FEMALE MEDICAL WARD

CONTINUING EDUCATION

BASIC NURSING SKILLS AS

DELEGATED TO NURSING
ATTENDANTS
RATIONALE:

 Basic skills are to be achieved by successful completion of 5 hours of training/

return demonstration of some delegated nursing activities which can be
achieved with proper orientation.
GENERAL OBJECTIVE:

 Upon completion of the continuing education, nurses and nursing attendants

will be able to effectively perform the delegated skills, will be competent
and will be able to deliver quality care to patients efficiently as a team.
LEARNING OBJECTIVE:

 Nurses and Nursing attendants will be able to:

 Perform delegated nursing activities such as nasogastric tube feeding and
monitoring of input and output effectively and efficiently.
 Identify the importance of nursing activities such as morning care, taking vital
signs etc., communication skills, end-of-life and post-mortem care.
 Apply basic principles of communication, especially those related to analyzing
audience and purpose.
 Speak clearly and project the voice sufficiently, employing appropriate verbal
and nonverbal strategies.
 Apply active listening skills in interpersonal settings.
 Improve the knowledge regarding end-of-life and post-mortem care.
 MODULE I: NURSING ACTIVITIES:
MORNING CARE / TEPID SPONGE BATH
Oral care/Mouth Care

Mouth care is the specific care of the teeth and mouth.

Purpose:

 To remove food particles from around and between the teeth

 To remove dental plaque to prevent caries
 To enhance the patient’s feelings of wee-being
 To prevent sores and infection of the oral tissues
 To prevent bad odor or halitosis
Equipment’s/ Materials:
 Toothbrush (use the person’s private item. If patient has none use of cotton tipped applicator and
plain water)
 Tooth paste (use the person’s private item. If patient has none of use cotton tipped applicator and
plain water)
 Cup of water
 Emesis basin
 Towel
 Denture bowel (if required)
 Cotton tipped applicator, padded applicator
 Vaseline if necessary
 Disposable gloves
 Mouthwash (optional)
 Dental floss (optional)
 Dental cup
 Washcloth or paper towel
 Lip lubricant (optional)
 Suction Apparatus and suction tip (if needed)
Assessment:

 Assess patient’s oral cavity and dentition

 Assess for any caries, sores or white patches.
 Assess the ability to perform own care
 Procedure:
 Prepare the patient
 Explain the procedure
 Gathered equipment’s/ materials and place at bedside
 Perform hand hygiene. Don disposable gloves if assisting
with oral care
 Assist the patient to a sitting position in bed (if the health
condition permits). If not assist the patient to side lying
with the head on pillows.
 Place the towel under the patient’s chin.
 If patient confined in bed, place the basin under the
patient’s chin
 Inspect the mouth and teeth
2. Brush the teeth
 Moisten the tooth with water and spread small amount of tooth paste on it
 Brush the teeth following the appropriate technique brushing technique
 Hold the brush against the teeth with the bristle at up degree angle and gums use the some
action on the front and the back of the teeth.
 Use back and forth motion over the biting surface of the teeth.
3. Brush the tongue last
4. Give the patient water to rinse the mouth and let him/her to spit the water into the basin.
 Assist patient in wiping the mouth
5. Re-comfort the patient
 Remove the basin
 Remove the towel
 Assist the patient in wiping the mouth
 Reposition the patient and adjust the bed to leave patient comfortably
6. Give proper care to the equipment’s
7. Document assessment of teeth, tongue, gums and oral mucosa. Report any abdominal
findings
Mouth care for unconscious patient

 Position
 Side lying with the head of the bed lowered, the saliva automatically runs out
by gravity rather than being aspirated by the lungs or if patient’s head cannot
be lowered, turn it to one side: the fluid will readily run out of the mouth,
where it can be suctioned
 Rinse the patient’s mouth by drawing about 10 ml of water or mouth wash to
the syringe and injecting it gently in to each side of the mouth
 If injected with force, some of it may flow down the clients throat and be
aspirated into the lung
 All the rinse solution should return; if not suction the fluid to prevent
aspiration
Flossing- It removes resides particles between the
teeth technique
 Wrap one end of the floss around the 3rd finger of
each hand
 To floss the upper teeth. Use the thumb and index
finger to stretch the floss. Move the floss up and
down between the teeth from the tops of the
crowns to the gum
 To floss the lower teeth, use your index fingers to
stretch the floss
 Note: If the patient has denture, remove them
before starting and wash them with brush.
BED BATH
 Giving a bed bath means washing someone who is in bed. A bed bath cleans the
skin and helps keep the skin free of infection. It helps to relax the person being
bathed and help him feel better. Let the person wash himself as much as possible.
You may only need to get the bath supplies ready and wash the person’s back. Or
you may need to do most or all of the bath.

To give a bath to someone in bed: Gather the following items and put them within
easy reach on a table by the bed.

 Disposable gloves.
 Water basin (bowl) to hold the water for the bed bath.
 Soft, lightweight cotton or flannel blanket.
 Bath towel and washcloth.
 Soap, powder, lotion, deodorant, comb, hairbrush, and mouth care supplies, such
as toothbrush and toothpaste.
 Clothing, such as underwear and clean bedclothes or robe.
Before giving a bed bath:
 Close the windows or turn up the heat to keep the room warm while giving
the bath.
 Fill the basin with warm water. The temperature of the water should not be
higher than 115 degrees F (46 degrees C) using a bath thermometer. If you do
not have a bath thermometer it should be comfortably warm to your elbow.
The water will cool to a lower temperature by the time it touches the
person’s body.
 Put the soft blanket over the top sheet that is covering the person. Pull back
the top sheet to keep it from getting wet. Help remove the person’s clothes.
The blanket will keep the person warm and give him privacy. During the bath,
keep the person covered with the blanket as much as possible.

Giving the bed bath:
 Wear disposable gloves if the person has draining wounds.
 Wet the washcloth without soap. Gently wipe one eyelid by wiping from the
inner corner of the eye to the outer corner. Dry the eyelid with a towel. Rinse
the washcloth in the water. Wash and dry the other eyelid.
 Using a mild soap, wash the face, neck, and ears. Rinse off the soap and dry
the washed areas. Put the towel under an arm. Wash the person’s hand, arm,
and underarm. Rinse off the soap and dry the arm well, especially under the
arm. Wash, rinse, and dry the other hand and arm.
 Fold down the blanket to wash the chest and stomach (belly). Wash, rinse,
and dry these areas. Cover the chest and stomach with the blanket.
 Remove the blanket from one of the legs and put a towel under the leg. Wash,
rinse, and dry the foot and leg. Do the same to the other leg.
 While lying in bed, the person may enjoy soaking his feet in a basin. Put a towel
under the basin to keep the bed from getting wet. Help the person put one foot
into the basin. You may need to support the leg while washing the foot. Take the
foot out of the water and dry it. Put the other foot into the basin. Wash, rinse,
and dry the foot.
Empty the dirty water into the sink. Fill the basin with clean warm water. Put the
lotion bottle into the basin. This will warm the lotion before you use it. Ask or
help the person to roll on his side so you can wash the back. The person should not
be too close to the edge of the bed to avoid a fall.
 Put the towel on the bed along the person’s back. Fold down the blanket. Wash
the person’s neck, back, buttocks (rear end), and thighs (upper legs). Rinse the
washcloth in the basin and remove the soap from the washed areas. Dry the back,
buttocks, and thighs. Ask the person if he would like to have a back rub with the
warmed lotion.
 The perineum (pair-uh-nee-um) is the last area to be washed. Wear disposable
gloves when washing this area. This area is also called the pubic area or genital
area. It is the area between the thighs and includes the genitals and anus. The
anus is the opening where BM leaves the body. This part of the body should be
washed every day. Washing the perineum keeps the body from smelling and
becoming infected.
Washing a woman’s perineum:
 Empty the dirty water into the sink. Fill the basin with clean warm water.
Fold the towel in half. Ask or help the woman to lift her buttocks. Put the
towel under the buttocks. Ask the woman to bend her knees and spread her
legs. With a soapy washcloth in one hand, separate the labia (“lips” of the
vagina) with the other hand. Wash the labia from front to back. Do not touch
the anus with the washcloth. Germs from the anus could get into the vagina
and cause an infection.
 Rinse the washcloth and remove the soap from the perineum. It is important
to remove all the soap because it can irritate the skin. Dry the area with a dry
towel. Do not put powder on the perineum because the powder may harden.
 Wash the anus next. Ask the woman to turn onto her side so that she is facing
away from you. Ask her to raise up her top leg. This will let you see and clean
the skin around the anus. Slide the towel under the woman’s buttocks. Use
toilet paper or a paper towel to remove BM that may be on the skin. You may
need to wet the toilet paper or paper towel if the BM has dried. Throw the
toilet paper or paper towel away in a trash bag. Wash, rinse, and dry the anal
area.
Washing a man’s perineum:
 Empty the dirty water into the sink. Fill the basin with clean warm water. Ask
or help the man to lie on his back. Fold the towel in half and put it under the
man’s buttocks. Ask the man to bend his knees slightly and spread his legs.
Hold the penis with one hand. With the other hand, wash the tip of the penis
with a soapy washcloth. Rinse the washcloth and remove the soap from the
penis.
 If the man has a foreskin, gently push it back. The foreskin is the skin that
covers the rounded end of the penis. Wash the end of the penis. Rinse the
washcloth and remove the soap from the end of the penis.
 Using a soapy washcloth, wash the rest of the penis and the scrotum. The
scrotum is the bag of skin that hangs under the penis. Rinse and dry well.
 The anus should be washed next. Ask the man to turn onto his side with the
top leg raised. This will let you see and clean the anal area easier. Fold the
towel in half and put it under the man’s buttocks. Use toilet paper or a paper
towel to remove BM that may be on the skin. You may need to wet the toilet
paper or paper towel if the BM has dried. Throw the toilet paper or paper
towel away in a trash bag. Wash, rinse, and dry the anal area.
After the bath:
 Rub lotion onto the person’s arms, legs, feet, or other dry
skin areas. Help to dress the person. Offer to help him with
mouth, hair, foot, or nail care.
 Throw away the dirty water and clean the washbasin. Put
away items used to give the bath.
Tepid Sponge Bath

Definition: Can reduce fever and stress when performed correctly

Purpose:
 To reduce body temperature.
 To alleviate pain or discomfort
 Equipment:
 Basin with warm water
 Gloves (non-sterile)- optional
 Sponge cloth/face towel
 Cotton balls
 Bath towel
Procedures:

 Prepare the patient.

 Explain the procedure to be done to patient
 Perform hand hygiene
 Gather all required materials to be used
 Provide privacy of the patient
 Sponge each limb for at least 5 minutes and the buttocks
 Dry the area with a towel
 Perform hand hygiene
 Discard used materials according to healthcare waste and management guidelines.
 Take the temperature 30 minutes after the procedure
 Report the latest temperature to nurse in charge or physician
 Document the procedure and any assessment
OSTERIZED FEEDING
Tube Feeding

Definition: Administration of nutrients via Nasogastric Tube (NGT) for patients

who are unable to tolerate oral feeding or who have decreased energy
requirements

Purpose:
 To provide adequate nutrition
 To give large amount of fluids for therapeutic purposes
 To provide alternative manner to some specific patients who has potential or
acquired swallowing difficulties
Equipments/Materials

 Feeding: Milk or Osterized

 Distilled water
 Measuring / calibrated glass
 Asepto Syringe
 Towel
 Stethoscope
Safety requirements

 Procedure properly explained

 Maintain patient on Fowler’s or sitting position
 Assess for gag reflex
 Check for level of sensorium
 Special considerations
 Determine the amount of feeding needed
 Observe for patient’s tolerance to the feeding
 Assess patient during the feeding procedure. Note for signs and symptoms of
nausea and vomiting
 Gradual feeding may prevent abrupt fullness of stomach that may lead to
vomiting
 If Osterized feeding will be used, ensure that the temperature of feeding will
be considered (warm)
 Procedure for Tube Feeding (NGT)
 Prepare all materials to be use including the feeding solution
 Wash hands thoroughly
 Elevate patients head of bed to at least 45 degrees
 Spread the small towel across the patient’s chest
 Detached the clamp of nasogastric tube feeding and pinch proximal end to
prevents air from entering patients stomach
 Connect the asepto syringe to the end of NGT

Check patency by:

 Aspirating 20-30ml of gastric content by applying negative pressure from the asepto
syringe
 Auscultating the abdomen with a stethoscope while infusing air from the bulb of the
asepto syringe to determine for whoozing, gurgling or bubbling sound
 Remove the bulb of the asepto syringe
 Pour feeding at the opening of the asepto syringe. Observe 12 inches height for
Adults from point of insertion
 Kink the tube in between pouring of feeding to prevent air from entering
 Flush feeding tube with 30-50 ml of sterile water immediately before all
formula has run through the tube
 Kink the tube near the opening and remove the asepto syringe
 Close the opening of the NGT appropriately
 Have the patient remain in fowler’s or semi-fowler’s position for 45-60 mins
 Wash hands thoroughly
 Document the procedure done and include the specific amount of feeding and
describe the reaction of the patient if any
Note:

 Assess patient after administration of enteral feeding. Note for tolerance and
other possible complications
 Avoid mixing of medication with osterized feeding
 Place patient on position of comfort
 Recheck vital signs after the procedure
 Records the time the procedure was done, vital signs before and after the
procedure and patients response to the procedure
 Clean equipment/materials used aseptically and store equipment
appropriately
TAKING VITAL SIGNS AND BLOOD PRESSURE
Pulse Oximetry

 Definition: Pulse Oximetry is a non-invasive method that enables rapid

measurement of the oxygen saturation of haemoglobin in arterial blood.
Pulse Oximetry can rapidly detect changes in oxygen saturation, thus
providing an early warning of hypoxaemia (insufficient oxygen content in the
blood)
 In case for any abnormality in oxygen saturation nursing attendant must refer
to NOD, any changes in sensorium in level 3 and level 4 patient must refer
accordingly.
Purpose:

 To assess how well a new lung medication is working

 To evaluate whether someone needs help breathing
 To evaluate how helpful a ventilator is
 To monitor oxygen levels during or after surgical procedures that require
sedation
 To determine how effective supplemental oxygen therapy is, especially when
treatment is new
 To assess someone’s ability to tolerate increased physical activity
 To evaluate whether someone momentarily stops breathing while sleeping —
like in cases of sleep apnea — during a sleep study
Equipment / Materials
 Pulse Oximeter
 Alcohol wab / cleaning wipes
 Patient Documentation

Procedures

 1. Identify the patient by asking for their full name and date of birth. If Client unable to confirm, check
identity with family.
 2. Explain procedure to the patient/relative
 3. Ensure the patient is comfortable and warm enough especially if continuous monitoring is needed.
 4. Whilst talking to the patient assess their respiratory condition including their ability to talk in full
sentences, the color of their skin, whether they appear distress or not, and whether they are alert and
oriented.
 5. Ensure the probe is cleaned using alcohol wab and ensure is in good working condition.
 6. Perform Handwashing
 7. Use patient fingertip and place the probe as directed by the manufacturer’s instructions
 8. Switch the pulse oximeter machine on, make sure that the probe sensor is detecting the pulse. This will
usually be indicated by a beep in time with each detected pulse or graphical indication of the pulse on a
display panel
 9. Once oxygen saturation monitoring is complete, remove the probe and ensure patient is comfortable
 10. Document all actions in patient’s record
Taking Pulse Rate

 The pulse is the total number of beats the heart makes in one minute. A
person’s resting heart rate is the pulse when at rest. A normal adult’s resting
heart rate is approximately 60 to 100 beats in one minute.
 Pulse rates vary greatly from person to person. Heart rates rise when people
take part in certain activities or take certain medications. The following are
factors that influence heart rate: emotions, fitness level, body size, activity
level, medication use, body position, and air temperature.
 Arteries that are close to the skin provide the best opportunity to feel the
pulse. Several arteries in the body are used to find a pulse. The most common
arteries for feeling the pulse are the carotid, apical, and radial.
Apical Pulse:

 A stethoscope is placed over the patient’s heart to get a pulse. Nurses should have a watch that has a second hand to take an apical pulse. The following offers
steps in which to take to find a patient’s pulse:
 Have the patient to lie down or sit up to have the pulse taken.
 Place the buds of the stethoscope in the ears and place the disk portion over the patient’s heart.
 After hearing the heartbeat, count the number of beats for 60 seconds. Use a watch with a second hand to take the pulse. Listen for a weak, missed, or strong
heartbeat.
 Record the pulse rate, time, and date the pulse was taken. The nurse should take note of any issues with the pulse rate.

Radial Pulse:
 Nurses can locate the radial artery inside the patient’s wrist close to the thumb. Count the patient’s pulse using a watch with a second hand. Use the following
steps to get a radial pulse.
 Ask the patient to place the arms at his or her side and bend the elbow with the palm facing an upward position.
 Find the pulse of the patient’s radial artery by using the index and middle fingers. Never use the thumb to find the patient’s pulse because the thumb has its
own pulse.
 Count the pulse for 60 seconds and pay close attention to the strength of the beat.
 The nurse should write down the patient’s pulse rate along with the time and date the pulse was taken. Also, write down the wrist in which the pulse was
taken.
 The radial artery offers an easy manner in which to check the patient’s pulse.

Carotid Pulse:
 Nurses can locate the patient’s carotid arteries on the left and right outer portion of the patient’s neck. Use a watch with a second hand and follow these
steps to take the patient’s pulse.
 Find the patient’s pulse on the right or left side of the neck by using the index and middle fingers. Use only one side of the neck to take the pulse.
 Once the patient’s pulse has been located, count the pulse in the carotid artery for one full minute.
 Write down the patient’s carotid pulse along with the time and date taken. Pay close attention to a weak or strong beat and make note of anything noticed in
the patient’s file.
Taking temperature

Taking Axillary (Armpit) Temperatur

 Use a multi-use digital thermometer. Look for a

digital thermometer designed to be used either
rectally, orally or in the armpit. This way you can
take the axillary temperature first, and if a high
temperature is indicated, you can try a different
method as well.
 It's best to dispose of old glass thermometers, if you
still have one. If they break, the mercury inside them is
hazardous.
2. Turn on the thermometer and place it
in the armpit. Lift the arm, insert the
thermometer, then lower the arm so the tip
of the thermometer is snug in the middle of
the armpit. The entire tip should be
covered.
3. Remove the thermometer when it beeps. Look at the digital display to
determine whether the person has a fever. Any temperature above 100.4 °F
(38.0 °C) is considered a fever, but going to the doctor right away isn't
necessary unless the fever is above a certain temperature:
 If your baby has any signs of fever, call the doctor for any fever.
 If the person with the fever is an older child or an adult, call the doctor if it's
101 °F (38 °C) or higher.
 Wash the thermometer before putting it
away. Use warm, soapy water and dry it
thoroughly before putting it away for
next time.
Infrared Thermometer

 Infrared Thermometer Measures thermal radiation (infrared) emitted from

ear and forehead to infer body temperature For ear thermometer, a new ear-
probe jacket should be used for different person; the ear canal must be
pulled straight when measuring. Forehead thermometer should only be used
for screening instead of diagnostic purpose due to greater measurement
error.
Taking Respiratory Rate

What are respirations?

 Respirations are when you breathe in and out. Your respiratory, or breathing,
rate is the number of times you breathe in and out in 1 minute. Most people
breathe in and out 12 to 20 times every minute.

Why are respirations counted?

 People who are ill, such as those with lung or heart disease, may need to have
their respirations counted. The respiratory rate can show how the person's
body is doing. A change in the respiratory rate may be a warning sign that the
person's condition is getting worse.
How do I count a person's respirations?

 Ask the person to sit upright.

 Try to count the other person's respirations without his knowing. If he knows,
he may try to control his breathing. This can give a false respiratory rate.
 Use a watch with a second hand and count his breaths for 60 seconds. Use any
of the following methods to count:
 Look at his chest rise and fall. One rise and one fall are counted as 1 breath.
 Listen to his breaths.
 Place your hand on the person's chest to feel the rise and fall.
When should I contact the person's healthcare provider?

 The person has a breathing rate that is less than 12 or more than 25.
 The person makes noise when he breathes, such as grunts, wheezes, or
gurgles.
 The person feels dizzy or more tired than usual.
 The person has cold, clammy, sweaty skin.
TAKING BLOOD PRESURE

How to Check Your Blood Pressure

with a Sphygmomanometer

 Setting Up the Equipment

1. Sit down and open the blood
pressure testing kit. Sit down at a table
or desk where you can easily set up the
necessary equipment. Remove the cuff,
stethoscope, pressure gauge, and bulb
from the kit, taking care to untangle the
various tubes.
2. Raise your arm to heart level. Elevate your
arm so that when you bend your elbow, your
elbow is parallel to your heart. This ensures
that you will not get either an overestimated
or underestimated reading on your blood
pressure. It is also important that your arm is
supported during the reading, so make sure to
rest your elbow on a stable surface.
3. Wrap the cuff around your upper arm. Most
cuffs have Velcro, making it easy to secure the
cuff in place. If your shirt has long or thick
sleeves, roll them up first, as you can only put
the cuff over very thin clothing. The bottom
edge of the cuff should be about an inch above
the elbow.
 Some experts recommend you use your left
arm; others suggest you test both arms. But
while you're first adjusting to self-testing, use
the left arm if you're right-handed, or vice
versa.
5. Place the wide head of the
stethoscope on your arm. The head of
the stethoscope (also known as the
diaphragm) should be placed flat against
the skin on the inside of your arm. The
edge of the diaphragm should be just
beneath the cuff, positioned over the
brachial artery. Gently put the earpieces
of the stethoscope in your ears.
 Do not hold the head of the stethoscope
with your thumb — your thumb has its
own pulse and this will confuse you
while you try to obtain a reading.
 A good method is to hold the head of
the stethoscope in place with your
index and middle fingers. This way, you
should not hear a thumping sound until
you have begun to inflate the cuff.
 Clip the pressure gauge to a stable
surface. If the pressure gauge is
clipped to the cuff, unclip it and
attach it to something sturdy instead,
such as a hardcover book. That way,
you can place it in front of you on the
table, making it easier to watch. It's
important to keep the gauge anchored
and stable.
 Make sure there is adequate light and
you can see the needle and pressure
markings well before you begin to test.
 Sometimes the gauge is attached to
the rubber bulb, in which case this
step does not apply.
7. Take the rubber bulb and tighten the
valve. The valve needs to be closed
completely before you start. This will
ensure that no air escapes as you pump,
which would produce an inaccurate
reading. Twist the valve clockwise, until
you feel it stop.
 It is also important to avoid over-
tightening the valve, otherwise you
will open it too far and release the air
too quickly.
Taking the Blood Pressure

1. Inflate the cuff. Rapidly pump the bulb to

inflate the cuff. Keep pumping until the needle on
the gauge reaches 180mmHg. The pressure from
the cuff will occlude a large artery in the bicep,
temporarily cutting off blood flow. This is why the
pressure from the cuff can feel a little
uncomfortable or strange.
 Release the valve. Gently turn the valve on the bulb counter-clockwise, so
that the air in the cuff is released steadily, but at a slow pace. Keep an eye
on the gauge; for best accuracy, the needle should be moving downwards at a
rate of 3mm per second.
 Releasing the valve while you hold the stethoscope can be a little tricky. Try
releasing the valve with the hand on your cuff arm, while holding the stethoscope
with your free arm.
 If there is someone nearby, ask him to assist you. An additional pair of hands can
make the process much easier.
3. Note your systolic blood pressure. As the pressure drops, use the stethoscope
to listen for a thumping or knocking sound. When you hear the first thump, make
a note of the pressure on the gauge. This is your systolic blood pressure.
 The systolic number represents the pressure your blood flow exerts on the walls of
an artery after the heart beats or contracts. It is the higher number of the two
blood pressure readings, and when blood pressure is written down, it appears at
the top.[3]
 The clinical name for the thumping sounds your hear is "Korotkoff sounds."
4. Note your diastolic blood pressure. Keep watching the gauge, while using the
stethoscope to listen to the thumping noises. Eventually the hard thumping
noises will turn into a "whooshing" sound. It is helpful to note this change, as it
indicates that you are close to your diastolic blood pressure. As soon as the
whooshing noise subsides, and you hear only silence, make a note of the pressure
on the gauge. This is your diastolic blood pressure.
 The diastolic number represents the pressure your blood flow exerts on the walls
of an artery when your heart relaxes between contractions. It is the lower number
of the two blood pressure readings, and when blood pressure is written down, it
appears at the bottom.

 Don't worry if you miss a reading. If you miss the exact measure of either
number, it's perfectly acceptable to pump the cuff back up a little to catch it.
 Just don't do it too much (more than twice) as this can affect accuracy.
 Alternatively, you can switch the cuff to the other arm and repeat the process
again.
 Check your blood pressure again. Blood pressure fluctuates within minutes
(sometimes dramatically) so if you take two readings within about a ten-minute
period, you can come up with a more accurate average number.
 For the most accurate results, check your blood pressure a second time, five to ten
minutes after the first go.
 It may also be a good idea to use your other arm for the second reading, especially if
your first reading was abnormal.

 Normal blood pressure: Systolic number of less than 120 and diastolic number of
less than 80.
 Prehypertension: Systolic number between 120 and 139, diastolic number
between 80 and 89.
 Stage 1 Hypertension: Systolic number between 140 and 159, diastolic number
between 90 and 99.
 Stage 2 Hypertension: Systolic number higher than 160 and diastolic number
higher than 100.
 Hypertensive Crisis: Systolic number higher than 180 and diastolic number higher
than 110

TAKING INTAKE
AND OUTPUT
INTAKE AND OUTPUT

 One of the most basic methods of monitoring a client's health is measuring

intake and output , commonly called I and O. By monitoring the amount of
fluids a client takes in and comparing this to the amount of fluid a client puts
out. The health care team can gain valuable insights into the client's general
health as well as monitor specific disease conditions.

INTAKE
- all those fluids entering the client's body such as water, ice chips, juice,
milk, coffee and ice cream. Artificial fluids include: parenteral, central lines,
feeding tubes, irrigation and blood transfusion.

OUTPUT
- all fluid that leaves the client's body such as: urine, perspiration,
exhalation, diarrhea, vomiting, drainage from all tubes and bleeding.

An accurate record of a client's fluid balance is an important nursing function.

 Equipments:

- I & O form at bedside

- I & O graphic record in chart
- Pencil and paper
- Calibrated drinking glass
- Bedside pan, commode or urinal
- Calibrated container to measure outputs
- Weighing scale
- Non-sterile gloves
- Sign at bedside stating patient is for I & O monitoring

 Ideal Daily fluid Intake and Output
Source/ AMOUNT/ Route/ AMOUNT
H2O consumed as fluid/ 1500ml/ urine/ 1400-1500ml
H2O present in food/ 750ml / insensible losses/ 350-400ml
H2O produced by oxidation/ 350ml / lungs/ 350-400ml
skin / 100ml
sweat/ 100-200ml
feces /
TOTAL/ 2600ml/ TOTAL/ 2300-2600ml

Purpose:

- helps evaluate client's fluid and electrolyte balance

- suggests various diagnosis
- influence the choice of fluid therapy
- document the client's ability to tolerate oral fluids
- recognize significant fluid losses
Mandatory for clients with burns, electrolyte imbalance, recent surgical procedure,
severe vomiting or diarrhea, taking diuretics or corticosteroids, renal failure,
congestive heart failure, NGT, drainage collection device and IV therapy.
Deviations:
Other sources of fluid loss and excessive losses from normal routes:
- drainage from catheter or tubes
- vomitus
- diarrhea
- diaphoresis
- hemorrhage
- ileostomy/ colostomy drainage
- excessive urine output

Average daily water requirement by age and weight:

AGE/ ml/ BODY WEIGHT ml/kg
3 days/ 250-350ml/80-100
1 year/ 1150-1300ml/ 120-135
2 years/ 1350-1500ml/ 115-125
4 years/ 1600-1800ml/100-110
10 years/ 2000-2500ml/70-85
14 years/ 2200-2700ml/ 50-60
18 years/ 2200-2700ml/40-60
adult /2400-2600ml/ 20-30
 Nursing Intervention:
Intervention/ Rationale

1. Ideally intake and output should be monitored/ To obtain an accurate record

2. In critical situations, intake and output should be monitored on an hourly basis/
Urine output less than 500ml in 24 hours or less than 30cc/hour indicates renal
failure
3. Daily weights are often done/ Indicate fluid retention or loss
4. Identify if patient undergone surgery or with medical problem / May affect fluid
loss
5. Make sure you know the total amount and fluid sources once you delegate this
task/ To get an accurate measurement
6. Record the type and amount of all fluids and describe the route at least every 8
hours
7. If irrigating a nasogastric or another tube or bladder, measure the amount
instilled and subtract it from the total output/ To get exact amount
8. Keep toilet paper out of client urine output/ For an accurate measurement
9. Measure drainage in a calibrated container and observe it at eye level.

A significant change in a client's weight or a significant difference in a client's total

intake and output should be reported immediately to the physician.
 WEIGHT CHANGES
- mild dehydration- 2 to 5% loss
- moderate dehydration- 6 to 9% loss
- severe dehydration - 10 to 14% loss
- death- 20% loss

- mild volume overload- 2% gain

- moderate volume overload - 5% gain
- severe volume overload - 8% gain
Clinical Signs of Dehydration:
- dry skin and mucous
membranes
- concentrated urine
- poor skin turger
- depressed periorbital space
- sunken fontanel
- dry conjunctiva
- cracked lips
- decreased saliva
- weak pulse
Client's signs of fluid excess:
- peripheral edema
- puffy eyelids
- sudden weight gain
- ascites
- rales in lungs
- blurred vision
- excessive salivation
- distended neck vein
MODULE II: COMMUNICATION TECHNIQUES /
HEALTH TEACHINGS
What is communication skills?

 Communication skills are verbal and non-verbal words, phrases, voice tones,
facial expressions, gestures, and body language that you use in the
interaction between you and another person.
 Verbal communication is the ability to explain and present your ideas in clear English, to
diverse audiences. This includes the ability to tailor your delivery to a given audience, using
appropriate styles and approaches, and an understanding of the importance of non-verbal
cues in oral communication. Oral communication requires the background skills of presenting,
audience awareness, critical listening and body language.

 Non-verbal communication is the ability to enhance the expression of ideas and concepts
without the use of coherent labels, through the use of body language, gestures, facial
expressions and tone of voice, and also the use of pictures, icons, and symbols. Non-verbal
communication requires background skills such as audience awareness, personal presentation
and body language.

 Effective communication is an essential part of building and maintaining good physician-

patient and physician-colleague relationships. These skills help people to understand and
learn from each other, develop alternate perspectives, and meet each others' needs.

 Hidden agendas, emotions, stress, prejudices, and defensiveness are just a few common
barriers that need to be overcome in order to achieve the real goal of communication,
namely mutual understanding. High Performers master and continually practice the basics, as
well as prepare for these communication pitfalls. Just as successful physicians routinely
practice basic medical skills, High-Performers understand that they too must pay attention to
communication skills or they risk getting out of shape pretty quickly.
Communication skills in a healthcare setting include the way you use to:

 Explaining diagnosis, investigation and treatment.

 Involving the patient in the decision-making.
 Communicating with relatives.
 Communicating with other health care professionals.
 Breaking bad news.
 Seeking informed consent/clarification for an invasive procedure or obtaining
consent for a post-mortem.
 Dealing with anxious patients or relatives.
 Giving instructions on discharge.
 Giving advice on lifestyle, health promotion or risk factors.
Approach to the patient
You should:
 Introduce and orientate the patient and yourself
 Establish an attentive, respectful and non-judgmental relationship
 Acknowledge the patient's emotions and concerns
 Listening, questioning and diagnosing

You should:
 Ensure you have understood the patient's symptoms/problem and concerns
 Summarize and clarify understanding

Explaining and advising

You should:
 Enable the patient to understand the problem/situation
 Reassure appropriately
 Summarize and clarify understanding
Involving patient in management
You should:

 Explore the patient's expectations/concerns

 Propose/explain management plan clearly
 Explore the patient's response
 Respect the patient's autonomy, and help him or her to make a decision based
on available information and advice
 Summarize and clarify understanding
MODULE III: END OF LIFE CARE AND POST
MORTEM CARE
End of Life Care

Definition: It refers to health care, not only of a person in the final hours or days of their lives,
but more broadly care of all those with a terminal condition that has become advanced,
progressive, and incurable.


 1. The Nursing Division shall facilitate a dignified and peaceful closure of life of patients by
providing an end-of-life care
 2. The Nursing Staff shall respect patient’s values, religion and cultural preferences and
practices, as demonstrated on the following:
 2.1 Pastoral services are provided based on spiritual beliefs of the patient and family
 2.2. The patient’s right to self-determination and choice are respected and accommodated
 2.3 Advance directives Do not Resuscitate, waiver, Living will if any, are respected
 2.4 Patient and family choices to donate organs and other tissues are supported through
provision of relevant information in accordance to statutory laws, rules and regulations
3. Assessment of appropriate intervention to alleviate the patient’s pain and
discomfort according to wishes of patient and family and re-assessment shall be
provided and are evident.
 3.1 Pain assessment, intervention and evaluation are monitored and
recorded
 3.2 Personal hygiene is rendered based on patient’s need
 3.3 Nutritional assessment and risks are identified and nutritional needs are
provided, such as feeding and hydration
 3.4 Interventions address patient and family’s psychosocial, emotional,
spiritual and cultural concerns
4. A designated place where patient’s family can stay shall be provided
5. The patient and family shall be involved in care management and decision
Post-Mortem Care
Definition: This is the care given to
the body after death
 Equipment’s/Materials:
Purposes:  Basin for water
 To show respect for the dead  Wash cloth and towel
 To prepare the body for burial  Cotton / Gauze
 To prevent spread of infection  Dressing and tape (if necessary)
 To show kindness to the family  Clean Linen
 Stretcher
 Forceps
 Cadaver’s Tag
 Gloves
 Syringe
 Screen


Procedures:

 1. Doctor pronounce the time of death.

 2. Record the exact time of death and prepare four (4) cadavers tag.
 3. Prepare all the materials to be use
 4. Wash hands and wear clean gloves.
 5. Provide privacy by putting screen or pull the curtain
 6. Raise bed to comfortable working level (when necessary)
 7. Close patient’s eyes and nose (if necessary)
 8. Remove all contraptions, diaper and clothes of the cadaver
 9. Cleanse the cadaver
 10. Attach cadavers tag on the corpse and linen
 11. Wrap the cadaver with clean linen
 12. Discard used materials and contraption (from patient) according to health care waste
management guidelines
 13. Remove gloves and perform hand hygiene
 14. Document the procedure done, time of death
Sources:

 JRRMMC Nursing Operation Manual

 https://www.registerednursern.com/how-to-take-a-pulse-taking-a-pulse-
clinical-nursing-skills/
 https://www.wikihow.com/Take-a-Temperature
 https://www.mdco.gov.hk/english/emp/emp_gp/files/thermometer_eng.pd
f
 https://www.oscehome.com/Communication-Skills.html
 http://thestudentnurse.com/class_notes/fundamental-nursing-
skills/fundamental-nursing-skills_how-to-give-a-bed-bath/
 -END-
THANK YOU!