Taylor's Clinical Nursing Skills: A Nursing Process Approach, Third Edition

Taylor’s Clinical Nursing Skills: A Nursing Process Approach, Third Edition......Page 1
Title Page......Page 3
Copyright......Page 4
Dedication......Page 5
Contributors and Reviewers......Page 6
FEATURES......Page 9
TEACHING/LEARNING PACKAGE......Page 10
Resources for Students......Page 11
Acknowledgments......Page 12
Contents......Page 13
UNIT I: ACTIONS BASIC TO NURSING CARE......Page 19
KEY TERMS......Page 21
Skill 1-1: Assessing Body Temperature......Page 23
Skill 1-2: Monitoring Temperature Using an Overhead Radiant Warmer......Page 35
Skill 1-3: Using a Cooling Blanket......Page 37
Skill 1-4: Assessing a Peripheral Pulse by Palpation......Page 41
Skill 1-5: Assessing the Apical Pulse by Auscultation......Page 45
Skill 1-6: Assessing Respiration......Page 48
Skill 1-7: Assessing Brachial Artery Blood Pressure......Page 51
ENHANCE YOUR UNDERSTANDING......Page 61
BIBLIOGRAPHY......Page 62
KEY TERMS......Page 63
Skill 2-1: Performing a General Survey......Page 69
Skill 2-2: Using a Bed Scale......Page 72
Skill 2-3: Assessing the Skin, Hair, and Nails......Page 75
Skill 2-4: Assessing the Head and Neck......Page 79
Skill 2-5: Assessing the Thorax and Lungs......Page 87
Skill 2-6: Assessing the Cardiovascular System......Page 94
Skill 2-7: Assessing the Abdomen......Page 97
Skill 2-8: Assessing the Neurologic, Musculoskeletal, and Peripheral Vascular Systems......Page 103
BIBLIOGRAPHY......Page 110
KEY TERMS......Page 112
Skill 3-1: Fall Prevention......Page 118
Skill 3-2: Implementing Alternatives to the Use of Restraints......Page 124
Skill 3-3: Applying an Extremity Restraint......Page 127
Skill 3-4: Applying a Waist Restraint......Page 130
Skill 3-5: Applying an Elbow Restraint......Page 133
Skill 3-6: Applying a Mummy Restraint......Page 136
BIBLIOGRAPHY......Page 139
KEY TERMS......Page 141
Skill 4-1: Performing Hand Hygiene Using Soap and Water (Handwashing)......Page 145
Skill 4-2: Performing Hand Hygiene Using an Alcohol-Based Hand Rub......Page 149
Skill 4-3: Preparing a Sterile Field Using a Packaged Sterile Drape......Page 150
Skill 4-4: Preparing a Sterile Field Using a Commercially Prepared Sterile Kit or Tray......Page 152
Skill 4-5: Adding Sterile Items to a Sterile Field......Page 155
Skill 4-6: Putting on Sterile Gloves and Removing Soiled Gloves......Page 158
Skill 4-7: Using Personal Protective Equipment......Page 162
ENHANCE YOUR UNDERSTANDING......Page 166
BIBLIOGRAPHY......Page 167
LEARNING OBJECTIVES......Page 169
KEY TERMS......Page 170
Skill 5-1: Administering Oral Medications......Page 175
Skill 5-2: Administering Medications via a Gastric Tube......Page 181
Skill 5-3: Removing Medication from an Ampule......Page 185
Skill 5-4: Removing Medication from a Vial......Page 189
Skill 5-5: Mixing Medications From Two Vials in One Syringe......Page 193
Skill 5-6: Administering an Intradermal Injection......Page 197
Skill 5-7: Administering a Subcutaneous Injection......Page 202
Skill 5-8: Administering an Intramuscular Injection......Page 208
Skill 5-9: Administering Continuous Subcutaneous Infusion: Applying an Insulin Pump......Page 216
Skill 5-10: Administering Medications by Intravenous Bolus or Push Through an Intravenous Infusion......Page 221
Skill 5-11: Administering a Piggyback Intermittent Intravenous Infusion of Medication......Page 225
Skill 5-12: Administering an Intermittent Intravenous Infusion of  Medication via a Mini-infusion Pump......Page 232
Skill 5-13: Administering an Intermittent Intravenous Infusion of Medication via a Volume-Control Administration Set......Page 236
Skill 5-14: Introducing Drugs Through a Medication or Drug-Infusion Lock (Intermittent Peripheral Venous Access Device) Using the Saline Flush......Page 240
Skill 5-15: Applying a Transdermal Patch......Page 245
Skill 5-16: Instilling Eye Drops......Page 249
Skill 5-17: Administering an Eye Irrigation......Page 254
Skill 5-18: Instilling Ear Drops......Page 257
Skill 5-19: Administering an Ear Irrigation......Page 262
Skill 5-20: Instilling Nose Drops......Page 266
Skill 5-21: Administering a Vaginal Cream......Page 270
Skill 5-22: Administering a Rectal Suppository......Page 275
Skill 5-23: Administering Medication via a Metered-Dose Inhaler (MDI)......Page 278
Skill 5-24: Administering Medication via a Small-Volume Nebulizer......Page 284
Skill 5-25: Administering Medication via a Dry Powder Inhaler......Page 288
ENHANCE YOUR UNDERSTANDING......Page 291
BIBLIOGRAPHY......Page 292
KEY TERMS......Page 295
Skill 6-1: Providing Preoperative Patient Care: Hospitalized Patient......Page 299
Skill 6-2: Deep Breathing Exercises, Coughing, and Splinting......Page 305
Skill 6-3: Leg Exercises......Page 309
Skill 6-4: Providing Preoperative Patient Care: Hospitalized Patient (Day of Surgery)......Page 312
Skill 6-5: Providing Postoperative Care When Patient Returns to Room......Page 316
Skill 6-6: Applying a Forced-Air Warming Device......Page 321
ENHANCE YOUR UNDERSTANDING......Page 324
BIBLIOGRAPHY......Page 325
UNIT II: PROMOTING HEALTHY PHYSIOLOGIC RESPONSES......Page 327
KEY TERMS......Page 329
Skill 7-1: Giving a Bed Bath......Page 334
Skill 7-2: Assisting the Patient With Oral Care......Page 344
Skill 7-3: Providing Oral Care for the Dependent Patient......Page 348
Skill 7-4: Providing Denture Care......Page 351
Skill 7-5: Removing Contact Lenses......Page 353
Skill 7-6: Shampooing a Patient’s Hair in Bed......Page 357
Skill 7-7: Assisting the Patient to Shave......Page 361
Skill 7-8: Making an Unoccupied Bed......Page 364
Skill 7-9: Making an Occupied Bed......Page 369
BIBLIOGRAPHY......Page 374
KEY TERMS......Page 376
Skill 8-1: Cleaning a Wound and Applying a Dry, Sterile Dressing......Page 383
Skill 8-2: Applying a Saline-Moistened Dressing......Page 390
Skill 8-3: Applying a Hydrocolloid Dressing......Page 394
Skill 8-4: Performing Irrigation of a Wound......Page 398
Skill 8-5: Collecting a Wound Culture......Page 403
Skill 8-6: Applying Montgomery Straps......Page 407
Skill 8-7: Caring for a Penrose Drain......Page 411
Skill 8-8: Caring for a T-Tube Drain......Page 415
Skill 8-9: Caring for a Jackson-Pratt Drain......Page 419
Skill 8-10: Caring for a Hemovac Drain......Page 423
Skill 8-11: Applying Negative Pressure Wound Therapy......Page 427
Skill 8-12: Removing Sutures......Page 432
Skill 8-13: Removing Surgical Staples......Page 435
Skill 8-14: Applying an External Heating Pad......Page 438
Skill 8-15: Applying a Warm Compress......Page 442
Skill 8-16: Assisting With a Sitz Bath......Page 446
Skill 8-17: Applying Cold Therapy......Page 448
BIBLIOGRAPHY......Page 452
LEARNING OBJECTIVES......Page 454
KEY TERMS......Page 455
Skill 9-1: Assisting a Patient With Turning in Bed......Page 461
Skill 9-2: Moving a Patient Up in Bed With the Assistance of Another Nurse......Page 465
Skill 9-3: Transferring a Patient From the Bed to a Stretcher......Page 468
Skill 9-4: Transferring a Patient From the Bed to a Chair......Page 472
Skill 9-5: Transferring a Patient Using a Powered Full-Body Sling Lift......Page 477
Skill 9-6: Providing Range-of-Motion Exercises......Page 482
Skill 9-7: Assisting a Patient With Ambulation......Page 491
Skill 9-8: Assisting a Patient With Ambulation Using a Walker......Page 493
Skill 9-9: Assisting a Patient With Ambulation Using Crutches......Page 497
Skill 9-10: Assisting a Patient With Ambulation Using a Cane......Page 500
Skill 9-11: Applying and Removing Antiembolism Stockings......Page 502
Skill 9-12: Applying Pneumatic Compression Devices......Page 506
Skill 9-13: Applying a Continuous Passive Motion Device......Page 510
Skill 9-14: Applying a Sling......Page 512
Skill 9-15: Applying a Figure-Eight Bandage......Page 515
Skill 9-16: Assisting With Cast Application......Page 518
Skill 9-17: Caring for a Cast......Page 522
Skill 9-18: Applying Skin Traction and Caring for a Patient in Skin Traction......Page 526
Skill 9-19: Caring for a Patient in Skeletal Traction......Page 530
Skill 9-20: Caring for a Patient with an External Fixation Device......Page 533
ENHANCE YOUR UNDERSTANDING......Page 536
BIBLIOGRAPHY......Page 537
KEY TERMS......Page 539
Skill 10-1: Promoting Patient Comfort......Page 547
Skill 10-2: Giving a Back Massage......Page 553
Skill 10-3: Applying and Caring for a Patient Using a TENS Unit......Page 557
Skill 10-4: Caring for a Patient Receiving Patient-Controlled Analgesia......Page 560
Skill 10-5: Caring for a Patient Receiving Epidural Analgesia......Page 568
Skill 10-6: Caring for a Patient Receiving Continuous Wound Perfusion Pain Management......Page 572
BIBLIOGRAPHY......Page 576
KEY TERMS......Page 579
Skill 11-1: Assisting a Patient with Eating......Page 584
Skill 11-2: Inserting a Nasogastric (NG) Tube......Page 588
Skill 11-3: Administering a Tube Feeding......Page 596
Skill 11-4: Removing a Nasogastric Tube......Page 604
Skill 11-5: Caring for a Gastrostomy Tube......Page 607
ENHANCE YOUR UNDERSTANDING......Page 610
BIBLIOGRAPHY......Page 611
KEY TERMS......Page 613
Skill 12-1: Assisting With the Use of a Bedpan......Page 617
Skill 12-2: Assisting With the Use of a Urinal......Page 622
Skill 12-3: Assisting With the Use of a Bedside Commode......Page 625
Skill 12-4: Assessing Bladder Volume Using an Ultrasound Bladder Scanner......Page 628
Skill 12-5: Applying an External Condom Catheter......Page 631
Skill 12-6: Catheterizing the Female Urinary Bladder......Page 634
Skill 12-7: Catheterizing the Male Urinary Bladder......Page 643
Skill 12-8: Removing an Indwelling Catheter......Page 651
Skill 12-9: Performing Intermittent Closed Catheter Irrigation......Page 653
Skill 12-10: Administering a Continuous Closed Bladder Irrigation......Page 657
Skill 12-11: Emptying and Changing a Stoma Appliance on an Ileal Conduit......Page 661
Skill 12-12: Caring for a Suprapubic Urinary Catheter......Page 666
Skill 12-13: Caring for a Peritoneal Dialysis Catheter......Page 669
Skill 12-14: Caring for a Hemodialysis Access (Arteriovenous Fistula or Graft)......Page 673
BIBLIOGRAPHY......Page 675
KEY TERMS......Page 678
Skill 13-1: Administering a Large-Volume Cleansing Enema......Page 681
Skill 13-2: Administering a Small-Volume Cleansing Enema......Page 687
Skill 13-3: Administering a Retention Enema......Page 690
Skill 13-4: Digital Removal of Stool......Page 694
Skill 13-5: Applying a Fecal Incontinence Pouch......Page 697
Skill 13-6: Changing and Emptying an Ostomy Appliance......Page 699
Skill 13-7: Irrigating a Colostomy......Page 708
Skill 13-8: Irrigating a Nasogastric Tube Connected to Suction......Page 711
ENHANCE YOUR UNDERSTANDING......Page 715
BIBLIOGRAPHY......Page 716
KEY TERMS......Page 718
Skill 14-1: Using a Pulse Oximeter......Page 722
Skill 14-2: Teaching Patient to Use an Incentive Spirometer......Page 727
Skill 14-3: Administering Oxygen by Nasal Cannula......Page 729
Skill 14-4: Administering Oxygen by Mask......Page 733
Skill 14-5: Using an Oxygen Tent......Page 739
Skill 14-6: Suctioning the Nasopharyngeal and Oropharyngeal Airways......Page 741
Skill 14-7: Inserting an Oropharyngeal Airway......Page 748
Skill 14-8: Suctioning an Endotracheal Tube: Open System......Page 752
Skill 14-9: Suctioning an Endotracheal Tube: Closed System......Page 758
Skill 14-10: Securing an Endotracheal Tube......Page 763
Skill 14-11: Suctioning the Tracheostomy: Open System......Page 769
Skill 14-12: Providing Tracheostomy Care......Page 774
Skill 14-13: Providing Care of a Chest Drainage System......Page 782
Skill 14-14: Assisting With Removal of a Chest Tube......Page 789
Skill 14-15: Using a Handheld Resuscitation Bag and Mask......Page 791
ENHANCE YOUR UNDERSTANDING......Page 794
BIBLIOGRAPHY......Page 795
KEY TERMS......Page 797
Skill 15-1: Initiating a Peripheral Venous Access IV Infusion......Page 801
Skill 15-2: Changing an IV Solution Container and Administration Set......Page 811
Skill 15-3: Monitoring an IV Site and Infusion......Page 816
Skill 15-4: Changing a Peripheral Venous Access Dressing......Page 820
Skill 15-5: Capping for Intermittent Use and Flushing a Peripheral Venous Access Device......Page 823
Skill 15-6: Administering a Blood Transfusion......Page 825
Skill 15-7: Changing the Dressing and Flushing Central Venous Access Devices......Page 831
Skill 15-8: Accessing an Implanted Port......Page 836
Skill 15-9: Deaccessing an Implanted Port......Page 841
Skill 15-10: Removing a Peripherally Inserted Central Catheter (PICC)......Page 844
BIBLIOGRAPHY......Page 846
KEY TERMS......Page 848
Skill 16-1: Obtaining an Electrocardiogram (ECG)......Page 852
Skill 16-2: Applying a Cardiac Monitor......Page 859
Skill 16-3: Obtaining an Arterial Blood Sample From an Arterial Line–Stopcock System......Page 864
Skill 16-4: Removing Arterial and Femoral Lines......Page 868
Skill 16-5: Performing Cardiopulmonary Resuscitation (CPR)......Page 871
Skill 16-6: Performing Emergency Automated External Defibrillation......Page 876
Skill 16-7: Performing Emergency Manual External Defibrillation (Asynchronous)......Page 880
Skill 16-8: Using an External (Transcutaneous) Pacemaker......Page 884
BIBLIOGRAPHY......Page 889
KEY TERMS......Page 891
Skill 17-1: Logrolling a Patient......Page 895
Skill 17-2: Applying a Two-Piece Cervical Collar......Page 898
Skill 17-3: Employing Seizure Precautions and Seizure Management......Page 900
Skill 17-4: Caring for a Patient in Halo Traction......Page 904
Skill 17-5: Caring for a Patient with an External Ventriculostomy (Intraventricular Catheter–Closed Fluid-Filled System)......Page 908
Skill 17-6: Caring for a Patient With a Fiber Optic Intracranial Catheter......Page 912
ENHANCE YOUR UNDERSTANDING......Page 914
BIBLIOGRAPHY......Page 915
LEARNING OBJECTIVES......Page 917
KEY TERMS......Page 918
Skill 18-1: Testing Stool for Occult Blood......Page 921
Skill 18-2: Collecting a Stool Specimen for Culture......Page 925
Skill 18-3: Obtaining a Capillary Blood Sample for Glucose Testing......Page 927
Skill 18-4: Obtaining a Nasal Swab......Page 930
Skill 18-5: Obtaining a Nasopharyngeal Swab......Page 933
Skill 18-6: Collecting a Sputum Specimen for Culture......Page 935
Skill 18-7: Collecting a Urine Specimen (Clean Catch, Midstream) for Urinalysis and Culture......Page 939
Skill 18-8: Obtaining a Urine Specimen From an Indwelling Urinary Catheter......Page 944
Skill 18-9: Using Venipuncture to Collect a Venous Blood Sample for Routine Testing......Page 947
Skill 18-10: Obtaining a Venous Blood Specimen for Culture and Sensitivity......Page 954
Skill 18-11: Obtaining an Arterial Blood Specimen for Blood Gas Analysis......Page 959
ENHANCE YOUR UNDERSTANDING......Page 966
BIBLIOGRAPHY......Page 967
UNIT III: INTEGRATED CASE STUDIES......Page 969
Part 1: Basic Case Studies......Page 971
Part 2: Intermediate Case Studies......Page 986
Part 3: Advanced Case Studies......Page 1001
CASE STUDY REFERENCES......Page 1009