Essential Nursing Skills E-Book , livre ebook

Table of Contents

Cover image
Front matter
Copyright
Preface
Chapter 1. Observation and monitoring
Chapter 2. Resuscitation
Chapter 3. Intravenous therapy
Chapter 4. Central venous catheters
Chapter 5. Blood transfusion
Chapter 6. Nutrition and hydration
Chapter 7. Medicines
Chapter 8. Elimination
Chapter 9. Prevention of cross-infection
Chapter 10. Wound assessment
Chapter 11. Patient hygiene
Chapter 12. Respiratory care
Chapter 13. Immobility and associated problems
Index
Front matter
Essential Nursing Skills
Commissioning Editor: Ninette Premdas
Development Editor: Fiona conn
Project Manager: Elouise Ball
Designer: Charlotte Murray
Illustrator: Cactus
Illustration Manager: Merlyn Harvey

Essential Nursing Skills
THIRD EDITION
MAGGIE NICOL BSc(Hons) MSc PGDipEd RN, Professor of Clinical Skills
CAROL BAVIN DipN(Lond) RCNT RN RM
PATRICIA CRONIN BSc(Hons) MSc(Nursing) DipN(Lond) RN, Senior Lecturer
KAREN RAWLINGS-ANDERSON BSc(Hons) MSc(Nursing) DipNEd RN, Senior Lecturer
Copyright

An imprint of Elsevier Limited
© 2008, Elsevier Limited. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier's Rights Department: phone: (+1) 215 239 3804 (USA) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail: healthpermissions@elsevier.com . You may also complete your request on-line via the Elsevier website at http://www.elsevier.com/permissions .
First edition 2000
Second edition 2004
Third edition 2008
ISBN: 9780723434740
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress.

Notice

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Authors assumes any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book.
The Publisher


Printed in China
Preface
Maggie Nicol, Carol Bavin, Patricia Cronin and Karen Rawlings-Anderson

Why this book?
As nurse teachers who teach clinical skills to undergraduate nursing students and newly qualified nurses, we wanted to write a book that detailed how to perform the skills and could serve as a reminder for the skills they had been taught but may not have had an opportunity to practise for several weeks, maybe months. The book is designed to be small enough to carry around, especially when in clinical practice. The practice of nursing is dynamic and rapidly changing. This third edition has been thoroughly updated to reflect new guidelines and nursing practices.

What is it?
This book deliberately focuses on the skills required by nurses caring for adult patients in a hospital setting, but the skills themselves can be adapted to any clinical setting. It is a manual of skills that are essential to nursing: a ‘how-to-do-it’ book. It is not a textbook and so does not include all the theory and rationale that underpins the various skills, but suggestions for further reading are provided at the end of each chapter. Most skills are accompanied by ‘Points for practice’, a section that provides hints, suggestions or explanations to ensure successful performance of the skill.
The focus is on the practical aspects rather than why the skill is necessary. For example, insertion of a nasogastric tube explains how to select, measure and insert the tube; it does not discuss the reasons why such a tube may be necessary. This book is designed to complement nursing textbooks, not replace them.

How do I use it?
Each skill first describes preparation of the patient, the environment and the nurse, and the equipment needed. This is followed by a step-by-step description of the procedure, supported by illustrations, and additional information in the ‘Points for practice’. The care required following the skill is then described. Essential Nursing Skills is designed to act as a reminder for skills that you have been taught, and to enable you to prepare yourself for new skills. As with all aspects of nursing, it is vital that a Registered Nurse supervises you until you have really mastered each skill and are competent to carry them out alone.
Nursing practice is subject to many local policies and protocols and the reader is reminded to refer to them throughout. Local policies and protocols refer to specific aspects of nursing practice that may vary between hospitals and include: drug-checking procedures (e.g. intravenous drug therapy); which nurses are permitted to perform the skill (e.g. male catheterisation); which dressing should be used (e.g. care of an intravenous cannula); the way equipment should be cleaned (e.g. dressing trolley); and the disposal of clinical waste. Notes pages have been included to enable you to make a note of relevant local policies and procedures.
We hope that you will find this book interesting, enjoyable and a valuable resource to support and enhance your clinical practice.
London, 2008

Acknowledgement
The authors would like to acknowledge the valuable contribution by Shelagh Bedford-Turner to the first two editions of this book.
Chapter 1. Observation and monitoring

Temperature recording 2

Use of electronic thermometers 5

Cooling the patient 7

Warming the patient 8

Pulse recording 9

Assessment of breathing and counting respirations 11

Blood pressure recording 13

Cardiac monitoring 19

Recording a 12-lead ECG 22

Observation of limb perfusion, movement and sensation 24

Assessment of level of consciousness 26

Care of the patient having a seizure 32

Weighing patients 34

Blood glucose monitoring 36

Pain assessment 38

Patient-controlled analgesia (PCA) 42

Epidural analgesia 45

TEMPERATURE RECORDING

Preparation
Patient Equipment/Environment Nurse

• Explain procedure, to gain consent and co-operation.

• Assess patient regarding suitable site for temperature recording PFP1 .

• Patient should not have had a hot or cold drink, smoked a cigarette within the previous 15 minutes when using the oral site.

• Disposable chemical thermometer, e.g. TempaDot PFP2 PFP3 .

• Observation chart.

• Hands must be clean.

• Additional protective clothing may be necessary if indicated by the patient's condition (see Chapter 9 ).

Procedure

Oral

1 Ask the patient to open their mouth, and gently insert the thermometer under their tongue, next to the frenulum PFP1 . This is adjacent to a large artery (sublingual artery), so the temperature will be close to core temperature ( Figure 1.1A ).

Figure 1.1
Disposable chemical thermometer. (A) Positioning the thermometer for oral use, (B) Positioning the thermometer for axillary use, (C) Reading the thermometer

2 Ask the patient to close their lips, but not their teeth, around the thermometer, to prevent cool air circulating in the mouth.

3 It is vital to leave the thermometer in position for the recommended length of time (usually 1 minute). However, it does not affect accuracy if it is left for longer than the minimum time.

4 Remove the thermometer, taking care not to touch the part that has been in the patient's mouth. In accordance with the manufacturer's instructions, read the temperature by noting the way that the dots have changed colour (see Figure 1.1C ).

Axilla

1 Ask/assist the patient to expose their axilla. For an accurate recording, the axilla must be dry and free from sweat.

2 With the dots facing the chest wall, position the thermometer vertically between the arm and the chest wall and ask/assist the patient to keep their arm close against the chest to ensure good contact with the skin (see Figure 1.1B ).

3 It is vital to leave leave the thermometer in position for the recommended length of time (usually 3 minutes). However, it does not affect accuracy if it is left for longer than the minimum time.

4 In accordance with the manufacturer's instructions, read the temperature by noting the way that the dots have changed colour (see Figure 1.1C ).

Post procedure
Patient Equipment/Environment Nurse

• Ensure patient comfort.

• Answer any questions regarding the recording.

• Dispose of the thermometer into the clinical waste bag.

• Record the temperature according to local policy. See page 16 for example of charting.

• Report any abnormality. Normal range for adults 36°–37.2° Celcius.

Points for practice

1 If the patient is unconscious, confused, prone to seizures, has mouth sores or has undergone oral surgery, the oral site should not be used for temperature measurement. Temperature in the axilla is 0.5° lower than oral temperature. The rectal site is no longer recommended except when an electronic probe is being used.

2 Mercury thermometers are no longer widely used as there are risks of breakage. If a mercury thermometer is used, it must be cleaned before and after use and the mercur