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Taylor's Clinical Nursing Skills: A Nursing Process Approach
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Figure Index
Box Index
Table Index
Calculator Index
Flowchart Index
Fundamental Review Index
Skill Index
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Taylor's Clinical Nursing Skills: A Nursing Process Approach
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Table of Contents
Free Topics
About
Accessing an Implanted Port
Activity
Activity, care related to
Adding Sterile Items to a Sterile Field
Administering a Blood Transfusion
Administering a Continuous Closed Bladder or Catheter Irrigation
Administering a Continuous Subcutaneous Infusion: Applying an Insulin Pump
Administering a Large-Volume Cleansing Enema
Administering a Nasal Spray
Administering an Ear Irrigation
Administering an Eye Irrigation
Administering an Intermittent Intravenous Infusion of Medication Via a Mini-Infusion Pump
Anatomy of the Genitourinary Tract
Assessing the Abdomen
Assessing the Neurologic, Musculoskeletal, and Peripheral Vascular Systems
Basic Principles of Medical Asepsis in Patient Care
Box - ANA Board of Directors Position Statement: Reduction of Patient Restraint and Seclusion in Health Care Settings
Box - Characteristics of Sputum and Potential Causes
Calculator - Fall Risk category - (Calc)
Calculator - FLACC Behavioral Scale - (Calc)
Caring for a Patient Receiving Epidural Analgesia
Caring for a Patient with a Cast
Comfort and Pain Management
Components of a Health History
Figure - Abdominal Quadrants and Underlying Organs
Figure - Palpating the Abdomen Lightly
Flowchart - Example of an Algorithm (Assessment Tool) to Aid in Decision Making Regarding Safe Patient Handling and Mobility to Reposition a Patient in Bed
Flowchart - Example of an Algorithm to Aid in Decision Making Regarding Safe Patient Handling and Mobility to Transfer a Patient from Bed to a Chair
Promoting Patient Comfort
Providing Range-of-Motion Exercises
Safety
Safety
Table - Adventitious Breath Sounds
Table - Arterial Blood Gas: Normal Values
I. Actions Basic to Nursing Care
1. Asepsis and Infection Control
1. Asepsis and Infection Control
1-1. Performing Hand Hygiene Using an Alcohol-Based Hand Sanitizer - Skills
1-2. Performing Hand Hygiene Using Soap and Water (Handwashing) - Skills
1-3. Using Personal Protective Equipment - Skills
1-4. Preparing a Sterile Field Using a Packaged Sterile Drape - Skills
1-5. Preparing a Sterile Field Using a Commercially Prepared Sterile Kit or Tray - Skills
1-6. Adding Sterile Items to a Sterile Field - Skills
1-7. Putting on Sterile Gloves and Removing Soiled Gloves - Skills
B - 1-1. Guidelines for Effective Use of PPE
F - 001-01. Applying the correct amount of product to the palm of one hand
F - 001-02. Ensuring use of the correct amount of product
F - 001-03. Rubbing hands together until dry
F - 002-01. Standing in front of sink
F - 002-02. Turning on the water at the sink
F - 002-03. Wetting hands to the wrist
F - 002-04. Lathering hands with soap and rubbing with firm circular motion
F - 002-05. Washing areas between fingers
F - 002-06. Washing to 1 inch above the wrist
F - 002-07. Using fingernails to clean under nails of opposite hand
F - 002-08. Rinsing hands under running water with water flowing toward fingertips
F - 003-01. Tying gown at neck and waist
F - 003-02. Applying mask over nose, mouth, and chin
F - 003-03. Putting on goggles
F - 003-04. Putting on face shield
F - 003-05. Putting on gloves, ensuring gloves cover gown cuffs
F - 003-06. Grasping the palm area of one glove and peeling off
F - 003-07. Sliding fingers of ungloved hand under the remaining glove at the wrist
F - 003-08. Peeling off the second glove, containing the first glove inside the other
F - 003-09. Removing goggles by grasping earpieces
F - 003-10. Touching only the inside of the gown, pull away from the neck and shoulders
F - 003-11. Keeping hands on the inner surface of the gown, pull gown from arms
F - 003-12. Turning gown inside out, rolling into a bundle
F - 003-13. Removing mask or respirator, grasping the neck ties or elastic, taking care to avoid touching the front
F - 003-14. Grasping the outside of the front of gown and pulling away from the body
F - 003-15. Rolling gown inside-out into a bundle
F - 003-16. Peeling off gloves as gown is being removed, touching only the inside of the gloves and gown
F - 003-17. Removing the goggles or face shield, grasping the headband or earpieces
F - 003-18. Removing the mask or respirator, grasping the bottom ties or elastic, and then the top ties or elastic
F - 004-01. Holding drape by corners and allowing it to unfold away from body and surfaces
F - 004-02. Positioning drape on work surface with the moisture-proof side down
F - 005-01. Opening outside cover of package
F - 005-02. Pulling top flap open, away from body
F - 005-03. Pulling open the first side flap
F - 005-04. Pulling open the remaining side flap
F - 005-05. Pulling open flap closest to body
F - 005-06. Positioning wrapper on work surface
F - 005-07. Outside wrapper of package is now sterile field
F - 006-01. Carefully peeling edges apart
F - 006-02. Dropping sterile item onto sterile field
F - 006-03. Opening bottle of sterile solution and placing cap on table with edges up
F - 006-04. Pouring solution into sterile container
F - 007-01. Pulling top layer of outside wrapper back
F - 007-02. Folding back side flaps
F - 007-03. Grasping cuff of glove for dominant hand
F - 007-04. Lifting glove from package
F - 007-05. Inserting dominant hand into glove
F - 007-06. Sliding fingers under cuff of glove for nondominant hand
F - 007-07. Sliding fingers of one hand under cuff of other hand and extending cuff down the arm
F - 007-08. Adjusting gloves as necessary
F - 007-09. Inverting glove as it is removed
F - 007-10. Sliding fingers of ungloved hand inside remaining glove
F - 007-11. Inverting glove as it is removed, securing first glove inside it
Fundamental Reviews - 1-1. Basic Principles of Medical Asepsis in Patient Care
Fundamental Reviews - 1-2. Basic Principles of Surgical Asepsis in Patient Care
Fundamental Reviews - 1-3. Standard Precautions
Fundamental Reviews - 1-4. Transmission-Based Precautions
2. Vital Signs
2. Vital Signs
2-1. Assessing Body Temperature - Skills
2-2. Regulating Temperature Using an Overhead Radiant Warmer - Skills
2-3. Regulating Temperature Using a Hypothermia Blanket - Skills
2-4. Assessing a Peripheral Pulse by Palpation - Skills
2-5. Assessing the Apical Pulse by Auscultation - Skills
2-6. Assessing Respiration - Skills
2-7. Assessing Blood Pressure Using an Automated, Electronic Oscillometric Device - Skills
2-8. Assessing Blood Pressure by Auscultation - Skills
B - 2-1. Normal Temperature Variations Based on Measurement Site
B - 2-2. Pulse Sites and Pulse Amplitude
B - 2-3. Considerations Related to Measurement of Blood Pressure
B - 2-4. Sources of Error in Blood Pressure Measurement
B - 2-5. Assessing for Orthostatic Hypotension
F - 001-01. Holding the device perpendicular from the patient's forehead
F - 001-02. Putting probe cover on the thermometer
F - 001-03. Placing thermometer under the tongue in the posterior sublingual pocket
F - 001-04. Holding probe in the patient's mouth
F - 001-05. Pushing button to dispose of cover
F - 001-06. Attaching the disposable cover onto the tympanic probe
F - 001-07. Thermometer in patient's ear canal with pinna pulled up and back
F - 001-08. Disposing of probe cover
F - 001-09. Placing the thermometer probe on the center of the forehead
F - 001-10. Sliding the probe across the forehead to the hairline
F - 001-11. Touching the probe behind the ear
F - 001-12. Exposing axilla to assess temperature
F - 001-13. Placing thermometer in the center of the axilla
F - 001-14. Removing appropriate probe and attaching disposable probe cover
F - 001-15. Lubricating thermometer tip
F - 001-16. Inserting thermometer into the anus
F - 002-01. Probe in place with foil cover
F - 002-02. Taking infant's axillary temperature
F - 003-01. Moving the Doppler tip until pulse is heard
F - 003-02. Turning the hypothermia blanket control unit on and checking the settings
F - 003-03. Positioning the hypothermia blanket under the patient
F - 004-01. Placing fingers over the artery
F - 004-02. Counting the pulse
F - 005-01. Inflating cuff while listening to artery pulsations
F - 005-02. The apical pulse is usually found at (A) the fifth intercostal space just inside the midclavicular line and can be heard (B) over the apex of the heart
F - 006-01. Assessing respirations
F - 007-01. The electronic oscillometric blood pressure monitor reports systolic and diastolic blood pressure as well as mean blood pressure
F - 007-02. Proper positioning for blood pressure assessment using brachial artery
F - 007-03. Centering the bladder of the cuff over the brachial artery
F - 007-04. Cuff tubing extending from the edge of the cuff nearer the patient's elbow
F - 007-05. Wrapping the cuff around the arm smoothly and snugly
F - 007-06. Noting the blood pressure reading
F - 008-01. Sphygmomanometer
F - 008-02. Positioning for blood pressure assessment using brachial artery
F - 008-03. Placing the blood pressure cuff on the upper arm
F - 008-04. Ensuring gauge starts at zero
F - 008-05. Palpating the brachial pulse
F - 008-06. Placement of diaphragm of stethoscope
F - 008-07. Noting the point on the gauge at which the first of at least two consecutive beats appears
F - 008-08. Noting the point at which the sound completely disappears
F - tbl004-01. Blood flow interrupted by inflated cuff
F - tbl004-02. As the pressure in the cuff is released, blood starts flowing again and Korotkoff sounds are audible
F - tbl004-03. Cuff is completely deflated after Phase V, restoring complete blood flow
Fundamental Reviews - 2-1. Age-Related Variations in Normal Vital Signs
Fundamental Reviews - 2-2. Techniques for Obtaining Vital Signs of Infants and Children
T - 2-1. Patterns of Respiration
T - 2-2. Categories for Blood Pressure Levels in Adults (Ages 18 and Older)
T - 2-3. Recommended Blood Pressure Cuff Sizes
T - 2-4. Korotkoff Sounds
3. Health Assessment
3. Health Assessment
3-1. Performing a General Survey - Skills
3-10. Assessing the Neurologic, Musculoskeletal, and Peripheral Vascular Systems - Skills
3-2. Using a Portable Bed Scale - Skills
3-3. Assessing the Skin, Hair, and Nails - Skills
3-4. Assessing the Head and Neck - Skills
3-5. Assessing the Thorax, Lungs, and Breasts - Skills
3-6. Assessing the Cardiovascular System - Skills
3-7. Assessing the Abdomen - Skills
3-8. Assessing the Female Genitalia - Skills
3-9. Assessing the Male Genitalia - Skills
B - 3-1. Methods for Palpating the Breasts
B - 3-2. Components of a Neurovascular Assessment
F - 001-01. Weighing patient using scale
F - 001-02. Measuring patient's height
F - 002-01. Using a bed scale
F - 003-01. Inspecting overall skin coloration
F - 003-02. Assessing skin temperature
F - 003-03. Assessing skin turgor
F - 003-04. Inspecting the scalp and hair
F - 004-01. Pupillary gauge measures pupils in millimeters (mm)
F - 004-02. Assessing pupillary reaction to light
F - 004-03. Assessing pupillary accommodation
F - 004-04. Assessing extraocular movements
F - 004-05. Assessing convergence
F - 004-06. Testing visual acuity with a Snellen chart
F - 004-07. Palpating the nose
F - 004-08. Palpating the sinuses
F - 004-09. Inspecting the mouth using a tongue blade and penlight
F - 004-10. Location of lymph nodes in neck
F - 004-11. Palpating lymph nodes
F - 004-12. Palpating (A) and auscultating (B) the carotid arteries
F - 004-13. Palpating to determine position of trachea
F - 004-14. Assessing the thyroid gland
F - 005-01. Inspecting the skin for abnormalities and variations
F - 005-02. Palpating the posterior thorax
F - 005-03. Palpating posterior thoracic excursion
F - 005-04. Auscultating the posterior thorax
F - 005-05. Palpating the anterior thorax
F - 005-06. Auscultating the anterior thorax
F - 006-01. Precordium cardiac landmarks
F - 006-02. Palpating the apical impulse in the mitral area
F - 006-03. Auscultating the mitral area
F - 007-01. Abdominal quadrants and underlying organs
F - 007-02. Auscultating the abdomen
F - 007-03. Locations to auscultate for vascular sounds
F - 007-04. Palpating the abdomen lightly
F - 008-01. External female genitalia
F - 009-01. External male genitalia
F - 010-01. Puffing out cheeks
F - 010-02. Assessing function of the spinal accessory nerve (CN XI) and muscular strength
F - 010-03. Moving each ear to the corresponding shoulder
F - 010-04. Assessing muscle strength of the upper extremities
F - 010-05. Palpating the wrist
F - 010-06. Testing grip
F - 010-07. Palpating (A) and auscultating (B) the femoral pulses
F - 010-08. Assessing for pitting edema in lower extremities
F - 010-09. Testing motor strength of upper leg
F - 010-10. A. Testing ankle flexion and dorsiflexion. The patient first pushes the balls of the feet against resistance of the nurse's hands.B. Then attempts to pull against nurse's resistance
F - 010-11. Testing heel to toe walking
F - 010-12. Positioning for the Romberg's test
Fundamental Reviews - 3-1. Components of a Health History
Fundamental Reviews - 3-2. Physical Assessment Techniques
Fundamental Reviews - 3-3. Brief General Physical Assessment
T - 3-1. Normal Breath Sounds
T - 3-2. Adventitious Breath Sounds
T - 3-3. Heart Sounds
4. Safety
4. Safety
4-1. Performing a Situational Assessment - Skills
4-2. Fall Risk and Fall-Related Injury Risk Reduction - Skills
4-3. Implementing Alternatives to the Use of Restraints - Skills
4-4. Applying an Extremity Restraint - Skills
4-5. Applying a Waist Restraint - Skills
4-6. Applying an Elbow Restraint - Skills
4-7. Applying a Mummy Restraint - Skills
B - 4-1. Patient Education for Preventing Falls in the Home
B - 4-2. ANA Board of Directors Position Statement: Reduction of Patient Restraint and Seclusion in Health Care Settings
F - 001-01. Observing the patient's behavior and affect
F - 002-01. Johns Hopkins fall risk assessment Tool
F - 002-02. Reviewing the results of the fall risk assessment and fall risk factors with the patient
F - 002-03. Low bed with floor mats
F - 002-04. Providing nonskid footwear
F - 002-05. Encouraging appropriate exercise
F - 002-06. Engaging bed locks
F - 002-07. Raising side rails on bed at the patient's request
F - 002-08. Patient wearing a personal alarm device
F - 004-01. Wrapping the restraint around the extremity with the soft part in contact with the skin
F - 004-02. Using a hand mitt, with cushion to the palmar aspect of hand
F - 004-03. Securing restraint on extremity
F - 004-04. Ensuring that two fingers can be inserted between the restraint and the patient's extremity
F - 004-05. Securing restraint to bed frame
F - 005-01. Positioning waist restraint
F - 005-02. Restraint secured behind chair, out of the patient's reach
F - 006-01. Child with elbow restraint secured in place
F - 007-01. Pulling blanket over right shoulder and chest and securing under patient's left side
F - 007-02. Securing blanket under right side of body
F - 007-03. Securing lower corner of blanket under each side of patient's body
Fundamental Reviews - 4-1. Preventing Accidents and Promoting Safety at Varying Developmental Stages
Fundamental Reviews - 4-2. General Guidelines for Restraint Use
T - 4-1. Recommended Fall-Prevention Strategies by Fall Risk Level
5. Medications
5. Medications
5-1. Administering Oral Medications - Skills
5-10. Administering Medications by Intravenous Bolus or Push Through an Intravenous Infusion - Skills
5-11. Administering Medications by Intravenous Bolus or Push Through a Medication or Drug-Infusion Lock - Skills
5-12. Administering a Piggyback Intermittent Intravenous Infusion of Medication - Skills
5-13. Administering an Intermittent Intravenous Infusion of Medication Via a Mini-Infusion Pump - Skills
5-14. Applying a Transdermal Patch - Skills
5-15. Administering Eye Drops - Skills
5-16. Administering an Eye Irrigation - Skills
5-17. Administering Ear Drops - Skills
5-18. Administering an Ear Irrigation - Skills
5-19. Administering a Nasal Spray - Skills
5-2. Administering Medications Via a Gastric Tube - Skills
5-20. Administering a Vaginal Cream - Skills
5-21. Administering a Rectal Suppository - Skills
5-22. Administering Medication Via a Metered-Dose Inhaler (MDI) - Skills
5-23. Administering Medication Via a Dry Powder Inhaler - Skills
5-24. Administering Medication Via a Small-Volume Nebulizer - Skills
5-3. Removing Medication From an Ampule - Skills
5-4. Removing Medication From a Vial - Skills
5-5. Mixing Medications From Two Vials in One Syringe - Skills
5-6. Administering an Intradermal Injection - Skills
5-7. Administering a Subcutaneous Injection - Skills
5-8. Administering an Intramuscular Injection - Skills
5-9. Administering a Continuous Subcutaneous Infusion: Applying an Insulin Pump - Skills
B - 5-1. Reducing Discomfort in Subcutaneous and Intramuscular Administrations
F - 001-01. Example of a specially designed vial that has the diluent and powder separated by a rubber stopper within the vial
F - 001-02. Measuring at eye level
F - 001-03. Comparing patient's name and identification number with eMAR
F - 001-04. Scanning bar code on patient's identification bracelet
F - 001-05. Remaining with patient until each medication is swallowed
F - 001-06. Recording each medication administered on eMAR
F - 001-07. Monoject⢠oral syringe
F - 002-01. Patient using insulin pen
F - 002-02. Scanning bar code on the patient's identification bracelet
F - 002-03. Pausing feeding pump
F - 002-04. Pinching (or clamping) gastric tubing to prevent backflow of gastric drainage and opening medication administration port
F - 002-05. Pouring water into syringe inserted in gastric tube
F - 002-06. Pouring medication into syringe inserted in gastric tube
F - 003-01. Tapping stem of the ampule
F - 003-02. Twisting wrist quickly while holding ampule vertically
F - 003-03. Using a snapping motion to break top of ampule
F - 003-04. Withdrawing medication from upright ampule
F - 003-05. Withdrawing medication from inverted ampule
F - 004-01. Injecting air with vial upright
F - 004-02. Example of a needleless system to access a medication vial
F - 004-03. Positioning needle tip in solution
F - 004-04. Withdrawing medication at eye level
F - 005-01. Lubricating suppository
F - 005-02. Inserting suppository into vagina
F - 005-03. Withdrawing prescribed amount of unmodified insulin
F - 005-04. Withdrawing modified insulin
F - 006-01. Holding the MDI 1 to 2 inches from the mouth
F - 006-02. Inserting needle almost flat against the skin
F - 006-03. Observing for wheal while injecting medication
F - 007-01. Body sites where subcutaneous injections can be given
F - 007-02. Scanning bar code on the patient's identification bracelet
F - 007-03. Cleaning injection site
F - 007-04. Pinching up the skin and underlying fatty tissue
F - 007-05. Inserting needle
F - 007-06. Sites for administration of enoxaparin
F - 008-01. Sites for intramuscular injections
F - 008-02. Scanning bar code on the patient's identification bracelet
F - 008-03. Identifying the appropriate landmarks
F - 008-04. Z-track or zigzag technique is recommended for intramuscular injections
F - 008-05. Darting needle into tissue
F - 008-06. Applying gentle pressure at injection site
F - 009-01. Insulin pump utilizing infusion tubing and a small needle-insertion device
F - 009-02. Insulin pump utilizing a wireless patch-pump system
F - 009-03. Scanning bar code on patient's identification bracelet
F - 009-04. Removing cap from syringe or insulin cartridge
F - 009-05. Placing syringe or cartridge in compartment according to the manufacturer's directions
F - 009-06. Programming pump according to prescribed insulin dosing following manufacturer's guidelines for the device
F - 009-07. Cleansing area around injection site with antimicrobial swab
F - 009-08. Insulin pump in place
F - 010-01. Closing the clamp on the administration set
F - 010-02. Removing the passive disinfection cap
F - 010-03. Inserting the saline flush syringe into the injection port
F - 010-04. Pulling back on the plunger to aspirate for a blood return
F - 010-05. Injecting medication at the recommended rate
F - 010-06. Attaching a passive disinfection cap
F - 011-01. Scanning bar code on patient's identification bracelet
F - 011-02. Removing the passive disinfection cap from the access port
F - 011-03. Inserting the saline flush syringe into the access port
F - 011-04. Releasing the clamp on the extension tubing
F - 011-05. Pulling back on the plunger to aspirate for a blood return
F - 011-06. Injecting the medication at the recommended rate
F - 011-07. Clamping the extension tubing
F - 011-08. Attaching a passive disinfection cap to the access port
F - 012-01. Lowering the primary IV fluid container to position the piggyback container higher than primary IV fluid container
F - 012-02. Vigorously scrubbing the access port
F - 012-03. Connecting piggyback administration set to access port
F - 012-04. Setting rate for secondary infusion on infusion pump
F - 012-05. Using roller clamp on primary infusion tubing to regulate gravity flow
F - 013-01. Inserting syringe into mini-infusion pump
F - 013-02. Removing the passive disinfection cap from the access port closest to IV insertion site
F - 013-03. Connecting secondary infusion tubing the access port
F - 013-04. Programming mini-infusion pump
F - 014-01. Scanning bar code on patient's identification bracelet
F - 014-02. Removing protective covering on patch
F - 014-03. Applying patch to patient's skin
F - 015-01. Scanning bar code on patient's identification bracelet
F - 015-02. Cleaning eyelids and eyelashes from the inner toward the outer canthus
F - 015-03. Turning head slightly to affected side
F - 015-04. Applying pressure downward over bony cheek prominence to expose lower conjunctival sac
F - 015-05. Squeezing container to administering drops into conjunctival sac
F - 015-06. Applying gentle pressure over inner canthus
F - 016-01. Tilting head toward affected eye
F - 016-02. Cleaning eyelids and eyelashes from inner canthus to outer canthus
F - 016-03. Placing basin to catch irrigating fluid
F - 016-04. Exposing lower conjunctival sac and holding upper lid open
F - 016-05. Holding irrigation syringe 3 to 4 cm but no more than 5 cm from eye
F - 017-01. Cleaning external ear
F - 017-02. Positioning patient on unaffected side
F - 017-03. Removing the cap from the medication bottle
F - 017-04. Pulling the pinna up and back and placing dropper tip above auditory canal
F - 017-05. Applying pressure to tragus
F - 017-06. Inserting cotton ball into ear canal
F - 017-07. Pulling pinna up and back for a child older than age 3 years
F - 017-08. Pulling pinna down and back for an infant or child younger than age 3 years
F - 018-01. Pulling pinna up and back to straighten the ear canal
F - 018-02. Instilling irrigation fluid
F - 018-03. Placing cotton ball in ear
F - 018-04. Pulling pinna up and back for child older than age 3 years
F - 018-05. Pulling pinna down and back for an infant or child younger than age 3 years
F - 019-01. Scanning bar code on the patient's identification bracelet
F - 019-02. Inserting tip of bottle into one nostril
F - 020-01. Scanning bar code on patient's identification bracelet
F - 020-02. Performing perineal care
F - 020-03. Filling vaginal applicator with cream
F - 020-04. Positioning applicator in vagina for administration of medication
F - 021-01. Scanning bar code on patient's identification bracelet
F - 021-02. Applying lubricant to rounded end of suppository
F - 021-03. Inserting suppository round end first along rectal wall
F - 022-01. Scanning bar code on patient's identification bracelet
F - 022-02. Placing spacer with MDI into mouth
F - 023-01. Scanning bar code on patient's identification bracelet
F - 023-02. Patient with teeth over and lips sealed around DPI mouthpiece
F - 024-01. Putting medication into nebulizer
F - 024-02. Inhaling slowly and deeply through the mouth
Fundamental Reviews - 5-1. Know Your Medications
Fundamental Reviews - 5-2. The Three Checks
Fundamental Reviews - 5-3. Rights of Medication Administration
Fundamental Reviews - 5-4. Nursing Responsibilities for Administering Drugs
Fundamental Reviews - 5-5. Needle/Syringe Selection
T - 5-1. Intramuscular Injection Needle Length
T - 5-2. Intramuscular Site Selection
T - 5-3. Patient Positioning
6. Perioperative Nursing
6. Perioperative Nursing
6-1. Teaching Deep-Breathing Exercises, Coughing, and Splinting - Skills
6-2. Teaching Leg Exercises - Skills
6-3. Providing Preoperative Patient Care - Skills
6-4. Providing Preoperative Patient Care: Day of Surgery - Skills
6-5. Providing Postoperative Care - Skills
6-6. Applying a Forced-Air Warming Device - Skills
B - 6-1. The I Cough Multidisciplinary Program
F - 001-01. Assisting patient to semi- or high-Fowler's position
F - 001-02. Having patient splint chest or abdominal incision by holding a folded bath blanket or small pillow against the incision
F - 001-03. Telling patient to take a deep breath and hold for 3 seconds
F - 001-04. Encouraging patient to cough out three short times after holding breath
F - 002-01. Assisting patient to semi-Fowler's position
F - 002-02. Extending lower portion of the leg and holding for a few seconds
F - 002-03. Lowering entire leg to bed
F - 002-04. Pointing toes of both feet toward foot of bed
F - 002-05. Pulling toes toward chin
F - 002-06. Having patient make circles with both ankles, first one way and then the other
F - 003-01. Identifying needs of patient and answering questions
F - 003-02. Helping patient to roll over to her right side while she pushes with left bent leg and pulls on the side rail
F - 004-01. Obtaining preoperative vital signs
F - 004-02. Postoperative bed, ready for patient's return
F - 005-01. Obtaining postoperative oxygen saturation level
F - 005-02. Checking dressings for color, odor, and amount of drainage
F - 006-01. Forced-air blanket on patient, plastic side up, with air hose inlet at foot of bed
Fundamental Reviews - 6-1. Nursing Assessment and Intervention Before Surgery
Fundamental Reviews - 6-2. Preoperative Information for Outpatient/Same Day Surgery
Fundamental Reviews - 6-3. Sample Preoperative Teaching: Activities and Events for In-Patient Surgery Preoperative Phase
Fundamental Reviews - 6-4. Nursing Interventions to Meet Psychosocial Needs of Patients Having Surgery
II. Promoting Healthy Physiologic Responses
10. Comfort and Pain Management
10. Comfort and Pain Management
10-1. Promoting Patient Comfort - Skills
10-2. Giving a Back Massage - Skills
10-3. Applying and Caring for a Patient Using a Transcutaneous Electrical Nerve Stimulation Unit - Skills
10-4. Caring for a Patient Receiving Patient-Controlled Analgesia - Skills
10-5. Caring for a Patient Receiving Epidural Analgesia - Skills
10-6. Caring for a Patient Receiving Continuous Wound Perfusion Pain Management - Skills
B - 10-1. Guidelines for Safe and Effective Use of Patient-Controlled Analgesia
B - 10-2. Guidelines for Safe Implementation of Authorized Agent-Controlled Analgesia
F - 002-01. Using light, gliding strokes to apply lotion
F - 002-02. Stroking upward to shoulders and back downward to the buttocks
F - 002-03. Kneading the patient's back
F - 002-04. Using long strokes with lessening pressure
F - 003-01. TENS unit
F - 003-02. Applying TENS electrodes
F - 003-03. Turning on TENS unit
F - 004-01. Checking label on prefilled drug syringe with patient identification
F - 004-02. Placing syringe/reservoir into PCA device
F - 004-03. Programming PCA device
F - 004-04. Reinforcing the need to press button to administer pain medication
F - 005-01. Placement of an epidural catheter for long-term use
F - 005-02. Assessing the epidural catheter exit site
F - 006-01. Wound perfusion pain management system consists of a balloon (pump), filter, and catheter that deliver a specific amount of prescribed local anesthetic at the rate determined by the prescribing health care provider
Fundamental Reviews - 10-1. General Guidelines for Pain Assessment
Fundamental Reviews - 10-2. Pain Assessment Tool
Fundamental Reviews - 10-3. Pain Assessment Scales
Fundamental Reviews - 10-4. FLACC Behavioral Scale
T - 10-1. Pasero Opioid-Induced Sedation Scale (POSS)
11. Nutrition
11. Nutrition
11-1. Assisting a Patient with Eating - Skills
11-2. Confirming Placement of a Nasogastric Tube - Skills
11-3. Administering a Tube Feeding (Open System) - Skills
11-4. Caring for a Gastrostomy Tube - Skills
B - 11-1. Special Considerations and Interventions for Assisting Patients with Dementia or Other Alterations in Cognition with Eating
B - 11-2. Special Considerations and Interventions for Assisting Patients with Dysphagia With Eating
B - 11-3. Monitoring for Tolerance of Enteral Nutrition
F - 001-01. Prefilled tube feedings in plastic containers and ready-to-use feeding in a can
F - 002-01. Measuring the length of the exposed nasogastric tube
F - 002-02. Aspirating gastric contents
F - 002-03. pH test strips to measure pH of aspirated fluid
F - 003-01. Cleaning top of feeding container with alcohol before opening it
F - 003-02. Attaching feeding administration set to NG tube
F - 003-03. Pouring water into feeding bag
F - 003-04. Capping NG tube after it is clamped
F - 003-05. Removing plunger from a 60-mL syringe
F - 003-06. Pouring formula into syringe
F - 003-07. Pouring water into almost-empty syringe
F - 003-08. Setting infusion rate on pump
F - 004-01. Wiping gastric tube site with cotton-tipped applicator and sterile saline
F - 004-02. Cleaning site with skin cleanser, water, and washcloth
Fundamental Reviews - 11-1. Clinical Observations for Nutritional Assessment
Fundamental Reviews - 11-2. Factors that May Affect Nutritional Status
T - 11-1. Modified Consistency and Selected Therapeutic Diets
12. Urinary Elimination
12. Urinary Elimination
12-1. Assisting with the Use of a Bedpan - Skills
12-10. Administering a Continuous Closed Bladder or Catheter Irrigation - Skills
12-11. Emptying and Changing a Stoma Appliance on a Urinary Diversion - Skills
12-12. Caring for a Suprapubic Urinary Catheter - Skills
12-13. Caring for a Peritoneal Dialysis Catheter - Skills
12-14. Caring for a Hemodialysis Access (Arteriovenous Fistula or Graft) - Skills
12-2. Assisting with the Use of a Urinal - Skills
12-3. Assisting with the Use of a Bedside Commode - Skills
12-4. Assessing Bladder Volume Using an Ultrasound Bladder Scanner - Skills
12-5. Applying an External Urinary Sheath - Skills
12-6. Applying an External Urine Collection Device (Female Genitalia) - Skills
12-7. Catheterizing the Urinary Bladder of a Patient with Female Genitalia - Skills
12-8. Catheterizing the Urinary Bladder of a Patient with Male Genitalia - Skills
12-9. Removing an Indwelling Urinary Catheter - Skills
B - 12-1. Guidelines for Care of the Patient with an Indwelling Catheter
B - 12-2. Patient Intermittent Self-Catheterization
B - 12-3. Guidelines for Care of the Patient with a Urinary Diversion
F - 001-01. Rolling patient on side to place bedpan
F - 001-02. Placing waterproof pad under patient's buttocks
F - 001-03. Assisting patient to raise hips upward and positioning the bedpan
F - 001-04. Placing call bell within patient's reach and handing patient toilet tissue
F - 002-01. Urinal
F - 002-02. Positioning urinal
F - 003-01. Bedside commode
F - 004-01. Two-piece appliances
F - 004-02. Gently pressing faceplate to skin
F - 004-03. A. Placing ultrasound gel about 1 to 1.5 inches above symphysis pubis.B. Gel pad
F - 004-04. A. Positioning scanner head with directional icon toward patient's head and aiming the scanner head toward the bladder.B. Scan button
F - 004-05. Centering image on crossbars
F - 005-01. Unrolling sheath onto penis
F - 005-02. Connecting external urinary sheath to drainage setup
F - 006-01. External urine collection device in place, secured to the suprapubic region
F - 006-02. External urine collection system (female genitalia)
F - 007-01. A. Indwelling urethral catheter.B. Intermittent urethral catheter
F - 007-02. Patient in dorsal recumbent position and draped properly
F - 007-03. Demonstration of side-lying position
F - 007-04. Patient with fenestrated drape in place over perineum
F - 007-05. Using dominant hand to separate and hold labia open
F - 007-06. Exposing urinary meatus with patient in side-lying position
F - 007-07. Wiping perineum with cotton ball held by forceps
F - 007-08. Inserting catheter with dominant hand while nondominant hand holds labia apart
F - 007-09. Inflating balloon of indwelling catheter
F - 007-10. Attaching catheter to drainage bag
F - 007-11. Catheter secured to leg
F - 008-01. Patient lying supine with fenestrated drape +over penis
F - 008-02. Lifting penis with gloved nondominant hand and cleaning meatus with cotton ball held with forceps in gloved dominant hand
F - 008-03. Inserting syringe into urethra and instilling lubricant
F - 008-04. Inserting catheter using dominant hand
F - 009-01. Removing fluid from balloon
F - 010-01. A triple-lumen catheter
F - 010-02. A continuous bladder irrigation (CBI) setup
F - 010-03. Inserting tubing into solution bag
F - 010-04. Removing air from irrigation tubing
F - 010-05. Attaching irrigation tubing to irrigation port on catheter
F - 010-06. Regulating irrigation flow rate using flow clamp
F - 011-01. Emptying urine into graduated container
F - 011-02. Gently removing appliance faceplate from skin
F - 011-03. Pushing skin from appliance rather than pulling appliance from skin
F - 011-04. Cleaning stoma with cleansing agent and washcloth
F - 011-05. Placing one or two gauze squares over stoma opening
F - 011-06. Cutting the faceplate opening 1/8 inch larger than stoma size
F - 011-07. Applying faceplate over stoma
F - 012-01. A suprapubic catheter positioned in bladder
F - 012-02. Cleaning area around catheter site with skin cleanser and water
F - 012-03. Using a sterile cotton-tipped applicator for cleaning
F - 012-04. Applying small drain sponge around catheter
F - 012-05. Forming a loop in tubing and taping to abdomen
F - 013-01. Position of catheter in peritoneal space
F - 014-01. Central catheter for hemodialysis
F - 014-02. Arteriovenous fistula for hemodialysis
F - 014-03. Arteriovenous graft for hemodialysis
F - 014-04. Palpating access site for thrill
Fundamental Reviews - 12-1. Anatomy of the Genitourinary Tract
Fundamental Reviews - 12-2. Factors Affecting Urinary Elimination
13. Bowel Elimination
13. Bowel Elimination
13-1. Administering a Large-Volume Cleansing Enema - Skills
13-10. Removing a Nasogastric Tube - Skills
13-2. Administering a Small-Volume Cleansing Enema - Skills
13-3. Administering a Retention Enema - Skills
13-4. Digital Removal of Stool - Skills
13-5. Applying an External Anal Pouch - Skills
13-6. Emptying and Changing an Ostomy Appliance - Skills
13-7. Irrigating a Colostomy - Skills
13-8. Inserting a Nasogastric Tube - Skills
13-9. Irrigating a Nasogastric Tube Connected to Suction - Skills
B - 13-1. Guidelines for Ostomy Care
F - 001-01. Two-piece appliances
F - 001-02. Gently press faceplate to skin
F - 001-03. Applying appliance pouch to faceplate
F - 001-04. Clamping tubing before removing
F - 001-05. Offering toilet tissue to patient on bedside commode
F - 002-01. Removing cap from prepackaged enema solution container
F - 002-02. Inserting tube into rectum, directing toward umbilicus
F - 002-03. Compressing container
F - 003-01. Inserting tube into rectum, directing toward umbilicus
F - 003-02. Compressing container
F - 004-01. Inserting lubricated forefinger of dominant hand into anal canal
F - 004-02. Gently working finger around to break up stool mass
F - 004-03. Cleaning anal area with washcloth and skin cleanser
F - 005-01. Removing paper backing from adhesive of rectal device
F - 005-02. Applying device over anal opening
F - 005-03. Attaching connector of fecal device to tubing of drainage bag
F - 005-04. Hanging drainage bag below level of patient
F - 006-01. Removing clamp, getting ready to empty pouch
F - 006-02. Emptying contents of appliance into a measuring device
F - 006-03. Wiping lower 2 inches of pouch with paper towel
F - 006-04. Gently removing appliance
F - 006-05. Using toilet tissue to remove excess stool from the stoma
F - 006-06. Assessing stoma and peristomal skin
F - 006-07. Using measurement guide to measure size of stoma
F - 006-08. Tracing the same-sized circle on back and center of skin barrier
F - 006-09. Cutting the opening 1/8 inch larger than stoma size
F - 006-10. Removing paper backing on faceplate
F - 006-11. Easing appliance over stoma
F - 006-12. Using clip to close bottom of appliance
F - 007-01. Irrigation sleeve and bag
F - 007-02. Positioning of irrigation sleeve on abdomen
F - 007-03. Colostomy irrigation
F - 008-01. Double-lumen nasogastric tube with a one-way antireflux valve in the airflow lumen
F - 008-02. Beginning insertion with patient positioned with head slightly flexed back
F - 008-03. Advancing tube after patient drops chin to chest and while swallowing
F - 008-04. Example of a commercially prepared securement device
F - 008-05. Making a 2-inch cut into a 4-inch strip of tape
F - 008-06. Applying tape to patient's nose
F - 008-07. Wrapping split ends around NG tube
F - 008-08. NG tube attached to wall suction
F - 008-09. Patient with Salem sump tube (NG) secured
F - 008-10. Example of a commercially prepared nasal bridle
F - 009-01. Preparing syringe with 30 mL of irrigation solution
F - 009-02. Clamping nasogastric tube while disconnecting
F - 009-03. Keeping both tubes upright to prevent leakage of gastric fluid
F - 009-04. Gently instilling irrigation
F - 010-01. Placing towel or disposable pad across patient's chest
F - 010-02. Flushing NG tube with 10-mL water
F - 010-03. Doubling tube on itself
F - 010-04. Measuring the amount of nasogastric drainage in collection device
Fundamental Reviews - 13-1. Anatomy of the Gastrointestinal Tract
Fundamental Reviews - 13-2. Factors that Affect Bowel Elimination
T - 13-1. Commonly Used Enema Solutions
14. Oxygenation
14. Oxygenation
14-1. Using a Pulse Oximeter - Skills
14-10. Suctioning an Endotracheal Tube: Closed System - Skills
14-11. Securing an Endotracheal Tube - Skills
14-12. Suctioning a Tracheostomy: Open System - Skills
14-13. Providing Care of a Tracheostomy Tube and Site - Skills
14-14. Providing Care of a Chest Drainage System - Skills
14-15. Assisting with Removal of a Chest Tube - Skills
14-16. Using a Manual Resuscitation Bag and Mask - Skills
14-2. Teaching a Patient to Use a Peak Flow Meter - Skills
14-3. Teaching a Patient to Use an Incentive Spirometer - Skills
14-4. Administering Oxygen by Nasal Cannula - Skills
14-5. Administering Oxygen by Mask - Skills
14-6. Caring for a Patient Receiving Noninvasive Continuous Positive Airway Pressure - Skills
14-7. Suctioning the Oropharyngeal and Nasopharyngeal Airways - Skills
14-8. Inserting an Oropharyngeal Airway - Skills
14-9. Suctioning an Endotracheal Tube: Open System - Skills
B - 14-1. Tips to Address Common Problems Patients Encounter When Using Cpap and Possible Interventions
B - 14-2. Methods to Determine Suction Catheter Depth
F - 001-01. Yankauer suction device
F - 001-02. Assessing pulse
F - 001-03. Assessing capillary refill
F - 001-04. Attaching probe to patient's finger
F - 001-05. Connecting sensor probe to unit
F - 001-06. Checking alarms
F - 001-07. Oximetry probe on infant's toe
F - 002-01. Example of a commercially available peak flow meter
F - 002-02. Patient placing meter in mouth
F - 002-03. Patient blowing out has hard and fast as they can in a single blow
F - 003-01. Measuring nasopharyngeal airway
F - 003-02. Lubricating nasopharyngeal airway
F - 003-03. Inserting nasopharyngeal airway
F - 003-04. Nasopharyngeal airway inserted until the rim is touching the naris
F - 004-01. Rotating inner cannula while stabilizing outer cannula
F - 004-02. Removing inner cannula for cleaning
F - 004-03. Using brush to clean inner cannula
F - 004-04. Replacing inner cannula
F - 004-05. Pulling tape through faceplate opening alongside old tie until ends are an even length
F - 004-06. Cleaning cannula, when indicated
F - 005-01. Types of oxygen masks
F - 005-02. Connecting face mask to oxygen source
F - 005-03. Allowing oxygen to fill bag
F - 005-04. Applying face mask over nose and mouth
F - 005-05. Adjusting elastic straps
F - 005-06. Adjusting flow rate
F - 006-01. Examples of CPAP face mask/nosepiece
F - 006-02. Placing the CPAP machine on a stable surface near the bed
F - 006-03. Attaching the CPAP hose and mask/nosepiece
F - 006-04. CPAP mask/nosepiece properly fitted on the patient's face
F - 007-01. Adjusting wall suction
F - 007-02. Connecting suction catheter to tubing
F - 007-03. Dipping catheter into sterile saline
F - 007-04. Inserting catheter into naris
F - 007-05. Rotating the catheter as it is withdrawn to suction the nasopharynx
F - 007-06. Rinsing catheter
F - 008-01. Measuring for oropharyngeal airway
F - 008-02. Inserting airway with curved tip pointing toward the roof of the mouth
F - 008-03. Rotating the airway so the tip points down
F - 008-04. Auscultating breath sounds
F - 009-01. Turning suction unit to appropriate pressure
F - 009-02. Inserting suction catheter into endotracheal tube
F - 009-03. Withdrawing suction catheter and intermittently occluding Y-port with thumb to apply suction
F - 010-01. Closed suction device
F - 010-02. Turning suction device to appropriate pressure
F - 010-03. Grasping the catheter through the protective sheath and inserting into endotracheal tube
F - 010-04. Depressing suction button
F - 010-05. Removing suction catheter by pulling back into sheath
F - 011-01. Commercially available endotracheal tube holder
F - 011-02. Ensuring endotracheal tube is stabilized and removing old tape
F - 011-03. Moving endotracheal tube to other side of mouth
F - 011-04. Removing excess adhesive on cheeks from tape
F - 011-05. Placing the top-half of the tape under the patient's nose
F - 011-06. Applying pressure to the tape on the endotracheal tube to ensure the tape is secure
F - 012-01. Patient in semi-Fowler position
F - 012-02. Turning suction unit to appropriate pressure
F - 012-03. Putting on goggles and mask
F - 012-04. Connecting suction catheter to suction tubing
F - 012-05. Moistening catheter in saline solution
F - 012-06. Occluding Y-port to check for proper suction
F - 012-07. Intermittently occluding the Y-port on the catheter to apply suction while withdrawing catheter
F - 012-08. Removing gloves while keeping catheter inside
F - 013-01. Carefully opening package with new disposable inner cannula
F - 013-02. Releasing lock on inner cannula
F - 013-03. Locking new inner cannula in place
F - 013-04. Cleaning from stoma site, outward
F - 013-05. Securing tabs on tracheostomy holder
F - 013-06. Reapplying oxygen source
F - 014-01. Chest drainage system
F - 014-02. Assessing dressing at chest tube insertion site
F - 014-03. Drainage marked on device
F - 014-04. Padded clamps on chest tube
F - 014-05. Unrolling foam tape
F - 014-06. Carefully cutting foam tape
F - 014-07. Inserting the end of the new drainage system into the chest tube
F - 014-08. Heimlich valve connected to chest tube
F - 016-01. Connecting mask to bag-valve device
F - 016-02. Connecting oxygen tubing on bag to oxygen source
F - 016-03. Squeezing the resuscitation bag with mask sealed on face
Fundamental Reviews - 14-1. Factors Affecting Oxygenation and Perfusion
T - 14-1. Oxygen Delivery Systems
T - 14-2. Comparison of Chest Drainage Systems
15. Perfusion and Cardiovascular Care
15. Perfusion and Cardiovascular Care
15-1. Performing Cardiopulmonary Resuscitation - Skills
15-2. Performing Emergency Automated External Defibrillation - Skills
15-3. Performing Emergency Manual External Defibrillation (Asynchronous) - Skills
15-4. Obtaining an Electrocardiogram - Skills
15-5. Applying a Cardiac Monitor - Skills
15-6. Using a Transcutaneous (External) Pacemaker - Skills
15-7. Removing a Peripheral Arterial Catheter - Skills
B - 15-1. Special Situations Related to Automated External Defibrillation
B - 15-2. Electrocardiograph Complex
F - 001-01. Using correct body alignment for chest compressions
F - 001-02. Alternate hand position for chest compressions
F - 001-03. Using the head tilt-chin lift method to open the airway
F - 001-04. Using the jaw-thrust maneuver to open the airway
F - 001-05. A. Using a one-way valve mask.B. Using a handheld resuscitation bag
F - 001-06. Recovery position
F - 002-01. Automated external defibrillator (AED)
F - 002-02. AED electrode pad placement
F - 002-03. Stating a âClear the patientâ message
F - 003-01. External defibrillator
F - 003-02. Anterolateral placement of self-adhering electrode pads
F - 003-03. Anteroposterior placement of self-adhering electrode pads
F - 004-01. Electrocardiogram (waveform) strip
F - 004-02. 12-lead ECG lead placement
F - 004-03. Applying limb electrode
F - 004-04. A. Applying chest electrode.B. Applying chest lead
F - 004-05. Completed application of 12-lead ECG
F - 004-06. Observing tracing quality
F - 004-07. 12-Lead ECG configuration
F - 005-01. Electrode positions for 3- (left) and 5-lead (right) systems
F - 005-02. Applying the electrodes
F - 006-01. Transcutaneous pacemaker pads in place
F - 015-01. Cardiac anatomy
F - 015-02. Cardiac conduction system
F - 015-03. Cardiac landmarks: Reference lines
Fundamental Reviews - 15-1. Electrical Therapy Devices
16. Fluid, Electrolyte, and Acid-Base Balance
16. Fluid, Electrolyte, and Acid-Base Balance
16-1. Initiating a Peripheral Intravenous Catheter Access and Intravenous Infusion - Skills
16-10. Removing a Peripherally Inserted Central Catheter - Skills
16-2. Monitoring an Intravenous Site and Infusion - Skills
16-3. Changing an Intravenous Solution Container and Administration Set - Skills
16-4. Changing a Peripheral Venous Access Device Site Dressing - Skills
16-5. Capping for Intermittent Use and Flushing a Peripheral Venous Access Device - Skills
16-6. Administering a Blood Transfusion - Skills
16-7. Changing the Dressing and Flushing Central Venous Access Devices - Skills
16-8. Accessing an Implanted Port - Skills
16-9. Deaccessing an Implanted Port - Skills
B - 16-1. Regulating Intravenous Flow Rate
B - 16-2. Phlebitis Scale
B - 16-3. Recommended Administration Set Change Schedule
B - 16-4. Needleless Connectors
F - 001-01. Infusion sites
F - 001-02. Basic administration set for gravity/free-flow infusion
F - 001-03. Closing clamp on administration set
F - 001-04. Inserting administration set spike into entry site of IV fluid container
F - 001-05. Squeezing drip chamber to fill at least halfway
F - 001-06. Priming administration set
F - 001-07. Inserting administration set into electronic infusion device
F - 001-08. Applying tourniquet
F - 001-09. Stretching skin taut and inserting needle
F - 001-10. Venous access site with labeled dressing
F - 001-11. Inserting administration set into the end cap of venous access device
F - 001-12. Initiating IV fluid infusion
F - 001-13. Inspecting insertion site
F - 001-14. Attaching a passive disinfection cap to each access site
F - 002-01. Checking infusion device settings
F - 002-02. Checking drip chamber and timing drops
F - 002-03. Checking tubing for anything that might interfere with flow rate
F - 002-04. Inspecting IV site
F - 003-01. Scanning the bar code on container
F - 003-02. Removing administration spike from old IV fluid container
F - 003-03. Inserting administration set spike into entry port of new IV fluid container
F - 003-04. Reopening clamp and adjusting flow rate
F - 003-05. Inserting the end of the administration set into the needleless connector or end cap
F - 003-06. Making sure clamp is open on new tubing, with short extension tubing taped in place
F - 004-01. Carefully removing old dressing
F - 004-02. Cleansing the site with an antiseptic solution
F - 004-03. Applying skin protectant to site
F - 004-04. Applying transparent dressing to site
F - 004-05. Site dressing with label and anchored tubing
F - 005-01. Using an antimicrobial swab to disinfect the connection surface and sides of the needleless connector or end cap on the extension tubing
F - 005-02. Flushing venous access device
F - 006-01. Squeezing the drip chamber to saturate the filter
F - 006-02. Assessing vital signs after 15 minutes
F - 007-01. Placement of peripherally inserted central catheter (PICC)
F - 007-02. Placement of triple-lumen, nontunneled percutaneous central venous catheter
F - 007-03. Tunneled percutaneous central venous catheter
F - 007-04. Inspecting CVAD insertion site
F - 007-05. Applying antimicrobial dressing
F - 007-06. Applying site dressing
F - 007-07. Attaching a passive disinfection cap to each access site
F - 008-01. An implanted port with catheter inserted in subclavian vein and noncoring needle inserted into port
F - 008-02. Stabilizing port with nondominant hand
F - 008-03. Inserting needle through skin into port
F - 008-04. Noncoring (Huber) needle in place
F - 008-05. Aspirating for blood return
F - 008-06. Removing gripper from needle
F - 008-07. Attaching a passive disinfection cap
F - 009-01. Flushing port with saline
F - 009-02. Pulling needle from port with autoengagement of needle guard
F - 010-01. Removing PICC in small increments, using a smooth and constant motion
Fundamental Reviews - 16-1. Average Adult Daily Fluid Sources and Losses
Fundamental Reviews - 16-2. Selected IV Solutions
Fundamental Reviews - 16-3. Complications Associated with Intravenous Infusions
T - 16-1. Blood Products
T - 16-2. Transfusion Reactions
17. Neurologic Care
17. Neurologic Care
17-1. Applying a Two-Piece Cervical Collar - Skills
17-2. Employing Seizure Precautions and Seizure Management - Skills
17-3. Caring for a Patient with a Halo External Fixation Device (Halo Traction) - Skills
17-4. Caring for a Patient with an External Ventriculostomy (Intraventricular Catheter-Closed Fluid-Filled System) - Skills
17-5. Caring for a Patient with a Fiberoptic Intracranial Catheter - Skills
B - 17-1. Signs and Symptoms of Increased Intracranial Pressure in Adults
B - 17-2. Interpreting ICP Waveforms
F - 001-01. Cervical collar in place
F - 001-02. Sliding the flattened back portion of the collar under the patient's head
F - 001-03. Securing the front and back halves of the cervical collar
F - 002-01. Protecting patient from injury
F - 003-01. Examining halo vest for stability, secure connections, and positioning
F - 003-02. Cleansing pin sites
F - 004-01. Transducer leveled with tragus
F - 004-02. Sutured external ventriculostomy catheter
F - 005-01. Fiberoptic catheter in ventricle
Fundamental Reviews - 17-1. Fundamental Review 17-1
Fundamental Reviews - 17-2. Brief Neurologic Exam
Fundamental Reviews - 17-3. Glasgow Coma Scale
Fundamental Reviews - 17-4. The Full Outline of Unresponsiveness (Four)
18. Laboratory Specimen Collection
18. Laboratory Specimen Collection
18-1. Obtaining a Nasal Swab - Skills
18-10. Obtaining a Venous Blood Specimen for Culture and Sensitivity - Skills
18-11. Obtaining an Arterial Blood Specimen for Blood Gas Analysis - Skills
18-12. Obtaining a Blood Sample From a Central Venous Access Device - Skills
18-13. Obtaining an Arterial Blood Sample From an Arterial Catheter - Skills
18-2. Obtaining a Nasopharyngeal Swab - Skills
18-3. Collecting a Sputum Specimen for Culture - Skills
18-4. Collecting a Urine Specimen (Clean Catch, Midstream) - Skills
18-5. Obtaining a Urine Specimen From an Indwelling Urinary Catheter - Skills
18-6. Testing Stool for Occult Blood - Skills
18-7. Collecting a Stool Specimen - Skills
18-8. Obtaining a Capillary Blood Sample for Glucose Testing - Skills
18-9. Using Venipuncture to Collect a Venous Blood Sample - Skills
B - 18-1. Characteristics of Sputum and Potential Causes
F - 001-01. Suction trap for sputum collection
F - 002-01. A. Observing the nasopharynx and inserting swab.B. Nasopharyngeal swab inserted to the posterior wall of the nasopharynx
F - 003-01. Instructing patient to expectorate into the collection container
F - 003-02. Labeling specimen container
F - 003-03. Placing specimen container in biohazard bag
F - 004-01. Instructing patient about urine collection procedure
F - 004-02. Cleaning female perineum
F - 004-03. Cleaning male perineum
F - 005-01. Attaching the syringe to the needleless aspiration port and slowly withdrawing urine specimen
F - 006-01. Using a wooden applicator to transfer stool specimen to window of testing card
F - 006-02. Applying developer to card windows
F - 006-03. Observing windows on card for blue areas
F - 006-04. Observing for pink color on test (T) line and the control (C) line
F - 007-01. Plastic specimen collection receptacle in toilet to catch stool
F - 007-02. Transferring stool to specimen container
F - 007-03. Placing specimen container in biohazard bag
F - 008-01. Piercing patient's finger with lancet
F - 008-02. Applying blood to test strip
F - 009-01. Blood vessels in the arm typically used for venipuncture
F - 009-02. Cleaning the patient's skin at the venipuncture site
F - 009-03. Reapplying the tourniquet
F - 009-04. Inserting the needle at a 15-degree angle, with the bevel up
F - 009-05. Observing blood flowing into the collection tube
F - 010-01. Applying the tourniquet
F - 010-02. Aligning the butterfly needle with the chosen vein
F - 010-03. Inserting the needle with the bevel up at a 15- to 30-degree angle
F - 010-04. Stabilizing the butterfly needle and pushing the Vacutainer onto the aerobic collection bottle, keeping the bottle upright while filling
F - 010-05. Placing a label on specimen container
F - 010-06. Placing specimen containers in biohazard bag
F - 011-01. Performing Allen's test
F - 011-02. Observing blood backflow into syringe
F - 012-01. Removing the passive disinfection cap or nonvented cap from the end of the lumen
F - 012-02. Inserting the flush syringe into the needleless connector
F - 012-03. Pulling back on the syringe to aspirate for positive blood return
F - 012-04. Connecting the needleless adapter of the Vacutainer to the connector or end cap on the CVAD lumen
F - 012-05. Inserting the blood sample tube to collect discard blood volume
F - 013-01. Pressure monitoring system
F - 013-02. Closed blood collection/withdrawal system
Fundamental Reviews - 18-1. Characteristics of Urine
Fundamental Reviews - 18-2. Characteristics of Stool
T - 18-1. Arterial Blood Gas: Normal Values
7. Hygiene
7. Hygiene
7-1. Assisting with a Shower or Tub Bath - Skills
7-10. Making an Unoccupied Bed - Skills
7-11. Making an Occupied Bed - Skills
7-2. Providing a Bed Bath - Skills
7-3. Assisting the Patient with Oral Care - Skills
7-4. Providing Oral Care for the Dependent Patient - Skills
7-5. Providing Denture Care - Skills
7-6. Removing Contact Lenses - Skills
7-7. Shampooing a Patient's Hair in Bed - Skills
7-8. Assisting the Patient to Shave - Skills
7-9. Providing Nail Care - Skills
B - 7-1. Meeting the Bathing Needs of Patients with Dementia
B - 7-2. Meeting the Oral Hygiene Needs of Patients with Cognitive Impairments
F - 001-01. Performing female perineal care
F - 001-02. Performing male perineal care
F - 002-01. Commercial self-contained bathing system
F - 002-02. Exposing the far arm and washing it
F - 002-03. Washing the abdomen, with perineal and chest areas covered
F - 002-04. Washing and drying far leg, keeping the other leg covered
F - 002-05. Washing the back
F - 003-01. Centering lens
F - 003-02. Gently pulling outer corner of eye toward ear
F - 003-03. Receiving lens as patient blinks
F - 003-04. Spreading eyelids
F - 003-05. Pressing lower lid up against bottom of lens
F - 003-06. Sliding lens out between lids
F - 004-01. Placing warmed shampoo cap on the patient's head
F - 004-02. Massaging the hair and scalp
F - 004-03. Using suction to remove excess fluid
F - 004-04. Example of a suction toothbrush
F - 005-01. Grasping side edge of sheet and lifting off the bed
F - 005-02. Laying sheet on top of bed to make triangular, flat fold
F - 005-03. Tucking the loose part of the sheet under the mattress
F - 005-04. Picking up the top of the triangular fold to place down over the side of the mattress
F - 005-05. Tucking the loose portion of triangular fold under mattress
F - 005-06. Tucking remaining sheet snugly under mattress
F - 006-01. Retracting lower lid with one hand and using pad of index finger of other hand to move lens down to the sclera
F - 006-02. Using the pads of thumb and index finger to grasp lens with a gentle pinching motion to remove it
F - 006-03. Storage cases are marked L and R, designating left and right lenses
F - 007-01. Placing protective pad under patient's head
F - 007-02. Placing patient's head on shampoo board
F - 007-03. Positioning drain container for shampoo board
F - 007-04. Pouring warm water over patient's head
F - 007-05. Rinsing shampoo from patient's head
F - 007-06. Patting patient's hair dry
F - 008-01. Applying shaving cream to face
F - 008-02. Shaving face
F - 008-03. Using a wet washcloth to remove remaining shaving cream
F - 009-01. Gently cleaning under nails
F - 009-02. Trimming straight across nails with clipper
F - 009-03. Gently pushing cuticles back off nail
F - 009-04. Drying hand thoroughly
F - 010-01. Bundling soiled linens in bottom sheet and holding them away from clothing
F - 010-02. Pushing the bottom sheet open to the center of the mattress
F - 010-03. Placing lifting/repositioning sheet on bed
F - 010-04. Mitering corner of top sheet and blanket
F - 010-05. Cuffing top linens
F - 011-01. Removing top linens from under bath blanket
F - 011-02. Moving soiled linen as close to patient as possible
F - 011-03. Pulling the bottom sheet over the corners at the head and foot of the mattress
F - 011-04. Pushing the bottom sheet toward the center of the bed, positioning it under old linens
F - 011-05. Tucking lifting/repositioning or friction-reducing sheet tightly
F - 011-06. Removing soiled bottom linens from other side of bed
F - 011-07. Removing bath blanket from under top linens
Fundamental Reviews - 7-1. General Skin Care Principles
T - 7-1. Cleaning and Skin Care Products
8. Skin Integrity and Wound Care
8. Skin Integrity and Wound Care
8-1. Preventing Pressure Injury - Skills
8-10. Removing Surgical Staples - Skills
8-11. Applying an External Heating Pad - Skills
8-12. Applying a Warm Compress - Skills
8-13. Assisting with a Sitz Bath - Skills
8-14. Applying Cold Therapy - Skills
8-2. Cleaning a Wound and Applying a Dressing (General Guidelines) - Skills
8-3. Performing Irrigation of a Wound - Skills
8-4. Collecting a Wound Culture - Skills
8-5. Caring for a Penrose Drain - Skills
8-6. Caring for a Jackson-Pratt Drain - Skills
8-7. Caring for a Hemovac Drain - Skills
8-8. Applying Negative-Pressure Wound Therapy - Skills
8-9. Removing Sutures - Skills
B - 8-1. Risk Factors Contributing to Development of Pressure Injuries
B - 8-2. Risk Factors for Medical Adhesive-Related Skin Injury
B - 8-3. Cleaning a Wound
F - 002-01. Loosening dressing tape or adhesive edge
F - 002-02. Noting characteristics of drainage on dressing that has been removed
F - 002-03. Cleaning the skin surrounding the wound
F - 002-04. Applying skin protectant to skin surrounding the wound
F - 002-05. Applying prescribed wound care product
F - 002-06. Applying cover dressing to site
F - 003-01. Drawing up solution into irrigation syringe
F - 003-02. Applying pressure to basin to form seal
F - 003-03. Irrigating wound with a stream of solution
F - 003-04. Drying around wound, not in wound, with gauze pad
F - 003-05. Applying wound contact material
F - 004-01. Checking culture label with the patient's identification band
F - 004-02. Removing cap from culture tube
F - 004-03. Rotating swab several times over wound surface
F - 004-04. Placing swab in culture tube
F - 004-05. Labeled culture tube in biohazard bag
F - 005-01. Cleaning drain site in circular motion toward periphery
F - 005-02. Placing pre-split dressing around Penrose drain
F - 005-03. Applying gauze pads over drain
F - 006-01. Jackson-Pratt drain
F - 006-02. Emptying contents of Jackson-Pratt drain into collection container
F - 006-03. Compressing Jackson-Pratt drain and replacing cap
F - 006-04. Compressed drain bulb
F - 007-01. Hemovac drain
F - 007-02. Emptying Hemovac drain into collection container
F - 007-03. Compressing Hemovac and securing cap
F - 008-01. Principles of negative pressure wound therapy
F - 008-02. Examples of components of an NPWT system
F - 008-03. Single-use NPWT (sNPWT)
F - 008-04. Cutting wound contact material (foam) to shape and measurement of wound
F - 008-05. Placing transparent adhesive drape to cover the wound
F - 008-06. Cutting a hole in the drape
F - 008-07. Applying the connecting pad over the hole
F - 008-08. Dressing is collapsed, shrinking to wound contact material and skin
F - 009-01. Incision with sutures
F - 009-02. Using forceps to pull up on a suture and cutting suture with sterile scissors
F - 009-03. Applying adhesive closure strips on incision
F - 010-01. Incision with surgical staples
F - 010-02. Grasping staple remover
F - 010-03. Firmly closing the staple remover, bending the staple in the middle, pulling the edges up out of the skin
F - 011-01. External heating pad electronic unit
F - 011-02. Attaching pad tubing to electronic unit tubing
F - 011-03. Applying heating pad to the prescribed area
F - 012-01. Applying compress to the intended area
F - 012-02. Covering site with clean dry bath towel
F - 013-01. Disposable sitz bath in place in toilet
F - 014-01. Filling ice bag with ice
F - 014-02. Covering ice bag with cover
F - 014-03. Positioning ice bag on the intended area and securing in place
Fundamental Reviews - 8-1. General Wound Assessment
Fundamental Reviews - 8-2. Measuring Wounds and Pressure Injuries
Fundamental Reviews - 8-3. Pressure Injury Stages
Fundamental Reviews - 8-4. Clean (Nonsterile) Technique and Wound Care
Fundamental Reviews - 8-5. Examples of Wound Dressings/Products
9. Activity
9. Activity
9-1. Assisting a Patient with Repositioning in Bed - Skills
9-10. Applying and Removing Graduated Compression Stockings - Skills
9-11. Applying Pneumatic Compression Devices - Skills
9-12. Applying a Continuous Passive Motion Device - Skills
9-13. Applying a Sling - Skills
9-14. Applying a Figure-Eight Bandage - Skills
9-15. Assisting with Cast Application - Skills
9-16. Caring for a Patient with a Cast - Skills
9-17. Applying Skin Traction and Caring for a Patient in Skin Traction - Skills
9-18. Caring for a Patient in Skeletal Traction - Skills
9-19. Caring for a Patient with an External Fixation Device - Skills
9-2. Transferring a Patient From the Bed to a Stretcher - Skills
9-3. Transferring a Patient From the Bed to a Chair - Skills
9-4. Transferring a Patient Using a Powered Full-Body Sling Lift - Skills
9-5. Providing Range-of-Motion Exercises - Skills
9-6. Assisting a Patient with Ambulation - Skills
9-7. Assisting a Patient with Ambulation Using a Walker - Skills
9-8. Assisting a Patient with Ambulation Using Crutches - Skills
9-9. Assisting a Patient with Ambulation Using a Cane - Skills
B - 9-1. Safe Handling of Patients with Dementia
B - 9-2. Principles of Effective Traction
F - 001-01. Example of an algorithm (assessment tool) to aid in decision making regarding safe patient handling and mobility to reposition a patient in bed
F - 001-02. Example of a repositioning sheet for use with a lift
F - 002-01. Example of an algorithm to aid in decision making regarding safe patient handling and mobility to transfer a patient from bed to stretcher
F - 002-02. Example of an air-assisted transfer device
F - 002-03. Using sheet to roll patient away from stretcher
F - 002-04. Positioning transfer device under patient
F - 002-05. Transferring patient onto stretcher
F - 002-06. Patient on stretcher
F - 003-01. Example of an algorithm to aid in decision making regarding safe patient handling and mobility to transfer a patient from bed to a chair
F - 003-02. Powered stand-assist device
F - 003-03. Example of a stand-assist aid
F - 003-04. Wrapping gait belt around patient's waist
F - 004-01. Rolling patient to one side and placing rolled sling underneath patient
F - 004-02. Rolling patient to opposite side and pulling sling under patient
F - 004-03. Widening stance of lift base
F - 004-04. Lowering lift arms
F - 004-05. Connecting lift straps
F - 004-06. Raising patient 6 inches above bed
F - 004-07. Positioning patient in sling over chair
F - 004-08. Lowering patient in sling into chair
F - 005-01. Moving patient's chin down to rest on chest
F - 005-02. Holding patient's head upright and centered
F - 005-03. Moving patient's head to one shoulder
F - 005-04. Moving patient's chin toward one shoulder
F - 005-05. Holding patient's arm at side
F - 005-06. Lifting patient's arm above patient's head
F - 005-07. Moving patient's arm laterally to an upright position above patient's head
F - 005-08. Moving arm across patient's body as far as possible
F - 005-09. Raising patient's arm until upper arm is in line with patient's shoulder, with elbow bent
F - 005-10. Bending patient's elbow, lower arm, and hand upward toward shoulder
F - 005-11. Rotating patient's lower arm and hand so palm is up
F - 005-12. Moving patient's hand downward toward inner aspect of forearm
F - 005-13. Returning hand to neutral position
F - 005-14. Bending patient's fingers to make a fist
F - 005-15. Straightening out patient's fingers
F - 005-16. Spreading patient's fingers apart
F - 005-17. Assisting patient to touch thumb to each finger on hand
F - 005-18. Extending and lifting patient's leg
F - 005-19. Lifting patient's leg laterally away from body (abduction)
F - 005-20. Returning leg back toward other leg and trying to extend it beyond midline, if possible
F - 005-21. Turning patient's foot and leg toward opposite leg to rotate it internally
F - 005-22. Turning patient's foot and leg outward, away from opposite leg, to rotate it externally
F - 005-23. Bending patient's leg and bringing heel toward back of leg
F - 005-24. Returning leg to a straight position
F - 005-25. At the ankle, moving patient's foot up and back until toes are upright
F - 005-26. Moving patient's foot with toes pointing down
F - 005-27. Turning sole toward midline
F - 005-28. Turning sole outward
F - 005-29. Curling patient's toes downward
F - 005-30. Straightening patient's toes
F - 005-31. Spreading patient's toes apart
F - 005-32. Bringing patient's toes together
F - 006-01. Example of an algorithm to aid in decision making regarding safe patient handling and mobility to assist a patient with ambulation
F - 006-02. Nurse positioned to side and slightly behind patient while walking, supporting patient by gait belt or waist
F - 007-01. Setting walker in front of a seated patient
F - 007-02. Assisting patient to walk with walker
F - 008-01. Assisting patient to stand erect facing forward in tripod position
F - 009-01. Nurse stands slightly behind patient
F - 010-01. Pulling graduated compression stocking inside-out
F - 010-02. Putting foot of stocking onto patient
F - 010-03. Ensuring heel is centered after stocking is on foot
F - 010-04. Pulling stocking up leg
F - 010-05. Pulling stocking up over thigh
F - 011-01. PCD machine at foot of bed
F - 011-02. Wrap the PCD sleeve snugly around the patient's leg
F - 011-03. PCD sleeves around patient's legs with sleeve tubing connected to device
F - 012-01. Placing patient's leg into CPM machine
F - 012-02. Adjusting footplate to maintain patient's foot in a neutral position
F - 012-03. Using two fingers to check fit between straps and leg
F - 013-01. Placing patient's arm into canvas sling
F - 013-02. Fastening the strap to the sling
F - 013-03. Placing padding between strap and patient's neck
F - 013-04. Patient with sling in place
F - 014-01. Wrapping bandage around patient's limb twice, below joint, to anchor it
F - 014-02. Using alternating ascending and descending turns to form a figure eight
F - 014-03. Overlapping each turn of bandage by one half to two thirds strip width
F - 014-04. Wrapping bandage around patient's limb twice, above joint, to anchor it
F - 015-01. Stockinette in place
F - 015-02. Casting material being applied
F - 015-03. Using palms to handle casted limb
F - 016-01. Assessing skin and neurovascular function, comparing with noncasted extremity
F - 016-02. Marking any breakthrough bleeding on cast, indicating date and time
F - 017-01. Applying traction boot with a compression stocking in place on leg
F - 017-02. Applying weight for skin traction
F - 017-03. Assessing distal pulses
F - 017-04. Assessing capillary refill
F - 017-05. Skin traction in place
F - 018-01. Skeletal traction in place, weights hanging freely
F - 018-02. Cleaning around pin sites with normal saline on an applicator
F - 019-01. External fixation device in place
F - 019-02. Cleaning around pin sites with normal saline on an applicator
Fundamental Reviews - 9-1. Effects of Immobility on the Body
Fundamental Reviews - 9-2. Guidelines for Safe Patient Handling and Movement
Fundamental Reviews - 9-3. Sphm Equipment and Devices
Fundamental Reviews - 9-4. Bedside Mobility Assessment Tool (Bmat 2.0)
III. Integrated Case Studies
Advanced Case Studies
Advanced Case Studies
Cole Mckean
Damian Wallace
George Patel, Gwen Galloway, Claudia Tran, and James White
Robert Espinoza
Basic Case Studies
Abigail Cantonelli
Basic Case Studies
Claudia Tran
James White
Joe Leroy
John Willis
Kate Townsend
Naomi Bell
Tiffany Jones
Tula Stillwater
III. Integrated Case Studies
Intermediate Case Studies
George Patel
Gwen Galloway
Intermediate Case Studies
Janice Romero
Jason Brown
Kent Clark
Lucille Howard
Olivia Greenbaum
Tula Stillwater
Victoria Holly
Appendix A.Guidelines for Delegation Decision Making
Appendix A.Guidelines for Delegation Decision Making
Appendix B.Equivalents
Appendix B.Equivalents
Appendix C.Adult Laboratory Values*
Appendix C.Adult Laboratory Values*
Front Matter
How to Use Taylor's Clinical Nursing Skills
Preface
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