Medical-Surgical Nursing
Skill Checklists — Missing Procedures
Nursing School – Second Year
Chest Physiotherapy (CPT)
Objectives: Students will be able to apply Chest Physiotherapy including Postural Drainage, Chest Percussion, Chest
Vibration, and the Airway Clearance System (Wrap).
➢ Procedure Check List
A. Preparing Client for CPT
1. Validate physician's order for CPT.
2. Perform hand hygiene.
3. Administer CPT before or at least 2 hr after meals to
prevent vomiting.
4. Establish the location of lung segments if the entire
lung field is to undergo CPT; the affected segment
should be drained first.
5. Provide privacy.
6. Prepare client by explaining CPT and purpose.
7. Auscultate chest for breath sounds and adventitious
sounds before therapy.
8. Obtain pulse oximetry (SPO2) if indicated before
therapy.
9. Place towel over skin when performing CPT
(optional).
B. Performing Postural Drainage
1. Loosen any tight clothing.
2. Lower head of bed slowly so that client's head is
positioned at no greater than a 25° downward angle.
3. Place sputum container and tissues in client's reach.
4. Tell client to remain in position for 3–15 minutes.
5. Instruct client to expectorate secretions.
6. Instruct client to turn to other side, then to supine
position, then repeat procedure. NOTE: Clients should
deep breathe between position changes.
7. Assist client to slowly return to normal sitting
position after coughing in dependent positions.
8. Determine pulse oximetry if ordered.
9. Auscultate chest areas for improved breath sounds.
10. Note character and measure sputum, then discard.
11. Remove gloves and perform hand hygiene.
12. Offer oral hygiene after secretion expectoration.
C. Performing Chest Percussion
1. Cover area to be percussed with gown or cloth towel
(optional).
2. Holding arms with elbows slightly flexed, cup your
hands with thumbs and fingers closed. Keeping wrists
loose and relaxed, rhythmically flex and extend wrists
to clap over area to be drained.
3. Percuss by alternating hands and listen for hollow
sound with strikes.
4. Slowly and rhythmically percuss each area for 3–5
minutes.
5. Do not percuss over bony prominences, breasts, or
tender areas.
6. Encourage client to "huff" cough after percussion of
lung areas.
7. Auscultate all lung areas for changes in breath
sounds.
8. Don gloves, note character and measure quantity of
sputum, and discard.
9. Remove gloves and perform hand hygiene.
10. Offer oral hygiene.
11. Document procedure and client's response.
D. Performing Chest Vibration
1. Perform vibration after postural drainage and
percussion in each position.
2. Cover area to be vibrated with gown or towel
(optional).
3. Instruct client to breathe in through nose and exhale
slowly through pursed lips.
4. Place your hands flat over area to be vibrated or place
one hand on top of the other. Keep your arms and
shoulders straight and wrists stiff.
5. Have client inhale deeply.
6. As client exhales through pursed lips, use moderate
pressure to vibrate chest by quickly contracting and
relaxing your arms and shoulders.
7. Vibrate for three or four exhalations over the area.
8. Encourage clients to "huff" cough before changing
positions.
9. Assess vital signs, pulse oximetry, and auscultate
breath sounds.
10. Don gloves.
11. Measure and note character of expectorated
secretions, then discard.
12. Remove gloves and perform hand hygiene.
13. Provide oral hygiene.
14. Document procedure and client's response.
E. Using an Airway Clearance System (Wrap)
1. Validate physician's order for high-frequency chest
wall oscillation therapy, frequency, and duration of
therapy.
2. Perform hand hygiene.
3. Identify client by name and birth date.
4. Provide privacy.
5. Explain function and purpose of vest/wrap.
6. Assess lung sounds before therapy.
7. Elevate head of bed or have client sit in chair.
Alternately, place wrap on bed and roll client onto
wrap.
8. Apply wrap over single layer of clothing, wrapping
deflated vest around client's chest, just beneath axillae;
have client inhale deeply; and secure with Velcro
fasteners.
9. Adjust generator to a comfortable working height.
10. Lock generator castors.
11. Slide air hose into connector port on front of
generator using a twist and push motion.
12. Slide other end of hose into disposable vest slits.
13. Fasten Velcro loops to secure air hoses in position.
14. Plug the power cord into the power inlet on back of
air pulse generator.
15. Plug power cord into grounded outlet.
16. Adjust arrows up or down to set frequency,
pressure, and treatment time, confirming that setting on
screen matches those prescribed.
17. Press "ON" button to inflate disposable vest.
18. Press "OFF" button to end treatment before set time
and wrap will deflate. "Session complete" message will
show on screen when treatment set time is complete and
wrap will deflate.
19. Unplug system and remove disposable air hoses and
vest from client.
20. Store vest and air hoses in client's area and return
generator to storage for future use.
21. Reassess client's breath sounds; note character and
amount of coughed/suctioned secretions.
22. Assist client to a comfortable position.
23. Perform hand hygiene.
Nasogastric Tube Insertion
Objectives: Students will be able to demonstrate the steps for inserting a nasogastric tube safely and correctly.
➢ Procedure Check List
Trial Trial Trial
PROCEDURE STEPS Mark Comment
1 2 3
1. Perform hand hygiene and gather supplies.
2. Visually inspect condition of patient's nasal and oral
cavities.
3. Assess for the best nostril before you begin by
occluding one side and asking the patient to sniff. Ask
the patient about previous injuries or history of a
deviated septum.
4. Palpate patient's abdomen for distension, pain, and/or
rigidity. Auscultate for bowel sounds.
5. Assess patient's level of consciousness and
understanding of procedure.
6. Check doctor's orders for type of NG tube to be
placed and reason for placement.
7. Check doctor's orders to determine whether the NG
tube is to be attached to suction or a drainage bag.
8. Position patient sitting up at 45 to 90 degrees (unless
contraindicated), with a pillow under the head and
shoulders.
9. Raise bed to a comfortable working height.
10. Place a towel on the patient's chest and provide
facial tissues and an emesis basin.
11. Provide patient with drinking water and a straw if
the patient is not fluid restricted.
12. Stand on patient's right side if you are right-handed
and the left side if you are left-handed.
13. Measure distance of the tube from the tip of the
nose, to the earlobe, to the xiphoid process and then
mark the tube at this point.
14. Lubricate NG tube tip.
15. Curve 10 to 15 cm of the end of the NG tube around
your gloved finger, and then release it.
16. Have patient drop head forward and breathe through
the mouth.
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PROCEDURE STEPS Mark Comment
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17. Insert NG tube tip slowly into the patient's nostril
and advance it steadily, in a downward direction, along
the bottom of the nasal passage, with the curved end
pointing downward in the direction of the ear on the
same side as the nostril.
18. If slight resistance is felt, twist the tube slightly,
apply downward pressure, and continue trying to
advance the tube. If significant resistance is felt,
remove the tube and allow the patient to rest before
trying again in the other nostril.
19. If difficulty persists, ask the patient to sip water
slowly through a straw (unless oral fluids are
contraindicated) or ask the patient to try dry swallowing
while advancing the tube. Check that the tube is not
coiled in the back of the mouth.
20. Continue to advance NG tube until you reach the
mark/tape placed for measurement.
21. Temporarily anchor the tube to patient's cheek with
a piece of tape until placement is checked.
22. Verify tube placement according to agency policy.
Use color-coded pH paper to check for acidic contents
(pH <5). If pH is more than 6, remove the tube.
Confirm placement by X-ray prior to using NG tube for
feeding.
23. Once tube placement has been confirmed, mark and
record the length of tubing extending from the nose to
the outer end of the tube.
24. Secure the tube to the patient's gown with a safety
pin, allowing enough tube length for comfortable head
movement.
25. Document the procedure according to agency
policy, and report any unexpected findings to the
appropriate health care provider.
Tube Feeding
Objectives: Students will be able to correctly prepare and administer tube feeding and maintain tube site and equipment.
➢ Procedure Check List
Trial Trial Trial
PROCEDURE STEPS Mark Comment
1 2 3
1. Wash hands.
2. Store unopened products at room temperature, not in
direct sunlight; shake can or bottle well and wipe the
top clean prior to opening.
3. Gather supplies: correct tube feeding formula,
feeding pump (if on continuous feeding), feeding set
(bag set or spike set), 60 ml syringe, 50 ml water, and
graduated container.
4. Position patient: propped up in bed at least 30
degrees (head raised) or sitting up in a chair.
5. Assess abdomen for distention.
6. Elevate head of the bed to at least 30 degrees.
7. Insert 60 ml syringe into port and pour feeding
product into syringe.
8. Add formula to drain by gravity.
9. Add more formula until the desired amount is
infused.
10. Flush with 50 ml of water.
11. Cap the tube.
12. Remain in upright position for at least one hour
after feeding.
13. Rinse equipment thoroughly. Clean tube feeding
bag sets with soap and water, running soapy water
through tubing; rinse with water to remove all soap.
Clean syringes with soap and water or place in
dishwasher on top rack.
14. Clean the tube site daily with soap and water and
perform site care per doctor's orders.
15. Administer formula at room temperature. Cover any
unused product, store in the refrigerator, and discard if
not used within 24 hours.
Enema
Objectives: Students will be able to correctly administer an enema procedure.
➢ Procedure Check List
Trial Trial Trial
PROCEDURE STEPS Mark Comment
1 2 3
1. Verify the order for the enema. Gather equipment.
2. Perform hand hygiene and put on PPE, if indicated.
3. Identify the patient.
4. Explain the procedure to the patient.
5. Assemble equipment on overbed table within reach.
Warm the enema solution to body temperature by
placing the container in a bowl of warm water.
6. Close the curtains around the bed and close the door
to the room, if possible. Discuss where the patient will
defecate. Have a bedpan, commode, or nearby
bathroom ready for use.
7. Adjust the bed to a comfortable working height.
Position the patient on the left side (Sims' position).
Fold top linen back just enough to allow access to the
patient's rectal area. Drape the patient with the bath
blanket. Place a waterproof pad under the patient's hip.
8. Put on gloves.
9. Remove cap of prepackaged enema solution. Apply a
generous amount of lubricant to the tube.
10. Lift buttock to expose anus. Ask the patient to take
several deep breaths. Slowly and gently insert the rectal
tube 3 to 4 inches (7 to 10 cm) for an adult.
11. Compress the container with your hands. Roll the
end up on itself, toward the rectal tip. Administer all the
solution in the container. Assess for dizziness,
lightheadedness, nausea, diaphoresis, and clammy skin
during administration.
12. Remove the container while keeping it compressed.
Have paper towel ready to receive tube as it is
withdrawn.
13. Instruct the patient to retain the enema solution for
at least 30 minutes or as indicated.
14. Remove your gloves. Return the patient to a
comfortable position. Make sure the linens under the
patient are dry and ensure that the patient is covered.
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PROCEDURE STEPS Mark Comment
1 2 3
15. Raise side rail. Lower bed height and adjust head of
bed to a comfortable position.
16. Remove additional PPE, if used. Perform hand
hygiene.
17. When the patient has a strong urge to dispel the
solution, place him or her in a sitting position on
bedpan or assist to commode or bathroom. Stay with
the patient or have call bell readily accessible.
18. Remind the patient not to flush the commode before
you inspect the results of enema, if used for bowel
evacuation. Record character of stool, as appropriate,
and the patient's reaction to the enema.
19. Leave patient clean and comfortable. Care for
equipment properly.
20. Perform hand hygiene.
21. Document the amount and type of enema solution
used; length of time retained by the patient; amount,
consistency, and color of stool, as appropriate; any
abnormality.
Colostomy Care
Objectives: Students will be able to correctly perform colostomy care including pouching system change.
➢ Procedure Check List
Trial Trial Trial
PROCEDURE STEPS Mark Comment
1 2 3
1. Perform hand hygiene.
2. Gather supplies: flange, ostomy bag and clip,
scissors, stoma measuring guide, waterproof pad,
pencil, adhesive remover for skin, powder, wet cloth,
non-sterile gloves, and additional cloths.
3. Identify the patient and review the procedure.
Encourage the patient to participate as much as possible
or observe/assist patient as they complete the
procedure.
4. Create privacy. Place waterproof pad under pouch.
5. Apply gloves. Remove ostomy bag, and measure and
empty contents. Place old pouching system in garbage
bag.
6. Remove flange by gently pulling it toward the stoma.
Support the skin with your other hand. An adhesive
remover may be used.
7. Clean stoma gently by wiping with warm water. Do
not use soap.
8. Assess stoma and peristomal skin. A stoma should be
pink to red in colour, raised above skin level, and moist.
9. Measure the stoma diameter using the measuring
guide (tracing template). Trace diameter of the
measuring guide onto the flange, and cut on the outside
of the pen marking. The opening should be 2 mm larger
than the stoma size. Keep the measurement guide with
patient supplies for future use.
10. Prepare skin and apply accessory products as
required or according to agency policy.
11. Remove inner backing on flange and apply flange
over stoma. Leave the border tape on. Apply pressure.
Hold in place for 1 minute to warm the flange to meld
to patient's body. Then remove outer border backing
and press gently to create seal.
12. Apply the ostomy bag. Attach the clip to the bottom
of the bag.
13. Hold palm of hand over ostomy pouch for 2
minutes to assist with appliance adhering to skin.
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PROCEDURE STEPS Mark Comment
1 2 3
14. Clean up supplies, and place patient in a
comfortable position. Remove garbage from patient's
room.
15. Perform hand hygiene.
16. Document procedure: appearance of stoma and
peristomal skin, products used, and patient's ability to
tolerate procedure and assistance with procedure.