Nursing Interventions & Clinical Skills - E-Book , livre ebook

Nursing Interventions & Clinical Skills
Sixth Edition
Anne Griffin Perry EdD, RN, FAAN
Professor Emerita, Former Interim Dean, School of Nursing, Southern Illinois University-Edwardsville, Edwardsville, Illinois
Patricia A. Potter PhD, RN, FAAN
Director of Research, Patient Care Services, Barnes-Jewish Hospital, St. Louis, Missouri
Wendy R. Ostendorf RN, MS, EdD, CNE
Professor of Nursing, Neumann University, Aston, Pennsylvania
Table of Contents
Cover image
Title page
Quick Reference for Standard Protocol for All Nursing Interventions
Before the Skill
During the Skill
Completion Protocol (End of Skill)
Copyright
About the Authors
Anne Griffin Perry, RN, EdD, FAAN
Patricia A. Potter, RN, MSN, PhD, FAAN
Wendy R. Ostendorf, RN, MS, EdD, CNE
Consultants and Contributors
Reviewers
Acknowledgments
Preface to the Student
Preface to the Instructor
Key Features
New to this Edition
Ancillaries
Unit 1 Quality and Safety in Nursing Practice
Chapter 1 Using Evidence in Nursing Practice
Introduction
Comparing Evidence-Based Practice with Research and Performance Improvement
Steps of Evidence-Based Practice
Evidence in Nursing Skills
Critical Thinking Exercises
References
Chapter 2 Communication and Collaboration
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Skill 2.1 Establishing the Nurse-Patient Relationship and Interviewing
Skill 2.2 Communicating with Patients Who Have Difficulty Coping
Skill 2.3 Communicating with Cognitively Impaired Patients
Procedural Guideline 2.1 Hand-Off Communications
Procedural Guideline 2.2 SBAR Communication
Skill 2.4 Discharge Planning and Transitional Care
Critical Thinking Questions
References
Chapter 3 Documentation and Informatics
Introduction
Patient-Centered Care
Safety
Electronic Health Record
Evidence-Based Practice
Confidentiality
Legal Guidelines in Documentation
Standards
Guidelines for Quality Documentation
Procedural Guideline 3.1 Documenting Nurses' Progress Notes
Procedural Guideline 3.2 Use of Electronic Health Records
Procedural Guideline 3.3 Documenting an Incident Occurrence
Critical Thinking Exercises
References
Chapter 4 Patient Safety and Quality Improvement
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Skill 4.1 Fall Prevention in a Health Care Setting
Skill 4.2 Designing a Restraint-Free Environment
Skill 4.3 Applying Physical Restraints
Skill 4.4 Seizure Precautions
Procedural Guideline 4.1 Fire, Electrical, and Chemical Safety
Critical Thinking Exercises
References
Chapter 5 Infection Control
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Skill 5.1 Hand Hygiene
Skill 5.2 Applying Personal Protective Equipment
Skill 5.3 Caring for Patients Under Isolation Precautions
Skill 5.4 Preparing a Sterile Field
Skill 5.5 Sterile Gloving
Critical Thinking Exercises
References
Unit 2 Patient Assessment Skills
Chapter 6 Vital Signs
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Temperature
Pulse
Respirations
Blood Pressure
Skill 6.1 Measuring Body Temperature
Skill 6.2 Assessing Apical Pulse
Skill 6.3 Assessing Radial Pulse
Procedural Guideline 6.1 Assessing Apical-Radial Pulse Deficit
Skill 6.4 Assessing Respirations
Skill 6.5 Assessing Blood Pressure
Procedural Guideline 6.2 Assessing Blood Pressure Electronically
Procedural Guideline 6.3 Measuring Oxygen Saturation (Pulse Oximetry)
Critical Thinking Exercises
References
Chapter 7 Health Assessment
Introduction
Patient-Centered Care
Assessment Techniques
Safety
Preparation for Assessment
Evidence-Based Practice
Skill Guidelines
Skill 7.1 General Survey
Procedural Guideline 7.1 Monitoring Intake and Output
Skill 7.2 Assessing the Head and Neck
Skill 7.3 Assessing the Thorax and Lungs
Skill 7.4 Cardiovascular Assessment
Skill 7.5 Assessing the Abdomen
Skill 7.6 Assessing the Genitalia and Rectum
Skill 7.7 Musculoskeletal and Neurological Assessment
Critical Thinking Exercises
References
Chapter 8 Specimen Collection
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Skill 8.1 Urine Specimen Collection-Midstream (Clean-Voided) Urine, Sterile Urinary Catheter
Procedural Guideline 8.1 Collecting a Timed Urine Specimen
Procedural Guideline 8.2 Urine Screening for Glucose, Ketones, Protein, Blood, and PH
Skill 8.2 Testing for Gastrointestinal Alterations-Gastroccult Test, Stool Specimen, and Hemoccult Test
Skill 8.3 Collecting Nose and Throat Specimens
Skill 8.4 Collecting a Sputum Specimen
Skill 8.5 Collecting Wound Drainage Specimens
Skill 8.6 Blood Glucose Monitoring
Skill 8.7 Collecting Blood and Culture Specimens by Venipuncture (Syringe and Vacutainer Method)
Critical Thinking Exercises
References
Chapter 9 Diagnostic Procedures
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Skill 9.1 Contrast Media Studies: Arteriogram (Angiogram), Cardiac Catheterization, Intravenous Pyelogram
Skill 9.2 Care of Patients Undergoing Aspirations: Bone Marrow, Lumbar Puncture, Paracentesis, Thoracentesis
Skill 9.3 Care of Patients Undergoing Bronchoscopy
Skill 9.4 Care of Patients Undergoing Gastrointestinal Endoscopy
Skill 9.5 Obtaining an Electrocardiogram
Critical Thinking Exercises
References
Unit 3 Basic Human Needs
Chapter 10 Bathing and Personal Hygiene
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Skill 10.1 Complete Bathing
Procedural Guideline 10.1 Perineal Care
Procedural Guideline 10.2 Oral Care for a Debilitated Patient
Procedural Guideline 10.3 Care of Dentures
Procedural Guideline 10.4 Hair Care-Combing, Shampooing, and Shaving
Procedural Guideline 10.5 Foot and Nail Care
Procedural Guideline 10.6 Making an Occupied Bed
Procedural Guideline 10.7 Making an Unoccupied Bed
Critical Thinking Exercises
References
Chapter 11 Care of the Eye and Ear
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Skill 11.1 Eye Irrigation
Procedural Guideline 11.1 Eye Care for the Comatose Patient
Skill 11.2 Ear Irrigation
Skill 11.3 Caring for a Hearing Aid
Critical Thinking Exercises
References
Chapter 12 Promoting Nutrition
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Skill 12.1 Feeding Dependent Patients
Skill 12.2 Aspiration Precautions
Skill 12.3 Insertion and Removal of a Small-Bore Feeding Tube
Skill 12.4 Verifying Placement and Irrigating a Feeding Tube
Skill 12.5 Administering Enteral Nutrition: Nasogastric, Gastrostomy, or Jejunostomy Tube
Procedural Guideline 12.1 Site Care of Enteral Feeding Tubes
Critical Thinking Exercises
References
Chapter 13 Pain Management
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Skill 13.1 Nonpharmacological Pain Management
Procedural Guideline 13.1 Relaxation and Guided Imagery
Skill 13.2 Pharmacological Pain Management
Skill 13.3 Patient-Controlled Analgesia
Skill 13.4 Epidural Analgesia
Skill 13.5 Local Anesthetic Infusion Pump for Analgesia
Skill 13.6 Moist and Dry Heat
Skill 13.7 Cold Application
Critical Thinking Exercises
References
Chapter 14 Promoting Oxygenation
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Skill 14.1 Oxygen Administration
Skill 14.2 Airway Management: Noninvasive Interventions
Procedural Guideline 14.1 Use of a Peak Flowmeter
Skill 14.3 Chest Physiotherapy
Skill 14.4 Airway Management: Suctioning
Skill 14.5 Airway Management: Endotracheal Tube and Tracheostomy Care
Skill 14.6 Managing Closed Chest Drainage Systems
Critical Thinking Exercises
References
Unit 4 Activity and Mobility
Chapter 15 Safe Patient Handling, Transfer, and Positioning
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Skill 15.1 Transfer Techniques
Procedural Guideline 15.1 Wheelchair Transfer Techniques
Skill 15.2 Moving and Positioning Patients in Bed
Critical Thinking Exercises
References
Chapter 16 Exercise and Mobility
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Procedural Guideline 16.1 Range of Motion
Procedural Guideline 16.2 Applying Elastic Stockings and Sequential Compression Device
Skill 16.1 Assisting with Ambulation
Skill 16.2 Teaching Use of Canes, Crutches, and Walkers
Critical Thinking Exercises
References
Chapter 17 Traction, Cast Care, and Immobilization Devices
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Skill 17.1 Assisting with Cast Application and Removal
Skill 17.2 Care of a Patient in Skin Traction
Skill 17.3 Care of a Patient in Skeletal Traction and Pin-Site Care
Skill 17.4 Care of a Patient with an Immobilization Device
Critical Thinking Exercises
References
Unit 5 Promoting Elimination
Chapter 18 Urinary Elimination
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Procedural Guideline 18.1 Assisting with Use of a Urinal
Skill 18.1 Applying a Condom-Type External Catheter
Procedural Guideline 18.2 Bladder Scan
Skill 18.2 Insertion of a Straight or Indwelling Catheter
Skill 18.3 Removal of an Indwelling Catheter
Procedural Guideline 18.3 Care of an Indwelling Catheter
Skill 18.4 Suprapubic Catheter Care
Skill 18.5 Performing Catheter Irrigation
Critical Thinking Exercises
References
Chapter 19 Bowel Elimination and Gastric Intubation
Introduction
Patient-Centered Care
Safety
Evidence-Based Practice
Procedural Guideline 19.1 Providing a Bedpan
Skill 19.1 Removing a Fecal Impaction
Skill 19.2 Administering an Enema
Procedural Guideline 19.2 Applying a Fecal Containment Device
Skill 19.3 Insertion, Maintenance, and Removal of a Nasogastric Tube for Gastric Decompress