Clinical Nursing Skills: A Concept-Based Approach, 3rd edition

CHAPTER 1: ASSESSMENT

• Chapter at a Glance

• General Assessment
  • 1.1 Appearance and Mental Status: Assessing
  • 1.2 Height: Newborn, Infant, Child, Adult, Measuring
  • 1.3 Newborn’s or Infant’s Head, Chest, and Abdomen: Measuring
  • 1.4 Weight: Newborn, Infant, Child, Adult, Measuring
• Vital Signs
  • 1.5 Blood Pressure: Newborn, Infant, Child, Adult, Obtaining
  • 1.6 Pulse, Apical and Peripheral: Obtaining
  • 1.7 Pulse Oximeter: Using
  • 1.8 Respirations: Newborn, Infant, Child, Adult, Obtaining
  • 1.9 Temperature: Newborn, Infant, Child, Adult, Obtaining
• Physical Assessment
  • 1.10 Abdomen: Assessing
  • 1.11 Anus: Assessing
  • 1.12 Breasts and Axillae: Assessing
  • 1.13 Ears: Hearing Acuity, Assessing
  • 1.14 Eyes: Visual Acuity, Assessing
  • 1.15 Genitals and Inguinal Area: Assessing
  • 1.16 Hair: Assessing
  • 1.17 Heart and Central Vessels: Assessing
  • 1.18 Mouth and Oropharynx: Assessing
  • 1.19 Musculoskeletal System: Assessing
  • 1.20 Nails: Assessing
  • 1.21 Neck: Assessing
  • 1.22 Neurologic Status: Assessing
  • 1.23 Nose and Sinuses: Assessing
  • 1.24 Peripheral Vascular System: Assessing
  • 1.25 Skin: Assessing
  • 1.26 Skull and Face: Assessing
  • 1.27 Thorax and Lungs: Assessing
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

CHAPTER 2: CARING INTERVENTIONS

• Chapter at a Glance

• Bed Care and Activities of Daily Living (ADLs)
  • 2.1 Bathing: Newborn, Infant, Child, Adult
  • 2.2 Bedmaking: Occupied, Unoccupied
  • 2.3 Eyes and Contact Lenses: Caring for
  • 2.4 Feet: Caring for
  • 2.5 Hair: Caring for
  • 2.6 Hearing Aid: Removing, Cleaning, and Inserting
  • 2.7 Mouth: Regular and for the Unconscious or Debilitated Patient, Caring for
  • 2.8 Perineal-Genital Area: Caring for
  • 2.9 Shaving: Male Patient
• Medication and Administration Systems
  • 2.10 Automated Dispensing System: Using
  • 2.11 Medication: Preparing and Administering
  • 2.12 Narcotic Control System: Using
• Medication Preparation
  • 2.13 Ampule Medication: Removing
  • 2.14 Calculating Dosages
  • 2.15 Mixing Medications in One Syringe
  • 2.16 Vial Medication: Removing
• Medication Routes
  • 2.17 Ear Medication: Administering
  • 2.18 Enteral Tube Medication: Administering
  • 2.19 Eye Medication: Administering
  • 2.20 Inhaler, Dry Powder Medication: Administering
  • 2.21 Inhaler, Metered-Dose Medication: Administering
  • 2.22 Nasal Medication: Administering
  • 2.23 Nebulized Medication, Nonpressurized Aerosol (NPA): Administering
  • 2.24 Oral Medication: Administering
  • 2.25 Rectal Medication: Administering
  • 2.26 Sublingual Medication: Administering
  • 2.27 Topical Medication: Applying
  • 2.28 Transdermal Patch Medication: Applying
  • 2.29 Vaginal Medication: Administering
• Parenteral Routes
  • 2.30 Injection, Intradermal: Administering
  • 2.31 Injection, Intramuscular: Administering
  • 2.32 Injection, Subcutaneous: Administering
  • 2.33 Injection, Subcutaneous Anticoagulant: Administering
  • 2.34 Injection, Z-Track Method: Using
  • 2.35 Insulin Injection: Using a Syringe, Pen, or Pump
  • 2.36 Intravenous Medication: Adding to Fluid Container
  • 2.37 Intravenous Medication, Intermittent: Using a Secondary Set
  • 2.38 Intravenous Medication, IV Push: Administering
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

CHAPTER 3: COMFORT

• Chapter at a Glance

• Acute/Chronic Pain Management
  • 3.1 Pain in Newborn, Infant, Child, Adult: Assessing
  • 3.2 Pain Relief: Back Massage
  • 3.3 Pain Relief: Complementary Health Approaches
  • 3.4 Pain Relief: Transcutaneous Electrical Nerve Stimulation (TENS) Unit, Using
  • 3.5 Patient-Controlled Analgesia (PCA) Pump: Using
  • 3.6 Sleep Promotion: Assisting
• Heat and Cold Application
  • 3.7 Cooling Blanket: Applying
  • 3.8 Dry Cold: Applying
  • 3.9 Dry Heat: Applying
  • 3.10 Moist Pack and Tepid Sponges: Applying
  • 3.11 Neonatal Incubator and Infant Radiant Warmer: Using
  • 3.12 Sitz Bath: Assisting
• End of Life Care
  • 3.13 Physiological Needs of the Dying Patient: Managing
  • 3.14 Postmortem Care: Providing
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

CHAPTER 4: ELIMINATION

• Chapter at a Glance

• Assessment — Collecting Specimens
  • 4.1 Bladder Scanner: Using
  • 4.2 Stool Specimen, Routine, Culture, Ova, Parasites: Obtaining
  • 4.3 Urine Specimen, Clean-Catch, Closed Drainage System for Culture and Sensitivity: Obtaining
  • 4.4 Urine Specimen, Ileal Conduit: Obtaining
  • 4.5 Urine Specimen, Routine, 24-Hour: Obtaining
• Bladder Interventions
  • 4.6 Bedpan: Assisting
  • 4.7 Bladder Irrigation: Continuous
  • 4.8 Bladder Irrigation: Providing
  • 4.9 Commode: Assisting
  • 4.10 Urinal: Assisting
  • 4.11 Urinary Catheter: Caring for and Removing
  • 4.12 Urinary Catheterization: Performing
  • 4.13 Urinary Diversion Pouch: Applying
  • 4.14 Urinary External Device: Applying
  • 4.15 Urinary Ostomy: Caring for
  • 4.16 Urinary Suprapubic Catheter: Caring for
• Bowel Interventions
  • 4.17 Bowel Routine, Develop Regular: Assisting
  • 4.18 Bowel Diversion Ostomy Appliance: Changing
  • 4.19 Colostomy: Irrigating
  • 4.20 Enema and Retention Enema: Administering
  • 4.21 Fecal Impaction: Removing
  • 4.22 Fecal Ostomy Pouch: Applying
  • 4.23 Rectal Tube: Inserting
• Dialysis
  • 4.24 Dialysis, Peritoneal: Catheter Insertion, Assisting
  • 4.25 Dialysis, Peritoneal: Procedures, Assisting
  • 4.26 Hemodialysis: Central Venous Dual-Lumen Catheter, Caring for
  • 4.27 Hemodialysis: Procedures, Caring for, Assisting
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

CHAPTER 5: FLUIDS AND ELECTROLYTES

• Chapter at a Glance

• Fluid Balance Measurement
  • 5.1 Intake and Output: Measuring
• Intravenous Therapy
  • 5.2 Central Line Dressing: Changing
  • 5.3 Central Line: Infusing Intravenous Fluids
  • 5.4 Central Line: Managing
  • 5.5 Implanted Vascular Access Devices: Managing
  • 5.6 Infusion Device: Discontinuing
  • 5.7 Infusion Flow Rate Using Controller or IV Pump: Regulating
  • 5.8 Infusion Intermittent Device: Maintaining
  • 5.9 Infusion: Initiating
  • 5.10 Infusion: Maintaining
  • 5.11 Infusion Pump and “Smart” Pump: Using
  • 5.12 Infusion Syringe Pump: Using
  • 5.13 Percutaneous Central Vascular Catheterization: Assisting
  • 5.14 PICC Line Dressing: Changing
  • 5.15 Venipuncture: Initiating
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

CHAPTER 6: INFECTION

• Chapter at a Glance

• Medical Asepsis
  • 6.1 Hand Hygiene: Performing
• Person Protective Equipment (PPE) and Isolation Precautions
  • 6.2 Enteric Contact Precautions: Using
  • 6.3 Isolation, Attire: Donning and Doffing
  • 6.4 Isolation, Patient and Others: Caring for
  • 6.5 Isolation, Double-Bagging: Using
  • 6.6 Isolation, Equipment, Specimens: Removing
  • 6.7 Isolation, Transporting Patient Outside Room
  • 6.8 PPE, Clean Gloves: Donning and Doffing
  • 6.9 PPE, Face Masks: Donning and Doffing
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

CHAPTER 7: INTRACRANIAL REGULATION

• Chapter at a Glance
  • 7.1 Glasgow Coma Scale: Using
  • 7.2 Intracranial Pressure: Monitoring and Caring for
  • 7.3 Lumbar Puncture: Assisting
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

CHAPTER 8: METABOLISM

• Chapter at a Glance

• General
  • 8.1 Endocrine Disorders: Assessing
  • 8.2 Endocrine Disorders: Complementary Health Approaches
  • 8.3 Paracentesis: Assisting
• Diabetes Care
  • 8.4 Capillary Blood Specimen for Glucose: Measuring
  • 8.5 Diabetes: Managing
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

CHAPTER 9: MOBILITY

• Chapter at a Glance

• Balance and Strength
  • 9.1 Body Mechanics: Using
  • 9.2 Range-of-Motion Exercises: Assisting
• Moving and Transferring a Patient
  • 9.3 Ambulating Patient: Assisting
  • 9.4 Hydraulic Lift: Using
  • 9.5 Logrolling Patient in Bed
  • 9.6 Moving Patient Up in Bed
  • 9.7 Positioning Patient in Bed
  • 9.8 Sitting on Side of Bed (Dangling): Assisting
  • 9.9 Transferring Patient Between Bed and Chair
  • 9.10 Transferring Patient Between Bed and Stretcher
  • 9.11 Transporting: Newborn, Infant, Toddler
  • 9.12 Turning Patient: Lateral or Prone Position in Bed
• Patient Assistive Devices
  • 9.13 Cane: Assisting
  • 9.14 Crutches: Assisting
  • 9.15 Walker: Assisting
• Traction and Cast Care
  • 9.16 Cast, Initial: Caring for
  • 9.17 Cast, Ongoing for Plaster and Synthetic: Caring for
  • 9.18 Traction, Skin and Skeletal: Caring for
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

CHAPTER 10: NUTRITION

• Chapter at a Glance

• Healthy Eating Habits
  • 10.1 Body Mass Index (BMI): Assessing
  • 10.2 Diet, Therapeutic: Managing
  • 10.3 Eating Assistance: Providing
  • 10.4 Mealtime: Complementary Health Approaches
  • 10.5 Nutrition: Assessing
• Enteral Nutrition Using a Feeding Tube
  • 10.6 Feeding, Continuous, Nasointestinal/Jejunostomy with a Small-Bore Tube: Administering
  • 10.7 Feeding, Gastrostomy or Jejunostomy Tubes: Administering
  • 10.8 Gastric Lavage: Performing
  • 10.9 Nasogastric Tube: Feeding
  • 10.10 Nasogastric Tube: Flushing and Maintaining
  • 10.11 Nasogastric Tube: Inserting
  • 10.12 Nasogastric Tube: Removing
• Parenteral Nutrition Using Intravenous Infusion
  • 10.13 Lipids, IV Infusion: Providing
  • 10.14 Total Parental Nutrition (TPN), IV Infusion: Providing
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

CHAPTER 11: OXYGENATION

• Chapter at a Glance

• Assessment
  • 11.1 Nose and Throat Specimen: Collecting
  • 11.2 Peak Expiratory Flow Rate: Measuring
  • 11.3 Sputum Specimen: Collecting
• Interventions
  • 11.4 Chest Physiotherapy: Preparing Patient
  • 11.5 Incentive Spirometer: Using
  • 11.6 Pursed-Lip Breathing
  • 11.7 Thoracentesis: Assisting
• Supplemental Oxygen Therapy
  • 11.8 Oxygen Delivery Systems: Using
  • 11.9 Oxygen, Portable Cylinder: Using
  • 11.10 Ventilator, Mechanical: Caring for Patient
• Maintaining a Patent Airway
  • 11.11 Airway, Nasopharyngeal: Inserting
  • 11.12 Airway, Oropharyngeal: Inserting
  • 11.13 Endotracheal Tube: Caring for
  • 11.14 Suctioning, Oropharyngeal and Nasopharyngeal: Newborn, Infant, Child, Adult
  • 11.15 Suctioning, Tracheostomy or Endotracheal Tube
  • 11.16 Tracheal Tube: Inflating the Cuff
  • 11.17 Tracheostomy: Caring for
• Maintaining Lung Expansion
  • 11.18 Chest Tube Drainage: Maintaining
  • 11.19 Chest Tube Insertion: Assisting
  • 11.20 Chest Tube Removal: Assisting
• Life Threatening Situations
  • 11.21 Airway Obstruction: Clearing
  • 11.22 Cardiac Compressions, External: Performing
  • 11.23 Rescue Breathing: Performing
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

CHAPTER 12: PERFUSION

• Chapter at a Glance

• Maintaining Blood Volume
  • 12.1 Blood Products: Administering
  • 12.2 Blood Transfusion: Administering
  • 12.3 Direct Pressure: Applying
  • 12.4 Pressure Dressing: Applying
• Antiembolism Devices
  • 12.5 Antiembolism Stockings: Applying
  • 12.6 Pneumatic Compression Device: Applying
  • 12.7 Sequential Compression Devices: Applying
• Electrical Conduction in the Heart
  • 12.8 Automated External Defibrillator (AED): Adult, Using
  • 12.9 ECG, 12-Lead: Recording
  • 12.10 ECG, Leads: Applying
  • 12.11 ECG, Strip: Interpreting
  • 12.12 Pacemaker, Insertion: Assisting
  • 12.13 Pacemaker, Permanent: Teaching
  • 12.14 Pacemaker, Temporary: Maintaining
  • 12.15 Temporary Cardiac Pacing, Transvenous, Epicardial: Monitoring
• Arterial Line
  • 12.16 Allen Test: Performing
  • 12.17 Arterial Blood Pressure: Monitoring
  • 12.18 Arterial Blood Samples: Withdrawing
  • 12.19 Arterial Line: Caring for
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

CHAPTER 13: PERIOPERATIVE CARE

• Chapter at a Glance

• General
  • 13.1 Preoperative Patient Teaching
  • 13.2 Surgical Hand Antisepsis and Scrubs
  • 13.3 Surgical Site: Preparing
• Using Sterile Technique
  • 13.4 Sterile Field: Maintaining
  • 13.5 Sterile Gown and Gloves: Donning (Closed Method)
  • 13.6 Surgical Patient: Preparing
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

CHAPTER 14: REPRODUCTION

• Chapter at a Glance

• Antepartum Care
  • 14.1 Amniocentesis: Assisting
  • 14.2 Antepartum, Maternal and Fetal: Assessing
  • 14.3 Antepartum Pelvic Examination: Assisting
  • 14.4 Deep Tendon Reflexes and Clonus: Assessing
  • 14.5 Fetal Well-Being, Nonstress Test and Biophysical Profile: Assessing
  • 14.6 Rh Immune Globulin: Administering
• Intrapartum Care
  • 14.7 Amniotomy (Artificial Rupture of Membranes): Assisting
  • 14.8 Epidural: Assisting and Caring for Patient
  • 14.9 Fetal External Electronic: Monitoring
  • 14.10 Fetal Heart Rate: Auscultating
  • 14.11 Fetal Internal Scalp Electrode Placement: Monitoring
  • 14.12 Induction of Labor with Oxytocin and Other Agents: Assisting and Caring for Patient
  • 14.13 Intrapartum, Maternal and Fetal: Assessing
  • 14.14 Intrapartum Pelvic Examination: Assisting
  • 14.15 Prolapsed Cord: Caring for Patient
• Postpartum Care
  • 14.16 Breastfeeding: Assisting
  • 14.17 Lochia: Evaluating
  • 14.18 Postpartum, Maternal: Assessing
  • 14.19 Postpartum, Perineum: Assessing
  • 14.20 Uterine Fundus, After Vaginal or Caesarean Birth: Assessing
• Newborn Care
  • 14.21 Apgar Score: Assessing
  • 14.22 Circumcision: Caring for
  • 14.23 Newborn: Assessing
  • 14.24 Newborn, Initial Bathing
  • 14.25 Newborn Thermoregulation: Assisting
  • 14.26 Phototherapy, Newborn, Infant: Providing
  • 14.27 Umbilical Cord Clamp: Caring for
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

CHAPTER 15: SAFETY

• Chapter at a Glance

• Patient Safety
  • 15.1 Abuse: Newborn, Infant, Child, Older Adult, Assessing for
  • 15.2 Fall Prevention: Assessing and Managing
  • 15.3 Seizure Precautions: Implementing
  • 15.4 Suicide: Caring for Suicidal Patient
• Environmental Safety
  • 15.5 Environmental Safety: Healthcare Facility, Community, Home
  • 15.6 Fire Safety: Healthcare Facility, Community, Home
  • 15.7 Thermal and Electrical Injuries: Preventing
• Immobilizers and Restraints
  • 15.8 Bed or Chair Alarm, Exit Monitor Device: Applying
  • 15.9 Immobilizer, Mummy: Applying
  • 15.10 Immobilizer, Papoose Board: Applying
  • 15.11 Restraints and Alternatives: Caring for
  • 15.12 Restraints, Torso and Belt: Applying
  • 15.13 Restraints, Wrist and Ankle: Applying
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

CHAPTER 16: TISSUE INTEGRITY

• Chapter at a Glance

• Assessment
  • 16.1 Wound Drainage Specimen: Obtaining
• Dressings and Binders
  • 16.2 Abdominal Binder: Applying
  • 16.3 Closed Wound Drains: Maintaining
  • 16.4 Dressing, Dry: Changing
  • 16.5 Dressing, Sterile: Changing
  • 16.6 Dressing, Venous Ulcer: Changing
  • 16.7 Dressing, Wet-to-Moist: Applying
  • 16.8 Elastic Bandage: Applying
  • 16.9 Surgical Wound: Caring for
• Wound Care
  • 16.10 Dressing, Alginate: Applying
  • 16.11 Dressing, Hydrocolloid: Applying
  • 16.12 Dressing, Transparent: Applying
  • 16.13 Electrical Stimulation: Using
  • 16.14 Negative Pressure Wound Therapy: Using
  • 16.15 Pressure Injury: Preventing and Caring for
  • 16.16 Staple and Suture: Removing
  • 16.17 Stump: Positioning and Exercising
  • 16.18 Stump: Shrinking and Molding
  • 16.19 Wound: Irrigating
  • Critical Thinking Options for Unexpected Outcomes
  • Review Questions

Appendix A: Answers to Review Questions

Appendix B: Guidelines for Laboratory and Diagnostic Assessment