EYES EARS

1. Eval distant (Snellen chart) 1. Ins. auricle, tragus, lobule

2. Eval near (handheld) 2. Palpate auricle, mastoid process (gloves)
3. Confrontation T est (cover eye, number) 3. Ins. external audit, (otoscope, ear up and back)
4. Corneal Light reflex (penlight bridge) 4. Ins. tympanic membrane (otoscope)
5. Cover T est (card, look away) 5. Valsalva maneuver (cover nose & breath,
6. Position T est (H) otoscope)
7. Ins. lids & lashes 6. Whisper Test (behind, whisper 3 words)
8. Ins. eyeball in eye sockets 7. Weber Test (head)
9. Ins. bulbar conj. & sclera (side-side, up) 8. Rinne Test (both ends)
10. Ins. palpebral conj. (look up) 9. Romberg Test (open & close eyes, 20 secs))
11. Ins. lacrimal app.
12. Pal. lacrimal (side of nose w/ index)
13. Ins. cornea & lens (shine light side)
14. Ins. iris & pupil (turn off light, shine eyes)
15. T est pupillary reaction (shine, look away)
16. T est accommodation far-near (finger toward
eyes)

PERINEAL CARE BED SHAMPOO

1. Wash hands & don gloves 1. Wash hands
2. Place waterproof pad 2. Provide privacy
3. Fold sheet in diamond expose area 3. Loosen gown
4. Fold top sheet to middle, replace with blanket
FEMALE 5. Cover chest with bath towel
1. Wipe labia majora (7) 6. Remove pillow, bring head diagonal
2. Wipe labia minora (retract, 7) 7. Protect pillow w/ rubber sheet and bath towel
3. Wipe center of meatus (if catheter, circular motion) 8. Place pillow under shoulder
4. Wash inner thighs 9. Place kelly pad under head and pail on floor w/
5. Place bedpan newspaper
6. Rinse with warm water 10. Comb hair
7. Remove bedpan 11. Place washcloth on eyes
8. Turn patient side anal area 12. Place cotton balls in ears
13. Moisten hair
MALE 14. Apply soap/shampoo, massage scalp w/ nail
1. Retract foreskin pads
2. Wash urinary meatus circular motion 15. Rinse with warm water
3. Wash shaft 16. Rinse with cool water
4. Wash scrotum 17. Squeeze hair
5. Wash inner thigh 18. Drop kelly pad
6. Place bedpan 19. Dry hair in turban
7. Rinse w/ warm water 20. Position in comfy
8. Dry in same sequence 21. Document
9. Replace foreskin
10. Turn patient side wipe anal area

BLOOD PRESSURE ORAL CARE

1. Perform Hand hygiene 1. Introduce and explain to watcher
2. Provide client privacy 2. 2. Assemble equipment
3. Place sitting position 3. Provide Privacy
4. Move client's clothing up 4. Put on gloves
5. Position arm at heart level 5. Position in side-lying and lower head of bed
6. Wrap cuff 6. Place towel under chin
7. Apply center over artery 7. Place basin against chin and cheek
8. Place low border approx 1in antecub spa 8. Brush teeth (tongue depressor)
9. Locate brachial w/ fingertips 9. Rinse mouth, inject 10ml of water/mouthwash
10. Palpate brachial 10. Make sure all has run out of mouth
11. Close valve 11. Repeat rinsing
12. Pump up cuff 12. Clean with swab or gauze on each cheek
13. Note pressure on sphygmomanometer 13. Do same on other side
14. Release pressure 14. Discard swab/tongue blades
15. Position stethoscope 15. Rinse mouth again
16. Place diaphragm over brachial 16. Remove basin and dry with towel
17. Place on skin not clothing 17. Replace dentures, if needed
18. Hold diaphragm w/ index and middle
19. Ausc. bp
20. Pump cuff add 30
21. Release valve
22. Identify manometer korotkoff I,IV,V
23. Deflate cuff
24. May repeat once/twice
25. May repeat on other arm
26. Remove cuff
27. Document
ITRAMASCULAR INJECTION INTRADERMAL INJECTION
1. Hand hygiene 1. Hand hygiene
2. Prepare medication from vial 2. Prepare medication from vial
3. Change needle on syringe 3. Provide privacy
4. Invert needle and expel air 4. Select a site
5. Provide privacy 5. Wear gloves
6. Locate site for injection 6. Cleanse site
7. Wear gloves 7. Dry the skin
8. Cleans site. Start from center and move outward 8. Remove needle cover
using circular motion 9. Expel air for syringe
9. Place the cotton in between the 3rd & 4th fingers 10. Hold the syringe using thumb and forefinger
(non-dominant) (dominant hand)
10. Dry the skin 11. Hold the syringe parallel to the skin with bevel
11. Remove the needle cover of the needle up
12. Pull skin to the side 12. Pull the skin to the side (non dominant hand)
13. Hold syringe with thumb and forefinger at 90 13. Insert only the tip of needle
degree angle 14. Inject medication slowly until a small wheal
14. Insert needle forms
15. Hold barrel of the syringe (non-dominant) 15. Withdraw needle
16. Aspirate for 5-10 secs 16. Do not massage area
17. Inject medication 17. Dispose needle and syringe
18. Place cotton 18. Remove gloves
19. Withdraw needle 19. Circle the injection site

EINC BAG TECHNIQUE

1. Lay out material 1. Place paper lining (clean side out) then place
2. Wear sterile gloves (double gloving) bag.
3. Support perineum 2. Ask for a basin of water & place outside
4. Call out time of birth and sex of baby 3. Open bag
5. Dry baby thoroughly for 30 seconds following the a. Place plastic lining
sequence b. Place paper lining (clean side out) then
a. eyes place bag.
b. Face 4. Take out:
c. Head a. hand towel
d. Front and back b. soap dish
e. Arms c. apron
f. legs 5. Perform hand washing
6. Assess breathing 6. Wear apron
7. Initiate skin-to-skin contact a. Slide head strap
a. Position the newborn in mother’s abdomen or b. Tie straps behind
chest 7. Put out things needed
8. Remove 1st set of gloves prior 8. Place waste bag outside
9. Clamp and cut cord 9. Close bag
10. Inject oxytocin 10 IU to mother’s deltoid 10. Do specific treatment
11. Deliver the placenta 11. Clean and alcoholize the things after
12. Initiate breastfeeding 12. Perform hand washing
a. latch her newborn towards her breast 13. Open bag and put back all things
13. Administer: 14. Remove apron folding away from the body and
a. Eye ointment place inside the bag
b. Vitamin K (thigh) 15. Fold paper & plastic linen and place inside the
c. Hepatitis B (thigh) bag
d. BCG (deltoid) 16. documentation
13. Perform anthropometric measurements
a. head
b. Chest
c. Abdomen
d. Arm
e. Thigh
f. Length (note the tone)
g. Weight

LEOPOLD’S MANEUVER NASOGASTRIC FEEDING FOR NEONATE

1. Explains procedure 1. Hand wash
2. Empty client's bladder. 2. Put towel over chest
3. Positions the client in supine & knees slightly flexed 3. Position neonate in right side lying, head & chest
4. Wash hands using warm water. slightly elevated
5. Measure fundal height 4. Aspirate tube before feeding
FIRST MANEUVER a. Open tube, kink, insert syringe, aspirate
1. Places both hands on her abdomen b. If over ½ is aspirated, withhold feeding.
2. Palpates the superior surface of the fundus Do not return the aspirated content
SECOND MANEUVER c. If small residual is aspirated, return to
1. Place the palms of each hand on either side of the stomach and subtract that to the total
abdomen. amount of formula given
2. Palpates the sides of the uterus 5. Attach the reservoir to catheter and fill with
3. Left hand push; right hand palpate top to bottom feeding
4. repeats palpation on the other side a. Remove, aspirate the syringe, remove the
THIRD MANEUVER plunger, attach the syringe back to the
1. Place hand below abdomen & above symphysis tube and kink the tube
pubis; between thumb and index finger, press 6. Flow of the feeding should be slow, elevate the
together reservoir 6-8 inches
2. Determines any movement and whether the part is 7. When feeding is complete, irrigate the catheter
firm or soft. with clean water. Before the water reaches the
FOURTH MANEUVER end of the catheter, clamp it off and withdraw it
1. Face foot part of the client; place fingers on both quickly
sides of the uterus 2 inches above the inguinal 8. Discard the feeding tube and any leftover solution
ligaments, pressing downward and inward in the 9. Burp the patient
direction of the birth canal 10. Position the baby on his right side for 1 hour
2. Allows fingers to be carried downward. 11. Observe for bradycardia and apnea after feeding
12. Note vomiting or abdominal distention
13. Describe and record procedure
a. Time fo feeding
b. Type of gavage tube feeding
c. Type and amount of feeding
d. Amount of retained
e. How the patient tolerates the feeding
14. After care

NEONATAL RESUSCITATION SURGICAL SCRUBBING

1. Handwash don gloves 1. Attend to personal needs.
2. Assess color tone, breathing and heart rate 2. Tuck hair inside cap.
3. Thoroughly dry and keep the baby warm 3. Cover nose, chin, mouth with mask
4. Clear the airway 4. Roll up sleeves 3 in. above elbow.
5. Stimulate 5. Remove jewelries/watch. Check fingernails.
6. Give 5 inflation breaths 6. Do regular handwashing. Rinse fingers to elbow.
a. Position head in neutral position 7. Get brush. Run in water.
b. Place ambu bag in “C” and “E” position 8. Scrub right hand first
c. Give 5 inflation breaths by slowly squeezing ❖ Finger and nails = 20
the bag ❖ Palms = 15
d. Provide 2-3 seconds (1-2-3, 2-2-3, 3-2-3, 4-2- ❖ Back of palm = 15
3, 5-2-3)
7. 30 seconds of ventilation breaths ❖ Interdigital spaces = 15
a. Use jaw thrust technique 9. Divide forearm in 3 in. increment.
b. 1-2 seconds for 30 seconds 10. Scrub every 4 sides in 15 circular strokes.
8. Chest compression 11. Brush elbow = 20 circular strokes
a. Hold chest and place thumb in sternum below 12. Rinse brush. Pour soap.
the nipple line 13. Brush left arm.
b. Compress for ⅓ depth, about 1 ½ inches 14. Pick up corner of hand towel.
c. Provide 3 chest compressions to one breath 15. Step back
d. Make sure there is time for the chest to recoil 16. Open towel lengthwise.
e. listen for heart rate for every 30 seconds 17. Spread towel in one arm, dry in circular motion.
f. Continue giving ventilation breaths if the baby 18. Flip towel. Dry other hand.
still has irregular breathing for 30 seconds 19. Discard towel.
9. Administer epinephrine if hr is still <60 bpm
10. After 20 minutes, discontinue or resuscitation

GOWNING AND GLOVING GOWNING AND GLOVING ANOTHER PERSON

1. Get gown with one hand. Touch inside only. 1. Give towel to surgeon.
2. Step back. 2. Unfold gown while holding at neckband.
3. Unfold gown. 3. Offer inside of gown to surgeon. Release. Ask
4. Keep hands at shoulder level. Wear gown. Ask circulating nurse to tie at back.
circulating nurse to tie at back. 4. Get right glove under cuff, palm side facing
5. Open gloves while hands are inside sleeves. surgeon.
6. Pick up right glove. Step back. Wear gloves. 5. Stretch cuff. Pull upward as surgeon puts hands.
7. Leave everted cuff as is. 6. Unfold cuff, pull upward.
8. Get left glove. Step back. Wear gloves. 7. Do the same on left hand.
9. Fix gloves.
10. Pleat left cuff. Pull glove cuff over gown.
11. Pleat right cuff. Pull glove cuff over gown.
REMOVAL
12. Grasp front of gown. Pull downwards.
13. Discard gown.
14. Grasp palm of left glove. Invert. Remove.
15. Hold left glove in right hand.
16. Grasp under cuff of right glove. Invert. Remove.
17. Discard gloves
18. Hand hygiene
DRAPING AND ARRANGING MAYO TABLE ECG
1. Pick up cover. Spread into antecubital fossa. 1. Review medical record.
2. Stabilize table. 2. Remove metal objects.
3. Drape another cloth. 3. Inspect chest.
4. Make pillow. 4. Arrange equipment. Put ECG close to bed. Plug
5. Arrange instruments. in outlet.
6. Charge the blade. 5. Hand hygiene.
7. Place needle in needle holder. 6. Privacy.
PASSING 7. Position client.
8. Hold scalpel in handle, blade facing downwards, 8. Instruct client not to talk.
pass handle to hands of surgeon. 9. Ground the machine.
9. Hold forceps/scissors in hinge. Pass the ring to 10. Attach limb leads. Put electrode paste first.
hands of surgeon. 11. Attach precordial leads.
10. Pass needle holder while needle facing up. Hold end 12. Turn on machine. Check ECG reading.
of the suture while passing. Rings directed on 13. Remove leads (chest then limb)
surgeon's thumb. 14. Document data.
11. Hand cotton/gauze/sponge using forceps/hands.
 MALE CATHETER FEMALE CATHETER
1. Introduce self. 1. Introduce self.
2. Check band of client. Explain. 2. Check band of client. Explain.
3. Arrange equipment. 3. Arrange equipment.
4. Hand hygiene. 4. Hand hygiene.
5. Ask for allergies. 5. Ask for allergies.
6. Provide light. 6. Provide light.
7. Privacy. 7. Privacy.
8. Position lying on his back. 8. Dorsal Recumbent.
9. Waterproof drape under patient. 9. Waterproof drape under patient.
10. Put sterile gloves. 10. Put clean gloves.
11. Lift penis with nondominant hand. Clean penile area. 11. Cleans vagina with washcloth. Remove gloves.
12. Hold penis upward w/ tension. Lubricate tip of penis 12. Hand hygiene.
and catheter. 13. Prepare drainage bag. Open sterile cath tray in
13. Place drainage end on basin. table.
14. Ask patient to bear down. Insert catheter. 14. Put sterile gloves.
15. Instruct to breathe deeply. Rotate catheter as you 15. Put fenestrated drape.
push. 16. Put tray between draped legs.
16. Hold catheter with non-dominant. 17. Fluff cotton, pour antiseptic.
17. Collect urine specimen. 18. Lubricate catheter tip.
18. Inflate balloon. 19. Clean labia and orifice with cotton held with
19. Tug gently. 20. forceps.
20. Attach to bag. 21. Place drainage end on basin.
21. Remove fenestrated drape. 22. Insert catheter tip.
22. Tape catheter in upper thigh. 23. Instruct to breathe deeply. Rotate catheter as you
23. Put bag in the side of bed. Should not be kinked. push.
24. Remove waterproof under drape, discard. 24. Hold catheter with non-dominant.
25. Remove equipment. 25. Collect urine specimen.
26. Position client. 26. Inflate balloon.
27. Perineal care. 27. Tug gently.
28. Remove gloves. Hand hygiene. 28. Attach to bag.
29. Document data 29. Remove fenestrated drape
30. Tape catheter in lower thigh, posterior.
31. Put bag in the side of bed. Should not be kinked.
32. Remove waterproof under drape, discard.
33. Remove equipment.
34. Position client.
35. Perineal care.
36. Remove gloves. Hand hygiene.
37. Document data.

TRACH CARE SUCTIONING

1. Verify doctor’s order. 1. Introduce, verify, explain.
2. Introduce self. Check band of client. Explain. 2. Hand hygiene.
3. Ask client to blink, raise a finger if they feel 3. Privacy
pain/distress. 4. Semi fowler’s position. Give analgesia if
4. Hand hygiene. necessary.
5. Privacy 5. Check function of suction and manual resu bag.
6. Semi to High- Fowler’s Position 6. Attach resu app. to oxygen. 100% flush.
7. Fill 1st basin with NSS. 7. Open sterile supplies.
8. Fills 2nd basin with equal NSS and Hydrogen 8. Place sterile towel in chest.
Peroxide. 9. Turn on suction, set the pressure.
9. Sterile towel on chest below tracheostomy. 10. Put sterile gloves. (Left hand as contaminated)
10. Make sterile field. 11. Lubricate catheter with right hand in saline.
11. Open sterile applicator, dressings, ties. 12. Thumb on nondominant will occlude thumb
12. Wear sterile gloves and put sterile eye sheet. control port, suction small saline through
13. Pick one gauze with sterile hand. catheter.
14. Stabilize neck plate.
15. Unlock inner cannula
16. Suction outer cannula. 13. Not copious = resu bag or ventilator; Copious =
17. Remove dressing to expose skin. increase flow, adjust FIO2 to 100% before
18. Use sterile gauze to remove secretions around tube. suctioning.
19. Discard gloves. Put another sterile gloves. 14. Get assistant.
20. Clean inner cannula with sterile gauze. Remove 15. Nondominant turn oxygen 12-15 l/min.
secretions outside and inside. 16. Disconnect oxugen from trach tube with
21. Rinse inner cannula with NSS. nondominant.
22. Wipe with dry gauze. 17. Attach resuscitator to trach tube.
23. Slide inner to outer cannula. Stabilize neckplate with 18. Compress ambubag 3x-5x as client inhales.
other hand, turn clockwise. 19. Observe rise and fall of chest.
24. Slips new tie in neckplate. Place on back of neck. 20. Remove resu device, place on bed or chest with
Do on the other end. connector facing up.
25. Apply tracheostomy dressing. 21. Nondominant thumb puts on suction port, insert
26. Position client in comfort. Discard materials. catheter into trach tube 12.5cm.
27. Hand hygiene. 22. Withdraw 1-2 cm before suctioning.
28. Raise side rails. 23. Intermittent suction 5-10 secs, place ND thumb
29. Document data. on catheter port. Rotate catheter. Withdraw,
release suction.
24. Hyperventilate client (bivalve bag/ventilator),
suction again.
25. Use pulse oxi then suction again.
26. Suction secretions in oropharynx. Use new set
of suction catheter.
27. Dispose equipment. Flush catheter. Turns off
suction.
28. Wrap catheter in sterile hand and peels glove.
29. Dispose clave and catheter.
30. Replenish materials.
31. Provide comfort
32. Document Data