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Advanced Adult Care Nursing Manual

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Kingdom of Saudi Arabia
Ministry of Higher Education
University of Ha’il
College of Nursing

ADVANCED ADULT CARE NURSING PRACTICE (NURS 314)
MEDICAL-SURGICAL DEPARTMENT

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

TOPIC OUTLINE
Advanced Cardiac System Care
Applying a Cardiac Monitor
Administering a Blood Transfusion
Advanced Respiratory System Care
Measuring Arterial Oxygen Saturation
Care of a Patient with a Chest Drainage System
Measuring Output from a Chest Drainage System
Care of Patient With Sensorineural Disorders
Administering an Eye Irrigation
Administering an Ear Irrigation
Care of a Client With Hearing Aid
Care of a Client With Eye Prosthesis
Care of Patient With Neurological System Disorders
Assessing the Neurological System
Assessing Level of Consciousness Using the Glasgow Coma Scale
Assessing the Patient’s Mental Status
Assessing Cranial Nerves
Assessing Deep Tendon Reflexes
Care of Patient With Integumentary System Disorders
Assisting with Hydrotherapy for Burn Injury
Care of Patient with Burn Injury (Closed Method)
Care of Patient with Burn Injury (Open Method)
Care of Patient With Renal System Disorders
Administering a Continuous Closed Bladder Irrigation
Caring for a Patient’s Vascular Access on Hemodialysis
Caring for a Patient’s Peritoneal Dialysis Catheter
Care of Patient With Musculoskeletal System Disorders
Assessing the Musculoskeletal System
Caring for a Patient in Skin Traction
Caring for a Patient in Skeletal Traction
Care of Patient With Immobilization Device (Cast, Splint, or Collar Brace)
Applying a Sling
Assisting With Cast Application
Caring for a Cast
Care of a Patient During Cast Removal

2

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

ADVANCED CARDIAC
SYSTEM CARE

3

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Applying a Cardiac Monitor
Purpose(s):
a. To diagnose/monitor cardiac arrhythmias in all patients at significant risk of an immediate, life-threatening
arrhythmia, specifically in:
− Patients who have been resuscitated from cardiac arrest.
− Patients in the early phase of acute coronary syndromes (ST-elevation or Non–ST-elevation MI, unstable
angina/“rule-out” MI).
− Patients with unstable coronary syndromes and newly diagnosed high-risk coronary lesions.
− Patients who have undergone cardiac surgery.
− Patients who have undergone nonurgent percutaneous coronary intervention (PCI) with complications;
− Patients who have undergone implantation of an automatic defibrillator lead or a pacemaker lead and are
considered pacemaker dependent.
− Patients with a temporary pacemaker or transcutaneous pacing pads;
− Patients with AV block;
− Patients with arrhythmias complicating Wolff-Parkinson-White syndrome with rapid anterograde
conduction over an accessory pathway.
− Patients with long-QT syndrome and associated ventricular arrhythmias;
− Patients receiving intraaortic balloon counterpulsation.
− Patients with acute heart failure/pulmonary edema.
− Patients with indications for intensive care.
− Patients undergoing diagnostic/therapeutic procedures requiring conscious sedation or anesthesia; and
Patients with any other hemodynamically unstable arrhythmia.
Equipment:







Cardiac monitor
Lead wires
Pregelled (gel foam) electrodes (number varies from 3 to 5)
Soap and water if necessary
Gauze pads
PPE, as indicated

4

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Assessment:
1. Review the patient’s medical record and plan of care for information about the patient’s need for cardiac
monitoring.
2. Assess the patient’s cardiac status, including heart rate, blood pressure, and auscultation of heart sounds.
3. Inspect the patient’s chest for areas of irritation, breakdown, or excessive hair that might interfere with
electrode placement.
4. Electrode sites must be dry, with minimal hair.
5. The patient may be sitting or supine, in a bed or chair.
Nursing Diagnosis:
1.
2.
3.
4.
5.
6.
7.

Decreased Cardiac Output
Impaired Gas Exchange
Acute Pain
Anxiety
Excess Fluid Volume
Deficient Knowledge
Activity Intolerance
IMPLEMENTATION

Steps:
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.

Rationale

b.
c.
d.
e.
4

Identify the patient.
Introduce yourself and explain the procedure.
Provide privacy and position comfortably.
Perform hand hygiene and wear PPE as
indicated.
Connect the correlated sensors to the sockets of
the machine according to the parameters needed.

5

This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
This ensures the patient’s privacy.
This prevents the spread of microorganisms.
Proper connection ensures proper functioning.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Parameters / Channels for data display:
a.
b.
c.
d.
e.
f.
g.

Electrocardiogram (ECG)
Respirations/impedance pneumography via the ECG leads
Intermittent noninvasive blood pressure (NIBP)
Oxyhemoglobin saturation (SpO2)
pEtCO2 (partial pressure of end-tidal CO2, capnography)
Body temperature
Intra-arterial pressure

6

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

5
6

Press the power switch then enter patient’s data.
Raise the bed to a comfortable working height.

7

Expose the patient’s chest and determine
electrode positions, based on which system and
leads are being used.

This ensures correct setup.
Having the bed at the proper height prevents back
and muscle strain.
This ensures correct functioning.

NOTE: If necessary, clip the hair from an area
about 10 cm in diameter around each electrode
site. Clean the area with soap and water and dry it
completely to remove skin secretions that may
interfere with electrode function.

These actions allow for better adhesion of the
electrode and thus better conduction. Alcohol,
benzoin, and antiperspirant are not recommended to
prepare the skin.

Electrode Name

Color

Position

RA

White

Right Arm

LA

Black

Left Arm

LL

Red

Left Leg

RL
C

Green
Brown

Right Leg
Central Chest
Over Sternum

7

System/
Configuration
3 Electrode
5 Electrode
3 Electrode
5 Electrode
3 Electrode
5 Electrode
5 Electrode
5 Electrode

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Electrode system:
a. 3-lead/electrode (red, yellow, green) or (red, yellow, black) - choice of limb leads

Modified central lead one (MCL1)

Place the RA / White or right
arm) below the right clavicle,
the second (LA / Black or left
arm) below the left clavicle, and
the third (LL / Red or left leg)
just below the left pectoral
muscle.
MCL1 configuration (best lead
for identification of bundle
branch blocks): red wire on the
left shoulder just below the
clavicle, black (or green) on the
right shoulder, yellow in 4th
intercostal space on the right
sternal border (the V1 position)
then select lead I. Alternatively,
black (or green) in the V6

8

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

electrode position then select to
lead II (this gives a simulated
lead V6).
Limb lead II is the most
common
monitoring
lead
configuration,
because
it
normally produces the largest
positive R wave.

b. 4-lead/electrode (red, yellow, green, black) - choice of limb leads

9

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

c. 5-lead/electrode (red, yellow, green, black, white) - limb leads plus a chest lead (using the white
wire, usually placed in the V1 position)

Electrode Name
RA
LA
LL
RL
C

Color
USA
White
Black
Red
Green
Brown

10

Europe
Red
Yellow
Green
Black
White

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

8

Remove the backing from the pregelled electrode.
Press the electrodes on the site firmly to ensure a
tight seal.

Gel acts as a conduit and must be moist and secured
tightly.

NOTE: Check the gel for moistness. If the gel is dry,
discard it and replace it with a fresh electrode.

Pregelled, disposable electrode

9
10

11

12

13
14

Connect the appropriate lead wire to each
electrode according to inscription.
Check waveform for clarity, position, and size.

This ensures accuracy of reading.
This ensures accuracy of reading.

NOTE: Use the gain control to adjust the size of the
rhythm tracing, and use the position control to
adjust the waveform position on the monitor. To
verify that the monitor is detecting each beat,
compare the digital heart rate display with an
auscultated count of the patient’s heart rate.
Set the upper and lower limits of the heart rate
alarm, based on the patient’s condition or unit
policy.
Press the “RECORD” key to obtain a rhythm strip
for baseline. Check the strip for Patient’s name and
room number, date, time, and rhythm
identification.
Place the rhythm strip in the appropriate location
in the patient’s chart.
Return the patient to a comfortable position.
Remove PPE and perform hand hygiene.

11

Setting the alarm allows for audible notification if the
heart rate is beyond limits. The default setting for
the monitor automatically turns on all alarms; limits
should be set for each patient.
A rhythm strip provides a baseline.

This secures the result in the chart.
Repositioning promotes patient comfort.
Removing PPE reduces the risk for infection
transmission and contamination of other items.
Hand hygiene prevents transmission of
microorganisms.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

15

NOTE: Lower bed height and adjust the head of
bed to a comfortable position.
Document the following:
a. Date and time that monitoring begins;
b. Monitoring lead used in the medical record;
and
c. Changes in the patient’s condition (or as
stated by facility’s policy).
Heart Rate (bpm)

Interpretation

Above 100
60-100
Below 60

Tachycardia (fast)
Normal (adult)
Bradycardia (slow)

Lowering the bed promotes patient safety.
This ensures continuity of care.

12

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‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Administering a Blood Transfusion
Purpose(s):

a. To increase the oxygen carrying capacity of the blood
− Acute and chronic anemia
− Congestive heart failure
− Thalassemia
− Sickle cell disease
b. To restore circulating blood volume
− Acute bleeding (25 to 30% of blood loss)
− Major surgery
c. To treat deficiencies in plasma proteins and clotting factors
− Thrombocytopenia
− Fibrinogen deficiency, e.g. disseminated intravascular coagulation (DIC)
− Cirrhosis of the liver
− Hepatitis
− Hemophilia
− Von Willebrand disease
− Factor XIII deficiency
− Severe leukopenia
Equipment:












Blood product
Blood administration set (tubing with in-line filter and Y for saline administration)
0.9% normal saline for IV infusion
Venous access; if peripheral site, preferably initiated with a 20-gauge catheter or larger
3 way stopcock
Clean gloves
IV infusion set
Additional PPE, as indicated
Tape (hypoallergenic)
Pressure infusion bag (optional)

13

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Assessment:

1. Obtain a baseline assessment of the patient, including vital signs, heart and lung sounds, and urinary output.
2. Review the most recent laboratory values, in particular, the complete blood count (CBC).
3. Ask the patient about any previous transfusions, including the number he or she has had and any reactions
experienced during a transfusion.
4. Inspect the IV insertion site, noting that the gauge of the IV catheter is a 20 gauge or larger.
Nursing Diagnosis:

1.
2.
3.
4.
5.

Risk for Injury
Deficient Fluid Volume
Decreased Cardiac Output
Excess Fluid Volume
Ineffective Peripheral Tissue Perfusion
IMPLEMENTATION

3

4

Action

Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy and position
comfortably.
e. Perform hand hygiene.
Two nurses compare and validate the
following information:
a. Medical order for transfusion of
blood product;
b. Informed consent;
c. Patient identification number;
d. Patient name;
e. Blood group and type;
f. Expiration date;
g. Inspection of blood product for
clots; and
h. Cross-matching.

Rationale

This ensures that the correct intervention is performed on
the correct patient.
Identifying the patient ensures the right patient receives the
intervention and helps relive anxiety.
This ensures the patient’s privacy.
Hand hygiene prevents the spread of microorganisms.
Most agencies require two registered nurses to verify the
following information: unit numbers match; ABO group and
Rh type are the same; expiration date (after 35 days, red
blood cells begin to deteriorate).
ABO group of compatible packed red blood cells/
whole blood
Group
O
B
A
AB
Recipient
ABO blood
group

Steps

14

AB
A
B
O

X
X
X
X

X
X

X
X

X

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Recipient
ABO blood
group

ABO group of compatible fresh frozen
plasma/cryoprecipitate
Group
O
B
A

AB
A
B
O

X
X

X
X

X

AB

X
X
X
X

Rh Negative patients should always receive Rh Negative
blood products.
Rh Positive patients can receive either Rh Negative or Rh
Positive blood products.
Source: http://www.rch.org.au/emplibrary/bloodtrans/RCH-BLOODPRODUCT-ADMINISTRAION.pdf

NOTE: Blood is never administered to a patient without an
identification band. If clots are present, return blood to the
blood bank.

a.

Blood Type
Whole blood

Composition
Cells and plasma (hematocrit 40%)

b.

Packed red blood cells

c.

Platelets

d.

Fresh frozen plasma

e.

Cryoprecipitate

f.
g.
h.

Antihemophilic factor
Factor IX concentrate
Albumin

Red blood cells (RBCs), some plasma
(hematocrit 75%)
10
Platelets (3x10 platelets/unit),
plasma with some RBCs and WBCs
Plasma including all coagulation
factor complement
Fibrinogen >150mg/bag,
antihemophilic factor 80-110
units/bag, von Willebrand factor
Factor VIII
Factor IX
Albumin 5%, 10%

i.

Globulin/ Granulocyte
concentrate
Antithrombin

j.

Indication
Volume replacement and oxygen carrying capacity
(25% blood volume lost)
RBCs mass ,symptomatic anemia
Bleeding due to decreased platelets
Bleeding in patient with coagulation factor
deficiencies
von Willebrand disease, hypofibrinoginemia,
hemophilia A

IgG antibodies

Hemophilia A
Hemophilia B
Hypoproteinemia, burns, volume expansion by 5%
to 25%
Hypogammaglobulinemia, recurrent infection

Antithrombin III

Antithrombin III deficiency, risk of thrombosis

15

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

5
6

Obtain baseline vital signs before beginning
transfusion.
Prime blood administration set with
normal saline.

Any change in vital signs during the transfusion may indicate
a reaction.
Normal saline is the solution of choice for blood product
administration. Solutions with dextrose may lead to
clumping of red blood cells and hemolysis.

One-Way Blood Set

(1) Blood chamber and filter; (2) Tube 3.0 x 4.0; (3) Precision Roller clamp; (4) Flashbulb; (5) Male
luer-lock; (6) Hypodermic needle

Two-Way Blood Set

(1) Spike protector; (2) Vented spike for tubing; (3) Vented air cap; (4) On/Off roller clamp; (5)
Tube 3.0 x 4.0; (6) Chamber cover; (7) Blood chamber; (8) Blood filter; (9) Precision roller clamp;
(10) Flashbulb; (11) Male luer-lock and cap

16

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

7

Connect the blood administration set to
the 3-way stopcock.

This ensures ease of connection to primary IV line.

Application of pressure infusion bag.

8

Stop the infusion of the primary
intravenous line. Then start transfusion of
blood slowly (10 drops per minute for the
first 15 minutes). Stay with the patient.

This ensures patient safety.

17

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

9

10

Observe patient for the following:
a. Flushing;
b. Dyspnea;
c. Itching;
d. Hyperthermia
After the observation period (5 to 15
minutes), increase the infusion rate to the
calculated rate to complete the infusion
within the prescribed time frame (4 hours).

11

Reassess vital signs after 15 minutes. Stop
transfusion immediately in case of
suspected transfusion reaction.

12

Discontinue transfusion according to
standard practice. Again, recheck vital
signs.

13

Discard blood bag according to hospital
policy.

14

Remove PPE and perform hand hygiene.

15

Document the following:
a. Date and time of transfusion;
b. Type of blood product; and
c. Any untoward reaction.

These signs and symptoms may be an early indication of a
transfusion reaction.

If no adverse effects occurred during this time, the infusion
rate is increased. If complications occur, they can be
observed and the transfusion can be stopped immediately.
Verifying the rate and device settings ensures patient
receives correct volume of solution. Transfusion must be
completed within 4 hours due to potential for bacterial
growth in blood product at room temperature.
Vital signs must be assessed as part of monitoring for
possible adverse reaction. Facility policy and nursing
judgment will dictate frequency.
If a transfusion reaction is suspected, the blood must be
stopped. Do not infuse the normal saline through the blood
tubing because you would be allowing more of the blood
into the patient’s body, which could complicate a reaction.
Besides a serious life-threatening blood transfusion
reaction, the potential for fluid–volume overload exists in
elderly patients and patients with decreased cardiac
function.
Proper disposal of equipment
reduces transmission of microorganisms and potential
contact with blood and body fluids.
Removing PPE reduces the risk for infection transmission
and contamination of other items. Hand hygiene prevents
transmission of microorganisms.
This ensures continuity of care.
TRALI - Transfusion related acute lung injury
TA-GVHD - Transfusion-associated-graft-versus-host disease

18

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

19

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

ADVANCED
RESPIRATORY SYSTEM
CARE

20

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Measuring Arterial Oxygen Saturation
Purpose(s):
a. To rapidly verify, both audibly and visually, adequate patient oxygenation.
Equipment:
• Pulse oximeter with an appropriate sensor or probe
• Alcohol wipe(s) or disposable cleansing cloth
• Nail polish remover (if necessary)
• PPE, as indicated
Assessment:
1. Assess the patient’s skin temperature and color, including the color of the nail beds. Temperature is
a good indicator of blood flow. Warm skin indicates adequate circulation. In a well-oxygenated
patient, the skin and nail beds are usually pink. Skin that is bluish or dusky indicates hypoxia
(inadequate amount of oxygen available to the cells).
2. Check capillary refill; prolonged capillary refill indicates a reduction in blood flow.
3. Assess the quality of the pulse proximal to the sensor application site.
4. Auscultate the lungs.
5. Note the amount of oxygen and delivery method if the patient is receiving supplemental oxygen.
Nursing Diagnosis:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Risk for Decreased Cardiac Tissue Perfusion
Risk for Ineffective Cerebral Tissue Perfusion
Impaired Gas Exchange
Ineffective Airway Clearance
Activity Intolerance
Decreased Cardiac Output
Excess Fluid Volume
Anxiety
Risk for Aspiration

21

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

IMPLEMENTATION
Steps
Action
3
Follow Standard Protocol.

Rationale

a. Verify or Check Doctor’s Order.

4

b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy and position comfortably.
e. Perform hand hygiene and put on PPE if
indicated.
Select an adequate site for application of the
sensor.
a. Use the patient’s index, middle, or ring
finger.

This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right
patient receives the intervention and helps
relive anxiety.
This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
Inadequate circulation can interfere with the
saturation of peripheral oxygen (SpO2) reading.
Fingers are easily accessible.

.
b. Check the proximal and capillary refill at
the pulse closest to the site.

22

Brisk capillary refill and a strong pulse indicate
that circulation to the site is adequate.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

5

c. If circulation at the site is inadequate,
consider using the earlobe, forehead, or
bridge of nose.
d. Use a toe only if lower extremity
circulation is not compromised

These alternate sites are highly vascular
alternatives.

Cleanse the selected area with the alcohol
wipe or disposable cleansing cloth.

Skin oils, dirt, or grime on the site can interfere
with the passage of light waves. Research is
conflicting regarding the effect of dark color
nail polish and artificial nails; refer to facility
policy and pulse oximeter’s manufacturer
instructions.

Peripheral vascular disease is common in lower
extremities.

.
Allow the area to dry. If necessary, remove nail
polish and artificial nails after checking pulse
oximeter’s manufacturer instructions.
6

Attach sensor to selected site making sure
photodetectors of the light sensors are aligned
opposite each other.

23

Secure attachment and proper alignment
promote satisfactory operation of the
equipment and accurate recording of the SpO2.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

7

Turn on the oximeter.
NOTE: Observe pulse waveform/intensity
display and audible beep. Compare oximeter
pulse rate with client’s radial pulse.

8

Leave sensor in place until oximeter reaches
constant value and pulse display reaches full
strength during each cardiac cycle. Read SpO2
on digital display.

Audible beep represents the arterial pulse, and
fluctuating waveform or light bar indicates the
strength of the pulse. A weak signal will
produce an inaccurate recording of the SpO2.
Tone of beep reflects SpO2 reading. If SpO2
drops, tone becomes lower in pitch.
This ensures a correct value.

NOTE: Reading may take 10-30 seconds.
9

Set the alarm limits for high and low pulse rate
settings.

Alarm provides additional safeguard and
signals when high or low limits have been
surpassed.

10

Check oxygen saturation at regular intervals, as
ordered by primary care provider, nursing
assessment, and signaled by alarms. Monitor
hemoglobin level.

Monitoring SpO2 provides ongoing assessment
of patient’s condition. A low hemoglobin level
may be satisfactorily saturated yet inadequate
to meet a patient’s oxygen needs.

11

Remove sensor on a regular basis and check
for skin irritation or signs of pressure (every 2
hours for spring-tension sensor or every 4
hours for adhesive finger or toe sensor).

Prolonged pressure may lead to tissue
necrosis. Adhesive sensor may cause skin
irritation.

12

Clean nondisposable sensors according to the
manufacturer’s directions. Remove PPE, if
used.

Cleaning equipment between patient use
reduces the spread of microorganisms.
Removing PPE reduces the risk for infection
transmission and contamination of other
items. Hand hygiene prevents the spread of
microorganisms.

24

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

13

Document the following:
a. SpO2 reading;
b. Amount of oxygen therapy;
c. Oxygen delivery method used;
d. Type of sensor and location; and
e. Other relevant assessment.
SpO2 (%)
95-100
90-94
85-89
Below 85

This ensures continuity of care.

Interpretation
Normal
Mild hypoxemia
Moderate hypoxemia
Severe hypoxemia

25

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Care of a Patient with a Chest Drainage System
Purpose(s):
a. To re-establish the normal intrathoracic pressure (−6 mmHg) by removing air (pneumothorax)
and/or fluid (pleural effusion, e.g. hemothorax, hydrothorax, chylothorax, empyema) through a
closed drainage system.
b. To evacuate any pooling of blood in the mediastinum (hemomediastinum) following cardiothoracic
surgery, thoracotomy, or esophageal surgery and chest trauma that can cause cardiac tamponade.
Equipment:
• Bottle of sterile normal saline or water
• Disposable gloves
• Additional PPE, as indicated
• Foam tape or bands
• Prescribed drainage system, if changing is required
• Rolled Towel
Assessment:
1. Assess the patient’s vital signs. Significant changes from baseline may indicate complications.
2. Assess the patient’s respiratory status, including oxygen saturation level. If the chest tube is not
functioning appropriately, the patient may become tachypneic and hypoxic.
3. Assess the patient’s lung sounds. The lung sounds over the chest tube site may be diminished due to
the presence of fluid, blood, or air.
4. Assess the patient for pain. Sudden pressure or increased pain indicates potential complications. In
addition, many patients report pain at the chest tube insertion site and request medication for the
pain.
5. Assess the patient’s knowledge of the chest tube to ensure that he or she understands the rationale
for the chest tube.
Nursing Diagnosis:
1.
2.
3.
4.
5.

Risk for Activity Intolerance
Risk for Impaired Gas Exchange
Deficient Knowledge
Acute Pain
Anxiety

26

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

IMPLEMENTATION
Steps
3

Action
Follow Standard Protocol.

Rationale

a. Verify or Check Doctor’s Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy and position
comfortably.
e. Perform hand hygiene and put on PPE
if indicated.
4

Check the tube connections and chest
drainage system.
a. Water seal drainage system: The tube
should be 1 inch below water level
submerged in sterile normal saline. The
short tube is left open to atmosphere.
b. Disposable chest drainage unit: The
water seal chamber should be at 2cm
level. If negative pressure is indicated,
the suction setting from the source
should be set at −80mmHg or higher
(more negative). The suction level can
be also adjusted using the suction dial
on the side of the chest drain from
−10cmH2O to −40cmH2O.

27

This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive
anxiety.
This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
To ensure patency of the tubes and ensure tight
fit. If tube is submerged too deep in the water,
a higher intrapleural pressure is needed to
expel air. Short tube is open to atmosphere
which allows air to escape from the bottle.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Chest tube

Water seal drainage system

28

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Disposable chest drainage unit

5

Assess the drainage output in the tubing
and collection bottle noting the color and
amount.
NOTE: Mark the date and time at the fluid
level on the drainage bottle.

29

This will show the amount of fluid loss and how
fast the fluid is collecting in the drainage
system.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

30

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

6

Ensure that the connections are securely
taped and that the chest tube is secured to
the client’s wall.
NOTE: Make sure tubing does not loop with
movements of patient.

7

Position patient comfortably. Reposition
the patient every 2 hours.

8

Put the arm and shoulder of the affected
side through range-of-motion exercises
several times daily.

Kinking, looping, or pressure on the drainage
tubing can produce back pressure forcing
drainage back to the pleural space or block the
drainage.

Proper positioning helps breathing and
promotes better air exchange. Frequent
position changes promote drainage, prevent
NOTE: When the patient is lying on the
complications, and provide comfort. Rolled
affected side, place rolled towels at the side
towels prevent occlusion of the chest tube by
of the tubing.
the client’s weight.
Exercise helps to avoid ankylosis of the
shoulder (stiffness or fixation of the joint) and
assist in lessening postoperative pain.

NOTE: Some pain medication may be
necessary.
9

Avoid aggressive chest tube manipulation
(milking the tube).
NOTE: If necessary, a gentle technique such
as squeezing hand over hand along the
tubing and releasing the tubing between
squeezes in the direction of the drainage
bottle as per doctor’s order.

10

Check for fluctuations of fluid during
inhalation or exhalation and air leaks as
indicated by constant bubbling in the water
seal bottle.

31

Constant attention to maintaining the patency
of the tube will facilitate prompt expansion of
the lung and minimize complications.
Studies have shown that these techniques
(milking and stripping the tube) do not improve
chest tube patency.

If fluctuation stops, it means either lung is
expanded or system is obstructed, or suction
motor is not operating properly.
Leaking and trapping can result in tension

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

pneumothorax.
11

Observe the dressing site at least every 4
hours.

The dressing provides an occlusive seal to the
site, preventing air from being drawn.

NOTE: Inspect the dressing for excessive
drainage, such as bleeding or foul-smelling
discharge.
12

Assess that the drainage system is safely on
the floor, lower than the client.

The drainage system needs to be lower than
the client to ensure adequate drainage.

13

Encourage deep breathing and coughing
every 2 hours.

Removes secretions so lung expands.

14

Report for signs of:

Provides baseline and information about
procedure related complications.

15

a. Rapid, shallow breathing;
b. Cyanosis;
c. Hemorrhage; and
d. Any symptoms (e.g., pressure in the
chest).
Remove PPE, if used and perform hand
washing. Document assessment and
nursing care

Removing PPE reduces the risk for infection
transmission and contamination of other items.
Hand hygiene prevents transmission of
microorganisms.
This ensures continuity of care.

32

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Measuring Output from a Chest Drainage System
Purpose(s):

a. To measure the amount of chest drainage.
Equipment:






Bottle of normal saline or water
Disposable gloves
Additional PPE, as indicated
Foam tape or bands
Prescribed drainage system, if changing is required

Assessment:

1. Assess the patient’s vital signs. Significant changes from baseline may indicate complications.
2. Assess the patient’s respiratory status, including oxygen saturation level. If the chest tube is not
functioning appropriately, the patient may become tachypneic and hypoxic.
3. Assess the patient’s lung sounds. The lung sounds over the chest tube site may be diminished
due to the presence of fluid, blood, or air.
4. Assess the patient for pain. Sudden pressure or increased pain indicates potential complications.
In addition, many patients report pain at the chest tube insertion site and request medication
for the pain.
5. Assess the patient’s knowledge of the chest tube to ensure that he or she understands the
rationale for the chest tube.
Nursing Diagnosis

1. Risk for Activity Intolerance
2. Deficient Knowledge
3. Acute Pain
4. Anxiety

33

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

IMPLEMENTATION
Steps
Action
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy and position
comfortably.
e. Perform hand hygiene and put on
PPE if indicated.
4
5
6

Expose the chest tube insertion site
only.
Check that all connections are taped
securely.
Measure the drainage output at the
end of each shift.
a. Note the amount and type of fluid
drainage.
b. Mark the level on the container or
by placing a small piece of tape at
the drainage level to indicate date
and time.

Rationale
This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
Maintains privacy.
Prevents any leakage of air into the closed system.

Provides an accurate record of the client’s output.

NOTE: The drainage system is removed
and replaced if full.

34

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

35

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

7

8
9

10

Subtract the total amount of previous
drainage from the total amount of
current drainage.
Dispose of the fluid according to facility
policy.
Remove gloves, and additional PPE, if
used. Perform hand hygiene.

The difference will indicate the amount of
drainage since the last measurement.

Document the following:
a. Site of the chest tube;
b. Amount and type of drainage;
c. Amount of suction applied;
d. Bubbling / tidaling;
e. Subcutaneous emphysema;
f. Type of dressing in place; and
g. Patient’s pain level and pain relief.

This ensures continuity of care.

Prevents transmission of infection.
Removing PPE reduces the risk for infection
transmission and contamination of other items.
Hand hygiene prevents transmission of
microorganisms.

36

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

CARE OF PATIENT WITH
SENSORINEURAL DISORDERS

37

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Administering an Eye Irrigation
Purpose(s)

a. To remove secretions or foreign bodies.
b. To cleanse and soothe the eye.
c. To instill ophthalmic medication.
Equipment:
• Sterile irrigation solution (warmed to 37°C [98.6°F])
• Sterile irrigation set (sterile container and irrigating or bulb syringe)
• Emesis basin or irrigation basin
• Washcloth
• Waterproof pad
• Towel
• Disposable gloves
• Additional PPE, as indicated
• Computer-generated Medication Administration Record (CMAR) or Medication Administration Record (MAR)
Assessment:
1.
2.
3.
4.

Assess the patient’s eyes for redness, erythema, edema, drainage, or tenderness.
Assess the patient for allergies.
Verify patient name, dose, route, and time of administration.
Assess the patient’s knowledge of the procedure. If patient has a knowledge deficit about the procedure, this
may be an appropriate time to begin patient education.
5. Assess the patient’s ability to cooperate with the procedure.
Nursing Diagnosis:
1. Deficient Knowledge
2. Acute Pain
3. Risk for Injury
IMPLEMENTATION
Steps:
Action
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.

Rationale

b. Identify the patient.
c. Introduce yourself and explain the procedure.
d. Provide privacy and position comfortably.
e. Perform hand hygiene and put on PPE if
38

This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive
anxiety.
This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

indicated.
4

5

Have patient sit or lie with head tilted toward side of
affected eye.

NOTE: Protect patient and bed with a waterproof pad.
Wipe from inner canthus to outer canthus. Clean lids
and lashes with washcloth moistened with normal
saline or the solution ordered for the irrigation.

NOTE: Use a different corner of washcloth with each
wipe.

39

microorganisms. PPE is required based on
Transmission Precautions.
Gravity aids flow of solution away from
unaffected eye and from the inner canthus of
the affected eye toward the outer canthus.

Materials lodged on lids or in lashes may be
washed into eye. This cleaning motion protects
nasolacrimal duct and other eye.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

6

7

8

Place curved basin at cheek on the side of the affected
eye to receive irrigating solution.

NOTE: If patient is able, ask him or her to support the
basin.
Expose lower conjunctival sac and hold upper lid open
with the nondominant hand.

Fill the irrigation syringe with the prescribed fluid.
Hold irrigation syringe about 2.5 cm (1 inch) from eye.
Direct flow of solution from inner to outer canthus
along conjunctival sac.

40

Gravity aids flow of solution.

Solution is directed into lower conjunctival sac
because the cornea is sensitive and easily
injured. This also prevents reflex blinking.

This minimizes the risk for injury to the cornea.
Directing solution toward the outer canthus
helps to prevent the spread of contamination
from the eye to the lacrimal sac, the lacrimal
duct, and the nose.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

9

10

11
12
13

Irrigate until the solution is clear or all the solution has
been used.
NOTE: Use only enough force to remove secretions
gently from the conjunctiva. Avoid touching any part
of the eye with the irrigating tip.
Pause irrigation and have patient close the eye
periodically during procedure.
Dry periorbital area after irrigation with gauze sponge.
Offer a towel to the patient if face and neck are wet.
Assist the patient to a comfortable position.
Remove PPE. Perform hand hygiene.

14

Evaluate the patient’s response to medication within
appropriate time frame.

15

Document the following:
a. Site;
b. Type of solution and volume used;
c. Length of time irrigation performed;
d. Pre- and postprocedure assessments;
e. Characteristics of any drainage; and
f. Patient’s response to the treatment.
g. Date, time, dose route of administration of
medication on the CMAR/MAR.
41

Directing solutions with force may cause injury
to the tissues of the eye as well as to the
conjunctiva. Touching the eye is uncomfortable
for the patient and may cause damage to the
cornea.
Movement of the eye when the lids are closed
helps to move secretions from the upper to the
lower conjunctival sac.
Leaving the skin moist after irrigation is
uncomfortable for the patient.
This ensures patient comfort.
Removing PPE reduces the risk for infection
transmission and contamination of other items.
Hand hygiene prevents the spread of
microorganisms.
The patient needs to be evaluated for
therapeutic and adverse affects from the
medication.
This ensures continuity of care.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Administering an Ear Irrigation
Purpose(s):

a. To clean the external auditory canal (e.g. certain foreign bodies and accumulation of cerumen) or
apply heat in the ear canal. To instill otic medication.
Equipment:










Prescribed irrigating solution (warmed to 37°C [98.6°F])
Irrigation set (container and irrigating or bulb syringe)
Waterproof pad
Emesis basin
Cotton-tipped applicators
Disposable gloves
Additional PPE, as indicated
Cotton balls
Computer-generated Medication Administration Record (CMAR) or Medication Administration
Record (MAR)

Assessment:

1.
2.
3.
4.
5.
6.

Assess the affected ear for redness, erythema, edema, drainage, or tenderness.
Assess the patient’s ability to hear.
Assess the patient for allergies.
Verify patient name, dose, route, and time of administration.
Assess the patient’s knowledge of medication and procedure.
If the patient has a knowledge deficit about the medication, this may be an appropriate time to begin
education about the medication.
7. Assess the patient’s ability to cooperate with the procedure.
Nursing Diagnosis:

1. Acute Pain
2. Impaired Skin Integrity
3. Risk for Injury
4. Deficient Knowledge

42

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

IMPLEMENTATION
Steps
Action
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.

4

5

6

Rationale

b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy and position
comfortably.
e. Perform hand hygiene and put on PPE if
indicated.
Have the patient sit up or lie with head tilted
toward side of the affected ear. Have the
patient support basin under the ear to
receive the irrigating solution.

NOTE: Protect the patient and bed with a
waterproof pad.
Clean pinna and meatus of auditory canal, as
necessary, with moistened cotton-tipped
applicators dipped in warm tap water or the
irrigating solution.
Fill bulb syringe with warm solution.

43

This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
Gravity causes the irrigating solution to flow from
the ear to the basin.

Materials lodged on the pinna and at the meatus
may be washed into the ear.

Priming the tubing allows air to escape from the
tubing. Air forced into the ear canal is noisy and

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

7

8

NOTE: If an irrigating container is used, prime
the tubing.
Straighten auditory canal by pulling
cartilaginous portion of pinna up and back for
an adult.

therefore unpleasant for the patient.

Direct a steady, slow stream of solution
against the roof of the auditory canal, using
only enough force to remove secretions.

Directing the solution at the roof of the canal
helps prevent injury to the tympanic membrane.
Continuous in-and-out flow of the irrigating
solution helps to prevent pressure in the canal.

NOTE: Do not occlude the auditory canal with
the irrigating nozzle. Allow solution to flow
out unimpeded.

44

Straightening the ear canal allows solution to
reach all areas of the canal easily.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

9

When irrigation is complete, place a cotton
ball loosely in auditory meatus and have
patient lie on side of affected ear on a towel
or absorbent pad.

10
11

Assist the patient to a comfortable position.
Remove PPE. Perform hand hygiene.

12

13

The cotton ball absorbs excess fluid, and gravity
allows the remaining solution in the canal to
escape from the ear.

This ensures patient comfort.
Removing PPE reduces the risk for infection
transmission and contamination of other items.
Hand hygiene prevents the spread of
microorganisms.
Evaluate the patient’s response to the
The patient needs to be evaluated for any
procedure.
adverse effects from the procedure. Drainage or
a. Return to patient’s bedside 10 to 15
pain may indicate injury to the tympanic
minutes to remove cotton ball and assess membrane. The patient needs to be evaluated for
drainage.
therapeutic and adverse effects from the
b. Evaluate the patient’s response to
medication.
medication within appropriate time
frame.
Document the following:
Timely documentation helps to ensure patient
a. Site;
safety.
b. Type of solution and volume used;
c. Length of time irrigation performed;
d. Characteristics of any drainage;
e. Patient’s response to the treatment; and
f. Date, time, dose, route of administration
of medication on the CMAR/MAR.

45

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Care of a Client With Hearing Aid
Purpose(s):
1. To ensure good operation before using.
2. To make sounds more audible and prevent patient from additional hearing injuries.
Equipment:
• Overbed table
• Soft towel and washcloth
• Brush or wax loop
• Storage case
• Disposable gloves (if drainage is present)
Assessment:
1. Sign and symptoms of hearing loss (muffled quality of speech and other sounds, difficulty
understanding words specially in crowds, need to turn up volume of radio or television, withdrawal
from conversations, avoidance of some social setting).
2. Assess the patient’s knowledge of proper ear care. If the patient has a knowledge deficit about the
device and procedure, this may be an appropriate time to begin education.
3. Assess the patient’s ability to cooperate with the procedure.
4. Activities of daily living
5. Hearing acuity test
Nursing Diagnosis:
1. Impaired social interaction
2. Diminished sensory perception (auditory)

46

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

IMPLEMENTATION
Steps

3

Action

Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy and position
comfortably.
e. Perform hand hygiene and put on
PPE if indicated.

4

Clean the hearing aid.
a. Wipe with soft wash cloth.
b. Open battery door, and allow it to air
dry.
c. Wash ear canal wash cloth moistened
with soap and water.
d. Rinse and dry.

Rationale

This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
Maintains normal sound transmission in the ear
canal.

47

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Types of Hearing Aid

5

6
7

8

Insert the hearing aid.
a. Check the battery.
b. Turn the hearing aid off and
volume control down.
c. Guiding the aid along client’s
cheek, bring it to the ear.

Hold the hearing aid so that the canallong portion with holes is in the bottom.
Use other hand to pull-up and back on
outer ear gently push aid into ear until it
is in place.
Adjust volume gradually to comfortable
level for talking.

This ensures function.
This ensures safety.
This ensures ease of application.

This ensures ease of application.
This ensures ease of application.

Gradual adjustments prevent exposing patient to
harsh squeal or feedback.
48

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

9
10

Remove PPE, if used. Perform hand
hygiene.
Document assessment and nursing care.

Prevents transmission of microorganisms.
This ensures continuity of care.

49

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Care of a Client With Eye Prosthesis
Purpose(s):
1. To clean the eye socket, the surrounding tissue, and the prosthesis to prevent infection and discomfort.
2. To examine the condition of the prosthesis and surrounding tissue.
Equipment:
• Soft wash cloth or cotton gauze square
• Wash basin with warm water or saline
• 4x4 gauze pads
• Mild soap
• Facial tissues
• Bath towel
• Suction device (bulb syringe)
• Disposable gloves
Nursing Assessment:
1. Unusual discomfort of the eye socket or irritation/redness of the surrounding tissue of the eye may indicate
conjunctivitis, debris under the eye prosthesis, or lack of proper hygiene of the eye area.
2. Any infection or irritation that does not subside needs prompt medical attention.
3. Assess the patient’s ability to insert and remove the eye prosthesis. Determine the usual method of cleansing
the eye and the socket at home, and follow that routine as near as possible.
Nursing Diagnosis:
1. Ineffective health maintenance
2. Bathing/hygiene self-care deficit
3. Disturbed sensory perception (visual)

50

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

IMPLEMENTATION
Steps
3

Action
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy and position comfortably.
e. Perform hand hygiene and put on PPE if
indicated.

4
5

6

7
8

9

Rationale
This ensures that the correct intervention is performed
on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.

This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on Transmission
Precautions.
With thumb, gently retract lower eyelid against Maneuver breaks suction causing prosthesis to rise and
lower orbital ridge.
slide out of socket.
Exert slight pressure below eyelid if prosthesis Eases removal of prosthesis.
does not slide out use bulb syringe or medicine
dropper bulb to apply direct suction to
prosthesis.
Place prosthesis in palm of hand and clean it
Soap is less irritating than detergent. Tears and
mild soap and water or plain saline by rubbing secretions containing microorganisms may collect on
between thumb and index finger.
surface of prosthesis.
Rinse well under running tap water and dry
Soft cloth or tissue maintains shinny appearance of
with soft wash cloth or facial tissue.
prosthesis paper towel may dull finish.
If client is not to have prosthesis reinserted,
Prevents misplacement of prosthesis.
store in sterile saline or water in plastic storage
case. Label client’s name and room number.
Clean eyelid margins and socket.
a. Retract upper and lower eyelid with thumb Exposes the eye socket.
and index finger.
b. Wash socket with washcloth or gauze
Removes secretions that may contain microorganisms.
square moistened in warm water or saline.
c. Remove excess moisture with gauze pads. Removes moisture that can harbor microorganisms.
d. Wash eyelid margins with mild soap and
Prevents secretions from entering tear duct in inner
water wipe from inner to outer canthus
canthus.
using a clean part of cloth with each wipe.
e. Dry eyelid using the same method.
51

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

10

Moisten prosthesis with water or saline.

11

Retract client’s upper eyelid with index finger
or thumb of nondominant hand.

12

With dominant hand, hold prosthesis so that
notched or pointed edge is positioned toward
nose and the iris faces outward.

Prosthesis will fit evenly into socket.

13

Prevents dislodgement.

14

Slide prosthesis up under upper eyelid then
push down lower lid to allow prosthesis to slip
in to place. Gently wipe away excess fluid if
necessary.
Remove PPE, if used. Perform hand hygiene.

Prevents transmission of microorganisms.

15

Document assessment and nursing care.

This ensures continuity of care.

Makes insertion easier because dry plastic would rub
against tissue surface.
Correct positioning of prosthesis ensures proper fit.

52

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

CARE OF PATIENT WITH
NEUROLOGICAL SYSTEM DISORDERS

53

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Assessing the Neurological System
Purpose(s):
To demonstrate techniques for a practical and reasonably comprehensive examination of the nervous system.
Equipment:
• Clean gloves
• Percussion hammer
• Sharp objects (e.g. paper clips, sterile pins, toothpicks)
• Coin
• Pen and paper
• Cotton
• Cotton swab
• Tuning fork, 128 Hz (low-pitched)
Assessment:
1. Assess the patient’s behavior.
2. Assess the patient’s level of arousal.
3. Assess the patient’s thought processes and speech, thought content, perception, and insight and
judgment.
4. Assess the patient’s motor system.
5. Assess the patient’s sensory system.
6. Assess for other signs of neurological impairment.
7. Assess a comatose patient.
Nursing Diagnosis:
1.
2.
3.
4.
5.
6.
7.
8.

Altered level of Consciousness
Ineffective Cerebral Tissue Perfusion
Impaired Physical Mobility
Unilateral Neglect
Acute Confusion
Chronic Confusion
Impaired memory
Impaired verbal communication

54

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

IMPLEMENTATION
Steps
3

Action
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.

Rationale
This ensures that the correct intervention is
performed on the correct patient.

b. Identify the patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.

c. Introduce yourself and explain the
procedure.
d. Provide privacy.

4

This ensures the patient’s privacy.

e. Perform hand hygiene and put on PPE, if Hand hygiene prevents the spread of
indicated.
microorganisms.
Place the patient in a comfortable position This ensures comfort.
(sitting, lying or standing).
Assess the patient’s behavior, noting:
a. Facial expression – observe
variations in facial expression;

Expressions of anxiety, depression, apathy, anger,
for elation; facial immobility suggests parkinsonism.
Abnormal positions suggest neurologic deficits such
as paralysis.
b. Posture – observe the patient’s body
position during movement and at rest;

c. Affect – observe for appropriateness of Anger, hostility, suspiciousness, or evasiveness
facial expressions with voice and body suggest paranoid patient. Elation and euphoria
movements; and
suggest manic syndrome. Flat affect and remoteness
suggest schizophrenia. Apathy (dulled affect with
detachment and indifference) suggests dementia,
anxiety, or depression.
d. Grooming – observe for grooming and Grooming and personal hygiene may deteriorate in
personal hygiene.
depression, schizophrenia, and dementia.
Excessive fastidiousness may be seen in an obsessive
compulsive disorder. One-sided neglect may result
from a lesion in the opposite parietal cortex, usually
the nondominant side.

55

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

5

Assess the patient’s level of arousal using, as
needed, and in this order:
a. Verbal stimuli – speak to the patient in a An alert patient opens the eyes, looks at you, and
normal tone to test for alertness or in a responds fully and appropriately to stimuli (arousal
intact). A lethargic patient appears drowsy but opens
loud voice to test for lethargy;
the eyes and looks at you, responds to questions,
and then falls asleep.
b. Tactile stimuli – shake the patient gently An obtunded patient opens the eyes and looks at
you, but responds slowly and is somewhat confused.
to test for obtundation; and
Alertness and interest in the environment are
decreased.
c. Painful stimuli – apply a painful stimulus
to test for stupor, e.g., pinch a tendon,
rub the sternum, or roll a pencil across a
nail bed.

6

NOTE: Coma if no response to repeated
painful stimuli.
Assess the logic, relevance, organization,
and coherence of the patient’s thought
processes and speech.
a. Circumstantiality – speech with
unnecessary detail but has meaningful
connection.
b. Derailment (Loosening of Associations)
– speech in which a person shifts from
one subject to others that are unrelated.
c. Flight of Ideas – continuous speech in
which changes are abrupt from topic to
topic.
d. Neologisms – speech of distorted or
invented words.
e. Incoherence – speech that is largely
incomprehensible or disordered
produced by severe flight of ideas.
f. Blocking – sudden interruption of
speech due to losing the thought.
56

A stuporous patient arouses from sleep only after
painful stimuli. Verbal responses are slow or even
absent. The patient lapses into an unresponsive state
when the stimulus ceases. There is minimal
awareness of self or the environment.

This evaluates how patients express their thoughts.

Suggests obsession.

Suggests schizophrenia, manic episodes, and other
psychotic disorders.
Suggests manic episodes.

Suggests schizophrenia, other psychotic disorders,
and aphasia.
Suggests severely disturbed psychotic persons
(usually schizophrenic).
Suggests schizophrenia.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

7

8

g. Confabulation – fabrication of facts or
events in response to questions, to fill in
the gaps in an impaired memory.
h. Perseveration – persistent repetition of
words or ideas.
i. Echolalia – repetition of the words and
phrases of others.
j. Clanging – rhyming speech.
Assess the patient’s thought content.
a. Compulsions – repetitive behaviors or
mental acts.
b. Obsessions – recurrent, uncontrollable
thoughts, images, or impulses.
c. Phobias – persistent, irrational fears
with compelling desire to avoid the
stimulus.
d. Anxieties – apprehensions, fears,
tensions, or uneasiness as focused
(phobia) or free floating (feeling of
impending doom).
e. Feelings of Unreality – sense that things
in the environment are strange, unreal,
or remote.
f. Feelings of Depersonalization – sense
that one self is different, changed, or
unreal, or has lost identity or become
detached from one’s mind or body.
g. Delusions – false, fixed, personal beliefs,
e.g., grandiose, somatic, and
persecution.
Assess the patient’s perception.
a. Illusions – misinterpretations of real
external stimuli (e.g., visual, auditory,
tactile, gustatory, kinesthetic, or
visceral).
b. Hallucinations – false perception that
occurs in the waking state in the
absence of external stimuli (e.g.,
auditory, visual, olfactory or gustatory,
tactile, or somatic).
57

Suggests amnesia.

Suggests schizophrenia and other psychotic
disorders.
Suggests manic episodes and schizophrenia.
Suggests manic episodes and schizophrenia.
This evaluates what patients think about themselves
or their environment. Abnormal thought may be
divided into the following categories: abnormal
perceptions, abnormal convictions, abnormal
preoccupations and impulses, and abnormalities in
the sense of self.

Suggests grief reactions, delirium, acute and
posttraumatic stress disorders, and schizophrenia.

Suggests delirium, dementia, posttraumatic stress
disorder, schizophrenia, and alcoholism.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

9

10

Assess the patient’s insight and judgment.
a. Insight – note if patient is aware that a
particular mood, thought, or perception
is abnormal or part of an illness.
b. Judgment – note the patient’s responses
to family situations, jobs, use of money,
and interpersonal conflicts.
Assess the patient’s motor system. Inspect
and palpate muscles for:
a. Size/Bulk – compare the size and
contours of muscles (e.g., Atrophy refers
to a loss of muscle bulk or wasting,
Hypertrophy refers to an increase in
bulk with proportionate strength,
Pseudohypertrophy refers to increased
bulk with diminished strength);
b. Strength – ask the patient to move
actively against resistance (e.g.,
Hemiparesis refers to weakness of one
half of the body, Hemiplegia refers to
paralysis of one half of the body,
Paraplegia refers to paralysis of the legs,
Quadriplegia refers to paralysis of all 4
limbs);
Grade
0
1
2
3
4
5

Interpretation
No muscular contraction or complete paralysis
A barely detectable or palpable muscular
contraction or partial paralysis.
Active movement of body part with gravity
eliminated, or cannot raise body
part/weakness.
Active movement against gravity, or can raise
and lower body part.
Active movement against gravity and some
resistance, or can raise body part with minimal
strength to push and pull.
Active movement against gravity and
full/strong resistance, or normal.

c. Tone – feel the muscle resistance to
passive stretch;
d. Involuntary movements – tremors, tics,
or fasciculations; and
58

Suggests psychotic disorders and neurologic
disorders.
Suggests delirium, dementia, mental retardation, and
psychotic states.

Suggests motor neuron diseases, disuse of the
muscles, rheumatoid arthritis, and protein-calorie
malnutrition.

Suggests Duchenne muscular dystrophy.
Decreased resistance suggests disease of the
peripheral nervous system, cerebellar disease, or the
acute stages of spinal cord injury. Marked floppiness
indicates hypotonic or flaccid muscles. Increased
resistance that varies, commonly worse at the
extremes of the range, is called spasticity. Resistance
that persists throughout the range and in both
directions is called lead-pipe rigidity.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

e. Flexion and extension of limbs (Select as Symmetric weakness of the proximal muscles
indicated.)
suggests a myopathy or muscle disorder.
Symmetric weakness of distal muscles suggests a
polyneuropathy, or disorder of peripheral nerves.
Upper Limbs:


Test flexion (C5 and C6 - biceps)
and extension (C6, C7, and C8 triceps) at the elbow by having
the patient pull and push against
your hand.



Test extension at the wrist (C6,
C7, and C8 - radial nerve) by
asking the patient to make a fist
and resist by pulling it down.

Weakness of extension is seen in peripheral nerve
disease (e.g., radial nerve damage) and in central
nervous system disease producing hemiplegia (e.g.,
stroke or multiple sclerosis).


Test the grip (C7, C8, and T1).
Ask the patient to squeeze two
of your fingers as hard as
possible and not let them go.
NOTE: To avoid getting hurt by
hard squeezes, place your own
middle finger on top of your
index finger. Testing both grips
simultaneously with arms
extended or in the lap facilitates

A weak grip may be due to either central or
peripheral nervous system disease. It may also result
59

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

comparison.


from painful disorders of the hands.

Test finger abduction (C8 and T1
- ulnar nerve). Position the
patient’s hand with palm down
and fingers spread. Instructing
the patient not to let you move
the fingers, try to force them
together.
Weak finger abduction indicates ulnar nerve
disorder.



Test opposition of the thumb
(C8 and T1 - median nerve). The
patient should try to touch the
tip of the little finger with the
thumb, against your resistance.

Weak opposition of the thumb indicates median
nerve disorders such as carpal tunnel syndrome.
Lower Limbs:


Test flexion at the hip (L2, L3,
and L4 - iliopsoas) by placing
your hand on the patient’s thigh
and asking the patient to raise
the leg against your hand.



Test adduction at the hips (L2,
L3, and L4 - adductors). Place
your hands firmly on the bed
between the patient’s knees.
Ask the patient to bring both
60

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

legs together.


Test abduction at the hips (L4,
L5, and S1 - gluteus medius and
minimus). Place your hands
firmly on the bed outside the
patient’s knees. Ask the patient
to spread both legs against your
hands.



Test extension at the hips (S1 gluteus maximus). Have the
patient push the posterior thigh
down against your hand.



Test extension at the knee (L2,
L3, and L4 - quadriceps). Support
the knee in flexion and ask the
patient to straighten the leg
against your hand. The
quadriceps is the strongest
muscle in the body, so expect a
forceful response.



Test flexion at the knee (L4, L5,
S1, and S2 - hamstrings) Place
the patient’s leg so that the knee
is flexed with the foot resting on
the bed. Tell the patient to keep
the foot down as you try to
straighten the leg.

61

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing



11

Test dorsiflexion (mainly L4 and
L5) and plantar flexion (mainly
S1) at the ankle by asking the
patient to pull up and push
down against your hand.

Assess the patient’s cerebellar function.
a. Test balance in walking/gait.



A gait that lacks coordination, with reeling and
instability, is called ataxic. Ataxia may be due to
cerebellar disease, loss of position sense, or
intoxication.

Ask the patient to walk heel-to-toe in
a straight line.

62

Tandem walking may reveal an ataxia not previously
obvious.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing



Ask the patient to walk on the toes,
then on the heels.



Ask the patient to hop in place on
each foot alternately.



Ask the patient to do a shallow knee
bend, first on one leg, then on the
other. Support the patient’s elbow if
you think the patient is in danger of
falling.

Walking on toes and heels may reveal distal muscular
weakness in the legs. Inability to heel-walk is a
sensitive test for corticospinal tract weakness.

NOTE: Rising from a sitting position
without arm support and stepping up
on a sturdy stool are more suitable
tests than hopping or knee bends
when patients are old or weak.

Difficulty with hopping may be due to weakness, lack
of position sense, or cerebellar dysfunction.
Difficulty suggests proximal weakness (extensors of
the hip), weakness of the quadriceps (the extensor of
the knee), or both.
People with proximal muscle weakness involving the
pelvic girdle and legs have difficulty with both of
these activities.

63

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

b. Test balance in standing.
− Romberg test. The patient should
stand with feet together and eyes
open and then close both eyes for 20
to 30 seconds without support.

In ataxia due to loss of position sense, vision
compensates for the sensory loss. The patient stands
fairly well with eyes open but loses balance when
they are closed, a positive Romberg sign.
In cerebellar ataxia, the patient has difficulty
standing with feet together whether the eyes are
open or closed.



Test for pronator drift. The patient
should stand for 20 to 30 seconds
with both arms straight forward,
palms up, and with eyes closed.
Instruct the patient to keep the arms
up and eyes shut, tap the arms briskly
downward. NOTE: A person who
cannot stand may be tested for a
pronator drift in the sitting position.

The pronation of one forearm suggests a
contralateral lesion in the corticospinal tract;
downward drift of the arm with flexion of fingers and
elbow may also occur. These movements are called a
pronator drift.

A weak arm is easily displaced and often remains so.
A patient lacking position sense may not recognize
the displacement and, if told to correct it, does so
poorly. In cerebellar incoordination, the arm returns
to its original position but overshoots and bounces.
In cerebellar disease, one movement cannot be
followed quickly by its opposite and movements are
slow, irregular, and clumsy. This abnormality is called
dysdiadochokinesis. Upper motor neuron weakness
and basal ganglia disease may also impair rapid
alternating movements, but not in the same manner.

c. Test coordination and skilled
movements.

64

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Rapid alternating movements (RAM):
− Palm-to-thigh test. Show the patient
how to strike one hand on the thigh,
raise the hand, turn it over, and then
strike the back of the hand down on
the same place. Ask the patient to
repeat these alternating movements
as rapidly as possible. Repeat with
the other hand. NOTE: The
nondominant hand often performs
somewhat less well.


Finger-to-thumb test. Show the
patient how to tap the distal joint of
the thumb with the tip of the index
finger, again as rapidly as possible.
Again, observe the speed, rhythm,
and smoothness of the movements.
NOTE: The nondominant side often
performs less well.



Hand-to-heel test. Ask the patient to
tap your hand as quickly as possible
with the ball of each foot alternately.
Note any slowness or awkwardness.
NOTE: The feet normally perform less
well than the hands.

Point-to-point movements:



In cerebellar disease, movements are clumsy,
unsteady, and inappropriately varying in their speed,
force, and direction. The finger may initially
overshoot its mark, but finally reaches it fairly well.
Such movements are termed dysmetria. An intention
tremor may appear toward the end of the movement.
These maneuvers test position sense and the
functions of both the labyrinth and the cerebellum.

Finger-to-nose test. Ask the patient
to touch your index finger and then
his or her nose alternately several
times. Move your finger about so that
the patient has to alter directions and
extend the arm fully to reach it.
Observe the accuracy and
smoothness of movements and
watch for any tremor.
65

Cerebellar disease causes incoordination that may
get worse with eyes closed. Inaccuracy that appears
with eyes closed suggests loss of position sense.
Repetitive and consistent deviation to one side
(referred to as past pointing), worse with the eyes
closed, suggests cerebellar or vestibular disease.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing



Finger-to-finger test. Hold your finger
in one place so that the patient can
touch it with one arm and finger
outstretched. Ask the patient to raise
the arm overhead and lower it again
to touch your finger. After several
repeats, ask the patient to close both
eyes and try several more times.
Repeat on the other side.

Heel-to-knee test. Ask the patient to
place one heel on the opposite knee,
and then run it down the thigh to the
big toe. Repeat on the other side.
Assess the patient’s sensory system.
a. Test superficial sensations.
− Patterns of testing include:
1. Both shoulders (C4);
2. Inner and outer aspects of the
forearms (C6 and T1);
3. Thumbs and small fingers (C6 and
C8);
4. Front of both thighs (L2);
5. Medial and lateral aspects of
both calves (L4 and L5);
6. Small toes (S1); and
7. Medial aspect of each buttock
(S3).
− If client does not perceive the touch
or if hypersensitivity is felt,
determine boundaries by testing at
about every inch (2.5 cm) and note
the area of sensory loss. NOTE:
Stimulate first at a point of reduced
sensation, and move by progressive
steps until the patient detects the
change.

Repetition with the patient’s eyes closed tests for
position sense. Cerebellar disease causes
incoordination.



12

Meticulous sensory mapping helps to establish the
level of a spinal cord lesion and to determine if a
more peripheral lesion is in a nerve root, a major
peripheral nerve, or one of its branches.

Dermatome Map

66

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing



Wait 2 seconds before moving to a
new site. NOTE: Vary the pace of
testing.

This is important so that the patient does not merely
respond to a repetitive rhythm.
Repetitive testing in a proximal direction reveals a
gradual change to normal sensation at the wrist. This
pattern fits neither a peripheral nerve nor a
dermatome (area of skin mainly supplied by a single
spinal nerve). If bilateral, it suggests the “glove and
stocking” sensory loss of a polyneuropathy, often
seen in alcoholism and diabetes.





Test first with wisp of cotton (light
touch), then tests for pain with
toothpick or sterile needle (first the
dull, then the sharp end). Alternate
dull and sharp ends when moving
from spot to spot.
Tests temperature sensation if pain
perception is abnormal.
Compare symmetric areas on the two
sides of the body. Also compare the
distal with the proximal areas of the
extremities.

b. Test deep vibratory sensation by placing
a vibrating tuning fork on a metatarsal
joint and distal interphalangeal joint and
having the patient identify when the
vibration is felt and when it stops. If
67

Anesthesia is absence of touch sensation,
hypesthesia is decreased sensitivity, and
hyperesthesia is increased sensitivity.
Analgesia refers to absence of pain sensation,
hypalgesia to decreased sensitivity to pain, and
hyperalgesia to increased sensitivity.
Hemisensory loss due to a lesion in the spinal cord or
higher pathways. Symmetric distal sensory loss
suggests a polyneuropathy.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

vibration sense is impaired, proceed to
more proximal bony prominences (e.g.,
wrist, elbow, medial malleolus, patella,
anterior superior iliac spine, spinous
processes, and clavicles).

Vibration sense is often the first sensation to be lost
in a peripheral neuropathy. Common causes include
diabetes and alcoholism. Vibration sense is also lost
in posterior column disease, as in tertiary syphilis or
vitamin B12 deficiency.
When testing vibration and position sensation, first
c. Test deep kinesthetic sensation (position
test the fingers and toes. Testing vibration sense in
sense) by holding the client’s finger or toe
the trunk may be useful in estimating the level of a
on the sides and moving it up or down.
spinal cord lesion.
Instruct client to keep his eyes closed and
identify the direction of the movement.
Repeat several times on each side,
avoiding simple alternation of the stimuli.
If position sense is impaired, move
proximally to test it at the ankle joint. In
a similar fashion, test position in the
fingers, moving proximally if indicated to
the metacarpophalangeal joints, wrist,
and elbow.
d. Test discriminative sensation. (Select as
indicated.)


These prevent extraneous tactile stimuli from
revealing position changes that might not otherwise
be detected.

Stereognosis. Assess by placing a
familiar object (e.g., a coin or a
button) in the palm of the patient’s
hand and having him identify it.
A disproportionate decrease in or loss of
discriminative sensations suggests disease of the
sensory cortex if touch and position sense is normal
68

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

or only slightly impaired.
Stereognosis, number identification, and two-point
discrimination are also impaired by posterior column
disease.
Astereognosis refers to the inability to recognize
objects placed in the hand, suggests a lesion in the
sensory cortex.


Graphesthesia. Assess by drawing a
number or letter in the palm of
patient’s hand using the blunt end of
a pen or pencil and having the patient
identify what was drawn. NOTE:
When motor impairment, arthritis, or
other conditions prevent the patient
from manipulating an object well
enough to identify it, test the ability
to identify numbers.
The inability to recognize numbers suggests a lesion
in the sensory cortex.



2-point discrimination. Instruct the
patient to close his eyes. Touch a
finger pad in two places
simultaneously using the sharp ends
of two opened paper clips, pins, or
toothpicks. Then move the points
together gradually and ask the
patient say “one” or “two” each time
the sharp ends are moved. Alternate
the double stimulus irregularly with a
one-point touch. Note distance and
location at which the patient can no
longer feel 2 separate points. NOTE:
Find the minimal distance at which
the patient can discriminate one from
two points (normally less than 5 mm
on the finger pads).
69

This test may be used on other parts of the body, but
normal distances vary widely from one body region
to another.
Lesions of the sensory cortex increase the distance
between two recognizable points.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing



This test, together with the test for extinction, is
especially useful on the trunk and the legs.

Point localization. Assess by having
the patient close his eyes while the
examiner touches him. Instruct him
point to the area touched. Repeat on
both sides and upper and lower
extremities.

Lesions of the sensory cortex impair the ability to
localize points accurately.

Sensory extinction. Assess by
simultaneously touching the patient
on both sides (e.g., on both hands,
both knees, both arms). Ask the
patient identify where he was
touched.
Assess for other signs of neurological
impairment.
a. Asterixis. Ask the patient to extend both
arms, with hands cocked up and fingers
spread. Watch for 1 to 2 minutes, coaxing
the patient as necessary to maintain this
position. NOTE: Asterixis helps identify a
metabolic encephalopathy in patients
whose mental functions are impaired.

With lesions of the sensory cortex, only one stimulus
may be recognized. The stimulus on the side
opposite the damaged cortex is extinguished.

b. Winging of the Scapula. Ask the patient
to extend both arms and push against
your hand or against a wall. Observe the
scapulae. When the shoulder muscles
seem weak or atrophic, look for winging.
NOTE: In very thin but normal people, the
scapulae may appear “winged” even
when the musculature is intact.

In winging, the medial border of the scapula juts
backward. It suggests weakness of the serratus
anterior muscle, as in muscular dystrophy or injury
to the long thoracic nerve.



13

70

Sudden, brief, nonrhythmic flexion of the hands and
fingers indicates asterixis.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

c. Meningeal Signs:







Testing for these signs is important if you suspect
meningeal inflammation from infection or
subarachnoid hemorrhage.

Neck stiffness. First make sure there
is no injury to the cervical vertebrae
or cervical cord. (In settings of
trauma, this may require evaluation
by x-ray.) Then, with the patient
supine, place your hands behind the
patient’s head and flex the neck
forward, until the chin touches the
chest if possible. NOTE: nuchal
rigidity.
Kernig’s Sign. Flex the patient’s leg at
both the hip and the knee, and then
straighten the knee. NOTE: Inability
to straighten the leg when the hip is
flexed at a 90 degree angle. The
hamstring muscles become very stiff
and produce pain.

Suggests meningeal inflammation, arthritis, or neck
injury.

Suggests meningeal irritation if bilateral.
Compression of a lumbosacral nerve root may also
cause resistance, together with pain in the low back
and the posterior thigh. (Only one leg is usually
involved.)

Suggests meningeal inflammation.

Brudzinski’s Sign (B). As you flex the
neck, watch the hips and knees in
reaction to your maneuver. NOTE:
The knees and hips flex at the same
time.

71

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

14

d. Anal reflex. Using a dull object, such as a
cotton swab, stroke outward in the four
quadrants from the anus. NOTE: Watch
for reflex contraction of the anal
musculature.

Loss of the anal reflex suggests a lesion in the S2-S3S4 reflex arc, as in a cauda equina lesion.

e. Oculocephalic reflex (Doll’s Eye
Movements). This reflex helps to assess
brainstem function in a comatose patient.
Holding open the upper eyelids so that
you can see the eyes, turn the head
quickly, first to one side and then to the
other. NOTE: In a comatose patient with
an intact brainstem, as the head is turned
the eyes move toward the opposite side.

Make sure the patient has no neck injury before
performing this test.

Assess a comatose patient.
a. First assess the ABCs (airway, breathing,
and circulation).
b. Establish the patient’s level of
consciousness.
c. Examine the patient neurologically. Look
for focal or asymmetric findings, and
determine the cause if metabolic or
structural. Do not dilate the pupils. Do
not flex the neck if there is any question

Absence of doll’s eye movements or if the ability to
move both eyes to one side is lost suggests lesion of
midbrain or pons.

The usual sequence of history, physical examination,
and laboratory evaluation does not apply.
Interview relatives, friends, or witnesses to establish
the speed of onset and duration of unconsciousness,
any warning symptoms, precipitating factors, or
previous episodes, and the prior appearance and
behavior of the patient. Any history of past medical
and psychiatric illnesses is also useful.

72

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

15

of trauma to the head or neck. NOTE:
Immobilize the cervical spine and get an
x-ray first to rule out fractures of the
cervical vertebrae that could compress
and damage the spinal cord.
Remove gloves and any other PPE, if used.
Perform hand hygiene. Document significant
findings.

Removing PPE reduces the risk for infection
transmission and contamination of other items. Hand
hygiene prevents the spread of microorganisms.
Documentation ensures continuity of care.

73

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Neurological Chart for Sensory and Motor Assessment

ASIA - American Spinal Injury Association

74

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Assessing Level of Consciousness Using the Glasgow Coma Scale
Purpose(s):

a. To assess neurological function and brain injury in comatose patients particularly in acute stages of traumatic injury or
illness.
Equipment:





Clean gloves
Pen
Paper

Assessment:

1. Monitor parameters such as respiratory status, eye signs, and reflexes on an ongoing basis.
2. Body functions (circulation, respiration, elimination, fluid and electrolyte balance) are examined in a systematic and
ongoing manner.
Nursing Diagnosis:
1. Ineffective airway clearance related to altered level of consciousness (LOC)
2. Risk of injury related to decreased LOC
3. Disturbed sensory perception related to neurologic impairment
Implementation
Steps
Action
Rationale
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
This ensures that the correct intervention is
performed on the correct patient.
b. Identify the patient.
Identifying the patient ensures the right patient
c. Introduce yourself and explain the procedure.
receives the intervention and helps relive anxiety.
d. Provide privacy and position comfortably.
This ensures the patient’s privacy.
e. Perform hand hygiene and put on PPE if indicated. Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
4
Determine level of arousal using the Glasgow Coma
To assess brain stem function.
Scale. (Skip steps 7 to 13 if cannot be assessed.)
5
Assess eye opening:
To evaluate arousal.
a. Score 4: eyes open spontaneously;
b. Score 3: eyes open to speech;
c. Score 2: eyes open in response to pain only, for
example trapezium squeeze (caution if applying a
painful stimulus);
d. Score 1: eyes do not open to verbal or painful
stimuli.
e. Record “C” if the patient’s eyes are closed, or
unable to open his or her eyes because of swelling,
ptosis (drooping of the upper eye lid) or a
75

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

6

7

dressing.
Assess verbal response:
a. Score 5: orientated;
b. Score 4: confused;
c. Score 3: inappropriate words;
d. Score 2: incomprehensible sounds;
e. Score 1: no response. This is despite both verbal
and physical stimuli.
f. Record “D” if the patient is dysphasic and “T” if the
patient has a tracheal or tracheostomy tube.
Assess motor response:
a. Score 6: obeys commands. The patient can
perform two different movements;
b. Score 5: localizes to peripheral pain. The patient
does not respond to a verbal stimulus but
purposely moves an arm to remove
the cause of a central painful stimulus.
NOTE: A true localizing response to pain involves
the patient bringing an arm up to chin level.
Painful stimuli that can elicit this response include
trapezium squeeze, suborbital ridge pressure (not
recommended if there is a suspected/confirmed
facial fracture) and sternal rub (not recommended
in some organizations);
c. Score 4: withdraws from pain. The patient flexes
or bends the arm towards the source of the pain
but fails to locate the source of the pain (no wrist
rotation);
d. Score 3: flexion to pain. The patient flexes or
bends the arm; characterized by internal rotation
and adduction of the shoulder and flexion of the
elbow, much slower than normal flexion;
e. Score 2: extension to pain. The patient extends the
arm by straightening the elbow and may be
associated with internal shoulder and wrist
rotation;
f. Score 1: no response to painful stimuli.

76

To evaluate awareness.

To determine the patient’s ability to obey a
command and to localize, and to withdraw or
assume abnormal body positions, in response to a
painful stimulus.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

8
9
10
11

Assist / place the patient to a comfortable position.
Remove PPE, if used. Perform hand hygiene.
Initiate appropriate referral to other healthcare
practitioners for further evaluation, as indicated.
Document specific assessments.
GCS
Score
15
13-14
9-12
3-8
8-10
3-6
6
3

To promote comfort.
To prevent transmission of infection.
This ensures continuity of care.
This ensures continuity of care.

Interpretation
Normal
Mild brain injury/Lethargy/Confusion/
Obtundation
Moderate brain injury/Stupor
Severe brain injury
Vegetative state (permanent)
Coma
Locked-in Syndrome (high cervical injury)
Brain death

77

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Assessing the Patient’s Mental Status
Purpose(s):

a. To assess neurological function and brain injury in comatose patients particularly in acute stages of traumatic injury or
illness.
Equipment:





Clean gloves
Pen
Paper

Assessment:

3. Monitor parameters such as respiratory status, eye signs, and reflexes on an ongoing basis.
4. Body functions (circulation, respiration, elimination, fluid and electrolyte balance) are examined in a systematic and
ongoing manner.
Nursing Diagnosis:
4. Ineffective airway clearance related to altered level of consciousness (LOC)
5. Risk of injury related to decreased LOC
6. Disturbed sensory perception related to neurologic impairment
Implementation
Steps
Action
Rationale
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
This ensures that the correct intervention is
performed on the correct patient.
b. Identify the patient.
Identifying the patient ensures the right patient
c. Introduce yourself and explain the procedure.
receives the intervention and helps relive anxiety.
d. Provide privacy and position comfortably.
This ensures the patient’s privacy.
e. Perform hand hygiene and put on PPE if indicated. Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
4
Assess patient’s behavior. Note:
To assess general behavior.
a. Facial expression;
b. Posture;
c. Affect; and
d. Grooming.
5
Assess patient's orientation.
Generally for evaluation of mental status (Abnormal
a. Check orientation to time.
findings: Confusion, Delirium).
b. Check orientation to place.
c. Checks orientation to person.
6
Assess frontal lobe function. (Select applicable.)
To evaluate alteration in function of the frontal lobe
a. Attention: working memory (e.g. Ask client to
(Abnormal finding: Dementia).
recite series of digits, spell backwards, or name
months of the year backwards.)
78

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

7

8

9

10

11

12
13

b. Judgment: abstract reasoning (e.g. Check client’s
ability on problem solving, verbal similarities, and
proverbs.)
c. Set generation (e.g. Check client’s verbal fluency
and the ability to generate a set of items.)
Assess temporal lobe function. (Select applicable.)
a. Orientation
b. Immediate memory (e.g. Ask client about month,
date, day of week and place.)
c. Recent memory (e.g. Ask client to recall three
words.)
d. Remote memory (e.g. Ask client about birth date.)
Assess frontal-temporal lobe function. (Select
applicable.)
a. Receptive language (e.g. Ask client to follow
simple verbal and written commands.)
b. Expressive language (e.g. Check client’s fluency
and correctness of content and grammar, or
reading comprehension.)
Assess parietal lobe (nondominant) function. (Select
applicable.)
a. Gnosis or ability to recognize objects perceived by
the senses (e.g. Ask client to identify objects
placed in their hand and numbers written on their
hand with eyes closed.)
b. Constructional (e.g. Ask client to draw geometric
figures − circle, X, square, triangle and star.)
Assess parietal lobe (dominant inferior parietal)
function.
a. Praxis or motor planning (e.g. Ask client to
perform skilled motor tasks without any nonverbal
prompting.)
Assess occipitotemporal lobe function.
a. Visual recognition (e.g. Check client’s ability to
recognize colors and faces.)

Assist / place the patient to a comfortable position.
Remove PPE, if used. Perform hand hygiene.
79

To evaluate alteration in function of the temporal
lobe.

Abnormal finding: Anterograde amnesia
Abnormal finding: Retrograde amnesia
To evaluate alteration in function of the frontaltemporal lobe.
Abnormal finding: Receptive aphasia
Abnormal finding: Expressive aphasia

To evaluate alteration in function of the parietal lobe.
Abnormal finding: Tactile agnosia

Abnormal finding: Visual apperceptive agnosia

To evaluate alteration in function of the parietal lobe
(Abnormal finding: Apraxia).

To evaluate alteration in function of the
occipitotemporal lobe (Abnormal findings: Visual
associative agnosia, Homonymous hemianopsia or
blindness in half of the visual field on the same side in
both eyes/hemianopia).
To promote comfort.
To prevent transmission of infection.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

14
15

Initiate appropriate referral to other healthcare
practitioners for further evaluation, as indicated.
Document specific assessments.

This ensures continuity of care.
This ensures continuity of care.

80

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Assessing Cranial Nerves
Purpose(s):
a. To identify problems to cranial nerves in the brain upon neurological examination.
Equipment:
• PPE, as indicated
• Snellen Chart/Rosenbaum Pocket Vision Screening Card
• Tongue depressor
• Pen light
• Metal tuning fork 512 Hz (high pitched)
• Test tubes of hot and cold water
• Containers of odorous materials (e.g. coffee or chocolate)
• Substances for taste assessment (e.g. sugar, salt, vinegar)
• Miscellaneous items (e.g. coin, pin, cotton, or paper clip)
• Cotton-tipped applicators
Assessment:
Complete a health history, focusing on the neurologic system.
Nursing Diagnosis:
1.
2.
3.
4.

Disturbed sensory perception related to neurologic impairment
Impaired Environmental Interpretation Syndrome
Activity Intolerance
Risk for Peripheral Neurovascular Dysfunction
IMPLEMENTATION
Steps
Action
Rationale
3 Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
This ensures that the correct intervention is
performed on the correct patient.
b. Identify the patient.
Identifying the patient ensures the right patient
c. Introduce yourself and explain the
receives the intervention and helps relive
procedure.
anxiety.
d. Provide privacy and position comfortably.
This ensures the patient’s privacy.
e. Perform hand hygiene and put on PPE if
Hand hygiene and PPE prevent the spread of
indicated.
microorganisms. PPE is required based on
Transmission Precautions.

81

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

4

CN I (olfactory nerve):
a. Ask the patient to close the eyes, occlude
one nostril, and then identify the smell of
different substances, such as coffee,
chocolate, or alcohol.
b. Repeat with other nostril.

5

CN II and III (optic and oculomotor nerves):
a. Test visual acuity (Snellen Chart /
Rosenbaum Pocket Vision Screening Card)
and pupillary constriction (move penlight
toward patient‘s eye from side position).

6

CN III, IV, and VI (oculomotor, trochlear, and
abducens nerves):
a. Ask client to focus on an object.
b. Move object in an “H” pattern or 6 cardinal
positions of gaze (medial, lateral, superior,
inferior, and circular).
c. Observe movement of both eyes in each
direction.
CN V (trigeminal nerve):
a. Have patient close the eyes.
b. Touch forehead, cheeks, and jaw by using
cotton or sharp and dull ends of a broken
tongue blade alternately and have patient

7

82

This action tests the function of CN I (olfactory
nerve). Significant findings include anosmia (loss
of the sense of smell), hyposmia (a decreased
sense of smell), parosmia (a perversion of the
sense of smell), or cacosmia (awareness of a
disagreeable or offensive odor that does not
exist).
This tests function of CN II and III (optic and
oculomotor nerves). Significant findings include
hemianopsia (blindness in half of the visual field,
one or both eyes), decreased visual acuity or
blindness, ptosis (oculomotor nerve palsy),
anisocoria (unequal pupil sizes), miosis (excessive
constriction of the pupil) and mydriasis
(prolonged/excessive dilatation of the pupil).

This testing evaluates the function of tests CN III,
IV, and VI (oculomotor, trochlear, and abducens
nerves). Significant findings include nystagmus,
conjugate gaze palsies (horizontal, upward, or
downward direction), ipsilateral facial
paresis/facial muscle weakness (abducens nerve
palsy).
This checks CN V (trigeminal nerve) function.
Sensitivity to superficial pain is tested in these
same three areas. Cold and warm water in tubes
can also be tested. Significant findings include
facial numbness.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

8

9

identify them.
c. While patient looks up, lightly touch a wisp
of cotton against the temporal surface of
each cornea.
d. Have the patient clench and move the jaw
from side to side.
e. Palpate the masseter and temporal muscles,
noting strength and equality.
CN VII (facial nerve):
a. Ask the patient to smile, frown, wrinkle
forehead, and puff out cheeks.

b. Observe for symmetry while patient
completely elevates eyebrows and tightly
closes the eyelid against resistance
(examiner attempts to open them).
c. Have patient extend tongue. Test ability to
discriminate between sugar and salt.
CN VIII (acoustic nerve):
a. Test hearing using tuning fork (Weber Test
and Rinne Test − conductive hearing loss and
sensorineural hearing loss).
b. Assess standing balance with eyes closed −
Romberg Test.

83

A blink and tearing are normal responses.
Significant findings include impaired or absent
corneal reflex.

Jaw weakness is a significant finding.
This maneuver evaluates the motor function of
CN VII (facial nerve). Significant findings include
facial weakness, inability to completely elevate
eyebrows, and impaired taste.

This evaluates function of CN VIII (acoustic
nerve). Significant results include decreased
hearing or deafness, air and bone conduction
deafness, and dizziness and imbalance.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

10 CN IX and X (glossopharyngeal and vagus):
a. Test the gag reflex by touching the posterior
pharynx with the tongue depressor. Explain
to patient that this may be uncomfortable.
b. Assess patient's ability to swallow and
discriminate between sugar and salt on
posterior third of the tongue.
c. Have patient say "AH." Observe for
symmetric rise of uvula and soft palate.
11 CN XI (spinal accessory nerve) function:
a. Place hands on the patient’s shoulders while
he or she shrugs against resistance.
b. Place hand on the patient’s left cheek, then
the right cheek, and have the patient push
against it.

84

An intact gag reflex indicates normal functioning
of CN IX and X (glossopharyngeal and vagus).
Significant findings include difficulty swallowing
(dysphagia) and impaired taste. Hoarseness in
voice and speech (dysarthria) and slurred reflex.

These actions check CN XI (spinal accessory
nerve) function and trapezius and
sternocleidomastoid muscle strength. Significant
findings include diminished or absent function of
the sternocleidomastoid muscle and upper
portion of the trapezius muscle.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

12 CN XII (hypoglossal) function:
a. Ask patient to protrude tongue note any
deviation or tremors.
b. Test the strength of the tongue by having
patient move the protruded tongue from
side to side against a tongue depressor.
13 Assist the patient to a comfortable position.
14 Remove PPE, if used. Perform hand hygiene.
15 Initiate appropriate referral to other healthcare
practitioners for further evaluation, as indicated.
Document specific asessments.

85

This action checks CN XII (hypoglossal) function
of tongue strength. Significant findings include
difficulty swallowing and slurred speech.

Ensures patient comfort.
Prevents transmission of microorganisms.
Ensures continuity of care. Provides accurate
data.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Rosenbaum Pocket Vision Screening Card

86

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Assessing Deep Tendon Reflexes
Purpose(s):
a. To determine the integrity of the spinal cord and peripheral nervous system.
b. To detect the presence of a neuromuscular disease.

Equipment:




Neurological reflex hammer
Small Hammers

Taylor/tomahawk
type (triangular
rubber)
PPE, as indicated

Large Hammers

Buck type (twoheaded)

Head oriented
horizontally

Head oriented
vertically

Assessment:
1. Monitor parameters such as respiratory status, eye signs, and reflexes on an ongoing basis.
2. Body functions (circulation, respiration, elimination, fluid and electrolyte balance) are examined in a
systematic and ongoing manner.

Nursing Diagnosis:
1.
2.
3.
4.

Risk for Peripheral Neurovascular Dysfunction
Ineffective Peripheral Tissue Perfusion
Impaired Physical Mobility
Activity Intolerance
Implementation
Steps
Action
Rationale
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
This ensures that the correct intervention is
performed on the correct patient.
b. Identify the patient.
Identifying the patient ensures the right
c. Introduce yourself and explain the procedure.
patient receives the intervention and helps
relive anxiety.
d. Provide privacy and position comfortably.
This ensures the patient’s privacy.
87

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

e. Perform hand hygiene and put on PPE if
indicated.
4

Assess the brachioradialis reflex. Place fingers above
the patient’s wrist and tap with a reflex hammer;
repeat on the other arm.

5

Assess the biceps reflex. Place fingers at the elbow
area with the thumb over the antecubital area and
tap with a reflex hammer; repeat on the other side.

88

Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
To evaluate alteration at C5 to C6.

To evaluate alteration at C5 to C6.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Arm supported

Arm unsupported

6

Assess the triceps reflex. Place fingers over the
triceps tendon area and tap with a reflex hammer;
repeat on the other side.

89

To evaluate alteration at C7 to C8.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Arm supported

Arm unsupported

7

Assess the patellar/quadriceps reflex. Tap just below
the patella with a reflex hammer; repeat on the other
side.
90

To evaluate alteration at L2 to L4.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Seated patient

Supine patient

8

Assess the Achilles’ reflex. Tap over the Achilles’
tendon area with reflex hammer; repeat on the other
side.

91

To evaluate alteration at L5 to S2.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Seated patient

Supine patient

92

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Supine patient: crossed leg

9

Assess the plantar reflex. Stroke the sole of the
patient’s foot with the end of a reflex hammer handle
or other hard object such as a key; repeat on the
other side. (Dorsiflexion of the great toe with fanning
of remaining toes is a positive Babinski response.)

93

This indicates upper motor neuron disease. A
negative Babinski reflex is normal 18 months
of age and older.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

10
11

Assist the patient to a comfortable position.
Remove PPE, if used. Perform hand hygiene.
Initiate appropriate referral to other healthcare
practitioners for further evaluation, as indicated.

12

Document assessment techniques performed, along
with specific findings.

Grade
0
1+
2+
3+
4+

Interpretation
No response
Diminished
Brisk, normal
Very brisk
Hyperactive, repeating (clonus)

94

To promote comfort.
Removing PPE reduces the risk for infection
transmission and contamination of other
items. Hand hygiene prevents the spread of
microorganisms. Additional assessments
should be completed, as indicated, to
evaluate the patient’s health status.
Intervention by other healthcare providers
may be indicated to evaluate and treat the
patient’s health status.
For continuity of care plan among health care
team members.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

95

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Deep Tendon Reflex Assessment Chart

Right

Left

NOTE: Indicate the assessment findings in the box using the
symbols.

96

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

CARE OF PATIENT WITH
INTEGUMENTARY SYSTEM
DISORDERS

97

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Assisting with Hydrotherapy for Burn Injury
Purpose(s):
1.
2.
3.
4.

To assess the burned area and calculate the percentage of burns.
To facilitate the removal of adherent dressing and topical medications.
To loosen debris, sloughing eschar and exudates.
To provide an opportunity for the patient to practice range of motion exercises.

Equipment:











Personal protective equipment (PPE): gown, gloves, mask, surgical cap, and shoe covers
Hydrotherapy tank (Hubbard tank)
Bath lifter/wheel chair
Dressing trolley
Gauze pads/Surgical sponge
Antiseptic surgical scrub (e.g. Chlorhexidine gluconate, Betadine)
Normal saline
Bandage scissors
Lund & Browder’s chart
Patient's gown

Assessment:
Monitor vital signs frequently.

Nursing Diagnosis:
1. Impaired Skin Integrity
2. Fluid volume deficit related to increased capillary permeability and evaporative losses from the burn
wound
3. Acute/Chronic Pain
4. Hypothermia related to loss of skin microcirculation and open wounds
5. Anxiety related to fear and the emotional impact of burn injury
6. Risk for Deficient Fluid Volume
7. Risk for Infection
8. Risk for Imbalanced Nutrition: Less than body requirements
9. Ineffective Protection

98

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Implementation
Action

Steps

3

Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
b. Identify the patient.
c. Introduce yourself and explain the procedure.
d. Provide privacy and position comfortably.
e. Perform hand hygiene and put on PPE.

4
5
6
7

8

9
10

11

Ensure analgesia has been administered 30 minutes
before the procedure as ordered.
Review the depth and severity of burn injury using
Lund & Browder’s Chart in the Patient’s File.
Assess the patient’s general condition.
Transfer the patient using bath lifter. Remove soiled
gown. Check the temperature of water and clean the
patient using antiseptic surgical scrub.
Perform wound cleaning and debridement using
normal saline.

Assist physiotherapist to perform exercises during
hydrotherapy procedure.
Limit hydrotherapy to not more than 30 minutes.
NOTE: Two to three nurses should attend the patient
during hydrotherapy. Hydrotherapy is not given on
post grafted patients for 10 days, patients with a
body temperature of below 36.5 degrees Celsius
[hypothermia], patients on mechanical ventilator or
patients with special cases designed by the physician.
Remove the patient from the hydrotherapy tank. Dry
the patient with surgical sponge / gauze for the
wound. Prepare for burn wound dressing.

99

Rationale

This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive
anxiety.
This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
Reduces severe physical and emotional distress
associated with debridement.
For evaluation of associated burns.
To allay fear and gain cooperation.
To prevent transmission of infection.

To hasten the removal of necrotic tissue from
the burn wound, to assist in preventing
proliferation of bacteria underneath the eschar
and to prepare a “clean” granulating wound for
definitive coverage.
To provide range of motion (ROM) exercises.
To avoid hypothermia and fatigue.

To avoid shivering and hypothermia.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

12
13

14
15

Apply patient's gown or place bath blanket over
exposed body surface.
Reassess and document:
a. Wound condition;
b. Type of dressing; and
b. Patient’s response.
Disinfect hydrotherapy tank before and after each
patient’s usage.
Remove PPE and perform hand washing.

100

To note stages of wound healing or signs of
infection and areas debrided on patient care
flow sheet.
To prevent transmission of infection.
Removing PPE reduces the risk for infection
transmission and contamination of other items.
Hand hygiene prevents transmission of
microorganisms.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Assessing Burn Injury

101

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Source: Eslinger, A. (2013). Retrieved from http://calgaryguide.ucalgary.ca/Dermatology.aspx

102

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Care of Patient with Burn Injury (Closed Method)
Purpose(s):

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

To reduce risk and promote good healing process.
To clean the burn wound and prevent from infection.
To protect the burn wound, absorb exudates and keep patient comfortable.
To hold topical agents against the wound.
To help preserve position of limb.
To conserve patient’s body heat.
To minimize scarring.
To prevent mechanical trauma.
To reduce pain and perform debridement of burn wound eschar.
To avoid muscle stiffness and contractures.
Equipment:
• Personal protective equipment (PPE)
• Dressing trolley
• Burn dressing set (includes sterile forceps and bowl)
• 4x4 sterile gauze pads
• Surgical dressing (e.g. Gamgee tissue, Surgicel), as indicated
• Normal saline
• Topical agents (e.g. Flamazine cream), as ordered
• Antimicrobial gauze dressing (e.g. Sofra-Tulle/Bactigras), as ordered
• Antiseptic surgical scrub (e.g. Chlorhexidine gluconate, Betadine)
• Crepe bandages (size according to patient and area of burn)
• Medical adhesive tape
• Patient gown and bed sheets
• Culture swab sticks
• Bandage scissors
Assessment:
Monitor vital signs frequently.
Nursing Diagnosis:
1. Impaired Skin Integrity
2. Fluid volume deficit related to increased capillary permeability and evaporative losses from the burn wound
3. Acute/Chronic Pain
4. Hypothermia related to loss of skin microcirculation and open wounds
5. Anxiety related to fear and the emotional impact of burn injury
6. Risk for Deficient Fluid Volume
7. Risk for Infection
8. Risk for Imbalanced Nutrition: Less than body requirements
9. Ineffective Protection
103

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Implementation
Steps

3

Action
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.

Rationale

b. Identify the patient.
c. Introduce yourself and explain the procedure.
d. Provide privacy and position comfortably.
e. Perform hand hygiene and put on PPE if indicated.

4
5

Ensure analgesia has been administered 30 minutes
before the procedure as ordered.
Pour normal saline when removing soiled dressing.

6
7

Discard dressing and clean gloves.
Assess patient’s burn wound for signs of infection.

8

10

Take swab on wound sites according to routine or as
required.
Apply the dressing as quickly as possible but aseptically.
a. Pour normal saline over sterile gauze sponges
placed in a sterile bowl.
b. Don sterile gloves.
c. Clean wound with sterile forceps from top to
bottom or from center outward.
d. Use one gauze sponge for each wipe and discard.
e. Dry wound in the same manner.
f. Apply topical agents as ordered and apply gauze
dressing as directed.
g. Apply a layer of dry sterile gauze or surgical
dressing as contact layer.
h. Apply a second layer of sterile gauze.
i. Apply crepe bandage over the sterile gauze.
Place the patient on bed comfortably.

11

Remove PPE and perform hand washing.

9

104

This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive
anxiety.
This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
Reduces severe physical and emotional distress
associated with burn wound dressing.
Normal saline softens and aids in removal of
dressing.
To prevent transmission of infection.
To determine types of creams or ointments
needed and inform doctor of changes.
Allows early recognition and specific treatment
of wound infection.
Use of sterile technique reduces the possibility
of introducing pathogens into the body.

Adequate fluid intake needs to be provided in
order to ensure adequate hydration.
Removing PPE reduces the risk for infection
transmission and contamination of other items.
Hand hygiene prevents transmission of

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

12

13

Check vital signs and I and O (intake and output) then
record.

Document the following:
a. Patient’s wound condition;
b. Type of dressing done; and
c. Response to treatment in the Nurse’s notes.

105

microorganisms.
To assess patient’s transition to floor status.
Replacing fluid that is lost helps prevent / treat
deficient fluid volume.
For continuity of care plan among health care
team members.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Care of Patient with Burn Injury (Open Method)
Purpose(s):

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

To reduce risk and promote good healing process.
To clean the burn wound and prevent from infection.
To protect the burn wound, absorb exudates and keep patient comfortable.
To hold topical agents against the wound.
To help preserve position of limb.
To conserve patient’s body heat.
To minimize scarring.
To prevent mechanical trauma.
To reduce pain and perform debridement of burn wound eschar.
To avoid muscle stiffness and contractures.
Equipment:
• Personal protective equipment (PPE)
• Dressing trolley
• Burn dressing set (includes sterile forceps and bowl)
• 4x4 sterile gauze pads
• Surgical dressing (e.g. Gamgee tissue, Surgicel), as indicated
• Normal saline
• Topical agents (e.g. Flamazine cream Gentamycin, Fucidine)), as ordered
• Antiseptic surgical scrub (e.g. Chlorhexidine gluconate, Betadine)
• Patient gown and bed sheets, per facility policy
• Culture swab sticks
• Bandage scissors
Assessment:
Monitor vital signs frequently.
Nursing Diagnosis:
1. Impaired Skin Integrity
2. Fluid volume deficit related to increased capillary permeability and evaporative losses from the burn wound
3. Acute/Chronic Pain
4. Hypothermia related to loss of skin microcirculation and open wounds
5. Anxiety related to fear and the emotional impact of burn injury
6. Risk for Deficient Fluid Volume
7. Risk for Infection
8. Risk for Imbalanced Nutrition: Less than body requirements
9. Ineffective Protection

106

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Implementation
Steps
3

Action
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.

Rationale

b. Identify the patient.
c. Introduce yourself and explain the procedure.
d. Provide privacy and position comfortably.
e. Perform hand hygiene and put on PPE if
indicated.
4
5
6
7
8

Ensure analgesia has been administered 30
minutes before the procedure as ordered.
Pour normal saline when removing soiled
dressing.
Discard dressing and clean gloves.
Assess patient’s burn wound for signs of infection

10

Take swab on wound sites according to routine or
as required.
Apply the dressing as quickly as possible but
aseptically.
a. Pour normal saline over sterile gauze sponges
in a sterile bowl.
b. Don sterile gloves.
c. Clean wound with sterile forceps from top to
bottom or from center outward.
d. Use one gauze sponge for each wipe and
discard.
e. Dry wound in the same manner.
f. Apply topical agents as ordered.
Place the patient on bed comfortably.

11

Remove PPE and perform hand washing.

9

107

This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive
anxiety.
This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
Reduces severe physical and emotional distress
associated with burn wound dressing.
Normal saline softens and aids in removal of
dressing.
To prevent transmission of infection.
To determine types of creams or ointments
needed and inform doctor of changes.
Allows early recognition and specific treatment
of wound infection.
Use of sterile technique reduces the possibility
of introducing pathogens into the body.

Adequate fluid intake needs to be provided in
order to ensure adequate hydration.
Removing PPE reduces the risk for infection
transmission and contamination of other items.
Hand hygiene prevents transmission of
microorganisms.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

12

13

Check vital signs and I and O (intake and output)
then record.

Document the following:
a. Patient’s wound condition;
b. Type of dressing done; and
c. Response to treatment in the Nurse’s notes.

108

To assess patient’s transition to floor status.
Replacing fluid that is lost helps prevent/treat
deficient fluid volume.
For continuity of care plan among health care
team members.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

CARE OF PATIENT WITH
RENAL SYSTEM DISORDERS

109

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Administering a Continuous Closed Bladder Irrigation
Purpose(s):
a. To maintain the patency of the urinary bladder and urethra from blood clots after urologic surgery (e.g.
transurethral resection of the prostate or TURP) or instill medications.
Equipment:
• Sterile irrigating solution (at room temperature or warmed to body temperature)
• Sterile tubing with drip chamber and clamp for connection to irrigating solution
• IV pole
• IV pump (if bladder is being irrigated with a solution containing medication)
• Three-way indwelling catheter in place in patient’s bladder
• Indwelling catheter drainage setup (tubing and collection bag)
• Alcohol swabs
• Bath blanket
• Clean gloves
• Underpad
• Additional PPE, as indicated
Assessment:
1. Verify the order in the medical record for continuous bladder irrigation, including type and amount of irrigant.
2. Assess the catheter to ensure that it has an irrigation port (if the patient has an indwelling catheter already in
place). Assess the characteristics of urine present in tubing and drainage bag.
3. Review the patient’s medical record for, and ask the patient about, any allergies to medications.
4. Before performing the procedure, assess the bladder for fullness either by palpation or with a handheld
bladder ultrasound device.
5. Assess for signs of adverse effects, which may include pain, bladder spasm, bladder distension/fullness, or lack
of drainage from the catheter.
Nursing Diagnosis:
1. Impaired Urinary Elimination
2. Risk for Infection

110

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

IMPLEMENTATION
Steps
Action
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.

Rationale
This ensures that the correct intervention is performed
on the correct patient.
Identifying the patient ensures the right patient receives
the intervention and helps relive anxiety.

d. Provide privacy.
e. Perform hand hygiene and put on PPE.

4
5
6

This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on Transmission
Precautions.
Measure urine output for baseline.
Assessment of urine provides baseline for future
comparison.
Prepare the patient in a comfortable position Waterproof pad protects the patient and bed from
and place waterproof pad.
leakage.
Prepare the sterile irrigation bag for use.
a. Clearly label the solution as: “BLADDER
Proper labeling provides accurate information for
IRRIGANT.” and Indicate time and date on caregivers.
the label.
Sterile solution not used within 24 hours of opening
b. Hang bag on IV pole 2.5 to 3 feet above
should be discarded.
the level of the patient’s bladder.
c. Secure tubing clamp and insert sterile
Aseptic technique prevents contamination of solution
tubing with drip chamber to container
irrigation system.
using aseptic technique.
d. Prime tubing and flush out air.
e. Clamp tubing and replace end cover.
Priming the tubing before attaching irrigation clears air
from the tubing that might cause bladder distention.

111

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

7

8
9

Prepare the irrigation port aseptically.
a. Put on clean gloves.

Gloves protect the nurse from contact with blood and
bodily fluids.
b. Cleanse the irrigation port on the catheter Aseptic
technique
prevents
the
spread
of
with an alcohol swab.
microorganisms into the bladder.
c. Using aseptic technique, attach irrigation
tubing to irrigation port of three-way
indwelling catheter.
Check the drainage tubing to make sure clamp, An open clamp prevents accumulation of solution in the
if present, is open.
bladder.
Release clamp on irrigation tubing and regulate This allows for continual gentle irrigation without
flow at determined drip rate, according to the causing discomfort to the patient. An electronic infusion
ordered rate. NOTE: If the bladder irrigation is device regulates the flow of the medication.
to be done with a medicated solution, use an
electronic infusion device to regulate the flow.)

10

Assist the patient to a comfortable position.

This promotes comfort.

11

Assess patient’s response to the procedure,
and quality and amount of drainage.
Replace new irrigation solution as it nears
empty.
Empty drainage collection bag as each new
container is hung and recorded.
Remove equipment. Remove gloves and
additional PPE, if used. Perform hand hygiene.

Assessment is necessary to determine effectiveness of
intervention and detection of adverse effects.
This prevents air in the tubing.

12
13
14

Gloves protect against exposure to blood, body fluids,
and microorganisms.
Proper disposal of equipment prevents transmission of
microorganisms. Removing PPE reduces the risk for
infection transmission and contamination of other items.
Hand hygiene prevents the spread of microorganisms.

112

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

15

Document the following:
This ensures continuity of care.
a. Amount and type of irrigation solution
used;
b. Amount of urine and irrigant emptied
from the drainage bag.
NOTE: Subtract the amount of irrigant
instilled from the total volume of drainage
to obtain the volume of urine output.
c. Patient’s tolerance of the procedure; and
d. Intake and output.

113

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Caring for a Patient’s Vascular Access on Hemodialysis
Purpose(s):
1. To remove fluid and wastes from the body of a patient with kidney failure through a surgically created
arteriovenous fistula or graft.
2. To maintain the patency of arteriovenous fistula or graft.
Equipment:
• Stethoscope
• PPE, as indicated
Assessment:
1. Ask the patient how much he or she knows about caring for the site.
2. Ask the patient to describe important observations to be made.
3. Note the location of the access site.
4. Assess the site for signs of infection, including inflammation, edema, and drainage, and healing of the incision.
5. Assess for patency by assessing for presence of bruit and thrill.
Nursing Diagnosis:
1. Deficient Knowledge
2. Risk for Injury/Infection
IMPLEMENTATION
Steps
Action
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.

Rationale

b. Identify the patient.
c. Introduce yourself and explain the procedure.
d. Provide privacy and position comfortably.
e. Perform hand hygiene and put on PPE if
indicated.
4

Assess the site.
a. Inspect area over access site for any redness,
warmth, tenderness, or blemishes.
b. Palpate over access site, feeling for a thrill or
vibration.
114

This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
Inspection, palpation, and auscultation aid in
determining the patency of the hemodialysis access.
Assessment of distal pulse aids in determining the
adequacy of circulation.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

c. Palpate pulses distal to the site.
d. Auscultate over access site with bell of
stethoscope, listening for a bruit or vibration.

e.
5

6
7
8

Expose the site and clean with antiseptic
solution.

Ensure that a sign is placed over head of bed
informing the healthcare team which arm is
affected.
NOTE: Do not measure blood pressures, perform a
venipuncture, or start an IV on the access arm.
Monitor vital signs every 15 minutes.
Instruct the patient not to sleep with the arm with
the access site under head or body.
Instruct patient not to lift heavy objects with, or put
pressure on, the arm with the access site.
NOTE: Advise the patient not to carry heavy bags
115

The affected arm should not be used for any other
procedures, such as obtaining blood pressure, which
could lead to clotting of the graft or fistula.
Venipuncture or IV access could lead to an infection
of the affected arm and could cause the loss of the
graft or fistula.
This ensures safety.
This could lead to clotting of the fistula or graft.
This could lead to clotting of the fistula or graft.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

9

10

(including purses) on the shoulder of that arm.
Remove PPE, if used. Perform hand hygiene.

Document the following:
a. Presence or absence of a bruit and thrill; and
b. Patient education and patient response.

116

Removing PPE reduces the risk for infection
transmission and contamination of other items.
Hand hygiene prevents the spread of
microorganisms.
Provide accurate report.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

Caring for a Patient’s Peritoneal Dialysis Catheter
Purpose(s):
1. To remove fluid and wastes from the body of a patient with kidney failure through a peritoneal
catheter safely.
2. To prevent catheter exit site and tunnel infection and peritonitis.
Equipment:
• Face masks (2)
• Sterile gloves
• Clean gloves
• Additional PPE, as indicated
• Antimicrobial cleansing agent, per facility policy
• Sterile gauze squares (4)
• Sterile basin
• Sterile drain sponge
• Topical antibiotic (e.g. mupirocin, gentamicin) depending on order and policy
• Sterile applicator
• Plastic trash bag
• Bath blanket
Assessment:
1. Inspect peritoneal dialysis catheter exit site for any erythema, drainage, bleeding, tenderness,
swelling, skin irritation or breakdown, or leakage.
2. Assess abdomen for tenderness, pain, and guarding.
3. Assess the patient for nausea, vomiting, and fever, which could indicate peritonitis.
4. Assess the patient’s knowledge about measures to care for the exit site.
Nursing Diagnosis:
1. Risk for Impaired Skin Integrity
2. Deficient Knowledge
3. Risk for Infection

117

IMPLEMENTATION
Steps
Action
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.

4

b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy.
e. Perform hand hygiene.
Prepare the patient.
a. Adjust bed to comfortable working
height.

Rationale
This ensures that the correct intervention is performed
on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
This ensures the patient’s privacy.
Hand hygiene prevents the spread of microorganisms.
Having the bed at the proper height prevents back and
muscle strain.

b. Assist the patient to a supine The supine position is usually the best way to gain
access to the peritoneal dialysis catheter.
position.

5
6

7

c. Expose the abdomen, draping the
patient’s chest with the bath
blanket, exposing only the catheter
site.
Put on mask (for patient and the
nurse).
Wear clean gloves. Assess the exit site.
a. Gently remove old dressing, noting
odor, amount and color of drainage,
leakage, and condition of skin
around the catheter.
b. Discard dressing in appropriate
container.
c. Remove gloves and discard.
Prepare the equipment at patient’s
bedside.
a. Set up a sterile field.
b. Open sterile dressing kit.
c. Place sterile applicator on field.
d. Squeeze a small amount of the
topical antibiotic on one of the
gauze squares on the sterile field.

Use of bath blanket provides patient warmth and
avoids unnecessary exposure.

Use of facemasks deters the spread of microorganisms
Drainage, leakage, and skin condition can indicate
problems with the catheter, such as infection.

Until catheter site has healed, aseptic technique is
necessary for site care to prevent infection.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Double-cuff Tenckhoff chronic peritoneal catheters

8

Clean the exit site aseptically.
a. Put on sterile gloves.
b. Pick up dialysis catheter with
nondominant hand.
c. With the antimicrobial-soaked
gauze / swab, cleanse the skin
around the exit site using a circular
motion, starting at the exit site and
then slowly going outward 3 to 4
inches.
d. Gently remove crusted scabs, if
necessary.

Aseptic technique is necessary to prevent infection. The
antimicrobial agent cleanses the skin and removes any
drainage or crust from the wound, reducing the risk for
infection.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

9

10
11

Clean the catheter aseptically.
a. Continue to hold catheter with
nondominant hand.
b. After skin has dried, clean the
catheter with an antimicrobial
soaked gauze, beginning at exit site,
going around catheter, and then
moving up to end of catheter.
c. Gently remove crusted secretions
on the tube, if necessary.
Apply the topical antibiotic to the
catheter exit site, if prescribed.
Apply absorbent dressing over the exit
site.
a. Place sterile drain sponge around
exit site.
b. Place 4x4-gauze over exit site.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Antimicrobial agents cleanse the catheter and remove
any drainage or crust from the tube, reducing the risk
for infection.

Application of mupirocin and gentamicin at catheter
exit site prevents exit site infection and peritonitis.
The drain sponge and 4x4 gauze are use to absorb any
drainage from the exit site. Occlusion of the site with a
dressing deters contamination of site. Once the site is
covered, masks are no longer necessary.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

c. Secure edges of gauze pad with
tape or apply a transparent dressing
over the gauze pads.

12

13

Coil the exposed length of tubing and
secure to the dressing or the patient’s
abdomen with tape.
Assist the patient to a comfortable
position and maintain privacy. Note
patient's response.

14

Perform aftercare. Discard equipment.
Remove PPE and perform hand hygiene.

15

Document the following:
a. Condition of skin surrounding exit site,
e.g. drainage, odor, etc.
b. Patient’s reaction to procedure; and
c. Patient teaching provided.

Anchoring the catheter absorbs any tugging, preventing
tension on and irritation to the skin or abdomen.
This promotes comfort.
The patient’s response may indicate acceptance of the
catheter or the need for health teaching.
Removing PPE reduces the risk for infection
transmission and contamination of other items. Hand
hygiene prevents the spread of microorganisms.
This ensures continuity of care.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

CARE OF PATIENT WITH
MUSCULOSKELETAL SYSTEM
DISORDERS

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Assessing the Musculoskeletal System
Purpose(s):
1. To identify abnormal findings in the musculoskeletal system like muscle atrophy, deformity,
joint swelling, abnormalities of gait.
2. To assess range of motion (ROM).
3. To assess tenderness or pain, warmth, weakness or paralysis, bone enlargement and extremity
strength.
4. To establish a baseline data specific to musculoskeletal system.
Equipment:
• Patient’s gown
• PPE (mask, clean gloves)
Assessment:
1. Assess the patient’s medical record, physician’s orders, and the nursing plan of care to
determine the health care needs of a patient with musculoskeletal impairment.
2. Assess the health history specifically in the musculoskeletal arena, e.g., back pain, joint pain,
arthritis and trauma or accident related.
3. Assess for complications of immobility, including alterations in respiratory function, skin
integrity, urinary and bowel elimination, and muscle weakness, contractures, thrombophlebitis,
pulmonary embolism, and fatigue.
Nursing Diagnosis:
1. Risk for Injury
2. Ineffective Airway Clearance
3. Anxiety
4. Risk for Constipation
5. Impaired Gas Exchange
6. Deficient Knowledge
7. Acute/Chronic Pain
8. Impaired Physical Mobility
9. Risk for Impaired Skin Integrity
10. Self-Care Deficit (bathing, feeding, dressing, or toileting)
11. Impaired Bed Mobility

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

IMPLEMENTATION
Steps
3

Action
Follow Standard Protocol.
f. Verify or Check Doctor’s
Order.
g. Identify the patient.

Rationale
This ensures that the correct intervention is performed
on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.

h. Introduce yourself and explain
the procedure.
i.

Provide privacy.

j.

4

5

6

Perform hand hygiene and put
on PPE, if indicated.
Place the patient in a comfortable
position (sitting, lying or standing)
and appropriately undressed.
Ask for the health history of the
patient like low back pain, neck
and joint pain.

This ensures the patient’s privacy.
Hand hygiene prevents the spread of microorganisms.
For patient’s comfort and best access to visualize the
body part.
Serves as baseline data for further assessment of the
patient’s health problem.

The Temporomandibular Joint (TMJ):

INSPECTION AND PALPATION
a. Inspect the joint for swelling
or redness.
b. Locate and palpate the joint
by placing the tips of your
index fingers just in front of
the tragus of each ear and ask
the patient to open his or her
mouth.

Swelling, tenderness, and decreased range of motion
suggest an inflamed joint.
Dislocation of the TMJ may be seen in trauma.
Swelling, tenderness, and decreased range of motion
suggest arthritis.
Palpable crepitus or clicking may occur in poor
occlusion, meniscus injury, or synovial swelling from
trauma.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

RANGE
OF
MANEUVERS

MOTION

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

AND

c. Ask the patient to perform the
following maneuvers:
− Flexion. Touch the chin to
the chest;
− Extension. Look up at the
ceiling;
− Rotation. Turn the head to
each side, looking directly
over the shoulder; and
− Lateral bending. Tilt the
head, touching each ear to
the
corresponding
shoulder.
d. Ask
the
patient
to
demonstrate
opening
(depression)
and
closing
(elevation), protrusion and
retraction.
7

The Shoulders:
INSPECTION
a. Observe the shoulder and Scoliosis may cause elevation of one shoulder. With
inspect the scapulae. Note any anterior dislocation of the shoulder, the rounded
swelling, deformity, or muscle lateral aspect of the shoulder appears flattened.
atrophy.
PALPATION
b. If there is a history of shoulder
pain, ask the patient to point
to the painful area and palpate
it to identify the structures

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

involved.
RANGE
OF
MOTION
AND
MANEUVERS
c. Ask
the
patient
to Inability to perform these movements may reflect
demonstrate the following for weakness or soft-tissue changes from bursitis,
shoulder girdle ROM: flexion, capsulitis, rotator cuff tears or sprains, or tendinitis.
extension,
abduction,
adduction, internal (medial)
and external (lateral) rotation
and circumduction.

Localized tenderness or pain with adduction suggests
inflammation or arthritis of the acromio-clavicular
joint.
Painful shoulders, localized tenderness arises from
subacromial or subdeltoid bursitis, degenerative
changes or calcific deposits in the rotator cuff.
Swelling suggests a bursal tear with communication
into the articular cavity.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

8

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

The Elbow:
INSPECTION AND PALPATION
a. Inspect the contours of the
elbow, note any nodules or
swelling.
b. Palpate the olecranon process
and press for tenderness and
note
any
displacement,
swelling and thickening.
RANGE
OF
MOTION
AND
MANEUVERS
c. Ask the patient to exhibit
flexion and extension at the
elbow and pronation and
supination of the forearm.

Swelling over the olecranon process in olecranon
bursitis; inflammation or synovial fluid in arthritis.
Tenderness in lateral epicondylitis (tennis elbow) and
in medial epicondylitis (pitcher’s or golfer’s elbow).
The olecranon is displaced posteriorly in posterior
dislocation of the elbow and supracondylar fracture.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

9

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

The Wrist and Hand:
INSPECTION
a. Inspect the palmar and dorsal Diffuse swelling in arthritis or infection; localized
surfaces of the wrist and hand swelling or ganglia from cystic enlargement.
carefully for swelling over the
joints.
PALPATION
b. Palpate the distal radius and
ulna on the lateral and medial
surfaces. Note any swelling, or
tenderness.
c. Squeeze the hand from each
side between the thumb and
fingers. Note any swelling and
tenderness.
RANGE
OF
MOTION
AND
MANEUVERS
d. Assess range of motion for the
wrists, fingers, and thumbs.
Ask
to
exhibit
flexion,
extension,
hyperextension,
abduction and adduction of
the wrists.
Test flexion,
extension,
abduction,
adduction and opposition of
the fingers.

Tenderness over the distal radius in Colles’ fracture.
Any tenderness or bony step-offs are suspicious for
fracture.
Swelling and/or tenderness suggests rheumatoid
arthritis if bilateral and of several weeks’ duration.
Conditions that impair range of motion include
arthritis, tenosynovitis, and Dupuytren’s contracture.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

10

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

The Spine:
INSPECTION
a. Observe the patient’s posture. In scoliosis, there is lateral and rotator curvature of the
spine to bring the head back to midline. Scoliosis often
Examine spinal curvatures.
becomes evident during adolescence, before
symptoms appear.
PALPATION
b. Palpate the spinous processes Tenderness suggests fracture or dislocation if
of each vertebra with the preceded by trauma, underlying infection, or
arthritis. Tenderness occurs with arthritis, especially at
thumb.
c. Inspect and palpate the para- the facet joints between C5 and C6.
vertebral
muscles
for

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

tenderness, spasm, loss of
sensation,
or
impaired
movement.
d. With the hip flexed and the
patient lying on the opposite
side, palpate the sciatic nerve.

Sciatic nerve tenderness suggests a herniated disc or
mass lesion impinging on the contributing roots.

RANGE
OF
MOTION
AND
MANEUVERS
e. Assess range of motion in the
spinal column.
f. Flexion. Ask the patient to
bend forward to touch the
toes.
g. Extension. Ask the patient to
bend backward.
h. Rotation. Rotate the trunk by
pulling the shoulder and then
the hip posteriorly.

Rheumatoid arthritis may also cause tenderness of the
intervertebral joints.
Limitations in range of motion may reflect stiffness
from arthritis, pain from trauma, or muscle spasm such
as torticollis.
Deformity of the thorax on forward bending in
scoliosis.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Persistence of lumbar lordosis suggests muscle spasm
or ankylosing spondylitis.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

11

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

The Hip:
INSPECTION
a. Observe the patient’s gait Changes in leg length are seen in abduction or
adduction deformities and scoliosis. Leg shortening
while entering the room.
b. Observe the lumbar for and external rotation suggest hip fracture.
lordosis.
c. Inspect the hip for any areas
of muscle atrophy or bruising.
PALPATION
d. On the anterior surface locate
the iliac crest, the iliac
tubercle, and the anterior
superior iliac spine.
e. On the posterior surface
identify the posterior superior
iliac spine, the greater
trochanter,
the
ischial
tuberosity, and the sciatic
nerve.
RANGE
OF
MOTION
AND
MANEUVERS
f. Flexion. Ask the patient to
bend each knee in turn up to
the chest and pull it firmly
against the abdomen.
g. Extension. Extend the thigh
toward you in a posterior
direction.
h. Hyperextension.
i. Abduction. Grasp the ankle
and abduct the extended leg
until you feel the iliac spine
move.
j. Adduction. Move the leg

Bulges along the ligament may suggest an inguinal
hernia or, on occasion, an aneurysm.
Enlarged lymph nodes suggest infection in the lower
extremity or pelvis.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

medially across the body and
over the opposite extremity.
k. Rotation. Swing the lower legmedially for internal rotation
at the hip and laterally for
external
rotation
circumduction.

Restricted abduction is common in hip disease from
osteoarthritis.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Abduction

Adduction

Rotation

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

12

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

The Knee and Lower Leg:
INSPECTION
a. Check the alignment and
contours of the knees.
Observe any atrophy of the
quadriceps muscles. Note for
swelling around the knee.
PALPATION
b. Ask the patient to sit on the
edge of the examining table
with the knees in flexion. Place
your thumbs in the soft-tissue
depressions on either side of
the patellartendon. Locate the
patella.
c. Palpate the ligament of the
knee paying special attention
to any areas of tenderness or
pain, thickening, and swelling,
warmth greater than in the
surrounding tissues.
d. Note any irregular bony ridges
along the joint margins.
RANGE
OF
MOTION
AND
MANEUVERS
e. Ask the patient to show
movements of the knee:
− Flexion;
− Extension;
− Internal rotation; and
− External rotation.

Swelling over the patella suggests prepatellar bursitis.
Swelling over the tibial tubercle suggests infrapatellar
or, if more medial, pes anserine bursitis.
Tenderness over the tendon orinability to extend the
leg suggests a partial or complete tear of the patellar
tendon.
Pain and crepitus suggest roughening of the patellar
undersurface that articulates with the femur. Similar
pain may occur with climbing stairs or getting up from
a chair.
Pain with patellar movement during quadriceps
contraction suggests chondromalacia, or degenerative
patella.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

13

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

The Ankle and Foot:
INSPECTION
a. Observe all surfaces of the
ankles and feet, noting any
deformities,
nodules,
or
swellings, and any calluses or
corns.
PALPATION
b. With your thumbs, palpate the
anterior aspect of each ankle
joint, noting any swelling, or
tenderness or pain.
c. Palpate the heel especially the
posterior
and
inferior
calcaneus, and the plantar
fascia for tenderness.
d. Palpate
the
metatarsophalangeal
joints
for
tenderness. Compress the
forefoot between the thumb
and fingers.

Localized tenderness in arthritis, ligamentous injury, or
infection of the ankle.
Pain during movements of the ankle and the foot helps
to localize possible arthritis.
Tenderness on compression is an early sign of
rheumatoid arthritis.
Acute inflammation of the first metatarsophalangeal
joint is associated with gout.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

RANGE
OF
MOTION
AND
MANEUVERS
e. Range of motion at the ankle
joint includes dorsiflexion and
plantar flexion. While in the
foot, inversion and eversion.

14

Document the following:
For continuity of care.
a. Date and time;
b. Abnormal findings like muscle
atrophy,
deformity,
joint
swelling, abnormalities of gait
and range of motion (ROM),
tenderness or pain, warmth,
weakness or paralysis, bone
enlargement and extremity
strength; and
c. Tolerance
and
Patient’s
reaction.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Caring for a Patient in Skin Traction (Lower Extremity)
Purpose(s):
a. To reduce fractures, treat dislocations, correct or prevent deformities, improve or correct
contractures, or decrease muscle spasms.
Equipment:
• Bed with traction frame and trapeze
• Weights
• Velcro straps or other straps
• Rope and pulleys
• Boot with footplate
• Elastic antiembolism stocking, as appropriate
• PPE, as indicated
• Skin cleansing supplies
Assessment:
1. Assess the patient’s medical record, physician’s orders, and the nursing plan of care to determine the
type of traction, traction weight, and line of pull.
2. Assess the traction equipment to ensure proper function, including inspecting the ropes for fraying
and proper positioning.
3. Assess the patient’s body alignment.
4. Perform skin and neurovascular assessments.
5. Assess for complications of immobility, including alterations in respiratory function, skin integrity,
urinary and bowel elimination, and muscle weakness, contractures, thrombophlebitis, pulmonary
embolism, and fatigue.
Nursing Diagnosis:
1.
2.
3.
4.
5.
6.
7.

Risk for Injury
Anxiety
Impaired Gas Exchange
Impaired Bed Mobility
Impaired Physical Mobility
Self-Care Deficit (bathing, feeding, dressing, or toileting)
Ineffective Airway Clearance

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

8. Risk for Constipation
9. Deficient Knowledge
10. Acute Pain
11. Risk for Impaired Skin Integrity
IMPLEMENTATION
Steps
Action
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.

4
5

6

b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy.
e. Perform hand hygiene and put on
PPE, if indicated.
Perform a pain assessment and assess
for muscle spasm.
Check the traction apparatus.
a. Ensure the traction apparatus is
attached securely to the bed.
b. Assess the traction setup.
c. Check that the ropes move freely
through the pulleys.
d. Check that all knots are tight and
are positioned away from the
pulleys.
NOTE: Pulleys should be free from the
linens.
Prepare the patient.
a. Place the patient in a supine
position with the foot of the bed
elevated slightly.
b. The patient’s head should be near
the head of the bed and in
alignment.

Rationale
This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
This ensures the patient’s privacy.
Hand hygiene prevents the spread of microorganisms.
Assessing pain promote patient comfort.

Assessment of traction setup and weights promotes
safety.
Free ropes and pulleys ensure accurate
counterbalance and function of the traction.

Proper patient positioning maintains proper
counterbalance and promotes safety.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

7

Place the traction boot over the
patient’s leg. Be sure the patient’s heel
is in the heel of the boot. Secure the
boot with straps.

8

Apply the prescribed weights.
a. Attach the traction cord to the
footplate of the boot.
b. Pass the rope over the pulley
fastened at the end of the bed.
c. Attach the weight to the hook on
the rope (5 to 10 pounds for an
adult).

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

The boot provides a means for attaching traction
proper application ensures proper pull.

Attachment of weight applies the pull for the traction.

d. Gently let go of the weight.

Gently releasing the weight prevents a quick pull on
the extremity and possible injury and pain.

NOTE: The weight should hang freely,
not touching the bed or the floor.

Properly hanging weights and correct patient
positioning ensure accurate counterbalance and
function of the traction.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

9

Ensure the patient’s alignment with the
traction.

Proper alignment is necessary for proper
counterbalance and ensures patient safety.

10

Ensure correct placement and alignment of
the boot.

Misalignment causes ineffective traction and may
interfere with healing. A properly positioned boot
prevents pressure on the heel.

NOTE: Make sure the line of pull is parallel
to the bed and not angled downward.

11

Place the bed in the lowest position that
still allows the weight to hang freely.

Proper bed positioning ensures effective application of
traction without patient injury.

12

Perform a skin traction assessment per
facility policy.
a. Check the traction apparatus. NOTE: Assessment provides information to determine proper
Line of pull is parallel to the bed and application and alignment, thereby reducing the risk
not angled downward.
for injury. Misalignment causes ineffective traction
and may interfere with healing.
Checking the weights and pulley system ensures
b. Check the weights and pulley
system. NOTE: Weights should hang proper application and reduces the risk for patient
injury from traction application.
freely off the floor and bed, knots
should be secure, ropes should
move freely through the pulleys,
and pulleys should not be
constrained by knots.
This helps detect signs of abnormal neurovascular
c. Examine the affected body part
function and allows for prompt intervention. Assessing
NOTE: Use the Neurovascular
neurovascular status determines the circulation and
Assessment Chart.
oxygenation of tissues. Pressure within the traction
d. Maintain proper body alignment.
NOTE: Patient should be positioned boot may increase with edema.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

in the center of the bed, with the
affected leg aligned with the trunk
of the patient’s body.

e. Perform skin assessment (e.g., skin
breakdown, abrasions, or pressure
ulcers).
Put on clean gloves. Remove the straps
every 4 hours per the physician’s order
or facility policy. Remove the boot, per
physician’s order or facility policy, every
8 hours. Provide skin care. Wash, rinse,
and thoroughly dry the skin.

Skin assessment provides early intervention for skin
irritation, impaired tissue perfusion, and other
complications.
Removing the straps provides assessment information
for early detection and prompt intervention of
potential complication should they arise. Washing the
area enhances circulation to skin; thorough drying
prevents skin breakdown.

14

Replace the traction boot and remove
gloves and dispose of them
appropriately.

Replacing traction is necessary to provide
immobilization and facilitate healing. Proper disposal
of gloves prevents the transmission of microorganisms.

15

Document the following:
a. Time;
b. Date;
c. Type of traction;
d. Amount of weight used;
e. Skin assessments;
f. Patient’s response to the traction;
and
g. Neurovascular status of the
extremity.

13

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Neurovascular Assessment Chart
Extremity
Right Leg
Right Arm
Left Leg
Left Arm

Skin Edema
Absent (0)
Slight (1+)
Moderate
(2+)
Severe (3+)

Skin Color
Flushed
Normal/Pinkish
Pale
Cyanotic
Jaundiced
Dusky
Mottled

Capillary Refill
Time
Normal (less
than 2
seconds)
Sluggish/
Delayed
(more than 2
seconds)
Absent

Sensation

Motion

Normal
Tingling
Decreased
Absent

Full
Decreased
Absent
Painful
Immobile

Peripheral Pulse (Distal)
Absent
Doppler/Auscultation
1+ Intermittent
2+ Weak
3+ Normal/Strong
4+ Bounding
Not Accessible

Skin Temperature
Warm
Cool
Cold
Hot

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Caring for a Patient in Skeletal Traction (Lower Extremity)
Purpose(s):
a. To immobilize a body part for prolonged periods.
Equipment:
Sterile gloves
Sterile applicators
Cleansing agent for pin care, usually sterile normal saline or chlorhexidine, per physician order or facility
policy
• Sterile container
• Antimicrobial ointment, if ordered
• Foam, nonstick, or gauze dressing, per medical order or facility policy
• PPE, as indicated
Assessment:




1. Assess the patient’s medical record, physician’s orders, and the nursing plan of care to determine the
type of traction, traction weight, and line of pull.
2. Assess the traction equipment to ensure proper function, including inspecting the ropes for fraying and
proper positioning.
3. Assess the patient’s body alignment.
4. Perform skin and neurovascular assessments.
5. Assess for complications of immobility, including alterations in respiratory function, skin integrity,
urinary and bowel elimination, and muscle weakness, contractures, thrombophlebitis, pulmonary
embolism, and fatigue.
Nursing Diagnosis:
1.
2.
3.
4.
5.
6.
7.

Risk for Injury
Ineffective Airway Clearance
Anxiety
Risk for Constipation
Impaired Gas Exchange
Deficient Knowledge
Impaired Bed Mobility

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

8. Acute Pain
9. Impaired Physical Mobility
10. Risk for Impaired Skin Integrity
11. Self-Care Deficit (bathing, feeding, dressing, or toileting)
IMPLEMENTATION
Steps:
Action
Rationale
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
This ensures that the correct intervention is performed
on the correct patient.
Identifying the patient ensures the right patient receives
b. Identify the patient.
c. Introduce yourself and explain the the intervention and helps relive anxiety.
procedure.
d. Provide privacy.
This ensures the patient’s privacy.
Hand hygiene prevents the spread of microorganisms.
e. Perform hand hygiene and put on
PPE, if indicated.
4
Perform a pain assessment and assess Assessing pain and administering analgesics promote
for muscle spasm.
patient comfort.

5

NOTE: Administer prescribed
medications in sufficient time to allow
for the full effect of the analgesic
and/or muscle relaxant.
Check the traction apparatus.
a. Ensure the traction apparatus is
attached securely to the bed.
b. Assess the traction setup.
c. Check that the ropes move freely
through the pulleys.
d. Check that all knots are tight and
are positioned away from the
pulleys.
NOTE: Pulleys should be free from the
linens.

Assessment of traction setup and weights promotes
safety.
Free ropes and pulleys ensure accurate counterbalance
and function of the traction. Skin assessment provides
early intervention for skin irritation, impaired tissue
perfusion, and other complications.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

6
7

Check the alignment of the patient’s
body, as prescribed.
Apply the prescribed weights.
a. Attach the traction cord to the
Steinman pin holder.
b. Pass the rope over the pulley and
fastened at the end of the bed.
c. Attach the weight to the hook on
the rope.

d. Gently let go of the weight.

NOTE: The weight should hang freely,
not touching the bed or the floor.

8

9

10

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Proper alignment maintains an effective line of pull and
prevents injury.

Attachment of weight applies the pull for the traction.

Gently releasing the weight prevents a quick pull on the
extremity and possible injury and pain.

Properly hanging weights and correct patient positioning
ensure accurate counterbalance and function of the
traction.
Perform a skin assessment on pressure Skin assessment provides early intervention for skin
points. (This includes ischial tuberosity, irritation, impaired tissue perfusion, and other
popliteal space, Achilles’ tendon,
complications.
sacrum, and heel.)
Perform a neurovascular assessment.
Neurovascular assessment aids in early identification and
allows for prompt intervention should compromised
circulation and oxygenation of tissues develop.
Perform pin site assessment.
a. Check for redness, edema, and
Pin sites provide a possible entry for microorganisms.
odor.
b. Check for skin tenting, prolonged
Skin inspections allow for early detection and prompt

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

11

or purulent drainage.
c. Check for elevated body
temperature.
d. Check for elevated pin site
temperature.
e. Check for bowing or bending of the
pins.
Provide pin site care.
a. Using sterile technique, open the
applicator package and pour the
cleansing agent into the sterile
container.
b. Put on sterile gloves.
c. Place the applicators into the
solution.
d. Clean the pin site starting at the
insertion area and working
outward, away from the pin site.
e. Use each applicator once.
f. Use a new applicator for each pin
site.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

intervention should complications develop.

Performing pin site care prevents crusting at the site that
could lead to fluid buildup, infection, and osteomyelitis.
Using sterile technique reduces the risk for transmission
of microorganisms.
Gloves prevent contact with blood and/or body fluids

Cleaning from the center outward ensures movement
from the least to most contaminated area. Using an
applicator once reduces the risk of transmission of
microorganisms.

Steinman pin and holder

12

Cleaning around pin sites with
normal saline on an applicator.
Apply an antimicrobial ointment to pin
sites and apply a dressing.

Antimicrobial ointment helps reduce the risk of infection.
A dressing aids in protecting the pin sites from
contamination and contains any drainage.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

13

Remove gloves and any other PPE, if
used. Perform hand hygiene.

14

Perform range-of-motion exercises on
all joint areas, unless contraindicated.
Encourage the patient to cough and
deep breathe every 2 hours.
Document the following:
a. Time;
b. Date;
c. Type of traction;
d. Amount of weight used;
e. Skin and pin site assessments;
f. Pin site care;
g. Patient’s response to the traction;
and
h. Neurovascular status of the
extremity.

15

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Removing PPE decreases the risk for infection
transmission and contamination of other items. Hand
hygiene prevents the spread of microorganisms.
Range-of-motion exercises promote joint mobility.
Coughing and deep breathing reduce the risk of
respiratory complications related to immobility.
This ensures continuity of care.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Neurovascular Assessment Chart
Extremity
Right Leg
Right Arm
Left Leg
Left Arm

Skin Edema
Absent (0)
Slight (1+)
Moderate
(2+)
Severe (3+)

Skin Color
Flushed
Normal/Pinkish
Pale
Cyanotic
Jaundiced
Dusky
Mottled

Capillary Refill
Time
Normal (less
than 2
seconds)
Sluggish/
Delayed
(more than 2
seconds)
Absent

Sensation

Motion

Normal
Tingling
Decreased
Absent

Full
Decreased
Absent
Painful
Immobile

Peripheral Pulse (Distal)
Absent
Doppler/Auscultation
1+ Intermittent
2+ Weak
3+ Normal/Strong
4+ Bounding
Not Accessible

Skin Temperature
Warm
Cool
Cold
Hot

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Care of Patient With Immobilization Device (Cast, Splint, or Collar Brace/Cervical Orthosis)
Purpose(s):
a. To prevent complication specific to immobility.
Equipment:
Commercial collar brace
Cotton bandage (e.g. Webril®) for padding
Plaster slabs or rolls or prepadded fiberglass splint material (e.g. OCL® and Orthoglass®) of various widths
(2, 3, 4, and 6 inches)
• Room temperature water
• Elastic bandage (e.g. Ace® bandage)
• Medical adhesive tape
Assessment:




1. Assessment of the patient’s general health, presenting signs and symptoms, emotional status and
understanding of the need for the device and condition of the body parts to be immobilized.
2. Physical assessment of the body parts to be immobilized must include neurovascular assessment, pain and
skin abrasions.
3. The nurse gives the patient information about the underlying pathologic condition and the purpose and
expectation of the prescribed treatment regimen.
Nursing Diagnosis:
1.
2.
3.
4.
5.

Impaired physical mobility
Risk for disuse syndrome
Anxiety
Deficient knowledge
Risk for Peripheral Neurovascular Dysfunction

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

IMPLEMENTATION
Steps:
Action
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy and position
comfortably.
e. Perform hand hygiene and put on
PPE.

4

5

6

Rationale
This ensures that the correct intervention is performed on
the correct patient.
Identifying the patient ensures the right patient receives the
intervention and helps relive anxiety.
This ensures the patient’s privacy.

Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on Transmission
Precautions.
Obtain baseline neurovascular
Assessment for adequate nerve functions and blood
assessment.
circulation to the parts of the body.
Part I: Application of Collar Brace
Patient lying down:
This allows correct application of the device.
a. Position arms to the side,
shoulders down and head aligned
centrally.
b. Slide the back carefully behind the
patient’s neck. Make sure it is
centered evenly.
c. Fasten the straps to the front of
the collar.
Patient sitting:
a. Patient should sit up straight on a
firm chair.
b. The head and neck should be in
neutral position (nose in line with
umbilicus and chin level).
c. Front of the collar should be
directed up toward the patient´s
ears.
d. Chin should be centered
comfortably on the chin piece.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

7

5
6

7

8

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

e. Fasten the straps.
When removing the collar, note the
position of the ends of the straps.
NOTE: Use a pen to mark the positions
on the plastic shell.
Part II: Application of Plaster Splint
Expose the extremity completely
This ensures ease of application.
before the splint is applied.
Immobilize at the joint.
This ensures correct application.
a. Immobilize the joints above and
below the fracture.
b. Immobilize the bones above and
below the dislocated joint.
Wrap cotton bandage (eg, Webril®)
About 24 to 48 hours are required for drying of a plaster
around the extremity in a distal to
cast. Dries from the outside inward, so many appear dry but
proximal fashion; overlap each turn to
is still moldable with movement of pressure.
cover the previous one by 50%. NOTE:
Be careful to avoid wrinkles because
they can create pressure points.
Extend the padding 2 to 3 cm beyond
the area to be splinted. NOTE: If
stockinette has been used, extend it
beyond the proximal and distal edges
of the cotton bandage.
Prepare the plaster slab.
a. Measure the plaster strips and cut
to length.
b. Cut the strips slightly longer than
necessary so they can be folded
back on themselves to create a
smooth edge and to allow for
contracture of the plaster as it
crystallizes.
c. Use approximately 8 to 10 layers

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

9
10

5

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

for an upper extremity splint and
12 to 14 layers for a lower
extremity splint. NOTE: The risk of
thermal injury occurring is related
directly to the number of plaster
layers.
d. Immerse the plaster in water at
room-temperature and then place
it on an open towel to remove
excess water and smooth the
plaster.
Apply the plaster to the extremity,
molding it to the extremity.
Wrap an elastic bandage (Ace® wrap)
around the extremity, distal to
proximal, to secure the plaster to the
extremity.
NOTE: Keep the limb in the desired
position until the plaster hardens.
Instruct the patient to keep the
affected part still until dry. Support the
curves of the cast with pillows. Avoid
excessive handling of the cast, and use
palms when handling it.
Part III: Application of Fiberglass Splint
Cut the fiberglass splint to the proper
This ensures correct application.
length (e.g. slightly longer than
necessary so it can be folded back on
itself to create a smooth edge).
NOTE: If the optional stockinette is to
be used, stretch and smooth it over the
extremity; extend the stockinette
beyond the proximal and distal edges
of the area to be splinted.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

6

Immerse the fiberglass splint in roomThis ensures correct application.
temperature water and then place it on
an open towel to remove excess water.
7
Apply the fiberglass splint to the
This ensures correct application.
extremity and mold it to the desired
shape; stretch the padding material
over the proximal and distal edges of
the splint to prevent sharp edges.
8
Apply an elastic bandage to hold the
This ensures correct application.
splint in place.
Nursing Care
Pressure or friction may disrupt skin integrity. May be
Assess the skin around edges of the device
daily for:
readily visible or occur under the device and not detected
a. Signs of skin irritation (especially over bony until advanced. Braces can be altered if skin irritation
becomes apparent.
areas like the chin, clavicles, or back of the
head with the use of a collar brace);
b. Abrasions;
c. Possible infections from loose or ill-fitting
splints;
d. Contact dermatitis;
e. Pressure sores; and
f. Thermal burns (from heat released during
setting of plaster).
Assess neurovascular status frequently after
Initial swelling from the injury may contribute to a vascular
application of device (e.g. tight-fitting splints), insufficiency or nerve compression.
then daily to detect compromise.
NOTE: Check splints 24 to 48 hours after
application to ensure adequate fit and
neurovascular integrity, evaluating for the five
Ps (pallor, pain, paresthesia, pulselessness, and
paralysis).
Teach patient to report any signs of:
This ensures meticulous care.
a. Redness;
b. Skin breakdown;
c. Localized pain;

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

d. Foul odor that may indicate open wounds
under device; and
e. Swelling.
NOTE: Ask the patient to keep the extremity
elevated, iced, and rested until reevaluation.
Remove PPE and perform hand hygiene.

Document assessment findings, procedure and
patient response.

Removing PPE reduces the risk for infection transmission
and contamination of other items. Hand hygiene prevents
the spread of microorganisms.
This ensures continuity of care.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Neurovascular Assessment Chart
Extremity
Right Leg
Right Arm
Left Leg
Left Arm

Skin Edema
Absent (0)
Slight (1+)
Moderate
(2+)
Severe (3+)

Skin Color
Flushed
Normal/Pinkish
Pale
Cyanotic
Jaundiced
Dusky
Mottled

Capillary Refill
Time
Normal (less
than 2
seconds)
Sluggish/
Delayed
(more than 2
seconds)
Absent

Sensation

Motion

Normal
Tingling
Decreased
Absent

Full
Decreased
Absent
Painful
Immobile

Peripheral Pulse (Distal)
Absent
Doppler/Auscultation
1+ Intermittent
2+ Weak
3+ Normal/Strong
4+ Bounding
Not Accessible

Skin Temperature
Warm
Cool
Cold
Hot

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Applying a Sling
Purpose(s):
a. To provide support for an arm or immobilize an injured hand.
Equipment:
• Commercial arm sling
• ABD (adhesive bandage) gauze pad
• Nonsterile gloves and/or other PPE, as indicated
Assessment:
1.
2.
3.
4.

Assess the situation to determine the need for a sling.
Assess the affected limb for pain and edema.
Perform a neurovascular assessment of the affected extremity.
Assess body parts distal to the site for cyanosis, pallor, coolness, numbness, tingling, swelling, and absent
or diminished pulses.

Nursing Diagnosis:
1.
2.
3.
4.
5.
6.

Impaired Physical Mobility
Risk for Peripheral Neurovascular Dysfunction
Risk for Impaired Skin Integrity
Acute Pain
Dressing Self-Care Deficit
Risk for Injury

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

IMPLEMENTATION
Steps:

3

Action

Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy.
e. Perform hand hygiene and put on
PPE.

4

5

Assist the patient to a sitting position.
Place the patient’s forearm across the
chest with the elbow flexed and the
palm against the chest. Measure the
sleeve length, if indicated.
Enclose the arm in the sling, making
sure the elbow fits into the corner of
the fabric.

Placing the patient’s arm into the
canvas sling with the elbow flush in the
corner of the sling.

Rationale

This ensures that the correct intervention is performed on
the correct patient.
Identifying the patient ensures the right patient receives
the intervention and helps relive anxiety.
This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on Transmission
Precautions.
Proper positioning facilitates sling application.
Measurement ensures proper sizing of the sling and proper
placement of the arm.

This position ensures adequate support and keeps the arm
out of a dependent position, preventing edema.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

6

7

Run the strap up the patient’s back and
across the shoulder opposite the injury,
then down the chest to the fastener on
the end of the sling.

Placing the strap around the patient’s
neck.
Place the ABD pad under the strap,
between the strap and the patient’s
neck.

Placing padding between the strap and
the patient’s neck.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

This ensures correct application.

Padding prevents skin irritation and reduces pressure on
the neck. Proper positioning ensures alignment, provides
support, and prevents edema.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

8
9

10

11

Patient with sling in place.
Place the bed in the lowest position,
with the side rails up.
Remove PPE, if used. Perform hand
hygiene.
Assess for:
a. Patient’s level of comfort;
b. Arm positioning;
c. Neurovascular status of the
affected limb every 4 hours or
according to facility policy; and
d. Axillary and cervical skin frequently
for irritation or breakdown.
Document the following:
a. Time and date the sling was
applied;
b. Patient’s response to the sling; and
c. Neurovascular status of the
extremity.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

This ensures patient safety.
Removing PPE reduces the risk for infection transmission
and contamination of other items. Hand hygiene prevents
the spread of microorganisms.
Frequent assessment ensures patient safety, prevents
injury, and provides early intervention for skin irritation and
other complications.

This ensures continuity of care.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Assisting With Cast Application
Purpose(s):
a. To immobilize and hold bone fragments after sustaining an injury or fracture.
Equipment:
Casting materials, such as plaster rolls or fiberglass, depending on the type of cast being applied
Padding material, such as stockinette, sheet wadding, or Webril, depending on the type of cast being
applied
• Plastic bucket or basin filled with warm water
• Disposable, nonsterile gloves and aprons
• Scissors
• Waterproof, disposable pads
• PPE, as indicated
Assessment:



1. Assess the skin condition in the affected area, noting redness, contusions, or open wounds.
2. Assess the neurovascular status of the affected extremity, including distal pulses, color, temperature,
presence of edema, capillary refill to fingers or toes, and sensation and motion.
3. Perform a pain assessment. (If the patient reports pain, administer the prescribed analgesic in sufficient
time to allow for the full effect of the medication.)
4. Assess for muscle spasms. (Administer the prescribed muscle relaxant in sufficient time to allow for the
full effect of the medication.)
5. Assess for the presence of disease processes that may contraindicate the use of a cast or interfere with
wound healing, including skin diseases, peripheral vascular disease, diabetes mellitus, and open or
draining wounds.
Nursing Diagnosis:
1.
2.
3.
4.
5.
6.
7.
8.

Risk for Impaired Skin Integrity
Acute Pain
Impaired Physical Mobility
Risk for Injury
Risk for Peripheral Neurovascular Dysfunction
Anxiety
Disturbed Body Image
Ineffective Peripheral Tissue Perfusion

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

9. Deficient Knowledge

IMPLEMENTATION
Steps
Action
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy and position
comfortably.
e. Perform hand hygiene and put on PPE.

4

5
6
7

8

Perform a pain assessment. Administer
prescribed medications. Orally (PO), 30 to 40
minutes before, IM, 20 to 30 minutes
before, IV, 2 to 5 minutes before.
If the bed is adjustable, raise it to a
comfortable working height.
Assist the doctor in positioning the patient
and the injured extremity.
Spread waterproof pads. Cleanse (mild soap)
and dry the affected body part or change
dressing if present.
Assist with the application of padding
materials (cotton roll / stockinette) around
body part to be casted. Avoid wrinkles or
uneven thickness.

Rationale
This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
Assessment of pain and analgesic administration
ensure patient comfort and enhance cooperation.

Having the bed at the proper height prevents back
and muscle strain.
This ensures safety.
To protect the gown and bed sheet from being wet.
Skin care before cast application helps prevent skin
breakdown.
Stockinette and other materials protect the skin from
casting materials preventing skin irritation and
abrasion.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

9

10

11

12

13

Assist with preparation of the cast. Dip
plaster bandage in water for a minute until
bubbles stop. Remove excess water by
squeezing slightly.
Continue to position the affected body part
as indicated by the physician. Apply the cast
from distal end to proximal, roll the bandage
gently.
Using scissors or knife, trim the cast around
fingers, toes, or thumb as necessary. Fold the
stockinette or cotton roll over the cast.
Handle hardening plaster casts with the
palms of hands and elevate the injured
casted limb above heart level with pillow and
allow drying.

Remove PPE and perform hand hygiene.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Cessation of bubbles signals that the cast is now
ready to be applied.

To promote venous return/blood circulation.

Smooth edges lessen the risk for skin irritation and
abrasion.
Proper handling avoids denting of the cast and
development of pressure areas.
Elevation promotes venous return.

Removing PPE reduces the risk for infection
transmission and contamination of other items. Hand
hygiene prevents the spread of microorganisms.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

14

15

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Check the neurovascular status in the first Assessment of complications.
24 hours. Monitor the patient for any
alteration in:
a. Sensation;
b. Numbness;
c. Tingling sensation; and
d. Severe pain or inability to move fingers
or toes in affected extremities.
Document the following
This ensures continuity of care.
a. Date and time;
b. Type of cast used;
c. Location/site;
d. Analgesic given/route;
e. Reaction of the patient;
f. Name of person who applied the cast;
and
g. Relevant assessment and intervention.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Neurovascular Assessment Chart
Extremity
Right Leg
Right Arm
Left Leg
Left Arm

Skin Edema
Absent (0)
Slight (1+)
Moderate
(2+)
Severe (3+)

Skin Color
Flushed
Normal/Pinkish
Pale
Cyanotic
Jaundiced
Dusky
Mottled

Capillary Refill
Time
Normal (less
than 2
seconds)
Sluggish/
Delayed
(more than 2
seconds)
Absent

Sensation

Motion

Normal
Tingling
Decreased
Absent

Full
Decreased
Absent
Painful
Immobile

Peripheral Pulse (Distal)
Absent
Doppler/Auscultation
1+ Intermittent
2+ Weak
3+ Normal/Strong
4+ Bounding
Not Accessible

Skin Temperature
Warm
Cool
Cold
Hot

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Caring for a Cast
Purpose(s):
1. To immobilize a body part in a specific position.
2. To apply uniform pressure on the encased soft tissue.
Equipment:
• Washcloth
• Towel
• Skin cleanser
• Basin of warm water
• Waterproof pads
• Tape
• Pillows
• Nonsterile gloves
Assessment:
1. Review the patient’s medical record and nursing plan of care to determine the need for cast care and care
of the affected area.
2. Perform a pain assessment and administer the prescribed medication in sufficient time to allow for the
full effect of the analgesic before starting care.
3. Assess the neurovascular status of the affected extremity, including distal pulses, color, temperature,
presence of edema, capillary refill to fingers or toes, and sensation and motion.
4. Assess the skin distal to the cast. Note any indications of infection, including any foul odor from the cast,
pain, fever, edema, and extreme warmth over an area of the cast.
5. Assess for complications of immobility, including alterations in skin integrity, reduced joint movement,
decreased peristalsis, constipation, alterations in respiratory function, and signs of thrombophlebitis.
6. Inspect the condition of the cast. Be alert for cracks, dents, or the presence of drainage from the cast.
7. Assess the patient’s knowledge of cast care.
Nursing Diagnosis:
1.
2.
3.
4.
5.
6.

Disturbed Body Image
Risk for Injury
Risk for Disuse Syndrome
Deficient Knowledge
Impaired Physical Mobility
Risk for Peripheral Neurovascular Dysfunction

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

7. Self-Care Deficit (bathing, feeding, dressing or toileting)
8. Acute Pain
9. Risk for Falls
10. Impaired Tissue Perfusion
11. Risk for Impaired Skin Integrity
IMPLEMENTATION
Steps
Action
Rationale
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
b. Identify the patient.
receives the intervention and helps relive anxiety.
c. Introduce yourself and explain the
procedure.
d. Provide privacy.
This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of
e. Perform hand hygiene and put on PPE if
indicated.
microorganisms. PPE is required based on
Transmission Precautions.
4
Elevate the affected area on pillows.
Elevation helps reduces edema and enhances
venous return.

5
6

Keep cast (plaster) uncovered until fully dry.

To allow heat and moisture to dissipate and air to
circulate to speed drying.
Assess the condition of the cast. Perform skin Assessment helps detect abnormal neurovascular
and neurovascular assessment every 1 to 2 function and allows for prompt intervention.
hours. Check for:
a. Pain;
b. Edema;

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

c. Inability to move body parts distal to the
cast; Pallor;
d. Pulses; and
e. Abnormal sensations.

7

If bleeding or drainage is noted on the cast, mark Marking the area provides a baseline for
the area on the cast. Indicate the date and time monitoring the amount of bleeding or drainage.
next to the area.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

8

9

Assess for signs of infection. Monitor the
following:
a. Patient’s temperature;
b. Foul odor from the cast; and
c. Increased pain.
Advise patient to avoid getting plaster cast wet
and never insert any object into the cast for any
purpose, e.g. scratch skin under cast.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Assessment allows for early detection and prompt
intervention. Infection deters healing.

Cast will disintegrate / deform when in contact
with water.
To prevent skin breakdown and infection.

10

11

12

13

14

Observe for symptoms of compartment
syndrome:
a. Pain;
b. Pallor (color);
c. Pulselessness;
d. Paresthesia (sensation and motion); and
e. Paralysis.
Teach patient how to clean the cast. Use a damp
cloth and mild cleanser to clean dirty spots on
the cast.
Remove PPE and perform hand hygiene.

Encourage range-of-motion exercises for
unaffected joints. Reposition the patient every 2
hours.
Document the following:
a. Assessments and care provided;

Removing PPE reduces the risk for infection
transmission and contamination of other items.
Hand hygiene prevents the spread of
microorganisms.
Promotes joint function of unaffected areas.
Promotes drying and prevents pressure ulcer.
This ensures continuity of care.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

b. Patient’s response to the cast;
c. Repositioning, and
d. Any teaching.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Neurovascular Assessment Chart
Extremity
Right Leg
Right Arm
Left Leg
Left Arm

Skin Edema
Absent (0)
Slight (1+)
Moderate
(2+)
Severe (3+)

Skin Color
Flushed
Normal/Pinkish
Pale
Cyanotic
Jaundiced
Dusky
Mottled

Capillary Refill
Time
Normal (less
than 2
seconds)
Sluggish/
Delayed
(more than 2
seconds)
Absent

Sensation

Motion

Normal
Tingling
Decreased
Absent

Full
Decreased
Absent
Painful
Immobile

Peripheral Pulse (Distal)
Absent
Doppler/Auscultation
1+ Intermittent
2+ Weak
3+ Normal/Strong
4+ Bounding
Not Accessible

Skin Temperature
Warm
Cool
Cold
Hot

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Care of a Patient During Cast Removal
Purpose(s):
a. To ensure that the cast is removed properly and that patient will experience mild or no pain.
Equipment:
• Cast cutter
• Felt pen
• White sheet
• Scissors
• Cast spreader
• Soap and water
• Lotion
• Dressing (for open wound)
• Disposable gloves
• Eye shield
Assessment:
1. Assess the skin condition in the affected area, noting redness, contusions, abrasions or open
wounds.
2. Assess the neurovascular status of the affected extremity: pain; pallor (color); pulselessness;
paresthesia (sensation and motion); and paralysis.
3. Check for presence of edema, capillary refill to fingers or toes and temperature.
4. Perform a pain assessment. (Administer analgesic as prescribed.)
Nursing Diagnosis:

1.
2.
3.
4.
5.

Risk for Impaired Skin Integrity
Acute Pain
Impaired Physical Mobility
Ineffective Peripheral Tissue Perfusion
Risk for Injury
6. Risk for infection

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

IMPLEMENTATION
Steps:
Action
3
Follow Standard Protocol.
a. Verify or Check Doctor’s Order.
b. Identify the patient.
c. Introduce yourself and explain the
procedure.
d. Provide privacy and position
comfortably.
e. Perform hand hygiene and put on
PPE.
4

Inform the patient to shield the eyes.

5

Determine where the cut will be made,
mark with a felt pen.
Hold firmly the cast cutter. Put thumb on
the cast.
Turn on electric cast cutter. Push blade
firmly and gently through the cast.

6
7

NOTE: A sudden lack of resistance is felt as
the blade cuts the plaster.

Rationale
This ensures that the correct intervention is
performed on the correct patient.
Identifying the patient ensures the right patient
receives the intervention and helps relive anxiety.
This ensures the patient’s privacy.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
Transmission Precautions.
Promotes patient’s safety. Plaster dust maybe
irritating to the eyes.
The mark will serve as guide in cutting the cast.
The thumb acts as a guard in front of the blade.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

8

Cut the cast on both sides.

9

Insert blades of cast spreader in the cut
through. Separate the two halves of cast
with hands.

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

Cutting both sides facilitates easy removal of the
cast.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

10

Cut padding and stockinette with scissors.

11

Inspect the skin after the cast has been
removed.
Provide skin care.
a. If skin is intact, apply mild cleanser to To prevent skin irritation.
skin.
b. Gently wash off cleanser with water.
c. Pat extremity gently dry and apply Prevents skin dryness and irritation.
thin coat of skin lotion.

12

13

14

15

NOTE: Do not scrub the skin. Warn
patient against scratching the skin.
Obtain doctor’s order to perform active
and passive range of motion (ROM) and
clarify level of activity allowed.
If with edema, apply cloth-covered ice
bags. Do not place ice directly. Elevate
affected extremity for the next 24 hours.
Remove PPE and perform hand hygiene.
Document the following:
a. Assessments and care provided;
b. Patient’s response to the procedure;
c. Date and time;
d. Name of person who removed the
cast; and
e. Nursing assessment and intervention.

Use bandage scissors, place the flat blade closest
to the skin.
To note areas of irritation or breakdown that may
require treatment.

Prevents muscle atrophy.

To promote venous return and prevent edema.

Removing PPE reduces the risk for infection
transmission and contamination of other items.
Hand hygiene prevents the spread of
microorganisms.
This ensures continuity of care.

KINGDOM OF SAUDI ARABIA
Ministry of Higher Education
University of Ha’il
College of Nursing

‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬
‫وزارة اﻟﺘﻌﻠﯿﻢ اﻟﻌﺎﻟﻲ‬
‫ﺟﺎﻣـﻌـﺔ ﺣـﺎﺋﻞ‬
‫ﻛﻠﯿﺔ اﻟﺘﻤﺮﯾﺾ‬

References

1. Lynn, P. (2011). Taylor’s clinical nursing skills: A nursing process approach (3rd ed). China: Lippincott
Williams & Wilkins, pp. 841-845.
2. Drew, B. J., et. al. (2004). Practice standards for electrocardiographic monitoring in hospital
settings. Circulation; 110: 2721-2746. doi: 10.1161/01.CIR.0000145144.56673.59
3. Davis, M. D., et. al. (1992). AARC clinical practice guideline: Sampling for arterial blood gas analysis.
Respiratory Care Journal; 8(37): 891–897. doi: 10.4187/respcare.02786
4. Pamela Lynn, Taylor Clinical Nursing Skills, A Nursing Process Approach, 3rd Edition 2011, LWW

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