Republic of the Philippines JOSE RIZAL MEMORIAL STATE UNIVERSITY The Premier State University in Zamboanga del Norte Main Campus, Dapitan City COLLEGE OF NURSING & ALLIED HEALTH SCIENCES Name of Student: Course & Year : __________________ __________________ Date of Return Demo : __________________ SY: ________ Semester: ________________ TEMPERATURE, PULSE, RESPIRATION TAKING Procedure Checklist E (3) Procedure S (2) NP (1) ND (0) Remarks AXILLARY TEMPERATURE 1 Wash hands 2. Gather TPR tray and other materials 3. Explain procedure to the patient 4. Check for adequate lighting 5. Check the digital thermometer if it is functioning well 6. Wipe thermometer with cotton ball soaked with alcohol from cleanest to dirtiest 7. Set thermometer as directed, insert to dry axilla and put hand across the chest 8. Wait for the beep sound then remove thermometer 9. Read and record result 10. Disinfect thermometer with cotton ball soaked with 75% alcohol & return to receptacle RADIAL PULSE 11. Place patient’s arm close to the body with the palm pointing downward 12. Place first three fingers against the radial pulse or artery 13. With gentle pressure, feel pulsation 14. Count pulse in one full minute. Note quality & rhythm of pulse 15. Record Results RESPIRATION 16. With fingers still in place after taking the pulse rate, note the rise and fall of patient’s chest during respiration. 17. Count respiration in one full minute 18. Record result 19. Position back patient to bed or chair and make comfortable 20. Return TPR Tray to CSR 21. Wash hands 22. Graph findings of vital signs: temperature, pulse & respiration 23. Make a graceful exit after the procedure Total Score: 69/69 EXCELLENT (E) – 3 Pts SATISFACTORY (S) – 2 Pts NEEDS PRACTICE (NP) – 1 Pt NOT DONE (ND) – 0 Pt Supervised by: ________________________________________ Clinical Instructor Date of Return Demo: ________________ Republic of the Philippines JOSE RIZAL MEMORIAL STATE UNIVERSITY The Premier State University in Zamboanga del Norte Main Campus, Dapitan City COLLEGE OF NURSING & ALLIED HEALTH SCIENCES Name of Student: Course & Year : __________________ __________________ Date of Return Demo : __________________ SY: ________ Semester: _______________ BLOOD PRESSURE TAKING Procedure Checklist PROCEDURE E (3) S (2) NP (1) ND (0) REMARKS 1 Check the physician’s order 2. Assemble needed equipment 3. Identify patient, introduce self and explain the procedure 4. Place patient in a comfortable position with supported forearm and palm facing upward 5. Place cuff with the inflatable bag centered over the brachial artery and the lower edge of cuff is 2cm above the antecubetal fossa 6. Wrap cuff slowly around the arm and tuck securely. 7. Use fingertips to feel for pulsation in antecubetal space 8. Place stethoscope where pulsation is noted 9. Pump bulb of manometer until mercury rises to approximately 130 mmHg above point of anticipated systolic pressure. 10. Using the valve of the inflatable bulb, release air 2-3 mm. per heart beat and note the point in the manometer at which first loud sound is heard. 11. Continue to release air in inflated cuff evenly and gradually and note the point in the manometer at which the last loud & distinct sound is heard. 12. Allow remaining air to escape quickly and remove cuff. 13. Do after care of equipment 14. Record reading of systolic over diastolic pressure & characteristics 15. Make the patient comfortable 16. Make a graceful exit Total Score: 48/48 EXCELLENT (E) – 3 Pts SATISFACTORY (S) – 2 Pts NEEDS PRACTICE (NP) – 1 Pt NOT DONE (ND) – 0 Pt Supervised by: ________________________________________ Clinical Instructor Date of Return Demo: ________________ Republic of the Philippines JOSE RIZAL MEMORIAL STATE UNIVERSITY The Premier State University in Zamboanga del Norte Main Campus, Dapitan City COLLEGE OF NURSING & ALLIED HEALTH SCIENCES Name of Student: Course & Year : __________________ __________________ Date of Return Demo : ______________ SY: ________ Semester: _______________ BED MAKING: OPEN BED Procedure Checklist PROCEDURE E (3) S (2) NP (1) ND (0) REMARKS 1 Wash hands. 2. Prepare necessary linens for appropriate bed. 3. Bring necessary linens to bedside and arrange in their order of use. 4. Straighten mattress. Turn if necessary. 5. Find the center of the mattress. 6. Place wrong side of bottom sheet out with its longitudinal center at the middle of the mattress 7. Draw bottom sheet towards head and tuck 8. Miter corners and tuck the side 9. Place rubber sheets and tuck at the sides 10. Cover rubber sheet with cotton draw sheet and tuck 11. Place top sheet right side up and draw to foot part and tuck 12. Miter corners and pull head part of top sheet over half of bed 13. Go to other side of the bed and do the same 14. Pull pillow into a pillow case 15. Place pillow with a case at the middle of the head part with opening facing away from the door 16. Inspect bed and do necessary stretching and adjustments Total Score: 48/48 EXCELLENT (E) – 3 Pts SATISFACTORY (S) – 2 Pts NEEDS PRACTICE (NP) – 1 Pt NOT DONE (ND) – 0 Pt Supervised by: ________________________________________ Clinical Instructor Date of Return Demo: ________________ Republic of the Philippines JOSE RIZAL MEMORIAL STATE UNIVERSITY The Premier State University in Zamboanga del Norte Main Campus, Dapitan City COLLEGE OF NURSING & ALLIED HEALTH SCIENCES Name of Student: Course & Year : __________________ __________________ Date of Return Demo : ______________ SY: ________ Semester: _______________ BED MAKING: OCCUPIED BED Procedure Checklist PROCEDURE E (3) S (2) NP (1) ND (0) REMARKS 1 Wash hands 2. Assemble necessary linens for appropriate bed 3. Greet patient and explain the procedure 4. Place bedside chair at the foot of the bed 5. Arrange linens in their order of use 6. Provide privacy if the patient is in the ward 7. Loosen the linens from beneath the mattress on all sides 8. Remove top covers except the top sheet, one at a time. Fold to bottom & pick up in the center. Place a clean sheet over the top sheet. 9. Slide the soiled sheet out from top to bottom. Discard in hamper 10. Move the pillow under the head of patient towards you. Ask the patient to move towards it. Assist if necessary. Place patient on his/her side. Raise side rails up if necessary. 11. Go to other side of the bed . Fanfold the soiled cotton draw sheet & bottom sheet and place close to the patient’s body. 12. Place a clean bottom sheet with its longitudinal center along the center of the mattress. Fanfold the other half close to the body of the patient. Spread the remaining half near to you. 13. Tuck the head part & miter the corner. Then, tuck the side of the bottom sheet under the mattress from head to foot part. 14. Place rubber draw sheet close to the patient. Fanfold half of it. 15. Spread half of the rubber draw sheet toward you and tuck under the mattress 16. Go to the other side. Move the pillow under the patient’s head near you. 17. Ask the patient to move to the other side near to you. 18. Turn to the other side and pull the soiled linens & place in hamper bag. 19. Pull the bottom sheet, tuck the head part & miter. 20. Tuck the side from head to foot part. 21. Pull the rubber draw sheet and tuck under the mattress 22. Place pillow under the head of the patient and at the middle of the head part. Ask the patient to roll unto the pillow. 23. Place the top sheet, wrong side and spread. 24. Ask patient to lift head, remove the pillow and change pillow case before placing it back under the patient’s head. 25. Make some adjustments. Make the patient comfortable 26. Document new observations if there are and make a nice exit. Total Score: 78/78 EXCELLENT (E) – 3 Pts SATISFACTORY (S) – 2 Pts NEEDS PRACTICE (NP) – 1 Pt NOT DONE (ND) – 0 Pt Supervised by: ________________________________________ Clinical Instructor Date of Return Demo: ________________ Republic of the Philippines JOSE RIZAL MEMORIAL STATE UNIVERSITY The Premier State University in Zamboanga del Norte Main Campus, Dapitan City COLLEGE OF NURSING & ALLIED HEALTH SCIENCES Name of Student: __________________ Course & Year : __________________ Date of Return Demo : ______________ SY: ________ Semester: _______________ PERINEAL CARE Procedure Checklist PROCEDURE E (3) S (2) NP (1) ND (0) REMARKS 1 Explain procedure to patient. 2. Assemble equipment at bedside and screen patient. 3. Place patient on bedpan. 4. Wet cotton with water, start from midline of the symphysis pubis with downward strokes toward anus. 5. With the next cotton ball start from mons veneris in a figure of 7 motions by way of external labium towards anus. Discard. 6. Do likewise on opposite side. (in an inverted 7 motion) 7. With four cotton ball clean far groin with upward strokes. Clean near groin the same way. 8. Rinse, dry area with the same strokes. 9. Remove bedpan, turn patient to her side. 10. Take another cotton ball, clean one side of buttocks. Do the same with the other side. 11. With another cotton ball, make upward stroke from perineum to anus. 12. Dry buttocks thoroughly. Toilet paper may be used to pat the buttocks dry. 13. Turn patient on her back. Make patient comfortable. Total Score: 39/39 EXCELLENT (E) – 3 Pts SATISFACTORY (S) – 2 Pts NEEDS PRACTICE (NP) – 1 Pt NOT DONE (ND) – 0 Pt Supervised by: ________________________________________ Clinical Instructor Date of Return Demo: ________________ Republic of the Philippines JOSE RIZAL MEMORIAL STATE UNIVERSITY The Premier State University in Zamboanga del Norte Main Campus, Dapitan City COLLEGE OF NURSING & ALLIED HEALTH SCIENCES Name of Student: Course & Year : __________________ __________________ Date of Return Demo : ______________ SY: ________ Semester: _______________ SHAMPOO ON BED Procedure Checklist PROCEDURE E (3) S (2) NP (1) ND (0) REMARKS 1 Assess need of patient to have bed shampoo. 2. Request for a medicine card from the Head Nurse. 3. Wash hands. 4. Assemble needed equipment. 5. Bring equipment to patient’s room. 6. Line bedside table with newspaper. 7. Explain the procedure to the patient. 8. Close windows and screen bed. 9. Offer bedpan. 10. Remove pillows. 11. Assist patient in lying diagonally across the bed. 12. Place a small pillow or rolled blanket under patient’s neck. 13. Place bath towel under patient’s head. 14. Make rubber sheet into an improvised Kelly pad and place it under patient’s head. 15. Place pail on chair lined with newspaper and adjust thoroughly in place. 16. Comb patient’s hair and place their combing in waste receptacle. 17. Get two cotton balls and place and place them into each ear. 18. Wet hair and lather hair and scalp using soap or shampoo. 19. Massage scalp. 20. Rinse head with warm water, repeating as needed. 21. Repeat washing hair with soap and water prn. 22. Give final rinsing with cold water. 23. Squeeze out excess water from hair and remove ear plug. 24. Roll rubber sheet, fold it carefully and place it on a tray or pail. 25. Rub head with towel until hair is partly dry. 26. Replace pillow protected with dry towel. 27. Comb hair and leave bath towel until hair is completely dry. 28. Make a graceful exit. Do after care. Total Score: 84/84 EXCELLENT (E) – 3 Pts SATISFACTORY (S) – 2 Pts NEEDS PRACTICE (NP) – 1 Pt NOT DONE (ND) – 0 Pt Supervised by: ________________________________________ Clinical Instructor Date of Return Demo: ________________ Republic of the Philippines JOSE RIZAL MEMORIAL STATE UNIVERSITY The Premier State University in Zamboanga del Norte Main Campus, Dapitan City COLLEGE OF NURSING & ALLIED HEALTH SCIENCES Name of Student: __________________ Course & Year : __________________ Date of Return Demo : ______________ SY: ________ Semester: _______________ CLEANSING BED BATH Procedure Checklist PROCEDURE E (3) S (2) NP (1) ND (0) REMARKS 1 Wash hands. 2. Explain the procedure to the patient. 3. Provide privacy. 4. Gather equipment. 5. Remove top linen & place bath blanket. 6. Obtain water. 7. Position patient near to the nurse’s side. 8. Remove patient’s gown. 9. Spread towel under patient’s head, bath, rinse, & pat dry the eyes, face, ears and neck. 10. Spread towel under far arm and then near arm, bath, rinse, and pat dry hands from wrist, arm and axilla with firm long stroke. 11. Place hands in the basin of water, soap and rinse thoroughly, pat dry. 12. Change water. 13. Spread towel over patient’s chest, bath, rinse & pat dry back & buttocks. 14. Assist patient to turn, bath, rinse & pat dry back & buttocks. 15. Spread towel under far leg & near leg bath, rinse & pat dry. 16. Place feet (one at a time) in the basin of water & rinse thoroughly. 17. Wash genital area or give patient the opportunity to do so. 18. Help patient put on clean gown. 19. Assist patient with hair and nail care. 20. Make an occupied bed. 21. Tidy up area 22. Wash hands & Document Observation Total Score: 66/66 EXCELLENT (E) – 3 Pts SATISFACTORY (S) – 2 Pts NEEDS PRACTICE (NP) – 1 Pt NOT DONE (ND) – 0 Pt Supervised by: ________________________________________ Clinical Instructor Date of Return Demo: ________________ Republic of the Philippines JOSE RIZAL MEMORIAL STATE UNIVERSITY The Premier State University in Zamboanga del Norte Main Campus, Dapitan City COLLEGE OF NURSING & ALLIED HEALTH SCIENCES Name of Student: Course & Year : __________________ __________________ Date of Return Demo : ______________ SY: ________ Semester: _______________ GIVING & REMOVING OF BEDPAN OR URINAL Procedure Checklist PROCEDURE E (3) S (2) NP (1) ND (0) REMARKS 1 Take the necessary articles to the bedside. 2. Greet the patient and explain the necessary procedure. 3. Screen the unit. 4. Change the top sheet with the bath blanket by folding the sheet to the front of the bed. 5. Have the patient flex the knees and draw as the feet are pressed against the bed. 6. Uncover the bedpan and slip it under the raised buttocks. 7. If the patient is physically capable. She is instructed to how to aid on putting the bedpan under the buttocks. Support the patient’s back by placing one hand under hips while the other hand draws up the gown or draws down the pajamas. 8. Place the bell and toilet paper within patient’s reach. Leave the patient alone unless he is very ill or weak. 9. When the patient is through, flushed if needed. If patient is unable to care for himself. Cleanse the anus with toilet tissue drawing it backward to prevent contamination of the external genetalia. 10. Remove the bedpan by supporting the patient as before while carefully drawing out the bedpan from under the buttocks. Cover & bring to the toilet. 11. Note the contents of the bedpan carefully before emptying. Observe accurately the quantity, color, odor, general consistency, the presence of urine or foreign matter: blood, parasites, etc. 12. Wash the patient’s hands and make him/her comfortable. 13. Do the after care of equipment, wash hands. 14. Record and chart observations of urine and feces. Total Score: 42/42 EXCELLENT (E) – 3 Pts SATISFACTORY (S) – 2 Pts NEEDS PRACTICE (NP) – 1 Pt NOT DONE (ND) – 0 Pt Supervised by: ________________________________________ Clinical Instructor Date of Return Demo: ________________
