POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
TREATMENTS
Abdominal Binder
Ace Bandages
Apical Pulse
Arm and Foot Soaks
Arm Sling
Back Rub
Blood Pressure Measurement
Compress
 Cold
 Warm
Death/Post Mortem Care
Elastic Stockings
Ice Collar/Bag
Temperature, Pulse and Respiration
Thermometer Care
Weight and Height Measurement
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
Abdominal Binder
Purpose/Policy
To reduce pain by restricting expansion of the rib cage or supporting abdominal area.
Procedure:
1. Assist Resident with removing clothing to the waist.
2. Position binder under Resident with top edge below the breasts. Apply binder around rib
cage and secure with firm even pressure, adjust shoulder straps.
3. Check Resident for comfort and assist with dressing.
4. Remove binder every eight hours. Inspect skin and apply lotion as needed.
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
Ace Bandage
Purpose/Policy
1.
2.
3.
4.
5.
To provide even, firm support.
To reduce pain.
To apply pressure.
To reduce swelling.
To facilitate return circulation from the extremities.
Procedure:
1. Place the Resident in a comfortable position that is convenient for you to work.
2. Anchor the bandage by two circular turns around the body part at the smallest point. Apply
bandage toward the heart. Smoothly and wrap firmly, but not to tightly. Exert even pressure.
Each turn should overlap the one before about one-half width of the bandage.
3. Secure end with bandage clip, safety pin or tape.
4. Check circulation by noting temperature, presence of edema, pulse, and color of skin area
bandaged.
5. Replace bandage as ordered by physician or as needed.
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
Apical Pulse
Purpose/Policy
To obtain accurate pulse rate, rhythm, and volume.
Procedure:
1. Assist Resident to a lying down position and expose the left chest area.
2. Place stethoscope on mid-chest area below the breast toward the left side.
3. Count pulse for one full minute.
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
Arm and Foot Soaks
Purpose/Policy
1. To hasten suppuration.
2. To promote healing.
3. To relieve pain.
Procedure:
1.
2.
3.
4.
Place container for soaking solution so Resident can comfortably immerse area to be treated.
Assist Resident with removing clothing or shoes and socks.
Temperature of soaking solution to be between 100-1100 F for comfort and safety.
Place area to be soaked into container of the solution. Time to be specified by nurse or
physician.
5. Assist Resident with drying area and dressing when time is completed.
6. Clean container and return to proper area.
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
Arm Sling
Purpose/Policy
1.
2.
3.
4.
5.
6.
To elevate and support the arm.
To reduce edema.
To relieve stress on the shoulder or elbow.
To immobilize a strained or sprained muscle.
To immobilize a fracture.
To facilitate return circulation from the extremities.
Procedure:
1. Assist the Resident to a comfortable position. Place soft material where two areas of skin
touch to prevent friction, such as under the breast, between the arm and the chest, and the
underarm area.
2. For a triangular sling, place one end over the uninjured shoulder with the point extending
under the injured arm.
3. Bring the other end over the injured side allowing enough bandage to reach around the neck.
Resident's hand must be higher than the elbow and supported. Tie the ends of the bandage at
the side of the neck.
4. Fold corner of sling at the elbow and pin in place.
5. Check the area every 2 hours for skin color, positioning, circulation and comfort.
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
Back Rub
Purpose/Policy
1.
2.
3.
4.
5.
To increase circulation.
To stimulate muscle tone.
To relieve nervous tension and relax muscle spasms.
To relieve pain and discomfort.
To prevent decubiti.
Procedure:
1. Assist the Resident to the position that is comfortable.
2. Warm the lotion by placing container in warm water or pour lotion into palm of your hand
and rub together using friction to warm lotion.
3. Use good body mechanics. Exert firm pressure as you stroke upward from the buttocks
toward the shoulder and gentle pressure as you stroke downward. Use circular motion on
each bony area. Finish by massaging up and down spinal column.
4. Back rubs are given after the Resident's bath, as part of evening care, to Residents on bed
rest, and for restless Residents who need relaxing.
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
Blood Pressure Measurement
Purpose/Policy
1. To obtain a measurement of the amount of pressure blood exerts against the walls of the
artery.
Procedure:
1. Assist Resident with lying down or sitting in a chair. Arm should be bare up to the shoulder
or sleeve well above the elbow, well supported with palm upward.
2. Wrap the cuff around the Resident's arm above the elbow snugly and smoothly. Place ear
pieces of stethoscope in your ears.
3. With your fingertips find the pulse at the inner side of the arm above the elbow (brachial
artery). This is where you will place the diaphragm of the stethoscope.
4. Place diaphragm on the pulse. Hold firmly against skin but it should not touch the cuff of the
apparatus. Tighten thumb screw clockwise.
5. Inflate the cuff until the dial points to 180 or you can no longer hear the pulse. Open valve
counter clockwise. Deflate slowly. Listen for the first clear sound. Note the calibration that
the pointer is on, this is the systolic pressure (top number).
6. Continue releasing air. Listen carefully for the sound to change to a soft muffled thump.
This sound is the diastolic pressure (bottom number).
7. Deflate the cuff completely. Remove it from Resident's arm.
8. Record immediately.
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
Cold Compress
Purpose/Policy
1. To reduce swelling.
2. To relieve pain.
3. To relieve inflammation.
Procedure:
1. Assist the Resident into a comfortable, safe position, have the area exposed that is to receive
the cold compress.
2. A disposable protector may be necessary under the body part that is to receive cold compress.
3. Put cold water in basin. Dip the compress into the water and wring it out. Apply to area
being treated as quickly as possible.
4. Change the compress as necessary to keep it cold.
5. Check the Resident every 5 minutes. If skin appears to be white, remove the compress.
6. A cold compress is usually applied for 15-20 minutes.
7. When treatment is completed, remove compress and gently pat the area dry.
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
Warm Compress
Purpose/Policy
1. To relieve inflammation and swelling.
2. To control pain.
Procedure:
1. Assist the Resident into a comfortable and safe position. Have body part exposed that is to
be given treatment. Place a disposable protector under the body area.
2. Fill basin with warm solution/water 110-1150 F. Moisten compress and wring out.
3. Apply compress to area. Cover compress with plastic sheet to keep warm.
4. Check Resident's skin for redness. If skin appears red, remove the compress. Report to the
nurse.
5. Warm compress is usually applied for 15-20 minutes. Follow instructions given by the nurse.
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
Death/Post Mortem Care
Purpose/Policy
The preparation of the deceased prior to release to the mortuary.
Procedure:
1. After death, the Resident's body should be treated with gentleness and reverence. Special
care should be taken to avoid bruises.
2. Place body in the supine position and place one pillow under the head. Place disposable bed
protector under buttocks.
3. Close Resident's eyes if they are open. Take lashes and gently pull eyelids over the eyes.
Bathe the body. Comb hair. Put on clean gown.
4. Close Resident's mouth by cupping hand under chin and applying slight pressure.
5. Cover body with clean sheet.
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
**INSERT: Death Record Elastic Stockings
Purpose/Policy
1. To provide support for lower extremities.
2. To aid return circulation from lower extremities.
Procedure:
1. Elastic stockings are applied while Resident is lying down and before getting out of bed in
the early AM.
2. Stockings can be either knee or full length. Resident will be measured for correct size and fit.
3. Be careful to smooth out all wrinkles and pull up firmly.
4. Stockings must be removed and reapplied at least once every day and as ordered by
physician.
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
Ice Collar/Bag
Purpose/Policy
1.
2.
3.
4.
To relieve inflammation.
To control hemorrhage.
To relieve pain.
To reduce swelling.
Procedure:
1. Fill ice collar or bag one-half full of ice.
2. Squeeze the sides of the ice bag to expel all air. Fasten the cap tightly. Dry outside of the
bag.
3. Invert the ice bag to test for leaking and place cover on the bag.
4. Apply ice collar or bag to the proper area being treated.
5. Check the Resident's skin every 20 minutes for color. If skin appears white, remove ice bag.
Leave ice bag on for the length of time ordered.
6. Replace ice as needed and use dry cover if wet.
7. Remove bag when treatment completed, inspect skin, clean and dry skin well.
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
Temperature, Pulse and Respiration
Page 1 of 2
Purpose/Policy
1. To measure body temperature.
2. To determine the quality and rate of pulse and respiration.
Procedure:
Temperature
0
1. Normal readings:
Oral
Axillary
Rectal
C
37.0
36.4
37.5
0
F
98.6
97.6
99.6
2. Oral temperature - select proper type thermometer (digital)
a. Wait 10 minutes if Resident recently had hot or cold fluids or has been smoking.
b. Insert thermometer gently into Resident’s mouth under the tongue and position to the side
of the mouth. Instruct the Resident to keep thermometer under the tongue by gently
closing the lips around the thermometer.
c. Leaving in the mouth until thermometer beeps then read and record.
d. Shake the mercury down and replace thermometer in its container with disinfectant
solution.
3. Rectal temperature - select proper type thermometer
a. Put small amount lubricating jelly on the bulb. Put on disposable gloves.
b. Assist Resident to turn on his/her side. Insert thermometer one half-inch into the rectum.
Hold in place for 3 minutes. Do not leave the Resident with rectal thermometer in the
rectum.
c. Remove thermometer. Wipe with tissue from stem to bulb. Read and record. Write R in
front of figure.
4. Axillary temperature
a. Assist Resident in removing arm from sleeve of clothing. If area is moist, pat dry with a
towel.
b. Place the bulb of the oral thermometer in the center of the arm pit (axillary). The
thermometer should be held upright by the arm and the chest. Position arm over chest.
c. Leave in place 10 minutes.
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
Temperature, Pulse, Respiration
Page 2 of 2
e. Remove thermometer and wipe with a tissue and read.
f. Record. Write A in front of the figure. Shake down thermometer. Replace in container
filled with proper disinfectant solution.
Pulse: Normal range for adults is from 72-80 beats per minute.
1. Have Resident sit down. Arm should be well supported and resting comfortably.
2. Find the pulse by placing the tips of your middle three fingers on the palm side of the
Resident’s wrist in line with the thumb. Press lightly until you feel the pulse. Never use your
thumb. Note the rhythm and force of the beat.
3. Using the second hand on your watch, count the pulse beat for 1 full minute. This is always
done if the Resident has an irregular beat.
Respiration: Normal breath rate for adults is from 16-20 times a minute.
1. Hold the Resident's wrist as if you were taking the pulse. Count the Resident's respirations
without them knowing it.
2. One rise and fall of the Resident's chest counts as one respiration.
3. If you can not clearly see the chest rise and fall, fold Resident's arms across his chest. Then
you can feel his breathing as you hold the wrist.
4. If the Resident's breathing rhythm is irregular always count for one full minute.
5. Note whether the respirations were noisy or labored.
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
Thermometer Care
Purpose/Policy
To prevent cross contamination and transfer of bacteria among Residents.
Procedure:
Disposable covers are used with all thermometers and are discarded after use.
Glass Thermometer (if applicable)
1. After use thermometers are cleansed with cool soapy water. Remove all debris.
2. Dry thermometer and place in appropriate soiled thermometer container of disinfectant
solution. Cover with lid.
3. Soak for designated time. Rinse in cool water, dry and place in appropriate clean
thermometer container with lid.
4. Inspect the bulb of the thermometer for cracks or chipped places prior to use.
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5
Weight and Height Measurement
Purpose/Policy
1. To obtain accurate weight of each Resident.
2. To maintain constant control of weight changes.
3. To assess nutrition and status of Resident.
Procedure:
1. Resident's weight and height are obtained on admission.
2. Resident's weight is monitored monthly and as ordered by attending physician.
 Use the same scale
 Weigh at about the same time of day
 Make sure scale is “zeroed”
 Record weight on Resident weight flow sheet
POLICY AND PROCEDURE
NURSING DEPARTMENT –
SECTION 5

INSERT: Resident Weight Form