SURGICAL HANDWASHING

Airiz Trisha A. Trinidad

Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

Legend:
1- Excellent
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 dispensing water and Prevents hands and
soap (faucets should be high enough for hands and forearms to forearms from touching any
fit comfortably contaminated surfaces.
2. Antiseptic detergent/soap This is to kill the micro-
organisms
3. Surgical scrub brush with plastic nail and pick To enhance efficiency of
friction to rub of
contaminants
4. Mask, cap or hood Acts as a barrier method to
decrease risk of
contamination
5. Sterile towel To dry off hands and forearm
6. Scrub suit attire A barrier to prevent
contamination
7. Protective eyewear (glasses or googles) Barrier method to protect
eyes
ASSESSMENT
1. Consult institutional policy regarding length of time of hand This is to follow the
wash. protocols and proper
procedure of institution
2. Be sure fingernails are short, clean and healthy. So nails wont puncture the
Artificial nails, nail polish should be removed. gloves and would decrease
the amount of organisms &
contamination
3. Inspect condition of cuticles, hands, and forearms for presence Prevents spreading of
of abrasions, cuts, or open lesions. microorganisms, blood,
dead cells etc. which can
cause infection
4. Be sure if wearing a two-piece pants and top scrub suit that Prevents contamination of
the top is secured at the waist and tucked into the pants. suit and to secure it from
flying around or getting in
the way
DIAGNOSIS
Defining characteristics from the assessment date may reveal the It is to plan for treatment to
following nursing diagnoses for clients requiring these skills: ensure that only a skilled
- Risk for infection nurse can treat for any of
- Risk for injury these risk
(Related factors are individualized based on client’s condition or
needs).
PLANNING
Expected outcomes following completion of procedure: Saves time, energy and
Client will not develop signs of surgical wound infection promote efficiency
1. Prepare equipment
2. Remove watch, rings or bracelets. Contaminants may be
present
3. Be sure sleeves are above elbows and uniform is fitted or Secure from any sort of
tucked at waist. contamination
IMPLEMENTATION
1. Apply surgical attire: shoe covers, cap or hood, face mask and Used as a barrier method to
protective yowler. prevent contamination
2. Turn on water knee or foot controls and adjust to comfortable To wash off micro-organism
temperature. and any other contaminants
3. Wet hands and arms under running lukewarm water and lather Broken skin permits
with detergent/soap up to 2 inches above the elbows (Hands microorganisms to enter
need to be held above elbows at all times). layers of the skin, providing
deeper microbial breeding
 grounds. These conditions
increase likelihood
microorganism residing on
skin surfaces
4. Rinse hand and arms thoroughly under running water. It is to wet and wash off any
Remember to keep hands above elbows. contaminants and keep clear
from any surfaces which can
contaminate it
5. Under running water, clean under nails both handles with file. Washes off any
Discard after use. contaminants & to file nails
to keep from being sharp
6. Wet brush and apply antimicrobial detergent/soap. Creates soap suds ready to
spread for cleaning
7. Scrub the nails of one hand with 15 strokes. Kills off microorganisms and
rub off contaminants with
friction
8. Holding brush perpendicular, scrub the palm, each side of the To clean palm, thumbs, and
thumb and fingers and the posterior side of the hand with 10 dorsum of the hands and to
strokes each. clean parts with friction
9. The arm is mentally divided into thirds and each is scrubbed 10 Promotes efficiency when
times. cleaning and to kill off most
microorganism and
contaminants
10. Entire scrub should last at least 2-3 minutes. To make sure all parts are
properly cleaned
11. Rinse brush and repeat the sequence for the other arm. Wash off detergent for new
one
12. Discard brush and rinse hands and arms thoroughly. Turn off Use foot or knee to turn off
water with foot or knee control and back into room entrance to prevent contamination of
with hands elevated in front of and away from the body. hands and for proper
disposal of brush & rinse to
wash off any more detergent
suds
13. Bending slightly forward at the waist, use a sterile towel to Prevents contamination of
dry one hand thoroughly moving from fingers to elbow. Dry in a uniform and to dry off the
rotating motion. Dry from cleanest to the least clean area. wet hands completely and
efficiency
14. Repeat drying method for the other hand, using a different Avoid contamination of
area of the towel or a new sterile towel. hands and forearm with the
dirty side
EVALUATION:
1. Observe the client for signs of localized wound infection. Prevents it from worsening
(Usually occurs 2-3 days postoperative)
ATTIDUE OF THE STUDENT:
21. Accept constructive suggestions and criticisms. To correct mistake and
further improve yourself
22. Assumes accountability. For responsibility
Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________

5x ____________ = __________

Total divided by no. of items = __________

Comments:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over

Printed name
 OPEN GLOVING
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

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 Allows to do proper
execution and prevent
spread of pathogenic
microorganisms
2. Mask, cap or blood Used as a barrier method to
decrease the risk of
contamination
3. Sterile gloves Used as a barrier method to
decrease the risk of
spreading of microorganisms
4. Scrub suit Prevents exposure to blood,
and bodily fluid splashes
during the procedure
ASSESSMENT
1. Check the expiration date of the sterile gloves. Prevents allergic reaction
and reduce the risk of
accidents
2. Sterile gloves should be sealed, free form tears and not Decrease the risk of
crumpled. contamination
3. Fingernails should be short, clean and healthy. Reduces transmission of
microorganisms
4. The top portion of the scrub suit should be secured at the Prevents the spread of
waist and tucked into the pants. infection
5. Make sure that you are not allergic to the sterile gloves. To avoid allergic reactions or
irritations
DIAGNOSIS
Defining characteristics from the assessment data my reveal the Avoids the risk of infections
following nursing diagnosis for clients requiring the skill:
Risk for Infection)
(Related factors are individualized based on the client’s
conditions and needs).
PLANNING
1. Expected outcomes following completion of the procedure: To maintain sterility, have a
continuous flow of
procedure
2. Prepare the equipment. To save time and to be
efficient
3. Sleeves should be above the elbows and uniform is fitted or Prevents the spreading of
tucked at the waist. microorganisms
IMPLEMENTATION
1. Do surgical handwashing Removes transient and
resident bacteria from
fingers, hands, and forearms
2. Open the package of the sterile gloves. To ensure that the object
• Place the package of the gloves on a clean dry surface. doesn’t get contaminated
• Some gloves are packed in an inner as well as an outer The outer surface of the
package is considered
package. Open the outer package without contaminating
unsterile
the gloves or the inner package.
Inner kit always remain
• Remove the inner package from the outer package. sterile
• Open the inner package as above or according to the To avoid contaminating the
manufacturer’s directions. Some of the manufacturer’s inner package
provide a numbered sequence for opening the flaps and To prevent inner glove
folded tabs to grasp for opening the flaps. If no tabs are package from accidentally
opening and touching
contaminated objects
 provided, pluck the flap so that the fingers do not touch If a sterile object touches any
the inner surfaces. unsterile object, it is
• Remove the envelop powder from the inside of the right considered as contaminated
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 For application position the
drawn with the left hand-grasping the cuff of the right glove on glove over cuffed hand,
the fold, pick up the glove and step back from the table. keeping the glove sterile.
Inner edge of the cuff lies
• If the glove is packed so that they lie side by side, grasp
against the skin and thus not
the glove for the dominant hand by its cuff (on the
sterile and if the outer
palmar side) with the thumb and the first finger of the surface of the glove touches
non-dominant hand. Touch only the inside of the cuff. the hand or wrist, it would
• Insert the dominant hand into the glove and pull the become contaminated
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 If the gloved hand comes in
fingers of the right gloved hand under the turned back cuff of the contact with the exposed
left glove, pick it up, step back and removed from the inside of hand, it would result in
the cuff. contamination.
This would prevent
• Pick up the other glove with the sterile gloved hand,
accidental contamination
inserting the gloved fingers under the cuff and holding from hand movement.
the gloved thumb close to the gloved palm. Sterile touching sterile
• Pull the second glove carefully. Hold the thumb of the prevents contamination,
first gloved hand as far as possible from the palm. cuffs protects gloved hand
• 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. For proper disposal
6. If a sterile gown is worn, it should be put on before the gloves, Seal created by glove over
in order that the glove cuffs maybe drawn up over its sleeves. gown prevents exit of
• Turn over the pleat on the cuff of the left sleeve and hold microorganisms over
operative sterile field
it with the right thumb with the fingers of the right cuff
of the left sleeve, avoid touching the glove.
EVALUATION: Provide time to care for
Observe the client for signs of localized wound infection (usually needs and would save
occurs 2-3 days postoperative). client’s energy
ATTIDUE OF THE STUDENT:
21. Accept constructive suggestions and criticisms. To correct mistake and
further improve yourself
22. Assumes accountability. For responsibility
Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________

5x ____________ = __________

Total divided by no. of items = __________

Comments:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
 CLOSED GLOVING
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________
Legend:
1- Excellent
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 sterile gloves. Maintains sterility of the
1. With your left hand still inside the gown, pick up the folded gloves
edge of the right glove.
2. Hold your right hand out, with palm up still inside the sleeve. Positions for glove insertion
3. Lay the right on the right hand (which is still inside the sleeve). Positions the glove for
Position it with the gloved fingers printing towards the fingertips. insertion and maintain its
The thumb of the glove should be over the thumb of your right sterility
glove.
4. Use your right hand (which is still inside the sleeve) to grasp Secure glove that is ready for
the bottom fold of the cuff end of the right glove. insertion
• You are touching sterile gown to sterile glove.
5. With your left hand (which is still inside the gown sleeve), Prevents hands from
grasp the right glove cuff by the top fold of the duff end, and pull touching the sterile gloves
the right glove cuff up and over the right gown cuff.
6. Adjust the right glove cuff over the right gown cuff as Secures the glove
necessary, keeping the left hand inside the gown.
7. Work your right hand down into the glove. For insertion of hand into the
• If the fingers are not in place, don’t worry you can correct glove and to maintain its
them when both gloves are on. sterility
8. Pick up left glove with the gloved right hand. Maintain sterility
9. Hold your left hand, palm up, inside the gown sleeve. Positions for glove insertion
10. Place the left glove on the left palm (which is still inside the To keep glove sterile, keep
gown), with glove fingers pointing toward the elbow and the cuff positions of glove for
end pointing toward your fingertips. application over cuffed hand
Position the glove thumb over the left of your hand. Hands will remain clean
11. Use your left hand (which is still inside the sleeve) to grasp Secures the glove in its place
the bottom fold of the cuff end of the left cuff.
12. Grasp the top of the cuff edge with the gloved right hand, and Maintains sterility and to be
pull the glove cuff up and over the gown cuff. secured in its place
13. Work your left hand down into the left glove. Insertion in place
14. Turn up and adjust the cuffs of both gloves. Secured in place
15. Pull the glove fingers out at the ends to reposition our fingers This secures fingers in place
if necessary.
Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________

5x ____________ = __________

Total divided by no. of items = __________

Comments:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over

Printed name
 GOWNING TECHNIQUE
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

Legend:
1- Excellent
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 Prevents contamination of
directly upward. uniform or any other
surfaces
2. Step far enough away from non-sterile area or objects. The gown will be unsterile if
its outer surface touches any
unsterile objects
3. Hold the neckband with both hands and gently shake the folds To put gown on and prevent
of the gown. contamination
4. Slip the hands into the armholes, holding hands upward in the To keep the gown in its place
level with the shoulder. that is ready to be tied
5. Swing belt to be tied at the back by the circulating nurse. Secures gown in place

Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________

5x ____________ = __________

Total divided by no. of items = __________

Comments:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over

Printed name
 GOWNING AND GLOVING THE SURGEON
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

Legend:
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 Maintain its sterility
the opposite end of the towel.
2. Grasp the gown in one hand. Avoid contamination
3. Shake out stretched hands holding it at the neckband. Shakes the gown to put it on
and prevent contamination
4. Offer inside of the gown to the surgeon. So that the surgeon could
easily put in their hands
5. Releasee the gown. For the surgeon to put it on
B. GLOVING THE SURGEON:
1. Squeeze lubricant or powder on the surgeon’s palm Smooth insertion of
surgeons hand into glove
2. Grasp the right glove firmly with the four gingers under the To follow glove to glove and
turned back-cuff. skin to skin principle
3. The palm of the glove should be facing the surgeon. Stretch Positions glove correctly to
the cuff enough to introduce his hands. slide in place
4. The surgeon place his hand into the glove. Unfold the turned Sealed completely to
back cuff of the glove over his sleeve. prevent from contamination
5. Repeat procedure for the left hand. Prepares for sterilization
6. Discard wrapper into the waste container. For proper disposal

Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________

5x ____________ = __________

Total divided by no. of items = __________

Comments:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over

Printed name
 ASSISTING DELIVERY
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

Legend:
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 Prepares pack and maintain
sterility. To save time and be
1.1 Get OB pack efficient
o Place it in the mayo table
1.2 Check the OB pack Ensures continuity of the
o Check if the instruments are complete procedure and no
equipment lacking
1.3 Open the outer lining of the OB pack Expose inner pack ready for
o Use bare hands in opening the outer lining next step
1.4 Open the outer lining of the pack To maintain sterility and
o Use sterile picking forceps facing down when expose inner lining
opening the inner lining of the OB pack.
1.5 Prepare additional equipment To save time and be
o Put the additional instruments to the open OB efficient. Maintain sterility
pack
2. Actions: Prevent spreading of
2.2 Do surgical hand washing microorganisms
2.3 Do gowning and gloving Used as a barrier method
o Strictly follow the principles of gowning and and maintain sterility
gloving.
2.4 Arrange the equipment acceding to use To have efficient procedure
ATTITUDE
1. Accept constructive criticism and suggestion To correct mistake and
further improve yourself
2. Accept responsibility of his/her action For responsibility
Scoring:
1x ____________ = __________
2x ____________ = __________
3x ____________ = __________
4x ____________ = __________
5x ____________ = __________
Total divided by no. of items = __________
Comments:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
 HANDLING DELIVERY
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

Legend:
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 be done with the assisting nurse
2. Action Prevents spreading of microorganisms
To be made sterile
2.1 Do surgical handwashing
Prevent exposure
• To be done with the assisting nurse
2.2 Perform gowning and gloving
2.3 Do draping
Drape the patient accordingly:
1. legging (left & right) Supports perineum
2. abdominal drape Exposes only what is required
3. perineal drape (to support the perineum) Prevents complications and lacerations
4. baby drape Provides warmth to the baby
2.4 handle the delivery of the fetus
• Slide your hands to the neck and the Secures the baby and could prevent any
baby of the fetus as it delivered smoothly accidents and complications to the
baby
and easily.
Provides baby comfort and promotes
2.5 Place the baby to the mother’s abdomen bonding of mother and baby
2.6 Clamp the cord 810 inches away from the Prevents gushing of blood and further
umbilicus with Kelly forceps one-inch apart loss of blood
clamp and cut with scissors in between.
2.7. Proceed with the delivery of placenta Maintains sterility
• Hold the forceps connecting the placenta
and wait 3-5 mins for sign of placenta Exerts slight pressure for the placenta
separation to come out
• Slowly pull cord while the other hand
exerts a slight pressure above the mons
pubis.
2.8 Once delivered, place placenta on the bowl and Ensures safety
inspect the completeness of its part.
• Take note of the methods of separation Proper execution of technique
2.9 Assist in suturing the episiotomy
• Anticipate doctor’s need during suturing Promotes efficiency of procedure and
save time
2.10 Flush site with normal saline.
Rinses fluids that hinder visualization
2.11 Apply betadine antiseptic
Prevents contamination
2.12 Apply sanitary pad/adult diaper Avoids the sheets from being soiled
2.13 Do after care:
• Position the mother comfortably-legs Provides comfort
closed
• Remove stained draper Avoids accidental contamination
• Take vital signs immediately Promotes accurate documentation
• Check the instruments if complete Avoid further accidents by loss of
instruments
• Wash the instrument and let these dry Promotes efficiency and proper
• Pack clean equipment and autoclave aftercare
ATTITUDE
1. Accepts constructive suggestions and criticisms To correct mistake and further improve
yourself
2. Assume responsibility of his or her actions. For responsibility
Scoring:
1x ____________ = __________
2x ____________ = __________
3x ____________ = __________
4x ____________ = __________
 5x ____________ = __________
Total divided by no. of items = __________

Comments:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
 IMMEDIATE NEWBORN CARE
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

Legend:
1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
PLANNING
1. Prepare all equipment. This is to avoid delay and save time

1.1 Cebu Puericulture Center and Maternity Convenient and faster job
Inc. (CPCMHI)
Cord clamp Avoids gushing of blood
Sterile OC (3-4 pcs) Nipping blood or other discharges
Sterile cotton balls (2-3 pcs) Disinfection purposes
Mayo Scissors For cutting the cord
Bulb Syringe Removal of fluid in baby’s mouth/nose
Tape measure Measuring the baby’s anthropometric
Vitamin K ampule Prevents bleeding in baby
Terramycin eye ointment tube Prevents infections
ICC Syringe Administration of Vitamin K
Baby diaper Discharges from baby
ID band – Blue (male), Pink (female) To identify the baby
Receiving blanket Keeps the baby warm
Digital Thermometer Measures the baby’s temperature
Baby’s cap Keeps the baby warm
Weighing scale Measures the baby’s weight
Goose neck lamp Avoids gushing of blood

1.2 Vicente Sotto Memorial Medical Center

(VSMMC)
Cord Clamp Avoids gushing of blood
Sterile OS (3-4 pcs) Nipping blood or other discharges
Sterile Cotton balls (2-3 pcs) Disinfection purposes
Cord cuter For cutting the cord
Tape measure Measuring the baby’s anthropometric
Vitamin K ampule Prevents bleeding in baby
Terramycin eye ointment tube Prevents infections
ICC Syringe Administration of Vitamin K
Baby diaper Discharges from baby
ID band – Blue (male), Pink (female) To identify the baby
Receiving blanket Keeps the baby warm
Digital Thermometer Measures the baby’s temperature
Baby’s clothes Keeps the baby warm
Baby’s blanket Prevents hypothermia
Weighing scale and goose neck lamp Measures the baby’s weight
IMPLEMENTATION
2. Prepare the room temperature of the delivery Prevents abnormal body temperature
room. Room temperature should be 25-28 C. of mother and baby
3. Notify appropriate staff. Provides appropriate care and
promotes teamwork
4. Arrange needed supplies in linear fashion. Continuous procedure and saves time
5. Check resuscitation equipment. For efficiency
6. Wear face mask and bonnet properly. For efficiency
7. Wash hands with clean water and soap. Prevents transmission of
microorganisms
8. Don’t double glove just before delivery. Prevents the possibility of ruptured
gloves
9. Within first 30 second;
9.1 Dry the newborn thoroughly for at least Provides warmth for the baby and would
30 seconds. reduce evaporation
9.2 Do a quick check of breathing while Would identify possible blockage of airway
drying. (do not suction unless the
 mouth/nose are blocked with secretions
or other materials) Removes fluid in the body
9.3 Wipe the eyes, face, head, front and back,
arms and legs. (DO NOT wipe off the
Prevents baby from getting cold
vernix caseosa)
9.4 Remove the wet cloth.
10. After 30 seconds, if newborn is breathing and
crying,
10.1 Position the newborn prone on the Provides comfort to the baby
mother’s abdomen or chest.
Prevents hypothermia
10.2 Cover the newborn’s back with a dry
blanket. Provides warmth to the baby and reduces
10.3 Cover the newborn’s head with a the chances of hypothermia
bonnet/cap.
11. After 1-3 minutes, properly time cord
clamping.
11.1 Remove the first set of gloves. Prevents transmission of microorganisms
11.2 After the umbilical pulsations have The 2 cm gives an ample space for the
stopped, lamp the cord using a sterile plastic umbilicus from bleeding
clamp at 2cm from the base.
Prevents the blood flow to the baby
11.3 Do not milk the cord towards the baby.
Stops blood circulation in the midpoint of 2
11.4 Clamp again at 5 cm using Kelly forceps clamps
from the base.
11.5 Cut the cord close to the plastic clamp. Avoids gushing of blood
12. Place the identification band on ankle (not Proper identification of baby and prevent
wrist) of corresponding gender. accidents
12. 1 CPCMHI – left ankle Helps link the baby
12.2 VSMMC – both ankles Make sure that the baby belongs to the
right parents
13. Leave the newborn in skin-to-skin contact. Allows the baby to locate the mother’s
13. 1 Observe for feeding cues, including areola
tonguing, licking, rooting. Allows mother to identify feeding time
13.2 Point these out to the mother and Allows baby to locate and suck the
mother’s areola
encourage her to nudge.
14. After 90 minutes, remove the newborn from It lets baby adapt to new environment
mother’s abdomen.
15. Transfer the newborn to the work table Perform thorough physical assessment of
baby
16. Weigh the newborn to the work table. Promotes accurate documentation of data
17. Perform physical assessment of the newborn Identifies and prevents possible diseases
and do APGAR scoring. and to check for abnormalities
18. Perform Anthropometric measurement
18.1 Head circumference Assess normal measurement
18.2 Chest circumference Assess abnormal conditions
18.3 Mid arm Assess any deformities
Assess normal measurement or abnormal
18.4 Body length
findings
19. Take the rectal temperature Assess baby’s temperature and anus
condition
20. Inject Vitamin K
20.1 CPCMHI – left thigh Production of Prothrombin
20.2 VSMMC – right thigh Production of Prothrombin

21. Apply eye prophylaxis. Prevents eye infection

22. Put on baby’s clothes. Prevents heat loss
23. Wrap the baby with baby’s blanket Prevents baby from coldness and
hypothermia
24. Obtain heart rate and respiratory rate. Identifies baseline and assess for
abnormalities
25. Show the baby to the mothers. Latch on the Promotes bonding and ease mother’s
baby to the mother’s breast. anxiety
26. Documentation immediately after cord care Promotes accurate documentation and for
and latch on. future reference use
27. Do after care. Attain cleanliness and orderliness
ATTITUDE
28. Accept constructive suggestions and criticism. To correct mistake and further improve
yourself
29. Assume responsibility of his/her action. For responsibility
Scoring:
1x ____________ = __________
2x ____________ = __________
3x ____________ = __________
4x ____________ = __________
5x ____________ = __________
Total divided by no. of items = __________
Comments:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
 PERINEAL CARE
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

Legend:
1- Excellent
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 acquaint, relieve stress
and to induce cooperation
2. Provide privacy. Relieve anxiety and for
confidentiality
3. Bring equipment and supplies to the bedside. Bring the tray Promotes time
with lining containing the following: management, efficiency and
a. pitcher with warm irrigating fluid (300-500 ml) at 40.5°C- continuous procedure
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. Prevents it from getting
soiled
[Link] the client on the bed pan in a dorsal recumbent position. Use bedpan to catch an
spilling and proper
positioning for ease
procedure
6. Drape the client with a bath blanket to permit exposing just Ables to expose only the
the perineal area. area required
7. Wash your hands. Prevents spread of
microorganism
8. Don on clean gloves. Used as a barrier method for
hands
9. Wash upper and inner thighs with lukewarm water. Cleanse of any dirt and use
lukewarm water to prevent
the client from experiencing
chills
10. Separate labia with non-dominant hand. Pour warm irrigating Ables to clean the external
solution gently over the vulva. reproductive system
11. Cleanse the perineal area with cherry balls soaked in betadine Cleanses perineal care, and
cleanser held by a dressing forceps. Cleansing should be done prevents cross
from the vagina outward. Follow the figure below which shows contamination and maintain
the typical pattern for cleansing the perineal area, using 8 sterility
strokes.
 12. Rinse the scrubbed areas well. Remove the client from the Washes off dirt & betadine
bed pan. cleanser. Dispose water
waste properly
13. Dry the perineal area using dry cherry balls in the same Maintains principles of
fashion as in cleaning (step 11). perineal drying
14. Help client to a side lying position and adjust the bath Prepares for anal area,
blanket. adjust bath blanket to
prevent client from being
exposed
15. Wash, rinse, and dry the anal area. Wipe from front to back. Cleanses off any dirt
16. Discard the soiled water, clean the equipment, dispose soiled Proper disposal and to
gloves and remove absorbent pad. prevent contamination
17. Help client to a comfortable position and remove the bath Provides comfort to client
blanket.
18. Wash hands. Prevents spread of
microorganism
DOCUMENTATION
1. Record any significant problem such as; redness, excoriation, Assess if required referral to
swelling. Episiotomy should be noted for edema, inflammation, doctor, for future reference
separation or presence of hematoma.
2. Note the amount, color, and odor of any discharge. Assess any abnormalities
3. Document the client’s tolerance of the procedure. For future reference

Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________

5x ____________ = __________

Total divided by no. of items = __________

Comments:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over

Printed name
 FLEET ENEMA
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

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 Avoids complications and to
primary care provider’s order promote proper administration
of enema
2. Equipment: Promotes time management
2.1 Fleet Enema and efficiency during procedure
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 Establish rapport, gain trust and
verify the client’s identity. identify correct patient
information
4. Perform hand hygiene. Wear clean gloves and observe Prevents transmission of
appropriate infection control procedure. pathogenic microorganisms
5. Provide privacy Minimize client discomfort &
anxiety
6. Place the bedpan or commode in position for patient who Prevents accidental bodily fluid
can’t ambulate to the toilet or have difficulty with sphincter splashes and provide client
control. comfort
7. Assist the client to the left lateral position with the right leg Prevents injury and promote
as acutely flexed as possible. safety
8. Lubricate about 5cm (2inches) of the rectal tube. Some Reduces client discomfort and
commercially prepared enema set already have lubricated pain during the procedure
nozzle.
9. Separate the buttocks and locate the rectum. Easy and proper access to insert
tube
10. Instruct the patient that you will insert the nozzle and to Minimize client discomfort and
take a slow deep breath. ensure trust between nurse and
client by providing comfort
11. Insert the tube smoothly and slowly administer the Reduces pain and discomfort
solution into the rectum directing towards the umbilicus.
12. Roll up the plastic container as the fluid is instilled. Prevents accidental
contamination and splashes
13. Do after care. Promotes cleanliness and
efficiency
14. Wash hands. Prevents transmission of
pathogenic microorganism
15. Document the procedure. Promotes accurate
documentation and
communication among medical
professionals
ATTITUDE
16. Accepts constructive suggestions and criticisms To correct mistake and further
improve yourself
17. Assume responsibility of his or her actions. For responsibility
Scoring:

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

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over

Printed name
 INSERTING A STRAIGHT OR INDWELLING CATHETER: MALE
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

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. Saves time and energy
2. Provide for privacy and explain procedure. Relieves anxiety and induce
cooperation
3. Provide client with opportunity to perform personal hygiene. Prepares oneself
Assist as necessary.
4. Wash hands. Prevents spread of
microorganism
5. Obtain, prepare and arrange equipment according to use. To be efficient
Carry at bedside.
• Open cleansing solution and pour over half of the sterile Mixes the solution with
cotton balls
cotton ball.
• Attach the catheter to the urine drainage bag if it is not Captures the urine
connected.
6. Assist the client to a supine position. Eases procedure by proper
positioning
7. Drape legs to midthigh. Position rubber sheet on buttocks. Exposes what is required &
prevent bed from being
soiled
8. Ensure adequate lighting of the perineal area. To properly see the area
9. Pull on sterile gloves. Uses as a barrier method for
protection
10. Place fenestrated drape over client’s genitalia. Prevents exposure
11. With non-dominant hand. Hold penis at 90 angle to his body. Easy cleaning of penis
If uncircumcised, pull down foreskin with his hand to visualize
urinary meatus. (This hand is now unsterile).
12. Using the sterile forceps, pick up antiseptic solution saturated Cleanses from the dirtiest to
cotton ball. Cleanse meatus with one downward stroke or use the cleanest
circular motion from meatus to base of penis.
13. With sterile hand, pick up catheter and lubricate generously Eases insertion of the
6-4 inches from tip. catheter
14. gently insert catheter into urethra approximately 6-8 inches Inserts catheter in place
until urine begins from tip.
• If catheter resist entry, ask patient to breath deeply and Moves the bladder out of the
way and to rotate to easily
rotate catheter slightly another inch and allow bladder to
slide in catheter
empty and remove straight catheter.
15. If using straight catheter. Insert catheter another inch and To remove the urine from
allow bladder to empty and remove straight catheter. the bladder
16. If using indwelling catheter. Continue inserting 1-3 inches. For proper placement
17. attach the water-filled 10 cc syringe to the inflation port. Ables to hold catheter in
Inflate the retention balloon. place
18. Check placement by gently pulling catheter until balloon is Checks if the catheter and
resting snugly against the bladder neck. (Resistance will be felt balloon are correctly in place
when balloon is in place).
19. Tape catheter securely to the abdomen. Prevents from moving out of
place
20. Attach drainage bag to bed frame, below the level of the Prevents spillage or risk of
bladder. Make sure the tubing lies over, not under the leg. Do not puncturing the bag
let it rest on the floor.
21. Remove the discard gloves. Do after care and wash hands. Maintains cleanliness,
discard of properly and to
prevent spread of
microorganism
22. Do proper documentation: time the procedure was For future references
completed, size & type of catheter used, client’s response and
amount, color quality of urine.
Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________

5x ____________ = __________

Total divided by no. of items = __________

Comments:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over

Printed name
 ROUTINE CATHETER CARE
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

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. Prevents spread of
microorganisms
2. Check institutional protocol or care plan Correctly follow procedure
and protocol
3. Identify the client and explain the procedure Relieves any anxiety & to
induce cooperation
4. Provide privacy Confidentiality & relieves
client’s anxiety
5. Place client in a supine position and expose the perineal area Ease & efficient procedure
and catheter.
6. Put on gloves. Used as a barrier method
7. Cleanse the perineal area with soap and water. Removes any dirt or any
contaminants
8. Cleanse meatus in circular motion from the most inner surface Cleanses from cleanest to
to the outside. Use soap and water unless these is purulent dirtiest. Use these solutions
drainage. The non-irritating antiseptic solutions on cotton maybe to properly kill off
used. microorganism& wash off
contaminants
9. Cleanse catheter from meatus out to end of the catheter, Prevents from pulling it out
taking care not to pull the catheter. of place & cleanses off any
contaminants
10. Be sure to repeat catheter care anytime it becomes soiled Maintains its cleanliness
with stool or drainage.
11. place linen or cotton balls in proper receptacle. Proper storage to prevent
cross contamination
12. Wash hands. Prevents spread 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:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over

Printed name
 REMOVING AN ENDWELLING CATHETER
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

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 Determines whether if to
proceed or not
2. Identify patient and explain the procedure. Relieves any anxiety & to
induce cooperation
3. Wash hands. Prevents spread of
microorganism
4. Obtain necessary equipment and carry to the bedside and Saves time, energy and to be
arrange according to use. efficient
5. Screen patient properly. Privacy of the patient
6. Assist patient to supine position. Properly position to ease
procedure
7. Don on clean disposable position. Proper positioning to ease
procedure
8. Loosen tape holding catheter in place. To ready for removal
9. Insert hub of syringe into balloon inflation of catheter and Deflates balloon ready for
draw out all liquid. removal
10. Ask client to breathe in and out deeply. Gently remove Relax muscles for easy
catheter as client exhales. removal
11. Wrap end catheter in paper towel and dispose properly. Prevents contamination of
other objects & proper
disposal
12. Assist client to cleanse and dry genitals. Make patient Cleanses off any dirt &make
comfortable. patient comfortable to
relieve any anxiety
13. Do after care. Wash hands. Maintains cleanliness &
prevents spreading of
microorganism
14. Measure and document urine in drainage bag and time of Proper documentation &
catheter removal. future reference
Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________

5x ____________ = __________

Total divided by no. of items = __________

Comments:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over

Printed name
 ADMINISTERING ORAL MEDICATION
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

Legend:
1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
1. Perform hand hygiene. Prevents spread of
microorganisms
2. Prepare medication, adhering to five rights of drug Prevents any medication error
administration.
3. Identify client by reading identification bracelet and by Confirms the identity of client
addressing client by name. thus ensures you are
administering medication to
the right client
4. explain procedure and purpose of drug. Reduces anxiety, induce
cooperation & for right client
education
5. prepare equipment needed. Saves time and energy
6. Verify any allergies listed on medication record or electronic Prevents any allergic reactions
medication record. because it’s a contraindication
of administering the
medication
7. obtain preassessment data. Determines if medication can
be given
8. Separate drugs that might be withheld on preassessment Prevents complications
data.
9. Assist client in semi-Fowler’s or sitting position. Facilitates easy swallowing &
prevents choking
10. Don gloves if there is possibility of exposure to oral Personal protection
secretions.
11. Open unit-dose packages and place one drug in client’s For client to swallow
hand or pour in medication cup and give to client; provide
assistance if needed.
12. Instruct client to place tablets or capsules into mouth and to Ensures the client has
follow with enough liquid to ensure. effectively swallowed the
medication
13. Administer liquid medications after pills, instructing client to Proper absorption of the pills
drink all of the solution; provide assistance if needed.
14. Remain with client until all medications are taken; check Ensures the medication is
mouth if there is any question of whether drug has been properly taken
swallowed.
15. Reposition client and place call light within reach. For client comfort & to be able
to be notified if client needs
help
16. Lift side rails. For client safety and to
prevent from accidentally
falling
17. Discard or restore equipment properly
• If client refuses drug or drug has not been given for any Prevents client from taking it
reason, DO NOT leave drug at the bedside. w/o the nurse’s knowledge
• Remove drug from the room and restore in medication
To reuse again
drawer or cabinet only if unopened unit-dose package
• If unit-dose package has been opened, discard in sink, To know that the client didn’t
or flush down toilet, with witness present, if necessary. take the medication
18. Remove gloves and perform hand hygiene Prevents spread of
microorganisms
19. Document administration in medication administration Used as a legal document
record
20. Assess client 30-60 mins after administration and document Assess the clients response to
client’s response to medication. medication & document it
ATTITUDE
1. Accepts constructive suggestions and criticisms To correct mistake and further
improve yourself
2. Assume responsibility of his or her actions. For responsibility
 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:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
 PREPARING MEDICATION FROM A VIAL
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

Legend:
1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
1. Perform hand hygiene. Prevents spread of
microorganisms
2. Organize equipment For efficient procedures
3. Check label of medication vial with medication record or Prevents any medication
electronic medication record using five rights of drug error
administration.
4. Perform dosage calculations if vial contains more medication Calculates the right dosage
than client requires.
5. Remove thin seal cap from top of vial without touching rubber Readies the vial and
stopper. maintains cleanliness
6. Firmly wipe rubber stopper on top of vial with alcohol swab.
6.1 Read the instruction at vial label as to the amount of Kills of the microorganism
diluent you are going to use.
6.2 Dilute/reconstitute the powder drug in the vial. Creates the right solution
7. Pull end of plunger back to fill syringe with a volume of air Ease the collection of the
equal to the amount of solution to be drawn up, do not touch solution
inside of plunger.
8. Remove needle cap and needle if necessary. For collection of solution,
with collecting needle
[Link] a slightly slanted angle, firmly insert needle into center of Slightly angled for better
rubber top of vial, with the sharpest point of the needle (tip of penetration & center of
bevel) entering first. rubber top to miss the edges
10. Continue insertion until needle is securely in vial yet above Instils the air
the level of fluid.
11. Press end of plunger of down to instill air to vial. Adds pressure within the vial
12. Hold vial with non-dominant hand and turn it up, keeping Better control of syringe & so
needle/spike inserted; control syringe with dominant hand and the plunger won’t move due
keep plunger down with thumb. to the pressure
[Link] needle/spike back to point at which bevel is beneath fluid Prevents air from being
level.; keep needle/spike beneath fluid as long as fluid is being collected in the needle
withdrawn.
14. Slowly pull end of plunger back until appropriate amount of Collects the right amount of
solution is aspirated into syringe. solution
15. if air bubbles enter syringe, gently flick syringe barrel with Prevents air bubbles
fingers of dominant hand; keep a finger on end of plunger; collected within the barrel
continue holding vial with non-dominant hand.
16. Push plunger in until air is out of syringe. Releases the air
17. withdraw additional solution if needed. Ensures right dosage is
collected
18. Pull needle out of bottle while keeping a finger on end of Prevents the plunger from
plunger. Apply sterile needle to syringe if IM/SQ or ID injections moving & to maintain
will be given. sterility
19. If bubbles remain in syringe: Removes remaining air
- hold syringe vertically (with needle pointing up if attached). bubbles using principle that
- Pull back slightly on plunger and flick syringe with fingers. air rises
Slowly push plunger up to release air, but not to the point of
expelling the solution.
20. Recheck amount of solution in syringe comparing with drug Double check to prevent
volume required. mistakes
21. Compare drug label with medication record or electronic Ensures that the medication
record. is correctly prepared
22. Change needle, if used to withdraw the solution from the vial Prevents tissue irritation
and drug is known to be irritating to tissue; replace cap.
23. Label syringe with drug name and amount of drug. Provides information to not
be mistaken
24. Place syringe, medication record, and additional alcohol Carries all along to the
swabs on medication tray. patient
 25. Discard or restore all equipment appropriately. For proper storage or
disposal
26. Perform hand hygiene Prevents spread of
microorganisms
ATTITUDE
1. Accepts constructive suggestions and criticisms To correct mistake and
further improve yourself
2. Assume responsibility of his or her actions. For responsibility
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:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
 ADMINISTERING INTRADERMAL MEDICATIONS
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

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

Medication to be administered

1 ml syringe with 26-28-gauge needle

Medication tray

Legend:
1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
1. Perform hand hygiene. Prevents spread of
microorganisms
2. Prepare drug to be administered according to the five Prevents any medication
rights of drug administration. errors
3. Identify client by checking identification bracelet and by Confirms the client`s identity
addressing client by name. thus ensures administration
is done to the right patient
4. Explain procedure and purpose of medication to client. Reduces anxiety, induce
cooperation & for right client
education
5. Verify allergies listed on medication record or electronic Prevents any allergic
medication record. reactions which is a
contraindication to
administration
6. Don gloves. Self-protection
7. Select injection site on forearm if no other site is For right route of injection
required by agency policy or doctor’s orders; use
alternative sites if forearm cannot be used.
8. Position client with forearm facing up For easy insertion
9. Cleanse site with alcohol, using a circular motion starting Removes any dirt &
from the center and working outward. Allow alcohol to microorganisms
dry.
10. Remove needle cap. Readies for administration
11. Place non dominant thumb about 1 inch below insertion Exposes insertion site
site and pull skin down (town hand).
12. Talk to client and warn of impending needlestick. Reduces anxiety
13. With bevel up and using dominant hand, insert needle Inserts in dermis of skin
just below the skin at a 10-15-degree angle.
14. Once entry into skin surface is made, advance needle To insert in place
another 1/8 inch.
15. Inject drug slowly and smoothly while observing for bleb Reduces the pain & to
(a raised welt) to form (the bleb should be present). control site of bleb
16. Remove at same angle that it was inserted. For easy removal
17. Gently remove blood, if any, by dabbing with second Cleans the site
alcohol swab.
 18. Observe skin for redness or swelling; if this is an allergy Assess whether the
test; observe for systematic reaction (e.g. respiratory medication causes an
difficulty, sweating, faintness, decreased blood pressure, allergic reaction
nausea, vomiting, cyanosis).
19. Reassess client and injection site after 5 minutes, after 15 Assess the bleb & any
minutes, then periodically while client remains in clinic. responses of the client
20. Place and capped needle on tray. Remove gloves. Readies for disposal
21. Mark with blue or black pen around the bleb and instruct Tests if bleb will swell
client not to rub area.
22. Reposition client. To comfort client
23. Discard equipment appropriately. For proper disposal
24. Perform hand hygiene.
25. Document administration on medication record.
ATTITUDE OF THE STUDENT
26. Accepts constructive suggestions and criticisms. To correct mistake and
further improve yourself
27. Assumes accountability. For responsibility
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
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
 ADMINISTERING INTRAMUSCULAR MEDICATION
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

PURPOSE:

Delivers ordered medication into muscle tissue.

MATERIALS:

Medication Administration record/Electronic medication ticket pen

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

Legend:
1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
1. Perform hand hygiene. Prevents spread of
microorganisms
2. Prepare medication adhering to the five rights of drug Prevents any medication
administration. errors
3. Identify client by checking identification bracelet and by Confirms the client`s identity
addressing client by name. thus ensures administration
is done to the right patient
4. Explain procedure and purpose of medication to client. Reduces the anxiety, induce
cooperation & for right client
education
5. Verify allergies listed on medication record or electronic Prevents any allergic
medication record. reactions w/c is a
contraindication to
administration
6. Don gloves. Self-protection
7. Select injection site appropriate for client’s size and age. Follows the right route
8. Assist client into position for comfort and easy visibility of Efficient and effectiveness of
injection site. procedures
9. Cleanse site with alcohol swab. Removes any dirt &
microorganisms
10. Remove needle cap. Prepare for administration
11. Pull skin taut by at insertion by using the following
sequence:
11.1 Place thumb and index finger of non-dominant hand To further expose site & not
over injection site (taking care not to touch cleaned contaminate it
area) to from a V.
Moves the excess skin to
11.2 Pull thumb and index finger in opposing direction expose site
spreading fingers about 3 in
12. Talk to client and warn of impending needlestick Reduces anxiety
13. Quickly insert needle at a 90-degree angle with dominant Proper insertion of needle
hand (as if throwing a dart).
14. Move thumb and first finger of non-dominant from skin Holds the syringe in place
to support barrel of syringe; place fingers on the barrel.
15. Pull back on plunger and aspirate for blood return in Sees if you hit any blood
syringe. vessels
16. If blood does return when aspirating pulls the needle out, To inject to another site
apply pressure to the insertion site and repeat injection where there is no blood
steps. vessel
 17. If no blood returns, push plunger slowly and smoothly; Eases the client’s pain & for
encourage client to talk or take deep breaths. the smoothness of
administration
18. Remove needle at the same angle as it was inserted. Easy removal
19. Massage and lean insertion are with second alcohol wipe Reduces the pain & removes
(if contraindicated for drug, apply firm pressure instead). any blood
20. Place needle on tray; do not recap. To never make mistake it as
a new needle
21. Remove gloves. For proper disposal
22. Reposition client; raise siderails and place bed in lowest Comfort client and ensure
position with call light within reach. safety
23. Discard equipment appropriately. For proper disposal
24. Perform hand hygiene. Prevents spread of
microorganisms
25. Document administration on medication record. Used as a legal document
ATTITUDE OF THE STUDENT
26. Accepts constructive suggestions and criticisms. To correct mistake and
further improve yourself
27. Assumes accountability. For responsibility
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:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
 Bag Technique
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

DEFINITION:

Bag Technique is a tool making use of a public health bag through which the nurse, during his/her home visit, can
perform nursing procedures with ease and deftness, saving time and effort with the end in view of rendering effective
care.

PURPOSE:

To render effective nursing care to clients and/or members of the family during home visit.

EQUIPMENT NEEDED:

Paper lining Sterile cord tie

Extra paper for making bag for waste materials (paper bag) Adhesive plaster
Plastic/linen lining Dressing (OS, Cotton ball)
Apron Alcohol lamp
Hand towel in plastic bag Tape measure
Soap in a soap dish Baby’s scale
Thermometers in case 1 pair of rubber gloves
(one oral and rectal) 2 test tubes
Test tube holder
Pairs of scissors Syringes (5m and 2ml)
(1 surgical and 1 bandage) Hypodermic needles G19, 22, 23, and 25
Sterile dressings (OS and cotton balls)
2 pairs of forceps (curved and straight)
Medicines: Legend:
- Betadine - 70 Alcohol 1- Excellent
- Zephiran solution - hydrogen peroxide 2- Very Satisfactory
- Spirit of ammonia - acetic acid 3- Satisfactory
- Benedict’s solution - ophthalmic ointment 4- Needs Improvement
(antibiotic)
5- Poor

Note: Blood pressure apparatus and stethoscope are carried separately.

PROCEDURE RATIONALE 1 2 3 4 5
1. Upon arriving at the client’s home, place the bag on the table Protects the bag from
or any flat surface lined with paper lining, clean side out (folded getting contaminated
part touching the table). Put bag’s handles or strap beneath the
bag.
2. Ask for a basin of water if faucet is not available. Place these Used for handwashing
outside the work area.
3. Open the bag, take the linen/plastic lining and spread over Prevents contamination of
work field or area. The paper lining, clean side out (folder part bag & prepares for
out). handwashing
4. Take out hand towel, soap dish and apron and place them at Prevents contamination of
one corner of the work area (withing the confines of the supplies
linen/plastic lining.)
5. Do handwashing. Wipe and dry with towel. Leave the plastic Prevents spread of
wrappers of the towel in in soap dish in the bag. contamination
6. Put on apron right side out and wrong side with cease touching Keeps yourself clean
the body, sliding the head into the neck strap. Neatly tie the
straps at the back.
7. Put out things most needed for the specific case (e.g. Promotes efficient work and
thermometer, kidney basin, cotton ball, waste paper bag) and time
place at one corner of the work area.
8. Place waste paper bag outside of work area. Prevents contamination
9. Close the bag. Prevents contamination
inside
10. Proceed to the specific nursing care or treatment (e.g., TPR Integrates required skill
taking, Urinalysis, or wound dressing).
11. After completing nursing care or treatment, clean and Kills of any microorganisms
alcoholize the things used.
 12. Do hand washing again. Prevents spread of
microorganism
13. Open the bag and put back all articles in their proper places. For organization
14. Remove apron folding away from the body, with soiled side Avoids contact of sterile
folded inwards, and the clean side out. Place it in the bag. things
15. Fold the linen/plastic lining. If clean, place it in the bag and Easier access
close the bag.
16. Make post-visit conference on matters relevant to health Preparedness of final
care, taking anecdotal notes preparatory to final reporting. reporting
17. Make appointment for the next visit (either home or clinic). Follow up purposes
POST-PROCEDURE ACTIVITY
18. After care of materials. Cleanliness & orderliness
19. Get the bag from the table, fold the paper lining and place in Avoids contamination of
between the flaps of the bag. Close bag. contents that are clean
20. Record all relevant findings about client and family. Take note Used as a baseline for future
of environmental factors which affect their health. Include uses
quality of nurse-patient relationship and nursing care provided.
ATTIDUE OF THE STUDENT:
21. Accept constructive suggestions and criticisms. To correct mistake and
further improve yourself
22. Assumes accountability. For responsibility
Source:
Pañares-Reyala, Jean, Community Health Nursing Services in the
Philippines, 9th edition. Manila: Community Health Nursing
Section, national League of Philippine Government Nurses, Inc.,
2000, pp.54-58).
Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________

5x ____________ = __________

Total divided by no. of items = __________

Comments:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over

Printed name
 Wound Care
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

DEFINITION:

The application of dry material such as absorbent gauze to protect or cover the wound or lesions.

PURPOSE:

To protect the healing wound from trauma or bacterial invasion.

EQUIPMENT NEEDED:

Clean examination gloves Legend:

Container for proper disposal of soiled dressing 1- Excellent
Sterile 4x4 gauze pads 2- Very Satisfactory
Betadine paint and cleanser 3- Satisfactory
plaster 4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
1. Wash hands. Prevents spread of
microorganisms
2. Prepare materials. Saves time and energy
3. Provide privacy For confidentiality
4. Explain procedure to the client. Encourages cooperation
5. Wash hands. Prevents spread of
microorganisms
6. Apply clean gloves. Used as a barrier method
from microorganisms
7. /remove old, soiled dressing and place in appropriate Prepares for cleaning &
receptacle. prevent any more
contamination
8. Apply new set of gloves. Protects nurse from
pathogens
9. Assess the appearance of the undressed wound bed for Assess extent of damage,
healing. swelling & irritation
10. Cleanse the wound with normal saline solution. Promotes cleanliness of
hand
11. Cleanse the wound with betadine cleanser. Promotes cleanliness for the
wound
12. Cleanse the wound with betadine paint. Kills of microorganisms and
seal the wound
13. Remove used gloves. Proper disposal
14. Wash hands. Prevents spread of
microorganisms
15. Apply new pair of gloves. Prevents the hands from
being contaminated
16. Grasping the edges, apply the new dressing on the wound. Prevents incision from
clothing & allow healing
17. Approximate, cute, and apply plaster on dressing. Promotes healing
18. Remove gloves and dispose properly. Reduces transmission of
microorganisms
19. Conduct client and family education about the dressing. Educates client for them to
do it independently at home
20. Do after care. Maintains cleanliness &
orderliness
21. Wash hands. Prevents spread of
microorganisms
22. Do proper documentation For proper documentation

Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________
 5x ____________ = __________

Total divided by no. of items = __________

Comments:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over

Printed name
 TESTING URINE FOR SUGAR
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

PURPOSE:

1. To check urine for presence of sugar, acetone, bacteria, and other urinary products.

2. To aid in diagnosis

3. To determine the condition of the patient.

4. To determine effectiveness of therapy.

EQUIPMENT NEEDED:

2 test tubes Clean gloves Test tube holder Legend:

Alcohol lamp Denatured alcohol Match or lighter 1- Excellent
Benedict’s solution Acetic acid Small glass 2- Very Satisfactory
Container of urine Colored chart 3 droppers 3- Satisfactory
Tissue Waste receptacle 4- Needs improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
1. Assemble all equipment. Saves time and energy
2. Wash hands. Prevents spread of
microorganisms
3. Explain procedure to the patient and explain proper collection of Encourage cooperation
urine. & promote efficiency
when undergoing
procedure
4. Explain procedure to the client. Eases anxiety & induces
cooperation
5. Don clean gloves. Prevents spread of
microorganisms
6. Apply clean gloves. Used as a barrier
method from
microorganism
Benedict’s Test
1. Place 5 cc of Benedict’s solution in a test tube. Assess presence of
glucose in urine
2. Add 8 drops of urine. Tests the urine
[Link] the button of the test tube until boiling point. Properly mixes &
diffuses the solution
4. Read the result and compare with the color chart. Finds out the result is
positive or negative
B. Acetic Acid Test
1. Place 5 cc of the urine and place it on a test tube. Prepares for testing
2. Heat the test tube on the upper half. To have an accurate
result
3. Add 3 drops of acetic acid once it boils. Ensures proper mixture
of solution
4. Heat again until boiling point. Ensures proper
breakdown for
accuracy
5. Read and compare the result with the color chart. To know if it’s positive
or negative
AFTER CARE
1. Explain result to the patient. To inform client
2. Place used instrument in the pouch for soiled instruments, place Prevents spread of
soiled articles outside the bag. contamination &
spread of
microorganism
3. Return clean equipment inside the bag. Proper storage of
equipment
[Link] hands. Prevents spread of
microorganisms
5. Return clean equipment inside the bag. Proper storage
6. Document findings. Future references
Scoring:
1x ____________ = __________
2x ____________ = __________
3x ____________ = __________
4x ____________ = __________
5x ____________ = __________
Total divided by no. of items = __________
Comments:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
 LEOPOLD’S MANEUVER
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

Legend:
1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
PREPARATION
1. Wash hands. Prevents spread of
microorganisms
2. Encourage the patient to empty the bladder. Relieves anxiety
3. Compute the following:
a. OB Score
b. EDC Assess client’s overall
c AOG condition
4. Physical Assessment
First Maneuver
[Link] the patient Promotes comfort and ease
2. Stand at the side of the bed, facing the mother. For proper positioning for a
more efficient procedure
3 Palpate the uterine fundus with warm hands. Warms hand so client won’t
experience chills
4. Determine which part of the baby’s body lies on the upper Tracks the position of the
fundus according to its: fetus
a. Relative consistency
b. Shape
c. Mobility
Second Maneuver
1. Place the palmar surface of both hands on either side of the Palpates and determines the
abdomen. fetal back
2. Apply gently but deep pressure in one side of the abdomen. Establishes the location of
the spine and extremities
3. Palpate the opposite side from the top to the lower segment Easily locates the back of the
of the uterus in a slightly circular motion. fetus
4. Determine which side of the uterus is the long axis of the fetus Determines the location of
located. the fetus
5. Check the fetal heart rate Examines the fetal condition
Third Maneuver
1. Grasp the lower uterine segment with thumb and fingers. Determines the presenting
part of the fetus
2. Identify the presenting part. Establishes what part of the
fetus body is being palpated
3. Determine the mobility of the presenting part. Decides whether the
presenting part is above the
pelvis or fixed in the pelvis
Fourth Maneuver
1. Stand to the side facing the patient’s feet. Comfortably access the fetus
in the mother’s womb
2. Place the tips of the first three fingers on both sides of the Easily detects the head or
midline about two inches from the inguinal ligament. the presenting part of the
fetus
3. Apply pressure downward and in the direction of the birth Determines the degree of
canal. flexion of fetal head
4. Confirm the presenting part. Verifies and to prepare what
type of delivery a mother
would possibly have
ATTITUDE
1. Accepts constructive suggestions and criticisms To correct mistake and
further improve yourself
2. Assume responsibility of his or her actions. For responsibility
Scoring:
1x ____________ = __________
2x ____________ = __________
3x ____________ = __________
4x ____________ = __________
5x ____________ = __________
Total divided by no. of items = __________
Comments:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
 NGT FEEDING
Airiz Trisha A. Trinidad
Name:________________________________________________________Grade:__________________________
BSN 2 - F
Year and Section:_______________________________________________Date:___________________________

DEFINITION:

Enteral feeding is a method of supplying nutrients directly into the gastrointestinal tract.

EQUIPMENT NEEDED:

NGT Medicine Cup Legend:

Asepto Syringe Tissue/Towel 1- Excellent
Stethoscope Kidney Basin 2- Very Satisfactory
Clean Gloves Plaster 3- Satisfactory
Glass of Warm Water Prepared Formula 4- Needs Improvement
Calibrated Glass 5- Poor

PROCEDURE RATIONALE 1 2 3 4 5
ASSESSMENT:

Prior to NGT feeding ensure that the tube is located in the stomach. To ensure that the
Coughing, vomiting and movement can move the tube out of the formula will be
correct position. The position of the tube must be checked: absorbed in the
stomach and to
prevent any serious
• Prior to each feed complication.
• Before each medication
• Before putting anything down the tube
• If the patient has vomited

Perform the following observations and obtain a gastric aspirate to

establish tube position. To conduct the
procedure smoothly.
To prevent any bad
• Ensure taping is secure
reaction to occur.
• Observe and document the position marker on NGT/OGT –
compare to initial measurements.
• Observe Patient for any signs of respiratory distress

Procedure:
1. Wash hands. Prevents spread of
microorganisms
2. Prepare materials. Saves time and
promotes efficiency
3. Provide privacy Comforts the client
4. Explain procedure to the client. Lessens anxiety and
promote cooperation
5. Wash hands. Prevents spread of
microorganisms
6. Apply clean gloves. Prevents cross
contamination
8. Measure the correct amount of formula and warm it to the desired Cold formula can cause
temperature. abdominal cramps
9. Elevate the patient’s bed to a high- or semi-Fowler’s position Helps the patient
swallow easily in this
position
10. Place protective sheet under tubing to protect bedding and Prevents any
clothes. contamination in the
sheet
11. Remove cap or plug from the feeding tube. Pinching or clamping
the tube prevents
excess air from
entering
12. Check tube patency and placement
• observing mark on NG tube
• pH testing To determine the
• use the asepto syringe to inject 10-15 mL of air while location of the tube.
auscultating with stethoscope listen for bubbling or gurgling
To ensure the tube is
sound.
properly placed in the
• Aspirate stomach contents. Note amount of residual stomach.
withdrawn and inject gastric fluid back into tube. DO NOT
discard this fluid. If residual is greater than 100 mL or twice
 the hourly rate of feeding, call physician. DO NOT administer This indicates gastric
feeding. emptying time. A
residual of more than
50% of the previous
hour’s intake is
significant and must be
reported to physician.
Fluid should be
returned to stomach so
as not to cause any
fluid or electrolytes
losses.
13. Clamp the tube and attach the tube to the asepto syringe. Prevents nourishment
from draining back into
the tube and air from
entering the stomach.
14. Flush with 50ml-60 ml water or as recommended To cleanse the tube
15. Pour the formula into the asepto syringe and unclamp the tube. Lets the formula flow
naturally and be
received by the
stomach.
16. Allow the formula to flow in by gravity. Nourishment enters
the stomach by gravity
when gastric gavage is
used
17. During the feeding, keep the bottom of the syringe no higher than Avoids formula from
6 inches above the patient’s stomach. flowing too quickly
18. Continue adding formula into the syringe until the prescribed Continuous feeding
amount is given. promotes less
aspiration
19. If there are medications to be given, do not mix the medication Adding medications
into the feeding, take note if the medication is to be given before or into formula feeds may
after the feeding, crushed the medication and mix it with water in the result in tube clogging
medicine cup, pour the medication into the asepto syringe. and cause undesirable
effects or
incompatibilities
20. When the syringe is empty, flush the tube with the prescribed Moves the formula
amount of warm water. sticking to the tube into
the stomach
21. Clamp the tube. Prevents nourishment
from draining back to
the tube
22. Leave patient in high- or semi-Fowler's position for at least 30 Aids in proper digestion
minutes and observe after for vomiting or any other unusualities.
23. Discard soiled supplies in appropriate containers. Avoids contamination
POST-PROCEDURE ACTIVITY
24. After care of materials. Cleanse reusable equipment and rinse. Prevents the growth of
Allow to airdry and wrap in clean towel to be used at next feeding. microorganisms and to
be
25. Proper Documentation: Proper documentation
a. Verification of proper tube placement. provides coordination
b. Amount of aspirated stomach content. of care and will serve as
c. Feeding solution and amount. a reference for
information.
d. Medications administered.
e. Amount of water administered.
f. Patient's response to procedure.
g. Instructions given to patient/caregiver.
h. Communication with physician, when necessary.
ATTIDUE OF THE STUDENT:
26. Accept constructive suggestions and criticisms. To correct mistake and
further improve
yourself
27. Assumes accountability. For responsibility
Reference:
[Link]
Scoring:

1x ____________ = __________

2x ____________ = __________

3x ____________ = __________

4x ____________ = __________

5x ____________ = __________

Total divided by no. of items = __________

Comments:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Airiz Trisha A. Trinidad

_______________________________________ Sir Carl Roucel Animos, MN, RN
_______________________________________

Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over

Printed name