Home Nursing Procedures Part I

Simple nursing procedures that can be carried out in the home are presented here step by step. It is difficult to visualize some of these without a demonstration or to acquire skill without guided practice. For this reason, it is expected that those who are responsible for giving this care in the home will have completed the Red Cross Home Nursing courses, or received help from a public health or other professional nurse, and that this section of the article will serve as a handy reference.

The home nurse should remember, however, that there is an art as well as a technic involved in giving good nursing care and that she is caring for a person and not just a patient. The development of a healthy mental attitude may be as important to the recovery of the patient as the required physical care.

It is taken for granted that the home nurse has the doctor's assurance that a patient's condition is such that he can be cared for safely in the home. For patients who do not need highly skilled care of special hospital equipment, the warm, friendly atmosphere of the home is often more conducive to recovery than the more formal, impersonal environment of the hospital.

When caring for a patient at home, whether he is confined to bed or not, the home nurse will find it helpful to remember the following things:

1. It is easier to care for the patient and do the other necessary household tasks if a schedule is planned for the day.

2. It will save time if:

a. Everything needed is collected before care is given, and things are cleared away and cleansed promptly afterward. When the same treatment is given frequently, the necessary articles should be kept together on a tray.

b. Unnecessary laundry can be avoided by protecting the bedding.

c. Work on one side of the bed should be completed, when possible, before going to the other side.

d. Menus should be planned in advance, and food suitable for both the family and patient should be prepared whenever possible.

3. The home nurse will help safeguard her own health or conserve her strength if she:

a. Washes her hands before and after giving care to a patient.

b. Wears comfortable, low-heeled shoes to lessen back strain and short-sleeved, washable clothing to permit freedom of action.

c. Maintains good working posture.

d. Gets someone to help lift a heavy or helpless patient.

e. Obtains the patient's help. When lifting, turning, or moving a patient in bed, the home nurse should ask or help the patient to bend his knees so that he can be moved with less effort. The home nurse and the patient should act upon an agreed signal. For example, when helping the patient lift his hips, both will act on the count of three.

f. Avoids direct contact with nose and throat spray when working in close contact with the patient.

4. The home nurse will help keep her patient as comfortable as possible and also help his recovery if she:

a. Protects him from further infection by preventing exposure to the nose and throat spray or soiled hands of the home nurse or visitors.

b. Checks to see that the room is warm and that the patient is protected against drafts when giving him a bath or treatment.

c. Explains what is to be done and, if he is able, how he may help.

d. Helps the patient maintain good bed posture at all times. When giving a treatment, she should make sure the patient is in the correct position to receive care and that he is comfortable, warm, and dry during and after the treatment. A lightweight, washable blanket is often more convenient to use during baths or treatments than the usual top bedclothes and may save laundry.

e. Maintains a cheerful, wholesome mental attitude at all times to build the patient's morale and confidence.

PUTTING ON AND TAKING OFF A COVER-ALL APRON

Purpose. To provide a means of helping prevent the spread of disease from the patient or to the patient.

The home nurse should wear some type of cover-all apron when entering the sickroom to give care to the patient and take it off when leaving the room, hanging it near the door of the sickroom in readiness for use.

Procedure

1. Don the apron.

a. Slip the arms into the sleeves of the apron without touching the outside, which will be next to the patient.

b. Fasten at the neck and waist for ease in working.

2. Wash the hands after caring for the patient.

3. Remove the apron.

a. Unfasten.

b. Slip the arms out of the sleeves.

c. Hang—keep inside in and clean.

MAKING A NEWSPAPER BAG

Purpose. To provide a means of safe disposal of waste material.

Waste material from a sickroom may carry infection and therefore must be disposed of properly. Paper bags may be used for disposing of many types of waste.

Equipment

Double sheet of newspaper

Procedure

1. Place the newspaper, folded in half, with the center fold toward the person making the bag.

2. Bring the top edge of the upper sheet of the paper down to the center fold. This makes a cuff.

3. Turn the paper over, smooth side up, keeping the center fold toward the person throughout the procedure.

4. Fold it in thirds from the sides; crease well to hold the fold.

5. Lock by tucking one whole side under the cuff of the other side.

6. Bring the flap over the locked cuff.

7. Place a hand in the opening at the top; stand the bag up; shape.

8. Use the flap as a cover for the bag or as a means of fastening the bag to the side of the bed.

WASHING THE HANDS

Purpose. The home nurse washes her hands before and after caring for the patient to help protect the patient, the home nurse, and others from infection.

Equipment

Basin or bowl

Running water or container of clean warm water

Clean towels

Waste container for soiled towels

Soap

Waste pail or other means of disposing of liquid waste

Roll up the sleeves if wearing long ones. Remove the wrist watch, or push it up on the arm. Remove jewelry that is likely to hurt the patient or collect lint and other soil.

The hands should be washed under running water; where this is not available, pour water from the container.

Procedure

1. Keep the hands lowered over the basin throughout the entire procedure.

2. Wet the hands so that the soap will lather.

3 Soap hands well, working up a lather.

4. Rinse the soap (if using a bar), leaving it clean for the next use.

5. Use friction, rubbing well between the fingers and around the nails, and be sure to wash the entire hand and wrist.

6. Rinse the hands to allow the first dirt to run off.

7. Soap again, being sure to work up a good lather, and using friction as before between the fingers and around the nails.

8. Rinse the soap.

9. Rinse the hands again, getting all the dirt off this time.

10. Dry the hands well. Wet skin or dried soap on the skin may cause chapping, and breaks in the skin may admit infection. Also, chapped hands are unsightly and are uncomfortable for both the patient and the nurse.

11. Discard the towels in a waste container.

12. Dispose of the waste container.

Essential Points To Remember.

1. Hold the hands down over the basin and wash under clean running water.

2. Use friction.

3. Dry well.

TAKING THE TEMPERATURE

Purpose. To determine the patient's temperature in order to help the doctor make a diagnosis and prescribe treatment.

Fever or clinical thermometers differ from most other thermometers in that the mercury remains at the highest point registered until it is shaken down. They are fragile and must be handled with care, kept in a safe place when not in use, and protected from heat. The temperature is usually taken by the mouth or rectum, but may also be taken at the armpit. For an accurate reading, keep the thermometer in place in the body for at least 3 minutes, except when the temperature is taken at the armpit, in which case leave the thermometer in place for 10 minutes.

Some mouth thermometers have a slender bulb about ½ inch in length. Others have a short, stubby bulb. Only thermometers with stubby bulbs should be used to take rectal temperatures as there is less danger of their breaking and injuring the patient. If only one thermometer can be purchased, it should be a thermometer with a stubby bulb, which can be used for taking temperatures by any of the above methods. Thermometers have two parts:

1. The bulb end: This holds the mercury and is the part that is placed in the mouth; it must be kept clean.

2. The glass tube: Through this tube the mercury rises and on it are shown the lines and numbers that indicate the degrees. The column of mercury can be seen between the lines and the numbers—through a ridge which extends the length of the tube. When handling the thermometer, always grasp it by the top of the tube.

When the thermometer is in position for taking the temperature, the heat of the body expands the mercury and pushes it up into the tube.

The long lines on the tube of the thermometer are the degrees—94, 95, 96, and so on—while the short lines between are each two-tenths of a degree. However space allows room for printing only the even numbers. The normal temperature by the mouth is usually 98.6° F. (Fahrenheit), which is indicated on the tube by a small arrow.

If the home nurse cannot read the thermometer after taking a temperature, she should cleanse it according to the directions given here and put it away until someone can be called who is able to read a thermometer. At her first opportunity, she should learn how to read the thermometer herself.

When reading the thermometer:

1. Make sure the light is adequate for accurate reading of the thermometer.

2. Hold the thermometer by the top, in line with the eye; turn the ridged side toward you.

3. Look for the thin column of mercury between the lines and numbers through the ridge. It may be necessary to roll the thermometer slowly back and forth to locate the mercury; the end of the mercury column indicates the temperature.

4. Read the scale to include the degree and nearest two-tenths of a degree.

When shaking down the mercury:

1. Stand away from the furniture to avoid striking the thermometer against any object and breaking it.

2. Hold the thermometer firmly by the top between the thumb and first two fingers.

3. Shake with a loose wrist movement—as though shaking water off the hand—to bring the mercury to 95° F. or below.

Taking the Mouth Temperature

Equipment

Clinical thermometer

Container of wipes: absorbent cotton, paper tissues, toilet paper, or pieces of clean gauze or rags

Soap

Waste container

Container of cool, clean water

Procedure

1. Have the patient sit or lie down.

2. Hold the thermometer firmly by the top.

3. Shake the mercury down to 95° F. or below.

4. Rinse the thermometer in clear, cool water to make it easier and more pleasant to hold in the mouth.

5. Place the bulb in the patient's mouth, well under the tongue and a little to one side.

6. Instruct the patient to keep his lips closed, to breathe through his nose, and not to bite down on the thermometer or to talk.

7. Leave the thermometer in place for 3 minutes to assure an accurate registering.

8. Remove by holding at the top and use a wipe to remove any saliva; use a rotary motion from the top toward the bulb and over the bulb. This makes it easier to read. Dispose of the wipe in a waste container.

9. Take the thermometer to a good light, still holding by the top, and read.

10. Cleanse the thermometer immediately:

a. Hold by the top, with the bulb down, over a waste container.

b. Moisten a wipe with cool water and soap well. Beginning at the top, rub down with a single rotary stroke with friction, getting well into the grooves of the tube and over the bulb. Discard the wipe.

c. Moisten a fresh wipe with clear, cool water and rinse the thermometer, using the same stroke as above.

d. Soap and rinse again—repeat procedures b and c.

e. Dry with a fresh wipe, using the same stroke, and put the thermometer away in its case, bulb end first.

11. Note the temperature on the daily record.

If there is any marked rise or drop in a patient's temperature, check the reading by taking the temperature again. Report the results to the doctor at once if the second reading confirms the first.

Taking the Rectal Temperature

The temperature of the body in the rectum is usually higher than in the mouth by approximately one degree; therefore, the normal rectal temperature is about 99.6° F. Always indicate on the daily record for the doctor when the temperature has been taken by the rectum.

Equipment

The same equipment will be needed as when taking a mouth temperature, with the exception that a thermometer with a stubby bulb should be used and a lubricant such as petrolatum will be needed.

Procedure for an Adult

1. Explain to the patient what is going to be done and instruct him to lie on his side.

2. Lubricate the bulb end of the thermometer with petrolatum, so that it will slide easily into the rectum. Any mild oil or cold cream may be used instead of petrolatum.

3. Slip the bulb end of the thermometer about 1 inch into the anus (opening of the rectum). Hold in place for 3 minutes to make sure the thermometer registers the actual temperature.

4. Remove the thermometer and follow directions 9 through 12 in Procedure for Taking the Mouth Temperature.

Procedure for an Infant or Child

1. Explain to the child what is going to be done, if he is old enough to understand.

2. Lubricate the thermometer in the same way as when taking the rectal temperature for an adult.

3. Have the child lie down (on his back or abdomen) on either the home nurse's lap, a bed, or a table.

4. Insert the bulb of the thermometer gently into the anus and hold it for 3 minutes. It must be held in place at all times. Help may be needed to hold a restless child.

5. Remove the thermometer and follow directions 9 through 12 in Procedure for Taking the Mouth Temperature.

Taking the Temperature by the Armpit

Temperature taken at the armpit is lower than the mouth temperature and should be recorded as taken in the armpit. To be reliable, it must be taken correctly. It may be ordered for infants and when other methods are difficult to follow. The same equipment will be needed as when taking a mouth temperature. Proceed as directed earlier in preparing the thermometer, except that the thermometer is not moistened.

Procedure

1. Dry the area under the arm.

2. Place the bulb of the thermometer in the armpit and have the patient press his arm firmly against his body with his hand on his opposite shoulder to hold the instrument in place. Leave the thermometer in this position for 10 minutes.

3. Remove the thermometer and read.

4. Cleanse the thermometer according to the directions in Procedure for Taking the Mouth Temperature.

5. Note the temperature and the manner of taking it on the daily record.

Essential Points To Remember.

1. Be sure the mercury is down to 95° F. or below before taking the temperature.

2. Allow sufficient time for an accurate registration of the temperature.

3. Take the temperature by the rectum or armpit when it cannot be taken accurately or safely by the mouth.

4. Cleanse the thermometer immediately after use.

TAKING THE PULSE AND RESPIRATION

Purpose. To count the pulse (number of heart beats) and respirations (breathing) that occur each minute.

Procedure

Pulse. 1. Have the patient lie or sit down. Place his arm and hand in a relaxed position, thumb up, supported on a chair arm, table, or bed.

2. Locate the pulse by placing the forefinger on the thumb side of the patient's wrist between the tendons and the wrist bone.

3. Count the pulse beats for 1 full minute; then check the rate by counting for another minute.

4. Note on the daily record for the doctor the pulse rate per minute, time, date, and any irregularity noted.

Respiration. Respirations may be counted immediately following the counting of the pulse and while the fingers are still on the pulse, as the patient is then less likely to be aware that the count is being made and to change his breathing.

1. Observe the rise and fall of the chest. Count for 1 full minute each rise of the chest.

2. Note on the daily record the rate and any unusual condition in breathing.

CHANGING THE BED LINEN

Purpose. To make a bed which provides for the patient safety, comfort, warmth, a smooth, clean surface to lie on, and freedom of movement.

Without the Patient in Bed

Equipment

Bed—comfortable and single, if possible

Firm, smooth mattress and pad

Clean sheets and pillow cases

Blankets, suited to room temperature

Pillows

Spread, lightweight

Extra sheet for a draw sheet with a waterproof sheet or pad to protect the mattress if necessary

Newspapers or a laundry bag for soiled linen

Procedure

1. Assemble the fresh linen; place newspaper; or a bag to receive the soiled linen.

2. Remove the spread, blankets, pillows, mattress pad, and linen. If the linen is soiled, place it at once on newspapers or in a laundry bag; hold the bedding away from the face and clothing to avoid contact.

3. Turn the mattress.

4. Place the mattress pad.

5. Center the bottom sheet lengthwise and place on the bed. To anchor the bottom sheet well, allow 18 inches to tuck smoothly under the head of the mattress. Make a corner at the head of the bed, as shown.

6. Tuck the sheet smoothly under the mattress all the way down the side of the bed. If a draw sheet is used, fold it end to end and place across the center of the bed, with the top fold high enough to come under the pillow and the open end toward the foot; tuck under well. If additional protection is needed for the mattress, place a rubber sheet or substitute under the draw sheet.

7. Center the top sheet lengthwise and place. Allow enough to fold back over the blanket at the head of the bed and to tuck under the mattress at the foot of the bed. Leave loose at the foot until the blanket is in place.

8. Center the blanket lengthwise and place it at shoulder height. Leave loose at the foot of the bed. If the blanket is not long enough, two may be used, placing one blanket as desired to cover the shoulders and the other to tuck well under the mattress at the foot.

9. Go to the other side of the bed.

10. Tuck the lower sheet smoothly under the head of the mattress. Anchor it well by making a corner. Grip the sheet near the head of the bed; pull diagonally and tuck securely under the mattress. Repeat this three or four times all the way down the second side of the bed.

11. Pull the draw sheet smooth and tuck under.

12. Provide toe space.

13. Tuck the sheet and blankets loosely under the mattress at the foot of the bed; retain the pleat; make loose corners.

14. Center and place the bedspread. If the patient is using the bed at once, fold the spread under the upper edge of the blanket and fold the top sheet back over both the blanket and spread; tuck the bed-spread loosely under the mattress at the foot.

15. Put on the pillow case. Keep the pillow away from the face and clothes.

16. Arrange the bed for occupancy. Fold the top covers—sheet, blankets, spread—in thirds to the foot of the bed with the free edge toward the head of the bed so the covers may be pulled up easily.

17. Remove the soiled linen.

With the Patient in Bed

Procedure

1. Assemble the equipment.

2. Loosen the bedding all around from under the mattress. Use care to avoid tearing.

3. Remove the spread; fold and hang over a chair. Remove one blanket, if using two; fold and hang over a chair. For the comfort of the patient, work from the head to the foot of the bed.

4. Remove the top sheet, sliding it down under the blanket. The patient may be asked to hold the top edge of the blanket while this is done, or the blanket can be tucked under the shoulders. If the top sheet is to be used as the bottom sheet or draw sheet, fold and place on a chair.

5. Remove all but one pillow—or all pillows. Remove the soiled cases and place with the soiled linen.

6. Turn the patient toward the other side of the bed in order to change the bottom sheet; keep him covered.

7. Change the bottom sheet.

a. Gather the soiled bottom sheet lengthwise and roll it up close to the patient.

b. Pull the mattress pad smooth under the patient.

c. Center the clean sheet lengthwise; place and unfold, keeping about 18 inches to tuck under at the head to protect the mattress and to anchor the sheet.

d. Gather the top half of the clean sheet and push in a flat roll under the soiled sheet, close up against the patient's back.

e. Tuck the clean sheet well under the mattress at the head and make a corner; tuck well under the mattress all along the side of the bed. If a draw sheet is used, place on the bed with the folded edge under the pillow; tuck under the mattress.

f. Turn the patient back toward the home nurse. Tell the patient what is about to be done. Loosen the blanket. Lift his feet over the soiled and clean sheets. Place one hand on his upper shoulder, the other on the upper hip on top of the bedding, and, on signal, roll the patient, all the way toward the home nurse. Continue giving support while the bunched sheets are pulled out. Roll the patient on his back. Adjust the position and covers.

g. Go to the other side of the bed and remove the soiled sheet, handling as little as possible; place with the soiled linen.

h. Smooth the mattress pad.

i. Adjust the clean bottom sheet. Tuck the sheet well under the mattress at the head of the bed; make a corner.

j. Tuck the sheet securely under the mattress all the way down the side of the bed, pulling the sheet diagonally.

k. Grasp and pull the draw sheet and tuck under the mattress.

8. Put on the clean pillow case and replace the pillow.

9. Place the top covers.

10. Make the patient comfortable; straighten the room and remove the soiled linen.

Essential Points To Remember.

1. The bottom sheet should be smooth and tight.

2. The top covers should be lightweight and suited to the temperature of the room, should provide for shoulder warmth and permit toe space, and should be held securely together.

3. Handle the soiled linen with care to prevent the spread of infection.

MOVING THE PATIENT IN BED

Purpose. To relax the patient, improve the circulation, prevent continued pressure on any part of the body over too long a time, avoid strain on the joints, prevent deformities, and adjust the position for comfort or for the giving of treatments.

Procedures

Helping the Patient Move to the Near Side of the Bed.

1. Place the hands, palms up, under the pillow, supporting the head and shoulders, and on signal pull toward the home nurse.

2. Place the hands, palms up, all the way under the hips and on signal pull toward the home nurse.

3. Place the hands under the knees and ankles, pull toward the home nurse, and adjust the body for position and comfort.

Helping the Patient Sit Up and Lie Down.

1. Face the head of the bed.

2. Flex the patient's knees.

3. Lock the near arms—the arm of the home nurse under the patient's arm with the hand braced at his shoulder; the patient's arm under her arm with his hand braced at her shoulder.

4. On signal, help the patient to a sitting position and pause in case he feels weak or dizzy.

5. Help the patient support himself, if he is able—hands braced back of him on the bed.

6. Lock arms as before and lower the patient to the pillow.

7. Adjust for correct position and comfort.

Helping the Patient Move Up and Down in Bed.

When the Patient Can Assist.

1. Raise the patient to a sitting position as above.

2. Help the patient support himself—hands braced back of him on the bed.

3. Move toward the head of the bed—face the bed; place one hand low on the patient's back, the other, palm up, well under his thighs and on signal help the patient swing backward as he digs in and pushes with his heels.

4. Move toward the foot of the bed—repeat the same procedure except the patient digs in and pushes with his hands as he swings forward.

When the Patient Is Helpless.

If the patient is entirely helpless, two or even three people may be needed to lift him up or down in bed. For a single bed, two stand opposite each other and join hands under the patient's shoulders and thighs and move him as desired; for a double bed, two or three persons may work on the same side of the bed; one lifting the head and shoulders, one the hips, and one the legs and feet, supporting the knees and ankles. The drawsheet may also be used to help move or roll the patient.

Source: http://www.healthguidance.org/authors/662/Ruth-B.-Freeman