A.

WASH HAIR

1. Definition:
Remove the dirt on the hair and scalp with soap or shampoo and then rinse with clean water

2. Objectives:
a. Providing a sense of comfort
b. Hair kept clean, tidy and well-maintained
c. Stimulate blood circulation under the scalp
d. Cleaning lice and / or dandruff
e. As a means of treatment

3. Stage Pre interaction:

a. Nursing and medical record checks client
b. Assess the needs of the client's self care
c. Effective hand washing
d. Prepare the tools:
1) Towel 2 pieces
2) clean disposable gloves 1 pair
3) cloth long as the base 1 piece
4) The basin of warm water and a dipper or a pot of warm water 1 piece
5) Shampoo
6) small comb1 piece
7) Comb 1 piece
8) Gauze and cotton to taste
9) The bucket is empty 1 piece
10) Crooked 1 piece
11) Apron 1 piece
12) curtain
13) Tool hair dryer or hairdryer 1 piece
14) Hand rubs
 e. Effective hand washing

4. Stage orientation
a. Greeting and introducing themselves
b. Identify, two identities: (ask your name, and see no.RM / date of birth)
c. Explain the procedure
d. contract time
e. The objective of the client and family
f. Ask the client complaints
g. Give the client the opportunity to ask

5. The work phase

a. Keep client privacy
b. Set the bed and hold appliance
c. Use apron
d. Wash hands with alcuta
e. Use gloves
f. Adjust the position of the patient with the head edge of the bed (lateral)
g. Put a bucket under the bed right on the head
h. Replace of cloth pads under the patient's head to the right and left side and rolled a little to
the ends are in the bucket
i. Cover the ears with cotton and cover both eyes with gauze
j. Replace the towels from the chest to the neck
k. Comb the hair from the tip to the base of the hair
l. Flush the hair with warm water
m. Apply shampoo with gauze on the scalp
n. Perform massage on the head until evenly
o. Hair Rinse several times with warm water to clean
p. Move the towel in the chest to the head and lift your head while pulling into the bucket
perlak further dry the hair with a towel or hairdrayer
q. Open cotton and gauze earplugs and eye
 r. Replace pillows are covered with a dry towel, put it under his head as a substitute wet towel
s. Comb the hair from the tip to the base of the hair
t. Readjust the position of the patient
u. Trim tool
v. Remove gloves
w. Open aprons
x. Open curtain
y. Effective hand washing

6. Stage termination
a. Evaluation of the results of the (subjective and objective)
b. Give positive reinforcement on the client
c. Make a contract for the next activity
d. Effective hand washing

7. Stage documentation
Make documentation: the client's name, the date nd time, activities, results achieved, name
and signature bright
 Intramuscular injection (IM)
A. Definitions
Administration of drugs or fluids by means inserted directly into the muscle (muscular).
Thigh (vastus lateralis): where the client is back with knees slightly flexed. Ventroglteal: the
position of the client lying on his side, supine, or supine with the knee or pelvis tilted injected
with a flexion. The upper arm (deltoid): where the client is sitting or lying down flat with
arms flexed but relaxed menyilangi abdomen or lap.

B. Objectives
Carry out the functions of collaboration with physicians to clients who were given the drug
intramuscularly

C. Equipment
1 Gloves 1 pair
2 Spuit to size as needed
3 1 sterile needle (21-23G and a length of 1 - 1.5 inches for adults; 25-27 G and 1 inch for
children)
4 Bak syringe 1
5 Cotton alcohol in kom (to taste)
6 Perlak and pengalas
7 Drug appropriate therapy program
8 Crooked 1
9 Books injection / drug list

D. Phase PraInteraksi
1 To verify the data previously when there
2 Washing hands
3 Preparing medicine correctly
4 Placing the device near the client correctly

E. Orientation Phase
1 Provides regards as a therapeutic approach
2 Describe the purpose and procedures for action on family or clients
3 Asking the client's readiness before the activities carried out
F. Work Phase
1 Adjust the position of the client, appropriate injection site
2 Installing perlak and saucer
3 Freedom for the area to be injected
4 Wearing gloves
5 Determining the injection site properly (palpation of the injection area for the presence
of edema, masses, tenderness. Avoid any scarring, bruising, abrasion or infection.
6 Clean the skin with an alcohol swab (circular from the inside to the outside \ diameter
5cm)
7 Using the thumb and forefinger to mereganggkan skin
8 Insert the syringe at an angle of 900, the needle enters 2/3
9 Doing aspirations and make sure blood does not enter the syringe
10 Incorporating the drug slowly (speed of 0.1 cc / sec)
11 Repeal of the transfixion needle
12 Pressing puncture area with disinfectant cotton
13 Throw away the syringe into a crooked

G. Phase Terminatio
1 To evaluate actions
2 Doing a contract for the next activity
3 to Leave with clients
4 Clearing tools
5 Washing hands
6 note of the activities in the nursing record sheet

INJECTION INTRAVENOUS (IV)

A. Definitions
Intravenous drug administration is the administration of drugs by introducing the drug into a
vein using a syringe. Points intravenous injection: the arm (the basilica vein and the cephalic
vein), the leg (saphenous vein), the neck (jugular vein), and the head (frontal veins or vena
temporalis).

B. Objectives and benefits

Giving a drug by intravenous way aims to:
1 Got a faster reaction, so it is often used in patients who sedaang emergency.
2 avoid tissue damage.
3 Incorporating drugs in greater volume
C. Preparation of equipment for intravenous drug administration
1 book record of drugs
2 Cotton alcohol
3 Disposable gloves
4 Drug appropriate
5 Spuit 2-5ml with size 21-25, needle length of 1.2 inches
6 Bak syringe
7 Tray drug
8 Plaster
9 Kasa sterile
10 Crooked
11 Perlak pengalas
12 hedge vein (tourniquets)
13 Kasa sterile
14 Betadin

D. Working Procedure:
1 Wash hands.
2 Explain the procedure to be performed
3 Release injected area by freeing the area that will be the injection of clothes and when
open or closed to ataskan.
4 Take the drug in its place with a syringe according to the dose to be given. If the drugs are
in a powder dosage form, then dissolved in a solvent (sterile distilled water).
5 Install perlak or pengalas under venous injection to be performed
6 Then place the drug had been taken on the vessel injection.
7 disinfection with an alcohol swab.
8 Perform bonding with rubber hedge (torniquet) at the top of the area that will be the
administration of drugs or tighten by hand / ask for help or stem above the vein to be
performed injection.
9 Take the syringe containing the drug.
10 Do penusukkan with holes facing up to enter into the blood vessels by injecting angle
150-300
11 Aspirate when there is blood and remove the rubber hedge directly spray the drug until
exhausted.
12 When finished take the syringe to draw and apply pressure on penusukkan area with an
alcohol swab, and syringes that have been used put into crooked.
13 Wash hands and record the administration of drugs or drug test, date, time and type of
medication as well as the reaction after the injection (if any)
Subcutaneous injection (SC)
1. Understanding
Administration of drugs by way subcutan enter the drug into the skin
bagianbawah. Recommendable place for these injections are the upper arms, upper legs,
and the area around the navel.
2. Objectives
Subcutan drug administration aims to include a number of toxins or drugs on
subcuta tissue under the skin for absorption.
Preparation of drug delivery devices subcutan
- Book record of drugs
- Cotton alcohol
- Disposable gloves
- Drug appropriate
- 2 ml syringes with size 25, long needle 5/8 to inch
- Bak syringe
- Tray drug
- Plaster
- Kasa sterile
- Crooked
3. Procedures
- Washing hands
- Prepare the drug in accordance with the principles of a true 5
- Identification of clients
- Notify clients working procedures
- Set the client in a comfortable position
- Select the area of injection
- Use hand sraung
- Clean the injection area with an alcohol swab
- Hold the alcohol swab to the middle finger on the non-dominant hand
- Open the lid of the needle
 - Pull the skin and fatty tissue with thumb and non-dominant hand with the tip of the
needle facing up and using the dominant hand input needle at an angle of 450 or
900.
- Remove the pull of non-dominant hand
- Pull the plunger and observation of blood in the syringe
- If there is no blood, enter the drug slowly, if there is blood retract the needle from
the skin where the injection press for 2 minutes and observe any bruises, if
necessary, provide plaster, to prepare a new drug.
- Remove the needle with the same angle when the needle is inserted, while applying
pressure using an alcohol swab on the area stabbing
- If there is bleeding, press the area using sterile gauze until the bleeding stops
- Return the client
- Remove the tools that are not used
- Remove gloves
- Wash hands and record the administration of drugs / drug test, date, time and type
of medication as well as the reaction after the injection (if any)

Intracutaneous injeksi (IC)

1. Understanding
Administration of drugs by way intracutan is the administration of drugs with
caramemasukkan drugs into the skin surface. Points were widely used to perform
injections intrakutan is the upper part of the forearm.
2. Administration of drugs with intracutan:
- Patients get pengobatb appropriate treatment program doctors.
- Streamlining the treatment process and avoid errors in drug administration.
- Helps determine the diagnosis of certain diseases (eg, tuberculin test).
- Protects the patient from the effects of drug allergy (the skin test).
3. Preparation tool intracutaneous drug delivery
- Book record of drugs
- Cotton alcohol
- Disposable gloves
- Drug appropriate
- 1 ml syringes with uk.25,26, or 27, a long needle till 5/8 inch
- Ballpoint pen or marker
- Bak syringe
- Tray drug

4. Procedures
- Washing hands
- Explain the procedure to be performed
- Release the areas to be injected, when using a long-sleeved shirt open and to ataskan
 - Put under the injection perlak
- Take medications for allergy tests and then dissolved / diluted with distilled water
(solvent) and then download the 0.5 cc and dilute again until approximately 1 cc and
prepare the tub or sterile injection.
- Disinfection with an alcohol swab on the area that will be injected
- Tighten with the left hand or the areas to be injected
- Make the stabbing with a hole facing upwards at an angle of 50-150 with the surface
of the skin
- Spray the drug until there is a bubble
- Pull the syringe and don'ts of massage
- Wash hands and record the administration of drugs / drug test, date, time and type of
medication and his reaction after the injection

Subcutaneous injection (SC)

4. Understanding
Administration of drugs by way subcutan enter the drug into the skin
bagianbawah. Recommendable place for these injections are the upper arms, upper legs,
and the area around the navel.
5. Objectives
Subcutan drug administration aims to include a number of toxins or drugs on
subcuta tissue under the skin for absorption.
Preparation of drug delivery devices subcutan
- Book record of drugs
- Cotton alcohol
- Disposable gloves
- Drug appropriate
- 2 ml syringes with size 25, long needle 5/8 to inch
- Bak syringe
- Tray drug
- Plaster
 - Kasa sterile
- Crooked
6. Procedures
- Washing hands
- Prepare the drug in accordance with the principles of a true 5
- Identification of clients
- Notify clients working procedures
- Set the client in a comfortable position
- Select the area of injection
- Use hand sraung
- Clean the injection area with an alcohol swab
- Hold the alcohol swab to the middle finger on the non-dominant hand
- Open the lid of the needle
- Pull the skin and fatty tissue with thumb and non-dominant hand with the tip of the
needle facing up and using the dominant hand input needle at an angle of 450 or
900.
- Remove the pull of non-dominant hand
- Pull the plunger and observation of blood in the syringe
- If there is no blood, enter the drug slowly, if there is blood retract the needle from
the skin where the injection press for 2 minutes and observe any bruises, if
necessary, provide plaster, to prepare a new drug.
- Remove the needle with the same angle when the needle is inserted, while applying
pressure using an alcohol swab on the area stabbing
- If there is bleeding, press the area using sterile gauze until the bleeding stops
- Return the client
- Remove the tools that are not used
- Remove gloves
- Wash hands and record the administration of drugs / drug test, date, time and type
of medication as well as the reaction after the injection (if any)

Intracutaneous injeksi (IC)

5. Understanding
Administration of drugs by way intracutan is the administration of drugs with
caramemasukkan drugs into the skin surface. Points were widely used to perform
injections intrakutan is the upper part of the forearm.
6. Administration of drugs with intracutan:
- Patients get pengobatb appropriate treatment program doctors.
- Streamlining the treatment process and avoid errors in drug administration.
- Helps determine the diagnosis of certain diseases (eg, tuberculin test).
- Protects the patient from the effects of drug allergy (the skin test).
7. Preparation tool intracutaneous drug delivery
 - Book record of drugs
- Cotton alcohol
- Disposable gloves
- Drug appropriate
- 1 ml syringes with uk.25,26, or 27, a long needle till 5/8 inch
- Ballpoint pen or marker
- Bak syringe
- Tray drug

8. Procedures
- Washing hands
- Explain the procedure to be performed
- Release the areas to be injected, when using a long-sleeved shirt open and to ataskan
- Put under the injection perlak
- Take medications for allergy tests and then dissolved / diluted with distilled water
(solvent) and then download the 0.5 cc and dilute again until approximately 1 cc and
prepare the tub or sterile injection.
- Disinfection with an alcohol swab on the area that will be injected
- Tighten with the left hand or the areas to be injected
- Make the stabbing with a hole facing upwards at an angle of 50-150 with the surface
of the skin
- Spray the drug until there is a bubble
- Pull the syringe and don'ts of massage
- Wash hands and record the administration of drugs / drug test, date, time and type of
medication and his reaction after the injection

PROCEDURE ENEMA
A. Definition
 Is a nursing action by entering the warm liquid into the colon through the anus dessendens
using a rectal cannula. Cannula entry into rectal 10-15 cm with a height of 50 cm irigator
position sims left.
B. Purpose
1. Stimulating intestinal peristalsis, so that patients can defecate because of the difficulty to
defecate (obstipasi constipation)
2. Empty the bowel preparation for surgery
3. As treatment measures
4. Preparation surgery / delivery / preparation for radiological examinations.
5. Giving a sense of comfort
C. Indications
1. Patients who obstipasi
2. The patient will be in operation
3. Preparation of diagnostic action for example (radiological examination)
4. Patients with melaena (black stools due to gastrointestinal bleeding)
D. Preparation
1. The language is clear, systematic and non-threatening
2. The client / family were given the opportunity to ask for clarification
3. Privacy client for communications appreciated.
4. Showing patience, empathetic, courteous, and considerate and respect for communicating
and taking action
1. Preparation tool
a. Clean gloves
b. Bath blanket or cloth cover
c. Perlak and buttocks pengalas
d. Irigator complete with canule recti, hoses and klemnya
e. The warm liquid as needed (eg liquids NaCl, soapy water, plain water)
f. Crooked
g. Lubricants (petroleum jelly, sylokain, Jelly 2% / water soluble lubricant
h. Pole mounting irigator
i. If necessary provide a potty, water cleaners and cotton wipe / tissue toilet
 2. Preparation of the patient
a. Greetings therapeutic
b. Introduce myself
c. Explaining to clients and families about the procedures and objectives of actions to be
implemented.
d. Explanations are given to understand client / family
e. During communication used i. Make a contract (time, place and actions to be taken)
j. Patients were prepared in a sleeping position tilted to the left (position sim)
3. Preparation Environment
a. Maintaining patient privacy
b. Providing a sense of comfort and safety of patients
4. Preparation of Nurses
a. Washing hands
b. Assess the patient's general condition
c. Measuring vital signs
d. the ability to mobilize
5. Procedure
1. Door closed / pair sampiran
2. Wash hands
3. Nurses standing to the right clients and pairs of gloves
4. Install perlak and pengalas
5. Replace blanket bath while clothing detachable bottom clients
6. Adjust the position of the left sim clients
7. Connect hoses and clamps (enclosed) with irigator
8. Fill irigator with a liquid that has been provided
9. Hanging irigator with a height of 40-50 cm from the butt clients
10. Remove the air from the hose to drain fluid into the crooked
11. Install kanule rectus and spread with jelly
12. Enter kanule to the anus, the clamp is opened, enter the liquid slowly
13. If the fluid runs out, hose clamps and remove the cannula and enter it into the crooked
14. Rearrange the position of the client and ask the client hold briefly
15. Help clients to the toilet if it is able, if it is not fixed in a tilted position and then install the
client dibokong bedpans.
16. Client dirapihkan
17. Tool trimmed back
18. Washing hands
19. noted the results of action taken
 6. Documentation / evaluation
a. Make a note of the actions taken and the results on a client record sheet
b. Record the client's response
c. Record number of outgoing fases
d. Note the color and consistency of fases that came out after the action
e. Note the date and time of action and the name of the nurse who did and signatures / initials
on the client record sheet

Oral care
A. General.

Mouth care should be given at least every morning and evening to all patients, and
preferably after every meal. Routine mouth care is essentially assisting a patient to brush
his teeth (figure 1-11) and to rinse his mouth thoroughly, as often as needed. The purposes
 are to keep the mouth clean, to prevent sores and mouth odors, to retard or prevent
deterioration of teeth, and to refresh the patient.

Figure 1-11. Cleaning the teeth.

B.Equipment.

The following equipment is appropriate for routine mouth care.

(1) Glass of water.

(2) Drinking tube if necessary.

(3) Hand towel.

(4) Toothbrush and dentifrice.

(5) Mouthwash, if desired.

C.Procedure for Patient Able to Help Himself.

Following is the procedure for routine mouth care for a bed patient able to help himself.

(1) Place the patient in a comfortable position.

(2) Arrange the equipment within his reach on the bedside cabinet or on an over bed table.

(3) Remove and clean the equipment promptly when he is finished.

NOTE: Rinse the toothbrush thoroughly under running water and allow it to air drynot
place the damp brush in the cabinet.

D. Procedure for a Patient Requiring Assistance.

Following is the procedure for routine mouth care for a bed patient requiring some assistance.

(1) Turn the patient on his side or if on his back, turn his head to the side.

(2) Place a towel under his chin and over the bedding.

(3) Pour the water over the brush; place dentifrice on it.
(4) Give the patient his brush and hold the basin under his chin while he brushes his teeth
(figure 1-12).

Figure 1-12. Assisting patient with mouth care.

(5) Encourage the patient to rinse his mouth frequently, using the drinking tube, if necessary
to draw water in his mouth. The basin receives the used rinse water.

(6) Remove the basin; wipe his face and lips with the hand towel.

(7) Remove and clean the equipment.

(8) Wash your hands.

E. Procedure for a Patient Unable to Brush His Teeth.

Following is the procedure for providing mouth care for a patient unable to brush his teeth.

(1) Proceed as in paragraph 1-12c above except that all steps are done for the patient.

(2) Finish the mouth cleansing with a gentle brushing of the tongue from back to front, and
with a thorough final rinsing.

(3) The patients teeth should be flossed at least weekly.