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Nurses' Guide to Clinical Procedures
Following the Nursing Process (Preparing a Plan of Care)
Table of Contents
Free Topics
1.1 Using Principles of Body Mechanics and Ergonomic Safety
1.2 Infection Control in the Home (Including Teaching Points)
1.3 Using Principles of Surgical Asepsis
10.1 Administering Heat Therapy: Aquathermia Pad
10.5 Administering a Sitz Bath
11.3 Changing Sterile and Nonsterile Dressings
2.1 Establishing a Nurse—Client Relationship
2.3 Preparing a Shift Report (Interdisciplinary Information Exchange)
2.3 Special Considerations when Communicating with Potentially Violentchr(133)
2.5 Charting/Documenting (Nurses' Progress Report)
3.5 Assessing Pain
4.8 Shaving a Client
5.17 Administering Intermittent Intravenous Medications
5.18 Administering Medication by Nasogastric Tube
5.2 Administering Eye (Ophthalmic) Drops
5.20 Administering Vaginal Medication
5.4 Administering Nasal Medication
5.8 Preparing Medication From a Vial
6.12 Managing a Tracheostomy/Endotracheal Tube Cuff
6.15 Obtaining Pulse Oximetry
6.8 Suctioning an Oral Airway
7.1 Managing Intake and Output (I&O)
7.19 Managing a Gastrostomy/Jejunostomy Tube
7.20 Managing Enteral Tube Feeding
8.12 Managing Peritoneal Dialysis
8.2 Collecting a Timed Urine Specimen
9.10 Providing Residual Limb Care Following Amputation
Acknowledgments
Contributors
Dedication
Figure 1.1
Figure 1.5
Figure 1.6
Figure 3.1
Figure 3.11
Figure 3.3
Figure 3.5
Figure 4.2
Figure 4.4
Figure 4.6
Figure 5.1
Figure 5.14C
Figure 5.19
Figure 5.23
Figure 6.2I
Figure 6.3
Figure 6.5
Figure 6.7
Guidelines for Preparing Various Forms of Medication
Nurses' Guide to Clinical Procedures
Preface
Section 2.5
Section 3.7
Section 3.8
Section 5.11
Section 5.14
Section 5.3
Section 5.9
Section 6.1
Section 6.3
Safety, Asepsis, and Infection Control
1.1 Using Principles of Body Mechanics and Ergonomic Safety
1.2 Using Principles of Medical Asepsis
1.3 Using Principles of Surgical Asepsis
1.4 Using Precaution (Isolation) Techniques: Infection Prevention
1.5 Disposing of Biohazardous Waste
1.6 Using Protective Devices: Limb and Body Restraints
Display(s)
1.1 Hand Hygiene
1.2 Infection Control in the Home (Including Teaching Points)
1.3 Injection Prevention: Standard and Expanded Precautions
Figure(s)
Figure 1.1
Figure 1.2
Figure 1.3
Figure 1.4
Figure 1.5
Figure 1.6
Overview
Sample Documentation
Section 1.1
Section 1.2
Section 1.3
Section 1.4
Section 1.6
Documenting and Reporting
2.1 Establishing a Nurse—Client Relationship
2.2 Providing Client and Family Education
2.3 Preparing a Shift Report (Interdisciplinary Information Exchange)
2.4 Following the Nursing Process (Preparing a Plan of Care)
2.5 Charting/Documenting (Nurses' Progress Report)
2.6 Reporting Incidents (Variance or Unusual Occurrence Reporting)
Display(s)
2.1 Barriers to Therapeutic Communication
2.2 Considerations for Interactions with Special Clients/Families
2.3 Special Considerations when Communicating with Potentially Violentchr(133)
2.4 Preparation Guide for Development of a Teaching Plan
2.5 Report FormatâSummary
2.6 The Nursing Process
2.7 Writing Goals
Overview
Sample Documentation
Section 2.1
Section 2.2
Section 2.3
Section 2.5
Section 2.6
Table(s)
Guidelines for Initial Assessment Notes
Essential Assessment Components
3.1 Measuring Electronic Vital Signs
3.2 Palpating Blood Pressure
3.3 Obtaining Doppler Pulse
3.4 Measuring Apical—Radial Pulse
3.5 Assessing Pain
3.6 Obtaining Weight with a Sling Scale
3.7 Obtaining Weight with Standard Scale (Standing, Chair)
3.8 Performing Basic Health Assessment
Figure(s)
Figure 3.1
Figure 3.10
Figure 3.11
Figure 3.12
Figure 3.2
Figure 3.3
Figure 3.4
Figure 3.5
Figure 3.6
Figure 3.7
Figure 3.8
Figure 3.9
Overview
Sample Documentation
Section 3.1
Section 3.2
Section 3.3
Section 3.4
Section 3.5
Section 3.6
Section 3.7
Section 3.8
Hygiene
4.1 Providing a Therapeutic Back Massage
4.2 Preparing a Bed
4.3 Providing Hair Care
4.4 Shampooing a Bedridden Client
4.5 Providing Oral Care: Brushing the Client's Teeth
4.6 Performing Denture Care
4.7 Caring for Contact Lenses and Artificial Eyes
4.8 Shaving a Client
Figure(s)
Figure 4.1
Figure 4.2
Figure 4.3
Figure 4.4
Figure 4.5
Figure 4.6
Overview
Sample Documentation
Section 4.1
Section 4.2
Section 4.3
Section 4.4
Section 4.5
Section 4.6
Section 4.7
Section 4.8
Medication Administration
5.1 Using Principles of Medication Administration
5.10 Administering Medication with the Needleless System
5.11 Mixing Medications
5.12 Administering Intradermal Medications
5.13 Administering Subcutaneous Medications
5.14 Using a Continuous Subcutaneous Insulin Pump
5.15 Administering Intramuscular Medications
5.16 Administering a Z-Track Injection
5.17 Administering Intermittent Intravenous Medications
5.18 Administering Medication by Nasogastric Tube
5.19 Administering Rectal Medication
5.2 Administering Eye (Ophthalmic) Drops
5.20 Administering Vaginal Medication
5.21 Applying Topical Medications
5.3 Administering Ear (Otic) Drops
5.4 Administering Nasal Medication
5.5 Administering Nebulizer Medication
5.6 Administering Oral Medication
5.7 Administering Buccal and Sublingual Medication
5.8 Preparing Medication From a Vial
5.9 Preparing Medication From an Ampule
Display(s)
5.1 Principles of Management, Storage, and Disposal of Medicationschr(133)
5.2 Methods of Dosage Calculation
Figure(s)
Figure 5.1
Figure 5.10
Figure 5.11
Figure 5.12
Figure 5.13
Figure 5.14A
Figure 5.14B
Figure 5.14C
Figure 5.14D
Figure 5.15
Figure 5.16
Figure 5.17
Figure 5.18
Figure 5.19
Figure 5.2
Figure 5.20
Figure 5.21
Figure 5.22
Figure 5.23
Figure 5.24
Figure 5.25
Figure 5.26
Figure 5.27
Figure 5.28
Figure 5.29
Figure 5.3
Figure 5.4
Figure 5.5
Figure 5.6
Figure 5.7
Figure 5.8
Figure 5.9
Overview
Sample Documentation
Section 5.1
Section 5.10
Section 5.11
Section 5.12
Section 5.13
Section 5.14
Section 5.15
Section 5.16
Section 5.17
Section 5.18
Section 5.19
Section 5.2
Section 5.20
Section 5.21
Section 5.3
Section 5.4
Section 5.5
Section 5.6
Section 5.7
Section 5.8
Section 5.9
Table(s)
Guidelines for Preparing Various Forms of Medication
Oxygenation
6.1 Chest Drainage System Preparation
6.10 Suctioning and Maintaining an Endotracheal Tube
6.11 Caring for a Tracheostomy (Suctioning, Cleaning, and Changing
6.12 Managing a Tracheostomy/Endotracheal Tube Cuff
6.13 Capping a Tracheostomy Tube
6.14 Collecting a Suctioned Sputum Specimen
6.15 Obtaining Pulse Oximetry
6.16 Maintaining Mechanical Ventilation
6.17 Using Incentive Spirometry
6.2 Maintaining a Chest Tube
6.3 Performing Autotransfusion/Reinfusion of Chest Tube Drainage
6.4 Performing Chest Physiotherapy: Postural Drainage, Chest Percussion
6.5 Applying a Nasal Cannula/Face Mask
6.6 Inserting an Oral Airway
6.7 Inserting and Maintaining a Nasal Airway
6.8 Suctioning an Oral Airway
6.9 Performing Nasopharyngeal/Nasotracheal Suctioning
Figure(s)
Figure 6.10
Figure 6.11
Figure 6.12
Figure 6.13
Figure 6.14
Figure 6.15
Figure 6.16
Figure 6.17
Figure 6.18
Figure 6.19
Figure 6.1A
Figure 6.1B
Figure 6.20
Figure 6.21
Figure 6.22
Figure 6.23
Figure 6.24
Figure 6.25
Figure 6.26
Figure 6.27
Figure 6.2A
Figure 6.2B
Figure 6.2C
Figure 6.2D
Figure 6.2E
Figure 6.2F
Figure 6.2G
Figure 6.2H
Figure 6.2I
Figure 6.2J
Figure 6.3
Figure 6.4
Figure 6.5
Figure 6.6
Figure 6.7
Figure 6.8
Figure 6.9
Overview
Sample Documentation
Section 6.1
Section 6.10
Section 6.11
Section 6.12
Section 6.13
Section 6.14
Section 6.15
Section 6.16
Section 6.17
Section 6.3
Section 6.4
Section 6.5
Section 6.6
Section 6.7
Section 6.8
Section 6.9
Table(s)
Modes of Ventilation
Ventilator Alarms
Fluids and Nutrition
7.1 Managing Intake and Output (I&O)
7.10 Converting to an IV Lock
7.11 Assisting with Inserting and Maintaining a Central Venous Line
7.12 Managing Total Parenteral Nutrition
7.13 Managing a Pulmonary Artery Catheter
7.14 Managing an Arterial Line
7.15 Managing Blood Transfusion
7.16 Inserting a Nasogastric/Nasointestinal Tube
7.17 Maintaining a Nasogastric Tube
7.18 Discontinuing a Nasogastric Tube
7.19 Managing a Gastrostomy/Jejunostomy Tube
7.2 Testing Capillary Blood Glucose
7.20 Managing Enteral Tube Feeding
7.3 Performing Venipuncture for Blood Specimen
7.4 Selecting a Vein for IV Therapy
7.5 Preparing Solutions for IV Therapy
7.6 Inserting a Catheter/IV Lock for IV Therapy
7.7 Calculating Flow Rate
7.8 Regulating IV Fluid
7.9 Changing IV Tubing and Dressings
Display(s)
7.1 IV Calculations
Figure(s)
Figure 7.1
Figure 7.10
Figure 7.11A
Figure 7.11B
Figure 7.12A
Figure 7.12B
Figure 7.13
Figure 7.14
Figure 7.15
Figure 7.16
Figure 7.17
Figure 7.18
Figure 7.19
Figure 7.2
Figure 7.20
Figure 7.21
Figure 7.22
Figure 7.23
Figure 7.24
Figure 7.25
Figure 7.26
Figure 7.3
Figure 7.4
Figure 7.5
Figure 7.6
Figure 7.7
Figure 7.8
Figure 7.9
Overview
Sample Documentation
Section 7.1
Section 7.11
Section 7.12
Section 7.13
Section 7.14
Section 7.15
Section 7.16
Section 7.17
Section 7.19
Section 7.2
Section 7.20
Section 7.3
Section 7.4
Section 7.7
Section 7.9
Table(s)
Flow Rates for Intravenous Infusions
Transfusion Reactions
Troubleshooting PA Catheter Problems
Troubleshooting Tips for IV Infusion Management
Elimination
8.1 Collecting a Midstream Urine Specimen
8.10 Scanning the Bladder
8.11 Caring for a Hemodialysis Shunt, Graft, and Fistula
8.12 Managing Peritoneal Dialysis
8.13 Caring for Nephrostomy Tubes
8.14 Removing Fecal Impaction
8.15 Administering an Enema
8.16 Applying an Ostomy Pouch and Wafer
8.17 Evacuating and Cleaning an Ostomy Pouch
8.18 Caring for an Ostomy Stoma
8.19 Irrigating a Colostomy
8.2 Collecting a Timed Urine Specimen
8.20 Testing Stool for Occult Blood with Hemoccult Slide
8.3 Collecting a Urine Specimen From an Indwelling Catheter
8.4 Applying a Condom Catheter
8.5 Performing a Male Catheterization (Urethral/Straight Cath and
8.6 Performing a Female Catheterization (Urethral/Straight Cath
8.7 Caring for a Urinary Catheter
8.8 Removing an Indwelling Catheter
8.9 Irrigating a Bladder/Catheter
Figure(s)
Figure 8.1
Figure 8.10
Figure 8.11
Figure 8.12A
Figure 8.12B
Figure 8.13
Figure 8.14
Figure 8.15
Figure 8.16
Figure 8.17
Figure 8.18
Figure 8.19
Figure 8.20
Figure 8.21
Figure 8.22
Figure 8.2A
Figure 8.2B
Figure 8.3
Figure 8.4
Figure 8.5
Figure 8.6
Figure 8.7A
Figure 8.7B
Figure 8.8
Figure 8.9
Overview
Sample Documentation
Section 8.1
Section 8.10
Section 8.11
Section 8.12
Section 8.13
Section 8.14
Section 8.15
Section 8.16
Section 8.17
Section 8.18
Section 8.19
Section 8.2
Section 8.20
Section 8.3
Section 8.4
Section 8.5
Section 8.6
Section 8.7
Section 8.8
Section 8.9
Activity and Mobility
9.1 Positioning the Body
9.10 Providing Residual Limb Care Following Amputation
9.11 Using a Hoyer Lift
9.2 Positioning the Body via Logrolling
9.3 Performing Range-of-Motion Exercises
9.4 Supporting Axillary Crutch Walking
9.5 Caring for a Cast
9.6 Maintaining Traction
9.7 Applying Antiembolism Hose
9.8 Applying a Pneumatic Compression Device
9.9 Using a Continuous Passive Motion (CPM) Device
Display(s)
9.1 Techniques for General Crutch-Walking Maneuvers
Figure(s)
Figure 9.10
Figure 9.11
Figure 9.12
Figure 9.13
Figure 9.14
Figure 9.15
Figure 9.16
Figure 9.17
Figure 9.18
Figure 9.19
Figure 9.1A
Figure 9.1B
Figure 9.1C
Figure 9.1D
Figure 9.1E
Figure 9.1F
Figure 9.1G
Figure 9.2
Figure 9.20
Figure 9.21
Figure 9.22A
Figure 9.22B
Figure 9.23
Figure 9.3A
Figure 9.3B
Figure 9.3C
Figure 9.3D
Figure 9.3E
Figure 9.3F
Figure 9.3G
Figure 9.3H
Figure 9.3I
Figure 9.3J
Figure 9.3K
Figure 9.3L
Figure 9.3M
Figure 9.3N
Figure 9.3O
Figure 9.3P
Figure 9.3Q
Figure 9.3R
Figure 9.3S
Figure 9.3T
Figure 9.4
Figure 9.5
Figure 9.6
Figure 9.7
Figure 9.8
Figure 9.9
Overview
Sample Documentation
Section 9.1
Section 9.10
Section 9.11
Section 9.2
Section 9.3
Section 9.4
Section 9.5
Section 9.6
Section 9.7
Section 9.8
Section 9.9
Table(s)
Body Positioning
Descriptions of Range-of-Motion Maneuvers
Rest and Comfort
10.1 Administering Heat Therapy: Aquathermia Pad
10.2 Administering Heat Therapy: Commercial Heat Pack/Moist, Warm
10.3 Administering Heat Therapy: Heat Cradle and Heat Lamp
10.4 Administering Cold Therapy: Ice Bag/Collar/Glove/Commercial
10.5 Administering a Sitz Bath
10.6 Administering a Tepid Sponge Bath
10.7 Using a Transcutaneous Electrical Nerve Stimulation (TENS) Unit
10.8 Using Patient-Controlled Analgesia
10.9 Using Epidural Pump Therapy
Figure(s)
Figure 10.1
Figure 10.2
Figure 10.3
Figure 10.4
Figure 10.5
Figure 10.6
Overview
Sample Documentation
Section 10.1
Section 10.2
Section 10.3
Section 10.4
Section 10.5
Section 10.6
Section 10.7
Section 10.8
Section 10.9
Table(s)
Hot and Cold Conditions
Perioperative Nursing and Wound Healing
11.1 Applying a Sterile Gown
11.10 Collecting a Wound Specimen
11.2 Applying Sterile Gloves
11.3 Changing Sterile and Nonsterile Dressings
11.4 Removing Sutures
11.5 Providing Preoperative Care
11.6 Providing Postoperative Care
11.7 Managing a Pressure Ulcer
11.8 Irrigating a Wound
11.9 Managing a Wound Drain
Figure(s)
Figure 11.1
Figure 11.10
Figure 11.2
Figure 11.3
Figure 11.4
Figure 11.5
Figure 11.6
Figure 11.7
Figure 11.8
Figure 11.9
Overview
Sample Documentation
Section 11.1
Section 11.10
Section 11.3
Section 11.4
Section 11.5
Section 11.6
Section 11.7
Section 11.8
Section 11.9
Special Procedures
12.1 Managing and Providing Client Teaching for an Automatic Implantable
12.2 Managing a Hyperthermia/Hypothermia Unit
12.3 Providing Postmortem Care
Figure(s)
Figure 12.1
Overview
Sample Documentation
Section 12.1
Section 12.2
Section 12.3
Community-Based Variations
13.1 Preplanning and Organizing for Home Health Care
13.2 Maintaining Supplies and Equipment
13.3 Performing Environmental Assessment and Management
13.4 Assessing a Support System
13.5 Preparing Solutions in the Home
Figure(s)
Figure 13.1
Figure 13.2
Overview
Sample Documentation
Section 13.3
Section 13.4
Section 13.5
Appendices
A. Pain Management
B. Common Clinical Abbreviations
C. Diagnostic Laboratory Tests: Normal Values
D. Types of Isolation
E. Medication Interactions: Drug-Drug
F. Medication Interactions: Drug-Nutrient
G. Equipment Substitution in the Home
H. Potential Bioterrorism and Chemical Terrorism Agents Posing Greatest
I. Nanda-Approved Nursing Diagnoses
Bibliography
Bibliography
Front Matter
Acknowledgments
Contributors
Dedication
Nurses' Guide to Clinical Procedures
Preface
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