COMMUNITY HEALTH NURSING

NURSING PROCEDURES
CLINIC VISIT
DEFINITION:
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Purpose:
1. _________________________________________________________________________________________________________________________________________
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2. _________________________________________________________________________________________________________________________________________
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3. _________________________________________________________________________________________________________________________________________
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PROCEDURE

RATIONALE

I. Registration/Admission
1. Greet the client upon entry and establish rapport.
2. Prepare the family record of new patients or retrieve records of old
clients.
3. Elicit and record the clients chief complaint and clinical history.
4. Perform physical examination on the client and record it accordingly.
II. Waiting Time
1. Give priority numbers to the clients.
2. Implement the first come, first served: policy except for
EMERGENCY/URGENT cases.
PROCEDURE
III. Triaging
1. Manage program based cases.
2. Refer to all non-program based cases to the physician. For all other
cases which has no potential danger, treatment/management is

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initiated by the nurse and she decides to do her own nursing

diagnosis and then refer to the physician for medical management.
3. Provide first aid treatment to emergency cases and refer when
necessary to the next level of care.
IV. Clinical Evaluation
1. Validate the clinical history and physical examination.
2. The nurse arrives at evidence-based diagnosis and provides rational
treatment based on DOH programs.
a. Identify the patients problem
b. Formulate/write the nursing diagnosis and validate
c. Give/perform the nursing intervention
d. Evaluate the intervention if it has enabled the patient to achieve
the desired outcome.
3. Inform the client on the nature of the illness, the appropriate
treatment and prevention and control measures.
V. Laboratory and other Diagnostic Examinations
1. Identify a designated referral laboratory when needed.
VI. Referral System
1. Refer the patient if he needs further management to following twoway referral systems: BHS to RHU, RHU to RHU, RHU to Hospital.
2. Accompany the patient when an emergency referral is needed.
VII. Prescription/Dispensing
1. Give proper instructions on drug intake.
VIII. Health Education
1. Conduct one-on-one counseling with the patient.
2. Reinforce health education and counseling messages.
3. Give appointments for next visit.

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HOME VISIT
DEFINITION:
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Principles:
1. _________________________________________________________________________________________________________________________________________
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2. _________________________________________________________________________________________________________________________________________
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3. _________________________________________________________________________________________________________________________________________
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4. _________________________________________________________________________________________________________________________________________
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5. _________________________________________________________________________________________________________________________________________
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1.
2.
3.
4.
5.
6.
7.

PROCEDURE
Greet the patient and introduce yourself.
State the purpose of the visit.
Observe the patient and determine the health needs.
Put the bag in a convenient place then proceed to perform the bag
technique.
Perform all the nursing care needed and give health teachings.
Record all important data, observation and care rendered.
Make appointment for a return visit.

RATIONALE

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BAG TECHNIQUE
DEFINITION:
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Principles:
1. _________________________________________________________________________________________________________________________________________
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2. _________________________________________________________________________________________________________________________________________
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3. _________________________________________________________________________________________________________________________________________
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4. _________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
Contents of the bag:
Paper lining
Extra paper for making waste bag
Plastic/linen lining
Apron
Hand towel
Soap in a soap dish
Thermometers (oral and rectal)
2 pairs of scissors (surgical and bandage)
2 pairs of forceps (curved and straight)
Disposable syringes with needs (g 23& 25)

Hypodermic needles g. 19, 23,22, 25

Sterile Dressing
Cotton balls (dry with alcohol)
Cord clamp
Micropore plaster
Tape measure
1 pair of sterile gloves
Babys scale
Alcohol lamp
2 test tubes
Test tube holders
** Sphygmomanometer and Stethoscope are carried separately.

PROCEDURE

Solutions of:
Betadine
Zephiral solution
Spirit of ammonia
Acetic Acid
70% Alcohol
Hydrogen Peroxide
Ophthalmic Solution
Benedicts solution

RATIONALE
34

1. Upon arrival at the patients home, place the bag on the tabled linen
with a clean paper. The clean side must be out and folded part
touching the table.
2. Ask for a basin of water or a glass of drinking water if tap water is not
available.
3. Open the bag and take out the towel and soap.
4. Wash hands using soap and water; wipe to dry.
5. Take out the apron from the bag and put it on with the right side out.
6. Put out all the necessary articles needed for the specific care.
7. Close the bag and put it in one corner of the working area.
8. Proceed in performing the necessary nursing care and treatment.
9. After giving the treatment, clean all things that were used and
perform hand washing.
10.Open the bag and return all things that were used in their proper
places after cleaning them.
11.Remove apron, folding it away from the person, the soiled side in and
the clean side out. Place it in the bag.
12.Fold the lining, place it inside the bag and close the bag.
13.Take the record and have a talk with the mother. Write down all
necessary data that were gathered, observations nursing care and
treatment rendered. Give instructions for care of patients in the
absence of the nurse.
14.Make appointment for the next visit (either home or clinic) taking
note of the date and time.

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BLOOD PRESSURE MEASUREMENT

DEFINITION:
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________________________________________________________________________________________________________________________________________________
Purpose:
1. _________________________________________________________________________________________________________________________________________
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2. _________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________________________________________
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PROCEDURE
I.Preparatory Phase
1. Introduce self to the client.
2. Make sure the client is relaxed and has rested for at least 5 minutes
and should not have smoked or ingested caffeine within 30 minutes
before BP measurement.
3. Explain the procedure to the client at his/her level of understanding.
4. Assist patient to seated or supine position.

RATIONALE

II.
1.
2.
3.
4.
5.

Applying the BP cuff and stethoscope.

Bare clients arm.
Apply cuff around the upper arm 2-3 cm above the brachial artery.
Apply cuff snuggly with no creases.
Keep the manometer at eye level.
Keep arm level with his/her heart placing it on a table or a chair arm
or by supporting it with examiners hand. If client is in recumbent
position, rest arm at his/her side.
6. Palpate brachial pulse correctly just below or slightly medial to the
antecubital area.

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III.
Obtaining the BP reading by auscultation
1. Place earpieces of stethoscope in ears and stethoscope head over
the brachial pulse.
2. Use the bell (or diaphragm for obese persons) of the stethoscope to
auscultate pulse.
3. Watching the manometer, inflate the cuff by pumping the bulb until
the column or needle reaches 30 mmHg above palpated SBP.
4. Deflate the cuff slowly at a rate of 2-3 mmHg/beat.
5. While the cuff is deflating, listen for pulse sounds (Korotkoff sounds).
** Note the appearance of the first clear tapping sound. Record this
as systolic BP (Korotkoff Phase I)
** Note the diastolic BP which is the disappearance of sounds
(Korotkoff Phase V) unless sounds are still heard near )mmHg, in
which case, softening/muffling of sounds is noted (Korotkoff Phase
IV).
IV.
Recording BP and other Guidelines.
For every first visit of the client:
1. Take the mean of 2 readings, obtained at least 2 minutes apart, and
consider this as the clients blood pressure.
2. If the first 2 readings differ by 5mmHg or more, obtain a 3 rd reading
and include this in the average. If first visit, repeat the procedure
with the other arm. Subsequently, BP readings should then be
performed on the arm with a higher BP.
3. Document Phases I, IV and V by following the format for recording BP
systolic/muffling/disappearance (e.g. 120-80-76)
4. Inform the client of result and stay for a while to answer clients
questions/concerns.

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THERMOMETER TECHNIQUE
DEFINITION:
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________________________________________________________________________________________________________________________________________________
Purpose:
1. _________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
2. _________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
PROCEDURE
1. Identify your client and explain the procedure.
2. Using the bag technique lay out, put out the thermometer leaving
the case inside the bag.
3. Check if the mercury in the thermometer is at the level of 35C.
4. Place the thermometer beneath the tongue or in the patients axilla
and take the temperature, pulse and respiration following the
procedure in taking vital signs.
5. Remove the thermometer from the patients mouth/axilla and wipe
with one dry cotton ball from your fingers downward to the bulb in a
twisting motion. Discard used cotton ball.
6. Read the thermometer.
7. Clean the thermometer in a downward spiral motion from the stem to
the bulb, holding it over the waste paper bag using the following
technique:
1st - 3 cotton balls moistened with soap
2nd 3 cotton balls moistened with water
3rd 3 cotton balls moistened with alcohol
Then wrap around the bulb of the thermometer and lay it inside the
kidney basin.

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NOTE: Oral temperature is taken 2-3 min.; per axilla 5-8 minutes and per
rectum 1 minute.
8. After the care is given and health teaching is over, remove the cotton
ball wrapped around the thermometer. Wipe with a dry cotton ball
and return to the case.

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ISOLATION TECHNIQUE IN THE HOME

DEFINITION:
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Principles:
1. _________________________________________________________________________________________________________________________________________
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2. _________________________________________________________________________________________________________________________________________
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3. _________________________________________________________________________________________________________________________________________
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4. _________________________________________________________________________________________________________________________________________
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5. _________________________________________________________________________________________________________________________________________
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NURSING CARE IN THE HOME

DEFINITION:
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Principles:
1. _________________________________________________________________________________________________________________________________________
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2. _________________________________________________________________________________________________________________________________________
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3. _________________________________________________________________________________________________________________________________________
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4. _________________________________________________________________________________________________________________________________________
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5. _________________________________________________________________________________________________________________________________________
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INTRAVENOUS THERAPY
DEFINITION:
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Purpose:
1. _________________________________________________________________________________________________________________________________________
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2. _________________________________________________________________________________________________________________________________________
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3. _________________________________________________________________________________________________________________________________________
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PROCEDURE
1. Verify the written prescription for IV therapy, check prepared IVF and
other things needed.
2. Explain the procedure and reassure the patient & significant others
and observed the 10 Rs.
3. Do hand hygiene before and after the procedure.
4. Choose site for IV.
5. Apply tourniquet 5 to 12 cm (2-6 in) above injection site depending
on condition of patient.
6. Check for radial pulse below the tourniquet.
7. Prepare the site with effective topical antiseptic according to hospital
policy or cotton balls with alcohol in circular motion and allow 30
seconds to dry.
8. Using the appropriate IV cannula, pierce the skin with needle
positioned at 15-30 degree angle.
9. Decrease the angle, advance the catheter and stylet (1/4 inch) into
the vein, check if tip of catheter can be rotated freely inside the vein.
10.Position the IV catheter parallel to the skin. Hold stylet stationary and
slowly advance the catheter until the hub is 1mm to the puncture
site.
11.Slip a sterile gauze under the hub. Release the tourniquet, remove

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the stylet while applying digital pressure over the catheter one finger
about 1-2 inch from the tip of the inserted catheter.
12.Connect the infusion tubing of the prepared IVF aseptically to the IV
catheter.
13.Open the clamp, regulate the flow rate. Reassure the patient.
14.Anchor needle firmly in place with the use of:
a. Transparent tape/dressing directly on the pucture site
b. Tape
c. Band-aid
Never place unsterile tape directly on IV insertion site, instead place
a small piece of sterile OS & then secure it with adhesive tape.
15.Tape a small loop of IV tubing for additional anchoring; apply splint (if
needed).
16.Calibrate the IVF bottle & regulate flow of infusion according to
prescribed duration.
17.Label on IV tape near the IV site to indicate the date of insertion,
type and gauge of IV catheter and countersign.
18.Label with plaster on the IV tubing to indicate the date when to
change the IV tubing.
19.Observe the patient and report any untoward effect.
20.Document in the patients chart.
21.Discard sharps.

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BENEDICTS TEST
DEFINITION:
______________________________________________________________________________________________________________________________________
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________________________________________________________________________________________________________________________________________________
Purpose:
1. _________________________________________________________________________________________________________________________________________
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2. _________________________________________________________________________________________________________________________________________
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3. _________________________________________________________________________________________________________________________________________
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PROCEDURE
Collect urine specimen before meals.
Put 5 ml of Benedicts solution into the test tube and heat it.
Note for the color changes.
Add 8-10 drops of urine into the test tube with 5 ml Benedicts
solution.
5. Heat the solution but do not boil.
6. Note and record for color changes.

RATIONALE

1.
2.
3.
4.

Interpretation:
Blue
Green
Yellow
Orange
Red

(-) Negative
+
++
+++
++++

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ACETIC ACID TEST

DEFINITION:
______________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Purpose:
1. _________________________________________________________________________________________________________________________________________
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2. _________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________________________________________
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1.
2.
3.
4.
5.
6.

PROCEDURE
Collect urine specimen before meals
Divide the urine sample into three parts
Put two-thirds of urine sample into a test tube and heat it.
Note for color changes.
Add one-third or few drops of acetic acid.
Do not heat the solution, instead note for color change.

RATIONALE

*cloudiness indicates albuminuria.

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