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24 Cards in this Set

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  • Back
p24 Hand Washing
1) Address Client, Introduce Self
2) Water ON
3) Wet Hands and Wrists
4) Soap
5) Lather everywhere, produce friction, 15 seconds
6) Rub fingernails on palms
7) Rinse with fingers down below elbows
8) Clean towel to dry, trash
9) Clean towel turn water Off, trash
10) NEVER touch inside of sink
p27 PPE ON and OFF
1) Open Gown
2) Insert Arms
3) Tie Neck
4) Tie Waist
5) Gloves ON
6) Overlap Cuffs
7) Remove glove 1 by grasping at palm, pull it inside out
8) Insert finger under glove 2, pull it inside out over both
9) Trash Gloves
10) Untie gown at Neck and Waist
11) Remove Gown, DON’T touch outside
12) Fold inside out, Away from Body
13) Trash Gown
14) Wash Hands
p24 Apply Knee-High Stocking
1) Introduce Self, Address Client, Explain Procedure
2) Privacy
3) Client Supine
4) Stocking inside out
5) Put stocking over Toes, Foot, Heel
6) Pull top over Foot, Heel, Leg
7) Move Foot and Leg gently
8) Finish with NO Twists or Wrinkles, Heel and Toe placement correct
9) Signal within Reach, Side Rails UP, Bed Down
10) Wash Hands
p34 Position on Side
1) Address Client, Introduce Self, Explain Procedure
2) Privacy
3) Bed Flat, lower Head
4) Raise Side Rail where Turning Toward
5) Slowly Roll
6) Pillow under Head
7) Arm Out of Way
8) Pillow under Top Arm
9) Pillow behind supporting Back
10) Pillow between Knees and Ankles, Top Knee Flexed,
11) Signal within Reach, Side Rails UP, Bed Low
12) Wash Hands
p39 Bed to Wheelchair with Transfer Belt
1) Address Client, Introduce Self, Explain Procedure
2) Privacy
3) Wheelchair in place
4) Footrests Up
5) Wheelchair Wheels Locked
6) Bed Wheels Locked
7) Bed Down, Head Raised
8) Shoes ON
9) Client sitting, Feet on floor
10) Apply Transfer Belt
11) Tell instructions for Assisting and Signaling
12) Face client, Leg between their Knees, Count to 3
13) On signal, Assist to Stand, their Hands Up
14) Pivot client in front of wheelchair, legs touching seat
15) Lower client, Hips to Rear of chair
16) Remove Belt
17) Feet on Footrests
18) Signal Device in Reach
19) Wash Hands
p25 Assists to Ambulate with Transfer Belt
1) Address Client, Introduce Self, Explain Procedure
2) Shoes ON
3) Bed Down
4) Bed Wheels Locked
5) Sitting Position, Feet flat on floor
6) Apply Transfer Belt
7) Tell Instructions for Assisting and Signaling
8) Face client, Leg between their Knees, Count to 3
9) On 3, Assist to Stand, their Hands Up
10) Walk Behind and to Side holding Belt, 10 feet
11) Return to Bed, Remove Belt
12) Signal Device in Reach, Side Rails UP, Bed Low
13) Wash Hands
p26 Assists with Bedpan
1) Address Client, Introduce Self, Explain Procedure
2) Privacy
3) Lower Head of Bed
4) Gloves ON
5) Put Bedpan Correctly under Client’s Butt
6) Gloves OFF, Trash, Wash Hands
7) Raise Head of Bed
8) Toilet Paper within Reach
9) Handwipe within Reach, Tell to Use
10) Signal within reach, tell Ring when Done
11) Clean Gloves ON
12) Lower Head of Bed
13) Avoid Client Overexposure
14) Remove, Empty, Rinse, Empty Bedpan
15) Put Bedpan in Dirty area
16) Gloves OFF, Trash, Wash Hands
17) Signal within Reach, Side Rails UP, Bed Low
p26 Clean Upper or Lower Denture
1) Gloves ON
2) Sink Lined
3) Rinse Denture in tepid Running Water
4) Rinse Denture Cup and Lid
5) Toothpaste to Toothbrush
6) Brush Denture
7) Rinse Denture
8) Put Denture in Cup with tepid water, Cover with Lid
9) Rinse toothbrush, put in holder
10) Remove Sink Liner, Drain Water, Rinse Sink
11) Gloves OFF, Wash Hands
p27 Count and Record Radial Pulse
1) Address Client, Introduce Self, Explain Procedure
2) Fingertips on Thumb side of Wrist
3) Count Beats for 1 minute
4) Signal within Reach
5) Wash Hands
6) Record Pulse {must be within 4 beats + or -}
p27 Count and Record Respirations
1) Address Client, Introduce Self, Explain Procedure
2) Count breaths for 1 minute
3) Signal within Reach
4) Wash Hands
5) Record Rate {must be within 2 breaths}
P28 Dress Client With Affected Right Arm
1) Address Client, Introduce Self, Explain Procedure
2) Privacy
3) Ask which Top
4) Limit Exposure, Remove Gown From Unaffected Side, then Affected
5) Put Right/Affected Arm through Sleeve, then Left
6) Move Body Gently, DON’T Over-Extend Limbs
7) Gown to Soiled Container
8) Signal within Reach, Side Rails UP, Bed Low
9) Wash Hands
P29 Feed Client
1) Address Client, Introduce Self, Explain Procedure
2) Name Card, Ask Client Name
3) Client Sitting Upright, 45-90 degrees
4) Place Tray where Client can See
5) Clean Hands with Handwipe
6) Face Client to Feed
7) Tell what Foods, Ask what First
8) With Spoon, offer One Bite of each, Telling What it Is
9) Offer Drink at Least Once
10) Mouth Empty before next Bite
11) End of Meal, Wipe Mouth and Hands
12) Remove Food Tray, place in Dirty area
13) Signal within Reach, Side Rails UP, Bed Low
14) Wash Hands
P29 Modified Bed Bath
1) Address Client, Introduce Self, Explain Procedure
2) Privacy
Dirty Linen Bag at Hand
3) Remove Gown, Keep Client Covered
4) Client Verifies Water Temp
5) Gloves On
6) No Soap, Wipe Inner to Outer Eyes, using Different part of Washcloth, Wash Face
7) Dry Face
8) Expose One Arm, Towel Underneath
9) Soap to Wet Washcloth
10) Wash ARM, HAND, UNDERARM
11) Rinse and Dry
12) Move Body Gently, Don’t Over-Extend Limbs
13) Clean Gown on Client
14) Empty, Rinse, Dry Basin
15) Place Basin in Dirty Area
16) Put used Gown and Linens in Bag
17) Avoid Body Contact with Used Linens
18) Gloves OFF, Wash Hands
19) Signal Within Reach, Side Rails UP, Bed Low
P30 Make Occupied Bed
1) Address Client, Introduce Self, Explain Procedure
2) Privacy
Dirty Linen Bag at Hand
3) Lower Head of Bed
4) Keep Client Covered
5) Loosen Top Sheet at Foot of Bed
6) Raise Side Rail where Client will Move, Have them Move Over
7) Loosen Bottom Sheet, Roll toward Center of Bed
8) Place Clean Fitted on, Tuck under used Linens and Client
9) Client Moves over to Clean Side
10) Raise Side Rail, go to Other Side
11) Remove Used Sheet, Avoid Contact, Put in Bag
12) Pull and Tuck Clean Fitted on, WRINKLE FREE
13) Cover Client with Clean Top Sheet
14) Remove Used Sheet, Avoid Contact, Put in Bag
15) Change Pillowcase, Avoid Contact, Used in Bag
16) Center Top Sheet, Tuck at Foot of Bed
17) Signal within Reach, Side Rails UP, Bed Low
18) Wash Hands
P31 Measure and Record Blood Pressure
1) Address Client, Introduce Self, Explain Procedure
2) Alcohol wipe Stethoscope
3) Client Upper Arm exposed, Palm up
4) Find Brachial Artery
5) Put BP Cuff on
6) Stethoscope in Ears and On Brachial Artery
7) Inflate Cuff to 180
8) Deflate Slowly, Listen for First and Last Sound
9) Remove Cuff
10) Signal within Reach
11) Wash Hands
12) Record Systolic and Diastolic {within 8 mm Hg}
P32 Measure and Record Urinary Output
1) Gloves ON
2) Pour Bedpan Contents into Measuring Cup, Don’t Splash
3) On Flat Surface, Measure at Eye Level
4) Empty into Toilet
5) Rinse and pour in Toilet
6) Rinse Bedpan, pour in Toilet
7) Gloves OFF, Wash Hands
8) Record Contents {within 25 ml/cc}
P32 Measure and Record Weight
1) Address Client, Introduce Self, Explain Procedure
2) Client Shoes ON, walk to Scales
3) Zero Scales
4) Stand next to Client, Assist onto Scales, Read Weight
5) Stand next to Client, Assist off Scales
6) Record Weight {within 2 lbs}
7) Wash Hands
P32 Passive ROM for One Knee and Ankle
1) Address Client, Introduce Self, Explain Procedure
2) Privacy
3) Tell Client to Holler if Pain Experienced
4) Support Leg at Knee and Ankle
5) Extension/Flexion - Bend Knee and Return, 3 times unless Pain
6) Support Foot and Ankle close to bed
7) Dorsiflexion/ Plantar Flexion - Push/Pull Foot towards Head, Push/Pull Toes Point Down, 3 times unless Pain
8) Supporting Limbs, Move Gently, Slowly unless Painful
9) Signal within Reach, Side Rails UP, Bed Low
10) Wash Hands
P33 Passive ROM for One Shoulder
1) Address Client, Introduce Self, Explain Procedure
2) Privacy
3) Tell Holler if Painful
4) Support Elbow and Wrist
5) Extension/Flexion – from Side of Body, raise Arm up toward Head to Ear Level and Return, 3 times
6) Abduction/Adduction – move Arm away from Side of Body to Shoulder Level and Return, 3 times
7) Supporting Limb, move Gently and Smoothly, unless Pain
8) Bed Rail UP, Bed Low
9) Signal within Reach
10) Wash Hands
P34 Catheter Care for Female
1) Address Client, Introduce Self, Explain Procedure
2) Privacy
Dirty Linen Bag at Hand
3) Get Warm Water, You Check Temp, Client Check Temp
4) Gloves ON
5) Linen Protector under Perineal Area
6) ONLY Expose Catheter Area
7) Soap to Wet Washcloth
8) Hold Catheter near Meatus, Clean 4 inches, Direction Away from Meatus, New Area of Washcloth for each Stroke
9) Rinse using above steps
10) Dry using above steps
11) Cover Client
12) Empty, Rinse, Dry Basin, Put in Dirty Area
13) Dirty Linen in Bag
14) Avoid Body Contact with Used Linen
15) Gloves OFF, Wash Hands
16) Signal within Reach, Side Rails UP, Bed Low
P35 Fingernail Care on One Hand
1) Address Client, Introduce Self, Explain Procedure
2) Get Water, You check Temp, Client check Temp
3) Basin Comfortable for Client
Used Linen Bag at Hand
4) Gloves ON
5) Fingers in Water
6) Clean under Each Nail with Stick
7) Wipe Stick after Each Use
8) Dry Fingers
9) Feel and File Nails as Needed
10) Trash Stick and Emery Board
11) Empty, Rinse, Dry Basin
12) Basin in Dirty Area
13) Used Linen in Bag
14) Gloves OFF, Wash Hands
15) Signal within Reach
P36 Foot Care on One Foot
1) Address Client, Introduce Self, Explain Procedure
2) Privacy
3) Get Water, You check Temp, Client check Temp
4) Basin Comfortable for Client, ON Protective Barrier
Used Linen Bag at Hand
5) Gloves ON
6) Foot in Water
7) Soap to Washcloth
8) Lift and Wash Foot, between Toes
9) Rinse Foot, between Toes
10) Dry Foot, between Toes
11) Lotion Top and Bottom of Foot, NO Toes
12) Empty, Rinse, Dry Basin
13) Basin in Dirty Area
14) Used Linen in Bag
15) Gloves OFF, Wash Hands
16) Signal within Reach
P37 Mouth Care
1) Address Client, Introduce Self, Explain Procedure
2) Privacy
3) Client Sitting UP
4) Gloves ON
5) Clothing Protector Across Chest
Used Linen Bag at Hand
6) Moisten Toothbrush over basin from cup of Water
7) Apply Toothpaste
8) Clean Teeth, Gums and Tongue Gently
9) Emesis basin to Chin to Rinse Mouth
10) Wipe Mouth
11) Remove Clothing Protector
12) Used Linen in Bag
13) Empty, Rinse, Dry Basin
14) Basin in Dirty Area
15) Used Linen in Bag
16) Gloves OFF, Wash Hands
17) Signal within Reach, Side Rails UP, Bed Low
P38 Perineal Care
1) Address Client, Introduce Self, Explain Procedure
2) Privacy
3) Get Water, You check Temp, Client check Temp
Used Linen Bag at Hand
4) Gloves ON
5) Linen Protector under Client
6) Only Expose Perineal Area
7) Soap to Washcloth
8) Wash Genital area, Front to Back, One Stroke down Middle, then One down Each Side, using New area of Washcloth for Each Stroke
9) Rinse using steps above
Used Linen in Bag
10) Dry area Front to Back
11) Roll Client to Side, Get New Washcloth
12) Repeat steps 8 and 9 for RECTAL area
Used Linen in Bag
13) Reposition Client
14) Empty, Rinse, Dry Basin – place in dirty area
15) Avoid Body Contact with Used Linens
16) Gloves OFF, Wash Hands
17) Signal within Reach, Side Rails UP, Bed Low