1.

Vital Signs (Ma’am Susan)  Provide a wide base

a. Reflect the body’s of support and move
physiologic status and closer to the sink
provide information during the activity
critical to evaluating  Friction, running
homeostatic balance water and a
b. Purpose cleansing agent are
 To obtain baseline necessary to remove
data about the patient microorganism or
condition other material that
 For diagnostic purpose maybe present on
 For the therapeutic the hands
purpose  Assemble articles
c. Includes taking of: needed near the sink
 Temperature  Make sure that the
uniform does not
 Pulse rate
come in contact with
 Respiratory rate the sink throughout
 Blood pressure the activity
d. Equipment:  Use lotion if needed
 Vital sign tray for dry skin. In some
 Stethoscope settings, lotions are
 BP apparatus not recommended
 Thermometer because it can be an
 Second hand watch excellent medium for
2. Handwashing (Ma’am Yolly) bacterial growth
a. Is the vigorous, brief 3. Gloving (Sir Marcial)
rubbing together of all a. Donning of sterile gloves
surfaces and crevices of b. Purpose:
the hand lathered in soap,  Help prevent the
followed by rinsing under transmission of
a stream of water pathogens by direct
b. Purposes: and indirect contact.
 To remove soil and c. Considerations:
transient organisms  the skill of open
from the hands gloving can be
 To reduce total delegated when
microbial counts over personnel are
time trained to perform a
 To prevent pathogenic sterile procedure.
microorganisms from  Consider proper size,
spreading patient to allergies to rubber or
patient latex.
 To protect the nurses 4. Occupied Bedmaking (Ma’am
Laila)
a. Is a type of bed with a
client on it
c. Considerations:
 b. Purposes: as a machine and as a
 To keep client clean means for locomotion.
and comfortable b. Purposes:
 To promote health  To maintain good
and comfortable body posture
 To Conserve client's  To help promote
energy and maintain and maintain
current health status physiologic
c. Equipment: functioning
 Bottom Sheet  To prevent injury
 Top sheet and fatigue
 Blanket (optional)  To improve
 Cotton draw sheet physical
(optional) appearance
c. Includes:
 Rubber draw sheet
(optional)  Standing
 Pillow case  Sitting
 Hamper for soiled  Walking
linen  Lifting and picking
5. Unoccupied Bed up of objects
a. is a type of bed without a 7. Positioning and Draping (Sir Art)
client on it a. Positioning - the technique
b. Purposes: of placing the patient
 To provide comfort safely, comfortably, and
to client effectively in preparation
for any procedure.
 To increase sense of
well being b. Draping - is the manner of
arranging the covering in
 To provide clean,
order to expose the part
neat environment for
being examined treated
the client
or cleaned.
 To provide wrinkle-
free bed and to c. Purposes:
minimize skin  To assist the patient
irritation to assume a position
c. Equipment: that would best afford
adequate examination
 Bottom Sheet
of the part.
 Top sheet
 To provide safety,
 Blanket (optional) comfort, and privacy
 Cotton draw sheet during the
 Pillow case examination.
 Hamper with soiled d. Special Considerations:
linen  The methods of
6. Body Mechanics (Ma’am Lau) draping vary with
a. It is the coordinated and condition of the
efficient use of body parts patient, the position
of the patient, the
 examination to be
done and the room
temperature.
 The draping should 8. Perineal Care/Serving Offering
be loose enough to bedpan (Ma’am Nora)
allow quick change of
position.
 Draping should
consider the
patient’s individual
make-up.
 Positioning depends a. involves washing the
upon the condition of external genitalia and
the patient and the surrounding with soap and
part to be examined. water or with water alone
e. Preparation: or in combination with any
 Equipment: Bring commercially prepared
to the bedside a peri-wash
b. Purposes:
 To prevent infection
 Provide comfort to
the patient
draping sheet.
 For maintaining the
 Patient and Unit:
hygiene
 Explain the
 Remove secretion
procedure to the
patient. c. Special Considerations to
 Adjust the height a patient who are:
of the bed or the  Unable to do self-care
table.  Genitor-urinary tract
f. Includes: infection
 Erect  Incontinence of urine
 Horizontal and stool
Recumbent  Indwelling catheter
 Dorsal Recumbent  Postpartum patient
 Dorsal Lithotomy  After surgery on the
 Sims (Lateral) genitor-urinary
system
 Prone
 Injury, ulcer or

 Fowlers
 Trendelenburg
Position
 Knee Chest surgery on perineal
(Genupectoral) areas
d. Equipment:
 Bedpan
  Towel prevent injury to the
 Razor mucous membrane of
 Mackintosh the urethra or to
cause the patient’s
 Warm water
discomfort.
 Cotton swab
 See to it that the
9. Catheterization (Ma’am Thelma)
patient is relaxed
a. is the introduction of the
during the insertion
catheter thru the urethra
of the catheter:
into the bladder in order
 In case of severe
to remove urine.
bladder distention
b. Purposes: observe gradual
 To remove urine decompression.
when it is not  Ensure adequate
advisable for the cleanliness of the
patient to void. external genitalia
 To determine before inserting the
whether failure to catheter.
void is due to urinary  If the specimen is to
retention or urinary be collected for a
suppression. needed examination,
 To determine caution the patient
residual urine not to void when
 To measure hourly being given an
urine output external douche.
c. Considerations: d. Equipment:
 Before starting the  catheterization tray:
procedure, check the o sterile catheter
catheter's expiration o disposable gloves
date and defects. o sterile gloves
 Insert the catheter, o lubricant (KY jelly)
GENTLY. o antiseptic solution
 Observe strict o cotton balls or
surgical asepsis gauze
throughout the o pick-up forceps
procedure.
o if the catheter is to
 See to it that the be kept in place
patient is protected (Indwelling/Foley/R
from unnecessary etention Catheter)
exposure and draft. include:
 Provide adequate o 10 cc syringe and
lighting in order to distilled water
visualize well the o adhesive plaster
urinary meatus and o scissor
to prevent
o urinary bag
contamination.
 floor lamp or flashlight
 Use the correct size
of catheter to b. Types:
  Single Catheterization  Toxicologic analysis-
– Straight/Nelaton the detection,
Catheter identification, and
 Retention measurement of
Catheterization – 2- foreign compounds
way Foley Catheter (xenobiotics) in
 Continuous Bladder biological and other
specimen
Irrigation (Cystoclysis) –
3-way Foley Catheter  Endotracheal tube- A
flexible tube that is
c. Sizes:
put in the mouth and
 M: Fr 16-18 then down into the
 F: Fr 12-14 trachea (airway).
d. Position: e. Equipment:
 M: Supine, legs  Large diameter
abducted and rubber gastric hose
extended (32 - 50 French).
 F: Dorsal recumbent  block or elliptical
position endoscopy °bite block
e. Location of urinary (if intubation is to be
meatus: oral)
 M: at the tip of the  Lubricating or local
glans penis anesthetic jelly (if
 F: b/w the clitoris and inserting a
vaginal orifice nasogastric tube)
f. Length of the catheter  50 ml catheter tipped
insertion: syringe
 M: 6-9 inches  Tape
 F: 3-4 inches  Y connector and
clamp
2. Gastric Lavage
a. also commonly called  Cuffed endotracheal
stomach wash or gastric (ET) tube
suction  3 L tap water
b. is the process of cleaning  Activated charcoal (1
out the contents of the gm/kg) with Sorbitol
stomach. (25 mg/kg)
c. Purpose: 3. Gastric Gavage
 to decontaminate the a. gastric gavage is a mean
stomach of patients of supplying nutritional
following an ingested substance via a small
overdose or plastic tube direct to the
poisoning. stomach.
d. Terminologies: b. Purpose:
 Cathartic- a  To provide a means of
substance that alimentation when the
accelerates oral route is
defecation. inaccessible.
c. Terminologies:  Bowl
 Gavage: a way of  Acepto syringe
giving medicines and  Medicine glass with
liquids, including liquid tap water
foods, through a small 4. Enema (Sir Modesto)
tube placed through a. Is the instillation of
the nose or mouth solution into RECTO-
into the stomach or SIGMOID-COLON
small intestine. b. Purposes:
 Gastrointestinal  to relieve constipation
diseases- refers to – most common
disease involving the problem
gastrointestinal tract,  to relieve fecal
namely the impaction
esophagus, stomach,  to expel flatus
small intestine, large
 to lower body temp
intestine and rectum,
and the accessory  to facilitate
organs of digestion, administration of
the liver, gallbladder, medications
and pancreas.  to prepare for
 Hypermetabolic diagnostic procedures
or surgery
stage- is the
physiological state of c. Types:
increased rate of  Cleansing Enema –
metabolic activity and emptying of the lower
is characterized by an part of the colon from
abnormal increase in feses and gases
the body's basal  Carminative – given to
metabolic rate. expel flatus
 Sepsis- is the body's  Retention – introduces
extreme response to oil or medication into
an infection the rectum and
 Neurologic disorder- sigmoid colon. –
medically defined as emptying of lower
disorders that affect section of colon from
the brain as well as fecal matter and
the disorders that gases (these are
affect the brain as given to soften faecal
well as the nerves matter)
found through the  Return-flow enemas –
human body and the aka colonic irrigation –
spinal cord. used to expel flatus
d. Equipment:
 Feeding fomula
 Calibrated drinking
glass