FUNDAMENTAL OF NURSING PROCEDURE …

1 FUNDAMENTAL OF NURSINGPROCEDURE MANUALfor PCL courseNursing Department,Khwopa Poly-Technic Institute Japan International Cooperation Agency (JICA) FUNDAMENTAL of NURSING PROCEDURE Manual2 Published by:Japan International Cooperation Agency (JICA) Nepal OfficeBlock B, Karmachari Sanshaya Kosh BuildingHariharbhavan, Lalitpur, NEPAL( Box 450, Kathmandu, NEPAL)Tel:(977-1) 5010310 Fax:(977-1) 5010284 All copyright reserved by JICAF irst Edition: March, 2008Re - print:November, 2008 FUNDAMENTAL of NURSING PROCEDURE Manual3 Contributor:Sanjita KhadkaDurgeshori KisiPadma RayaSaphalta ShresthaEdited by Kei Miyamoto( NURSING Education, Senior Volunteer, JICA) Khwopa polytechnic institute, NURSING departmentPrinciple:Dr.

2 Rajan SuwalFaculty members of NURSING DepartmentHead of Department : Sharmila ShresthaLecturer:Sanjita Khadka(1styear coordinator)Chitra Kala Sharma(2ndyear coordinator)Merina Giri(3rdyear 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, Tara, and Ms. of NURSING PROCEDURE Manual4 Table of ContentsI.

3 Basic NURSING Care/ makinga. Making an Un-occupied bedb. Changing an Occupied bedc. Making a Post-operative oral carea. Assisting the client with oral careb. Providing oral care for dependent bed back hair for fingernails/ perineal vital signsa. Taking axillary temperature by glass thermometerb. Measuring radial pulsec. Counting respirationd. Measuring blood physical 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.

4 Supplying oxygen inhalationa. Nasal Cannula Methodb. Mask Method: Simple face maskII. Administration of oral oral medications through a Nasal-Gastric medications from an medications from a of the needle-stick an Intra-muscular an Intra-venous of medications by Heparin Nebulizer Therapya. Inhalerb. Ultrasonic nebulizer7913161921232630323537394143454 6499898101102106109111113115117120123126 129130135140144147148149 FUNDAMENTAL of NURSING PROCEDURE Manual5 III. Specimen blood specimena. Performing venipunctureb. Assisting in obtaining blood for urine specimena.

5 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 a sputum cultureAppendixReferences151153153157159 160161163164166168168169171181 FUNDAMENTAL of NURSING PROCEDURE Manual6 FUNDAMENTAL of NURSING PROCEDURE Manual7I. Basic NURSING Care/ SkillFundamental of NURSING PROCEDURE Manual8 FUNDAMENTAL of NURSING PROCEDURE Manual9 Bed makinga. Making an Un-occupied BedDefinition:A bed prepared to receive a new patient is an un-occupied Un-occupied bedPurpose1.

6 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 Kidney tray or paper bag (1)11.

7 Laundry bag or Bucket (1)12. Trolley(1)Fig. 2. Equipment required on a trolleyFundamental of NURSING PROCEDURE Manual10 PROCEDURE :by one nurseCare ActionRationale1. Explain the purpose and PROCEDURE to the client. Providing information fosters Perform hand hygiene. To prevent the spread of Prepare all required equipments and bring thearticles to the bedside. Organizationfacilitatesaccurateskillperf ormance4. Move the chair and bed side locker It makes space for bed making and helps Clean Bed-side locker:Wipe with wet and dry. To maintain the cleanliness6.

8 Clean the mattress:1) Stand in right ) Start wet wiping from top to center and fromcenter to bottom in right side of ) Gather the dust and debris to the ) Collect them into kidney ) Give dry wiping as same as PROCEDURE 2).6) Move to left ) Wipe with wet and dry the left side. To prevent the spread of infection7. Move to right sheet:1) Place and slide the bottom sheet upward overthe top of the bed leaving the bottom edge of ) Open it lengthwise with the center fold along thebed ) Fold back the upper layer of the sheet toward theopposite side of the ) Tuck the bottom sheet securely under the head ofthe mattress(approximately 20-30cm).

9 ( )Make a mitered corner. Pick up the selvage edge with your handnearest the hand of the bed. Lay a triangle over the side of the bed ( ) Tuck the hanging part of the sheet under themattress.( Fig. 5) Drop the triangle over the side of the bed.( Fig. 6 6 ) Tuck the sheet under the entire side of bed.( )5) Repeat the same PROCEDURE at the end of thecorner of the bed6) Tuck the remainder in along the side Unfolding the sheet in this manner allows you tomake the bed on one side. A mitered corner has a neat appearance and keepsthe sheet securely under the mattress.

10 Tucking the bottom sheet will be done by turn,the corner of top firstly and the corner of thebottom later. To secure the bottom sheet on one side of the Mackintosh and draw sheet:1) Place a mackintosh at the middle of the bed ( ifused), folded half, with the fold in the center ofthe bed. used), folded half, with the fold in thecenter of the ) Lift the right half and spread it forward the nearSide. Mackintosh and draw sheet are additionalprotection for the bed and serves as a lifting orturning sheet for an immobile of NURSING PROCEDURE Tuck the bottom sheet under the Picking the selvage and laying a triangle onthe Tucking the hanging part of the sheet underthe Putting and holding the sheet bedside themattress at the level of Dropping the triangle over the side of the Tucking the sheet under the entire side of thebedFundamental of NURSING PROCEDURE Manual12 Care ActionRationale3) Tuck the mackintosh under the )