[1451192711] [9781451192711] Taylor's Clinical Nursing Skills: A Nursing Process Approach 4th Edition-Paperback

Taylor’s Clinical Nursing Skills: A Nursing Process Approach, FOURTH EDITION Title Page Copyright Dedication Contributors and Reviewers Preface How to Use Taylor’s Clinical Nursing Skills Acknowledgments Contents UNIT I Actions Basic to Nursing Care Chapter 1 Asepsis and Infection Control SKILL 1-1 PERFORMING HAND HYGIENE USING AN ALCOHOL-BASED HANDRUB SKILL 1-2 PERFORMING HAND HYGIENE USING SOAP AND WATER (HANDWASHING) SKILL 1-3 USING PERSONAL PROTECTIVE EQUIPMENT SKILL 1-4 PREPARING A STERILE FIELD USING A PACKAGED STERILE DRAPE SKILL 1-5 PREPARING A STERILE FIELD USING A COMMERCIALLY PREPARED STERILE KIT OR TRAY SKILL 1-6 ADDING STERILE ITEMS TO A STERILE FIELD SKILL 1-7 PUTTING ON STERILE GLOVES AND REMOVING SOILED GLOVES Chapter 2 Vital Signs LEARNING OBJECTIVES KEY TERMS SKILL 2-1 ASSESSING BODY TEMPERATURE SKILL 2-2 REGULATING TEMPERATURE USING AN OVERHEAD RADIANT WARMER SKILL 2-3 REGULATING TEMPERATURE USING A HYPOTHERMIA BLANKET SKILL 2-4 ASSESSING A PERIPHERAL PULSE BY PALPATION SKILL 2-5 ASSESSING THE APICAL PULSE BY AUSCULTATION SKILL 2-6 ASSESSING RESPIRATION SKILL 2-7 ASSESSING BLOOD PRESSURE BY AUSCULTATION Chapter 3 Health Assessment LEARNING OBJECTIVES KEY TERMS SKILL 3-1 PERFORMING A GENERAL SURVEY SKILL 3-2 USING A BED SCALE SKILL 3-3 ASSESSING THE SKIN, HAIR, AND NAILS SKILL 3-4 ASSESSING THE HEAD AND NECK SKILL 3-5 ASSESSING THE THORAX, LUNGS, AND BREASTS SKILL 3-6 ASSESSING THE CARDIOVASCULAR SYSTEM SKILL 3-7 ASSESSING THE ABDOMEN SKILL 3-8 ASSESSING THE FEMALE GENITALIA SKILL 3-9 ASSESSING MALE GENITALIA SKILL 3-10 ASSESSING THE NEUROLOGIC, MUSCULOSKELETAL, AND PERIPHERAL VASCULAR SYSTEMS Chapter 4 Safety LEARNING OBJECTIVES KEY TERMS SKILL 4-1 FALL PREVENTION SKILL 4-2 IMPLEMENTING ALTERNATIVES TO THE USE OF RESTRAINTS SKILL 4-3 APPLYING AN EXTREMITY RESTRAINT SKILL 4-4 APPLYING A WAIST RESTRAINT SKILL 4-5 APPLYING AN ELBOW RESTRAINT SKILL 4-6 APPLYING A MUMMY RESTRAINT Chapter 5 Medication Administration SKILL 5-1 ADMINISTERING ORAL MEDICATIONS SKILL 5-2 ADMINISTERING MEDICATIONS VIA A GASTRIC TUBE SKILL 5-3 REMOVING MEDICATION FROM AN AMPULE SKILL 5-4 REMOVING MEDICATION FROM A VIAL SKILL 5-5 MIXING MEDICATIONS FROM TWO VIALS IN ONE SYRINGE SKILL 5-6 ADMINISTERING AN INTRADERMAL INJECTION SKILL 5-7 ADMINISTERING A SUBCUTANEOUS INJECTION SKILL 5-8 ADMINISTERING AN INTRAMUSCULAR INJECTION SKILL 5-9 ADMINISTERING A CONTINUOUS SUBCUTANEOUS INFUSION: APPLYING AN INSULIN PUMP SKILL 5-10 ADMINISTERING MEDICATIONS BY INTRAVENOUS BOLUS OR PUSH THROUGH AN INTRAVENOUS INFUSION SKILL 5-11 ADMINISTERING A PIGGYBACK INTERMITTENT INTRAVENOUS INFUSION OF MEDICATION SKILL 5-12 ADMINISTERING AN INTERMITTENT INTRAVENOUS INFUSION OF MEDICATION VIA A MINI-INFUSION PUMP SKILL 5-13 ADMINISTERING AN INTERMITTENT INTRAVENOUS INFUSION OF MEDICATION VIA A VOLUME-CONTROL ADMINISTRATION SET SKILL 5-14 INTRODUCING DRUGS THROUGH A MEDICATION OR DRUG-INFUSION LOCK (INTERMITTENT PERIPHERAL VENOUS ACCESS DEVICE) USING THE SALINE FLUSH SKILL 5-15 APPLYING A TRANSDERMAL PATCH SKILL 5-16 INSTILLING EYE DROPS SKILL 5-17 ADMINISTERING AN EYE IRRIGATION SKILL 5-18 INSTILLING EAR DROPS SKILL 5-19 ADMINISTERING AN EAR IRRIGATION SKILL 5-20 ADMINISTERING A NASAL SPRAY SKILL 5-21 ADMINISTERING A VAGINAL CREAM SKILL 5-22 ADMINISTERING A RECTAL SUPPOSITORY SKILL 5-23 ADMINISTERING MEDICATION VIA A METERED-DOSE INHALER (MDI) SKILL 5-24 ADMINISTERING MEDICATION VIA A DRY POWDER INHALER SKILL 5-25 ADMINISTERING MEDICATION VIA A SMALL-VOLUME NEBULIZER Chapter 6 Perioperative Nursing SKILL 6-1 TEACHING DEEP BREATHING EXERCISES, COUGHING, AND SPLINTING SKILL 6-2 TEACHING LEG EXERCISES SKILL 6-3 PROVIDING PREOPERATIVE PATIENT CARE: HOSPITALIZED PATIENT SKILL 6-4 PROVIDING PREOPERATIVE PATIENT CARE: HOSPITALIZED PATIENT (DAY OF SURGERY) SKILL 6-5 PROVIDING POSTOPERATIVE CARE WHEN PATIENT RETURNS TO ROOM SKILL 6-6 APPLYING A FORCED-WARM AIR DEVICE UNIT II Promoting Healthy Physiologic Responses Chapter 7 Hygiene SKILL 7-1 ASSISTING WITH A SHOWER OR TUB BATH SKILL 7-2 PROVIDING A BED BATH SKILL 7-3 ASSISTING THE PATIENT WITH ORAL CARE SKILL 7-4 PROVIDING ORAL CARE FOR THE DEPENDENT PATIENT SKILL 7-5 PROVIDING DENTURE CARE SKILL 7-6 REMOVING CONTACT LENSES SKILL 7-7 SHAMPOOING A PATIENT’S HAIR IN BED SKILL 7-8 ASSISTING THE PATIENT TO SHAVE SKILL 7-9 PROVIDING NAIL CARE SKILL 7-10 MAKING AN UNOCCUPIED BED SKILL 7-11 MAKING AN OCCUPIED BED Chapter 8 Skin Integrity and Wound Care SKILL 8-1 CLEANING A WOUND AND APPLYING A DRY, STERILE DRESSING SKILL 8-2 APPLYING A SALINE-MOISTENED DRESSING SKILL 8-3 APPLYING A HYDROCOLLOID DRESSING SKILL 8-4 PERFORMING IRRIGATION OF A WOUND SKILL 8-5 COLLECTING A WOUND CULTURE SKILL 8-6 APPLYING MONTGOMERY STRAPS SKILL 8-7 CARING FOR A PENROSE DRAIN SKILL 8-8 CARING FOR A T-TUBE DRAIN SKILL 8-9 CARING FOR A JACKSON-PRATT DRAIN SKILL 8-10 CARING FOR A HEMOVAC DRAIN SKILL 8-11 APPLYING NEGATIVE PRESSURE WOUND THERAPY SKILL 8-12 REMOVING SUTURES SKILL 8-13 REMOVING SURGICAL STAPLES SKILL 8-14 APPLYING AN EXTERNAL HEATING PAD SKILL 8-15 APPLYING A WARM COMPRESS SKILL 8-16 ASSISTING WITH A SITZ BATH SKILL 8-17 APPLYING COLD THERAPY Chapter 9 Activity SKILL 9-1 ASSISTING A PATIENT WITH TURNING IN BED SKILL 9-2 MOVING A PATIENT UP IN BED WITH THE ASSISTANCE OF ANOTHER CAREGIVER SKILL 9-3 TRANSFERRING A PATIENT FROM THE BED TO A STRETCHER SKILL 9-4 TRANSFERRING A PATIENT FROM THE BED TO A CHAIR SKILL 9-5 TRANSFERRING A PATIENT USING A POWERED FULL-BODY SLING LIFT SKILL 9-6 PROVIDING RANGE-OF-MOTION EXERCISES SKILL 9-7 ASSISTING A PATIENT WITH AMBULATION SKILL 9-8 ASSISTING A PATIENT WITH AMBULATION USING A WALKER SKILL 9-9 ASSISTING A PATIENT WITH AMBULATION USING CRUTCHES SKILL 9-10 ASSISTING A PATIENT WITH AMBULATION USING A CANE SKILL 9-11 APPLYING AND REMOVING GRADUATED COMPRESSION STOCKINGS SKILL 9-12 APPLYING PNEUMATIC COMPRESSION DEVICES SKILL 9-13 APPLYING A CONTINUOUS PASSIVE MOTION DEVICE SKILL 9-14 APPLYING A SLING SKILL 9-15 APPLYING A FIGURE-EIGHT BANDAGE SKILL 9-16 ASSISTING WITH CAST APPLICATION SKILL 9-17 CARING FOR A CAST SKILL 9-18 APPLYING SKIN TRACTION AND CARING FOR A PATIENT IN SKIN TRACTION SKILL 9-19 CARING FOR A PATIENT IN SKELETAL TRACTION SKILL 9-20 CARING FOR A PATIENT WITH AN EXTERNAL FIXATION DEVICE Chapter 10 Comfort and Pain Management LEARNING OBJECTIVES KEY TERMS SKILL 10-1 PROMOTING PATIENT COMFORT SKILL 10-2 GIVING A BACK MASSAGE SKILL 10-3 APPLYING AND CARING FOR A PATIENT USING A TENS UNIT SKILL 10-4 CARING FOR A PATIENT RECEIVING PATIENT-CONTROLLED ANALGESIA SKILL 10-5 CARING FOR A PATIENT RECEIVING EPIDURAL ANALGESIA SKILL 10-6 CARING FOR A PATIENT RECEIVING CONTINUOUS WOUND PERFUSION PAIN MANAGEMENT Chapter 11 Nutrition SKILL 11-1 ASSISTING A PATIENT WITH EATING SKILL 11-2 INSERTING A NASOGASTRIC (NG) TUBE SKILL 11-3 ADMINISTERING A TUBE FEEDING SKILL 11-4 REMOVING A NASOGASTRIC TUBE SKILL 11-5 CARING FOR A GASTROSTOMY TUBE Chapter 12 Urinary Elimination LEARNING OBJECTIVES KEY TERMS SKILL 12-1 ASSISTING WITH THE USE OF A BEDPAN SKILL 12-2 ASSISTING WITH THE USE OF A URINAL SKILL 12-3 ASSISTING WITH THE USE OF A BEDSIDE COMMODE SKILL 12-4 ASSESSING BLADDER VOLUME USING AN ULTRASOUND BLADDER SCANNER SKILL 12-5 APPLYING AN EXTERNAL CONDOM CATHETER SKILL 12-6 CATHETERIZING THE FEMALE URINARY BLADDER SKILL 12-7 CATHETERIZING THE MALE URINARY BLADDER SKILL 12-8 REMOVING AN INDWELLING CATHETER SKILL 12-9 PERFORMING INTERMITTENT CLOSED CATHETER IRRIGATION SKILL 12-10 ADMINISTERING A CONTINUOUS CLOSED BLADDER OR CATHETER IRRIGATION SKILL 12-11 EMPTYING AND CHANGING A STOMA APPLIANCE ON AN ILEAL CONDUIT SKILL 12-12 CARING FOR A SUPRAPUBIC URINARY CATHETER SKILL 12-13 CARING FOR A PERITONEAL DIALYSIS CATHETER SKILL 12-14 CARING FOR A HEMODIALYSIS ACCESS (ARTERIOVENOUS FISTULA OR GRAFT) Chapter 13 Bowel Elimination LEARNING OBJECTIVES KEY TERMS SKILL 13-1 ADMINISTERING A LARGE-VOLUME CLEANSING ENEMA SKILL 13-2 ADMINISTERING A SMALL-VOLUME CLEANSING ENEMA SKILL 13-3 ADMINISTERING A RETENTION ENEMA SKILL 13-4 DIGITAL REMOVAL OF STOOL SKILL 13-5 APPLYING A FECAL INCONTINENCE DEVICE SKILL 13-6 CHANGING AND EMPTYING AN OSTOMY APPLIANCE SKILL 13-7 IRRIGATING A COLOSTOMY SKILL 13-8 IRRIGATING A NASOGASTRIC TUBE CONNECTED TO SUCTION Chapter 14 Oxygenation LEARNING OBJECTIVES KEY TERMS SKILL 14-1 USING A PULSE OXIMETER SKILL 14-2 TEACHING A PATIENT TO USE AN INCENTIVE SPIROMETER SKILL 14-3 ADMINISTERING OXYGEN BY NASAL CANNULA SKILL 14-4 ADMINISTERING OXYGEN BY MASK SKILL 14-5 USING AN OXYGEN TENT SKILL 14-6 SUCTIONING THE OROPHARYNGEAL AND NASOPHARYNGEAL AIRWAYS SKILL 14-7 INSERTING AN OROPHARYNGEAL AIRWAY SKILL 14-8 SUCTIONING AN ENDOTRACHEAL TUBE: OPEN SYSTEM SKILL 14-9 SUCTIONING AN ENDOTRACHEAL TUBE: CLOSED SYSTEM SKILL 14-10 SECURING AN ENDOTRACHEAL TUBE SKILL 14-11 SUCTIONING A TRACHEOSTOMY: OPEN SYSTEM SKILL 14-12 PROVIDING CARE OF A TRACHEOSTOMY TUBE SKILL 14-13 PROVIDING CARE OF A CHEST DRAINAGE SYSTEM SKILL 14-14 ASSISTING WITH REMOVAL OF A CHEST TUBE SKILL 14-15 USING A MANUAL RESUSCITATION BAG AND MASK Chapter 15 Fluid, Electrolyte, and Acid–Base Balance LEARNING OBJECTIVES KEY TERMS SKILL 15-1 INITIATING A PERIPHERAL VENOUS ACCESS IV INFUSION SKILL 15-2 CHANGING AN IV SOLUTION CONTAINER AND ADMINISTRATION SET SKILL 15-3 MONITORING AN IV SITE AND INFUSION SKILL 15-4 CHANGING A PERIPHERAL VENOUS ACCESS DRESSING SKILL 15-5 CAPPING FOR INTERMITTENT USE AND FLUSHING A PERIPHERAL VENOUS ACCESS DEVICE SKILL 15-6 ADMINISTERING A BLOOD TRANSFUSION SKILL 15-7 CHANGING THE DRESSING AND FLUSHING CENTRAL VENOUS ACCESS DEVICES SKILL 15-8 ACCESSING AN IMPLANTED PORT SKILL 15-9 DEACCESSING AN IMPLANTED PORT SKILL 15-10 REMOVING A PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) Chapter 16 Cardiovascular Care SKILL 16-1 PERFORMING CARDIOPULMONARY RESUSCITATION (CPR) SKILL 16-2 PERFORMING EMERGENCY AUTOMATED EXTERNAL DEFIBRILLATION SKILL 16-3 PERFORMING EMERGENCY MANUAL EXTERNAL DEFIBRILLATION (ASYNCHRONOUS) SKILL 16-4 OBTAINING AN ELECTROCARDIOGRAM (ECG) SKILL 16-5 APPLYING A CARDIAC MONITOR SKILL 16-6 USING AN EXTERNAL (TRANSCUTANEOUS) PACEMAKER SKILL 16-7 OBTAINING AN ARTERIAL BLOOD SAMPLE FROM AN ARTERIAL CATHETER SKILL 16-8 REMOVING PERIPHERAL ARTERIAL CATHETERS Chapter 17 Neurologic Care LEARNING OBJECTIVES KEY TERMS SKILL 17-1 LOGROLLING A PATIENT SKILL 17-2 APPLYING A TWO-PIECE CERVICAL COLLAR SKILL 17-3 EMPLOYING SEIZURE PRECAUTIONS AND SEIZURE MANAGEMENT SKILL 17-4 CARING FOR A PATIENT IN HALO TRACTION SKILL 17-5 CARING FOR A PATIENT WITH AN EXTERNAL VENTRICULOSTOMY (INTRAVENTRICULAR CATHETER–CLOSED FLUID-FILLED SYSTEM) SKILL 17-6 CARING FOR A PATIENT WITH A FIBER OPTIC INTRACRANIAL CATHETER Chapter 18 Laboratory Specimen Collection LEARNING OBJECTIVES KEY TERMS SKILL 18-1 OBTAINING A NASAL SWAB SKILL 18-2 OBTAINING A NASOPHARYNGEAL SWAB SKILL 18-3 COLLECTING A SPUTUM SPECIMEN FOR CULTURE SKILL 18-4 COLLECTING A URINE SPECIMEN (CLEAN CATCH, MIDSTREAM) FOR URINALYSIS AND CULTURE SKILL 18-5 OBTAINING A URINE SPECIMEN FROM AN INDWELLING URINARY CATHETER SKILL 18-6 TESTING STOOL FOR OCCULT BLOOD SKILL 18-7 COLLECTING A STOOL SPECIMEN FOR CULTURE SKILL 18-8 OBTAINING A CAPILLARY BLOOD SAMPLE FOR GLUCOSE TESTING SKILL 18-9 USING VENIPUNCTURE TO COLLECT A VENOUS BLOOD SAMPLE FOR ROUTINE TESTING SKILL 18-10 OBTAINING A VENOUS BLOOD SPECIMEN FOR CULTURE AND SENSITIVITY SKILL 18-11 OBTAINING AN ARTERIAL BLOOD SPECIMEN FOR BLOOD GAS ANALYSIS UNIT III Integrated Case Studies Part 1 Basic Case Studies Part 2 Intermediate Case Studies Part 3 Advanced Case Studies Appendix A Guidelines for Delegation Decision Making Index This text aims to help you learn the nursing skills necessary for safe and effective patient care. The text includes unexpected situations that you may encounter, along with related interventions for how to respond to these unexpected situations. With both basic and advanced skills, this text will be an essential resource to you across the curriculum and throughout your career