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

Published by Pearson (May 20, 2021) © 2019

  • Barbara Callahan
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Nursing: A Concept-Based Approach to Learning is the only concepts curriculum built from the ground up as a comprehensive, cohesive learning system. This 3-volume series provides all the nursing curriculum content and materials needed to prepare you for nursing practice. With exemplars and assessment tools, you'll deepen your grasp of connections between concepts, with broad applications throughout a nursing career.

Volume III, Clinical Nursing Skills, is the only volume of any concept-based curriculum devoted exclusively to nursing skills. It will help you learn and apply essential skills and knowledge for patient care, while relating topics to broader contexts. The 3rd Edition is a full-scale revision bringing the text in line with new evidence-based practice, care and safety guidelines.

Table of Contents

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

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