Abdomen [5min] (IAPP) INSPECTION Have patient void before exam.

. Inspect from side and foot of bed Assess the abdomen. Note size, shape and symmetry and condition of skin Note abdominal movement: respiratory, pulsations and peristalsis Note position, contour, color and herniation of umbilicus AUSCULTATION Auscultate for bowel sounds in each quadrant Use scratch test to locate inferior edge of liver Auscultate for bruits over aorta, renal, iliac and femoral arteries PERCUSSION Percuss abdominal organs: liver, gallbladder, spleen, kidneys and bladder Notes areas of tympany, dullness or tenderness Percuss for costovertebral angle - Place nondominant hand over organ - Make fist with dominant hand - Note any tenderness - If indicated, use blunt percussion to assess for organ [liver or gallbladder] tenderness PALPATION Palpate all four quadrants beginning with a light palpation, then go deep bimanual palpation If indicated, assess for rebound tenderness at Mcburneys point, the Illopsoas test, and the Obturator test Test abdominal reflexes by lightly stroking each quadrant toward the umbilicus Palpate for inguinal lymph nodes - Use light palpation; palpate horizontal and vertical inguinal nodes. Note size, shape, consistency, tenderness, and mobility. Chest [5min] (IPPA) INSPECTION Anterior/ posterior or lateral. Compare side to side. Work apex to base Assess respiratory rate and rhythm, depth, symmetry for chest movement Assess AP ratio, costal angle, spinal deformities, muscles for breathing and condition of skin PALPATION Anterior/ posterior or lateral. Compare side to side. Work apex to base Palpate the trachea Palpate the chest for abnormalities

Assess chest excursion Assess for tactile fremitus PERCUSSION Percuss anterior / posterior or lateral portion of the chest Note general percussion sound of chest AUSCULTATION Use diaphragm of stethoscope. Have patient take slow, deep breaths through the mouth Assess anterior/ posterior or lateral. Compare side to side. Work apex to base Unoccupied Bed making [3min] Place bottom sheet with centerfold in the center of the bed. Place protective pad Place the draw sheet Tuck bottom sheet under head of mattress, making a mitered corner. Tuck the rest of the sheet. Move to other side of the bed to secure the sheet and tuck in Place top sheet on bed with its centerfold in the center of the bed (top sheet is even with the head of the bed) Tuck top sheet under foot in the bed, miter corners. Place pillow on bed Fan fold Wound Care [3min] Assist pt to comfortable position with easy access to wound Remove old dressing using sterile normal saline solution Note presence, amount, color, odor, drainage Put sterile gloves Clean wound using sterile cleaning solution (inner to outer) Apply layers of dressing Remove, discard gloves. Secure dressing with plaster. Label dressing. Remove all remaining equipment. Blood Transfusion [5mins] Obtain blood product, check for - ABO group & Rh type - Amount - Serial number - Expiration date - VDRL Verify clients identity Hand hygiene. Put on gloves. Prepare blood bag. Invert several times to mix cells with plasma

 Prepare blood set. Close clamp. Attach gauze 18/19 needle with cap at adaptor of the blood set Expose port of bag by pulling back of tab and insert piercing pin (spike) Hang the bag. Open clamp. Squeeze filter chamber, allow blood to flow until the needle then close the clamp Clamp primary IV line of PNSS near Y-port Disinfect Y-port. Uncap G18 needle, attach to Y-port. Secure with plaster Open clamp of blood set, run blood slowly for 1st 15min @ KVO rate Observe client for 5-10mins. If no reaction, regulate according to physicians order Male Catheterization [5min] Provide privacy Position pt on his back with thighs slightly apart Do draping exposing penis Don gloves, clean penile area with downward strokes Lubricate catheter, insert tip into meatus Inflate balloon, gently pull until resistance is felt Attach catheter to drainage bag Anchor catheter to upper thigh with penis directed towards patients chest Make patient comfortable, after care Female Catheterization [5min] Provide privacy Dorsal recumbent, knees flexed Do diagonal draping with bath blanket Perineal care with downward strokes Put sterile gloves, lubricate, insert catheter tip into meatus Inflate balloon, gently pull until resistance is felt Attach catheter to drainage bag Anchor catheter to inner aspect of thigh Make pt comfortable, after care Tube Feeding [3min] Explain procedure to pt

Assemble equipment Hand hygiene Position head of bed 30 to 45 Remove cap of NG tube, kinking the tube itself, connect asepto syringe with its bulb Check for patency and placement of tube Aspirate for gastric contents, inspect, check acidity and pH return to stomach Auscultate gurgling sound Pour feeding into asepto syringe, administer to pt After feeding, flush 30-60cc of water When empty, kink tube & disconnect asepto syringe Cap NG tube remain in upright position for @ least 30min to 1 hour After care, hand hygiene Intramuscular Injection [3min] Assemble equipment, check doctors order Explain procedure to pt Hand hygiene If necessary, withdraw med from ampule/vial Do not add air syringe Privacy, have pt assume a position Locate site of choice. Don disposable gloves Clean area with antimicrobial swab, allow alcohol to dry Remove needle cap by pulling it straight off Displace skin Z-tack manner by pulling one side or by spreading skin using nondominant hand Hold syringe between thumb and forefinger. Quickly dart into tissue @ 90 angle Use nondominant to hold lower end of syringe; slide dominant to tip of barrel Aspirate slowly pulling back plunger Remove needle Apply gentle pressure with dry cotton ball Do not recap used needle, discard in appropriate receptacle Assist pt to position of comfort Remove gloves, dispose. Hand hygiene Chart administration of med include site of administration Suctioning Endotracheal Tube [3min]

 Explain procedure to pt & reassure that you will interrupt procedure if pt indicates respi difficulty Gather equipment, provide privacy for pt Hand hygiene Assist pt to semi-fowlers or fowlers Turn suction in appropriate pressure Place clean towel, across pts chest Open sterile kit equipment & prepare to suction Keeping catheter wrapped around sterile hand, remove ventilator from Endotracheal tube with nonsterile hand Hyperventilate with manual resuscitation bag 3-5times, keep catheter sterile, gently insert catheter into the endotracheal tube, advancing until pt coughs or resistance is met. Do not occlude Y-port Apply intermittent suction by occluding Y-port with thumb of unsterile gloved hand. Gently twist catheter as being withdrawn. Do not allow suctioning continue for more than 10seconds Flush catheter with saline and repeat as needed. Allow pt to rest@ least 30 sec -1min. Reconnect ventilator and hyperoxygenate with AMBU bag 3-5 times between suctioning When procedure is completed, turn of suction and disconnect catheter from suction tubing. Remove gloves inside and out then dispose. Hand hygiene Adjust pts position. Auscultate chest to evaluate breath sounds Record the time of suctioning and the nature and amount of secretions, note character of pts respi before and after suctioning.