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4. Hands over sensitive information about patient at the nurse's office e.g. condition of
patient
7. Checks with incoming staff that gadgets on patients are functioning e.g. cardiac
monitor, intravenous line, oxygen flow meter etc.
8. Checks and hands over controlled drugs and any other relevant resources available
9. Hands over ward annexes for in-coming nurse to ensure they are clean
10. Reports on any defects on equipment and requests made for urgent repairs
11. Reports on departmental instructions and other important information in the ward
diary
2. Asks for oral information on major happenings on the ward from the outgoing nurse
5. Takes over ward from bed to. bed verifying the state of a" patients; especially very ill
patients
6. Establishes rapport with patients during taking over and asks about state of health
8. Ensures resources needed for work are available and adequate and takes over controlled
drugs
REQUIREMENT ON TROLLEY
COMPONENT TASK
1. Welcomes patient and relatives to the nurses’ station and makes them comfortable.
Introduces herself and any staff present.
2. Collects necessary documents, admission notes and any other information from the
accompanying nurse.
3. Identifies and confirms patient’s name, particulars and reassures him.
4. Sends patient to bedside and introduces him to other patients near him.
5. Checks vital signs and record and collects specimen if ordered
6. Administers urgent prescribed drugs if ordered.
7. Assist patient to change into his night dress or pyjamas.
8. Takes care of the patient’s valuable according to the institutions policy.
9. Let patient or legal guardian sign a consent form for treatment etc. Where necessary.
10. Explains national health insurance system to patient and relatives.
11. Informs relatives about visiting time and allows them to see patient and say goodbye
12. Orientate patient to ward and its annexes
13. Uses the nursing process to plan care
14. Enter patients name into the admission and discharge book and onto the ward state
and document in the nurses’ notes.
COMPONENT TASK
Requirement
Ward state
COMPONENT TASK
1. Establishes rapport and explains the need for education on condition to patient
2. Makes patient comfortable either sitting or lying down
3. Sits comfortably by patient's side
4. Ensures enabling and relaxed environment and maintains privacy
6. Builds on what the patient knows with scientific data of condition in language
that patient understands
8. Ensures patient understands the teaching and co-operates with health team
REQUIREMENTS
COMPONENT TASK
COMPONENT TASK
1. Collects, arranges items on trolley and sends to bedside
2. Arranges items in order of use on a chair or heart table
3. Places bottom sheet evenly on the bed
4. Tucks the sheet evenly under the mattress at the top and bottom corners
5. Places draw mackintosh across bed and covers with draw sheet
6. Places long mackintosh on the bed
7. Uses one bath blanket or sheet over and tucks in all around or folds under itself
8. Places second bath blanket over the bed
9. Puts in hot water bottles if necessary
10. Puts on top bed clothes
11. Places counterpane loosely over the top bed clothes
12. Tucks in the bed clothes on the other side
13. Folds the bed clothes on the other side nearest to the door, leaving it open to facilitate
quick admittance.
REQUIREMENTS
COMPONENT TASK
1. Explains the need for education to patient.
2. Make patient comfortable either sitting or lying down.
3. Sit comfortable by patient’s side.
4. Ensures enabling and relaxing environment to maintain privacy and individuality of
patient.
5. Find patients level of awareness of condition/diet.
6. Build on what the patient knows with scientific data on condition and in a language
that patient understands.
7. Explain to patient the rational for treatment and possible outcome.
8. Ensure patient understand the teaching and cooperate with the health team.
9. Allows patient to ask question for clarification.
10. Provides patient with clear simple pamphlet if available.
11. Thank patient and document education.
REQUIREMENTS
Requirement on trolley
bed sheet
draw sheet and draw mackintosh
COMPONENT TASK
1. Explain procedure to patient and ensure privacy.
2. Collects and arranges items on trolley.
3. Arranges sheets in order of use on chairs or heart table.
4. Loosen sheets at side of bed leaves patient with only one pillow and covers her with
top sheet.
5. Turns patient to one side of the bed supported by another nurse and draws mackintosh
and sheet.
6. Rolls dirty bottom sheet under patient.
7. Covers the bed with a clean rolled bottom sheet half way in the middle of the bed.
8. Put on draw mackintosh and draw sheet across bed tucking in greater part nearest to
the door.
9. Removes dirty bottom sheet and places it in a receptacle.
10. Pull tight and tucks in bottom sheet.
11. Covers patient with top sheet and bed cover, leaves him comfortable.
12. Clears equipment and removes screen.
13. Washes and dry hands.
REQUIREMENT ON TROLLEY
Top shelf
A bowl or basin
2 jugs (one containing cold water and the other hot water)
Soap in a soap dish
A face towel
Two medium size towel or a large towel
Sponge
A pail
Pomade, powder
Hair Comb or brush
Mirror
Lower Shelf
COMPONENT TASK
1. Explain procedure to the patient and provide privacy.
2. Prepare and take trolley to bed side.
3. Offers bed pan or urinal if required
4. Loosens and removes top bed clothes and arranges on a chair / bed table.
5. Removes patients’ cloths and covers him with a bath sheet/ cloth.
6. Protect bed and pillow with long Macintosh/ plastic sheet and draw sheet.
7. Maintain individuality of patient by asking him if he would like soap on the face,
temperature of water or if he will like to clean the gentalia himself.
8. Washes rinses and dry patients face beginning from the inner to the outer canthus of each
eye.
9. Washes rinses and dries the rest of the face, ears and neck.
10. Washes and rinses and dries patients arm farther away from the nurse, then washes, rinses
and dries patients arm near to the nurse.
11. Washes rinses and dries the chest and abdomen paying attention to the skin folds.
12. Washes rinses and dries the legs in the same way as the arms.
13. Turns patient on his side and washes, rinses and dries the back.
14. Examines and treat pressure areas.
15. Changes bottom linen and rolls patient on his back.
16. Cleans patients genitalia (performs vulva toileting if a female).
17. Groom and dresses patient in clean clothes.
18. Makes patients comfortable and thanks him.
19. Discards trolley, washes and dries hands properly.
20. Document procedure and reports abnormalities.
COMPONENT TASK
TEPID SPONGING
Requirement on trolley
A bowl
2 jugs ( on for hot and the other for cold water)
Six flannels ( 0r face towels)
A temperature tray
Long mackintosh and bath blankets
A receiver for used water
REQUIREMENTS ON TRAY
COMPONENT TASK
REQUIREMENTS ON TRAY
Two gallipots ( for mouth cleaning lotion and cotton wool or gauze )
Bottle containing the mouth cleaning lotion ( e.g. normal saline, sodium bicarbonate,
weak strength of hydrogen peroxide, maxolon mouthwash)
Padded Spatula
Mouth gag
Artery, sponge or dressing forceps
Dissecting forceps
Bowl for dentures
Glycerine or Vaseline
Receiver for used swabs
Orange sticks (toothpick)
COMPONENT TASK
1. Explain procedure to patient and provide privacy
2. Prepare a tray and takes it to the patient’s bedside
3. Put patient in a suitable position
4. Protects patients’ gown and bed linen with mackintosh and towel.
5. Pour lotion into gallipots washes and dry hands.
6. Cleans lips and outer part of teeth. Opens mouth with padded spatula.
7. Inspect mouth for any abnormality and remove dentures.
8. Take swab with forceps dip into cleansing lotion and squeeze out excess.
9. Cleans mouth thoroughly but gently, i.e. from inside the cheeks, both sides of the gum,
tongue and palate changing swabs frequently.
10. Controls movement of the tongue with spatula.
11. Uses tooth pick to clean in between of teeth.
12. Cleans mouth with water or any mouth wash.
13. Cleans lips and applies Vaseline.
14. Make patient comfortable in bed and removes screen.
15. Discard tray, decontaminates, washes and sterilizes instruments.
16. Washes hands and documents procedures and findings.
REQUIREMENTS ON TROLLEY
Gallipot containing cotton balls to plug the ears and protect the eyes
A long mackintosh
A mackintosh and towel
A pail
Hair comb
Shampoo
2 jugs for hot and cold water
A basin/bucket
A receptacle for used water
Towel
Hair drier
Hair cream
COMPONENT TASK
1. Explain procedure t patent and provide privacy.
2. Prepare and send trolley to bed side.
3. Puts patient in a suitable position.
4. Arrange long mackintosh into a trough, fashion under the patients’ shoulders neck and
head and extend it down into a bowl or bucket.
5. Covers mackintosh with a bath towel under the patients’ shoulders, neck and around the
shoulders.
6. Combs, removes tangles, wet hair and applies soap/ shampoo.
7. Massages hair well, rinse and repeats till clean.
8. Wipes any moisture around the eyes, face and neck.
9. Squeezes hair gently and ties hair up in a towel and dries thoroughly with a towel or hand
drier.
10. Applies pomade, combs and styles hair to patients liking.
11. Remove mackintosh and towel and leaves patient dry and comfortable in bed.
12. Discard trolley, washes and dries hands.
13. Document procedure and report findings.
SHAVING A BEARD
1. Explains procedure to patient
2. Sends tray to bedside or place of treatment
3. Provides privacy when necessary
4. Gathers the equipment the patient prefers to use and modifies any equipment for potential
safety hazard
5. Places patient in a sitting up position
6. Covers patients with protective clothing
7. Determines the patient's usual shaving routine
8. Inspects the face for elevation moles, birthmarks or lesions
9. Lather the face with shaving cream or soap
10. Washes and hands
11. Using short strokes with razor, shaves in the direction or the hair growth
12. Starts from the upper face and lip and extend to the neck
13. Instructs patient to tilt his head to help shave in hollow or curved areas
14. Uses the hand without the razor to pull the skin below the area being shaved
15. Rinses the razor after each stroke.
TASK: TREATMENT OF PRESSURE AREAS
REQUIREMENTS ON TROLLEY
Top shelf
A bowl or basin
2 jugs (one containing cold water and the other hot water)
Soap in a soap dish
towel
Sponge
Barrier cream (Zinc oxide,/powder )
Lower shelf
Receiver for used water
Bath blanket and a long mackintosh or bed sheet and long mackintosh
Patient garment
Receptacle for soiled linen
In the absence of a trolley, cardiac table or a bed side locker can be used.
COMPONENT TASK
REQUIREMENTS ON TROLLEY
COMPONENT TASK
REQUIREMENTS
TRAY ONE
COMPONENT TASK
COMPONENT TASK
1. Washes hands and prepares meal tray with food, spoon, jug of drinking water, cup
and napkin.
2. Tell patient she wants to feed him and offers a bedpan if required.
3. Put patient in a comfortable position, washes and dries hands.
4. Give patient a mouth wash.
5. Brings food in a tray to patient’s bedside and protects clothing with napkin.
6. Places herself in a comfortable position and ask patient if prayer is preferred.
7. Take food by spoon in small bits into patient’s mouth.
8. Allows patient time to chew and swallow.
9. Repeats step 7-8 until patient is satisfied.
10. Give water intermittently as required by patient or gives water after feeding.
11. Cleans patient’s lips and gives a mouth wash.
12. Removes napkin and makes patient comfortable.
13. Congratulates patient and discards tray.
14. Washes hands and documents on nurses notes.
ADMINISTRATION OF MIXTURE
COMPONENT TASK
Requirement on tray
Medication
Bib or protective towel
Napkin
Medication cup
Measuring cup
Spoon
Jug of water
Cup
medication chart/treatment sheet/ patients folder
1. Identifies and checks for the right patient, right drug and right time, dose and route
2. Establishes rapport, explains procedure to patient and sends tray to bedside
3. Identifies patient by mentioning the name and checks with treatment sheet.
4. Reads and compares the label on the bottle with patient's treatment sheet
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5. Shakes the bottle well
6. Removes the cork and holds it with the little or ring finger, compares label on the bottle a
second time with patient's treatment sheet
7. Picks the medicine glass and with the thumb nail marks the level of the measure to be
taken
8. Pours out the prescribed dose at eye level in bright light, holding the bottle with the label
upper most
9. Replaces the cork, reads the label a third time, compares with patient's treatment sheet
and dose in the glass
10. Carries medicine to the patient on a tray or saucer, a teaspoon may be added for stirring if
it is a suspension
11. Supervises patient to drink the medicine and serves water if necessary
12. Congratulates patient and makes him comfortable in bed
13. Discards tray, washes and dries hands
14. Documents procedure and signs treatment sheet
REQUIREMENTS ON TRAY
COMPONENT TASK
1. Identifies patient by mentioning the name and checks treatment sheet against doctors’
order.
2. Explain procedure to patient and sends tray to the bed side.
3. Check for the right patient, right drug, right time and right dose.Ensures patients right
to know/consent and right to refuse.
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4. Read the label on the container and compare with patients treatment sheet.
5. Assesses patients’ condition and level of consciousness and checks vital signs where
necessary. e.g. digoxin.
6. Remove lid of container, check label on container and compares with patients’
treatment sheet for the third time.
7. Pours out water into a drinking glass or cup.
8. Take the tablet with a spoon.
9. Gives the tablet to the patient and ensure that patient swallows it.
10. Congratulates patient and makes him comfortable in bed.
11. Discards tray, washes and dries hands.
A tray containing
Medication
Mackintosh and dressing towel
Receiver
Folder and medication sheet and nurses notes
gallipot containing water
gallipot containing cotton wool
gloves
1. Identifies patient by mentioning the name and checks treatment sheet against doctor's
order
2. Establishes rapport and explains procedure to patient and encourage him to empty bowel
3. Sends tray to bedside, provides privacy and clean anal area with water and cotton wool
swabs
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6. Protects bed with dressing mackintosh and towel at the buttocks
7. Assists patient to a left lateral or left Sim's position, with the upper leg flexed
9. Removes medication, checks label and compares with patient's treatment sheet the third
time
11. Unwraps the suppository, lubricate the smooth rounded end with gloved index finger
12. Encourages the patient to relax by breathing through the mouth presses the patient's
buttocks together for few minutes
13. Asks the patient to remain in the left lateral or supine position at least for five (5) minutes
or according to manufacturer's instruction
Washes and dries hands, and sets trolley with the following items:
Top Shelf
Bottom Shelf
1. Infusion bottle/bag
2. Giving set
3. Sterile syringe and needles
4. Infusion stand
5. Scalp vein needle/right size of cannula
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6. Strapping and scissors
7. Sterile glove pack
8. Cleansing agent e.g. methylated spirit or povidine
9. Protective mackintosh
10. Tourniquet/sphygmomanometer
11. Receiver for used swabs
12. Bottle holder
13. Intake and output chart
REQUIREMENT
A tray containing
An ampule/vial
Diluent
Gallipot containing swabs
Gallipot with a lid or container with antiseptic solution
Syringe
Needle
receiver
1. Identifies and checks for the right patient, right drugs, right route and right time
2. Establishes rapport, explains procedure to patient and provides privacy
3. Prepares and takes tray to patient's bedside
4. Checks details again with patient's treatment sheet
5. Washes and dries hands
6. Assembles syringe and needle using aseptic technique
7. Files and breaks ampoule or removes metal cap of vial with a clean swab, draws
drug and discards ampoule or vial
8. Replaces needle with a new one and expels air (if drawn from a vial)
9. Assists patient into a comfortable position and exposes site for injection
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10. Cleans site with swab dipped in antiseptic lotion (upper outer quadrant of buttocks if
buttocks is used and outer aspect if thigh is used)
11. Inserts the needle quickly and firmly deep into the muscle at right angle
12. Withdraws piston a little to ensure needle is not in a blood vessel
(if blood appears withdraws needle, and repeat step 10)
13. Pushes to release drug into the tissue
14. Withdraws the syringe and needle quickly and with a swab gently applies pressure
to the site of injection
15. Discards syringe and needle into a "safety box" or container
16. Thanks patient and leaves him comfortable in bed
17. Washes and dries hands, signs treatment sheet and documents any findings
REQUIREMENT
A tray containing
An ampule/vial
Diluent
Gallipot containing swabs
Gallipot with a lid or container with antiseptic solution
Syringe
Needle
receiver
2. Checks the physician's order for the type of medication and the ten rights
of drug administration
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4. Washes hands, reconstitutes and examines for cloudiness, sediments
Draws medication and expels air from the barrel of the syringe
5. Protects bed linen with a dressing mackintosh and towel and positions patient
comfortably
6. Washes hands, wears gloves and cleans entry port of cannula with
methylated spirit and cotton wool swab
7. Fixes syringe into the empty port of cannula and pushes medication slowly
using the push-stop-push-stop technique till administration is completed whiles observing
patient.
11. Removes dressing mackintosh and towel and discards used items
12. Washes and dries hands and record procedure on treatment chart and on the.
nurses notes
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Gallipot containing swab
Gallipot/ container containing methylated spirit
1. Establishes rapport and explains procedure and its purpose to patient and
reassures him
2. Checks the physician's order for the type of solution and checks the rights of drug
administration
3. Ensures quality of the infusion (checks for cloudiness, sediments, other particles
and expiry date) Sends prepared trolley and other equipment to the patient's
bedside
4. Encourages patient to use bedpan and checks vital signs
5. Selects and inspects sites and shave if necessary
6. Places infusion stand at the side of the bed and prepares plaster strips/tape
7. Inserts the piercing needle of giving set into the rubber seal of the infusion
bag/bottle and hangs the bottle/bag on the drip stand
8. Makes patient comfortable in bed and instructs him to notify nurse
when there is a problem
9. Checks infusion rate accuracy after 5 minutes and continue to observe the
site of insertion for swelling
10. Thanks patient, discards tray, washes and dries hands
11. Records time of setting up, type and amount of fluid on the intake and
output chart
12. Documents procedure on nurses notes
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7. Informs the nurse in charge/doctor immediately if amount of output is greater than the
amount taken in or when there is abnormally low output.
REQUIREMENT ON TROLLEY
Top shelf
A bowl
A jug of water
Soap in a soap dish
A towel
Toilet roll
Disposable gloves
Draw sheet and mackintosh( this is brought along so that in a situation where the draw
sheet in place gets soiled it can be replaced)
Bottom shelf
COMPONENT TASK
1. Provide privacy
2. Bring a covered bedpan to the bed side and explain procedure to the patient
3. Stand at the right side of the bed with assistant on the other side
4. Lift patient with the assistant onto bedpan
5. Lift patient again with assistant to remove the bedpan after use , cover the bed pan
immediately
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6. Cleans patient
7. Arrange bed clothes and leave patient comfortable in bed
8. Allow patient to wash hand with soap and water and dry hands
9. Take bed pan to the sluice room and inspect content before emptying it.
10. Measure urine if any and when necessary and records.
11. Empties bed pan and decontaminates, washes and sterilises it.
12. Washes and dries hand and removes screen
13. Documents procedure and reports any abnormalities
COMPONENT TASK
Requirement of trolley
(Just as that for serving a bed pan)
Plus a specimen container
Request form
Spatula
1. Explains procedure to the patient and parent if child and provides privacy
2. Sets trolley and sends it to patient's bedside with stool specimen container
3. Washes and dries hands and puts on gloves and serves' bedpan.
4. Leaves patient till he has finished
5. Assists to clean up and removes bedpan and covers immediately
6. Allows patient to wash and dry hand
7. Thanks patient and make him comfortable
8. Uses wooden spatula to take most representative stool specimen from the bedpan,
including mucus, blood, pus if any into the specimen container and covers it
9. Wraps the wooden spatula in paper towel and discards.
10. Disposes stool, decontaminates bedpan and removes disposable gloves and Discards
11. Washes and dries hand
12. Document procedure and findings
13. Reports any abnormality to the nurse in charge
14. Labels and sends specimen to the laboratory immediately with signed request from
31
TASK: DRESSING OF WOUND WITH ASSISTANT
REQUIREMENTS
Top shelf
2 kidney dishes with a cover (one containing cotton wool balls and gauze)
A probe
2 galipots(one of the cleaning lotion and the other for the lotion used in
dressing the wound)
Dressing forceps (2)/A pair of Sterile gloves if the dressing will be done with
the hands
Dissecting forceps (2) ( insituations where the hand is used in cleaning the
wound only one dissecting forceps will be required to pick the last layer of old
dressing on the wound after washing of hands)
Bottom shelf
Mackintosh and towel
Receptacle for soiled dressing
Lotions for dressing e.g. povidone iodine, normal saline, hydrogen peroxide
Face mask
Scissors
Bandage
Face mask
Disposable gloves
Plaster
COMPONENT TASK
1. Explain procedure to patient and ensure privacy.
2. Put on mask, prepare and take trolley to bed side.
3. Ask for assistant for.
i. Put patient in desire position
ii. Protect bed cloths and expose area.
32
iii. Pour out lotion into gallipots
iv. And remove plaster or bandage
4. Washes and dries hands and wears sterile gloves or uses sterile forceps.
5. Removes soiled dressing using dissecting forceps and discards.
6. Cleans wound with swabs soaked in normal saline using sterile forceps / worn sterile
gloves starting from the inner part of the wound to outer region using one swab at a time.
7. Cleans wound with series of swabs until clean.
8. Applies sufficient sterile dressings and secures into position with a plaster or bandage.
9. Informs patient about state of wound, thanks and makes him comfortable in bed.
10. Discards trolley, decontaminates used items and removes gloves.
11. Washes and dries hands and removes screen.
12. Documents and reports state of wound.
REQUIREMENTS
Top shelf
2 kidney dishes with a cover ( one containing cotton wool balls and gauze)
A probe
2 galipots
Dressing forceps (2)
Dissecting forceps (2)
A pair of peeled Sterile gloves if the dressing will be done with the hands
Bottom shelf
Mackintosh and towel
Receptacle for soiled dressing
Lotions for dressing e.g. povidone iodine, normal saline, hydrogen peroxide
Face mask
Scissors
Bandage
Face mask
Disposable gloves
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Plaster
COMPONENT TASK
REQUIREMENT ON TROLLEY
COMPONENT TASK
34
2. Put on mask, prepare and take trolley to bed side.
3. Ask assistant to:
a. Put patient in desire position, protect bed cloths and expose area to be dressed only.
b. Pour out lotion into gallipots
c. And remove plaster or bandage
4. Washes and dries hands
5. Removes soiled dressing using dissecting forceps and discards.
6. Cleans wound with series of swabs soaked in antiseptic lotion using sterile forceps.
Places sterile swab near the wound.
7. Takes dissecting forceps and stitch removing scissors, grasp ends of the stitch with
dissecting forceps and pulls gently to expose an area between the knot and the skin.
8. Cuts stitch between the knot and the skin, pulls out sutures gently and slowly.
9. Inspect carefully to make sure sutures are removed and discarded on a piece of gauze,
noting number of sutures removed.
10. Cleans wound, applies dressing and secures in position.
11. Thanks and makes patient comfortable in bed..
12. Discards trolley, decontaminates instruments
13. Removes gloves, washes and dries hands
14. Removes screen
15. Documents and reports state of wound.
REMOVAL OF CLIPS
A trolley for dressing of wounds (In addition a clip remover is added)
35
dissecting forceps and inserts one blade of the clip remover on top of it
9. Presses the blades together and then frees the clip from the skin on either sides and
places it on the swab, noting number of clips removed
10. Cleans wound, applies dressing and secures into position
11. Thanks and makes patient comfortable in bed
12. Discards trolley and decontaminates instruments
13. Removes gloves, washes and dries hands
14. Documents procedure and reports finding
REQUIREMENT ON TROLLEY
Top shelf
2 kidney dishes with a cover( onecontaining cotton wool balls and gauze)
A probe
2 galipots
Dressing forceps (2)
Dissecting forceps (2)
A pair of Sterile gloves if the dressing will be done with the hands
Sterile Specimen container with a swab stick
Bottom shelf
Mackintosh and towel
Receptacle for soiled dressing
Lotions for dressing e.g. povidone iodine, normal saline, hydrogen peroxide
Face mask
Scissors
Bandage
Face mask
Disposable gloves
Plaster
36
COMPONENT TASK
REQUIREMENT ON TRAY
A pair of Utility gloves
A bucket containing 5% chlorine solution
Sponge
Soap in a soap dish or liquid soap
A receptacle to collect the cleaned instruement
A veronica bucket containing warm or cool water or a standing
A sink or bowled for used water
Soft bristled scrubbing brush
Towel for drying instrument
COMPONENT TASK
37
1. Immerseall used instruments in a plastic bucket of freshly prepared 1-10 parazone
solution for at least 10 minutes.
2. Put on utility gloves and remove instruments from the parazone 1-10 after 10minutes.
3. Rinse the instrument in warm or cool water.
4. Scrubs instrument using a soft brush with liquid detergent pay attention to the
crevices/serrated ends.
5. Rinse instrument thoroughly with clean water to remove all detergent
6. Boil for 20 minutes in a steriliser with a lid well covered.
OR dries by air or clean with clean towel if to be sterilised (CSSD).
REQUIREMENTS
A trolley containing
COMPONENT TASK
38
Shaving material, gauze, antiseptic lotion, bowel of water, soap and sponge, operation
towel, operation gown, B/P apparatus, thermometer, mackintosh.
2. Explain procedure to patient and reassures him.
3. Sends trolley to bed side and provide privacy.
4. Places patient into desired position.
5. Exposes the area to be prepared and protects the bed clothes.
6. Wears gloves, washes the area with soap, sponge and water.
7. Dries and cleans with antiseptic lotion.
8. Covers area with operating towel and secures it in position with adhesive strapping.
9. Gowns patient with a clean theatre gown.
10. Ask patient to empty bladder and remove dentures of any.
11. Check vital signs and record TPR andBP.
12. Thank patient, discards trolley and washes hands.
13. Gives prescribed medication when patient is ready for the theatre.
REQUIREMENTS ON TROLLEY
Sterile towel
Sterile dressing
1 artery forceps
39
Sterile syringe (5-10ml) and needles
Specimen bottles
A pair of scissors
Adhesive strapping
1. Establish rapport , explain procedure to patient and ensures consent form is signed
2. Washes and prepares the trolley with the following requirement
a. Two plain dissecting forceps
b. 1 artery forceps
c. Sterile syringe (5-10ml) and needles
d. 50ml syringe with aspiratory needle size, 16,18 and 20
e. 2 or 3 way stop cork with extensive tube
f. Sterile gloves and marks
g. Sterile towel and dressing
3. Dressing mackintosh
a. Receptacle and specimen bottles
b. Local anaesthetic agent
c. TPR tray with a blood pressure apparatus
d. A pair of scissors
e. Receptacle for used instrument and swabs
f. Adhesive strapping
4. Sends trolley to bedside and provides privacy
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5. Ensure chest x-rays are ready
6. Check vital signs ad records
7. Sits patient on the edge of the bed with his legs supported and his head and folded
arms resting on th over bed tables or have him embraced on a chair backward and rest
his head and folds arm on the back of the chair. Or if not able to sit positon patient by
turning him on the unaffected side with the arm on the affected side raised above his
head, elevates the head of the bed 30-45 degrees.
Requirement
Rope
Pulley
Traction kits
Prescribed weight
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1. Explain procedure to patient and ensure patient understands activity restriction
2. Check vital signs and records, assesses patients neuromuscular status of affected
extremity ( peripheral pulse, colour, amount of movement, oedema, numbness
temperature and sensation)
3. Assess patient regularly for signs of thrombi and emboli i.e. pulse, blood pressure,
respiration, breath sounds for evidence of emboli inspect extremity involved for
redness, swelling and pain and patients mental status
4. Assess pressure areas for signs of irritation on breakdown of the continuity of the
skin especially bonny prominences ( heels, ankles ,sacrum ,elbow, chin and
shoulders)
5. Assess skin for allergies or signs of infection or injuries
6. Inspect traction apparatus regularly for level of elevation of the foot end knee
flexion on bed 20 -30 degrees
7. Ensure free play of ropes on the pulley
8. Ensure weights are hanging freely and not resting on the bed or the floor when
bed is in the lowest position
9. Ensure ropes are straight without knots kinks between points of attachment and in
the same plane as the ling axis of the bone
10. Ensures ropes are securely attached with slip knot and the short ends of the ropes
are attached with a tape.
11. Ensure bed clothes and other objects do not impinge on the traction and spreader-
bar wide enough to prevent the traction tape from rubbing on the bony
prominences
12. Ensure patient is in the supine position and maintain body alignment when turning
him
13. Ensure trapezes is padded to assist patient in lifting his body for back care and
provide slipper bedpan to minimise movement on bed
14. Provide protective devices and measures to safeguard the skin for example watr
bags to the heels sacrum, shoulders and other pressure areas.
15. Treat pressure areas four hourly
16. Changes adhesive skin traction when ordered provides skin care and re-wraps into
position.
17. Encourage patient to do deep breathing, coughing and range of motion and flexion
and extension exercise
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18. Remove gloves, washes hands, dries and document findings
REQUIREMENTS ON TROLLEY
Shroud kits
43
a. a list of property in a value or property book , locks the property in a safe place
b. hands them over to the nest of kin if available and asks this person to sign the
book
14. Clears away any equipment used and observes infection prevention protocol
15. Clears the bed locker and all appliances.
16. Documents in the admission and discharge book and daily ward state.
17. Takes patients folder to the revenue office for assessment of hospital bill.
REQUIREMENT ON TRAY
Water
Disposable gloves
Sterile towel
Receiver
44
5. Washes and dries hands and put on gloves
6. Cleans the area with antiseptic lotion
7. Applies sterile dressing towel or paper towel and secures into position
8. Thanks the patient removes and discard tray
9. Decontaminate the items used, removes gloves washes hands and dries hands
10. Documents procedure and reports finding
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14. Removes and observes the content of the bed pan and discards
15. Removes gloves washes and dries hands
16. Give patient soap and water to wash hands and makes him comfortable in bed
17. Thank patient, records procedure and finding.
18. Decontaminates, cleans and stores articles used.
REQUIREMENT
Sterile towel
Irrigating apparatus
Gloves
1. Establishes rapport and explain procedure to the patient and ensures privacy.
2. Assembles necessary items for irrigation.
3. Assist patient into a desired position.
4. Turns back the top bed cloth to expose the retention catheter.
5. Protects bed with mackintosh and dressing towel.
6. Washes and dries hands, wears sterile gloves.
7. Puts sterile towel under the end of catheter.
8. Cleans the lumen of the catheter and connects the irrigating apparatus
9. Infuses 40-60 drops of irrigation fluid per minute or as prescribed
10. Continues the process until purpose of the irrigation is accomplished
11. Observes patient for any discomfort during the process
12. Empties the receptacle and record the output and observation made
13. Removes gloves washes and dries hands
14. Makes patient comfortable in bed
15. Decontaminate and sterilise used equipment if not disposable
46
16. Washes and dries hands and document procedure
REQUIREMENT
47
REMOVAL OF AN INDWELLING CATHETER
Tray containing
Gloves
Mackintosh and towel
Syringe(10-20ml)
Receiver
Gallipot containing swabs
Towel
Measuring jug
Small towel( for cleaning the genital area)
1. Establishes rapport and explains the procedure to patient
2. Prepares and takes tray to bedside and provides privacy
3. Positions patient as for catheterization
4. Places mackintosh and dressing towel beneath the patient and around genital area
5. Washes and dries hands
6. Wears gloves and places towel between legs of the female patient/on the thighs of the
male patient
7. Inserts the syringe into the injection part of catheter and withdraws water from the
balloon
8. Gently withdraws the catheter and places in the waste receptacle
9. Dries the genital area with towel
10. Measures urine in the drainage bag and removes gloves
11. Thanks patient and discards used items
12. Washes and dries hands and documents findings
Gloves
K Y jelly
48
1. Establishes rapport and explains procedure to patient
3. Ensures privacy
6. Covers patient up so that only vulva area is exposed washes hands and wears gloves
8. Cleans vulva using cotton wool swab and antiseptic solution towards anus,
cleans urethral meatus, moving down the catheter
10. Uses cotton wool swab soaked in antiseptic lotion, wipes in a circular motion along
length of catheter and anchors back into position
11. Applies antibiotics ointment at urethral meatus and along 2.5cm of catheter if ordered by
Physician/Surgeon
13. Disposes all contaminated items, removes gloves and wash hands
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2. Assesses patient regularly for signs of thrombi and emboli i.e. pulse, blood pressure
respirations, breath sounds for evidence of emboli, inspects extremity involved fore
redness swelling and pain and patient's mental status
3. Assesses pressure areas for signs of irritation or breakdown in the continuity of the
skin
especially bony prominences (heels, ankles, sacrum, elbow, chin and shoulders).
Areas
susceptible 0 pressure from the traction e.g. (the tibia for Buck's extension)
5. Inspects traction apparatus regularly for level of elevation of foot end knee flexion on
bed 20 to 30 degrees
7. Ensures weight are hanging freely and not resting on the bed or floor when bed is in
the lowest position
8. Ensures ropes are straight without knots or kinks between points of attachment and in
the same plane as the long axis of the bone
9. Ensures ropes are securely attached with slip knots and the short ends of ropes are
attached with a tape
10. Ensures bedclothes and other objects do not Impinge on the traction and spreader-bar
wide enough to prevent the traction tap on the bony prominences
11. Ensures patient is in the supine position body alignment when turning him
12. Ensures trapeze is padded to assist patient in lifting his body for back care and
provide slipper bedpan to minimize movement in bed
13. Provides protective devices and measures to safeguard the skin example, water bags
for the heels, sacrum, shoulders and other pressure areas
50
15. Changes adhesive skin traction as ordered, provides skin care and re-wraps into
position
16. Encourages patient to do deep-breathing, coughing and range of motion and flexion
and extension exercises
3. Ensures privacy
4. Washes and dries hands and puts patient in the supine position
7. Removes anchor device to free catheter tubing, washes hands and wears gloves
8. Retracts foreskin if present to expose urethral meatus, cleans around catheter first, and
then wipes in circular motion around meatus and glans
10. Uses cotton swab soaked in antiseptic lotion, wipes in circular motion along the
length of catheter and anchors it back
11. Applies antibiotics ointment at urethral meatus and along 2.5cm of catheter if ordered
by Physician/Surgeon
13. Disposes all contaminated items, removes gloves and washes hands
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TASK: CHECKING VITAL SIGNS-TEMPERATURE, PUSLE,
RESPIRATION,BLOOD PRESSURE(USING THE INDIVIDUAL
ELECTRONIC THERMOMETRE AND ELECTRONIC
SPHYGMOMANOMETRE)
52
7. Wipe axilla with cotton swab (dry)
8. Inserts thermometer in to axilla between two skin folds
9. Leave thermometer in axilla for three full minutes
10. Whiles the thermometer is in position check pulse and respiration rate
19. Releases cuff pressure slowly and listens to sound with stethoscope
20. Removes cuff and reassembles
21. Thanks and makes patient comfortable in bed
22. Washes and dries hands
23. Records Blood Pressure readings on nurse note and vital signs chart
7. Places/elevates backs rest at top of bed and arranges pillows in an arm chair-like fashion
on it
8. Places top sheet on bed with the wrong side upper most and folds sheet
over at the bottom
9. Places foot rest in position
10. Places heart table with covered pillows in position
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13. Clears chairs/tables, trolley, washes dries hand or use alcohol rub if applicable
54