Taylor's Handbook of Clinical Nursing Skills

Taylor’s Handbook of
Clinical Nursing Skills
Pamela Lynn, msn, rn

Instructor
School of Nursing
Gwynedd-Mercy College
Gwynedd Valley, Pennsylvania
Executive Acquisitions Editor: Carrie Brandon

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Copyright © 2011 by Wolters Kluwer Health / Lippincott Williams & Wilkins.
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Library of Congress Cataloging-in-Publication Data
Lynn, Pamela Barbara, 1961-

Taylor’s handbook of clinical nursing skills / Pamela Lynn. — 1st ed.
p. ; cm.
Other title: Handbook of clinical nursing skills
Abridgement of: Taylor’s clinical nursing skills / Pamela Lynn. 3rd ed.
© 2011.
ISBN 978-1-58255-735-9 (alk. paper)
1. Nursing—Handbooks, manuals, etc. I. Taylor, Carol, CSFN. II. Lynn,
Pamela Barbara, 1961- Taylor’s clinical nursing skills.
III. Title. IV. Title: Handbook of clinical nursing skills.
[DNLM: 1. Nursing Process—Handbooks. 2. Clinical
Medicine—methods—Handbooks. 3. Nursing Care—methods—Handbooks. WY
49] RT51.L96 2011
610.73—dc22
2010032323
Care has been taken to confirm the accuracy of the information presented and to describe
generally accepted practices. However, the authors, editors, and publisher are not responsible
for errors or omissions or for any consequences from the application of the information in
this book and make no warranty, express or implied, with respect to the content of the
publication.
The authors, editors, and publisher have exerted every effort to ensure that drug selection
and dosage set forth in this text are in accordance with the current recommendations and
practice at the time of publication. However, in view of ongoing research, changes in govern
ment regulations, and the constant flow of information relating to drug therapy and drug re
actions, the reader is urged to check the package insert for each drug for any change in
indications and dosage and for added warnings and precautions. This is particularly impor
tant when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have U.S. Food and Drug
Administration (FDA) clearance for limited use in restricted research settings. It is the re
sponsibility of the healthcare provider to ascertain the FDA status of each drug or device
planned for use in his or her clinical practice.
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Contributors and Reviewers
Beaumont, Texas
CONTRIBUTORS
Patti Simmons, RN, MN,
Lynn Burbank, RN, CPNP, MSN
CHPN Assistant Professor of
Learning Resource Coordinator
Nursing North Georgia College
Dixon School of Nursing
and State University
Abington Memorial
Dahlonega, Georgia
Hospital Abington,
Pennsylvania
Diane E. Witt, RN, PhD,
Medications
CNP Assistant Professor
REVIEWERS
School of Nursing
Rose A. Harding, MSN, RN Minnesota State
Instructor University Mankato,
Lamar University Minnesota
JoAnne Gay Dishman
Department of Nursing
iv
Preface
Taylor’s Handbook of Clinical Nursing Skills is a quick-reference
guide to basic and advanced nursing skills. It outlines step-by-step
instructions and reinforces the cognitive and technical knowledge
needed to perform skills safely and effectively. The convenient
handbook format is helpful for student review in the lab or clinical
setting and as a reference for graduate nurses in practice.
LEARNING EXPERIENCE
This text and the entire Taylor Suite have been created with the
student’s experience in mind. Care has been taken to appeal to all
learning styles. The student-friendly writing style ensures that students
will comprehend and retain information. The extensive art program
enhances understand
ing of important actions. In addition, each element of the Taylor Suite,
which is described later in the preface, coordinates the information to
provide a consistent and cohesive learning experience.
ORGANIZATION
In general, the content of this book provides streamlined skills
consistent with those in Taylor’s Clinical Nursing Skills, 3rd Edition.
Skills are or ganized alphabetically, based on the main word(s) of the
skill, allowing the user to access the information about the desired skill
quickly and easily.
FEATURES
• Step-by-Step Skills. Each skill is presented in a concise, straight
forward, and simplified two-column format to facilitate competent
performance of nursing skills.
• The nursing process framework is used to integrate related nursing
responsibilities for each of the five steps.
• Scientific rationales accompany each nursing action to promote a
deeper understanding of the basic principles supporting nursing
care.
yg
• Hand hygiene icons alert you to this crucial step that is the best
wa
way to prevent the spread
of microorganisms.
• Patient i
• Patient identification icons alert you to this crucial step ensuring
the
the right patient receives the intervention and helping pre
ve
vent errors.
v
• Documentation guidelines direct students and graduate nurses in
accurate documentation of the skill and their findings.
• General considerations appear throughout to explain the varying
needs of patients across the lifespan and in various settings. • Photos.
Key steps are clarified and reinforced with pictures.
TAYLOR SUITE RESOURCES

From traditional texts to video and interactive products, the
Taylor Fundamentals/Skills Suite is tailored to fit every learn ing style.
This integrated suite of products offers students a seamless learning
experience you will not find anywhere else. The following products
accompany Taylor’s Handbook of Clinical Nursing Skills: •
Fundamentals of Nursing: The Art and Science of Nursing Care, 7th
Edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, and Pamela
Lynn. This traditional fundamentals text promotes nursing as an
evolving art and science, directed to human health and well being. It
challenges students to focus on the four blended skills of nursing care,
which prepare students to combine the highest level of scientific
knowledge and technologic skill with responsible, caring practice. The
text includes engaging features to promote critical thinking and
comprehension.
• Taylor’s Clinical Nursing Skills, 3rd Edition, by Pamela Lynn,
MSN, RN. This text covers all of the Skills and Guidelines for
Nursing Care identified in Fundamentals of Nursing, as well as ad
ditional skills, at the basic, intermediate, and advanced levels. Each
Skill follows the nursing process format. Features include Funda
mentals Review displays, which reinforce important concepts; Skill
Variations, which present alternate techniques; Documentation
Guidelines and Samples; Unexpected Situations and Associated In
terventions; and Special Considerations. A new feature for the third
edition, Evidence for Practice, highlights available best practice
guidelines and/or research-based evidence to support the skills as
available.
• Taylor’s Video Guide to Clinical Nursing Skills, 2nd Edition. From
reinforcing fundamental nursing skills to troubleshooting clinical
problems on the fly, this dynamic video series follows nursing stu
dents and their instructors as they perform and discuss a range of
essential nursing procedures. The second edition of these videos is
updated with tons of brand new footage to reflect the most current
best practice, to address changes in medication administration and
equipment, and to include even more skills. Ideal as a stand-alone
learning tool or as a companion to this book, these videos parallel
the text and are organized into topical modules for easy reference.
The videos are available in DVD/DVD-ROM or video streaming
vi
versions for purchase by schools. Student versions of the videos are
available on DVD/DVD-ROM or online through thePoint.
Contact your sales representative or check out LWW.com/Nursing
for more details and ordering information.
Pamela Lynn, MSN, RN

*Material related to nursing diagnoses from Nursing Diagnoses—Definitions and
Classification 2009–2011. Copyright © 2009, 2007, 2005, 2003, 2001, 1998,
1996, 1994 by NANDA International. Used by arrangement with
Wiley-Blackwell Publishing, a company of John Wiley & Sons, Inc. In order to
make safe and effective judgments using NANDA-I nursing diagnoses, it is
essential that nurses refer to the definitions and defining characteristics of the
diagnoses listed in this work.
vii
Acknowledgments
This edition is the work of many talented people. I would like to ac
knowledge the hard work of all who have contributed to the completion
of this project. Thanks to Carol Taylor, Carol Lillis, and Priscilla
LeMone for offering generous support and encouragement. You have
been excel lent mentors.
The work of this book was skillfully coordinated by my dedicated
Product Manager, Michelle Clarke, in the Nursing Education division
of Lippincott Williams & Wilkins. I am grateful to you for your
patience, support, unending encouragement, and total commitment. My
thanks to Jean Rodenberger, Executive Acquisitions Editor, for her
hard work and guidance throughout most of the project. Thank you to
the members of the production department, who patiently pulled
everything together to form a completed book: Helen Ewan, Director
of Nursing Production; Cindy Rudy, Vendor Manager; Holly Reid
McLaughlin, Design Coordi nator; and Brett MacNaughton, Illustration
Coordinator.
A special thanks to my colleagues at Gwynedd-Mercy College, who
offer unending support and professional guidance.
Finally, I would like to gratefully acknowledge my family, for their
love, understanding, and encouragement. Their support was essential
during the long hours of research and writing.
Pamela Lynn, MSN, RN
viii
Contents
3 Ambulation: Crutches,
A Assisting a Patient with
1 Ambulation, Assisting Using 9
with 1 4 Ambulation: Walker,
Assisting a Patient with
2 Ambulation: Cane, Assisting a
Using 14
Patient with Using 5
5 Antiembolism Stockings.
Applying and Arterial Blood Gas
Removing 18 Analysis 96
6 Arterial and Femoral Lines, 20 Blood Specimen,
Removing 23 Obtaining from an
Arterial Line–Stopcock
System 104
B
21 Blood Specimen, Using
7 Back Massage, Giving 27 8 Venipuncture to Collect for
Bath: Bed, Giving 32 Routine Testing 111
9 Bath: Sitz, Assisting 22 Blood Specimen: Venous,
with 44 Obtaining for Culture and
10 Bed Making, Sensitivity 120
Occupied 47 23 Blood Transfusing,
11 Bed Making, Administering 128
Unoccupied 52
12 Bedpan, Assisting with the C
Use of 59
24 Cardiac Monitor,
13 Bed Scale, Using 66 Applying 134
14 Bladder Volume, Assessing 25 Cardiopulmonary
Using a Bladder Ultrasound Resuscitation (CPR),
Scanner 71 Performing 140
15 Blood Glucose Testing, 26 Cast Application,
Obtaining a Capillary Assisting 146
Sample 75 27 Cast Care 151
16 Blood Pressure, Assessing 28 Central Venous Access
Brachial Artery Device (CVAD):
Auscultated 80 Accessing an Implanted
17 Blood Pressure, Assessing Port 156
Using a Doppler
29 Central Venous Access
Ultrasound 87
Device (CVAD): Changing Site
18 Blood Pressure, Assessing Dressing and
Using an Electronic Flushing 162
Automated Device 92
19 Blood Specimen, Obtaining
ix
30 Central Venous Access 32 Cervical Collar, Applying a
Device (CVAD): Two-Piece 175
Deaccessing an Implanted
33 Chest Tube: Providing Care
Port 168
of a Chest Drainage
31 Central Venous Access System 179
Device (CVAD): Removing a
34 Chest Tube: Assisting with
Peripherally Inserted
Removal 187
Central Catheter
(PICC) 172 35 Cold Therapy,
Applying 189 Automated External
36 Colostomy, Irrigating 194 (Emergency) 256
37 Comfort, Promoting 49 Denture Care,
Patient 198 Providing 261
38 Commode, Assisting with 50 Digital Removal of
the Use of 207 Stool 265
39 Compress, Applying a 51 Drain: Hemovac, Caring
Warm 211 for 269
40 Condom Catheter, 52 Drain: Jackson-Pratt,
Applying 217 Caring for 275
41 Contact Lenses, 53 Drain: Penrose, Caring
Removing 222 for 281
42 Continuous Closed Bladder 54 Drain: T-tube, Caring
Irrigation (CBI), for 287
Administering 226 55 Dressing: Cleaning a
43 Continuous Passive Motion Wound and Applying a
Device (CPM), Dry, Sterile 293
Applying 230 56 Dressing: Hydrocolloid,
44 Continuous Wound Applying 299
Perfusion Pain 57 Dressing: Changing a
Management 234 Peripheral Venous
45 Cooling Blanket, Access 305
Using 240 58 Dressing: Saline
D Moistened, Applying 309
46 Deep Breathing Exercises:
Coughing and E
Splinting 245
59 Ear Drops,
47 Defibrillation, Performing Instilling 315
Manual External
60 Ear Irrigation,
(Emergency,
Administering 321
Asynchronous) 250
48 Defibrillation, Performing
x
61 Eating, Assisting 65 Endotracheal Tube: Open
Patient 326 System, Suctioning 353
62 Electrocardiogram (ECG), 66 Enema: Large
Obtaining 331 Volume Cleansing,
63 Endotracheal Tube, Administering 361
Securing 339 67 Enema: Retention,
64 Endotracheal Tube: Administering 367
Closed System, 68 Enema: Small
Suctioning 346 Volume Cleansing,
Administering 372
69 Epidural Analgesia, H
Caring for a Patient
Receiving 377 81 Hand Hygiene: Alcohol
Based Hand Rub,
70 External Fixation, Caring
Performing 436
for a Patient with 383
82 Hand Hygiene: Hand
71 Eye Drops, Washing with Soap and
Instilling 387 Water 438
72 Eye Irrigation, 83 Heating Pad, Applying an
Administering 394 External 441
84 Hemodialysis Access
F (Arteriovenous Fistula or
73 Fall Prevention 397 74 Fecal Graft), Caring for 445
Incontinence Pouch, Applying
403 I
75 Fiber Optic Intracranial 85 Incentive Spirometer,
Catheter, Caring for a Teaching a Patient to
Patient with 406 Use 448
76 Figure-Eight Bandage, 86 Inhaler: Dry Powder,
Applying 410 Administering Medication
77 Forced-Air Warming via 452
Device, Applying 414 87 Inhaler: Metered-Dose,
G Administering Medication
78 Gastric Tube: Administering via 458
a Tube Feeding 417 88 Injection: Intradermal,
79 Gastric Tube: Caring Administering 464
for a Gastrostomy 89 Injection: Intramuscular,
Tube 428 Administering 471
80 Gloves: Putting on 90 Injection: Subcutaneous,
Sterile and Removing Administering 478
Soiled 432
xi
91 Insulin Pump, 94 IV Infusion: Changing an
Administering Continuous IV Solution Container and
Subcutaneous via 486 Administration
92 IV Access: Initiating a Set 507
Peripheral Venous Access IV 95 IV Infusion: Monitoring
Infusion 493 an IV Site and
93 IV Access: Capping for Infusion 514
Intermittent Use and
Flushing a Peripheral L
Venous Access Device 503
Oral 566
96 Leg Exercises 518 97
105 Medication: Removing
Logrolling a Patient 521
from an Ampule 573
106 Medication: Removing
M
from a Vial 578
98 Medication: Administering 107 Medication: Transdermal
Medications via a Gastric Patch, Applying 584
Tube 525
108 Medication: Vaginal Cream,
99 Medication: IV Infusion, Administering 590
Administering Medications by
109 Montgomery Straps,
Intravenous Bolus or
Applying 596
Push Through an
Intravenous Infusion 533 110 Moving a Patient Up in
Bed 601
100 Medication: IV Infusion,
Administering a Piggyback
Intravenous of N
Medication 539
111 Nasal Swab,
101 Medication: IV Infusion, Obtaining 605
Administering an
112 Nasopharyngeal Swab,
Intermittent Intravenous
Obtaining 609
Infusion of Medication
via a Mini-Infusion 113 Nasogastric Tube,
Pump 546 Insertion 613
102 Medication: IV Infusion, 114 Nasogastric Tube,
Administering an Irrigating 621
Intermittent Intravenous 115 Nasogastric Tube,
Infusion of Medication via Removing 625
a Volume-Control
116 Nasopharyngeal Airway,
Administration Set 552
Inserting 629
103 Medication: Mixing
117 Nebulizer, Administering
Medications from Two
Medication via Small
Vials in One Syringe 559
Volume 633
104 Medication: Administering
xii
118 Negative Pressure Wound 122 Oropharyngeal Airway,
Therapy, Applying 639 Inserting 660
119 Nose Drops, 123 Ostomy: Changing and
Instilling 646 Emptying Appliance 664
124 Ostomy: Changing Urinary
O Stoma Appliance on an
120 Oral Care, Assisting the Ileal Conduit 672
Patient 651 125 Oxygen Administration:
121 Oral Care, Providing for the Using an Oxygen
Dependent Patient 656 Hood 678
126 Oxygen Administration: 136 Pulse: Peripheral Using
Administering Oxygen by Palpation, Assessing 731
Mask 681 137 Pulse: Periperhal Using
127 Oxygen Administration: Portable Doppler
Administering Oxygen by Ultrasound, Assessing 735
Nasal Cannula 685 138 Pulse Oximeter, Using 738
128 Oxygen Administration:
Using an Oxygen R
Tent 688
139 Radiant Warmer (Overhead),
Monitoring Temperature
P Using an 744
129 Pacemaker: Using 140 Range-of-Motion
an External Exercises, Providing 747
(Transcutaneous) 692 141 Rectal Suppository,
130 Patient-Controlled Administering 752
Analgesia (PCA), Caring 142 Respiration, Assessing 757
for a Patient 143 Restraints, Implementing
Receiving 699 Alternatives to the Use
131 Peritoneal Dialysis Catheter: of 760
Caring for a 706 144 Restraint, Applying an
132 Personal Protective Elbow 764
Equipment (PPE),
Using 710 145 Restraint, Applying an
Extremity 768
133 Pneumatic Compression
Devices, Applying 715 146 Restraint, Applying a
Mummy 772
134 Postoperative Patient Care,
Providing when Patient 147 Restraint, Applying a
Returns to Room 719 Waist 776
135 Pulse: Apical Using 148 Resuscitation: Using a
Auscultation, Handheld Bag and
Assessing 727 Mask 780
xiii
S Sterile Items 806
149 Seizure Precautions and 155 Sterile Field: Preparing
Management 784 Using a Commercially
Prepared Sterile Kit or
150 Shaving, Assisting the
Tray 810
Patient 790
156 Sterile Field: Preparing
151 Shampooing a Patient’s
Using a Packaged Sterile
Hair in Bed 793
Drape 814
152 Sling, Applying 798
157 Stool Culture: Collecting a
153 Sputum for Culture, Stool Specimen 817
Collecting 801
158 Stool Culture: Testing for
154 Sterile Field: Adding Occult Blood 820
159 Suctioning the Bed to Chair 895
Nasopharyngeal and 170 Transferring a Patient
Oropharyngeal from Bed to
Airways 826 Stretcher 901
160 Staples, Removing 171 Transferring a Patient
Surgical 836 Using a Powered
161 Sutures, Removing 841 Full-Body Sling
Lift 906
172 Turning a Patient in Bed,
T
Assisting 914
162 Temperature, Assessing
Body 845
U
163 TENS Unit, Applying and
Caring for Patient 173 Urinal, Assisting with the
Using 855 Use of 919
164 Tracheostomy Care, 174 Urinary Catheter: Female,
Providing 859 Catheterizing the Urinary
165 Tracheostomy Care: Bladder 923
Open System, 175 Urinary Catheter: Male,
Suctioning 871 Catheterizing the Urinary
166 Traction: Halo, Caring for Bladder 933
a Patient in 878 176 Urinary Catheter:
167 Traction: Skeletal, Irrigation, Performing
Caring for a Patient Intermittent Closed
in 884 Catheter 944
168 Traction: Skin, Applying 177 Urinary Catheter:
Skin Traction and Indwelling Catheter,
Caring for a Patient Removing an 948
in 889
169 Transferring a Patient from
xiv
178 Urinary Catheter: V
Suprapubic, Caring
181 Ventriculostomy (Closed
for 952
Fluid-Filled System) 966
179 Urine Specimen,
Collecting (Clean Catch,
Midstream) for Urinalysis W
and Culture 956 182 Wound Culture,
180 Urine Specimen: Collecting 970
Indwelling Urinary 183 Wound Irrigation,
Catheter, Obtaining Performing 977
from 962
xv
Assisting a Patient with Ambulation 1
Skill • 1 Assisting a Patient with Ambulation A
Walking exercises most of the body’s muscles and increases joint flexi
bility. It improves respiratory and gastrointestinal function. Ambulating
also reduces the risk for complications of immobility. However, even a
short period of immobility can decrease a person’s tolerance for ambu
lating. If necessary, make use of appropriate equipment and assistive
devices to aid in patient movement and handling.
EQUIPMENT
• Gait belt, as necessary • Nonskid shoes or slippers •
Nonsterile gloves and/or other necessary, if available
PPE, as indicated • Additional staff for assistance,
as needed
ASSESSMENT GUIDELINES
• Stand-assist device, as
• Assess the patient’s ability to walk and the need for assistance.
Review the patient’s record for conditions that may affect
ambulation.
• Perform a pain assessment before the time for the activity. If the
patient reports pain, administer the prescribed medication in
sufficient time to allow for the full effect of the analgesic.
• Take vital signs and assess the patient for dizziness or lightheadedness
with position changes.
NURSING DIAGNOSES
• Impaired Physical Mobility
• Impaired Walking
• Deficient Knowledge
• Impaired Bed Mobility
• Acute Pain
• Activity Intolerance
• Chronic Pain
• Fatigue
OUTCOME IDENTIFICATION AND PLANNING

Expected outcomes may include:
• The patient ambulates safely, without falls or injury.
• The patient improves or maintains muscle strength.
• The patient’s level of independence increases.
• The patient remains free of complications of immobility.
2 Assisting a Patient with Ambulation
IMPLEMENTATION
ACTION RATIONALE
1. Review the medical record procedure for ambulation.

and nursing plan of care for Identify any movement
conditions that may influence the limitations.
patient’s ability to move and 2. Perform hand
ambulate. Assess for hygiene. Put on
tubes, IV lines, incisions, or on PPE as
equipment that may alter the indicated.
and limitations reduces the risk
for patient injury.
3 Identify
3. Identify the
patient. Explain
the Hand hygiene and PPE prevent
the procedure to the the spread of microorganisms.
pa PPE is required based on
patient. Ask the patient transmission precautions.
to
to report any feelings Patient identification validates
of the correct patient and correct
of dizziness, weakness, procedure. Discussion and expla
or shortn nation help allay anxiety and
or shortness of breath while prepare the patient for what to
walking. Decide how far to expect.
walk.
4. Place the bed in the lowest
position. Proper bed height ensures safety
when getting the patient out of
5. Encourage the patient to bed.
make use of a stand-assist Encourages independence,
aid, either free-standing or reduces strain for staff, and
attached to the side of the decreases risk for patient injury.
bed, if available, to move to
the side of the bed. Assist
the patient to the side of the
bed, if necessary.
6. Have the patient sit on the Having the patient sit at the side
side of the bed for several of the bed minimizes the risk for
minutes and assess for blood pressure changes (ortho
dizziness or lightheadedness. static hypotension) that can
Have the patient stay sitting occur with position change.
until he or she feels secure. Allowing the patient to sit until
Reviewing the medical record he or she feels secure reduces
and plan of care validates the anxiety and helps prevent injury.
correct patient and correct proce
dure. Checking for equipment
Assisting a Patient with Ambulation 3
ACTION RATIONALE
7. Assist the patient to put on footwear and a

robe, if
desired.
8. Wrap the gait belt around the patient’s
waist, based on
assessed need and facility policy.
9. Encourage the patient to make use of the

stand-assist device. Assist the patient to stand,
using the gait belt, if necessary. Assess the
patient’s balance and leg strength.
If the patient is weak or
unsteady, return the patient to bed or assist to a
chair.
10. If you are the only nurse assisting, position
yourself to the side and slightly
behind the patient. Support the patient by the
waist or transfer belt (FIGURE 1).
Doing so ensures safety and patient warmth.
Gait belts improve the caregiv er’s grasp,

reducing the risk of musculoskeletal injuries to
staff and the patient. The belt also provides a
firmer grasp for the caregiver if the patient
should lose his or her balance.
Use of gait belt prevents injury to nurse and
patient. Assessing balance and strength helps
to identify need for additional assistance to
prevent falling.
Positioning to the side and slightly behind the
patient encourages the patient to stand and
walk erect. It also places the nurse in a safe
position if the patient should lose his or her
balance or begin to fall.
FIGURE 1 Nurse positioned to the side and

slightly behind the patient while walking,
supporting the patient by the gait belt or waist.
4 Assisting a Patient with Ambulation
ACTION RATIONALE
When two nurses assist, posi lower arm or hand.

tion yourself to the side and 11. Take several steps forward
slightly behind the patient, with the patient. Continue to
supporting the patient by assess the patient’s strength and
the waist or gait belt. Have balance. Remind the
the other nurse carry or man patient to stand erect.
age equipment or provide
12. Continue with ambulation for
additional support from the
the planned distance and time.
other side.
Return the patient to the bed or
Alternatively, when two nurses chair, based on the patient’s
assist, stand at the patient’s tolerance and condition.
sides (one nurse on each
13. Remove
side) with near hands
gait belt. Clean
grasping the gait belt and far
tra
hands holding the patient’s
transfer aids, per facil culoskeletal injuries to staff and
ity the patient, and allow for a firmer
ity policy, if not indi grasp for the caregiver if patient
ca should lose his or her balance.
cated for single patient
us Taking several steps with the
use. Remove gloves patient and standing erect pro
and any mote good balance and stability.
and any other PPE, if used. Continued assessment helps
Perform hand hygiene. maintain patient safety.
Ambulation as prescribed pro
motes activity and prevents
fatigue.
EVALUATION
Gait belts improve the caregiver’s
grasp, reducing the risk of mus Proper cleaning of equipment
culoskeletal injuries to staff and between patient use prevents the
the patient, and allow for a firmer spread of microorganisms.
grasp for the caregiver if patient Removing PPE properly reduces
should lose his or her balance. the risk for infection transmis
sion and contamination of other
items. Hand hygiene prevents the
spread of microorganisms.
Gait belts improve the caregiver’s
grasp, reducing the risk of mus
• The patient ambulates safely for the prescribed distance and time and
remains free from falls or injury.
• The patient exhibits increasing muscle strength, joint
mobility. • The patient exhibits increasing independence.
• The patient remains free of any signs and symptoms of immobility.
Assisting a Patient with Ambulation Using a Cane 5
DOCUMENTATION
• Document the activity, any observations, the patient’s tolerance of the
procedure, and the distance walked. Document the use of transfer
aids and number of staff required for transfer.
GENERAL CONSIDERATIONS
• Secure all equipment, such as indwelling urinary catheters, drains, or
IV infusions, to a pole for ambulation.
• Do not carry equipment while helping the patient. Your hands should
be free to provide support.
Skill • 2 Assisting a Patient with Ambulation
Using a Cane
Canes are useful for patients who can bear weight but need support for
balance. They are also useful for patients who have decreased strength
in one leg. Canes provide an additional point of support during ambula
tion. Canes are made of wood or metal and often have a rubberized cap
on the tip to prevent slipping. Canes come in three variations: single
ended canes with half-circle handles (recommended for patients requir
ing minimal support and for those who will be using stairs frequently);
single-ended canes with straight handles (recommended for patients
with hand weakness because the handgrip is easier to hold, but not
recom mended for patients with poor balance); canes with three (tripod)
or four prongs (quad cane) or legs to provide a wide base of support
(recom mended for patients with poor balance). The cane should rise
from the floor to the height of the person’s waist, and the elbow should
be flexed about 30 degrees when holding the cane. The patient holds
the cane in the hand opposite the weak or injured leg.
EQUIPMENT
• Cane of appropriate size with
rubber tip ASSESSMENT GUIDELINES
• Nonskid shoes or slippers • • Stand-assist aid, if necessary
Nonsterile gloves and/or other and available
PPE, as indicated • Gait belt, based on assessment
• Assess the patient’s upper body strength, ability to bear weight,

ability to walk, and the need for assistance. Review the patient’s
record for conditions that may affect ambulation.
patient reports pain, administer the prescribed medication in suffi
cient time to allow for the full effect of the analgesic.
6 Assisting a Patient with Ambulation Using a Cane
• Take vital signs and assess the patient for dizziness or light
headedness with position changes.
• Assess for muscle strength in the legs and arms.
• Assess the patient’s knowledge regarding the use of a cane.
NURSING DIAGNOSES
• Acute Pain
• Chronic Pain
• Risk for Falls

• The patient ambulates safely without falls or injury.
• The patient demonstrates proper use of the cane.
• The patient demonstrates increased muscle strength and joint
mobility. • The patient demonstrates increased independence.
IMPLEMENTATION
ACTION RATIONALE
1. Review the medical record of dizziness, weakness,

and nursing plan of care for or shortn
conditions that may influence the or shortness of breath while
patient’s ability to move and walking. Decide how far to
ambulate. Assess for walk.
tubes, IV lines, incisions, or Review of the medical record
equipment that may alter the and plan of care validates the
procedure for ambulation. correct patient and correct proce
2. Perform hand dure. Identification of equipment
hygiene. Put on and limitations helps reduce the
on PPE, as risk for injury.
indicated.
Hand hygiene and PPE prevent

the spread of microorganisms.
3 Identify PPE is required based on trans
3. Identify the mission precautions.
patient. Explain
the Patient identification validates
the procedure to the the correct patient and correct
pa procedure. Discussion and expla
patient. Tell the patient nation help allay anxiety and
to prepare the patient for what to
to report any feelings expect.
of
Assisting a Patient with Ambulation Using a Cane 7
ACTION RATIONALE
4. Encourage the patient to make use of a

stand-assist aid, either free standing or
attached to the side of the bed, if available,
to move to and sit on the side of the bed.
5. Wrap the gait belt around the patient’s
waist, based on
assessed need and facility policy.

stand-assist device to stand with weight
evenly distributed between the feet and the
cane.
7. Have the patient hold the cane on his or her
stronger side, close to the body, while you
stand to the side and slightly behind the
patient. (FIGURE 1).
Encourages independence, reduces strain for

staff, and decreases risk for patient injury.
Gait belts improve the caregiver’s grasp,
reducing the risk of mus culoskeletal injuries to
staff and the patient and provide firmer grasp
for the caregiver if patient should lose his or
her balance.
A stand-assist device reduces strain for
caregiver and decreases the risk for patient
injury. Evenly distributed weight provides a
broad base of support and balance.
Holding the cane on the stronger side helps to
distribute the patient’s weight away from the
involved side and prevents leaning. Posi
tioning to the side and slightly behind the
patient encourages the patient to stand and
walk erect. It also places the nurse in a safe
position if the patient should lose his or her
balance or begin to fall.
FIGURE 1 The nurse stands slightly behind the

patient. The cane is held on the patient’s
stronger side close to the body.
8 Assisting a Patient with Ambulation Using a Cane
ACTION RATIONALE
8. Tell the patient to advance the weaker foot for ward, parallel
cane 4 to 12 inches (10 to 30 with the cane.
cm) and then, while sup porting 9. While supporting his or her
his or her weight on the stronger weight on the weaker leg and the
leg and the cane, advance the cane, have the patient advance
the stronger leg support and balance.
forward ahead of the cane
(heel slightly beyond the tip
of the cane).
10. Tell the patient to move the
weaker leg forward until it is Moving in this manner provides
even with the stronger leg, and support and balance.
then advance the cane again.
the planned distance and time.
Return the patient to the bed or
chair, based on the patient’s
This motion provides support
tolerance and condition,
and balance.
ensuring the patient’s com
fort. Make sure call bell and
other necessary items are
Continued ambulation promotes
within easy reach.
activity. Adhering to the planned
12. Clean the distance and patient’s tolerance
transfer aids, per prevents the patient from becom
fac ing fatigued.
facility policy, if
not
ind
indicated for single
pa Proper cleaning of equipment
patient use. Remove between patient use prevents the
PP spread of microorganisms.
PPE, if used. Perform Removing PPE properly reduces
hand hyg the risk for infection transmis
hand hygiene. sion and contamination of other
EVALUATION
Moving in this manner provides
• The patient uses the cane to ambulate safely and is free from falls or
injury.
• The patient demonstrates proper use of the cane.
• The patient exhibits increased muscle strength, joint mobility, and
independence.
Assisting a Patient with Ambulation Using Crutches 9
DOCUMENTATION
• Document the activity, any observations, the patient’s ability to use
the cane, the patient’s tolerance of the procedure, and the distance
walked. Document the use of transfer aids and the number of staff
required for transfer.
• Patients with bilateral weakness should not use a cane. Crutches or a
walker would be more appropriate.
• To climb stairs, the patient should advance the stronger leg up the
stair first, followed by the cane and weaker leg. To descend, reverse
the process.
• When less support is required from the cane, the patient can advance
the cane and weaker leg forward simultaneously while the stronger
leg supports the patient’s weight.
• Teach patients to position their canes within easy reach when they sit
down so that they can rise easily.
Skill • 3 Assisting a Patient with Ambulation

Using Crutches
Crutches enable a patient to walk and remove weight from one or both
legs. The patient uses the arms to support the body weight. Crutches
can be used for the short or the long term. This section discusses
short-term crutch use. Crutches must be fitted to each person. Have the
patient stand up straight with the palm of the hand pressed against the
body under the arm. The hand should fit between the top of the
crutches and the armpit. When using crutches, the elbow should be
slightly bent at about 30 degrees and the hands, not the armpits, should
support the patient’s weight. Weight on the armpits can cause nerve
damage. If anything needs to be carried, it is best to use a backpack
(University of Iowa, 2006). The procedure for crutch walk ing is
usually taught by a physical therapist, but it is important for the nurse
to be knowledgeable about the patient’s progress and the gait being
taught. Be prepared to guide the patient at home or in the hospital after
the initial teaching is completed. Remind the patient that the support of
body weight should come primarily on the hands and arms while using
the crutches. There are a number of different ways to walk using
crutches, based on how much weight the patient is allowed to bear on
one or both legs.
EQUIPMENT
• Crutches with axillary pads, • Nonskid shoes or slippers
hand grips, and rubber suction • Nonsterile gloves and/or other
tips PPE, as indicated
• Stand-assist device, as necessary, if available
10 Assisting a Patient with Ambulation Using Crutches
• Review the patient’s record and nursing plan of care to determine the
reason for using crutches and instructions for weight-bearing. Check
for specific instructions from Physical Therapy.
patient reports pain, administer the prescribed medication in
sufficient time to allow for the full effect of the analgesic.
• Determine the patient’s knowledge regarding the use of crutches and
assess the patient’s ability to balance on the crutches.
• Assess for muscle strength in the legs and arms.
• Determine the appropriate gait for the patient to use.
NURSING DIAGNOSES
• Acute Pain
• Chronic Pain
• Risk for Falls

• The patient ambulates safely with the crutches and is free from falls
or injury.
• The patient demonstrates proper crutch-walking technique. • The
patient demonstrates increased muscle strength and joint mobility.
IMPLEMENTATION
ACTION RATIONALE
1. Review the medical record regarding the use of crutches.

and nursing plan of care for Determine that the appropri
conditions that may influence the ate size crutch has been
patient’s ability to move and obtained.
ambulate. Assess for Reviewing the medical record
tubes, IV lines, incisions, or and plan of care validates the
equipment that may alter the correct patient and correct proce
procedure for ambulation. dure. Assessment helps identify
Assess the patient’s knowl problem areas to minimize the
edge and previous experience risk for injury.
ACTION RATIONALE
2. Perform hand hygiene. Put on

on PPE, if indicated.
3. Identify the patient. Explain

3. Identify
the
the procedure to the
pa
patient. Tell the patient
to
to report any feelings
of
of dizziness, weakness,
or shortn
or shortness of breath while walking. Decide
how far to walk.
stand-assist device, if available. Assist the
patient to stand erect, face forward in the
tripod position (FIGURE 1). This
means the patient holds the crutches 12 inches
in front of and 12 inches to the side of each
foot.
Hand hygiene and PPE prevent the spread of
microorganisms. PPE is required based on
transmission precautions.
Patient identification validates the correct

patient and correct proce dure. Discussion and
explanation
help allay anxiety and prepare the patient for
what to expect.
Stand-assist device reduces care giver strain

and decreases risk of patient injury.
Positioning the crutches in this manner
provides a wide base of support to increase
stability and balance.
FIGURE 1 Assisting the patient to stand erect
facing forward in the tri pod position.
12 Assisting a Patient with Ambulation Using Crutches
ACTION RATIONALE
5. For the four-point gait: stronger leg forward to the

a. Have the patient move the level of the crutches.
right crutch forward 12 7. For the two-point gait:
inches and then move the a. Have the patient move the
left foot forward to the left crutch and the right
level of the right crutch. foot forward about 12
b. Then have the patient move inches at the same time.
the left crutch forward 12 b. Have the patient move the
inches and then move the right crutch and left leg
right foot forward to the forward to the level of the
level of the left crutch. left crutch at the same
6. For the three-point gait: time.
a. Have the patient move the 8. For the swing-to gait:
affected leg and both a. Have the patient move
crutches forward about 12 both crutches forward
inches. about 12 inches.
b. Have the patient move the b. Have the patient lift the
legs and swing them to the both feet.
crutches, supporting his or
her body weight on the
crutches.
the planned distance and
time. Return the patient to
the bed or chair based on the
This movement ensures stability
Swing-to gait provides mobility
and safety.
for patients with weakness or
paralysis of the hips or legs.
Continued ambulation promotes

Patient bears weight on the stron activity. Adhering to the planned
ger leg. distance and time prevents the
patient from becoming fatigued.
Patient bears partial weight on

ACTION RATIONALE
patient’s tolerance and condi

tion, ensuring that the patient
is comfortable and that the
call light is within reach.
10. Remove
PPE, if used. Per
fo
form hand
hygiene.
EVALUATION
Removing PPE properly reduces
the risk for infection transmis
• The patient demonstrates correct use of crutches to ambulate safely
and without injury.
• The patient demonstrates increased muscle strength and joint
mobility.
DOCUMENTATION
the crutches, the patient’s tolerance of the procedure, and the distance
walked. Document the use of transfer aids and number of staff
• Crutches can be used when climbing stairs. The patient grasps both
crutches as one on one side of the body and uses the stair railing.
Have the patient stand in the tripod position facing the stairs. The
patient transfers his or her weight to the crutches and holds the rail
ing. The patient places the unaffected leg on the first stair tread. The
patient then transfers his or her weight to the unaffected leg, moving
up onto the stair tread. The patient moves the crutches and affected
leg up to the stair tread and continues to the top of the stairs. Using
this process, the crutches always support the affected leg.
• Long-term use of the swing-to gait can lead to atrophy of the hips and
legs. Include appropriate exercises in the patient’s plan of care to
avoid this complication.
• Patients should not lean on the crutches. Prolonged pressure on the
axillae can damage the brachial nerves, causing brachial nerve palsy,
with resulting loss of sensation and inability to move the upper
extremities.
• Patients using crutches should perform arm- and
shoulder-strengthening exercises to aid with crutch walking.
14 Assisting a Patient with Ambulation Using a Walker
Skill • 4 Assisting a Patient with

Ambulation Using a Walker
A walker is a lightweight metal frame with four legs. Walkers provide

stability and security for patients with insufficient strength and bal ance
to use other ambulatory aids. There are several kinds of walkers; the
choice of which to use is based on the patient’s arm strength and
balance. Regardless of the type used, the patient stands between the
back legs of the walker with arms relaxed at the side; the top of the
walker should line up with the crease on the inside of the patient’s
wrist. When the patient’s hands are placed on the grips, elbows should
be flexed about 30 degrees (Mayo Clinic, 2007). Usually, the legs of
the walker can be adjusted to the appropriate height.
EQUIPMENT
• Walker, adjusted to the appro • Additional staff for assistance,
priate height as needed
• Nonskid shoes or slippers • • Stand-assist device, as neces
Nonsterile gloves and/or other sary, if available
PPE, as indicated • Gait belt
• Assess the patient’s ability to walk and the need for assistance.
Review the patient’s record for conditions that may affect
ambulation.
patient reports pain, administer the prescribed medication in suffi
cient time to allow for the full effect of the analgesic.
• Take vital signs and assess the patient for dizziness or lightheaded
ness with position changes.
• Assess the patient’s knowledge regarding the use of a walker. Ensure
that the walker is at the appropriate height for the patient.
NURSING DIAGNOSES
• Risk for Falls
• Risk for Injury
• Acute Pain
• Chronic Pain
• Fatigue

• The patient ambulates safely with the walker and is free from falls or
injury.
Assisting a Patient with Ambulation Using a Walker 15
• The patient demonstrates proper use of the walker and states the need
for the walker.
• The patient’s level of independence increases.
• The patient demonstrates increasing muscle strength and joint
mobility.
• The patient remains free of complications of immobility.
IMPLEMENTATION
ACTION RATIONALE
1. Review the medical record 5. Encourage the patient to

and nursing plan of care for make use of a stand-assist
conditions that may influence aid, either free standing or
the patient’s ability to move attached to the side of the
and ambulate, and for spe bed, if available, to move to
cific instructions for ambula the side of the bed.
tion, such as distance. Assess Reviewing the medical record
for tubes, IV lines, incisions, and plan of care validates the
or equipment that may alter correct patient and correct proce
the procedure for ambulation. dure. Checking for equipment
Assess the patient’s knowl and limitations helps minimize
edge and previous experience the risk for injury.
regarding the use of a walker.
Identify any movement
limitations.
2. Perform hand
hygiene. Put on
on PPE, if
indicated.

3 Identify t the spread of microorganisms.
3. Identify the PPE is required based on Trans
patient. Explain mission Precautions.
the
Patient identification validates
the procedure to the
the correct patient and correct
pa
procedure. Discussion and expla
patient. Tell the patient
nation help allay anxiety and
to
prepare the patient for what to
to report any feelings of
expect.
diz
dizziness, weakness, or
shortness Proper bed height ensures safety
shortness of breath while when getting the patient out of
walk ing. Decide how far to bed.
walk. Use of assistive devices encour
4. Place the bed in the lowest ages independence, reduces
position, if the patient is in strain for staff, and decreases risk
bed. for patient injury.
16 Assisting a Patient with Ambulation Using a Walker
ACTION RATIONALE
6. Assist the patient to the side Having the patient sit on the side
of the bed, if necessary. Have of the bed minimizes the risk for
the patient sit on the side of blood pressure changes (ortho
the bed. Assess for dizziness static hypotension) that can
or lightheadedness. Have the occur with position change.
patient stay seated until he or Assessing patient complaints
she feels secure. helps prevent injury.
7. Assist the patient to put on Doing so ensures safety and
footwear and a robe, if warmth.
desired.
8. Wrap the gait belt around the Gait belts improve the caregiv
patient’s waist, based on er’s grasp, reducing the risk of
assessed need and facility musculoskeletal injuries to staff
policy. and the patient and provide for a
firmer grasp if patient should
lose his or her balance.
9. Place the walker directly in Proper positioning with the
front of the patient. Ask the walker ensures balance. Standing
patient to push himself or within the walker and holding the
herself off the bed or chair; hand grips firmly provide stabil
make use of the stand-assist ity when moving the walker and
device or assist the patient to helps ensure safety. Positioning
stand. Once the patient is to the side and slightly behind the
standing, have him or her patient encourages the patient to
hold the walker’s hand grips stand and walk erect. It also
firmly and equally. Stand places the nurse in a safe position
slightly behind the patient, if the patient should lose his or
on one side. her balance or begin to fall.
10. Have the patient move the Having all four feet of the walker
walker forward 6 to 8 inches and on the floor provides a broad
set it down, making sure all four base of support. Moving the
feet of the walker stay on the walker and stepping forward
floor. Then, tell the patient to moves the center of gravity
step forward with either foot into toward the walker, ensuring
the walker, supporting himself or balance and pre venting tipping
herself on his or her arms. of the walker.
Follow through with the other
leg.
11. Move the walker forward
again, and continue the same Moving the walker promotes
pattern. Continue with ambu activity. Continuing for the
lation for the planned distance planned distance and time pre
and time (FIGURE 1). Return vents the patient from becoming
the patient to the bed or chair fatigued.
Assisting a Patient with Ambulation Using a Walker 17
ACTION RATIONALE
based
on the patient’s tolerance
and condition, ensuring that the
patient is comfortable and the
call bell is within reach.
FIGURE 1 Assisting the patient to

walk with the walker.
12. Remove the gait

belt, if used. Cl
Clean transfer aids,
EVALUATION
per Proper cleaning of equipment
fa between patient use prevents the
facility policy, if not spread of microorganisms.
in Removing PPE properly reduces
indicated for single the risk for infection transmis
pa sion and contamination of other
patient use. Remove items. Hand hygiene prevents the
gloves an spread of microorganisms.
gloves and any other PPE, if
used. Perform hand hygiene.
• The patient uses the walker to ambulate safely and remains free of
injury. • The patient exhibits increasing muscle strength and joint
mobility. • The patient exhibits increasing independence.
• The patient remains free from complications of immobility.
DOCUMENTATION
the walker, the patient’s tolerance of the procedure, and the distance
walked. Document the use of transfer aids and number of staff
18 Applying and Removing Antiembolism Stockings
• Never use a walker on the stairs.
• The patient should wear nonskid shoes or slippers.
• Some walkers have wheels on the front legs. These walkers are best
for patients with a gait that is too fast for a walker without wheels
and for patients who have difficulty lifting a walker. This type of
walker is rolled forward while the patient walks as normally as
possible. Because lifting repeatedly is not required, energy
expenditure and stress to the back and upper extremities is lower
than with a standard walker (Mincer, 2007).
• Keep in mind, walkers often prove to be difficult to maneuver
through doorways and congested areas.
• Advise the patient to check the walker before use for signs of dam
age, frame deformity, or loose or missing parts.
• Teach patients to use the arms of the chair or a stand-assist device for
leverage when getting up from a chair. Explain to patients that they
should not pull on the walker to get up; the walker could tip or
become unbalanced.
Skill • 5 Applying and Removing

Antiembolism Stockings
Antiembolism stockings are often used for patients at risk for deep-vein
thrombosis and pulmonary embolism, and to help prevent phlebitis.
They are made of elastic material and are available in either knee-high
or thigh-high length. By applying pressure, antiembolism stockings
increase the velocity of blood flow in the superficial and deep veins and
improve venous valve function in the legs, promoting venous return to
the heart. A medical order is required for their use. Be prepared to
apply the stockings in the morning before the patient is out of bed and
while the patient is supine. If the patient is sitting or has been up and
about, have the patient lie down with legs and feet elevated for at least
15 minutes before applying the stockings. Otherwise, the leg vessels are
congested with blood, reducing the effectiveness of the stockings.
EQUIPMENT
• Elastic antiembolism stockings • Talcum powder (optional)
in ordered length in correct size. • Skin cleanser, basin,
See Assessment for appro priate towel • Nonsterile gloves
measurement procedure. • • Additional PPE as indicated
Measuring tape
• Assess the skin condition and neurovascular status of the legs. Report
any abnormalities before continuing with the application of the
Applying and Removing Antiembolism Stockings 19
stockings. Assess patient’s legs for any redness, swelling, warmth,

ten derness, or pain that may indicate a deep-vein thrombosis. If any
of these symptoms are noted, notify the primary care provider before
applying the stockings.
• Measure the patient’s legs to obtain the correct size stocking. For
knee high length: Measure around the widest part of the calf and the
leg length from the bottom of the heel to the back of the knee, at the
bend. For thigh-high length: Measure around the widest part of the
calf and the thigh. Measure the length from the bottom of the heel to
the gluteal fold. Follow the manufacturer’s specifications to select
the correct sized stockings. Each leg should have a correct fitting
stocking; if mea surements are different, then two different sizes of
stocking need to be ordered to ensure correct fitting on each leg
(Walker & Lamont, 2008).
NURSING DIAGNOSES
• Ineffective Peripheral Tissue Perfusion
• Risk for Impaired Skin Integrity
• Excess Fluid Volume
• Risk for Injury

• The stockings will be applied and removed with minimal discomfort
to the patient.
• Edema will decrease in the lower extremities.
• The patient will verbalize an understanding of the rationale for stock
ing application.
• The patient will remain free of deep-vein thrombosis.
IMPLEMENTATION
ACTION RATIONALE
1. Review the medical record the use of elastic
and medical orders to deter sto
mine the need for antiembo stockings.
lism stockings. Reviewing the medical record
2. Perform hand and order validates the correct
hygiene. Put on patient and correct procedure.
on PPE, as
indicated. Hand hygiene and PPE prevent
PPE is required based on trans
mission precautions.
3 Identify
3. Identify the Patient identification validates
patient. Explain the correct patient and correct
wh procedure. Discussion and expla
what you are going to nation allay anxiety and prepare
do the patient for what to expect.
do and the rationale for
the
ACTION RATIONALE
4. Close curtains around bed breathing problem, dry skin,

and close the door to the or sensitivity to the powder.
room, if possible. If the skin is dry, a lotion may
5. Adjust the bed to a comfort be used. Powders and lotions
able working height, usually are not recommended by
elbow height of the caregiver some manufacturers; check
(VISN 8 Patient Safety Cen the package material for man
ter, 2009). ufacturer specifications.
6. Assist the patient to a supine 8. Stand at the foot of the bed.
position. If patient has been Place hand inside stocking and
sitting or walking, have him grasp heel area securely. Turn
or her lie down with legs and stocking inside-out to the heel
feet well elevated for at least area, leaving the foot inside the
15 minutes before applying stocking leg.
stockings. 9. With the heel pocket down,
7. Expose legs one at a time. ease the stocking foot over the
Wash and dry legs, if neces patient’s foot and heel (FIGURE
sary. Powder the leg lightly 1). Check that the patient’s
unless the patient has a heel is centered in heel pocket
of stocking.
10. Using your fingers and
thumbs, carefully grasp the
stocking edge and pull it up
smoothly over the ankle and
This ensures the patient’s
privacy.
Inside-out technique provides for
Having the bed at the proper easier application; bunched elas
height prevents back and muscle tic material can compromise
strain. extremity circulation.
Dependent position of legs Wrinkles and improper fit inter

encourages blood to pool in the fere with circulation.
veins, reducing the effectiveness
of the stockings if they are
applied to congested blood
vessels.
Easing the stocking carefully
into position ensures the stocking
Helps maintain patient’s privacy. fits properly to the contour of the
Powder and lotion reduce fric leg. Even distribution prevents
tion and make application of interference with circulation.
stockings easier.
Applying and Removing Antiembolism Stockings 21
ACTION RATIONALE
FIGURE 1 Putting foot of stocking

onto patient.
calf, toward the knee. Make

sure it is distributed evenly.
11. Pull forward slightly on toe properly positioned. Adjust,
section. If the stocking has a if necessary, to ensure mate
toe window, make sure it is rial is smooth.
12. If the stockings are knee
length, make sure each stock
ing top is 1 to 2 inches below
the patella. Make sure the
Prevents pressure and interfer
stocking does not roll down.
ence with circulation. Rolling
13. If applying thigh-length stockings may have a constrict
stock ing, continue the ing effect on veins.
application. Flex the patient’s
leg. Stretch the stocking over This ensures even distribution.
the knee.
14. Pull the stocking over the
thigh until the top is 1 to 3
inches below the gluteal Prevents excessive pressure and
fold (FIGURE 2). Adjust the interference with circulation.
stocking, as necessary, to Rolling stockings may have a
distribute the fabric evenly. constricting effect on veins.
Make sure the stocking does
not roll down.
FIGURE 2 Pulling the stocking

Ensures toe comfort and prevents up over the thigh.
interference with circulation.
ACTION RATIONALE
15. Remove equipment and

return the patient to a posi
tion of comfort. Remove Removing Stockings
your gloves. Raise side rail 17. To remove stocking, grasp
and lower bed. top of stocking with your
16. Remove any thumb and fingers and
other PPE, if us smoothly pull stocking off
used. Perform inside-out to heel. Support
hand foot and ease stocking over
hy it.
hygiene.
EVALUATION spread of microorganisms.
Promotes patient comfort and
safety. Removing gloves prop
This preserves the elasticity and
erly reduces the risk for infection
contour of the stocking. It allows
transmission and contamination
assessment of circulatory status
of other items.
and condition of skin on lower
Removing PPE properly reduces extremity and for skin care.
the risk for infection transmis
• The stockings are applied and removed as

indicated. • The patient exhibits a decrease in
peripheral edema.
• The patient can state the reason for using the stockings.
DOCUMENTATION
• Document the patient’s leg measurements as a baseline. Document
the application of the stockings, size stocking applied, skin and leg
assessment, and neurovascular assessment.
• Remove stockings once every shift for 20 to 30 minutes. Wash and
air-dry, as necessary, according to manufacturer’s directions. • Assess
at least every shift for skin color, temperature, sensation, swell ing, and
the ability to move. If complications are evident, remove the stockings
and notify the physician or primary care provider. • Evaluate stockings
to ensure the top or toe opening does not roll with movement. Rolled
stocking edges can cause excessive pressure and interfere with
circulation.
• Despite the use of elastic stockings, a patient may develop deep-vein
thrombosis or phlebitis. Unilateral swelling, redness, tenderness,
pain, and warmth are possible indicators of these complications.
Notify the primary care provider of the presence of any symptoms.
Removing Arterial and Femoral Lines 23
Skill • 6 Removing Arterial and Femoral

Lines R
Arterial and femoral lines are used for intensive and continuous cardiac
monitoring and intraarterial access. Once the lines are no longer neces
sary or have become ineffective, they need to be removed. Consult facil
ity policy to determine whether nurses are permitted to perform this
procedure. Two nurses should be at the bedside until bleeding is con
trolled, and are available to give emergency medications, if necessary.
The patient should be kept NPO until catheter is removed in case of
nausea with a vasovagal response.
EQUIPMENT
• Sterile gloves • For femoral line: small sandbag
• Clean gloves (5 to 10 pounds), wrapped in
• Goggles or face shield towel or pillowcase
• Sterile gauze pads • Emergency medications (e.g.,
• Waterproof protective pad atropine, for a vasovagal
• Sterile suture removal set response with femoral line
• Transparent dressing removal) for emergency
• Alcohol pads response, per facility policy
• Hypoallergenic tape and guidelines
• Indelible pen
• Review the patient’s medical record and plan of care for information
about discontinuation of the arterial or femoral line.
• Assess the patient’s coagulation status, including laboratory studies,
to reduce the risk of complications secondary to impaired clotting
ability. • Assess the patient’s understanding of the procedure.
• Inspect the site for leakage, bleeding, or hematoma.
• Assess skin color and temperature and assess distal pulses for
strength and quality. Mark distal pulses with an ‘X’ for easy
identification after the procedure.
• Assess patient’s blood pressure; systolic blood pressure should be
less than 180 mm Hg before catheter is removed.
NURSING DIAGNOSES
• Risk for Injury
• Risk for Infection
• Impaired Skin Integrity
• Anxiety

• Line is removed intact and without injury to the patient. • Site
remains clean and dry, without evidence of infection, bleeding, or
hematoma.
24 Removing Arterial and Femoral Lines
IMPLEMENTATION
ACTION RATIONALE
1. Verify the order for removal alarms and then turn off the
of arterial or femoral line in flow
the patient’s medical record. This ensures that the correct
2. Gather all equipment and intervention is performed on the
bring to bedside. correct patient.
Having equipment available
3. Perform hand saves time and facilitates accom
hygiene and pu plishment of procedure.
put on PPE, if Hand hygiene and PPE prevent
in the spread of microorganisms.
indicated. PPE is required based on trans
4. Identify Identifying the patient ensures
4. Identify the patient. the right patient receives the
intervention and helps prevent
errors.
This ensures the patient’s pri

5. Close cu vacy. Explanation relieves anxi
5. Close curtains around bed ety and facilitates cooperation.
and close the door to the
room, if possible. Explain the Emptying the bladder ensures
procedure to the patient. patient comfort. IV access may
6. Ask patient to empty bladder. be needed in case of hypotension
Maintain an IV infusion of or bradycardia.
normal saline via another
venous access during proce
dure, as per medical orders or Having the bed at the proper
height prevents back and muscle
facility guidelines.
strain.
7. If bed is adjustable, raise bed
to comfortable working
height, usually elbow height These prevent contact with blood
of the caregiver (VISN 8 and body fluids.
Patient Safety Center, 2009).
This ensures accurate location of
8. Put on clean gloves, goggles,
femoral artery.
and gown.
9. If line being removed is in a
femoral site, use Doppler
ultrasound to locate the fem oral
artery 1 to 2 inches
above the entrance site of the These measures help prepare for
femoral line. Mark with ‘X’ withdrawal of the line.
using indelible marker.
10. Turn off the monitor
Removing Arterial and Femoral Lines 25
ACTION RATIONALE
clamp to the flush solution.

Carefully remove the dressing
over the insertion site. Remove
any sutures using the suture
removal kit; make sure all
sutures have been removed.
11. Withdraw the catheter the femoral artery.
using a gentle, steady 14. Cover the site with an appro
motion. Keep the catheter priate dressing and secure the
parallel to the blood vessel dressing with tape. If
during withdrawal. Watch Using a gentle, steady motion
for hematoma formation parallel to the blood vessel
during catheter removal by reduces the risk for traumatic
gently palpating surround injury.
ing tissue. If hematoma
starts to form, reposition
hands until optimal pres
sure is obtained to prevent
further leakage of blood.
12. Immediately after with
drawing the catheter, apply
pressure 1 or 2 inches
above the site at the previ If sufficient pressure is not
ously marked spot with a applied, a large, painful hema
sterile 4 4 gauze pad. toma may form.
Maintain pressure for at
least 10 minutes, or per
facility policy (longer if
bleeding or oozing
persists). Apply additional
pressure to a femoral site if
the patient has coagulopathy
or is receiv ing
anticoagulants.
13. Assess distal pulses every 3 Assessment of distal pulses
to 5 minutes while pressure determines blood flow to the
is being applied. Note: Dor extremity. Pulses should return to
salis pedis and posterior tib ial baseline after pressure is
pulses should be markedly released.
weaker from baseline if suffi
cient pressure is applied to
prevent continued bleeding and
hematoma formation.
Sufficient pressure is needed to

26 Removing Arterial and Femoral Lines
ACTION RATIONALE
stipulated by facility policy,

make a pressure dressing for
a femoral site by folding four
sterile 4 4 gauze pads in
half, and apply the dressing.
15. Cover the dressing with a then every 4 hours, or
tight adhesive bandage, per according to facility policy.
policy, and then cover the Use log roll to assist patient
femoral bandage with a sandbag. in using bedpan, if needed.
Remove gloves. Maintain the
patient on bed rest, with the
head of the bed elevated less EVALUATION
than 30 degrees, for 6 hours Sufficient pressure is needed to
with the sandbag in place. prevent continued bleeding and
Lower bed height. Remind hematoma formation.
the patient not to lift his or
Removing gloves properly
her head while on bed rest.
reduces the risk for infection
16. Remove transmission and contamination
additional PPE. of other items. Raising head of
Per fo the bed increases intraabdominal
form hand pressure, which could lead to
hygiene. bleeding from site.
Se
Send specimens to the
lab Removing PPE properly reduces
laboratory immediately. the risk for infection
transmission and contamination
of other items.
Hand hygiene prevents transmis
17. Observe the site for bleeding. sion of microorganisms. Speci
Assess circulation in the mens must be processed in a
extremity distal to the site by timely manner to ensure
evaluating color, pulses, and accuracy.
sensation. Repeat this assess
Continued assessment allows for
ment every 15 minutes for
early detection and prompt inter
the first 1 hour, every 30
vention should problems arise.
minutes for the next 2 hours,
hourly for the next 2 hours,
• Patient exhibits an arterial or femoral line site that is clean and dry
without evidence of injury, infection, bleeding, or hematoma. •
Patient demonstrates intact peripheral circulation and verbalizes a
reduction in anxiety.
Giving a Back Massage 27
DOCUMENTATION
• Document the time the line was removed and how long pressure was
applied.
• Document site assessment every 5 minutes while pressure is being
applied (second nurse can do this).
• Document assessment of peripheral circulation, appearance of site,
type of dressing applied, the timed assessments, patient’s response,
and any medications given.
• Sometimes, a culture of the catheter tip is ordered to aid in identify
ing the source of infection. If ordered, place the catheter tip on a 4
4 sterile gauze pad. After the bleeding is under control and the dress
ing is secure, hold the catheter over the sterile container. Cut the tip
of the catheter with sterile scissors and allow it to fall into the sterile
container. Label the specimen and send it to the laboratory.
Skill • 7 Giving a Back Massage G
Massage has many benefits, including general relaxation and increased

circulation. Massage can help alleviate pain (The Joint Commission,
2008). A back massage can be incorporated into the patient’s bath, as
part of care before bedtime, or at any time to promote increased patient
com
fort. Some nurses do not always give back massages to patients because
they do not think they have enough time. However, giving a back
massage provides an opportunity for the nurse to observe the skin for
signs of breakdown. It improves circulation; decreases pain, symptom
distress, and anxiety; improves sleep quality; and also provides a
means of communi
cating with the patient through the use of touch. A back massage also
provides cutaneous stimulation as a method of pain relief. Because
some patients consider the back massage a luxury and may be reluctant
to accept it, communicate its importance and value to the patient. An
effective back massage should take 4 to 6 minutes to complete. A
lotion is usually used; warm it before applying to the back. Be aware of
the patient’s medical diagnosis when considering giving a back
massage. A back massage is contraindicated, for example, when the
patient has had back surgery or has fractured ribs. Position the patient
on the abdomen or, if this is contraindicated, on the side for a back
massage.
EQUIPMENT
• Massage lubricant or lotion, • Bath blanket
warmed • Towel
• Pain assessment tool and/or • Nonsterile gloves, if indicated
scale • Powder, if not • Additional PPE, as indicated
contraindicated
28 Giving a Back Massage
• Review the patient’s medical record and plan of care for information
about the patient’s status and contraindications to back massage.
Question the patient about any conditions that might require modifi
cations or that might contraindicate a massage. Inquire about any
allergies, such as to lotions or scents.
• Ask if the patient has any preferences for lotion or has his or her own
lotion. • Assess the patient’s level of pain.
• Check the patient’s medication administration record for the time an
analgesic was last administered. If appropriate, administer an
analgesic early enough so that it has time to take effect.
NURSING DIAGNOSES
• Acute Pain
• Chronic Pain
• Anxiety
• Disturbed Sleep Pattern

• Patient reports increased comfort and/or decreased pain. •
Patient displays decreased anxiety and improved relaxation. •
Patient is free of skin breakdown.
• Patient verbalizes an understanding of the reasons for back massage.
IMPLEMENTATION
ACTION RATIONALE
1. Perform hand patient and explain the

hygiene and put on procedure.
on PPE, if Hand hygiene and PPE prevent
indicated. the spread of microorganisms.
2. Identify the Identifying the patient ensures
patient.
the right patient receives the
2. Identify
errors.
Explanation encourages patient

understanding and cooperation
3. Offer a back and reduces apprehension.
massage to the
3 Off b
ACTION RATIONALE
4. Put on gloves, if indicated. elbow height of the caregiver

(VISN 8, Patient Safety
Center, 2009), and lower the
5. Close room door or curtain. side rail.
8. Assist the patient to a comfort
able position, preferably the
prone or side-lying position.
Remove the covers and move the
6. Assess the patient’s pain,
patient’s gown just enough to
using an appropriate assess
expose the patient’s back from
ment tool and measurement
the shoulders to the sacral area.
scale.
Drape the patient, as
7. Raise bed to a needed, with the bath blanket.
comfortable working
9. Warm the lubricant or lotion
position, usually
in the palm of your hand, or Having the bed at the proper
place the container in small height prevents back and muscle
basin of warm water. During strain.
massage, observe the
patient’s skin for reddened
or open areas. Pay particu This position exposes an ade
lar attention to the skin quate area for massage. Draping
over bony prominences. the patient provides privacy and
10. Using light gliding strokes warmth.
(effleurage), apply lotion to the
patient’s shoulders, back, and
sacral area (FIGURE 1).
11. Place your hands beside each
other at the base of the
Cold lotion causes chilling and
patient’s spine and stroke
discomfort. Pressure may inter
upward to the shoulders
fere with circulation and lead to
and back downward to the
pressure ulcers.
Gloves are not usually necessary.
Gloves prevent contact with
blood and body fluid.
Closing the door or curtain pro
vides privacy, promotes relax
ation, and reduces noise and Effleurage relaxes the patient and
stimuli that may aggravate pain lessens tension.
and reduce comfort.
Accurate assessment is
Continuous contact is soothing
necessary to guide
and stimulates circulation and
treatment/relief interven tions
muscle relaxation.
and to evaluate the effec tiveness
of pain control measures.
30 Giving a Back Massage
ACTION RATIONALE
FIGURE 1 Using effleurage on a

patient’s back.
buttocks in slow, continuous
strokes. Continue for several
minutes.
12. Massage the patient’s shoul 14. Complete the massage with
der, entire back, areas over iliac additional long stroking
crests, and sacrum with circular A firm stroke with continuous
stroking motions. Keep your contact promotes relaxation.
hands in contact with the
patient’s skin.
Continue for several minutes,
applying additional lotion, as
necessary.
13. Knead the patient’s skin by
gently alternating grasping Kneading increases blood
and compression motions circulation.
(pétrissage) (FIGURE 2).
FIGURE 2 Using pétrissage.
Long, stroking motions are

soothing and promote relaxation;
ACTION RATIONALE
movements that eventually plan of care, as appropriate.
become lighter in pressure.
15. Use the towel to pat the EVALUATION

patient dry and to remove continued stroking with gradual
excess lotion. lightening of pressure helps
extend the feeling of relaxation.
16. Remove gloves, if worn.
Reposition patient’s gown Drying provides comfort and
and covers. Raise side rail reduces the feeling of moisture
and lower the bed. Assist on the back.
patient to a position of Repositioning bedclothes, linens,
comfort. and the patient helps to promote
17. Remove patient comfort and safety.
additional PPE, if
us
used. Perform
hand Removing PPE properly reduces
hy the risk for infection transmis
hygiene. sion and contamination of other
items. Hand hygiene prevents
transmission of microorganisms.
18 E al ate Reassessment allows for individ
18. Evaluate the patient’s ualization of plan of care and
response to interventions. promotes optimal patient
Reassess level of discomfort comfort.
or pain using original assess
ment tools. Reassess and alter
• Patient reports increased comfort and/or decreased pain. •

Patient displays decreased anxiety and improved relaxation. •
Patient’s skin is without evidence of breakdown.
• Patient verbalizes an understanding of the reasons for back massage.
DOCUMENTATION
• Document pain assessment and other significant assessments. Docu
ment the use of, and length of time of, massage, and patient response.
Record alternative treatments to consider, if appropriate.
• Before giving a back massage, assess the patient’s body structure and
skin condition, and tailor the duration and intensity of the massage
accordingly. If you are giving a back massage at bedtime, have the
patient ready for bed beforehand so the massage can help him or her
fall asleep.
32 Giving a Bed Bath
• If the patient has oily skin, substitute a talcum powder or lotion of the
patient’s choice. However, to avoid aspiration, do not use powder if the
patient has an endotracheal or tracheal tube in place. Avoid using
powder and lotion together because this may lead to skin maceration.
• When massaging the patient’s back, stand with one foot slightly for
ward and your knees slightly bent to allow effective use of your arm
and shoulder muscles.
Skill • 8 Giving a Bed Bath G
A bed bath may be considered a partial bed bath if the patient is well
enough to perform most of the bath, and the nurse needs to assist with
washing areas that the patient cannot reach easily. A partial bath may
also refer to bathing only those body parts that absolutely have to be
cleaned, such as the perineal area and any soiled body parts. Many of
the bedside skin-cleaning products available today do not require
rinsing. After cleaning the body part, dry it thoroughly. Refer to the
accompany
ing skill variations for the procedures related to perineal cleansing and a
bath using a disposable self-contained bathing system.
EQUIPMENT
• Washbasin and warm water • Washcloths (2)
• Personal hygiene supplies • Bath blanket
(deodorant, lotion) • Gown or pajamas
• Skin-cleaning agent • Bedpan or urinal
• Emollient and skin barrier, as • Laundry bag
indicated • Nonsterile gloves; other PPE as
• Towels (2) indicated
• Assess the patient’s knowledge of hygiene practices and bathing pref

erences—frequency, time of day, and type of hygiene products. •
Assess for any physical-activity limitations. Assess the patient’s abil
ity to bathe himself or herself. Allow the patient to do any part of the
bath that he or she can do. For example, the patient may be able to
wash his or her face, while the nurse does the rest.
• Assess the patient’s skin for dryness, redness, or areas of breakdown,
and gather any other appropriate supplies that may be needed as a
result.
NURSING DIAGNOSES
• Bathing Self-Care Deficit
Giving a Bed Bath 33
• Disturbed Body Image

• Impaired Skin Integrity
• Ineffective Coping

• The patient will be clean and fresh.
• The patient regains feelings of control by assisting with the bath.
• The patient verbalizes positive body image.
• The patient demonstrates an understanding about the need for
cleanliness.
IMPLEMENTATION
ACTION RATIONALE
1. Review chart for any limita the procedure with the

tions in physical activity. pa
2. Bring necessary equipment patient and assess his
to the bedside stand or over or
bed table. or her ability to assist
in
in the bathing process,
as well a
as well as personal hygiene
3. Perform hand preferences.
hygiene and pu
put on gloves and/or
oth 5. Close curtains around bed and
other PPE, if close the door to the room, if
in possible. Adjust the room
indicated. temperature, if necessary.
Identifying limitations prevents
y patient discomfort and injury.
4. Identify the patient. Bringing everything to the bed
Discuss the side conserves time and energy.
Arranging items nearby is conve the right patient receives the
nient, saves time, and avoids intervention and helps prevent
unnecessary stretching and twist errors. Discussion promotes reas
ing of muscles on the part of the surance and provides knowledge
nurse. about the procedure. Dialogue
Hand hygiene and PPE prevent encourages patient participation
the spread of microorganisms. and allows for individualized
PPE is required based on trans nursing care.
mission precautions. This ensures the patient’s privacy
and lessens the risk for loss of
body heat during the bath.
Identifying the patient ensures
ACTION RATIONALE
6. Remove sequential compres remove the top sheet while

sion devices and antiembo lism the patient holds the bath
stockings from lower blanket in place. If linen is
extremities according to to be reused, fold it over a
agency protocol. chair. Place soiled linen in
7. Offer the patient bedpan or laundry bag. Take care to
urinal. prevent linen from coming
in contact with your
clothing.
12. Remove the patient’s gown
8. Remove gloves and perform and keep the bath blanket in
hand hygiene. place. If the patient has an IV
9. Adjust the bed to a comfort line and is not wearing a gown
able working height, usually with snap sleeves, remove the
elbow height of the caregiver gown from other arm first.
(VISN 8 Patient Safety Cen Most manufacturers and agencies
ter, 2009). recommend removal of these
devices before the bath to allow
10. Put on gloves. Lower side
for assessment.
rail nearer to you and assist
patient to side of bed where
you will work. Have patient Voiding or defecating before the
lie on his or her back. bath lessens the likelihood that
the bath will be interrupted,
because warm bath water may
11. Loosen top covers and stimulate the urge to void.
remove all except the top Hand hygiene deters the spread
sheet. Place bath blanket of microorganisms.
over the patient and then Having the bed at the proper
height prevents back and muscle unavailable, the top sheet may be
strain. used in place of the bath blanket.
Gloves prevent transmission of

microorganisms. Having the
patient positioned near the nurse
and lowering the side rail prevent
unnecessary stretching and twist
ing of muscles on the part of the This provides uncluttered access
nurse. during the bath and maintains
The patient is not exposed warmth of the patient. IV fluids
unnecessarily, and warmth is must be maintained at the pre
maintained. If a bath blanket is scribed rate.
ACTION RATIONALE
Lower the IV container and

pass the gown over the tub
ing and the container.
Rehang the container and
check the drip rate.
13. Raise side rail. Fill basin washcloth, wipe one eye
with a sufficient amount of from the inner part of the
comfortably warm water eye, near the nose, to the
(110ºF to 115ºF). Add the outer part. Rinse or turn
skin cleanser, if appropriate, the cloth before washing
according to manufacturer’s the other eye.
directions. Change as neces
sary throughout the bath. 17. Bathe patient’s face, neck,
Lower side rail closer to you and ears. Apply appropriate
when you return to the bed emollient.
side to begin the bath.
14. Put on gloves, if necessary. 18. Expose the patient’s far arm
Fold the washcloth like a mitt and place the towel length wise
on your hand so that there are under it. Using firm strokes,
no loose ends. wash hand, arm, and axilla,
lifting the arm as nec essary to
access axillary
Side rails maintain patient safety.
15. Lay a towel across patient’s Warm water is comfortable and
chest and on top of bath relaxing for the patient. It also
blanket. stimulates circulation and pro
16. With no cleanser on the vides for more effective
cleansing.
carrying debris toward the
nasolacrimal duct. Rinsing or
turning the washcloth prevents
spreading organisms from one
eye to the other.
Gloves are necessary if there is
potential contact with blood or Use of emollients is
body fluids. Having loose ends recommended to restore and
of cloth drag across the patient’s maintain skin integ rity (Voegeli,
skin is uncomfortable. Loose 2008a; Watkins, 2008; Brown &
ends cool quickly and feel cold Butcher, 2005).
to the patient. The towel helps to keep the bed
This prevents chilling and keeps dry. Washing the far side first
the bath blanket dry. eliminates contaminating a clean
area once it is washed. Gentle
Soap is irritating to the eyes. friction stimulates circulation
Moving from the inner to the and muscles and helps remove
outer aspect of the eye prevents
ACTION RATIONALE
region. Rinse, if necessary, or one susceptible to back

and dry. Apply appropriate strain might be to bathe one
emollient. side of the patient and move
to the other side of the bed to
complete the bath.
21. Spread a towel across the
patient’s chest. Lower the bath
blanket to the patient’s
umbilical area. Wash, rinse, if
19. Place a folded towel on the necessary, and dry chest. Keep
bed next to the patient’s hand chest covered with
and put basin on it. Soak the towel between the wash and
patient’s hand in the basin. rinse. Pay special attention to
Wash, rinse if necessary, and skin folds under the breasts.
dry hand. Apply appropriate 22. Lower the bath blanket to the
emollient. perineal area. Place a towel over
the patient’s chest.
23. Wash, rinse, if necessary, and
dry the abdomen. Carefully
20. Repeat Actions 15 and 16 for inspect and clean the umbilical
the arm nearer you. An dirt, oil, and organisms. Long,
option for the shorter nurse firm strokes are relaxing and
more comfortable than short, drying one part of the body at a
uneven strokes. Rinsing is neces time avoids unnecessary expo
sary when using some cleansing sure and chilling. Skin-fold areas
products. Use of emollients is may be sources of odor and skin
recommended to restore and breakdown if not cleaned and
maintain skin integrity (Voegeli, dried properly.
2008a; Watkins, 2008; Brown &
Butcher, 2005).
Placing the hand in the basin of Keeping the bath blanket and
water is an additional comfort towel in place avoids exposure
measure for the patient. It facili and chilling.
tates thorough washing of the Skin-fold areas may be sources
hands and between the fingers of odor and skin breakdown if
and aids in removing debris from not cleaned and dried properly.
under the skin. Use of emollients
is recommended to restore and
maintain skin integrity (Voegeli,
2008a; Watkins, 2008; Brown &
Butcher, 2005).
Exposing, washing, rinsing, and

ACTION RATIONALE
area
and any abdominal folds
or creases.
24. Return the bath blanket to its attention to the areas between
original position and expose the toes. Apply appropriate
far leg. Place towel under the far emollient.
leg. Using firm
strokes, wash, rinse, if neces
sary, and dry the leg from 26. Repeat Actions 21 and 22 for
ankle to knee and knee to the other leg and foot.
groin. Apply appropriate
27. Make sure the patient is cov
emollient.
ered with the bath blanket.
Change water and washcloth at
25. Wash, rinse if necessary, and
this point, or earlier, if
dry the foot. Pay particular
necessary.
28. Assist patient to prone or 2009). Use of emollients is rec
side-lying position. Put on ommended to restore and main
gloves, if not applied earlier. tain skin integrity (Voegeli,
Position bath blanket and towel 2008a; Watkins, 2008; Brown &
to expose only the Butcher, 2005).
back and buttocks.
29. Wash, rinse, if necessary, and
dry back and buttocks area. The bath blanket maintains
Pay particular attention to warmth and privacy. Clean,
cleansing between gluteal warm water prevents chilling and
folds, and observe for any maintains patient comfort.
redness or skin breakdown
in the sacral area. Positioning the towel and bath
blanket protects the patient’s pri
30. If not contraindicated, give
vacy and provides warmth.
patient a backrub. Back
massage may be given also
body fluids.
after perineal care. Apply
The towel protects linens and
prevents the patient from feeling Fecal material near the anus may
uncomfortable from a damp or be a source of microorganisms.
wet bed. Washing from ankle to Prolonged pressure on the sacral
groin with firm strokes promotes area or other bony prominences
venous return. Use of emollients may compromise circulation and
is recommended to restore and lead to development of decubitus
maintain skin integrity (Voegeli, ulcer.
2008a; Watkins, 2008; Brown & A backrub improves circulation
Butcher, 2005). to the tissues and is an aid to
Drying of the feet is important to relaxation. A backrub may be
prevent irritation, possible skin contraindicated in patients with
breakdown, and infections (NIA,
ACTION RATIONALE
appropriate emollient and/or

skin barrier product.
31. Raise the side rail. Refill

basin with clean water. Dis
card washcloth and towel. and maintain skin integrity
Remove gloves and put on (Voegeli, 2008a; Watkins, 2008;
clean gloves. Brown & Butcher, 2005). Skin
barriers protect the skin from
p damage caused by excessive
32. Clean perineal area or set exposure to water and irritants,
up pa such as urine and feces (Voegeli,
patient so that 2008a).
he or The washcloth, towel, and water
sh are contaminated after washing
she can complete the patient’s gluteal area. Chang
pe ing to clean supplies decreases
perineal self-care. If the spread of organisms from the
the anal area to the genitals.
the patient is unable,
Providing perineal self-care may
lower the
decrease embarrassment for the
lower the side rail and com
patient. Effective perineal care
plete perineal care, following
reduces odor and decreases the
guidelines in the accompany
risk for infection through con
ing Skill Variation. Apply
tamination. Skin barriers protect
skin barrier, as indicated.
the skin from damage caused by
Raise side rail, remove
excessive exposure to water and
gloves, and perform hand
irritants, such as urine and feces
hygiene.
(Voegeli, 2008a).
33. Help patient put on a clean
gown and assist with the use of
other personal toiletries, such as
deodorant or This provides for the patient’s
cosmetics. warmth and comfort.
34. Protect pillow with towel and
groom patient’s hair.
35. When finished, make sure
the patient is comfortable,
with the side rails up and the
Proper positioning with raised
bed in the lowest
side rails and proper bed height
position.
provide for patient comfort and
cardiovascular disease or muscu
safety.
loskeletal injuries. Use of emol
lients is recommended to restore
ACTION RATIONALE
36. Change bed

linens. Dispose
g of
of soiled linens • The patient is clean.
ac Removing PPE properly reduces
according to agency the risk for infection transmis
po sion and contamination of other
policy. Remove gloves items. Hand hygiene prevents the
an spread of microorganisms.
and any other PPE, if
used. Per
used. Perform hand hygiene.
EVALUATION
• The patient demonstrates some feeling of control in his or her

care. • The patient verbalizes an improved body image.
• The patient verbalizes the importance of cleanliness.
DOCUMENTATION
• Record any significant observations and communication on the
patient’s chart. Document the condition of the patient’s skin. Record
the procedure, amount of assistance given, and patient participation.
Document the application of skin care products, such as a skin
barrier.
• To remove the gown from a patient with an IV line, take the gown off
the uninvolved arm first and then thread the IV tubing and bottle or
bag through the arm of the gown. To replace the gown, place the
clean gown on the unaffected arm first and thread the IV tubing and
bottle or bag from inside the arm of the gown on the involved side.
Never disconnect IV tubing to change a gown, because this causes a
break in a sterile system and could introduce infection.
• Lying flat in bed during the bed bath may be contraindicated for cer
tain patients. The position may have to be modified to accommodate
their needs.
• Incontinent patients require special attention to perineal care. Patients
with urinary or fecal incontinence are at risk for perineal skin dam
age. This damage is related to moisture, changes in the pH of the
skin, overgrowth of bacteria and infection of the skin, and erosion of
perineal skin from friction on moist skin. Skin care for these patients
should include measures to reduce overhydration (excess exposure to
moisture), reduce contact with ammonia and bacteria, and reduce
friction. Remove soil and irritants from the skin during routine
hygiene, as well as cleansing when the skin becomes exposed to irri
tants. Avoid using soap and excessive force for cleaning. The use of
perineal skin cleansers, moisturizers, and moisture barriers are rec
ommended for skin care for the incontinent patient. These products
help promote healing and prevent further skin damage.
• If the patient has an indwelling catheter and the agency recommends

daily care for the catheter, this is usually done after perineal care.
Agency policy may recommend use of an antiseptic cleaning agent or
plain soap and water on a clean washcloth. Put on clean gloves before
cleaning the catheter. Clean 6 to 8 inches of the catheter, moving
from the meatus downward. Be careful not to pull or tug on the cathe
ter during the cleaning motion. Also inspect the meatus for drainage
and note the characteristics of the urine.
Skill Variation
Performing Perineal Cleansing P

Perineal care may be carried area back over the genital
out while the patient remains in area (FIGURE A). Always
bed. When performing perineal proceed from the least
care, follow these guidelines: 1. contaminated area to the
Assemble supplies and pro vide most contaminated area.
for privacy. Use a clean portion of the
p washcloth for each stroke.
2. Explain the procedure Rinse the washed areas
to the pa well with plain water.
patient, • For a male patient, clean
perform the tip of the penis first,
ha moving the washcloth in a
hand hygiene, and circular motion from the
pu meatus outward. Wash the
put on disposable shaft of the penis using
gl downward strokes toward
gloves. the pubic area (FIGURE B).
3. Wash and Always proceed from the
3. Wash and rinse the groin least contaminated area to
area (both male and female the most contaminated
patients). area. Rinse the washed
• For a female patient, spread areas well with plain
the labia and move the water. In an uncircumcised
washcloth from the male patient (teenage or
pubic area toward the anal older),
area to prevent carrying
organisms from the anal
FIGURE A Performing female perineal care.
(continued on page 41)

Performing Perineal Cleansing continued
FIGURE B Performing male perineal care.

tum, which houses the tes
retract the foreskin (pre ticles, with care because
puce) while washing the the area is sensitive.
penis. Pull the uncircum 4. Dry the cleaned areas and
cised male patient’s fore apply an emollient, as indi
skin back into place over
the glans penis to prevent
constriction of the penis,
which may result in
edema and tissue injury. It
is not recommended to
Gi
retract Se Skill Variation
the foreskin for cleaning cated. Avoid the use of pow
during infancy and child der. Powder may become a
hood, because injury and medium for the growth of
scarring could occur (Med bacteria.
linePlus, 2007b). Wash and 5. Turn the patient on his or
rinse the male patient’s her side and continue
scrotum. Handle the scro cleansing the anal area.
Continue in the direction of 6. Remove gloves and perform
least contaminated to most
contaminated area. In the ha
female patient, cleanse from hand hygiene.
the vagina toward the anus. Co
In both female and male Continue with
patients, change the wash ad
cloth with each stroke until additional care, as
the area is clean. Rinse and ne
dry the area. necessary.
Remove glo
Giving a Bath Using a

Disposable Self-contained
Bathing System
This product is packaged with 8 low these guidelines:
to 10 premoistened, disposable 1. Warm the unopened
washcloths. If more than eight package in the microwave,
cloths are available in package, according
use a separate cloth for hands
and feet. When giving a bath
with a disposable system, fol
Giving a Bath Using a Disposable

Self-contained Bathing System continued
patient’s gown and keep the
to manufacturer’s bath blanket in place. 5.
directions or remove the Remove first cloth from
package from storage package. Wipe one eye from
warmer. the inner part of the eye,
2. Provide for privacy. near the nose, to the outer
p part. Use a different part
3. Explain the of the cloth for the other
procedure to th eye.
the patient; 6. Bathe the face, neck, and
perform ears. Allow the skin to air dry
ha for approximately 30 seconds,
hand hygiene and put according to man ufacturer’s
on directions. Air drying allows
on disposable gloves the emollient ingredient of the
an cleanser to remain on the skin.
and/or other PPE, as Alternately, dry the skin
indicate with a towel, based on the
indicated. product used. Apply appro
4. Cover the patient with a priate emollient. Dispose
bath blanket and remove top of cloth in trash receptacle.
linens. Remove the 7. Expose the patient’s far
arm. Remove another accord ing to
cloth. Using firm strokes, manufacturer’s
wash hand, arm, and axilla. directions. Air drying
Allow the skin to air dry allows the emollient
for approximately 30 sec ingredient of the cleanser
onds, according to manu to remain on the skin.
facturer’s directions. Air Alternately, dry the
drying allows the emollient skin with a towel, based
ingredient of the cleanser on the product used.
to remain on the skin. Apply
Alternately, dry the skin appropriate emollient. Dis
with a towel, based on the pose of cloth in trash
product used. Apply appro recep tacle. Cover the
priate emollient. Dispose patient’s
of cloth in trash receptacle. body with blanket.
Cover arm with blanket. 10. Expose far leg. Remove
8. Repeat for nearer arm with new cloth and cleanse leg and
a new cloth. Cover arm foot. Allow the skin to air dry
with blanket. for approximately 30 seconds,
9. Expose the patient’s chest. according to manufacturer’s
Remove new cloth and directions. Air drying allows
cleanse chest. Allow the the
skin to air dry for emollient ingredient of the
approximately 30 seconds, cleanser to remain on the
according to skin. Alternately, dry the
manufacturer’s skin with a towel, based on
directions. Cover chest the product used. Apply
with a towel. appropriate emollient. Dis
Expose patient’s abdomen. pose of cloth in trash
Cleanse abdomen. Allow
the skin to air dry for
approxi
mately 30 seconds,
Giving a Bath Using a Disposable

Self-contained Bathing System continued
cleanse back and buttocks
receptacle. Cover the area. Allow the skin to air
patient’s leg with blanket. 11. dry for approxi mately 30
Repeat for nearer leg with a seconds, accord ing to
new cloth. Cover leg manufacturer’s
with blanket. directions. Air drying
12. Assist patient to prone or allows the emollient
side-lying position. Put on ingredient of the cleanser
gloves, if not applied to remain on the skin.
earlier. Position blanket to Alternately, dry the
expose back and buttocks. skin with a towel, based
Remove a new cloth and on the product used.
Apply perineal area. Dispose of
appropriate emollient. Dis cloth in trash receptacle.
pose of cloth in trash Apply skin barrier, as
recep indicated.
14. Remove gloves. Assist
patient to put on clean
gown. Assist with the use of
other personal toiletries. 15.
Change bed linens. 16.
Remove gloves
M and per fo
wi Skill Variation
tacle. If not form hand
contraindicated, give the hy
patient a back mas sage. hygiene. Dispose
Apply skin barrier, as of
indicated. Cover the of soiled linens
patient with blanket. ac
13. Remove gloves and put on according to
clean gloves. Remove last facility polic
cloth and cleanse the facility policy.
Meeting the Bathing Needs of Patients

with Dementia
an expression of unmet
1. Shift the focus of the inter
needs; unwillingness to par
action from the “task of
ticipate may be a response
bathing” to the needs and
to uncomfortable water tem
abilities of the patient.
peratures or levels of sound
Focus on comfort, safety,
or light in the room.
autonomy, and self-esteem,
4. Consider other methods for
in addition to cleanliness.
bathing. Showers and tub
2. Individualize patient
baths are not the only
care. Consult the patient,
options in bathing. Towel
the
baths, washing under
patient’s record, family
clothes, and bathing “body
mem bers, and other
sections” one day at a time
caregivers to determine
are other possible options.
patient preferences.
5. Maintain a relaxed
3. Consider what can be
demeanor. Use calming
learned from the behaviors
language. Try to
associated with dementia
about the needs and prefer
ences of the patient. A
patient’s behavior may be
44 Assisting with a Sitz Bath
Meeting the Bathing Needs of Patients

with Dementia continued
discomfort during
determine phrases and bathing.
terms the patient
7. Wash the face and hair at the
understands in relation to
end of the bath or at a
bathing and make use of
separate time. Water
them. Offer frequent
dripping in the face and
reassurance.
having a wet head are often
6. Explore the need for rou
the most upsetting parts of
tine analgesia before bath ing.
the bathing process for peo
Move limbs carefully and be
ple with dementia.
aware of signs of
Adapted from Flori, L. (2007). Don’t throw in the towel: Tips for bathing a
patient who has dementia. Nursing, 37(7), 22–23; and Rader, J., Barrick, A.,
Hoeffer, B., et al. (2006). The bathing of older adults with dementia: Easing
the unnecessarily unpleasant aspects of assisted bathing. American Journal of
Nursing, 106(4), 40–49.
Skill • 9 Assisting with a Sitz Bath A
A sitz bath can help relieve pain and discomfort in the perineal area,
such as after childbirth or surgery, and can increase circulation to the
tissues, promoting healing.
EQUIPMENT
• Clean gloves • Adjustable IV pole
• Additional PPE, as • Disposable sitz bath bowl with
indicated • Towel water bag
• Review any orders related to the sitz bath.

• Determine patient’s ability to ambulate to the bathroom and maintain
sitting position for 15 to 20 minutes.
• Assess patient’s perineal/rectal area for swelling, drainage, redness,
warmth, and tenderness.
• Assess bladder fullness and encourage the patient to void before sitz bath.
NURSING DIAGNOSES
• Acute Pain
• Risk for Hypothermia
• Impaired Tissue Integrity
Assisting with a Sitz Bath 45
• Patient verbalizes an increase in comfort.
• Patient experiences a decrease in healing time, maintains normal
body temperature, remains free of any signs and symptoms of infec
tion, and exhibits signs and symptoms of healing.
IMPLEMENTATION
ACTION RATIONALE
1. Review the medical order for using a bedside commode, or

the application of a sitz bath, in the bathroom.
including frequency, and 7. Raise lid of toilet or com
length of time for the appli mode. Place bowl of sitz
cation. bath,
2. Gather the necessary supplies Reviewing the order and plan of
and bring to the bedside care validates the correct patient
stand or overbed table. and correct procedure.
Preparation promotes efficient

time management and an orga
nized approach to the task.
Bringing everything to the bed
3. Perform hand hygiene and side conserves time and energy.
pu Arranging items nearby is conve
put on PPE, if nient, saves time, and avoids
in unnecessary stretching and twist
indicated. ing of muscles on the part of the
nurse.
4 Identify the spread of microorganisms.
4. Identify the patient. PPE is required based on trans

5 Close cu intervention and helps prevent
5. Close curtains around bed errors.
and close door to the room, if
possible. This ensures the patient’s
6. Put on gloves. Assemble privacy.
equipment, at the bedside if
the task.
Gloves prevent exposure to Sitz bath will not drain appropri
blood and body fluids. Organiza ately if placed in toilet backward.
tion facilitates performance of
46 Assisting with a Sitz Bath
ACTION RATIONALE
with drainage ports to rear prescribed time), put on

and infusion port in front, in clean gloves. Assist the
the toilet. Fill bowl of sitz patient to stand and gently
bath about halfway full with pat perineal area dry.
tepid to warm water (37ºC to Remove gloves. Assist the
46ºC [98ºF to 115ºF]). patient to the bed or chair.
8. Clamp tubing on bag. Fill Ensure that the call bell is
bag with same temperature within reach.
water as mentioned above. Tepid water can promote relax
Hang bag above patient’s ation and help with edema; warm
shoulder height on the IV water can help with circulation.
pole.
9. Assist patient to sit on toilet
or commode and provide any If bag is hung lower, the rate of
extra draping if needed. flow will not be sufficient and
Insert tubing into infusion water may cool too quickly.
port of sitz bath. Slowly
unclamp tubing and allow
sitz bath to fill.
10. Clamp tubing once the sitz If tubing is placed into sitz bath
bath is full. Instruct the before the patient sits on the toi
patient to open the clamp let, the patient may trip over the
when the water in the bowl tubing. Filling the sitz bath
becomes cool. Ensure that ensures that the tissue is sub
the call bell is within reach. merged in water.
Instruct the patient to call
if he or she feels light Cool water may produce hypo
headed or dizzy or has any thermia. Patient may become
problems. Instruct the light-headed due to vasodilation,
patient not to try standing so call bell should be within
without assistance. reach.
11. Remove gloves and perform
hand hygiene.
12. When patient is finished (in
about 15 to 20 minutes, or
blood and body fluids. Patient
may be light-headed and dizzy
due to vasodilation. Patient
should not stand alone, and
bending over to dry self may
Hand hygiene deters the spread cause patient to fall.
of microorganisms.
Making an Occupied Bed 47
ACTION RATIONALE
13. Put on gloves. Empty and Proper equipment cleaning deters

disinfect the sitz bath bowl the spread of microorganisms.
according to agency policy.
14. Remove gloves Removing PPE properly reduces
and any addi tio the risk for infection transmis
tional PPE, if sion and contamination of other
used. items. Hand hygiene prevents the
Pe spread of microorganisms.
Perform hand hygiene.
EVALUATION
• Patient verbalizes a decrease in pain or discomfort.

• Patient tolerates sitz bath without incident.
• Patient demonstrates signs of healing.
DOCUMENTATION
• Document administration of the sitz bath, including water tempera
ture and duration. Document patient response, and assessment of
perineum before and after administration.
Skill • 10 Making an Occupied Bed M

If the patient cannot get out of bed, the linens may need to be changed
with the patient still in the bed. This is termed an “occupied” bed. The
following procedure explains how to make the bed using a fitted bot
tom sheet. Some facilities do not provide fitted bottom sheets, or some
times a fitted bottom sheet may not be available. If this is the case,
refer to the Skill Variation at the end of Skill 11, for using a flat bottom
sheet instead of a fitted sheet.
EQUIPMENT
• One large flat sheet • One fitted • Bedside chair
sheet • Drawsheet (optional) • • Waterproof protective pad
Blankets (optional)
• Bedspread • Disposable gloves
• Pillowcases • Additional PPE, as indicated
• Linen hamper or bag
48 Making an Occupied Bed
• Assess the patient’s preferences regarding linen changes.
• Assess for any precautions or activity restrictions for the
patient.
• Check for any patient belongings that may have accidentally
been placed in the bed linens, such as eyeglasses or prayer
cloths.
• Note the presence and position of any tubes or drains that the patient
may have.
NURSING DIAGNOSES
• Risk for Activity Intolerance
• Impaired Bed Mobility
• Impaired Transfer Ability

• The bed linens will be changed without injury to the nurse or
patient.
• The patient verbalizes feelings of increased comfort.
IMPLEMENTATION
ACTION RATIONALE
1. Check chart for limitations on do
the patient’s physical activity. do.
This facilitates patient coopera
2. Assemble equipment and tion, determines level of activity,
arrange on bedside chair in and promotes patient safety.
the order the items will be Organization facilitates perfor
used. mance of the task.
3. Perform hand
hygiene. Put on Hand hygiene and PPE prevent
on PPE, as the spread of microorganisms.
Patient identification validates the

4. Identify correct patient and correct proce
4. Identify the
dure. Discussion and explanation
patient. Explain
allay anxiety and prepare the
wh
patient for what to expect.
what you are going to
ACTION RATIONALE
5. Close curtains around bed under it and remove top linens.

and close the door to the Leave the top sheet in place if a
room, if possible. bath blanket is not used. Fold
6. Adjust the bed to a comfort linen that is to be reused over the
able working height, usually back of a
elbow height of the caregiver chair. Discard soiled linen in
(VISN 8 Patient Safety Cen laundry bag or hamper. Do
ter, 2009). not place on floor or furni
ture. Do not hold soiled lin
7. Lower side rail nearest you,
ens against your uniform.
leaving the opposite side rail up.
Place bed in flat position unless 10. If possible, and another per
contraindicated. son is available to assist,
grasp the mattress securely
8. Put on gloves. Check bed lin
and shift it up to the head of
ens for patient’s personal
the bed.
items. Disconnect the call
bell or any tubes/drains 11. Assist the patient to turn
from bed linens. toward the opposite side of
the bed, and reposition the
pillow under the patient’s
9. Place a bath blanket over the head.
patient. Have patient hold on to This ensures the patient’s
bath blanket while you reach privacy.
directly into the hamper helps
Having the bed at the proper prevent the spread of microor
height prevents back and muscle ganisms. The floor is heavily
strain. contaminated; soiled linen will
further contaminate furniture.
Soiled linen contaminates the
Having the mattress flat makes it nurse’s uniform, and this may
easier to prepare a wrinkle-free spread organisms to another
bed. patient.
Gloves prevent the spread of

microorganisms. It is costly and This allows more foot room for
inconvenient when personal the patient.
items are lost. Disconnecting
tubes from linens prevents dis
comfort and accidental dislodg
This allows the bed to be made
ing of the tubes.
on the vacant side.
The blanket provides warmth
and privacy. Placing linens
50 Making an Occupied Bed
ACTION RATIONALE
12. Loosen all bottom linens patient’s midsec

from head, foot, and side of tion. Open the drawsheet and
bed. fan-fold to the center of the
13. Fan-fold soiled linens as mattress. Tuck the drawsheet
close to the patient as securely under the mattress.
possible. If a protective pad is used,
place it over the drawsheet in
14. Use clean linen and make the
the proper area and open to
near side of the bed. Place
the center fold. Not all
the bottom sheet with its cen
agencies use drawsheets
ter fold in the center of the
routinely. The nurse may
bed. Open the sheet and fan
decide to use one.
fold to the center, positioning
it under the old linens. Pull 16. Raise side rail. Assist the
the bottom sheet over the patient to roll over the folded
corners at the head and foot linen in the middle of the bed
of the mattress. toward you. Reposition pillow
and bath blanket or top sheet.
15. If using, place the drawsheet
Move to the other side of the
with its center fold in the center
bed and lower the side rail.
of the bed and posi tioned so it
will be located under the 17. Loosen and remove all
bot tom linen. Discard soiled ens on the bed. A drawsheet can
linen in laundry bag or ham aid moving the patient in bed.
per. Do not place on floor or
furniture. Do not hold
soiled linens against your
uniform.
This facilitates removal of
linens.
This makes it easier to remove

linens when the patient turns to
the other side. This ensures patient safety. The
movement allows the bed to be
Opening linens on the bed
made on the other side. The bath
reduces strain on the nurse’s
blanket provides warmth and
arms and diminishes the spread
privacy.
of microorganisms. Centering the
sheet ensures sufficient coverage
for both sides of the mattress.
Placing linens directly into the
Positioning under the old linens
hamper helps prevent the spread
makes it easier to remove linens.
of microorganisms. The floor is
heavily contaminated; soiled
linen will further contaminate
If the patient soils the bed, draw
furniture. Soiled linen
sheet and pad can be changed
contaminates the
without the bottom and top lin
ACTION RATIONALE
nurse’s uniform, and

this may
spread organisms to another
patient.
18. Ease clean linen from under as you opened other linens.
the patient. Pull the bottom Gather the pillowcase over
sheet taut and secure it at the one hand toward the closed
corners of the head and foot of end. Grasp the pillow with
the mattress. Pull the the hand inside the pillow
drawsheet tight and smooth. case. Keep a firm hold on the
Tuck the drawsheet securely top of the pillow and pull the
under the mattress. cover on to the pillow. Place
the pillow under the patient’s
19. Assist the patient to turn
head.
back to the center of the bed.
Remove pillow and change 20. Apply top linen, sheet, and
pillowcase. Open each pil blanket, if desired, so that they
lowcase in the same manner are centered. Fold the top
linens over at the on air currents.
patient’s shoulders to make a
cuff. Have the patient hold
on to top linen and remove
the bath blanket from under
neath.
21. Secure top linens under the
foot of the mattress and miter
corners (Refer to
Skill Variation, Skill 11).
Loosen top linens over the
patient’s feet by grasping This allows bottom hems to be
them in the area of the feet tucked securely under the mat
and pulling gently toward tress and provides for privacy.
foot of bed.
This removes wrinkles and
creases in the linens, which are
uncomfortable to lie on.
This provides for a neat appear

ance. Loosening linens over the
patient’s feet gives more room
Opening linens by shaking them for movement.
causes organisms to be carried
52 Making an Unoccupied Bed
ACTION RATIONALE
22. Return the patient to a posi

tion of comfort. Remove
your gloves. Raise side rail
and lower bed. Reattach call
bell.
EVALUATION
23. Dispose of soiled linens
Promotes patient comfort and
according to agency policy.
safety. Removing gloves prop
24. Remove any erly reduces the risk for infection
other PPE, if us transmission and contamination
used. Perform of other items.
hand
Deters the spread of
hy
microorganisms.
hygiene.
Removing PPE properly reduces
the risk for infection
transmission and contamination prevents the spread of
of other items. Hand hygiene microorganisms.
• The bed linens are changed without any injury to the patient or
nurse. • The patient verbalizes feelings of increased comfort after the
bed is changed.
DOCUMENTATION
• Changing of bed linens does not need to be documented. The use of a
specialty bed, or bed equipment, such as Balkan frame or foot cradle,
should be documented. Document any significant observations and
communication.
Skill • 11 Making an Unoccupied Bed M
Usually bed linens are changed after the bath, but some agencies
change linens only when soiled. If the patient can get out of bed, the
bed should be made while it is unoccupied to decrease stress on the
patient and the nurse. The following procedure explains how to make
the bed using a fitted bottom sheet. Some facilities do not provide fitted
bottom sheets, or sometimes a fitted bottom sheet may not be available.
If this is the case, refer to the accompanying Skill Variation for using a
flat bottom sheet, instead of a fitted sheet.
Making an Unoccupied Bed 53
EQUIPMENT
• One large flat sheet • Linen hamper or bag
• One fitted sheet • Bedside chair
• Drawsheet (optional) • Waterproof protective pad
• Blankets (optional)
• Bedspread • Disposable gloves
• Pillowcases • Additional PPE, as indicated
• Assess the patient’s preferences regarding linen changes.

• Assess for any physical activity limitations.
• Check for any patient belongings that may have accidentally been
placed in the bed linens, such as eyeglasses or prayer cloths.
NURSING DIAGNOSES
• Risk for Activity Intolerance

• The bed linens will be changed without injury to the nurse or patient.
IMPLEMENTATION
ACTION RATIONALE
1. Assemble equipment and tubes from bed linens.

arrange on a bedside chair in Organization facilitates perfor
the order in which items will mance of task.
be used.
2. Perform hand
hygiene. Put on Hand hygiene and PPE prevent
on PPE, as the spread of microorganisms.
Having the bed at the proper

3 Adjust th height prevents back and muscle
3. Adjust the bed to a comfort strain. Having the side rails
able working height, usually down reduces strain on the nurse
elbow height of the caregiver while working.
(VISN 8 Patient Safety Cen ter,
2009). Drop the side Disconnecting devices prevents
rails. damage to the devices.
4. Disconnect call bell or any
ACTION RATIONALE
5. Put on gloves. Loosen all

linen as you move around the
bed, from the head of the bed 6. Fold reusable linens, such as
on the far side to the head of sheets, blankets, or spread, in
the bed on the near side. place on the bed in fourths
and hang them over a clean bed.
chair. Folding saves time and energy
when reusable linen is replaced
7. Snugly roll all the soiled on the bed. Folding linens while
linen inside the bottom sheet they are on the bed reduces
and place directly into the strain on the nurse’s arms. Some
laundry hamper. Do not agencies change linens only
place on the floor or furni when soiled.
ture. Do not hold soiled lin
Rolling soiled linens snugly and
ens against your uniform.
placing them directly into the
hamper helps prevent the spread
of microorganisms. The floor is
heavily contaminated; soiled
8. If possible, shift mattress up
linen will further contaminate
to head of bed. If mattress is
furniture. Soiled linen contami
soiled, clean and dry accord
nates the nurse’s uniform, and
ing to facility policy before
this may spread organisms to
applying new sheets.
another patient.
9. Remove your gloves, unless
indicated for transmission This allows more foot room for
precautions. Place the bottom the patient.
sheet with its center fold in
the center of the bed. Open
the sheet and fan-fold to the
Gloves are not necessary to han
center.
dle clean linen. Removing gloves
properly reduces the risk for
infection transmission and con
tamination of other items. Open
10. If using, place the drawsheet ing linens on the bed reduces
with its center fold in the cen ter strain on the nurse’s arms and
of the bed and positioned so it diminishes the spread of micro
will be located under the organisms. Centering the sheet
patient’s midsection. Open ensures sufficient coverage for
Gloves prevent the spread of both sides of the mattress.
microorganisms. Loosening the If the patient soils the bed, draw
linen helps prevent tugging and sheet and pad can be changed
tearing on linen. Loosening the without the bottom and top linens
linen and moving around the on the bed. Having all bottom
bed systematically reduce strain linens in place before tucking
caused by reaching across the
ACTION RATIONALE
the drawsheet and fan-fold to the center of the mattress. If a

protective pad is used, place them under the mattress avoids
it over the drawsheet in the unnecessary moving about the
proper area and open to the bed. A drawsheet can aid moving
center fold. Not all agencies the patient in bed.
use drawsheets routinely. The
nurse may decide to use one.
In some institutions, the pro
tective pad doubles as a
drawsheet.
11. Pull the bottom sheet over
the corners at the head and foot Making the bed on one side and
of the mattress. (See then completing the bed on the
accompanying Skill Variation other side saves time. Having
for using a flat bottom sheet, bottom linens free of wrinkles
instead of a fitted sheet.) reduces patient discomfort.
Tuck the drawsheet securely
under the mattress.
12. Move to the other side of the
bed to secure bottom linens. This removes wrinkles from the
Pull the bottom sheet tightly bottom linens, which can cause
and secure over the corners patient discomfort and promote
at the head and foot of the skin breakdown.
mattress. Pull the drawsheet
tightly and tuck it securely
under the mattress.
13. Place the top sheet on the bed Opening linens by shaking them
with its center fold in the cen ter spreads organisms into the air.
of the bed and with the hem Holding linens overhead to open
even with the head of the them causes strain on the nurse’s
mattress. Unfold the top sheet. arms.
Follow same procedure with top
blanket or spread, placing the
upper edge about 6 inches below
the top of the sheet.
This saves time and energy and
14. Tuck the top sheet and blan
keeps the top linen in place.
ket under the foot of the bed
on the near side. Miter the
corners. (See accompanying
Skill Variation.)
This makes it easier for the
15. Fold the upper 6 inches of patient to get into bed and pull
the top sheet down over the the covers up.
spread and make a cuff.
ACTION RATIONALE
16. Move to the other side of the Working on one side of the bed
bed and follow the same pro at a time saves energy and is
cedure for securing top more efficient.
sheets under the foot of the
bed and making a cuff.
17. Place the pillows on the bed. Opening linens by shaking them
Open each pillowcase in the causes organisms to be carried
same manner as you opened on air currents. Covering the pil
other linens. Gather the pil low while it rests on the bed
lowcase over one hand reduces strain on the nurse’s
toward the closed end. Grasp arms and back.
the pillow with the hand
inside the pillowcase. Keep a
firm hold on the top of the
pillow and pull the cover
onto the pillow. Place the pil
low at the head of the bed. Having linens opened makes it
18. Fan-fold or pie-fold the top more convenient for the patient
linens. to get into bed.
The patient will be able to call
19. Secure the signal device on for assistance as necessary. Pro
the bed, according to agency motes patient comfort and
policy. safety.
20. Raise side rail and lower bed. Promotes patient comfort and
safety.
21. Dispose of soiled linen Deters the spread of
according to agency policy. microorganisms.
22. Remove any Removing PPE properly reduces
other PPE, if us the risk for infection transmis
used. Perform sion and contamination of other
hand items. Hand hygiene prevents the
hy spread of microorganisms.
hygiene.
EVALUATION
• The bed linens are changed without any injury to the patient or nurse.
DOCUMENTATION
• Changing of bed linens does not need to be documented. The use of a
specialty bed, or bed equipment, such as Balkan frame or foot cradle,
should be documented.
Skill
Variation Making a Bed with a Flat Bottom Sheet M

1. Assemble equipment and 8. If possible, shift mattress
arrange on a bedside chair in up to head of bed.
the order in which the items 9. Remove your gloves.
will be used. Two Place the bottom sheet
large flat sheets are with its center fold in the
needed. Perform center of the bed and high
han enough to be able to tuck
2. Perform hand under the head of the mat
hygiene. Put tress. Open the sheet and
on fan-fold to the center.
on gloves. 10. If using, place the
drawsheet with its center fold
in the center of the bed and
Adjust bed t posi tioned so it will be located
3. Adjust bed to high position under the patient’s midsec tion.
and drop side rails. Open the drawsheet and
4. Disconnect call bell or any fan-fold to the center of the
tubes from bed linens. mattress. If a protective pad is
5. Loosen all linen as you used, place it over the
move around the bed, from the drawsheet in the proper area
head of the bed on the far side and open to the center fold.
to the head of the bed on the 11. Tuck the bottom sheet
near side. securely under the head of
6. Fold reusable linens, such the mattress on one side of
as sheets, blankets, or the bed, making a corner.
spread, in place on the bed Corners are usually mitered.
in fourths and hang them Grasp the side edge of the
over a clean chair. sheet about 18 inches down
7. Snugly roll all the soiled from the mattress top (FIG
linen inside the bottom URE A). Lay the sheet on top
sheet and place directly of the mattress to form a tri
into the laundry hamper. angular, flat-fold (FIGURE
Do not place on floor or B). Tuck the portion of the
furniture. Do not hold sheet that is hanging loose
soiled linens against your below
uniform.
FIGURE A Grasping the side flat fold.
edge of the sheet and lifting up
to form a triangle.
FIGURE B Laying sheet on top (continued on page 58)
of the bed to make triangular
Making a Bed with a Flat Bottom Sheet continued

side.
the mattress under the mat
tress without pulling on
the triangular fold
(FIGURE C). Pick the top
of the triangle
fold and place it over
the side of the mattress
(FIGURE D). Tuck this
loose portion of the sheet
under the mattress. FIGURE E Tucking end of
triangu lar linen fold under
Continue tuck
mattress to complete mitered
corner.
ing the remaining bottom
sheet and drawsheet
securely under the mattress
(FIGURE E).
Move to the other side of the
bed to secure bottom linens.
Pull the sheets across the
FIGURE C Tucking sheet mattress from the center
under mattress.
fold. Secure the bottom of
the sheet under the head
of the bed and miter the
cor
ners. Pull the remainder of
the sheet and the
drawsheet tightly and
tuck under the
mattress, starting at the
FIGURE D Placing top of head and moving toward
triangu lar fold over mattress the foot (FIGURE F).
the head of the mattress.
Unfold the top sheet. Fol
low same procedure with
top blanket or spread,
placing the upper edge
about 6 inches below the
top of the sheet.
13. Tuck the top sheet and blan
ket under the foot of the
FIGURE F Tucking sheet
snugly under mattress. bed on the near side. Miter
the corners.
12. Place the top sheet on the
bed with its center fold in the (continued on page 59)
center of the bed and with the
hem even with
Assisting With the Use of a Bedpan 59
Making a Bed with a Flat Bottom Sheet continued

the hand inside the pillow
14. Fold the upper 6 inches of case. Keep a firm hold on
the top sheet down over the the top of the pillow and
spread and make a cuff. pull the cover onto the pil
15. Move to the other side of low. Place the pillow at the
the bed and follow the same head of the bed.
procedure for securing top 17. Fan-fold or pie-fold the top
sheets under the foot of the linens.
bed and making a cuff. 18. Secure the signal device on
16. Place the pillows on the the bed, according to
bed. Open each pillowcase in agency policy.
the same manner as you 19. Adjust bed to low position.
opened other linens. 20. Dispose of soiled linen,
Gather the pillowcase over according to agency pol icy.
one hand toward the closed Perform hand hygiene.
end. Grasp the pillow with
Skill • 12 Assisting With the Use of a Bedpan A
Patients who cannot get out of bed because of physical limitations or

phy sician’s orders need to use a bedpan or urinal for voiding. Male
patients confined to bed usually prefer to use the urinal for voiding and
the bedpan for defecation; female patients usually prefer to use the
bedpan for both. Many patients find it difficult and embarrassing to use
the bedpan. When a patient uses a bedpan, promote comfort and
normalcy and respect the patient’s privacy as much as possible. Be sure
to maintain a professional manner. In addition, provide skin care and
perineal hygiene after bedpan use. Regular bedpans have a rounded,
smooth upper end and a tapered, open lower end. The upper end fits
under the patient’s buttocks toward the sacrum, with the open end
toward the foot of the bed. A special bedpan called a “fracture bedpan”
is frequently used for patients with fractures of the femur or lower
spine. Smaller and flatter than the ordinary bedpan, this type of bedpan
is helpful for patients who cannot easily raise themselves onto the
regular bedpan. Very thin or elderly patients often find it easier and
more comfortable to use the fracture bedpan. The fracture pan has a
shallow, narrow upper end with a flat wide rim, and a deeper, open
lower end. The upper end fits under the patient’s buttocks toward the
sacrum, with the deeper, open lower end toward the foot of the bed.
EQUIPMENT
• Bedpan (regular or • Additional PPE, as indicated •
fracture) • Toilet tissue Cover for bedpan or urinal (dis
• Disposable clean gloves posable waterproof pad or cover)
60 Assisting With the Use of a Bedpan
• Assess the patient’s normal elimination habits. Determine why the
patient needs to use a bedpan, (e.g., a medical order for strict bed rest
or immobilization).
• Assess the patient’s degree of limitation and ability to help with
activity. Assess for activity limitations, such as hip surgery or spinal
injury, which would contraindicate certain actions by the patient.
• Check for the presence of drains, dressings, intravenous fluid infu
sion sites/equipment, traction, or any other devices that could inter
fere with the patient’s ability to help with the procedure or that could
become dislodged.
• Assess the characteristics of the urine and the patient’s skin.
NURSING DIAGNOSES
• Impaired Urinary Elimination
• Functional Urinary Incontinence
• Toileting Self-Care Deficit

• Patient is able to void with assistance.
• Patient maintains continence.
• Patient demonstrates how to use the bedpan with
assistance. • Patient maintains skin integrity.
IMPLEMENTATION
ACTION RATIONALE
1. Review the patient’s chart for indicated.

any limitations in physical Activity limitations may con
activity. (See Skill Variation: traindicate certain actions by the
Assisting With Use of a Bed pan patient.
When the Patient Has Limited
Movement.)
2. Bring bedpan and other nec
Bringing everything to the
essary equipment to the bed
bedside conserves time and
side stand or overbed table.
energy. Arrang ing items nearby
is convenient, saves time, and
avoids unnecessary stretching
3. Perform hand hygiene and put and twisting of muscles on the
part of the nurse.
on PPE, if
Assisting With the Use of a Bedpan 61
ACTION RATIONALE
4. Identify the
patient.
y and assess the patient’s abil
ity to assist with the proce
dure, as well as personal
hygiene preferences.
6. Unless contraindicated, apply
5. Close curtains powder to the rim of the bed
around bed pan. Place bedpan and cover
5 Cl on chair next to bed. Put on
and close the door to the gloves.
room, if possible. Discuss the
procedure with the patient
logue encourages patient
participation and allows for indi
vidualized nursing care.
Powder helps keep the bedpan

7. Adjust the bed to comfortable from sticking to the patient’s skin
working height, usually and makes it easier to remove.
elbow height of the caregiver Powder is not applied if the
(VISN 8 Patient Safety patient has respiratory problems
Center, 2009). Place the or is allergic to powder or if a
patient in a supine position, urine specimen is needed (could
with the head of the bed contaminate the specimen). The
elevated about 30 degrees, bedpan on the chair allows for
unless contraindicated. easy access. Gloves prevent con
tact with blood and body fluids.
8. Fold top linen back just
enough to allow placement of Having the bed at the proper
the bedpan. If there is no height prevents back and muscle
waterproof pad on the bed strain. Supine position is neces
and time allows, consider sary for correct placement of the
placing a waterproof pad patient on the bedpan.
under patient’s buttocks
before placing bedpan.
9. Ask the patient to bend the Folding back the linen in this
knees. Have the patient lift his or
manner minimizes unnecessary
her hips upward. Assist the
exposure while allowing the
patient, if necessary, by
nurse to place the bedpan. The
waterproof pad will protect the
bed should there be a spill.
errors.
The nurse uses less energy when
This ensures the patient’s pri the patient can assist by placing
vacy. This discussion promotes some of his or her weight on the
reassurance and provides knowl heels.
edge about the procedure. Dia
62 Assisting With the Use of a Bedpan
ACTION RATIONALE
placing your hand that is

closest to the patient palm
up, under the lower back, and
assist with lifting. Slip the
bedpan into place with other
hand.
10. Ensure that bedpan is in
proper position and the
patient’s buttocks are rest This position makes it easier for
ing on the rounded shelf of the patient to void or defecate,
the regular bedpan or the avoids strain on the patient’s
shallow rim of the fracture back, and allows gravity to aid in
bedpan. elimination. Covering promotes
warmth and privacy.
11. Raise the head of bed as near
to sitting position as toler Falls can be prevented if the
ated, unless contraindicated. patient does not have to reach for
Cover the patient with bed items he or she needs. Placing the
linens. bed in the lowest position pro
motes patient safety. Leaving the
12. Place the call bell and toilet patient alone, if possible, pro
tissue within easy reach. motes self-esteem and shows
Place the bed in the lowest respect for privacy. Side rails
position. Leave patient if it is assist the patient in repositioning.
safe to do so. Use side rails Proper removal of PPE prevents
appropriately. transmission of microorganisms.
Hand hygiene deters the spread
of microorganisms.
13. Remove
gloves and addi
tio Hand hygiene deters the spread
tional PPE, if used. of microorganisms. Gloves pre
Pe vent exposure to blood and body
Perform hand hygiene. fluids. Having the bed at the
proper height prevents back and
muscle strain. Proper disposal of
Removing the Bedpan
soiled tissue prevents transmis
i sion of microorganisms.
14. Perform hand hygiene and
put on gloves and additional
PPE, as indicated. Adjust bed to
comfortable working
height, usually elbow height
of the caregiver (VISN 8
Patient Safety Center, 2009).
Have a receptacle, such as
plastic trash bag, handy for
discarding tissue.
Having the bedpan in the proper
position prevents spills onto the
bed, ensures patient comfort, and
prevents injury to the skin from a
misplaced bedpan.

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Taylor's Handbook of Clinical Nursing Skills

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Taylor’s Handbook of

Clinical Nursing Skills

Pamela Lynn, msn, rn

Executive Acquisitions Editor: Carrie Brandon

Copyright © 2011 by Wolters Kluwer Health / Lippincott Williams & Wilkins.

Library of Congress Cataloging-in-Publication Data

Lynn, Pamela Barbara, 1961-

TAYLOR SUITE RESOURCES

Pamela Lynn, MSN, RN

Pamela Lynn, MSN, RN

Skill • 1 Assisting a Patient with Ambulation A

OUTCOME IDENTIFICATION AND PLANNING

1. Review the medical record procedure for ambulation.

7. Assist the patient to put on footwear and a

9. Encourage the patient to make use of the

Doing so ensures safety and patient warmth.

Gait belts improve the caregiv er’s grasp,

FIGURE 1 Nurse positioned to the side and

When two nurses assist, posi lower arm or hand.

• Assess the patient’s upper body strength, ability to bear weight,

OUTCOME IDENTIFICATION AND PLANNING

1. Review the medical record of dizziness, weakness,

Hand hygiene and PPE prevent

4. Encourage the patient to make use of a

6. Encourage the patient to make use of the

Encourages independence, reduces strain for

FIGURE 1 The nurse stands slightly behind the

Skill • 3 Assisting a Patient with Ambulation

OUTCOME IDENTIFICATION AND PLANNING

1. Review the medical record regarding the use of crutches.

2. Perform hand hygiene. Put on

3. Identify the patient. Explain

Patient identification validates the correct

Stand-assist device reduces care giver strain

5. For the four-point gait: stronger leg forward to the

Continued ambulation promotes

Patient bears partial weight on

patient’s tolerance and condi

Skill • 4 Assisting a Patient with

A walker is a lightweight metal frame with four legs. Walkers provide

OUTCOME IDENTIFICATION AND PLANNING

1. Review the medical record 5. Encourage the patient to

Hand hygiene and PPE prevent

FIGURE 1 Assisting the patient to

12. Remove the gait

Skill • 5 Applying and Removing

stockings. Assess patient’s legs for any redness, swelling, warmth,

OUTCOME IDENTIFICATION AND PLANNING

4. Close curtains around bed breathing problem, dry skin,

Dependent position of legs Wrinkles and improper fit inter

FIGURE 1 Putting foot of stocking

calf, toward the knee. Make

FIGURE 2 Pulling the stocking

15. Remove equipment and

• The stockings are applied and removed as

Skill • 6 Removing Arterial and Femoral

OUTCOME IDENTIFICATION AND PLANNING

This ensures the patient’s pri

clamp to the flush solution.

Sufficient pressure is needed to

stipulated by facility policy,

Skill • 7 Giving a Back Massage G

Massage has many benefits, including general relaxation and increased