluating client’s progress and
restraints (at least every 8 hours). response to restraints.
 Nursing Skill Procedures 30

Making a Clove Hitch Knot:

A. Make a figure-eight;
B. Pick up the loops; and
C. Put the limb through the loops and
secure.

Procedure Checklist
Application of Restraints
Check (􀀹) Yes or No

No Action Yes No Comments

1 Explain rationale for application of
restraint. Repeatedly reinforce rationale.
2 Select the proper type of restraint.

3 Assess skin for irritation.

4 Apply restraint to client assuring some

movement of body part. One to two
fingers should slide between restraint
and client’s skin. Tie straps securely
with clove hitch knot To make a clove
hitch: make a figure-eight; pick up the
loops; put the limb through the loops
and secure. Pad bony
Prominences.
5 Secure restraint to bed frame; do not tie
the straps to the side rail.
6 Assess restraints and skin integrity
every 30 minutes. Release restraints at
least every 2 hours.
7 Continually assess the need for
 Nursing Skill Procedures 31

restraints (at least every 8

hours).Making a Clove Hitch Knot:
A. Make a figure-eight;
B. Pick up the loops; and
C. Put the limb through the loops and
secure.

Recommendation: Pass ____________ Need more practice ___________________________

Student: ________________________Date: ______________________________________

Instructor: _______________________ Date: _____________________________________

Giving the Bath on Bed

Definition:
A method of washing a patient who is too weak or frail to be taken to a bathroom. W
aterproof sheets areused and one side is sponged at a time.

Purposes of Bathing

Cleanse the skin. Bathing remove dirt, perspiration, sebum, some bacteria, and
slough off dead skin cells. It helps to prevent irritations and rashes that would
otherwise transform into infections.

Stimulate blood circulation. Good circulation is promoted through the use of warm
water and gentle stroking of the extremities. The person feels revitalize and relax
through the washing process.

Improved self-image. Bathing promotes relaxation and a feeling of being refreshed

and comfortable. It helps the person to maintain an acceptable social standards of
cleanliness, both appearance and olfactory.

Reduce body odors. Excessive secretion of sweat cause unpleasant body odors.
Bathing and use of antiperspirants minimize odors.

Promote range of motion exercises. Movement of the upper and lower extremities
during bathing maintains joint function.
 Nursing Skill Procedures 32

.
Equipment’s;
1. Bath blanket
2. Towel
3. Face cloths
4. Soap
5. Wash basin with warm water
6. Clean Pajamas or gown
7. Clean bed linen
8. Essential toiletries (e.g.. talcum powder, mouth gargle, nail clipper)

Procedure

S# Action Rational

1 Wash your hand. Reduce the spread of microorganisms.

2 Pull the privacy curtain. Demonstrates the respect for modesty.

3 Raise the bed to an appropriate height. Reduce muscle strain on the black when
providing care.
4 Remove extra pillows or positioning Prepare the pt for washing the anterior
devices and place the pt on his or her body surface.
back.
5 Cover the pt with a bath blanket. Show respect for the pt`s modesty and
provides warmth.
6 Remove the pt`s gown. Facilitate washing the pt.

7 Place the linen on the chair. Keeps linen, which may be reused, clean.

8 If linen is wet than place in the hamper. Reduce the spread of microorganisms.

9 Wet the wash cloth and fold it to fashion Keeps water from dripping from the
a mitt. margins of the cloth.
10 Wipe each eye with a separate corner of Prevents getting soap in the eyes.
 Nursing Skill Procedures 33

the mitt from the nose toward the ear.

11 Lather the wet washcloth with soap and Remove oil, sweat, and microorganisms.
finish washing the face.
12 Rinse the washcloth and remove soapy Prevents Drying the skin.
residue from the face, then dry well.
13 Bath each of pt`s arms separately the Cleanses soiled material and keeps the pt
axillae. May be include now or when the from becoming too child.
chest is washed.
14 Offer to apply deodorant or Demonstrates the respect for the pt`s usual
antiperspirant after axillae have been hygiene practice; reduces perspiration and
washed. body odor.
15 Place each hand in the basin of water as Facilitates more through washing than just
it is washed. using the washcloth.
16 Discard and replace the water in the wash Eliminates debris, microorganisms, and
basin; rinse the washcloth well or replace soap residue, and increases the warmth of
it with a clean one. the water in preparation for cleaner areas
of the body.
17 Wash the chest, abdomen, each leg and Follows the principle of washing from
then the feet, following the steps cleaner to more soiled areas.
described for the upper body.
18 Help the pt onto his or her side. Repositions the pt so the posterior of the
body can be bathed.

19 Change the water and bathe the pt`s back. Allows washing to begin at cleaner area on
the posterior aspects of the body.
20 Offer to apply lotion and provide a back Improves circulation
rub. And relaxes the pt.

21 Don gloves and wash the buttocks, Reduces the potential for contact with
genitals, and anus last. Dry thoroughly. lesions or drainage that may contain
infectious microorganisms.
Prevents moisture accumulation.
22 Discard the water and wipe the basin dry. Controls the growth and spread of
microorganisms.
23 Remove gloves and help the pt don a Restores comfort and mdesty.
fresh gown.
 Nursing Skill Procedures 34

Procedure Checklist

Giving Bed Bath

Check (􀀹) Yes or No

S# Procedure Yes No Comments

1. Wash your hand.
2. Pull the privacy curtain.
3. Raise the bed to an appropriate
height.
4. Remove extra pillows or
positioning devices and place
the pt on his or her back.
5. Cover the pt with a bath
blanket.
6. Remove the pt`s gown.
7. Place the linen on the chair.
8. If linen is wet than place in the
hamper.
9. Wipe each eye with a separate
corner of the mitt from the
nose toward the ear.
10. Lather the wet washcloth with
soap and finish washing the
face.
 Nursing Skill Procedures 35

11. Rinse the washcloth and

remove soapy residue from the
face, then dry well.
12. Bath each of pt`s arms
separately the axillae. May be
include now or when the chest
is washed.
13. Offer to apply deodorant or
antiperspirant after axillae
have been washed.
14. Place each hand in the basin of
water as it is washed.
15. Discard and replace the water
in the wash basin; rinse the
washcloth well or replace it
with a clean one.
16. Wash the chest, abdomen, each
leg and then the feet, following
the steps described for the
upper body.
17. Help the pt onto his or her
side.
18. Change the water and bathe the
pt`s back.
19. Offer to apply lotion and
provide a back rub.
20. Don gloves and wash the
buttocks, genitals, and anus
last. Dry thoroughly.
21. Discard the water and wipe the
basin dry.
22. Remove gloves and help the pt
don a fresh gown.

Recommendation: Pass ______ Need more practice __________________________

Student: _______________________ Date: _________________________________

Instructor: _______________________ Date: ______________________________

 Nursing Skill Procedures 36

Weight and Height

Definition:

Height and weight measurements provide the necessary details to calculate the body
mass index of subjects. This information provides a quantitative measure of obesity
in individuals.

2. Responsibilities:
 Nursing Skill Procedures 37

Research nurses trained in the method are responsible for recording height and
weight measurements from all subjects.

3. Equipment

 Marsden digital weighing scales

 Calibration weights (80kg) and height measure standards
 Marsden ultrasonic height measure

PROCEDURE:

I. Guidelines

A. Height and weight should be done at every clinic visit.

B. Height and weight are needed to determine BMI.

C. It is important to notify the Provider of any significant weight gain or weight loss.

D. Document the height and weight in the vital signs section of the electronic medical
record.

E. Follow manufacturer’s instructions on proper use of specific scales such as standing,

electronic, child and infant table.

F. Staff should not accept stated height and weight measurements, unless the patient can’t
stand.

II. Procedural Guidelines

A. Height Measurement

S# Action Rational
1 For patients 2 years and older For accurate record

Assist patient to remove shoes, especially

if patient is wearing high heels.
2 Assist patient to stand against the wall For accurate measuring of Height
measurement tape.

3 Have patient stand with buttocks and For straight position

head against the wall measuring tape.
4 With L-shaped sliding arm on the wall For supporting the body
raised, slide the sliding arm down until it
rests level on top of the patient’s head.
5 For patients less than 2 years of age For safety

Place patient on a horizontal table that

has a measuring tape attached, or use a
 Nursing Skill Procedures 38

disposable tape to mark and measure the

child’s length on the paper table cover.
6 Record the height in total inches in the For appropriate calculation
vital sign section of the electronic
medical record.

B. Weight Measurement

S# Action Rational
1 Infant table scale

Weigh children that cannot stand on the

pediatric table scale without clothing.
2 Staff should calibrate the scale to zero
before use.
3 Digital readout should display in a few
seconds
4 Document weight in pounds in the vital
sign section of the electronic medical
record.
5 Standing scale

Assist the patient to stand on the scale.

6 If a digital scale is used, readouts
display weight in a few seconds.
7 If a balancing scale is used, move the
larger bottom weight to the right below
estimated weight of the patient. Make
sure it is in the groove.
8 Then move the smaller top weight to
the right until the scale is balanced.
9 Read the lower bar and upper bar and
add the numbers together for the total
weight.
10 Document the weight in pounds in the
vital signs section of the electronic
medical record. : 3 / 5 g. Notify Provider
of any significant weight gain or weight
loss.
 Nursing Skill Procedures 39

Procedure Checklist

Weight and height

Check (􀀹) Yes or No

S# Procedure Yes No Comments

1 For patients 2 years and older

Assist patient to remove shoes,

especially if patient is wearing high
heels.
2 Assist patient to stand against the wall
measurement tape.
3 Have patient stand with buttocks and
head against the wall measuring tape.
4 With L-shaped sliding arm on the wall
raised, slide the sliding arm down until
it rests level on top of the patient’s
head.
5 For patients less than 2 years of age

Place patient on a horizontal table that

has a measuring tape attached, or use
a disposable tape to mark and
measure the child’s length on the
 Nursing Skill Procedures 40

paper table cover.

6 Record the height in total inches in the
vital sign section of the electronic
medical record.
7 Infant table scale

Weigh children that cannot stand on

the pediatric table scale without
clothing.
8 Staff should calibrate the scale to zero
before use.
9 Digital readout should display in a few
seconds
10 Document weight in pounds in the
vital sign section of the electronic
medical record.
11 Standing scale

Assist the patient to stand on the

scale.
12 If a digital scale is used, readouts
display weight in a few seconds.
13 If a balancing scale is used, move the
larger bottom weight to the right
below estimated weight of the patient.
Make sure it is in the groove.
14 Then move the smaller top weight to
the right until the scale is balanced.
15 Read the lower bar and upper bar and
add the numbers together for the total
weight.
16 Document the weight in pounds in the
vital signs section of the electronic
medical record. : 3 / 5 g. Notify
Provider of any significant weight gain
or weight loss.
 Nursing Skill Procedures 41

Admission Process

Definition:

Entering a health care agency for nursing care and medical or surgical treatment.

Elements of a good nursing history

• Patients information

• Allergy Assessment

• Chief Complaint/Reason For Admission

 Nursing Skill Procedures 42

• Past Health History

• Current Home Medication List

• Personal & Social History

• Review of System.

S# Action Rational
1 Review patient data at hand (e.g., patient
care report, patient „s old health record)
2 Clarify information
3 Familiarize yourself with unclear
diagnoses, surgeries, etc.
4 Prepare patient environment as able Once
the patient arrives…
5 Ensure a comfortable and private
environment for interview
6 Settle the patient
7 Does the patient want family members
present for support?
8 Change patient identification band
9 Apply allergy band (if necessary)
10 Initial patient assessment/nursing history
11 Valuables/belongings
12 Allergy History and Allergy Record
13 Medication History/Medication
Reconciliation
14 Braden scale
15 ARO screening
16 Resuscitation/End-of-Life Care Plan
17 Fall Risk Assessment (signage + yellow
armband)
18 Discharge Planning
19 To main adult nursing history forms
20 Specialty programs have augmented
versions of standard nursing history
forms
21 To be completed within 24 hours of
admission
22 One nurse can start it (e.g. middle of the
night admissions) and nurse on next shift
can complete
23 Must be completed before transferring
patient from one unit to another
24 Admission notes
25 Record time, method of arrival,
accompanied by whom if relevant, reason
for admission and record
 Nursing Skill Procedures 43

26 All significant psychological findings. In

the clinical progress notes
27 Includes reason why Nursing History not
completed (if applicable)

Procedure Check List

Admission Process

Check (􀀹) Yes or No

S# Procedure Yes No Comments

1 Review patient data at hand (e.g.,
patient care report, patient „s old health
record
2 Clarify information
3 Familiarize yourself with unclear
diagnoses, surgeries, etc.
4 Prepare patient environment as able
Once the patient arrives…
5 Ensure a comfortable and private
environment for interview
6 Settle the patient
7 Does the patient want family members
present for support?
8 Change patient identification band
9 Apply allergy band (if necessary)
10 Initial patient assessment/nursing
history
11 Valuables/belongings
 Nursing Skill Procedures 44

12 Allergy History and Allergy Record

13 Medication History/Medication
Reconciliation
14 Braden scale
15 ARO screening
16 Resuscitation/End-of-Life Care Plan
17 Fall Risk Assessment (signage +
yellow armband)
18 Discharge Planning
19 To main adult nursing history forms
20 Specialty programs have augmented
versions of standard nursing history
forms
21 To be completed within 24 hours of
admission
22 One nurse can start it (e.g. middle of
the night admissions) and nurse on next
shift can complete
23 Must be completed before transferring
patient from one unit to another
24 Admission notes
25 Record time, method of arrival,
accompanied by whom if relevant,
reason for admission and record
26 All significant psychological findings.
In the clinical progress notes
27 includes reason why Nursing History
not completed (if applicable)
 Nursing Skill Procedures 45

Discharge Process

Definition:

When all the preliminary business is completed, the nurse helps the patient gather his or her
belongings, plan for discharge, and actually leave the agency.

Planning:

 Discuss the patient’s time frame work for leaving the hospital.
 Nursing Skill Procedures 46

 Coordinate the discharge with the home health care agency.

 Determine the patient`s mode of transportation.
 Notify the business office of the patient`s impending discharge.
 Inform to housekeeping department that patient will be leaving.
 Cancel any meals that the patient will miss after discharge.
 Notify the pharmacy of the approximate time of discharge.
 Plan to provide hygiene and medical treatment early.

Discharge Process
S# Action Rational
1 Wash your hand Reduces transmission of microorganisms
2 Provide for hygiene but omit changing Elimination unnecessary work
the bed linen.
3 Complete medical treatment and Promotes continuation of nursing care.
nursing interventions according to the
plan for care.
4 Helps the patient dress in street Demonstrate the concern for the patient`s
clothing appearance.
5 Review discharge instructions and Promotes safe self-care.
complete health teaching.
6 Have the patient sign the discharge Validates the patients has understood
instruction sheet and paraphrase the instructions for maintaining health.
information it contains.
7 Assist the patient with packing personal Reduce the claim that personal items were
items if appropriate, have the patient lost or stolen.
sign the clothing inventory valuable
list.
8 Assist the patient into a wheel chair Reduce the potential for a fall if the patient
when transportation is available. is weak or unsteady
9 Escort the patient to the waiting Promote safety while still has left the
vehicle. hospital.
10 Return any forms from the business Confirm that the patient has left the hospital.
office.
11 Replace the wheelchair in its proper Make equipment’s available for the other
location on the nursing unit. use.
12 Wash hands Reduce the transmission of Microorganisms.
13 Complete the discharge summery in the Closes the medical record for this admission.
medical record.

Procedure Check List

Discharge Process

Check (􀀹) Yes or No

 Nursing Skill Procedures 47

S# Procedure Yes No Comments

1 Wash your hand
2 Provide for hygiene but omit
changing the bed linen.
3 Complete medical treatment and
nursing interventions according to the
plan for care.
4 Helps the patient dress in street clothing
5 Review discharge instructions and
complete health teaching.
6 Have the patient sign the discharge
instruction sheet and paraphrase the
information it contains.
7 Assist the patient with packing
personal items if appropriate, have
the patient sign the clothing
inventory valuable list.
Assist the patient into a wheel chair
8 when transportation is available
Assist the patient into a wheel chair
9 when transportation is available
10 Return any forms from the business
office.
11 Return any forms from the business
office.
12 Wash hands
13 Complete the discharge summery in the
medical record.