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Davis's Guide to Clinical Nursing Skills
Assessing Wounds and Staging Pressure Ulcers
Table of Contents
Free Topics
Administering Intramuscular Injections by the Z-Track Method
Administering Subcutaneous Injections
Assessing Blood Pressure
Assessing Heart Rate
Assessing the Abdomen
Assessing the Nose and Sinuses
Blood Transfusion Therapy
Calculator - Norton Scale for Assessing Risk of Pressure Ulcers (Calculator)
Calculator - The Braden Scale for Predicting Pressure Sore Risk (Calculator)
Figure - Correct Position to Drain Right and Left Back
Figure - Egg-Crate Mattress
Inserting a Short-Term Peripheral Intravenous Catheter
Instilling Medications into the Ear
Managing Mechanical Ventilation (MV)
Oxygen Therapy
Parenteral Nutrition
Performing Nasopharyngeal and Nasotracheal Suctioning
References
Table - Medication Chart
Table - Support Groups for People with Ostomies
1. Basic Care
1. Hygiene
1-1. Giving a Complete Bed Bath
1-2. Providing Mouth Care
1-3. Performing Foot Care
1-4. Making an Occupied Bed
Hygiene
2. Infection Control
2-1. Handwashing
2-2. Donning Isolation Gown and Gloves
2-3. Droplet Precautions
2-4. Contact Precautions
2-5. Airborne Precautions
Infection Control
2. Assessment
3. Vital Signs
3-1. Assessing Body Temperature
3-2. Assessing Heart Rate
3-3. Assessing Respiratory Rate
3-4. Assessing Blood Pressure
F - 3-1. Types of Thermometers
F - 3-2 - A. Sites Commonly Used for Assessing Radial Pulse
F - 3-2 - B. Location of Apical Pulses for Adults and Children
F - 3-4. Site for Blood Pressure Cuff Placement
T - 3-1. Comparing Fahrenheit and Centigrade Temperatures
T - 3-3. Respiratory Rates and Rhythms
Vital Signs
4. Physical Assessment
4-1. Assessing the Eyes
4-10. Assessing the Neurologic System
4-11. Assessing the Skin, Hair and Scalp, and Nails
4-2. Assessing the Ears
4-3. Assessing the Nose and Sinuses
4-4. Assessing the Mouth and Pharynx
4-5. Assessing the Neck
4-6. Assessing the Thorax and Lungs
4-7. Assessing the Heart and Vascular System
4-8. Assessing the Musculoskeletal System
4-9. Assessing the Abdomen
F - 4-1. Ophthalmoscope
F - 4-10. Decorticate (A) and Decerebrate (B) Posturing
F - 4-2 - A. Otoscope
F - 4-2 - B. Tuning Fork
F - 4-2 - C. Otoscope in Sertion
F - 4-2 - D. Eardrum
F - 4-2 - E. Weber Test
F - 4-2 - F. Rinne Test
F - 4-3 - A. Inspect Nasal Cavity
F - 4-3 - B. Palpate Sinuses
F - 4-4. Inspecting the Pharynx
F - 4-5. Palpating the Thyroid
F - 4-6 - A. Example of Chest Palpation
F - 4-6 - B. Percussion Sequence
F - 4-6 - C. Auscultation Sequence
F - 4-7 - A. Sites for Cardiac Assessment; Palpating the Mitral Valve Area; Palpating the Pulmonic Area
F - 4-7 - B. Location of Jugular Veins
F - 4-9. Light Palpation
Physical Assessment
T - 4-6. Respiratory Rates for Children
3. Medication Administration
5. Oral and Topical Medications
5-1. Administering Oral Medications
5-2. Helping Patients with Self-Medication
5-3. Applying Medications to the Skin
5-4. Administering Eye Drops and Ointments
5-5. Instilling Medications into the Ear
5-6. Administering Medications via Metered-Dose Inhaler (MDI)
5-7. Administrating Medications via Rectal Suppository
F - 5-4 - A. Instilling Eye Drops
F - 5-4 - B. Instilling Eye Ointment
F - 5-5 - A. Method for Instilling Ear Medications
F - 5-6. Metered-Dose Inhaler
F - 5-7. Inserting a Rectal Suppository
Oral and Topical Medications
T - 5-2. Medication Chart
6. Parenteral Medications
6-1. Administering Subcutaneous Injections
6-2. Administering Intramuscular Injections
6-3. Administering Intramuscular Injections by the Z-Track Method
6-4. Administering Intradermal Injections
6-5. Administering Intravenous Medications by Intermittent Infusion Sets or Mini-Infusion Pumps
6-6. Administering Medication by Intravenous Bolus
6-7. Teaching Patients How to Administer Self-Injections
6-8. Mixing Two Types of Insulin
6-9. Using Patient-Controlled Analgesia (PCA) Infusion Devices
F - 6-1 - A. Subcutaneous Injection Sites
F - 6-1 - B. Pinch Tissue Between Thumb and Forefinger
F - 6-1 - C. Insert Needle at a 45-Degree or 90-Degree Angle
F - 6-2 - A. Locating the Ventrogluteal Site
F - 6-2 - B. Locating the Vastus Lateralis Injection Site
F - 6-2 - C. Locating the Dorsogluteal Injection Site
F - 6-2 - D. Locating the Deltoid Injection Site
F - 6-3 - A. Applying Traction
F - 6-3 - B. Medication is Sealed in the Muscle
F - 6-4 - A. Locations for Intradermal Injections
F - 6-4 - B. Angle of Needle for Insertion
F - 6-4 - C. Bleb Formation
F - 6-5 - A. Needleless Adapter Connection with Saline Flush
F - 6-5 - B. Insertion of Needle/Needleless Adapter into Heparin Lock
F - 6-5 - C. Use Port Closer to Insertion Site
F - 6-5 - D. Intravenous Medication Administration Using a Buretrol-Type Setup
F - 6-5 - E. For IVPB, Use Extender So Primary IV Bag Hangs Lower Than Secondary Bag
F - 6-6 - A. Clamp or Pinch IV Tubing Just above Port
F - 6-6 - B. Administer Medication in Increments According to Rate of Infusion
F - 6-8 - A. Mixing Two Kinds of Insulin in One Syringe
Parenteral Medications
4. Respiratory
10. Airway Suctioning
10-1. Inserting an Oral or Nasal Airway
10-2. Performing Oropharyngeal (Yankauer) Suctioning
10-3. Performing Nasopharyngeal and Nasotracheal Suctioning
10-4. Performing Endotracheal or Tracheostomy Tube Suctioning
Airway Suctioning
F - 10-1 - A. Oropharyngeal Airway in Place
F - 10-1 - B. A Nasopharyngeal Airway in Proper Position
F - 10-1 - C. Taping the Airway
F - 10-2 - A. Yankauer Suction Tube
F - 10-4 - A. Ambu Bag Connected to 100% Oxygen
F - 10-4 - B. Hold Suction Catheter with Dominant (Sterile) Hand
F - 10-4 - C. Collection of a Specimen from the Suction Pathway
F - 10-4 - D. Seal the Specimen Cup
T - 10-1A. Oral Airway Size in Children and Adults
T - 10-2A. Vacuum and Suction Settings
T - 10-3A. Suction Catheter Sizes
11. Lung Re-Expansion or Chest Drainage
11-1. Managing Chest Tube and Drainage Systems
11-2. Assisting with Chest Tube Removal
F - 11-1 - A. Bottle and Disposable Chest Drainage Systems
F - 11-1 - B. Dressing Application
F - 11-1 - C. Ensure Tubing is Free of Kinks
Lung Re-Expansion or Chest Drainage
7. Noninvasive Pulmonary Hygiene
7-1. Performing Postural Drainage
7-2. Teaching Controlled Coughing Techniques
F - 7-1 - A. Correct Position to Drain Right Posterior Segment
F - 7-1 - B. Correct Position to Drain Right Middle Lobe
F - 7-1 - C. Correct Position to Drain Lower Right and Left Lobes
F - 7-1 - D. Correct Position to Drain Right and Left Back
Noninvasive Pulmonary Hygiene
8. Oxygen Therapy
8-1. Administering Oxygen Therapy
8-2. Administering Oxygen Therapy to the Patient with an Artificial Airway
F - 8-1 - A. Oxygen-Delivery Systems
F - 8-1 - B. Oxygen Percentage Regular
F - 8-2 - A. Trach Collar
F - 8-2 - B. T-Piece
Oxygen Therapy
9. Ventilation Support
9-1. Managing Continuous Positive Airway Pressure (CPAP)
9-2. Managing Intermittent Positive Pressure Ventilation
9-3. Managing Mechanical Ventilation (MV)
9-4. Using an Ambu Manual Ventilator
9-5. Performing Endotracheal Tube Care
9-6. Performing Tracheostomy Care
9-7. Managing a Cuffed Endotracheal or Tracheostomy Tube
F - 9-1 - A. CPAP Mask
F - 9-2 - A. Pressure-Controlled Noninvasive Ventilator
F - 9-3 - A. Ambu Bags, Infant to Adult Sizes
F - 9-4 - A. Create a Good Seal
F - 9-6 - A. Clean Inner Cannula with Hydrogen Peroxide and Small Brush
F - 9-6 - B. Clean Stoma with Cotton-Tipped Swab
F - 9-6 - C. Securing Face Plate with Ties
F - 9-6 - D. Insert Clean Dressing Under Ties and Face Plate
Ventilation Support
5. Cardiovascular
12. Intravenous Fluid Therapy
12-1. Inserting a Short-Term Peripheral Intravenous Catheter
12-2. Inserting Peripheral Midline and Central Catheters (PICC)
12-3. Calculating and Regulating Intravenous Flow Rate
12-4. Changing Intravenous Site Dressings (Peripheral and Central)
12-5. Assisting with Percutaneous Central Line Placement
F - 12-1 - A. Pulling Skin Taut
F - 12-1 - B. Insert Needle at Correct Angle
F - 12-1 - C. Advance the Catheter
F - 12-1 - D. Removing the Needle
F - 12-1 - E. U Method
F - 12-1 - F. Chevron Method
F - 12-1 - G. Cover Site with Transparent Film
F - 12-2 - A. Midline Catheter
F - 12-2 - B. Peripheral Intravenous Central Catheters (PICCs)
F - 12-5 - A. Injection Ports of a Triple Lumen Catheter
F - 12-5 - B. Tunneled Catheter
F - 12-5 - C. Ports
Intravenous Fluid Therapy
T - 12-1A. Catheter Sizes and Uses
T - 12-5A. Types, Use, Advantages and Disadvantages of Central Catheters
13. Circulatory Maintenance
13-1. Caring for Vascular Access Devices
13-2. Applying Sequential Compression Devices
13-3. Applying Antiembolic Hose
13-4. Teaching Postoperative Leg Exercises
Circulatory Maintenance
14. Blood Transfusion Therapy
14-1. Transfusing Blood Products
14-2. Assisting with Autotransfusion
Blood Transfusion Therapy
6. Nutritional and Digestive
15. Oral and Enteric Nutrition
15-1. Administering Nasogastric, Nasoenteric, and Enteric Tube Feedings
15-2. Administering Medications Through a Feeding Tube
F - 15-1 - A. Continuous Tube Feeding Administered by Enteral Pump
F - 15-1 - B. Intermittent Feeding by Gravity
Oral and Enteric Nutrition
16. Parenteral Nutrition
16-1. Administering Total Parenteral Nutrition (TPN)
16-2. Administering Peripheral Partial Nutrition
16-3. Administering a Fat Emulsion (Lipids)
Parenteral Nutrition
17. Gastrointestinal Intubation
17-1. Inserting a Nasogastric Tube
17-2. Advancing a Nasoenteric Decompression Tube
F - 17-1 - A. Measuring Tube for Placement
F - 17-1 - B. Inserting Tube into a Patent Nostril
F - 17-1 - C. Secure Tube with Tape
Gastrointestinal Intubation
18. Bowel Elimination
18-1. Administering an Enema
18-2. Managing a Rectal Tube
18-3. Managing Ostomy Care
Bowel Elimination
F - 18-1 - A. Inserting the Enema Tube into the Rectum
F - 18-1 - B. Inserting Commercially Prepared Enema Tip into the Rectum
F - 18-3 - A. Remove Old Wafer from the Skin
F - 18-3 - B. Use of Stoma Measuring Guide
F - 18-3 - C. Center the Wafer over the Stoma
T - 18-3A. Support Groups for People with Ostomies
7. Renal and Urinary
19. Urinary Elimination
19-1. Inserting a Straight or Indwelling Catheter (Male and Female)
19-2. Performing Catheter Care
19-3. Applying a Urinary Incontinence Collection Device
19-4. Teaching Clean Intermittent Self-Catheterization
F - 19-1 - A. Draping the Patient
F - 19-1 - B. Cleansing the Urinary Meatus, Male Patient
F - 19-1 - C. Inserting a Catheter into the Urinary Meatus, Male Patient
F - 19-1 - D. Cleansing the Urinary Meatus, Female Patient
F - 19-1 - E. Inserting a Catheter into the Urinary Meatus, Female Patient
F - 19-3 - A. Placing the Penis Inside Urinary Incontinence Collection Device
Urinary Elimination
20. Bladder Irrigation and Function
20-1. Performing and Managing Bladder Irrigation Through a Three-Way Foley Catheter
20-2. Obtaining a Post-Void Residual Urine Volume
Bladder Irrigation and Function
F - 20-1 - A. Triple Lumen Catheter
F - 20-1 - B. Setup for Continuous Bladder Irrigation
8. Musculoskeletal
21. Body Alignment and Mechanics
21-1. Maintaining Proper Body Alignment
21-2. Performing Correct Lifting Techniques
Body Alignment and Mechanics
F - 21-1 - A. A Footboard is Placed at the End of the Bed to Prevent Foot Drop
F - 21-1 - B. Trochanter Roll Prevents External Rotation
F - 21-1 - C. The Oblique Position
F - 21-1 - D. Assisting Patient to Chair Using a Transfer Belt
F - 21-2. Wide Stance Lowers the Center of Gravity and is More Stable
22. Exercise and Ambulation
22-1. Performing Passive Range-of-Motion (ROM) Exercises
22-2. Teaching Isometric Exercises
22-3. Teaching the Patient to Crutch Walk or Use a Walker
Exercise and Ambulation
F - 22-1. Passive Range-of-motion Exercises
F - 22-3. Gait Patterns
T - 22-3A. Different Types of Gait Patterns
23. Transfer and Positioning
23-1. Moving and Positioning the Patient in Bed
23-2. Transferring a Patient from Bed to Wheelchair
23-3. Teaching Hip Precautions
F - 23-1 - A. Moving Patient Up in Bed (Two Nurses)
F - 23-1 - B. Turning a Patient in Bed
F - 23-3 - A. Abductor Pillow Prevents Hip Adduction
F - 23-3 - B. Hip Precautions, Hip Flexion
Transfer and Positioning
24. Orthopedic Interventions
24-1. Providing Cast Care
24-2. Managing Skin Traction
24-3. Managing Skeletal Traction
24-4. Applying a Moist Compress
24-5. Applying an Ice Bag, Ice Pack, or Collar
F - 24-1. Handle Wet Cast with Palms Only
F - 24-2 - A. Buck's Traction
F - 24-2 - B. Russell's Traction
F - 24-3 - A. Balanced Suspension and Skeletal Traction for Femur
Orthopedic Interventions
25. Beds, Frames, and Mattresses
25-1. Placing the Patient on a Specialty Surface
25-2. Placing the Patient on an Air-Suspension or Air-Fluidized Bed
Beds, Frames, and Mattresses
F - 25-1. Egg-Crate Mattress
9. Integumentary System and Wound Care
26. Pressure Ulcers
26-1. Assessing Pressure Ulcer Risk
26-2. Implementing Pressure-Ulcer Prevention Strategies
26-3. Assessing Wounds and Staging Pressure Ulcers
F - 26-1 - A. Norton Scale for Assessing Risk of Pressure Ulcers
F - 26-1 - B. The Braden Scale for Predicting Pressure Sore Risk
F - 26-3. Pressure Sore Stages
Pressure Ulcers
27. Wound Care
27-1. Applying a Pressure Bandage
27-2. Administering a Sitz Bath
27-3. Performing Wound Irrigation
27-4. Managing Wound Drainage
27-5. Teaching Self-Management of Wound-Drainage Devices
27-6. Applying Wound Dressings
27-7. Applying and Managing a V.A.C. ATS(TM) System
F - 27-3. Direct Stream of Irrigant to All Areas of the Wound
F - 27-5. Teach Patient to Carefully Dry Periwound Edges
F - 27-6 - A. Place Moistened Gauze in Wound Cavity While Avoiding Wound Edges
F - 27-6 - B. Take Care to Avoid Creasing Film
F - 27-6 - C. Apply Hydrocolloid Dressing
F - 27-7 - A. Foam Sponge, Drapes, and Suction Wafer
F - 27-7 - B. Cut Foam to Fit into the Wound Bed
F - 27-7 - C. Cut Hole in Drape Film over the Foam Sponge
F - 27-7 - D. Apply T.R.A.C. over the Cutout, Opening in the Drape
F - 27-7 - E. Observe âPruningâ of the Foam, and Drape Dressing after Suction is Applied
Wound Care
10. Specimen Collection
28. Collecting Blood Samples
28-1. Performing Venipuncture
28-2. Obtaining a Blood Glucose Level by Finger Stick
28-3. Obtaining a Specimen for Arterial Blood Gas Analysis
Collecting Blood Samples
F - 28-2 - A. Proper Position of Lancet
F - 28-2 - B. Apply Blood Drop to Reagent
29. Collecting Urine Samples
29-1. Collecting a Midstream Urine Specimen
29-2. Collecting a Timed (24-Hour) Urine Specimen
29-3. Collecting a Sterile Urine Specimen from an Indwelling Catheter
29-4. Measuring Specific Gravity of Urine
Collecting Urine Samples
F - 29-3. Obtaining a Sterile Urine Specimen from an Indwelling Catheter
30. Collecting Other Specimens
30-1. Collecting a Nose or Throat Specimen for Culture
30-2. Collecting a Sputum Specimen
30-3. Obtaining a Wound Drainage Specimen
Collecting Other Specimens
F - 30-2 - A. Attach Suction Tube to Specimen Container
F - 30-2 - B. Obtaining a Sterile Urine Specimen from an Indwelling Catheter
F - 30-3. Rotate Cotton Swab in Wound Drainage
References
References
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