204 RLE Procedures

Post Mastectomy Exercise


These exercises done by patients who underwent mastectomy or the surgical removal on one or both of breasts.


> To increase blood circulation

> To increase muscular strength.

> Prevents joints stiffness and contractures

> To restore full range of motion of the arms and shoulder.


> Checks doctor’s order

> This exercise should be performed three times a day for 20 minutes at a time

> Let patient shower with warm water prior to exercise

> Administer analgesic 30 minutes prior to exercise

> If the patient has a graft, exercises may need to be prescribed and introduces gradually.


> Rod or broom stick (1.5 – 2 meters long)

> Rope (1.5 – 2 meters long)

1. Check doctor’s order and identify the patient.

Rationale: To be sure that the exercise is not contraindicated to the patient.

2. Explain procedure to the patient.

Rationale: To gain patient’s cooperation and also give her time to prepare.

3. Assume/place patient in a standing/sitting position.

Rationale: Allow the patient to a full range of motion.

4. Ball squeezing. A rubber ball or a crumpled newspaper squeeze in the hand of the involved side.

Rationale: This does not strain the patient while preparing her for more strenuous exercise.

5. Wall climbing. The women sit/stand facing the wall with her toes next to the wall. Place both hands on the wall with uninvolved arm followed  by the involved arm.

Rationale: This increases circulation and muscular strength, prevent elbow and shoulder joint stiffness and contractures, and restore full range of motion of the shoulders and arms.

6. Pendulum or arm swinging. The points bends at the waist and swing her arms from side to side without bending the elbows.

Rationale: This will prevent shoulder joint stiffness that may result to frozen shoulder as a result of the surgery.

7. Fitting clasped hands. The patient clasps her hands and lifts them slowly over head, keeping the elbows straight.

Rationale: To restore arm and shoulder joints full range of motion and muscle strength prevents stiffness as well as increase blood circulation.

8. Elbow spread. The patient interlocks her hands behind her neck and raises her elbows to chin level, then gradually brings the elbows together.

Rationale: To restore arms ans shoulder joints  full range of motion and restore elbow strength.

9. Pulley or rope pulling. The patient pulls the string down and opposite arm is raised.

Rationale: To restore the abduction and adduction range of motion of the shoulder joints to prevent the frozen shoulder syndrome.

10. Deep breathing. The patient is placed on sitting position, her hand over the involve portion of her chest and takes a deep breath through the nose, feeling her chest expand as the breath is inhaled, as she exhaled, the chest and shoulder sags and reflex.

Rationale: To support muscles in affected side during chest expansion.

11. Make patient comfortable.

Rationale: Allowing patient to rest for the next sessions of post mastectomy exercises.

12. Chart procedure done, time and reaction of patient.

Rationale: Record and allow nurse and therapist to adjust to patient’s capability.


Kozier, Barbara, Fundamentals of Nursing. Philippines: Pearson Educations South Asia PTE LTD. 2004 pp.

204 RLE Procedures

Self Breast Examination


Involves both inspection  and palpation procedures for early detection of disease resulting in a greater chance of cure and less complex treatment.


> To detect early changes in the breast.

> To detect lumps or any abnormalities in the breast.


> Self breast examination should be done 1 week after menstruation.

> Self breast examination should be done at least once a month.


In front of a mirror:

1. Stand before a mirror. Inspect both breasts for anything unusual such as  any changes  from the nipples, puckering, dimpling or scaling of the skin.

2. Watching closely in the mirror, clasps hands behind your head and press hands forward.

3. Next, press hands firmly on hips and bow slightly toward the mirror as you pull y0ur mirrors as you pull your shoulders and elbows up.


a. Stand before a mirror

  • Inspection of breast in front of the mirror aids in visualization of the breast which can easily detect unusual changes of the breast.
  • Clasping hands behind the head and pressing forward exposes both breasts and allows the breast to hang to detect for any unusualities.This examines the lateral and under surfaces of each breast.
  • Pressing the hands firmly on hips tightens the pectoral muscles. Contraction of the pectoral muscles exaggerates signs of retraction or skin flattering. Slight bowing allows the breast to hang freely.

4. While in the shower:

5. Raise left arm. Use three or four fingers of your right hand to explore your left breast firmly, carefully and thoroughly. Beginning at the outer part edge, press the flat part of your portion. Feel any unusual lump or mass under the skin. Pay attention between the breast and armpit.

6. Gently squeeze the nipple and look for discharges.

7. Do the same with the other breast.


  • Done in the shower because soapy hands glides more easily wet skin thus palpating the breast with ease.
  • Squeezing the nipple detects for abnormal discharges.
  • To examine the other breast.

Supine Position:

8. Lie flat on your back, left arm over your head and a pillow or folded towel under your left shoulder. This position flattens the breast and makes it clear to examine. Repeat steps 4 & 5. Use the same circular motion as described earlier.


  • Lying flat on bed distributes breast evenly on chest. The folded towel exposes the breast further. For  thorough examination of the breast.
  • To examine the other breast.


1. Observe the nipple and areola for ulceration, nodules, swelling and discharges.

2. Palpate the areola for nodule and tenderness.


  • To detect any abnormalities.
  • To detect any abnormalities.


Kozier, Barbara, Fundamentals of Nursing. Philippines: Pearson Education South Asia PTE LTDF. 2004. pp.986-987

204 RLE Procedures



Crutches are artificial supports and assists patients who need aid in walking because of disease, injury, or a birth defect.


> To assist client who cannot bear  any weight on one leg.

> To assist client who have full weight bearing on both legs.

> Prevent injury to client who has difficulty in ambulation.


> Assess client’s physical limitations to determine safety and comfort.

> Take time to show patients how to walk with crutches for them to learn

> Maintain proper body mechanics.


> Gait belt                                         > Tape measure

> Crutches                                        > Sturdy footwear, properly fitted

Crutch Walking

1. Inform the client you will be teaching crutch ambulation.

Rationale:  Reduces anxiety. Helps increase comprehension and cooperation, promotes client independence.

2. Assess the client for strength, mobility, ROM, visual acuity, perceptual difficulties and balance. Note: nurse and therapist often collaborate on this assessment.

Rationale: Helps determine the clients capabilities and amount of assistance required.

3. Adjust crutches to fit the client. With the client supine, measure from the heel to the axilla. With the client standing, set the crutch position at a 4-5 inches lateral to the client and 4-6 inches in front of the client. The crutch pad should fit 1.5 – inches below the axilla (3 finger width). The hand grip should be adjusted to allow for  the client to have elbows bent at 30 degree flexion.

Rationale: Provide broad base of support for the client. Space between the crutch pad and axilla prevents pressure on radial nerves. The elbow flexion allows for space between the crutch pad and axilla.

4. Lower the height of the bed.

Rationale: Allows the client to sit with feet on the floor for stability.

5. Have the client dangle legs. Assess for vertigo.

Rationale: Allows for stabilization of blood pressure, thus preventing orthostatic hypotension.

6. Instruct the client to position crutches lateral to and forward to feet. Demonstrate correct positioning.

Rationale: Increases client comprehension and cooperation.

7. Apply the gait belt around the client’s waist if needed.

Rationale: Provides support, promotes client safety.

8. Assist the client to a standing position with crutches.

Rationale: Standing for a few minutes will assist in preventing orthostatic hypotension.

Four-Point Gait

9. a. Position crutches to the side and in front of each foot.

b. Move the right crutch forward 4 to 6 inches.

c. Move the left foot forward, even with the left crutch.

d. Move the left crutch forward 4 to 6 inches.

e. Move the right foot forward, even with the left crutch.

f. Repeat the four-point gait.

Rationale: The four point gait provides greater stability. Weight bearing is on three points at all times. The client must be able to bear weight with both legs.

Three-Point Gait

10. a. Advance both crutches and the weaker leg forward together.

b. Move the stronger leg forward, even with crutches.

c. Repeat three-point gait.

Rationale: The three point gait provides a strong base of support. This gait can be used if the client has a weak or non-weight-bearing leg.

Two-Point Gait

11. a. Move left crutch and right leg forward 4 – 6 inches.

b. Move right crutch and left leg forward 4 – 6 inches.

c. Repeat two-point gait.

Rationale: The two pint gait provides a strong base of support. The client must be able to bear on both legs. This gait is faster than four-point gait.

Walking UP stairs

12.a.  Instruct the client to position the crutches as if walking.

b. Place the strong leg on the first step.

c. Pull weak leg up and move the crutches up to the first step.

d. Repeat for all steps

Rationale: Prevents weight bearing on the weaker leg.

Walking DOWN stairs

13. a. Position the crutches as if walking.

b. Place weight on the strong leg.

c. Move crutches down the next lower step.

d. Place partial weight on hands and crutches.

e. Move the weak leg down to the step with crutches.

f. Put the total weight on arms and crutches.

g. Move strong leg same step as weak leg and crutches.

h. Repeat for all steps.

Rationale: Prevents weight bearing on weaker leg.

14. Set realistic goals.

Rationale: Crutch walking takes up to 10 times the energy required for unassisted ambulation.

15. Consult with a physical therapist.

Rationale: The physical therapist is the expert on the health care team for crutch-walking techniques.

16. Wash hands.

Rationale: Reduces the transmission of microorganisms.


Kozier, Barbare, Fundamentals of Nursing. Philippines: Pearson Education South Asia PTE LTD. pp. 1102-1104

204 RLE Procedures



A tool making use of  a public health bag through which the nurse, during his /her home visit can perform nursing procedure with ease and deftness, saving time and effort with the end in view of rendering effective nursing care.


To render effective nursing care due to clients and/or members of the family during home visits.


  • The use of the bag should minimize if not totally prevent the spread of infection from individuals to families, hence, to the community.
  • Bag techniques should save time and effort on the part of the nurse in the performance of nursing procedures.
  • Bag technique should not overshadow concern for the patient rather should show the effectiveness of total care given to an individual or family.
  • Bag techniques can be performed in variety of ways depending upon agency policies, actual home situation, etc. as along as principles of avoiding transfer of infection is carried out.


> Paper Lining

> Extra paper for making bag for waste materials (paper bag)

> Plastic / linen lining

> Apron                                                           > 1 pair of rubber gloves

> Hand towel in plastic bag                      > 2 test tubes

>  Soap in soap dish                                     > Test tube holder

> Thermometers in case (one oral and rectal)

> 2 pairs of scissors (1 surgical and 1 bandage)

> 2 pairs of forceps (curved and straight)

> Syringes (5ml and 2 ml)

> Hypodermic needles g 19, 22, 23, 25

> Sterile dressings                                       > Betadine

> Sterile cord tie                                          > 70 % alcohol

> Adhesive plaster                                     > Ophthalmic ointment

> Alcohol lamp                                            > Zephiran solution

> Tape measure                                           > Hydrogen peroxide

> Medicines                                                   > Spirit of ammonia

> Acetic acid                                                 > Benedict’s solution

1. Upon arriving of the client’s home, place the bag on the table or any flat surface lined with paper lining, clean side out (folded part touching the table). Put the bag’s handles or strap beneath the bag.

Rationale To protect bag from contamination.

2. Ask for a basin of water and glass of water if faucet is not available. Place these outside the work area.

Rationale To be used for washing. To protect the work field from being wet.

3. Open the bag, take the linen/plastic lining and spread over the work field or area. The paper lining, clean side out (folded part out).

Rationale To make a non-contaminated work field or area.

4. Take out hand towel, soap dish and apron and place them at one corner of the work area (within the confines of the linen/plastic lining)

Rationale To prepare for hand washing.

5. Do hand washing. Wipe, dry with towel. Leave the plastic wrappers of the towel in soap dish in the bag.

Rationale Hand washing prevents possible infection from care provider to the client.

6. Put on apron right side out and wrong side with the crease touching the body, sliding the head into the neck strap, neatly tie into straps at the back.

Rationale To protect the nurse’s uniform. keeping the crease creates aesthetic appearance.

7. Put out things most needed for the specific case (example thermometer, kidney basin, cotton ball, waste proper bag) and place at one corner of the work area.

Rationale To make them readily accessible.

8. Place waste paper bag outside of work area.

Rationale To prevent contamination of clean area.

9. Close the bag.

Rationale To prevent contamination of bag and contents.

10. Proceed to the specific nursing care of treatment.

Rationale To give comfort and security, maintain personal hygiene and hasten recovery.

11. After completing nursing care treatment, clean and alcoholize the thing used.

Rationale To avoid microbes.

12. Do hand washing again.

Rationale To promote caregiver and prevent spread of infection to others.

13. Open the bag and put back all articles in their proper places.

Rationale To keep it organized.

After care: before keeping all articles in the bag, clean and alcoholize them.


Kozier, Barbara, Fundamental of Nursing. Philippines: Pearson Education South Asia PTE LTD 2004

204 RLE Procedures



Maintaining an optimum hygienic of a surgically created opening between colon and abdominal wall that allows fecal elimination.


  • To allow fecal elimination
  • To prevent infection on operative site
  • To facilitate accommodation of excretion and avoid spillage of contents
  • To collect effluent for assessment of the amount and type of output
  • To minimize odors for the client’s comfort and self-esteem


  • Obtain doctor’s order
  • Explain the procedure to the patient
  • Provide privacy
  • Use universally precautions in handling body secretions
  • Uphold aseptic technique


  • Large tail closure                                     Irrigator bag or enema bag
  • Water soluble lubricant                        Cone tip or soft rubber catheter
  • Cleansing agent                                         no. 22 or no. 24 with shield
  • Clean gloves
  • Skin protectant
  • Irrigation sleeve

1. Check doctor’s order and explain procedure to the patient.

Rationale: Relieve anxiety and promote compliance

2. Select a consistent time of the day that best fit patient lifestyle to irrigate free from distraction.

Rationale: Establish regularity.

3. Have patient sit on a chair or commode. Provide privacy.

Rationale: To be in comfortable position.

4. Hang the irrigating reservoir with prescribed solution so bottom of reservoir is at the level of patients shoulder and above the stoma.

Rationale: Height regulates pressure of irrigant.

5. Wear gloves and mask

Rationale: Prevent transmission of microorganism and inhalation of fecal odor.

6. Remove pouch or covering of stoma and apply irregular sleeve, directing the open tail into the commode.

Rationale: Allows water and feces to flow directly into the commode.

7. Open tubing clamp or irrigating reservoir to release a small amount of solution into the commode.

Rationale: Removes air from the set-up; prevent air to enter into the colon and cause cramping again.

8. Lubricate the tip of the cone/catheter, insert about 3 inches into the stoma. Hold cone/shield gently but firmly  to prevent back-flow of water.

Rationale: Prevent intestinal perforation and irritation of mucus membrane.

9. Allow water to enter  colon slowly over 5-10 minutes period. If cramping occurs, slow the flow rate or clamp tubing to allow cramping to subside.

Rationale: Slow relaxes bowel to facilitate passage of catheter.

10. Hold cone for 10 sec. after water is instilled, then gently remove cone from stoma.

Rationale: Cramping occur if too rapid flow, cold water excess solution on a colon ready to function.

11. As feces and water flow down sleeve, periodically rinse sleeve with water. Allow 10-15 min  for most of the return, then dry sleeve tail and apply tail closure.

Rationale: To cleanse the sleeve for patency.

12. Leave sleeve in place for approximately 20 more minutes while patient gets up and moves around.

Rationale: For patient’s comfort.

13. When returns are complete, clean stoma area with mild soap and water, pat dry, reapply pouch.

Rationale: To cleanse the stoma and make the pouch available for use.

14. Leave patient dry and comfortable.

Rationale: For patient comfort.

15. Do aftercare of equipment with soap and water, dry and store in well-ventilated area.

Rationale: To be ready for the next use.

16. Chart procedure done, reaction of patient.

Rationale: For documentation purposes.


Kozier, Barbara, Fundamentals of Nursing Philippines: Pearson Education South Asia PTE LTD.2004. pp. 1247-1250