SURGICAL HANDWASHING

Name: Ang, Kathleen T. Grade: Legend:

1- Excellent
Year and Section: BSN 2B Date: November 2, 2020
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
PREPARATION
1. Deep sink with foot or knee controls for This promotes the prevention of
dispensing water and soap (faucets should be high contact to any surfaces therefore
enough for hands and forearms to fit comfortably prevents contamination and it allows
ease of movement in washing.
2. Antiseptic detergent/soap This is to reduce the risk of infection by
reducing the germs present.
3. Surgical scrub brush with plastic nail and pick It provides additional decontamination
and enhances effectivity.
4. Mask, cap or hood This is to prevent contamination from
pathogens and minimizes risk of
infection in the cephalic portion of the
body.
5. Sterile towel This is to dry one’s hands without
contamination from microorganisms.
6. Scrub suit attire It is used to prevent cross
contamination, it can be easily washed
and changed.
7. Protective eyewear (glasses or googles) It is used as protection to the eyes to
prevent entry of any materials and
microorganisms.
ASSESSMENT
1. Consult institutional policy regarding length of It is to ensure the principles are upheld
time of hand wash. and observe the proper hand washing
techniques with the right contact time.
2. Be sure fingernails are short, clean and healthy. This is observed to ensure that
Artificial nails, nail polish should be removed. cleanliness is observed and hands are
free from contaminants.
3. Inspect condition of cuticles, hands, and This is to mitigate portals of entry and
forearms for presence of abrasions, cuts, or open risk of infection.
lesions.
4. Be sure if wearing a two-piece pants and top To prevent the top from hanging down
scrub suit that the top is secured at the waist and and it contributes in maintaining a
tucked into the pants. sterile environment.
DIAGNOSIS
Defining characteristics from the assessment date Preparedness promotes mitigation and
may reveal the following nursing diagnoses for assessment of risks. Therefore, prevents
clients requiring these skills: the likeliness of these risks to
- Risk for infection aggregate.
- Risk for injury

(Related factors are individualized based on client’s

condition or needs).
PLANNING
Expected outcomes following completion of This is to promote efficiency and
procedure: specificity.

Client will not develop signs of surgical wound

infection

1. Prepare equipment
2. Remove watch, rings or bracelets. Inanimate objects can bear
microorganisms and could potentially
be the cause of infection and defeat the
purpose of promoting a sterile
environment.
3. Be sure sleeves are above elbows and uniform is This is to prevent and lessen the contact
fitted or tucked at waist. of the clothes to the sterile
environment and decrease the likeliness
of contamination.
 IMPLEMENTATION
1. Apply surgical attire: shoe covers, cap or hood, This serves as protection to one’s self
face mask and protective yowler. from the external environment.
2. Turn on water knee or foot controls and adjust This is to avoid contact of the hand and
to comfortable temperature. arms to any surfaces, the temperature
of the water has no effect in effectivity.
3. Wet hands and arms under running lukewarm This is to keep the flow of water from
water and lather with detergent/soap up to 2 the hands to the elbows, thus sliding
inches above the elbows (Hands need to be held the water contaminated area up to the
above elbows at all times). least contaminate area.
4. Rinse hand and arms thoroughly under running The use of running water is to wet the
water. Remember to keep hands above elbows. arms well, this allows macroparticles to
slide off.
5. Under running water, clean under nails both This eliminates the trapped
handles with file. Discard after use. particles/dirt that contains germs.
6. Wet brush and apply antimicrobial Soap promotes the breaking of surface
detergent/soap. tension and breaks lipids, which are
basically what encloses bacteria.
7. Scrub the nails of one hand with 15 strokes. This is to clean the cuticle, nail beds,
and the area under the nails.
8. Holding brush perpendicular, scrub the palm, Brushing aids in removal of any
each side of the thumb and fingers and the contaminants present in the skin.
posterior side of the hand with 10 strokes each.
9. The arm is mentally divided into thirds and each This is to ensure that every area is
is scrubbed 10 times. thoroughly cleaned.
10. Entire scrub should last at least 2-3 minutes. The contact time for the soap to truly
follow its function which is to clean.
11. Rinse brush and repeat the sequence for the To have both equally clean arms before
other arm. participating in the operating room.
12. Discard brush and rinse hands and arms This is to make sure that no one will use
thoroughly. Turn off water with foot or knee the brush again, for it is tainted with
control and back into room entrance with hands bacteria already. This method prevents
elevated in front of and away from the body. contamination of the hands.
13. Bending slightly forward at the waist, use a This is to ensure that the hands are the
sterile towel to dry one hand thoroughly moving cleanest. This method is drying the
from fingers to elbow. Dry in a rotating motion. washed area by maintaining the
Dry from cleanest to the least clean area. cleanliness.
14. Repeat drying method for the other hand, Previously used towel isn’t ensured that
using a different area of the towel or a new sterile it is free from microorganisms, so a new
towel. one must be used for the other hand.
EVALUATION:
1. Observe the client for signs of localized wound It is performed so that care is provided
infection. (Usually occurs 2-3 days postoperative) immediately for inspection control.
ATTIDUE OF THE STUDENT:
21. Accept constructive suggestions and criticisms. It is done to make room for
improvements
22. Assumes accountability. Allows us to be responsible of our
actions.

Scoring:
1x =

2x =

3x =

4x =

5x =

Total divided by no. of items =

Comments:

Kathleen T. Ang
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name

OPEN GLOVING Name: Ang,

Kathleen T. Grade: Year and Section:

BSN 2B Date: November 2, 2020 Legend:

1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
PREPARATION
1. Clean and flat surface To be able to maintain sterility
and provide adequate space in
performing the procedure.
2. Mask, cap or blood To prevent contamination
from microorganisms in the
mouth and hair.
3. Sterile gloves To maintain sterility.
4. Scrub suit It is done to prevent cross
contamination.
ASSESSMENT
1. Check the expiration date of the sterile gloves. To ensure that the gloves are
in high quality and fit for use.
2. Sterile gloves should be sealed, free form tears and not Gloves with tear or defect
crumpled. must be disposed properly
3. Fingernails should be short, clean and healthy. This is done to avoid rupturing
the gloves.
4. The top portion of the scrub suit should be secured at the To prevent the top from
waist and tucked into the pants. hanging down and it
contributes in maintaining a
sterile environment.
5. Make sure that you are not allergic to the sterile gloves. Done to avoid skin irritations,
one may opt to use a latex or
non-latex glove.
DIAGNOSIS
Defining characteristics from the assessment data my reveal To be able to make a quality
the following nursing diagnosis for clients requiring the skill: plan of care that is unique to
Risk for Infection) the patient.
(Related factors are individualized based on the client’s
conditions and needs).
PLANNING
1. Expected outcomes following completion of the For continuous flow of
procedure: procedures.
2. Prepare the equipment. To preserve time and energy.
3. Sleeves should be above the elbows and uniform is fitted To prevent the sleeves from
or tucked at the waist. being in the way during the
procedure.
IMPLEMENTATION
1. Do surgical handwashing It is done to cleanse one’s
hand from pathogens and
promote cleanliness
2. Open the package of the sterile gloves. This is done to ensure that the
 Place the package of the gloves on a clean dry gloves used conforms to the
surface. standard that describes
 Some gloves are packed in an inner as well as an quality.
outer package. Open the outer package without To maintain cleanliness.
contaminating the gloves or the inner package. To maintain sterility.
 Remove the inner package from the outer package. To ensure that there’s no tear
 Open the inner package as above or according to the To ensure it’s not been used.
manufacturer’s directions. Some of the In opening the package, we
manufacturer’s provide a numbered sequence for must follow the proper way in
opening the flaps and folded tabs to grasp for order to maintain the
opening the flaps. If no tabs are provided, pluck the cleanliness and the sterility of
flap so that the fingers do not touch the inner the gloves.
surfaces.
 Remove the envelop powder from the inside of the
right glove wrist without touching the outside of the
gloves.
  Powder the hands over a waste basket. The powder
that falls from the hands is no longer sterile so
powder hands away from the sterile objects.
3. Put the first glove on the dominant hand. The first glove is To prevent transmission of the
drawn with the left hand-grasping the cuff of the right glove microorganisms and
on the fold, pick up the glove and step back from the table. contamination of the inner
 If the glove is packed so that they lie side by side, wrapper. It also helps
grasp the glove for the dominant hand by its cuff (on maintain the sterility of the
the palmar side) with the thumb and the first finger equipment. It should be
of the non-dominant hand. Touch only the inside of dominant hand who should
the cuff. handle the procedure of doing
 Insert the dominant hand into the glove and pull the gloving.
glove on. Keep the thumb of the inserted hand
against the palm of the hand during insertion.
 Leave the cuff turned down.
4. Put the second glove on the non-dominant hand. Slip the To maintain the sterility of the
fingers of the right gloved hand under the turned back cuff gloves. One must be cautious
of the left glove, pick it up, step back and removed from the in tearing the gloves as it
inside of the cuff. might carry any
 Pick up the other glove with the sterile gloved hand, microorganisms which causes
inserting the gloved fingers under the cuff and infections. Keep a perfect or
holding the gloved thumb close to the gloved palm. right fit to the fingers and on
 Pull the second glove carefully. Hold the thumb of the whole hand.
the first gloved hand as far as possible from the
palm.
 Adjust each glove so that it fits smoothly and
carefully pull the fingers under the cuffs.
 The cuff is turned up by manipulating only the sterile
surfaces of the glove and not that which has come in
contact with the hand.
5. Remove and dispose used gloves. To avoid the spread of
contamination.
6. If a sterile gown is worn, it should be put on before the To be able to maintain the
gloves, in order that the glove cuffs maybe drawn up over its sterility and to prevent the risk
sleeves. of transmission of
 Turn over the pleat on the cuff of the left sleeve and microorganisms.
hold it with the right thumb with the fingers of the
right cuff of the left sleeve, avoid touching the glove.
EVALUATION:
Observe the client for signs of localized wound infection To promote immediate care
(usually occurs 2-3 days postoperative). and ease feeling of discomfort
of the patient.
ATTIDUE OF THE STUDENT:
21. Accept constructive suggestions and criticisms. To learn and correct one’s
mistakes.
22. Assumes accountability. To take responsibility of one’s
actions.

Scoring:

1x =

2x =

3x =

4x =

5x =

Total divided by no. of items =

Comments:

Kathleen T. Ang
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
 CLOSED GLOVING

Name: Ang, Kathleen T. Grade: Legend:

1- Excellent
Year and Section: BSN 2B Date: November 2, 2020 2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
Using the closed-glove technique, put on the To maintain sterility.
sterile gloves.
1. With your left hand still inside the gown, pick up the
folded edge of the right glove.
2. Hold your right hand out, with palm up still inside the To maintain the sterile field.
sleeve.
3. Lay the right on the right hand (which is still inside For easy access in wearing the
the sleeve). Position it with the gloved fingers printing gloves.
towards the fingertips. The thumb of the glove should
be over the thumb of your right glove.
4. Use your right hand (which is still inside the sleeve) Do a sterile touch to prevent cross
to grasp the bottom fold of the cuff end of the right contamination.
glove.
 You are touching sterile gown to sterile glove.
5. With your left hand (which is still inside the gown To prevent hands from being
sleeve), grasp the right glove cuff by the top fold of the contaminated.
duff end, and pull the right glove cuff up and over the
right gown cuff.
6. Adjust the right glove cuff over the right gown cuff as For easier placement of gloves.
necessary, keeping the left hand inside the gown.
7. Work your right hand down into the glove. To maintain the sterility of the
 If the fingers are not in place, don’t worry you gloves to prevent contact from
can correct them when both gloves are on. microorganisms.
8. Pick up left glove with the gloved right hand. Helps in the sterility of the glove.
9. Hold your left hand, palm up, inside the gown sleeve. To prevent the hands from
spreading the contamination into
the sterile glove.
10. Place the left glove on the left palm (which is still For easier or better access when
inside the gown), with glove fingers pointing toward the extending the fingers into the glove
elbow and the cuff end pointing toward your fingertips. and to maintain sterility of the
glove.
Position the glove thumb over the left of your hand.
11. Use your left hand (which is still inside the sleeve) to To prevent cross contamination.
grasp the bottom fold of the cuff end of the left cuff.
12. Grasp the top of the cuff edge with the gloved right To provide proper closed sterile
hand, and pull the glove cuff up and over the gown cuff. method for gloving.
13. Work your left hand down into the left glove. To maintain the sterility of the
glove.
14. Turn up and adjust the cuffs of both gloves. To promote dexterity of gloved
hands.
15. Pull the glove fingers out at the ends to reposition To promote comfort and for proper
our fingers if necessary. fitting of gloves into the hands.

Scoring:
1x =

2x =

3x =

4x =

5x =

Total divided by no. of items =

Comments:

Kathleen T. Ang
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
Name: Ang, Kathleen T.
GOWNING TECHNIQUE 1- Excellent

Grade: Legend:
Year and Section: BSN 2B Date: November 2, 2020 2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
1. Reach down top the sterile table and grasp the whole gown To maintain the sterility
directly upward. of the gown.

2. Step far enough away from non-sterile area or objects. To keep the gown sterile.
3. Hold the neckband with both hands and gently shake the folds To prepare in wearing the
of the gown. gown.
4. Slip the hands into the armholes, holding hands upward in the To prevent the gown
level with the shoulder. from touching the non-
sterile objects and to
ensure that only sterile
items come in contact
with sterile items.
5. Swing belt to be tied at the back by the circulating nurse. To provide complete
coverage and to prevent
contamination from the
gown flapping.

Scoring:

1x =

2x =

3x =

4x =

5x =

Total divided by no. of items =

Comments:

Kathleen T. Ang
Student’s Signature over Printed
Name Clinical Instructor’s Signature and Date over
Printed name

GOWNING AND GLOVING THE SURGEON

Name: Ang, Kathleen T. Grade:

Legend:
Year and Section: BSN 2B Date: November 2, 2020 1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
A. GOWNING THE SURGEON:
1. Open hand towel and hold end part for the Surgeon to grasp To maintain the sterility.
the opposite end of the towel.
2. Grasp the gown in one hand. To prevent
contamination.
3. Shake out stretched hands holding it at the neckband. To avoid contamination
and preparation of suiting
on.
4. Offer inside of the gown to the surgeon. For better access of
putting the surgeon’s
hands inside.
5. Release the gown. For easier suiting of the
gown.
 B. GLOVING THE SURGEON:
1. Squeeze lubricant or powder on the surgeon’s palm To make it easier for the
surgeon to slide in the
hand.
2. Grasp the right glove firmly with the four gingers under the To avoid glove
turned back-cuff. contamination.
3. The palm of the glove should be facing the surgeon. Stretch To allow access and
the cuff enough to introduce his hands. proper positioning of the
glove in order to easily
slide the hands in place.
4. The surgeon place his hand into the glove. Unfold the turned To properly seal the glove
back cuff of the glove over his sleeve. to avoid contamination.
5. Repeat procedure for the left hand. To prepare for
sterilization.
6. Discard wrapper into the waste container. To control transmission of
microorganisms and
infection.

Scoring:

1x =

2x =

3x =

4x =

5x =

Total divided by no. of items =

Comments:

Kathleen T. Ang
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
ASSISTING DELIVERY

Name: Ang, Kathleen T. Grade:

Legend:
Year and Section: BSN 2B Date: November 2, 2020 1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
STEPS
Preparation and Action of a student nurse Assisting the Delivery:
Assisting Nurse:
1. Preparation of equipment To save time and energy.

1.1 Get OB pack To prepare and avoid

o Place it in the mayo table delays. Mayo table is
used to keep instruments
upon the procedure.
1.2 Check the OB pack To allow a smooth flow of
o Check if the instruments are complete doing the procedure.
1.3 Open the outer lining of the OB pack To promote sterility.
o Use bare hands in opening the outer lining
1.4 Open the outer lining of the pack To avoid cross
o Use sterile picking forceps facing down when contamination of
opening the inner lining of the OB pack. instruments.
1.5 Prepare additional equipment To easily access needed
o Put the additional instruments to the open OB instruments.
pack
2. Actions: To prevent transmission
2.2 Do surgical hand washing of microorganisms.
 2.3 Do gowning and gloving To promote an aseptic
o Strictly follow the principles of gowning and environment.
gloving.
2.4 Arrange the equipment acceding to use For better access and
smooth flow of procedure
ATTITUDE
1. Accept constructive criticism and suggestion To improve learnings and
correct mistakes.
2. Accept responsibility of his/her action To be accountable of
one’s actions.

Scoring:
1x =
2x =
3x =
4x =
5x =
Total divided by no. of items =
Comments:

Kathleen T. Ang
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
HANDLING DELIVERY

Name: Ang, Kathleen T. Grade:

Legend:
Year and Section: BSN 2B Date: November 2, 2020 1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
PREPARATION AND ACTION OF A STUDENT NURSE ASSISTING
THE DELIVERY:
Handling Nurse:
1. Preparation To save time and energy,
 To be done with the assisting nurse and avoid delays.
2. Action
2.1 Do surgical handwashing To prevent transmission
 To be done with the assisting nurse of microorganisms.
2.2 Perform gowning and gloving To maintain sterility.
2.3 Do draping Provide comfort and
privacy to the mother.
Drape the patient accordingly:
1. legging (left & right) To help isolate from the
perineal area.
2. abdominal drape To firmly seal the edge of
the fenestration of the
client’s skin.
3. perineal drape (to support the perineum) To perform operations on
the perineum genitalia
with the client in
lithotomy position.
4. baby drape
2.4 handle the delivery of the fetus To observe the progress
 Slide your hands to the neck and the baby of the of the labor.
fetus as it delivered smoothly and easily.
2.5 Place the baby to the mother’s abdomen Aids in increasing the
2.6 Clamp the cord 810 inches away from the volume of umbilical cord
umbilicus with Kelly forceps one-inch apart clamp and blood collected.
cut with scissors in between.
2.7. Proceed with the delivery of placenta To interrupt the blood
 Hold the forceps connecting the placenta and wait flow of the umbilical
3-5 mins for sign of placenta separation cord.
 Slowly pull cord while the other hand exerts a Proper flexion lets the
slight pressure above the mons pubis. baby out easier.
2.8 Once delivered, place placenta on the bowl and inspect the
completeness of its part. To ensure there are no
 Take note of the methods of separation residues left inside the
mother and that the
placenta and other
membranes have been
completely removed to
prevent infection.
When the separation
occurs, surface area of
the uterus shrinks and
helps in cutting off the
blood flow.

2.9 Assist in suturing the episiotomy To close the incision as

 Anticipate doctor’s need during suturing well as to repair any tears
and to lessen discomfort.

2.10 Flush site with normal saline. Aids in treating minor

2.11 Apply betadine antiseptic wounds and prevent
infections.

2.12 Apply sanitary pad/adult diaper Prevention of leaking.

 2.13 Do after care: To keep the area clean
 Position the mother comfortably-legs closed and sterile.
 Remove stained draper
 Take vital signs immediately Ensure a rhythmic
 Check the instruments if complete baseline data.
 Wash the instrument and let these dry
 Pack clean equipment and autoclave
ATTITUDE
1. Accepts constructive suggestions and criticisms To improve learnings and
correct mistakes.
2. Assume responsibility of his or her actions. To be accountable of
one’s actions.

Scoring:
1x =
2x =
3x =
4x =
5x =
Total divided by no. of items =

Comments:

Kathleen T. Ang
Student’s Signature over Printed Clinical Instructor’s Signature and Date over
Name Printed name
IMMEDIATE NEWBORN CARE

Name: Ang, Kathleen T. Grade: Legend:

1- Excellent
Year and Section: BSN 2B Date: November 2, 2020 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 energy,
and avoid delays.

1.1 Cebu Puericulture Center and Maternity Inc.

(CPCMHI)
Cord clamp
Sterile OC (3-4 pcs)
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
Sterile OS (3-4 pcs)
Sterile Cotton balls (2-3 pcs)
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
2. Prepare the room temperature of the delivery room. To reduce the risk of
Room temperature should be 25-28 C. hypothermia and
hyperthermia to the
newborn.
3. Notify appropriate staff. To ensure quality care is
provided to the patient,
and quality work in the
healthcare setting.
4. Arrange needed supplies in linear fashion. To promote smooth flow
of procedure.
5. Check resuscitation equipment. To prepare and take
instant response in the
event that a problem may
occur.
6. Wear face mask and bonnet properly. To avoid transmission of
microorganisms.
7. Wash hands with clean water and soap. To remove any
microorganisms.
8. Don’t double glove just before delivery. To reduce the risk of
glove perforation.
9. Within first 30 second;
9.1 Dry the newborn thoroughly for at least 30 seconds. To provide warmth to the
9.2 Do a quick check of breathing while drying. (do not newborn.
suction unless the mouth/nose are blocked with
secretions or other materials)
9.3 Wipe the eyes, face, head, front and back, arms and Vernix caseosa protects
legs. (DO NOT wipe off the vernix caseosa) the baby from infections.
9.4 Remove the wet cloth. Prevent the baby from
losing normal body
temperature.
10. After 30 seconds, if newborn is breathing and crying,
10.1 Position the newborn prone on the mother’s To keep the mother and
abdomen or chest. baby warm, and helps the
10.2 Cover the newborn’s back with a dry blanket. baby to encourage
10.3 Cover the newborn’s head with a bonnet/cap. breastfeeding.
11. After 1-3 minutes, properly time cord clamping.
11.1 Remove the first set of gloves. To avoid contamination
and transmission of
microorganisms.

11.2 After the umbilical pulsations have stopped, lamp 2 cm gives enough space
the cord using a sterile plastic clamp at 2cm from the from the umbilical cord to
base. prevent from bleeding.

11.3 Do not milk the cord towards the baby. To prevent the baby from
11.4 Clamp again at 5 cm using Kelly forceps from the taking in blood.
base.
11.5 Cut the cord close to the plastic clamp.
12. Place the identification band on ankle (not wrist) of It is placed in the ankle to
corresponding gender. prevent becoming loose
12. 1 CPCMHI – left ankle or get lost in blankets and
12.2 VSMMC – both ankles linens.
13. Leave the newborn in skin-to-skin contact.
13. 1 Observe for feeding cues, including tonguing, To encourage and give
licking, rooting. support for
13.2 Point these out to the mother and encourage her to breastfeeding.
nudge.

14. After 90 minutes, remove the newborn from mother’s To prepare for newborn
abdomen. care.
15. Transfer the newborn to the work table. To prevent the baby from
falling.
16. Weigh the newborn to the work table. To determine the weight
and documentation
purposes.
17. Perform physical assessment of the newborn and do To identify any illnesses
APGAR scoring. and ensure there are no
complications.
18. Perform Anthropometric measurement To assess any
18.1 Head circumference abnormalities and to
18.2 Chest circumference ensure there is no
18.3 Mid arm malformations.
18.4 Body length
19. Take the rectal temperature Rectal temperature gives
the most accurate
temperature of the baby.
20. Inject Vitamin K To prevent a serious
20.1 CPCMHI – left thigh disease called
20.2 VSMMC – right thigh hemorrhagic disease of
the newborn.

21. Apply eye prophylaxis. To avoid eye infection.

22. Put on baby’s clothes. To give warmth.
23. Wrap the baby with baby’s blanket To avoid hypothermia.
24. Obtain heart rate and respiratory rate. To determine any
abnormalities.
 25. Show the baby to the mothers. Latch on the baby to the To encourage
mother’s breast. breastfeeding which gives
accurate nutrients to the
baby.
26. Documentation immediately after cord care and latch on. To monitor and maintain
the standard of care
given to the patient.
27. Do after care. For cleanliness and
sanitation.
ATTITUDE
28. Accept constructive suggestions and criticism. For self’s improvement.
29. Assume responsibility of his/her action. For one to be responsible
of one’s actions.

Scoring:
1x =
2x =
3x =
4x =
5x =
Total divided by no. of items =
Comments:

Kathleen T. Ang
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
PERINEAL CARE

Name: Ang, Kathleen T Grade: Legend:

1- Excellent
Year and Section: BSN 2B Date: November 2, 2020 2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
1. Introduce yourself and explain the procedure to the patient. To build rapport to the
patient. To promote
cooperation and
participation.
2. Provide privacy. To provide comfort
respect to the patient.
3. Bring equipment and supplies to the bedside. Bring the tray To save time and energy,
with lining containing the following: and avoid delays.
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
e. absorbent pad/cotton draw sheet
f. clean gloves
g. waste receptacle
h. screen for ward use
i. rubber sheet
j. pail
k. kidney
l. bed pan
4. Protect the bed with an absorbent pad. To prevent leaking.
[Link] the client on the bed pan in a dorsal recumbent position. Allow patient to urinate
to prevent interruption
during care.
6. Drape the client with a bath blanket to permit exposing just To give privacy to your
the perineal area. patient.
7. Wash your hands. To prevent transmission
of microorganisms.
8. Don on clean gloves. To avoid transmission of
microorganisms and
promote sterility.
9. Wash upper and inner thighs with lukewarm water. Wipe build up of perineal
secretion soils
surrounding the area.
10. Separate labia with non-dominant hand. Pour warm irrigating To prevent rectal flora
solution gently over the vulva. from being contaminated
in the external genitalia.
11. Cleanse the perineal area with cherry balls soaked in betadine To lessen the spread of
cleanser held by a dressing forceps. Cleansing should be done any contaminated
from the vagina outward. Follow the figure below which shows secretions and ensure
the typical pattern for cleansing the perineal area, using 8 that the area is clean with
strokes. each stroke of section of
the washcloth.
 12. Rinse the scrubbed areas well. Remove the client from the To prevent any skin
bed pan. irritations and to give
comfort to your patient.
13. Dry the perineal area using dry cherry balls in the same To avoid spread of
fashion as in cleaning (step 11). microorganisms.
14. Help client to a side lying position and adjust the bath To give client comfort.
blanket.
15. Wash, rinse, and dry the anal area. Wipe from front to back. Wiping from front to back
reduces chance of
transmitting fecal
organisms to urinary
meatus.
16. Discard the soiled water, clean the equipment, dispose soiled To avoid the spread of
gloves and remove absorbent pad. any microorganisms.
17. Help client to a comfortable position and remove the bath To give client comfort.
blanket.
18. Wash hands. To remove any
microorganisms.
DOCUMENTATION
1. Record any significant problem such as; redness, excoriation, Information influence
swelling. Episiotomy should be noted for edema, inflammation, selection of skin care
separation or presence of hematoma. products and provide
care to the problem.
2. Note the amount, color, and odor of any discharge. To be able to determine
the problem upon the
secretions or discharges.
3. Document the client’s tolerance of the procedure. To determine client’s
ability to perform the car

Scoring:

1x =

2x =

3x =

4x =

5x =

Total divided by no. of items =

Comments:

Kathleen T. Ang
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name

FLEET ENEMA Name: Ang, Kathleen T.

Grade: Year and Section: BSN 2B

Date: November 2, 2020 Legend:

1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
PLANNING
1. Before administering enema, determine that there is a primary To determine how many
care provider’s order enemas client will
require, type of enema to
be given.
2. Equipment: To save time and energy,
2.1 Fleet Enema and avoid delays.
2.2 Disposable linen-saver pad/incontinent pad
2.3 bath blanket
2.4 clean gloves
2.5 bedpan or commode
2.6 water-soluble lubricant
2.7 paper towel
IMPLEMENTATION
3. Prior to performing the procedure, introduce yourself and To build good rapport to
verify the client’s identity. the patient and ensure it
is the correct patient.
4. Perform hand hygiene. Wear clean gloves and observe To avoid transmission of
appropriate infection control procedure. microorganisms.
5. Provide privacy To prevent
embarrassment and
provide comfort to the
client.
6. Place the bedpan or commode in position for patient who For the clients strictly on
can’t ambulate to the toilet or have difficulty with sphincter bed rest who wants to
control. urinate or defecate.
7. Assist the client to the left lateral position with the right leg as To facilitate the flow of
acutely flexed as possible. solution by gravity to the
sigmoid and descending
colon which are located
on the left side. Proper
flexion gives adequate
exposure of anus.
8. Lubricate about 5cm (2inches) of the rectal tube. Some For easier insertion and
commercially prepared enema set already have lubricated nozzle. prevents injury or trauma
9. Separate the buttocks and locate the rectum. To locate it easier and for
better visualization.
10. Instruct the patient that you will insert the nozzle and to take To avoid shock coming
a slow deep breath. from the insertion.
11. Insert the tube smoothly and slowly administer the solution The angle follows the
into the rectum directing towards the umbilicus. normal contour of the
rectum and the slow
insertion avoid spasms of
sphincter.
12. Roll up the plastic container as the fluid is instilled. To give comfort and for
patient’s safety.
13. Do after care. To promote cleanliness
and prevent transmission
of microorganisms.
14. Wash hands. To remove any
microorganisms.
15. Document the procedure. To monitor and maintain
the standard of care
given to the patient.
ATTITUDE
16. Accepts constructive suggestions and criticisms To make room for
improvement.
17. Assume responsibility of his or her actions. To be accountable of
one’s actions.
Scoring:

1x =
2x =
3x =
4x = _
5x =
Total divided by no. of items =
Comments:

Kathleen T. Ang
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
 INSERTING A STRAIGHT OR INDWELLING CATHETER: MALE

Name: Ang, Kathleen T. Grade:

Year and Section: BSN 2B Date: November 2, 2020

EQUIPMENT: Legend:
Indwelling or straight catheter 10 cc syringe, prefilled with water 1- Excellent
Urinary bag with drainage tubing Sterile KY Jelly 2- Very Satisfactory
Adequate lighting source Plaster and bandage scissor 3- Satisfactory
Disposable sterile gloves Warm water, soap 4- Needs Improvement
Towel, blanket Sterile forceps 5- Poor

PROCEDURE RATIONALE 1 2 3 4 5
[Link] the equipment needed. To save time and energy.
2. Provide for privacy and explain procedure. To preserve client’s
dignity, and promote
patient cooperation and
participation.
3. Provide client with opportunity to perform personal hygiene. To respect the autonomy
Assist as necessary. of client or have a
freedom to do their self-
care.
4. Wash hands. To avoid transmission of
microorganisms.
5. Obtain, prepare and arrange equipment according to use. To promote smooth flow
Carry at bedside. of the procedure and
 Open cleansing solution and pour over half of the sterile better access of
cotton ball. equipment.
 Attach the catheter to the urine drainage bag if it is not
connected.
6. Assist the client to a supine position. For better visualization of
the area and easier
access upon inserting the
catheter.
7. Drape legs to midthigh. Position rubber sheet on buttocks. To give privacy and
comfort to patient.
8. Ensure adequate lighting of the perineal area. To have a clearer
visualization of the area.
9. Pull on sterile gloves. To maintain sterility.
10. Place fenestrated drape over client’s genitalia. To provide a sterile field
for the procedural site
and lessen accidental
contamination in the
adjacent areas.
11. With non-dominant hand. Hold penis at 90 angle to his body. Lifting the penis helps
If uncircumcised, pull down foreskin with his hand to visualize straighten the urethra.
urinary meatus. (This hand is now unsterile).
12. Using the sterile forceps, pick up antiseptic solution saturated To minimize the risk of
cotton ball. Cleanse meatus with one downward stroke or use UTIs through removing
circular motion from meatus to base of penis. surface pathogens.
13. With sterile hand, pick up catheter and lubricate generously To facilitate insertion,
6-4 inches from tip. and prevent pain and
discomfort.
14. gently insert catheter into urethra approximately 6-8 inches To avoid trauma upon
until urine begins from tip. insertion.
 If catheter resist entry, ask patient to breath deeply and
rotate catheter slightly another inch and allow bladder to
empty and remove straight catheter.
15. If using straight catheter. Insert catheter another inch and To drain the bladder.
allow bladder to empty and remove straight catheter.
16. If using indwelling catheter. Continue inserting 1-3 inches. To ensure proper
insertion.
17. attach the water-filled 10 cc syringe to the inflation port. To anchor the catheter.
Inflate the retention balloon.
18. Check placement by gently pulling catheter until balloon is To maximize the
resting snugly against the bladder neck. (Resistance will be felt continuous bladder
when balloon is in place).
 drainage and prevent
urine leakage.
19. Tape catheter securely to the abdomen. To prevent the catheter
from moving around and
to secure in place.
20. Attach drainage bag to bed frame, below the level of the To maximize the
bladder. Make sure the tubing lies over, not under the leg. Do not continuous drainage of
let it rest on the floor. urine from the bladder.
21. Remove the discard gloves. Do after care and wash hands. To reduce transmission of
microorganisms.
22. Do proper documentation: time the procedure was To monitor and maintain
completed, size & type of catheter used, client’s response and the standard of care
amount, color quality of urine. given to the patient.
Scoring:

1x =

2x =

3x =

4x =

5x =

Total divided by no. of items =

Comments:

Kathleen T. Ang
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
 ROUTINE CATHETER CARE

Name: Ang, Kathleen T. Grade:

Year and Section: BSN 2B Date: November 2, 2020

EQUIPMENT: Legend:
Antiseptic Solution 1- Excellent
Sterile swabs 2- Very Satisfactory
Clean Gloves 3- Satisfactory
Washcloth, soap and water 4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
1. Wash hands. To reduce transmission of
microorganisms.
2. Check institutional protocol or care plan To avoid any error and
provide quality care to
the patient.
3. Identify the client and explain the procedure To ensure if it is the
correct client and
promote cooperation.
4. Provide privacy To avoid embarrassment
and promote comfort.
5. Place client in a supine position and expose the perineal area To give a better
and catheter. visualization of the
perineal area.
6. Put on gloves. To maintain sterility.
7. Cleanse the perineal area with soap and water. To remove any
microorganisms.
8. Cleanse meatus in circular motion from the most inner surface To distinguished the
to the outside. Use soap and water unless these is purulent condition of the
drainage. The non-irritating antiseptic solutions on cotton maybe perineum and the
used. frequency and type of
ongoing care required.
9. Cleanse catheter from meatus out to end of the catheter, To lessen the presence of
taking care not to pull the catheter. secretions or drainage on
the outside of the
catheter surface.
10. Be sure to repeat catheter care anytime it becomes soiled To lessen the presence of
with stool or drainage. secretions or drainage on
the outside of the
catheter.
11. place linen or cotton balls in proper receptacle. To promote cleanliness
and prevent cross
contamination.
12. Wash hands. To reduce transmission of
microorganisms.
DOCUMENTATION
Nurse’s Notes:
 Document the time the procedure was performed and the condition of the are surrounding the catheter.
Nurse’s Tips:
 When doing catheter care, do not allow urine to drain back into the bladder.
Scoring:
1x =

2x =

3x =

4x =

5x =

Total divided by no. of items =

Comments:

Kathleen T. Ang
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
 REMOVING AN ENDWELLING CATHETER

Name: Ang, Kathleen T. Grade:

Year and Section: BSN 2B Date: November 2, 2020

EQUIPMENT: Legend:
100 cc syringe 1- Excellent
Clean Gloves 2- Very Satisfactory
Paper towel or gauze 3- Satisfactory
Waste receptacle 4- Needs Improvement
5- Poor

PROCEDURE RATIONALE 1 2 3 4 5
1. Verify doctor’s order To avoid error and
provide quality care.
2. Identify patient and explain the procedure. Promote patient
cooperation and
participation.
3. Wash hands. To reduce transmission of
the microorganisms.
4. Obtain necessary equipment and carry to the bedside and To promote smooth flow
arrange according to use. of the procedure.
5. Screen patient properly. For client to have its own
privacy.
6. Assist patient to supine position. To provide comfort and
better visualization.
7. Don on clean disposable position. To reduce the risk of
cross infection.
8. Loosen tape holding catheter in place. For easier removal of the
catheter.
9. Insert hub of syringe into balloon inflation of catheter and For easy removal of
draw out all liquid. client’s catheter as the
balloon deflates inside.
10. Ask client to breathe in and out deeply. Gently remove To allow relaxation of the
catheter as client exhales. muscles.
11. Wrap end catheter in paper towel and dispose properly. To avoid cross
contamination.
12. Assist client to cleanse and dry genitals. Make patient To avoid irritations on the
comfortable. genital part or area.
13. Do after care. Wash hands. To promote cleanliness
and avoid the spreading
of microorganisms.
14. Measure and document urine in drainage bag and time of For legal purposes and to
catheter removal. monitor the standard of
care given to the patient.
Scoring:

1x =

2x =

3x =

4x =

5x =

Total divided by no. of items =

Comments:

Kathleen T. Ang
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
ADMINISTERING ORAL MEDICATION
Name: Ang, Kathleen T. Grade: Legend:
Year and Section: BSN 2B Date: November 2, 2020 1- Excellent
2- Very Satisfactory
3- Satisfactory 5- Poor
4- Needs Improvement
PROCEDURE RATIONALE 1 2 3 4 5
1. Perform hand hygiene. To reduce transmission of
microorganisms.
2. Prepare medication, adhering to five rights of drug To save time and energy.
administration. To minimize error.
3. Identify client by reading identification bracelet and by To ensure the medication
addressing client by name. is given to the right
patient.
4. explain procedure and purpose of drug. To be aware of the
effects after taking.
5. prepare equipment needed. To avoid delays and
promote smooth flow.
6. Verify any allergies listed on medication record or electronic To prevent any
medication record. complications.
7. obtain preassessment data. Learning the client’s
history enables to avoid
drug interactions and
adverse drug effects.
8. Separate drugs that might be withheld on preassessment data. To avoid any incident of
adverse drug reactions.
9. Assist client in semi-Fowler’s or sitting position. To facilitate swallowing
and protect client from
choking.
10. Don gloves if there is possibility of exposure to oral To protect oneself from
secretions. transmission of
microorganisms.
11. Open unit-dose packages and place one drug in client’s hand Allows cleanliness to the
or pour in medication cup and give to client; provide assistance if patient.
needed.
12. Instruct client to place tablets or capsules into mouth and to One medication at a time
follow with enough liquid to ensure. to prevent choking.
13. Administer liquid medications after pills, instructing client to Liquid eases the
drink all of the solution; provide assistance if needed. swallowing.
14. Remain with client until all medications are taken; check To ensure client has
mouth if there is any question of whether drug has been taken the medication,
swallowed. and for legal purposes of
the documentation.
15. Reposition client and place call light within reach. To have easier access if
client needs any help.
16. Lift side rails. To prevent client from
falling.
17. Discard or restore equipment properly To minimize potential
 If client refuses drug or drug has not been given for any exposure to harm. Record
reason, DO NOT leave drug at the bedside. and document the reason
 Remove drug from the room and restore in medication when client refuses the
drawer or cabinet only if unopened unit-dose package medication.
 If unit-dose package has been opened, discard in sink, or
flush down toilet, with witness present, if necessary.
18. Remove gloves and perform hand hygiene To lessen the
contamination.
19. Document administration in medication administration To give the record of
record treatment and care which
includes time of
administration, drug
name, the dose, route
and client’s reactions.
20. Assess client 30-60 mins after administration and document To monitor the
client’s response to medication. therapeutic effects and
look for any drug adverse
reactions.
 ATTITUDE
1. Accepts constructive suggestions and criticisms To make room for self-
improvement.
2. Assume responsibility of his or her actions. To be accountable for
one’s actions.
Source: Jean Smith-Temple and Joyce Young Johnson. Nurses Guide to Clinical Procedures. Lippincott Williams and
Wilkin, 5th edition 2006, pp177-79

Scoring:
1x =
2x =
3x =
4x =
5x =
Total divided by no. of items =
Comments:

Kathleen T. Ang
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
PREPARING MEDICATION FROM A VIAL
Name: Ang, Kathleen T. Grade: Legend:
Year and Section: BSN 2B Date: November 2, 2020 1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
1. Perform hand hygiene. To reduce the spread of
the microorganisms.
2. Organize equipment To save time and energy,
and avoid delays.
3. Check label of medication vial with medication record or To avoid any errors and
electronic medication record using five rights of drug promote client’s safety.
administration.
4. Perform dosage calculations if vial contains more medication To prevent overdosing
than client requires. the client.
5. Remove thin seal cap from top of vial without touching rubber Not all drug
stopper. manufacturers guarantee
that rubber seals of
unused vials are sterile.
6. Firmly wipe rubber stopper on top of vial with alcohol swab. The swabbing with
6.1 Read the instruction at vial label as to the amount of alcohol reduces
diluent you are going to use. transmission of the
6.2 Dilute/reconstitute the powder drug in the vial. microorganisms.
To prepare diluent for
injection into the vial
containing powdered
medication.
7. Pull end of plunger back to fill syringe with a volume of air Drains the air into the
equal to the amount of solution to be drawn up, do not touch syringe to make positive
inside of plunger. pressure in the vial and
maintains plunger
sterility.
8. Remove needle cap and needle if necessary. To prepare for insertion.
[Link] a slightly slanted angle, firmly insert needle into center of To prevent solution from
rubber top of vial, with the sharpest point of the needle (tip of being contaminated with
bevel) entering first. sediment from rubber
top.
10. Continue insertion until needle is securely in vial yet above To avoid the needle from
the level of fluid. slipping out of the vial.
11. Press end of plunger of down to instill air to vial. It infuses the air to make
positive pressure in the
vial.
12. Hold vial with non-dominant hand and turn it up, keeping Enables solution to move
needle/spike inserted; control syringe with dominant hand and to the area closest to the
keep plunger down with thumb. rubber stopper for easy
removal.
[Link] needle/spike back to point at which bevel is beneath fluid It places the needle in a
level.; keep needle/spike beneath fluid as long as fluid is being position in which the fluid
withdrawn. can be obtained.
14. Slowly pull end of plunger back until appropriate amount of To ensure delivery of
solution is aspirated into syringe. prescribed amount of
medication.
15. if air bubbles enter syringe, gently flick syringe barrel with To congregates bubbles
fingers of dominant hand; keep a finger on end of plunger; in an area for removal
continue holding vial with non-dominant hand. and prevents plunger
from popping.
16. Push plunger in until air is out of syringe. It displaces the bubbles of
air into vial.
17. withdraw additional solution if needed. It replaces solution lost
when clearing bubbles.
18. Pull needle out of bottle while keeping a finger on end of Avoids plunger from
plunger. Apply sterile needle to syringe if IM/SQ or ID injections popping out of the barrel.
will be given.
19. If bubbles remain in syringe: Eliminates remaining air
- hold syringe vertically (with needle pointing up if attached). bubbles from the syringe
- Pull back slightly on plunger and flick syringe with fingers.
 Slowly push plunger up to release air, but not to the point of using the principle that
expelling the solution. air rises.
20. Recheck amount of solution in syringe comparing with drug To ensure correct amount
volume required. of drug has been
prepared.
21. Compare drug label with medication record or electronic To ensure right
record. medication will be given
to patient.
22. Change needle, if used to withdraw the solution from the vial Tissue irritation may
and drug is known to be irritating to tissue; replace cap. happen due to drug
clinging to outer surfaces
of needle when the
solution is inserted.
23. Label syringe with drug name and amount of drug. Avoid confusion and error
in drug administration.
24. Place syringe, medication record, and additional alcohol To promote organization
swabs on medication tray. during drug
administration.
25. Discard or restore all equipment appropriately. Prevents harm, and
promotes a clean and
well-organized
environment.
26. Perform hand hygiene To reduce transmission of
microorganisms.
ATTITUDE
1. Accepts constructive suggestions and criticisms To correct mistakes.
2. Assume responsibility of his or her actions. To be accountable of
one’s actions.
Source: Jean Smith-Temple and Joyce Young Johnson. Nurses Guide to Clinical Procedures. Lippincott Williams and
Wilkin, 5th edition 2006, pp 184-187

Scoring:
1x =
2x =
3x =
4x =
5x =
Total divided by no. of items =
Comments:

Kathleen T. Ang
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
 ADMINISTERING INTRADERMAL MEDICATIONS

Name: Ang, Kathleen T. Grade:

Year and Section: BSN 2B Date: November 2, 2020

PURPOSE:

Permits administration of small amounts of toxins or mediation deposited under the skin for absorption

EQUIPMENT NEEDED:

Serves as method of diagnostic testing for allergens or for exposure to specific diseases.

MATERIALS:

Medication Administration record/Electronic mediation ticket pen

Appropriate size of syringe and needle for type of injection and viscosity of Solution

Disposable gloves (optional)

Alcohol swabs Legend:

1- Excellent
Medication to be administered 2- Very Satisfactory
1 ml syringe with 26-28-gauge needle 3- Satisfactory
4- Needs Improvement
Medication tray 5- Poor

PROCEDURE RATIONALE 1 2 3 4 5
1. Perform hand hygiene. To reduce contamination
and transmission of
microorganisms.
2. Prepare drug to be administered according to the five To minimize error and
rights of drug administration. promote client’s safety.
3. Identify client by checking identification bracelet and by To ensure medication is
addressing client by name. given to the right patient.
4. Explain procedure and purpose of medication to client. To educate patient and
promote participation.
5. Verify allergies listed on medication record or electronic To avoid any incidents of
medication record. adverse drug reactions.
6. Don gloves. To protect and prevent
oneself from secretions.
To promote sterility.
7. Select injection site on forearm if no other site is Injection site should be
required by agency policy or doctor’s orders; use free of discoloration or
alternative sites if forearm cannot be used. hair to interpret the
results properly.
8. Position client with forearm facing up Promote comfort to
patient, and stabilizes the
injection site for easy
accessibility.
9. Cleanse site with alcohol, using a circular motion starting To reduce the spread of
from the center and working outward. Allow alcohol to microorganisms.
dry.
10. Remove needle cap. To prepare for the
procedure.
11. Place non dominant thumb about 1 inch below insertion Drawing the skin back or
site and pull skin down (town hand). to the side cause the skin
to return to its normal
position when pressure is
released and will cause
the needle bevel to either
go deeper into the skin or
to leave the skin.
12. Talk to client and warn of impending needlestick. To avoid shocking the
patient.
13. With bevel up and using dominant hand, insert needle Do not place thumb or
just below the skin at a 10-15-degree angle. fingers under syringe
because this will cause
the angle of insertion to
 exceed 15 degrees
causing the needle to
insert beyond the dermis.
14. Once entry into skin surface is made, advance needle To ensure the needle is
another 1/8 inch. inserted enough.
15. Inject drug slowly and smoothly while observing for bleb To deliver the medication
(a raised welt) to form (the bleb should be present). slowly which allows the
nurse to stop the
administration in
systemic injection begins.
16. Remove at same angle that it was inserted. To prevent the tearing of
the skin.
17. Gently remove blood, if any, by dabbing with second To cleanse the area while
alcohol swab. avoiding pushing the
medication out.
18. Observe skin for redness or swelling; if this is an allergy To assess any local or
test; observe for systematic reaction (e.g. respiratory systemic reaction.
difficulty, sweating, faintness, decreased blood pressure,
nausea, vomiting, cyanosis).
19. Reassess client and injection site after 5 minutes, after 15 To evaluate the client’s
minutes, then periodically while client remains in clinic. responses to medication
and to help distinguish
possible toxic effects.
20. Place and capped needle on tray. Remove gloves. For the prevention of
needle pulks.
21. Mark with blue or black pen around the bleb and instruct This mark will serve as a
client not to rub area. guide which skin area is
to be assessed.
22. Reposition client. To facilitate the patient’s
comfort.
23. Discard equipment appropriately. To prevent harm and to
promote clean and well-
organized environment.
24. Perform hand hygiene. To reduce transmission of
microorganisms.
25. Document administration on medication record. For legal purposes and to
monitor the standard of
care given to the patient.
ATTITUDE OF THE STUDENT
26. Accepts constructive suggestions and criticisms. For self-improvement.
27. Assumes accountability. To be responsible of
one’s actions.
Source:
Jean Smith-Temple and Joyce Young Johnson. Nurses’ Guide to
Clinical Procedures. Lippincott Williams and Wilkins, 5th Edition,
pp. 202-205.

Scoring:
1x =
2x =
3x =
4x =
5x =
Total divided by no. of items =
Comments

Kathleen T. Ang
Student’s Signature over Printed Clinical Instructor’s Signature and Date over
Name Printed name
 ADMINISTERING INTRAMUSCULAR MEDICATION

Name: Ang, Kathleen T. Grade:

Year and Section: BSN 2B Date: November 2, 2020

PURPOSE:
Legend:
Delivers ordered medication into muscle tissue. 1- Excellent
2- Very Satisfactory
MATERIALS:
3- Satisfactory
Medication Administration record/Electronic medication ticket pen 4- Needs Improvement
5- Poor
Appropriate size of syringe and needle for type of injection and viscosity of Solution

Disposable gloves (optional)

Alcohol swabs

Medication to be administered

3 ml syringe with 21, 22, 23-gauge needle

Medication tray

PROCEDURE RATIONALE 1 2 3 4 5
1. Perform hand hygiene. To reduce contamination
and transmission of
microorganisms.
2. Prepare medication adhering to the five rights of drug To avoid medication
administration. errors.
3. Identify client by checking identification bracelet and by To ensure medication is
addressing client by name. given to the right patient.
4. Explain procedure and purpose of medication to client. To educate the patient
about the medication. To
promote cooperation.
5. Verify allergies listed on medication record or electronic To prevent any
medication record. complications and
adverse reactions.
6. Don gloves. To protect and prevent
oneself from secretions.
To promote sterility.
7. Select injection site appropriate for client’s size and age. To see to it that the
needle will be injected to
the muscle.
8. Assist client into position for comfort and easy visibility of Relaxation minimizes
injection site. discomfort.
9. Cleanse site with alcohol swab. To eliminate secretions
and microorganisms.
10. Remove needle cap. To prepare for the
procedure.
11. Pull skin taut by at insertion by using the following Pulling the skin and
sequence: subcutaneous tissue
11.1 Place thumb and index finger of non-dominant hand makes it firmer which
over injection site (taking care not to touch cleaned facilitates needle
area) to from a V. insertion.
11.2 Pull thumb and index finger in opposing direction
spreading fingers about 3 in
12. Talk to client and warn of impending needlestick To avoid shocking the
patient.
13. Quickly insert needle at a 90-degree angle with dominant The quick motion will
hand (as if throwing a dart). lessen the patient’s
discomfort.
14. Move thumb and first finger of non-dominant from skin To take the time for the
to support barrel of syringe; place fingers on the barrel. blood to appear if the
needle is in the small
blood vessel.
15. Pull back on plunger and aspirate for blood return in To determine if the
syringe. needle has been inserted
into a blood vessel.
 16. If blood does return when aspirating pulls the needle out, It means that needle is
apply pressure to the insertion site and repeat injection inserted at the wrong
steps. site.
17. If no blood returns, push plunger slowly and smoothly; Injecting the medication
encourage client to talk or take deep breaths. slowly promotes comfort
and gives time for tissue
to expand and to start
the absorption of the
medication. Client should
take deep breaths to
relax.
18. Remove needle at the same angle as it was inserted. To minimize injury to the
tissue.
19. Massage and lean insertion are with second alcohol wipe To lessen the pain and
(if contraindicated for drug, apply firm pressure instead). remove any blood.
20. Place needle on tray; do not recap. So that the needle will
not be mistaken as a new
one, and prevent reusing
it.
21. Remove gloves. For sanitary purposes and
for proper disposal.
22. Reposition client; raise siderails and place bed in lowest To give the patient
position with call light within reach. comfort and safety.
23. Discard equipment appropriately. To avoid the spread of
microorganisms.
24. Perform hand hygiene. To control the spread of
microorganisms.
25. Document administration on medication record. For legal purposes and to
monitor the standard of
care given to the patient.
ATTITUDE OF THE STUDENT
26. Accepts constructive suggestions and criticisms. To learn from mistakes
and self-improvement.
27. Assumes accountability. To be responsible of
one’s action.
Source:
Jean Smith-Temple and Joyce Young Johnson. Nurses’ Guide to
Clinical Procedures. Lippincott Williams and Wilkins, 5th Edition
2006, pp. 215-219.

Scoring:
1x =
2x =
3x =
4x =
5x =
Total divided by no. of items =
Comments:

Kathleen T. Ang
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name