Name: Niña Jean T.

Aldaba Inclusive Date of duty:

March 31, April 7,8,9 2022
Year Level: BSN- 2A Clinical Area Assigned: PEDIA
Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

DONNING AND DOFFING OF PPE

Definition:
Personal protective equipment is a shield that protects both healthcare workers and
patients and should be applied and removed in the correct sequence to avoid
cross-contamination.
Objectives:
1. To protect employees from exposure to work place hazards and the risk of
injury.
2. To identify the proper equipment that is used for standard personal
protective equipment.
3. To understand the proper sequence of donning and doffing standard
personal protective equipment.
4. To recognize the importance of when to remove respiratory protection during
the doffing process.
Materials/Equipment to Use:
1. Soap/ Alcohol
2. PPE
3. Surgical Mask/ N95
4. Goggles/ Face shield
5. Sterile/ Non- Sterile gloves

DONNING OF PPE

PROCEDURE RATIONALE

1. Remove rings, bracelets, and This prepares hands for direct patient
watches. Perform hand hygiene. care.
2. Apply waterproof long-sleeved Waterproof gown prevents any potential
gown. Tie the neck and waist cross-contamination from blood or body
strings fluids onto forearms and body.
3. .Apply surgical or N95 mask. Wearing a poor-fitting mask is the
Ensure the fit is secure with no number one reason for exposure to
air leaks. Secure the metal band pathogens for health care providers.
around the nose and pull mask
over chin as required.
4. Apply goggles or face shield. Goggles or a face shield prevents
accidental exposure to eyes, nose, and
mouth. Goggles can be placed on top of
eyeglasses.

5. Apply non-sterile gloves over top Non-sterile gloves ensure complete

 of the cuff of the gown. coverage of skin on arms for direct
patient care.
DONNING OF PPE
STEPS RATIONALE
1. Remove gloves.

2. Perform hand hygiene.

3. Remove gown.

4.  Perform hand hygiene Always perform hand hygiene after

removing gown. Hands may have been
contaminated upon removal of the
gown.
5. Remove eye protection or face
shield.
6. Remove mask/N95 respirator.
7. Perform hand hygiene This step reduces the transmission of
microorganisms.

Source/s:
Barratt, Shaban, & Moyle, 2011; PIDAC, 2012; PHAC, 2012b
 Barratt et al., 2011; Perry et al., 2014; PHAC, 2012b; Siegal et al., 2007

Name of Student: Bedasua, Nidrice Inclusive Date of Rotation: March 31-

Zileon G. April 7,8,9
Year Level: BSN-2B Clinical Area Assigned: PEDIA 2
Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

HAND WASHING
DEFINITION:

The act of cleaning the hands for the purpose of removing soil, dirt and
microorganisms

OBJECTIVES:
To reduce the number of microorganisms on the hands
To reduce the risk of transmission of microorganisms to clients
To reduce the risk of transmission of infectious organisms to oneself
MATERIALS/EQUIPMENTS:
  Easy-to-reach sink with warm running water
 Antimicrobial soap
 Dry Towels
Waste receptacle
PROCEDURE RATIONALE
1. Inspect hands for visible soiling, Open cuts can harbor microorganisms;
breaks, or cuts. Cover skin lesions soiled hands may carry microorganism
before providing care. If lesions are
too large, direct patient care is
restricted.
2. Inspect fingernails. Fingernails Harbor high concentrations of
must be short. Remove artificial microorganisms; increase microbial load on
nails, extenders, or polish. hands.

3. Push wristwatch and long Complete access to fingers, hands, and

uniform sleeves above the wrists. wrists.
Avoid wearing rings.
4. Stand in front of sink, keeping The edge and inside of the sink are
hands and uniform away from the contaminated; reaching over the sink
sink surface. increases risk of touching and
contamination.

5. Turn on the faucets to begin the Knee and foot pedals prevent hand contact
flow of water. Avoid splashing with faucet. Faucet handles are likely to be
water against uniform. contaminated.

6. Regulate flow of water so Warm water removes less protective oils.

temperature is warm.
7. Wet hands and wrist thoroughly. Hands are the most contaminated part;
Keep hands and forearms lower water flows from least to most contaminated
than elbows during washing. area, rinsing microorganisms into the sink.

8. Apply antiseptic soap and rub Ensure hands and fingers’ surface area are
hands together vigorously, lathering cleaned.
thoroughly. For liquid soap apply 3
to 5 ml. For bar soap rub firmly
between hands (rinse bar soap
before returning).

9. Use a rotating frictional motion, Soap cleans by emulsifying fat and oil and
applying friction to all surfaces of lowering surface tension. Friction and
the hands and wrists, including the rubbing mechanically loosen and remove
 balls of hands, between fingers, and dirt and transient bacteria.
around and under the nails.
Interlace the fingers and rub up and Interlacing fingers and thumbs ensures that
down. Continue washing for at least all surfaces are cleansed. Adequate time is
20 seconds. Hum the “Happy needed to expose skin surfaces to
Birthday” song from beginning to antimicrobial agent
end twice as a timer

10. Rinse hands and wrists Washes away dirt and microorganisms.
thoroughly, keeping hands lower
than elbows.

11. Dry hands thoroughly from Drying from cleanest to least clean area
fingers to wrists and forearms with avoids contamination; prevents chapping
paper towel, single-use cloth, or and roughened skin.
warm air dryer.
12. Discard paper towel in proper Prevents transfer of microorganisms.
receptacle.
13. Turn off water. For hand faucet Wet towel and hands allow transfer of
use clean, dry paper towel; avoid pathogens from faucet to hands. Faucet
touching handles with hands. handles are contaminated.
Discard paper towel in proper
receptacle.

Source/s:
https://drive.google.com/file/d/1_W2eObyyXLifitK-OlfM4gkhv11O4Ehv/view?
usp=drivesdk
Fundamentals of Nursing Potter / Perry / Stockert / Hall, Ninth Edition, Volume I

Name of Student: Bodiongan, Jobelie Inclusive Date of rotation March 31,

R. April 1,2,7
Year Level: BSN-2A Clinical Area Assigned: PEDIA 2
Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

OPEN AND CLOSE GLOVING

Definition:
Open gloving technique means a gloving technique in which the hand slides all
the way through the sleeves and cuffs when a sterile gown is put on prior to
 donning sterile gloves.
Closed gloving technique means a gloving technique in which the hands are nit
extended from the sleeves and cuffs when the gown is put on. Instead, the hands
are pushed through the cuff openings as the gloves are pulled into place.
Objectives:
 To enable the nurse to handle or touch sterile objects freely without
contaminating them.
 To prevent transmission of potentially infective organisms from the nurse’s
hands to clients at high risk for infection
Materials/Equipment to Use:
1. Sterile gloves (proper size)

PROCEDURE RATIONALE
1. Perform thorough hand hygiene. Removes microorganisms and reduces
transmission of infection

2. Remove outer glove package Prevents inner glove package from

wrapper by carefully separating and accidentally opening and touching
peeling apart sides. contaminated objects
3. Grasp inner package and lay it Sterile object held below waist is
on clean, flat surface just above contaminated. Inner surface of glove
waist level. Open package, keeping package is sterile.
gloves on wrappers inside surface.
4. Identify right and left glove. Each Proper identification of gloves prevents
glove has cuff approximately 5 cm contamination by improper fit. Gloving of
(2 in.) wide. Glove dominant hand dominant hand first improves dexterity.
first.

5. With thumb and fist two fingers of Inner edge of cuff lies against skin and thus
non-dominant hand. Touch only is not sterile.
inside surface of glove.
6. Carefully pull glove over If outer surface of glove touches hand or
dominant hand, leaving cuff and wrist, it is contaminated.
being sure that it does not roll up
wrist. Be sure that thumb and
fingers are in proper spaces.

7. With gloved dominant hand, slip Cuff protects gloved fingers. Sterile touching
fingers underneath cuff of second sterile prevents glove contamination.
glove.
8. Carefully pull second glove over Contact of gloved hand with exposed hand
non-dominant hand. Do not allow results in contamination.
fingers and thumb of gloved
dominant hand to touch any part of
 exposed non-dominant hand. Keep
thumb of dominant hand abducted
back.
9. After second glove is on, Prevents accidental contamination from
interlock fingers of gloved hands hand movement.
and hold away from body above
waist level until beginning
procedure.
10. Glove disposal. Grasp outside Minimizes contamination of underlying skin.
of one cuff with other gloved hand.
Avoid touching wrist. Pull halfway
down palm of hand. Take thumb of
half ungloved hand and place under
cuff of other glove.
11. Pull glove off, turning it inside Outside of glove does not touch skin
out. Discard in receptacle. surface.

12. Take fingers of bare hand and Minimizes contamination

tuck inside remaining glove cuff.
Peel gloves off, inside out. Discard
in receptacle.

Source/s:
https://drive.google.com/file/d/1_W2eObyyXLifitK-OlfM4gkhv11O4Ehv/view?
usp=drivesdk
Fundamentals of Nursing Potter / Perry / Stockert / Hall, Ninth Edition, Volume I

Name: Jewell Glints N. Carpio Inclusive Date of duty:

March 31- April 1,2,7
Year Level: BSN- 2A Clinical Area Assigned: PEDIA
Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

ADMINISTRATION OF MEDICATION: INTRADERMAL

Definition:
Intradermal injections (ID) are injections administered into the dermis, just below
the epidermis. The ID injection route has the longest absorption time of all
parenteral routes. These types of injections are used for sensitivity tests, such as
TB, allergy, and local anesthesia tests.
Objectives:
1. To obtain a local effect at the site of injection of local anesthesia such as
xylocaine and novocaine.
2. Diagnostic purpose as in sick test, tuberculin test, etc.
3. To test for allergic reaction of a drug, e.g., penicillin serum, etc.
Materials/Equipment to Use:
A tray containing
 Syringe and needles of various sizes according to the need in a covered tray
(sterile)
 Sterile cotton swabs and gauge piece in sterile containers
 Methylated spirit in a container
 Kidney tray and paper bag
 Drug order sheet
 Small covered tray (sterile) to carry the prepared injections (syringes and
needles with medication) to the bed side
Safety Considerations:
 Use your knowledge about pharmacokinetics and pharmacodynamics to
determine the appropriateness of the ordered medication, dose, and route.
 Perform a point of care risk assessment for PPE.
 Always take steps to eliminate interruptions and distractions during medication
preparation.
 Never leave medication unsupervised once prepared.
 If the patient expresses concerns about the medication or procedure, stop and
explore the concerns. Re-verify order with physician if appropriate.
 Do not aspirate. It is not necessary to aspirate because the dermis is relatively
without vessels.
 Whenever possible, choose needleless systems to prepare injectable
medication.
 NEVER recap needles after giving an injection. Engage the needle’s safety
system and dispose in the closest sharps container.

PROCEDURE RATIONALE

1. Perform hand hygiene; gather Supplies include: medication syringe &

supplies. needle, non-sterile gloves, alcohol swab
and sterile gauze, Band-Aid (if required).

2. Prepare medication or solution as Properly identifying medication decreases

per agency policy. This may risk of inadvertently administering the wrong
include: medication. Preparing medications correctly
 Checking physician orders and decreases risks to the patient.
MAR to validate medication
order.
 Checking your agency’s
Parenteral Drug Therapy Manual
(PDTM) about guidelines for
administration.
 Independent double check by a
colleague.
3. Enter room and introduce Explaining rationale increases the patient’s
yourself, explain procedure and knowledge and reduces their anxiety.
 the medication, and allow patient
time to ask questions.
4. Close the door or pull the This provides patient privacy.
bedside curtains.
5. Identify patient using at least two This ensures accuracy of the correct
patient identifiers. Confirm with medication to the correct patient. Two
MAR; confirm allergies; explain patient identifiers used most often are
procedure and the medication; patient name and date of birth.
allow the patient time to ask
questions.
6. Reassess patient for any Assessment is a prerequisite for every
contraindications to the medication given.
medications.

7. Select appropriate site for Site should be free from lesions, rashes,
administration. Assist the patient and moles. Selecting the correct site allows
to the appropriate position as for accurate reading of the test site at the
required. appropriate time.

8. Perform hand hygiene and apply Gloves help prevent exposure to BBF.
non-sterile gloves.
9. Clean the site with an alcohol The needle poke opens the skin allowing
swab or antiseptic swab. Use a pathogens to enter. Cleaning the skin
firm, circular motion. Allow the reduces pathogens. Allowing the antiseptic
site to dry. to dry renders it effective. In addition, wet
alcohol on the skin during injection can be
irritating and uncomfortable.

10. Remove needle from cap by This decreases risk of accidental needle-
pulling it off in a straight motion. stick injury.

11. Using non-dominant hand, Taut skin provides easy entrance for the
spread the skin taut over the needle.
injection site.
12. Hold the syringe in the dominant This allows for easy handling of the syringe.
hand between the thumb and
forefinger, with the bevel of the
needle up.
13. Hold syringe at a 5- to 15-degree Keeping the bevel side up allows for
angle from the site. Place the smooth piercing of the skin and induction of
needle almost flat against the the medication into the dermis.
patient’s skin, bevel side up, and
insert needle into the skin. Insert
the needle only about 1/4 in, with
the entire bevel under the skin.

14. Once syringe is in place, slowly The presence of the weal or bleb indicates
 inject the solution while watching that the medication is in the dermis.
for a small weal or bleb to
appear.
15. Withdraw the needle at the same Withdrawing at the same angle as insertion
angle as insertion, engage safety minimizes discomfort to the patient and
shield or needle guard, and damage to the tissue. Proper needle
discard in a sharps container. disposal prevents needle-stick injuries.

Do not massage area after Massaging the area may spread the
injection. solution to the underlying subcutaneous
tissue. Gently pat with sterile gauze if blood
is present.

16. If injection is a TB skin test, circle

the area around the injection site
to allow for easy identification of
site in three days.
17. Discard remaining supplies, This prevents the spread of
remove gloves, and perform microorganisms.
hand hygiene.

18. Document the procedure and Proper documentation helps ensure patient
findings according to agency safety. Document time, date, location, and
policy. type of medication injected.

19. Evaluate the patient response to The patient will need to be evaluated for
injection within appropriate time therapeutic and adverse effects of the
frame. medication or solution.

Source/s:
Berman & Snyder, 2016; Brookside Associates, 2015a; Clayton, Stock, & Cooper,
2010; Perry et al., 2018

Name of Student: Julie Mae L. Emia Inclusive Date of Rotation: March 31,
April 1,2,7 2022
Year Level: BSN-2A Clinical Area Assigned: PEDIA 2
Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

ADMINISTRATION OF MEDICATION: INTRAMUSCULAR

Definition:
An intramuscular injection is a technique used to deliver a medication deep into
the muscles. This allows the medication to be absorbed into the bloodstream
quickly.
Objectives:
1. To use for the delivery of certain drugs not recommended for other routes of
administration, for instance intravenous, oral, or subcutaneous.
2. To offer a faster rate of absorption than the subcutaneous route, and muscle
tissue can often hold a larger volume of fluid without discomfort.

Materials/Equipment to Use:
1. Syringe
2. Clean Gloves
3. Alcohol Pads
4. Gauze
5. Adhesive Tape
6. Needle (length varies on the muscle used)

PROCEDURE RATIONALE
1. Check accuracy and The prescribers order is the most reliable
completeness of the MAR or source and legal record of patients
computer printout with prescriber’s medications.
written medication order. Check
patient’s name, medication name
and dosage, route of administration,
and time of administration. Recopy
or reprint any portion of the MAR
that is difficult to read.
2. Prepare medications for one Ensures that medication is sterile.
patient at a time using aseptic Preventing distractions reduces medication
technique. Keep all pages of MARs preparation errors.
or computer printouts for one
patient together, or look at only one
patient’s electronic MAR at a time.
Check label of medication carefully
with MAR or computer printout 2
times when preparing medication.
3. Take medication to patient at Hospital must adopt administration policy
right time. hand procedure for timing of medication
administration that considers nature of
prescribe medication.

4. Identify patient using two Ensures correct patient

identifiers (e.g., name and birthday
or name and account number)
according to agency policy.
Compare identifiers with information
on patient’s MAR or medical record.
5. At patient’s bedside again This is the third check for accuracy and
compare MAR or computer printout ensures that patient receives correct
with names of medications on medication. Confirms patients allergy
medication labels and patient history.
name. Ask patient if he or she has
allergies.
6. Discuss purpose of each Patient has to be informed and patients
medication, action, and possible understanding of each medication improves
adverse effects. Allow patient to ask adherence to drug therapy. Helps minimize
any questions. Tell patient that patients anxiety.
injection will cause a slight burning
or sting.
7. Perform hand hygiene and apply Reduces transmission of infections. Respect
clean gloves. Keep sheet or gown patients dignity while exposing injections
draped over body parts not site.
requiring exposure.
8. Select appropriate site. Note Ventrogluteal is performed injection site for
integrity and size of muscle. adults. It is also preferred sites for children
Palpate for tenderness or hardness. of all ages
Avoid these areas. If patient
receives frequent injections, rotate
sites. Use ventrogluteal if possible.
9. Help patient to comfortable Reduces strain on muscle and minimizes
position. Position patient depending injection discomfort.
on chosen site (e.g., sit, lie flat, on
side, or prone).
10. Relocate site using anatomical Injection into correct anatomical site
landmarks. prevents injury to nerves bone and blood
vessels.

11. Cleanse site with antiseptic Mechanical action of swab removes

swab. Apply swab at center of site, secretions containing microorganisms.
and rotate outward in circular Decreases pain of injection site.
direction for about 5 cm (2 inches).
Option:Apply EMLA cream on
injection site at least 1 hour before
IM injection, or use vapocoolant
spray (e.g., ethyl chloride) just
before injection.
12. Hold swab or gauze between Quickly access to the swab or gauze when
third and fourth fingers of withdrawing needle.
nondominant hand.
13. Remove needle cap by pulling it Preventing needle from touching sides of
straight off. cap prevents contamination.
14. Hold syringe between thumb Quick, smooth injection requires paper
and forefinger of dominant hand; manipulation of syringe parts.
hold as dart, palm down.
15. Administer injection.
• Position ulnar side of nondominant Z-track creates zigzag path through tissues
hand just below site, and pull skin that seals needle track to avoid tracking
laterally approximately 2.5 to 3.5 medication.
cm (1 to 1 1/2inches). Hold position
until medication is injected. With
dominant hand, inject needle
quickly at 90-degree angle into
muscle.
• Option: If patient’s muscle mass is Ensures that the medication reaches muscle
small, grasp bodyof muscle mass.
between thumb and forefingers.
• After needle pierces skin, still Smooth manipulation of syringe reduces
pulling on skin with nondominant discomfort from needle movement.
hand, grasp lower end of syringe
barrel with fingers of nondominant
hand to stabilize it. Move dominant
hand to end of plunger. Avoid
moving syringe. Aspiration of blood into syringe indicates
possible placement into a vein.
• Pull back on plunger 5 to 10
seconds. If no blood appears, inject
medication slowly at a rate of 10
sec/mL (Nicholl and Hesby, 2002).
SAFETY ALERT If blood appears in
syringe, remove needle, dispose of
medication and syringe properly,
and prepare another dose of Allows time for medication to absorb into
medication for injection. muscle before syringe is removed.

• Wait 10 seconds, then smoothly

and steadily withdraw needle,
release skin, and apply alcohol
swab or gauze gently over site.
16. Apply gentle pressure to site. Massage damages underlying tissue.
Do not massage site. Apply
bandage if needed.
17. Discard uncapped needle or Prevents injury to patients and health care
needle enclosed in safety shield personnel.
and attached syringe into a
puncture-proof and leak-proof
receptacle.
 18. Complete postprocedure
protocol.
19. Return to room in 15 to 30 Continued discomfort may indicate injury to
minutes, and ask if patient feels any underlying bones or nerves.
acute pain, burning, numbness, or
tingling at injection site.
20. Immediately after Accurate and timely documentation and
administration, record medication reporting promote patient safety.
dose, route, site, time, and date
given on MAR. Correctly sign MAR
according to institutional policy.

Source/s:
Nursing Skills and Procedures Perry•Potter Eight Edition

Name of Student: Jobelie R. Inclusive Date of Rotation: March 31,

Bodiongan April 1,2,7
Year Level: BSN-2A Clinical Area Assigned: Pedia 2
Assigned Clinical Instructor: Juvy L. Lagcao, RN,MN

ADMINISTRATION OF MEDICATION: SUBCUTANEOUS

Definition:
Administering medications into subcutaneous tissues, the layer of fat located
below the dermis and above the muscular layer.

Objectives:
 Ensure more rapid absorption and action of drug that cannot be achieved
orally.
 Administer drugs to clients who are unable to take oral medications.
 Administer medications that are not active by the oral route are inactivated
by digestive enzymes.
Equipment:
 Medication card
 Sterile syringes and needles. (25 G (5-8”) or 26G needle)
 Prescribed medications (vial or ampule)
 Small gauze pad (optional)
 Alcohol swab
 Clean gloves
RATIONALE
1. Check accuracy and The order sheet is the most reliable source
completeness of each MAR or and legal record of the patient’s
computer printout with prescriber’s medications. Ensures that patient receives
written medication order. Check the correct medications. Handwritten MARs
patient’s name, medication name are a source of medication errors (ISMP,
and dosage, route of administration, 2010; Jones and Treiber,2010).
and time of administration. Recopy
or reprint any portion of MAR that is
difficult to read.
2. Perform hand hygiene and Ensures that medication is sterile. These
prepare medication using aseptic are the first and second checks for accuracy
technique. Check label of the and ensure that correct medication is
medication carefully with the MAR administered.
or computer printout two times when
preparing medication.
3. Identify patient using two patient Ensures correct patient. Complies with the
identifiers (e.g., name and birthday joint commission requirements for patient
or name and account number) safety (TJC, 2014).
according to agency policy.
Compare identifiers with information
on patient’s MAR or medical record.
4. At patient’s bedside, again This is the third check for accuracy and
compare MAR or computer printout ensures that patient receives correct
with names of medications on medication. Confirms patient’s allergy
medication labels and patient name. history.
Ask patient if he or she has
allergies.
5. Perform hand hygiene and apply Reduces transfer microorganisms.
clean gloves. Keep sheet or gown Respects patients’ dignity during injection.
draped over body parts not requiring
exposure.
6. Select appropriate injection site. Injection sire are free of abnormalities that
Inspect skin surface over sites for interfere with drug absorption. Sites used
bruises, inflammation, or edema. Do repeatedly become hardened from lip
not use an area that is bruised or hypertrophy (increased growth inn fatty
has signs associated with infection. tissue)

7. Palpate sites; avoid those with You can mistakenly give subcutaneous
masses or tenderness. Be sure that injections into muscle, especially in the
needle is correct size by grasping abdomen and thigh sites
skinfold at site with thumb and
forefinger. Measure foldfrom top to
bottom. Make sure needle is one-
half length of fold.

Risk for bruising is not affected by site

• When administering insulin or
heparin subcutaneously, use
abdominal injection sites first,
followed by thigh injection site.
• When administering lowmolecular-
weight heparin (LMWH) Injecting LMWH on the side of the abdomen
subcutaneously, choose a site on will help decrease pain and bruising at the
the right or left side of the abdomen, injection site
at least 5 cm (2 inches) away from
the umbilicus.
Rotating injection site within the same
• Rotate insulin site within an anatomical site maintains consistency in
anatomical area (e.g., the day to day insulin absorption
abdomen), and systematically rotate
sites within that area.
SAFETY ALERT Applying ice to the injection site for 1 minute before the injection
may decrease the patient’s perception of pain (Hockenberry and Wilson, 2011).
8. Help patient into comfortable Relaxation of site minimizes discomfort
position. Have him or her relax arm,
leg, or abdomen, depending on site
selection.
9. Cleanse site with antiseptic swab. Mechanical action of swab removes
Apply swab at center of site and secretions. Containing microorganisms
rotate outward in circular direction
for about 5 cm (2 inches).
10. Hold swab or gauze between Swab or gauze remains readily accessible
third and fourth fingers of for use when withdrawing needle after
nondominant hand. injection.

11. Remove needle cap or Preventing needle from touching sides of

protective sheath by pulling it cap prevents contamination
straight off.

12. Hold syringe between thumb Quick, smooth injection requires proper
and forefinger of dominant hand; manipulation of syringe parts
hold as dart.

13. Administer injection: Needle penetrates tight skin more easily

• For average-size patient, hold skin more than loose skin. Pinching skin
across injection site or pinch skin elevates subcutaneous tissue and
with nondominant hand. desensitizes area.

• Inject needle quickly and firmly at

45- to 90-degree angle. Release
skin, if pinched. Option: When using Quick firm insertion minimizes discomfort.
 injection pen or giving heparin, Correct angle prevents accidental injection
continue to pinch skin while injecting into muscle.
medicine.
• For obese patient, pinch skin at
site and inject needle at 90-degree
angle below tissue fold. Obese patients have fatty layer of tissue
• After needle enters site, grasp above subcutaneous layer
lower end of syringe barrel with Movement of syringe may displace needle
nondominant hand to stabilize it. and cause discomfort
Move dominant hand to end of
plunger, and slowly inject
medication over several seconds
(Hunter, 2008b). Avoid moving
syringe.
SAFETY ALERT Aspiration after injecting a subcutaneous medication is not
necessary. Piercing a blood vessel in a subcutaneous injection is very rare
(Hunter, 2008b). Aspiration after injecting heparin and insulin is not recommended
(Aschenbrenner and Venable, 2009).
• Withdraw needle quickly while Supporting tissues around injection site
placing antiseptic swab or gauze minimizes discomfort during needle
gently over site. withdrawal.

14. Apply gentle pressure to site. Do Aids discomfort. Massage can damage
not massage site.(If heparin is underlying tissue
given, hold alcohol swab or gauze
to site for 30 to 60 seconds.)
15. Help patient to comfortable Gives patient a sense of well being
position.
16. Discard uncapped needle or Prevents injury to patient’s health care.
needle enclosed in safety shield and Recapping needles increases risk for a
attached syringe into puncture- and needlestick injury
leakproof receptacle.
17. Complete postprocedure
protocol.
18. Immediately after administration, Accurate and timely documentation
record medication, dose, route, site, reporting promote patient safety
time, and date given on MAR.
Correctly sign MAR according to
institutional policy.
Source/s:
Nursing Skills and Procedures Perry•Potter Eight Edition
Name: Stephanie A. Lee Inclusive Date of duty: February 24,
2022
Year Level: BSN- 2A Clinical Area Assigned: PEDIA
Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

ADMINISTRATION OF MEDICATION:
ORAL
Definition:
Oral medication is defined as the administration of medication by mouth and
ensuring that patient swallows the medicine.
Objectives:
1. Medications are administered orally to produce local effect on the alimentary
canal or systemic effect after absorption into the blood stream.
2. To cure the disease, and to promote the health
3. To reduce medication errors and ensure patient safety.
Materials/Equipment to Use:
1. Automated, computer-controlled drug-dispensing system or medication cart
2. Disposable medication cups
3. Glass of water, juice, or preferred liquid and drinking straw
4. Device for crushing or splitting tablets (optional)
5. Clean gloves (if handling a medication)
6. Medication administration record (MAR) (electronic or printed)
7. Paper towels

PROCEDURE RATIONALE

Safety considerations:
 Perform hand hygiene.
 Check room for additional precautions.
 Introduce yourself to patient.
 Confirm patient ID using two patient identifiers (e.g., name and date of
birth).
 Check allergy band for any allergies.
 Complete necessary focused assessments and/or vital signs, and
document on MAR.
 Provide patient education as necessary.
 Plan medication administration to avoid disruption:
o Dispense medication in a quiet area.
o Avoid conversation with others.
o Follow agency’s no-interruption zone policy.
o Prepare medications for ONE patient at a time.
o Follow the SEVEN RIGHTS of medication administration.
20. Check MAR against doctor’s orders. Check that MAR and doctor’s orders
are consistent.

Night staff usually complete and

verify this check as well.

21. Perform the SEVEN RIGHTS x 3 The right patient: check that you
(must be done with each individual have the correct patient using two
medication): patient identifiers (e.g., name and
 The right patient date of birth).
 The right medication (drug)
 The right dose The right medication (drug): check
 The right route that you have the correct medication
 The right time and that it is appropriate for the
patient in the current context.
 The right reason
 The right documentation The right dose: check that the dose
makes sense for the age, size, and
condition of the patient. Different
dosages may be indicated for
different conditions.

The right route: check that the route

is appropriate for the patient’s current
condition.

The right time: adhere to the

prescribed dose and schedule.

The right reason: check that the

patient is receiving the medication for
the appropriate reason.

The right documentation: always

verify any unclear or inaccurate
documentation prior to administering
medications.

NEVER document that you have

given a medication until you have
actually administered it.

22. The label on the medication must be These checks are done before
checked for name, dose, and route, administering the medication to your
and compared with the MAR at three patient.
different times:
 When the medication is taken out If taking drug to bedside (e.g., eye
of the drawer drops), do third check at bedside.
 When the medication is being
poured
 When the medication is being put
 away/or at bedside

23. Place all medications that patient will Keeping medications that require
receive in one cup, except pre-assessment separately acts as a
medications that require pre- reminder and makes it easier to
assessment (e.g., blood pressure or withhold medications if necessary.
pulse rate). Place these in a separate
cup and keep wrapper intact.

24. Do not touch medication with Using gloves reduces contamination

ungloved hands. Use clean gloved of the medication.
hands if it is necessary to touch the
medication.
25. Circle medication when poured. Pour medication. Circle MAR to
show that medication has been
poured.
26. Patient education The patient has the right to be
 Discuss purpose of each informed and provided with reasons
medication, action, and possible for medication, action, and potential
adverse effects. adverse effects. Giving this
 Ask patient if they have any information will likely improve
allergies. adherence to medication therapy and
patient reporting of adverse effects.

Confirms patient’s allergy history.

IMPORTANT: If patient expresses concerns over medications, do not give

medication. Verify doctor’s order and explore patient concerns before
administering medication.
27. Positioning Correct positioning reduces risk of
 Help patient to sitting position. If aspiration during swallowing.
patient is unable to sit, use the
side-lying position. Water or other oral fluids will help
 Have patient stay in this position with swallowing of medication.
for 30 minutes after administering
medication. Proper body mechanics reduces risk
 Offer patient water or desired of injury to health care provider.
oral fluid.
 Ensure proper body mechanics
for health care provider.

28. Administer medication orally as Follow any specific descriptions for

prescribed. administration of the medication.
 Tablets: place in mouth and
swallow using water or other oral Wear gloves if placing the
fluids. medication inside the patient’s
 Orally disintegrating medications: mouth.
Remove carefully from
packaging. Place medication on
top of patient’s tongue, and have
 patient avoid chewing the
medication. Water is not needed.
 Sublingually: Place medication
under patient’s tongue and allow
to dissolve completely. Ensure
patient avoids swallowing the
medication.
 Buccal: place medication in
mouth and against inner cheek
and gums and allow to dissolve
completely.
 Powdered medication: mix at
bedside with water to avoid
thickening of medication that may
occur with time.

29. Post-medication safety check Do not sign for any medications if

 Stay with patient until all you are not sure the patient has
medications are swallowed or taken them.
dissolved.
 Perform post assessments Post assessments determine effects
and/or vital signs if applicable. and potential adverse effects of
 Sign MAR and place in medications.
appropriate chart.
 Perform hand hygiene.
 Document any additional
information, such as patient
education, reasons why
medication not administered, and
adverse effects, as per agency
policy.

30. Return within appropriate time to Most sublingual medications act in

evaluate patient’s response to the 15 minutes, and most oral
medications and to check for medications act in 30 minutes.
possible adverse effects.

If patient presents with any adverse

effects:

 Withhold further doses.

 Assess vital signs.
 Notify prescriber.
 Notify pharmacy.
 Document as per agency policy.

Source/s:
BCIT, 2015; Lilley et al., 2011; Perry et al., 2014
Name of Student: Pielago, Kaycel Ann Inclusive Date of Rotation: March 31-
P.
April 7,8,9
Year Level: BSN-2A Clinical Area Assigned: PEDIA 2
Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

DEFINITION: Intravenous therapy or IV therapy is the giving of liquid substances

directly into a vein. It can be intermittent or continuous; continuous administration
is called intravenous drip.

AIMS and OBJECTIVES:

 To supply fluid when clients are unable to take in an adequate volume of
fluids by mouth
 To provide salts and other electrolytes needed to maintain electrolyte
imbalances
 To establish a lifetime for rapidly needed medication

 Maintain an aseptic technique at all times

 Maintain patient intravenous line

MATERIALS/ EQUIPMENT
 IV Fluids or Dextrose

 IV Tubing
 IV Pole
 Intracatheter or IV Catheter
 Splint
 Adhesive Tape
 Cotton Balls
 Alcohol
 Tourniquet
 Gloves
 Syrince 3cc or1cc

ADMINISTRATION OF MEDICATION:INTRAVENOUS
PROCEDURES RATIONALE
1. Perform hand hygiene. Prepare Ensures that medication is sterile.
ordered medication from vial or Following the same routine when preparing
ampule using aseptic technique. medications eliminating distractions, and
Check label of medication carefully checking label of medication with
with MAR 2 times transcribed order reduce error. This is the
first and second accuracy check

2. Take medication to patient at Ensures intended therapeutic effects and

correct time (see agency policy). complies with professionals standards

3. Identify patient using at least two Ensures correct patient. Complies with the
identifiers (e,g., name and birthday Joint Commission Standards and improves
or name and medical record patient safety.
number) according to agency policy
. Compare identifiers with
information on patient’s MAR or
medical record.

.
4. Compare names of medications Third check for accuracy ensures that right
on
5. Explain procedure to patient. Keeps patient informed and ensures patient-
Encourage patient to report centered care, helps identify possible
symptoms of discomfort at IV site. infiltration early.
Provide instruction on purpose and
action of medication and possible
side effects.
6. Apply clean gloves. If patient has Reduces transmission of microorganisms.
latex allergy, use latex-free gloves. During IV administration, there is risk of
blood exposure.

7. IV push (existing line):

1. Select injection port of IV tubing Follows provision of needle safety and

closest to patient. Whenever prevention
possible, injection port should
accept a needleless syringe. Use IV
filter if required by medication
reference or agency policy.
2. Clean injection port with Prevents the introduction of microorganism
antiseptic swab. Allow to dry. during needle insertion. During enhances
effects of antiseptic.
3. Connects syringe to port of IV Prevents damage to the diaphragm of part
line. Insert needleless tip to small- and subsequent leakage
gauge needle of syringe containing
prepared drug through center of
injection port. The final check that medication is being
4. Occlude IV line by pinching delivered into the bloodstream
tubing just above injection port. Pull
back gently on syringe plunger to Ensures safe medication infusion. Rapid
aspirate blood return. injection of IV medication can be fatal
5. Release tubing and inject
medication within amount of time
recommended by agency policy,
pharmacist or medication reference
manual. Use watch to time
administration. You can pinch IV
line while medication and release it Injection of bolus alters the rate of fluid
when not pushing it. Allow IV to infusion. Rapid fluids medication infusion
infuse when nothing pushing causes circulatory over-lood
medication.
6. After injecting medication,
release tubing withdraw syringe,
and recheck fluid infusion rate
8. IV push (IV lock):
1. Prepare two syringes with 2 to Saline flushes are effective in maintaining
3Ml of normal saline (0.9%) in the the patency of IV lines and do not carry the
syringe. risk of thrombocytopenia associated with
heparin flushes

2. Administer medication: Prevents the introduction of microorganisms

 Clean injection port of lock during needle insertion. Drying enhances
with an antiseptic swab. the effects of antiseptic.
Allow drying

To begin the cleaning of IV catheter

 Insert a syringe containing
normal saline 0.9%) into the
injection port of the IV lock Determines whether an IV Needle or
 Pull back gently on the catheter is positioned in the vein
syringe plunger and look for
blood return Clean IV lock of blood

 Flushed IV lock with normal Prevents transmission of infection

saline by pushing slowly on Prevents transmission of a lock with an
the plunger antiseptic swab
 Remove the saline flush
syringe To begin medication administration through
 Clean injection port or lock IV.
with an antiseptic swab.
  Insert syringe containing
prepared medication into Rapid medication injection of IV can result in
injector port of IV lock death. Following guidelines for IV push rates
 Inject medication within the promotes patient’s safety
amount of time management
by agency policy,
pharmacist, or medication
reference manual. Use watch
time for the administration.
Port of lock Prevents the transmission of
 After administrating bolus, microorganisms
withdraw syringe
 Clean injection port with Irrigations with saline prevent occlusion of
antiseptic swab IV assess device and ensure that all
 Flush injection port by medication is delivered. Flushing IV site at
attaching syringe with normal some rate as medication ensures that any
saline. Inject normal saline medication remaining within IV needle is
flush as the same rate delivered
medication was delivered

9. Disposed of uncapped, needles Reduces accidental needles

and syringes in a puncture-proof,
leak-proof container
10. Remove and dispose of gloves. Reduces transmission of microorganisms
Perform hand hygiene.

Source/s:
Fundamentals of Nursing, 9e by Patricia A. Potter, Anne Griffin Perry, Patricia A.
Stockert Amy M. Hall

Name of Student: Inclusive Date of Rotation: March 31,

2021
Year Level: BSN-2 Clinical Area Assigned: PEDIA
Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

ADMINISTRATION OF MEDICATION: VAGINAL SUPPOSITORIES

Definition:
Vaginal suppositories
are oval shaped and individually packaged in foil wrappers. They are
larger and more oval than rectal suppositories. Storage in a refrigerator
prevents the solid suppositories from melting.
Objectives:
 It is to provides targeted relief from conditions affecting the vagina.
 To help with the treatment of fungal infections and vaginal dryness

Equipment
■ Vaginal cream, foam, jelly, tablet, or suppository, or irrigating
solution
■ Applicators (if needed)
■ Clean gloves
■ Tissues
■ Towels and/or washcloths
■ Perineal pad; drape or sheet
■ Water-soluble lubricants
■ Bedpan
■ Irrigation or douche container (if needed)
■ Medication administration record (MAR) or computer printout

Safety considerations:

 Perform hand hygiene.

 Check room for additional precautions.

 Introduce yourself to patient.

 Confirm patient ID using two patient identifiers (e.g., name and date of
birth).
 Check allergy band for any allergies.
 Complete necessary focused assessments and/or vital signs, and
document on MAR.
 Provide patient education as necessary.
 Plan medication administration to avoid disruption:
o Dispense medication in a quiet area.
o Avoid conversation with others.

o Follow agency’s no-interruption zone policy.

o Prepare medications for ONE patient at a time.
o Follow the SEVEN RIGHTS of medication administration.

STEPS RATIONALE

1. Check MAR against doctor’s Students must check that MAR and Doctor’
orders. order are consistent.
Compare physicians order and MAR

Night staff usually complete and verify this

 check as well

2. Perform the SEVEN RIGHTS x 3 The right patient: check that you have the
(must be done with each individual correct patient using two patient
medication): identifiers (e.g., name and date of birth).

 The right patient The right medication (drug): check that you
 The right medication (drug) have the correct medication and that it is
 The right dose appropriate for the patient in the current
context.
 The right route
 The right time The right dose: check that the dose makes
sense for the age, size, and condition of the
 The right reason patient. Different dosages may be indicated
 The right documentation for different conditions.

Medication calculation: D/H x S = A

The right route: check that the route is
(D or desired dosage/H or have appropriate for the patient’s current
available x S or stock = A or amount condition.
prepared)
The right time: adhere to the prescribed
dose and schedule.

The right reason: check that the patient is

receiving the medication for the appropriate
reason.

The right documentation: always verify any

unclear or inaccurate documentation prior
to administering medications.

NEVER document that you have given a

medication until you have actually
administered it.
3. The label on the medication must Perform seven checks three times before
be checked for name, dose, and administering medication
route, and compared with the MAR
at three different times:
These checks are done before
administering the medication to your
 When the medication is taken
patient. If taking drug to bedside (e.g., eye
out of the drawer
drops) do third check at bedside.
 When the medication is being
poured
 When the medication is being
put away/or at bedside

4. Before inserting the medication Patient may feel more comfortable self-
vaginally, explain the procedure to administering vaginal medication.
the patient. If patient prefers to self-
administer the vaginal medication,
give specific instructions to patient
on correct procedure.
5. Ensure that you have water- Lubricant reduces friction against vaginal
soluble lubricant available for mucosa as medication is inserted.
medication administration.
6. Have patient void prior to Voiding prevents passing of urine during
procedure. procedure
7. Raise bed to working height. Position helps prevent injury to nurse
administering medication.
 Position patient on back with
Draping protects patient’s privacy and
legs slightly bent and feet flat
facilitate relaxation.
on the bed.
 Provide privacy, and drape
patient so that vaginal area is
exposed.

8. Apply clean non-sterile gloves. Gloves protect the nurse from contact with
mucous membranes and body fluids.
Apply non-sterile gloves

9. Remove suppository from Lubricant reduces friction against vaginal

wrapper and apply a liberal amount mucosa as medication is inserted.
of water-soluble lubricant to
suppository and index finger of Lubricate suppository
dominant hand. Suppository should
be at room temperature.
10. With non-dominant hand, gently Exposes vaginal orifice and help to ensure
separate labial folds. With gloved equal distribution of medication.
index finger of dominant hand, insert
lubricated suppository about 8 to 10
cm along posterior vagina wall.
11. Withdraw finger and wipe away Wiping maintains patient comfort.
excess lubricant.
NOTE: An applicator may be used to insert vaginal medication. Follow procedure
above and specific manufacturer directions.
12. Discard gloves by turning them Using gloves reduces transfer of
inside out and disposing of them microorganisms.
and any used supplies as per
agency policy. Perform hand Dispose of gloves.
hygiene.
Hand hygiene with ABHR
 13. Document procedure as per Timely and accurate documentation
agency policy, and include patient’s promotes patient safety.
tolerance of administration.

Source/s:
BCIT, 2015; Lilley et al., 2011; Perry et al., 2014

Name of Student: Inclusive Date of Rotation: March 31,

2021
Year Level: BSN-2 Clinical Area Assigned: PEDIA
Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

ADMINISTRATION OF MEDICATION: VAGINAL SUPPOSITORIES

Definition:
Vaginal suppositories
are oval shaped and individually packaged in foil wrappers. They are
larger and more oval than rectal suppositories. Storage in a refrigerator
prevents the solid suppositories from melting.

Objectives:
 It is to provides targeted relief from conditions affecting the vagina.
 To help with the treatment of fungal infections and vaginal dryness

Equipment
■ Vaginal cream, foam, jelly, tablet, or suppository, or irrigating
solution
■ Applicators (if needed)
■ Clean gloves
■ Tissues
■ Towels and/or washcloths
■ Perineal pad; drape or sheet
■ Water-soluble lubricants
■ Bedpan
■ Irrigation or douche container (if needed)
■ Medication administration record (MAR) or computer printout

Safety considerations:

 Perform hand hygiene.

 Check room for additional precautions.

 Introduce yourself to patient.

 Confirm patient ID using two patient identifiers (e.g., name and date of
 birth).
 Check allergy band for any allergies.
 Complete necessary focused assessments and/or vital signs, and
document on MAR.
 Provide patient education as necessary.
 Plan medication administration to avoid disruption:
o Dispense medication in a quiet area.
o Avoid conversation with others.

o Follow agency’s no-interruption zone policy.

o Prepare medications for ONE patient at a time.
o Follow the SEVEN RIGHTS of medication administration.

STEPS RATIONALE

1. Check MAR against doctor’s Students must check that MAR and Doctor’
orders. order are consistent.
Compare physicians order and MAR

Night staff usually complete and verify this

check as well

2. Perform the SEVEN RIGHTS x 3 The right patient: check that you have the
(must be done with each individual correct patient using two patient
medication): identifiers (e.g., name and date of birth).

 The right patient The right medication (drug): check that you
 The right medication (drug) have the correct medication and that it is
 The right dose appropriate for the patient in the current
context.
 The right route
 The right time The right dose: check that the dose makes
sense for the age, size, and condition of the
 The right reason patient. Different dosages may be indicated
 The right documentation for different conditions.

Medication calculation: D/H x S = A

The right route: check that the route is
(D or desired dosage/H or have appropriate for the patient’s current
available x S or stock = A or amount condition.
prepared)
The right time: adhere to the prescribed
dose and schedule.

The right reason: check that the patient is

 receiving the medication for the appropriate
reason.

The right documentation: always verify any

unclear or inaccurate documentation prior
to administering medications.

NEVER document that you have given a

medication until you have actually
administered it.
3. The label on the medication must Perform seven checks three times before
be checked for name, dose, and administering medication
route, and compared with the MAR
at three different times:
These checks are done before
administering the medication to your
 When the medication is taken
patient. If taking drug to bedside (e.g., eye
out of the drawer
drops) do third check at bedside.
 When the medication is being
poured
 When the medication is being
put away/or at bedside

4. Before inserting the medication Patient may feel more comfortable self-
vaginally, explain the procedure to administering vaginal medication.
the patient. If patient prefers to self-
administer the vaginal medication,
give specific instructions to patient
on correct procedure.
5. Ensure that you have water- Lubricant reduces friction against vaginal
soluble lubricant available for mucosa as medication is inserted.
medication administration.
6. Have patient void prior to Voiding prevents passing of urine during
procedure. procedure
7. Raise bed to working height. Position helps prevent injury to nurse
administering medication.
 Position patient on back with
Draping protects patient’s privacy and
legs slightly bent and feet flat
facilitate relaxation.
on the bed.
 Provide privacy, and drape
patient so that vaginal area is
exposed.

8. Apply clean non-sterile gloves. Gloves protect the nurse from contact with
mucous membranes and body fluids.
Apply non-sterile gloves
 9. Remove suppository from Lubricant reduces friction against vaginal
wrapper and apply a liberal amount mucosa as medication is inserted.
of water-soluble lubricant to
suppository and index finger of Lubricate suppository
dominant hand. Suppository should
be at room temperature.
10. With non-dominant hand, gently Exposes vaginal orifice and help to ensure
separate labial folds. With gloved equal distribution of medication.
index finger of dominant hand, insert
lubricated suppository about 8 to 10
cm along posterior vagina wall.
11. Withdraw finger and wipe away Wiping maintains patient comfort.
excess lubricant.
NOTE: An applicator may be used to insert vaginal medication. Follow procedure
above and specific manufacturer directions.
12. Discard gloves by turning them Using gloves reduces transfer of
inside out and disposing of them microorganisms.
and any used supplies as per
agency policy. Perform hand Dispose of gloves.
hygiene.
Hand hygiene with ABHR
13. Document procedure as per Timely and accurate documentation
agency policy, and include patient’s promotes patient safety.
tolerance of administration.

Source/s:
BCIT, 2015; Lilley et al., 2011; Perry et al., 2014

Name of Student: Mae Amor M. Inclusive Date of Rotation: March 31,

Yecyec 2022

Year Level: BSN-2B Clinical Area Assigned: PEDIA

Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

ADMINISTRATION OF MEDICATION: EYE OINTMENT APPLICATION

DEFINITION: Eye ointments are drugs in a greasy, semisolid form.

OBJECTIVES:
Used to prevent:
1. Acute or long-term eye problems
2. Eye infections
3. Inflammatory conditions
4. Soreness, as you might have with dry-eye syndrome
EQUIPMENT/ MATERIALS USES
 Medication bottle with sterile eyedropper, ointment tube, or medical
intraocular disk.
 Cotton ball or tissue
 Wash basin filled with warm water and washcloth ( if eyes have crust
or drainage)
 Eye patch and tape ( optional)
 Clean gloves
 Medication administration record (MAR)

PROCEDURE RATIONALE

1. Check accuracy and The health care provider’s order is the most
completeness of each MAR with reliable source and legal record of drugs
prescriber’s written medication the patient should receive. Ensures that
order. Check patient’s name, drug patients received correct medication. Hand
name and dosage, route (eye[s]), written MARs are source of medication
and time of administration. Clarify errors.
incomplete or unclear orders with
health care provider before
administration.

2. Identify patient using two Ensures correct patient. Some agencies are
identifiers (e.g., name and birthday now using a bar- code system to help with
or name and account number) patient identifications.
according to agency policy.
Compare identifiers with information
on patient’s MAR or medical record.

3. Discuss purpose of each Patient has right to be informed, and

medication, action, and possible patients understanding of each medications
adverse effects. Allow patient to ask improves adherence to drug therapy.
any questions about the drugs.
Patients who self-instill medications
may be allowed to give drops under
nurse’s supervision (check agency
policy). Tell patients receiving
eyedrops (mydriatics) that vision will
be blurred temporarily and
sensitivity to light may occur.

4. Apply clean gloves. Ask patient to Position provides easy access to eye for
lie supine or to sit back in chair with medication instillation and minimizes
head slightly hyperextended, drainage of medication into tear duct.
looking up.
 5. If drainage or crusting is present Soaking allows easy removal of crust
along eyelid margins or inner without applying pressure to eye cleaning
canthus, gently wash away. Soak from inner to outer canthus avoids entrance
any dried crusts with warm, damp of microorganism into lacrimal duct
washcloth or cotton ball applied
over eye for several minutes.
Always wipe clean from inner to
outer canthus. Remove gloves and
perform hand hygiene.

SAFETY ALERT Do not hyperextend the neck of a patient with cervical spine
injury.

6. Holding applicator above lower lid Distribute medication evenly across eye and
margin, apply thin ribbon of lid margin
ointment evenly along inner edge of
lower eyelid on conjunctiva from
inner to outer canthus.

7. Have patient close eye and rub Further distributes medication without
lid lightly in circular motion with traumatizing eye.
cotton ball, if rubbing is not
contraindicated. Avoid placing
pressure directly against patient’s
eyeball.

8. If excess medication is on eyelid, Promotes comfort and prevents trauma to

gently wipe it from inner to outer eye.
canthus.

9. If patient needs an eye patch, Clean eye patch reduces the risk of
apply clean one by placing it over infection.
affected eye so entire eye is
covered. Tape securely without
applying pressure to eye.

Source/s:
Nursing Skills and Procedures Perry•Potter Eight Edition

Name of Student: Niña Jean T. Aldaba Inclusive Date of Rotation: March 31,
2022

Year Level: BSN-2B Clinical Area Assigned: PEDIA

Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

 ADMINISTRATION OF MEDICATION: EYE DROP INSTILLATION

DEFINITION: Eye drop instillation is the dispensation of a sterile ophthalmic

medication into a patient’s eye.
OBJECTIVES:
 To combat infection
 To relieve pain and discomfort
 To dilate or constrict the pupil

EQUIPMENT/ MATERIALS USES

 Sterile solution of medication
 Small gauze squares or cotton balls
 Gloves
PROCEDURE RATIONALE

1. Check the patient’s name For proper patient identification.

2. Check physician’s directives To avoid medication error.

3. Wash hands prior to instilling To prevent transfer of microorganisms to the

medication. patient.

4. Cleanse the eyelids and lashes Prevent debris to be carried into the eye
with cotton balls or gauze pledgets when the conjunctival sac is exposed.
moistened with normal saline.

5. Use each cotton ball or pledget Prevents carrying of debris to the lacrimal
for only one stroke, moving from the duct.
inner to the outer canthus of the
eye.

6. Tilt the patient’s head back To prevent solution or tear from flowing
slightly if he is sitting or place the towards the other eye.
head over a pillow if he is lying
down.

7. Fill eye dropper with medication Loose particles of rubber from bulb end may
but prevent from flowing back into slip into medication.
the bulb end.

8. Using forefinger, pull lower lid To expose inner surface of lid and cul-de-
down gently. sac

9. Instruct patient to look upward. Prevent medication from sensitive cornea.

10. Hold the dropper close to the Touching the eyelids may startle the patient
eye but avoid touching the eyelids. and cause him to blink.

11. Allow the prescribed number of It cases unpleasant sensation to the patient
drops to fall in the lower or may injure the cornea.
conjunctival sac but do not allow to
fall onto the cornea.

12. Release the lower lid after the Squeezing or rubbing may irritate the eye
drops are instilled. Instruct the tissue or would express the medication from
patient to close eyes slowly, move the eye. Closing and moving the eye allow
the eye and not to squeeze or rub. medicines to be distributed over the eye.

13. Wipe off excess solution with Prevents possible skin irritation.
gauze or cotton balls.

14. Wash hands after instilling the Prevents transfer of microorganisms to self
medication. or to other patients.

Sources/s:
Vera, M., 2022. Eye Drop Instillation — Nursing Procedure.
Nurseslabs.https://nurseslabs.com/eye-drop-instillation-nursing-procedure/?
fbclid=IwAR3x26RePIi44XvxYJp9lJ_FUXFvowTJG1CdAzW0_SwURyoIfeMWGkUv
0u4

Name of Student: Inclusive Date of Rotation: March 31,

to
April 7,8,9 , 2022
Year Level: BSN-2A Clinical Area Assigned: PEDIA
Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

DEFINITION:
• Administration of solution containing a medication into the ear
PURPOSE:
• For the treatment of localized infection or inflammation of the ear.
• To soften earwax and to facilitate removal of foreign body.
EQUIPMENT:
• Otic or Ear drop solution
• Paper tissue Dropper provided by the manufacturer
• Penlight or otoscope
 ADMINISTRATION OF MEDICATION: EAR DROPS INSTALLATION
PROCEDURE RATIONALE
1. Check for doctor's order. Administration of medication is
dependent on the
on the order of the physician
2. Observe the 5R's drug. Observing 5R's in drug administration
Prevents error in giving medication.
a) Right patient
b) Right route
c) Right dose
d) Right frequency
e) Right time
3.Provide privacy and give To obtain client's cooperation.
thorough explanation of the
procedure
4. Perform hand hygiene. Apply to reduce the spread of microorganism
clean gloves (only if drainage is
present).
5. Place client in a position so the for thorough visualization of the internal ear.
affected ear is directed upward with
adequate lightning
6. Assess ear canal for wax Ear wax may trap the ear solution, removal
accumulation. If present get an of it may facilitate the absorption of the
order to irrigate the canal. before solution.
instilling the ear drops.
7. Allow medication to warm to Warm solution promotes comfort.
room temperature.
8. Administration of the solution. Proper instillation of the eardrops is
Observing the special essential to good response to drug therapy.
consideration. Instill only the
amount ordered. Avoid the tip of the To reach the deepest structure of the ear.
dropper to touch in the inner ear Avoid infection.

9. Have the patient remain on the Promote absorption of medication.

side for a few minutes follow
installation

10. Repeat procedures if ear drops To ensure both ear are treated.
are ordered for both ears.
11. Wash hands To reduce transmission of microorganisms.
12. Documentation. To provide accurate data in the care of
client.
Source/s:
Nursing Skills and Procedures Perry•Potter Eight Edition

Name of Student: Inclusive Date of Rotation: March 31,

2021
Year Level: BSN-2 Clinical Area Assigned: PEDIA
Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

IVF FLOW UP
DEFINITION :
OBJECTIVES:
1.
2.
3.
EQUIPMENTS/ MATERIALS USED:
 EID, IV pump
 Watch with second hand
 Calculator or paper and pen/pencil
 Tape
 Label
 Clean gloves

PROCEDURE RATIONALE
1. Perform hand hygiene. Reduces the transmission of
microorganisms.
2. Introduce yourself and explain the To establish rapport and allows time
purpose of the assessment. for patient to ask questions.
3. Confirm patient ID using two patient Ensure you have the correct patient
identifiers (e.g., name and date of birth), and complies with agency standard for
and compare the MAR printout with the patient identification.
patient’s wristband
4. Apply non sterile gloves (optional) Reduces the transmission of
microorganism.
5. Assess the IV insertion site and Ensure patient is informed to alert the
transparent dressing on IV site health care provider if they experience
pain or swelling/redness is noticeable
at the IV site. If patient is unable to
report pain at IV site, more frequent
checks are required.
6. Inspect the patient’s arm for streaking Assess complications on hand and
or venous cords; assess skin arm for signs and symptoms of
temperature. phlebitis and infiltration.
7. assess IV tubing for kinks or bends Kinks or bends in tubing may
decrease or stop the flow of IV fluids.
Ensure tubing is not caught on
equipment or side rails on bed.
8. Check the rate of infusion on the If IV solution is on gravity, calculate
primary and secondary IV tubing. Verify and count the drip rate for one minute.
infusion rate in physician orders or If solution is an IV pump, ensures the
medication administration record (MAR) rate is correct and all clamps are open
as per agency protocol. If secondary
IV medication is infusing, ensure
clamp on secondary IV tubing is open.
9. Assess the type of solution and label it Ensures the correct solution is given.
on bag. Check volume of solution in bag.
10. assist the patient into comfortable Prevents injury to the patient.
position, place call bell in reach, and put
up side rails on bed as per agency policy.
11. Perform hand hygiene. Prevents the spread of
microorganisms.
12. Document procedure and findings as Timely and accurate documentation
per agency policy. promotes patient safety.
TERMINATION :
PROCEDURE : RATIONALE:
1. Check physician order or the Prevents error in the health care
reason to remove the IV cannula settings.

2. Confirm hand hygiene and collect To prevent microorganisms. To be

supplies. prepared for the procedure.

3. Identify yourself; identify the Proper identification prevents errors.

patient using two identifies and Explaining the procedure educates
comparing the MAR to the patients and allows patient to ask
patient’s wristband; explain the questions.
procedure to the patient.

4. Perform hand hygiene and apply Preparing gauze allows for easy
clean gloves. Open up sterile access once cannula is removed.
gauze for easy access and place
close by.

5. Remove tape of extension tubing Tape must be removed prior to

removing cannula.
6. Remove transparent dressing:
 Stabilize the IV cannula Allows easy access to the site
 Loosen one edge of
transparent dressing toward To access IV site
the IV site by stretching the
dressing of direction the
 loosened .
 Loosen the other edge of
dressing and repeat
previous step.

7. If purulent drainage is present, This provides follow up data for

perform C and S swab and clean potential infection.
area with alcohol swab.

8. Hold sterile gauze above the Applying pressure to the IV site upon
insertion site; do not apply removal of the catheter is painful for
pressure. Keeping the cannula the patient. Remove catheter first,
parallel to the, pull out in a straight, then apply pressure.
slow and steady motion. Asses
catheter tip and discard cannula as
per agency policy.

9. Place sterile gauze over insertion If the patient is in coagulation therapy,

site and apply gentle pressure until extended pressure will be required to
bleeding stops, usually for 2 to 3 stop the bleeding at IV site for 5
minutes. minutes.

10. Apply sterile gauze and tape to Prevents bacteria from entering the
create occlusive dressing and old old IV site.
IV site.

11. Discard supplies, remove gloves, Prevents the spread of

and perform hand hygiene. microorganisms.

12. Document procedure as per Timely and accurate documentation

agency possibly. promotes patient safety.

Source/s:
Fundamentals of Nursing Potter / Perry / Stockert / Hall, Ninth Edition, Volume II
Name: Stephanie A. Lee Inclusive Date of duty:
March 31, April 7,8,9 2022
Year Level: BSN- 2A Clinical Area Assigned: PEDIA
Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

URINE SPECIMEN COLLECTION

Definition:
Urinalysis, in which the components of urine are identified, is part of every client
assessment at the beginning and during an illness.
Objectives:
5. To diagnose illness
6. To monitor the disease process
7. To evaluate the efficacy of treatment
Materials/Equipment to Use:
1. Laboratory form
2. Clean container with lid or cover (1): wide-mouthed container is
recommended
3. Bedpan or urinal (1): as required
4. Disposable gloves (1): if available
5. Toilet paper as required

COLLECTING A SINGLE VOIDED SPECIMEN

PROCEDURE RATIONALE

31. Explain the procedure Providing information fosters his/her

cooperation

32. Assemble equipment and check

the specimen form with client’s Organization facilitates accurate skill
name, date and content of Performance
urinalysis
Ensure that the specimen collecting is
correct

33. Label the bottle or container with

the date, client’s name, Ensure correct identification and avoid
department identification, and mistakes
Dr’s name.
34. Perform hand hygiene and put on To prevent the spread of infection
gloves

35. Instruct the client to void in a

clean receptacle. To prevent cross-contamination

36. Remove the specimen Substances in urine decompose when

immediately after the client has exposed to air. Decomposition may alter
voided the test results

37. Pour about 10-20 mL of urine Ensure the client voids enough amount
into the labeled specimen bottle of the urine for the required tests
or container and cover the bottle
or container Covering the bottle retards
 decomposition and it prevents added
contamination.

38. Dispose of used equipment or To prevent the spread of infection

clean them. Remove gloves and
perform hand hygiene
39. Send the specimen bottle or Organisms grow quickly at room
container to the laboratory temperature
immediately with the specimen
form.
40. Document the procedure in the Documentation provides coordination of
designated place care

Source/s:
FUNDAMENTAL OF NURSING PROCEDURE MANUAL

Name: Stephanie A. Lee Inclusive Date of duty:

March 31, April 7,8,9 2022
Year Level: BSN- 2A Clinical Area Assigned: PEDIA
Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

COLLECTING STOOL SPECIMEN

Definition:
Collection of stool specimen deters a process which is aimed at doing chemical
bacteriological or parasitological analysis of fecal specimen
Objectives:
1. To identify specific pathogens
2. To determine presence of ova and parasites
3. To determine presence of blood and fat
4. To examine for stool characteristics such as color, consistency and odor
Materials/Equipment to Use:
1. Laboratory form
2.Disposable gloves if available (1)
3. Clean bedpan with cover (1)
4. Closed specimen container as ordered
5. Label as required
6.Wooden tongue depressor (1-2)
7.Kidney tray or plastic bag for dirt (1)
 PROCEDURE RATIONALE

1. Assemble equipment. Label the Organization facilitates accurate skill

container. Performance

Careful labeling ensures accuracy of the

report and alerts the laboratory
personnel to the presence of a
contaminated specimen

2. Explanation: Providing information fosters his/her

1) Explain the procedure to the client cooperation
2) Ask the client to tell you when
he/she feels the urge to have a Most of clients cannot pass on
bowel movement command
3. Perform hand hygiene and put on To prevent the spread of infection
gloves if available.

4. Placing bedpan: To provide privacy

1) Close door and put curtains/ a
screen. You are most likely to obtain a usable
2)Give the bedpan when the client is specimen at this time.
ready. To gain accurate results
3)Allow the client to pass feces
4) Instruct not to contaminate
specimen with urine
.
5. Collecting a stool specimen: It is grossly contaminated
1) Remove the bedpan and assist
the client to clean if needed To gain accurate results
2) Use the tongue depressor to
transfer a portion of the feces to the It prevents the spread of odor
container without any touching
3) Take a portion of feces from three
different areas of the stool specimen
4) Cover the container
6. Remove and discard gloves. Perform To prevent the spread of infection
hand hygiene
7. Send the container immediately to Stools should be examined when fresh.
the laboratory
Examinations for parasites, ova, and
organisms must be made when the
stool is warm.

8. Document the procedure in the Documentation provides coordination of

designated place care
Source/s:
FUNDAMENTAL OF NURSING PROCEDURE MANUAL

Name of Student: Bedasua, Nidrice Inclusive Date of Rotation: March 31,

Zileon G. April 1,2,7
Year Level: BSN-2B Clinical Area Assigned: PEDIA 2
Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

DEFINITION:
A method of administering a drug by spraying it into the respiratory passages of the
patient. The medication may be given with or without oxygen to help carry it into the
lungs.

AIMS AND OBJECTIVES:

• To open the collapse alveoli and deliver medicated aerosol therapy.
• To relieve patient from having shortness of breath.
• Help expand the lungs thus loosen secretions.
• Commonly used at home on a long-term basis especially for those patients with
Chronic
Obstructive Pulmonary Disease (COPD) to dispense inhaled medication.

MATERIALS/EQUIPMENTS:
• Nebulizer machine
• Nebulizer kit/set (tubing, mouthpiece, manifold, mask)
• Syringe 3cc
• Saline solution (NSS)
• Air compressor, wall air, wall oxygen (O2 driven)
• Medication administration record
• Baffle (controls the air, helps in the convention)
• T-piece

NEBULIZATION
PROCEDURE RATIONALE
1. Check MAR against doctor's Check that MAR and doctors order are
orders. consistent. Compare physician order an
MAR. Night staff usually complete and
verify this check as well.

2. The label on the medication must Perform seven checks three times before
be checked for name, dose, and administering the medication to your
route, and compared with the MAR patient. These checks are done before
administering the medication to your
at three different times: patient. If taking drug to bedside (e.g. eye
When the medication is taken drops), do third check of bedside.
out of the drawer
When the medication is being
poured
When the medication is being
put away/or at bedside
3. Assemble nebulizer as per Assembly specific to manufacturer’s
manufacturer’s instructions. instructions ensures proper delivery of
medication.

4. Add medication as prescribed by Ensures the proper delivery of medication.

pouring medication into the nebulizer
cup.
Some medications may be
mixed together if there are no
contraindications.
Some medications may
require the addition of saline
per prescription for dilution.
5. Use a mask if patient is unable to Ensures the proper delivery of medication.
tolerate a mouthpiece, and an
adaptor specific to tracheostomies if
the patient has a tracheostomy.
6. Position patient sitting up in a Improves lung expansion and medication
chair or in bed at greater than 45 distribution.
degrees.

7. Assess pulse, respiratory rate, Assessing them determine a baseline

breath sounds, pulse oximetry, and respiratory assessment prior of
peak flow measurement (if ordered) administration of medication.
before beginning treatment.
NOTE: Attach the nebulizer to compressed air if available; use oxygen if there is
no compressed air. If patient is receiving oxygen, do not turn it off. Continue to
deliver oxygen through nasal prongs with the nebulizer.
8. Turn on air to nebulizer and This process verifies that equipment is
ensure that a sufficient mist is visible working properly.
exiting nebulizer chamber. A flow
rate of 6 to 10 L should provide
sufficient misting.
Ensure that nebulizer
chamber containing
medication is securely
 fastened.
Ensure that chamber is
connected to face mask or
mouthpiece, and that
nebulizer tubing is connected
to compressed air or oxygen
flowmeter.
9. If mouthpiece is being used, Sealed lips ensure proper inhalation of
ensure lips are sealed around medication.
mouthpiece.
10. Have patient take slow, deep, This maximizes effectiveness of
inspiratory breaths. Encourage a medication.
brief 2- to 3-second pause at the end
of inspiration, and continue with
passive exhalations.
Note: If patient is dyspneic,
encourage holding every fourth or
fifth breath for 5 to 10 seconds.
11. Have patient repeat this Maximizes the effectiveness of medication.
breathing pattern until medication is
complete and there is no visible
misting. This process takes
approximately 8 to 10 minutes.
12. Tap nebulizer chamber This action releases drops of medication
occasionally and at the end of the that cling to the side of the chamber.
treatment.

13. Monitor patient’s pulse rate Beta – adrenergic bronchodilators have

during treatment, especially if beta- cardiac effects that should be monitored
adrenergic bronchodilators are being during treatment.
used.

14. Once treatment is complete, turn This promotes patient comfort and safety.
flowmeter off and disconnect
nebulizer.
15. Rinse, dry, and store nebulizer Proper care reduces the transfer of
as per agency policy. microorganisms.

16. If inhaled medication included Rinsing removes residual medication from

steroids, have patient rinse mouth mouth and throat, and helps prevent oral
and gargle with warm water after candidiasis related to steroid use.
treatment.
 17. Once treatment is complete, Treatments are often prescribed specifically
encourage patient to perform deep to encourage mucous expectoration.
breathing and coughing exercises to
help remove expectorate mucous.
18. Return patient to a comfortable This promotes patient comfort and safety
and safe position.
19. Perform hand hygiene. Prevents the transfer of microorganisms

20. Document treatment as per Accurate and timely documentation and

agency policy, and record and report reporting promote patient safety.
any unusual events or findings to the
appropriate health care provider.

Source/s:
BCIT, 2015; Lilley et al., 2011; Perry et al., 2014

Name: Jobelie R. Bodiongan Inclusive Date of duty: March 31, April

1,2,7
Year Level: BSN- 2A Clinical Area Assigned: PEDIA 2
Assigned Clinical Instructor: Juvy L. Lagcao, RN, MN

INDWELLING URINARY CATHETERIZATION

Definition:
Also known as a Foley catheter, an indwelling urinary catheter remains in the bladder to
provide continuous urine drainage. A balloon inflated at the catheter’s distal end prevents
it from slipping out of the bladder after insertion.
Objectives:
1. To withdraw urine and monitor urinary output
2. To provide relief of discomfort from bladder distention or urinary retention /
decompression of the bladder
3. To empty the bladder before and during surgery where general or spinal anesthesia is
used and before certain diagnostic examinations
Materials/Equipment to Use:

INSERTION REMOVAL
1. Double-Lumen Catheter 1. Dressing pack containing
2. Drapes paper towel, swabs and
3. Lubricant gallipot;
4. Cleansing solution incorporated in an 2. Kidney dish to receive the
applicator or to be added to cotton balls catheter;
(forceps to pick up cotton balls) 3. Syringe for deflating the
 5. Prefilled syringe with sterile water for balloon (usually a 10ml
balloon inflation syringe);
6. Sterile drainage tubing bag 4. Disposable gloves and apron
7. Sterile gloves 5. Cleansing solution, for example
8. Specimen Container 0.9% sodium chloride.

PROCEDURE RATIONALE
1. Checkphysician’s order for Catheterization is a dependent nursing
catheter insertion. action.
2. Check patient’s identification band. To ensure that the patient has a good
Explain and discuss the procedure with understanding of the procedure and
the patient and gain consent. gives informed consent.

Provide opportunity to ask questions To elicit cooperation.

3. Assess for bladder fullness and pain by Palpation of a full bladder will cause an
palpation. urge to void and/or pain.

Check current medications and any Assess the patient to prevent medication
known allergies. reaction.
4. Perform hand hygiene To reduce the transmission of
microorganism.
5. Provide privacy by closing the curtains To prevent feeling of embarrassment and
or doors discomfort.
6. Raise bed to appropriate working height. Promotes good body mechanics. Use of
If side rails in use: side rails in this manner promotes patient
• Lower the working side safety.
• Close the opposite side
7. Place waterproof pad under patient. Prevents soiling of bed linen.
8. Positioning the patient depends on Patient should be comfortable, with
gender. perineum or penis exposed, to ensure
accessibility and to maintain dignity and
For female patient: On back with knees comfort.
flexed and thighs relaxed so that hips
rotate to expose perineal area.

For male patient: Supine position with

legs extended and slightly apart.

9. Place a blanket or sheet to cover patient This step helps protect patient dignity.
and expose only required anatomical
areas.
10. Provide perineal hygiene if needed Hygiene before catheter insertion
(apply clean gloves, complete cleansing, removes secretions, urine, and feces that
discard gloves and perform hand could contaminate the sterile field and
hygiene). increase risk for catheter-associated
urinary tract infection (CAUTI).
11. Ensure adequate lighting. Adequate lighting helps with accuracy
and speed of catheter insertion.
12. Arrange equipment to provide Placing equipment in order of use
convenience and to avoid having to increase speed of performance.
reach over sterile field. Reaching over sterile items increases the
risk of contamination.
13. If using indwelling catheter and closed Urinary bag should be closed to prevent
drainage system, attach urinary bag to urine drainage leaving bag.
the bed and ensure that the clamp is
closed.
14. Drape patient with drape found in The outer 2.5 cm is considered non-
catheterization kit only touching the sterile on a sterile drape.
outer edges of the drape. Ensure that
any sterile supplies touch only the
middle of the sterile drape (not the
edges), and that sterile gloves do not
touch non-sterile surfaces. Drape patient
to expose perineum or penis.
To reduce the transmission of
15. Perform hand hygiene then apply
microorganism.
sterile gloves using sterile technique.

16. Check balloon inflation using a sterile

This maintains sterility of catheter.
syringe.
17.Place sterile tray with catheter between Sterile tray will collect urine once
patient’s legs. catheter tip is inserted into bladder.
18. Clean perineal area as follows.

Female patient: Separate labia with fingers Optimal visualization of urethral meatus
of non-dominant hand (now is possible.
contaminated and no longer sterile).
Using sterile technique and dominant Front-to-back cleansing is cleaning from
hand, clean labia and urethral meatus area of least contamination toward highly
from clitoris to anus, and from outside contaminated area. Dominant gloved
labia to inner labial folds and urethral hand remains sterile.
meatus. Use sterile forceps and a new
cotton swab with each cleansing stroke.

Male patient: Gently grasp penis at shaft Positioning penis at this 90-degree angle
and hold it at right angle to the body to patient straightens out curvature of
throughout procedure with non-dominant male urethra and eases insertion
hand (now contaminated and no longer
sterile). Using sterile technique and Circular cleansing pattern follows
dominant hand, clean urethral meatus in principles of medical asepsis
a circular motion working outward from
meatus. Use sterile forceps and a new
cotton swab with each cleansing stroke.

19. Pick up catheter with sterile dominant Holding catheter closer to the tip will help
hand 7.5 to 10 cm below the tip of the to control and manipulate catheter during
 catheter. insertion.
20. Lubricate tip of catheter using sterile Lubrication minimizes urethral trauma
lubricant included in tray, or add and discomfort during procedure.
lubricant using sterile technique.

21. Insert catheter as follows.

Female patient: This process helps visualize urethral
 Ask patient to bear down gently (as if meatus and relax external urinary
to void) to help expose urethral sphincter.
meatus.
 Advance catheter 5 to 7.5 cm until
urine flows from catheter, then
advance an additional 5 cm.

Male patient:
 Hold penis perpendicular to body and
pull up slightly on shaft.
 Ask patient to bear down gently (as if
to void) and slowly insert catheter
through urethral meatus.
 Advance catheter 17 to 22.5 cm or
until urine flows from catheter.

22. Place catheter in sterile tray and collect Urine specimen may be required for
urine specimen if required. analysis. Collect as per agency policy.
23. Slowly inflate balloon for indwelling The size of balloon is marked on the
catheters according to catheter size, catheter port.
using prefilled syringe.

24. After balloon is inflated, pull gently on Moving catheter back into bladder will
catheter until resistance is felt and then avoid placing pressure on bladder neck.
advance the catheter again.

25. Connect urinary bag to catheter using Keep urinary bag below level of patient’s
sterile technique. bladder.
26. Secure catheter to patient’s leg using Securing catheter reduces risk of CAUTI,
securement device at tubing just above urethral erosion, and accidental catheter
catheter bifurcation. removal.

Female patient: Secure catheter to inner

thigh, allowing enough slack to prevent
tension.
For male patients, leaving the foreskin
Male patient: Secure catheter to upper thigh retracted can cause pain and edema.
(with penis directed downward) or
abdomen (with penis directed toward
chest), allowing enough slack to prevent
tension. Ensure foreskin is not retracted.
27. Dispose of supplies following agency This reduces the transmission of
policy. microorganisms.
28. Remove gloves and perform hand This reduces the transmission of
hygiene. microorganisms.
29. Document procedure according to Timely and accurate documentation
agency policy, including patient promotes patient safety.
tolerance of procedure, any unexpected
outcomes, and urine output.

REMOVAL OF INDWELLING FOLEY CATHETER

1. Review medical order for removal of Premature removal of catheter inpatients

catheter. In cases of genitourinary who have undergone GU surgery could
surgery, it is especially important to injure patient.
obtain an order.

2. Perform hand hygiene, put on clean Procedure requires use of medical asepsis.
gloves, and provide privacy

3. Prepare the patient:

(a) Provide an explanation of procedure. Prepares patient to minimize anxiety.

(b) Position patient with waterproof pad Shows respect for patient dignity by only
under buttocks and cover with bath blanket, exposing genital area and catheter.
exposing only genital area and catheter.
Position females in dorsal recumbent
position and male patients in supine
position.

(c) Remove catheter securement device

and free drainage tubing.

4. If needed provide hygiene of genital area Antiseptic cleaners have not been proven
with soap and water. to
decrease risk for CAUTI.
5. Move syringe plunger up and down to Partially inflated balloon can traumatize
loosen and then withdraw plunger to 0.5 urethral wall during removal.
mL. Insert hub of syringe into inflation Passive drainage of catheter balloon will
valve (balloon port). Allow balloon fluid to prevent formation of ridges in balloon.
drain into syringe by gravity. Make sure These ridges can cause discomfort or
that entire amount of fluid is removed by trauma during removal.
comparing removed amount to volume
needed for inflation.

6. Pull catheter out smoothly and slowly. Promotes patient comfort and safety.
Examine it to ensure that it is whole.
Catheter should slide out easily. Do not
 use force. If you note any resistance,
repeat Step 5 to remove remaining water.
Notify health care provider if balloon does
not deflate completely.

7. Wrap contaminated catheter in Prevents transmission of microorganisms.

waterproof pad. Unhook collection bag
and drainage tubing from bed.

8. Reposition patient as necessary. Provide

hygiene as needed. Lower level of bed
and position side rails accordingly.
9. Empty, measure, and record urine Records urinary output.
present in drainage bag. Discard in Reduces transmission of microorganisms.
appropriate receptacle. Remove and
discard gloves.
Perform hand hygiene

10. Encourage patient to maintain or Maintains normal urine output.

increase fluid intake (unless
contraindicated).

11. Initiate voiding record or bladder diary. Evaluates bladder function.

Instruct patient to report when urge to
void occurs and that all urine needs to be
measured. Make sure that patient
understands how to use collection
container.

12. Ensure easy access to toilet, bedpan, or

urinal. Place urine “hat” on toilet seat if
patient is using toilet. Place call bell
within easy reach.