Lippincott’s Nursing Procedures PDF
Preview Lippincott’s Nursing Procedures
LWBK1103-FM_i-xvi.qxd 7/19/12 6:09 AM Page i LWBK1103-FM_i-xvi.qxd 7/19/12 6:09 AM Page ii LWBK1103-FM_i-xvi.qxd 7/19/12 6:10 AM Page iii LWBK1103-FM_i-xvi.qxd 7/19/12 6:10 AM Page iv Staff The clinical treatments described and recommended in this publication are based on research and consultation with nursing, medical, and legal au- Publisher thorities. To the best of our knowledge, these procedures reflect currently Jay Abramovitz accepted practice. Nevertheless, they can’t be considered absolute and uni- versal recommendations. For individual applications, all recommendations Chief Nurse Judith A. Schilling McCann, RN, MSN must be considered in light of the patient’s clinical condition and, before administration of new or infrequently used drugs, in light of the latest Clinical Director package-insert information. The authors and publisher disclaim any re- Joan M. Robinson, RN, MSN sponsibility for any adverse effects resulting from the suggested procedures, from any undetected errors, or from the reader’s misunderstanding of Clinical Project Manager the text. Melissa Morris, RN, MBE, JD Clinical Editors © 2013 by Lippincott Williams & Wilkins. All rights reserved. This book is Kate Stout, RN, MSN, CCRN protected by copyright. No part of it may be reproduced, stored in a retrieval Mary Ann Foley, RN, BSN system, or transmitted, in any form or by any means—electronic, mechanical, photocopy, recording, or otherwise—without prior written permission of the Product Director David Moreau publisher, except for brief quotations embodied in critical articles and reviews, and testing and evaluation materials provided by the publisher to instructors Senior Product Manager whose schools have adopted its accompanying textbook. For information, Diane Labus write Lippincott Williams & Wilkins, 323 Norristown Road, Suite 200, Ambler, PA 19002-2756. Editor Margaret Eckman Printed in China. Copy Editor Debra Share LNP6011012 Editorial Assistants Megan L. Aldinger, Karen J. Kirk, Jeri O’Shea, Linda K. Ruhf Art Director Library of Congress Cataloging-in-Publication Data Elaine Kasmer Lippincott’s nursing procedures.—6th ed. Design Joseph John Clark, MW Design (Cover) p. ; cm. Nursing procedures Design Assistant Includes bibliographical references and index. Karen Kappe Nugent ISBN 978-1-4511-4633-2 (alk. paper) I. Lippincott Williams & Wilkins. II. Title: Nursing procedures. Vendor Manager Cynthia Rudy [DNLM: 1. Nursing Care. WY 100.1] Senior Manufacturing Coordinator 610.73–dc23 2012021642 Beth J. Welsh Production Services Aptara, Inc. LWBK1103-FM_i-xvi.qxd 7/19/12 6:10 AM Page v Contents Contributors and consultants xi Binder application 68 Bispectral index monitoring 70 How to use this book xv Bladder ultrasonography 73 ALPHABETICAL LISTING OF NURSING Blood culture sample collection 74 PROCEDURES ■ 1 Blood glucose monitoring 75 Blood pressure assessment 77 A Body jewelry removal 81 Body mechanics 84 Abdominal paracentesis, assisting 1 Bone marrow aspiration and biopsy 85 Admission 2 Brain tissue oxygen monitoring and care 88 Admixture of drugs in a syringe 4 Brain tissue oxygen monitoring device insertion, Advance directives 6 assisting 89 Airborne precautions 10 Bronchoscopy, assisting 92 Air-fluidized therapy bed use 12 Buccal and sublingual drug administration 94 Alignment and pressure-reducing devices 14 Burn care 96 Angioplasty care 16 Burn dressing application, biological and Antiembolism stocking application 20 synthetic 101 Aquapheresis 23 Arterial and venous sheath removal 27 Arterial pressure monitoring 29 C Arterial puncture for blood gas analysis 35 Canes 104 Assessment techniques 38 Capillary blood gas sampling 105 Autologous blood collection, preoperative 41 Carbon monoxide oximetry 106 Autologous blood transfusion, perioperative 44 Cardiac monitoring 108 Automated external defibrillation 46 Cardiac output measurement 112 Cardiopulmonary resuscitation, adult 116 B Cardiopulmonary resuscitation, child 123 Cardiopulmonary resuscitation, infant 125 Back care 48 Care plan preparation 127 Balloon valvuloplasty care 49 Cast application 129 Bariatric bed use 53 Cast removal 132 Bed bath 54 Central venous access catheter 133 Bed equipment, supplemental 56 Central venous pressure monitoring 146 Bedmaking, occupied 58 Cerebrospinal fluid drainage management 151 Bedmaking, unoccupied 61 Cervical collar application 153 Bedpan and urinal use 62 Chemotherapeutic drug administration 154 Bedside spirometry 66 v LWBK1103-FM_i-xvi.qxd 7/19/12 6:10 AM Page vi vi CONTENTS Chemotherapeutic drug preparation and handling 159 Endotracheal drug administration 259 Chest physiotherapy 161 Endotracheal intubation 260 Chest tube drainage system monitoring and care 165 Endotracheal tube care 266 Chest tube drainage system setup 170 End-tidal carbon dioxide monitoring 269 Chest tube insertion 173 Enema administration 272 Chest tube removal, assisting 175 Epicardial pacing and care 275 Clavicle strap application 177 Epidural analgesic administration 280 Closed-wound drain management 179 Esophageal tube care 283 Code management 181 Esophageal tube insertion and removal 285 Cold application 186 External fixation management 288 Colostomy and ileostomy care 188 Eye care 290 Colostomy irrigation 193 Eye compress application 291 Contact lens care 194 Eye irrigation 292 Contact precautions 196 Eye medication administration 295 Continent ileostomy care 201 Continuous ambulatory peritoneal dialysis 204 F Continuous bladder irrigation 207 Continuous passive motion device use 209 Fall prevention and management 297 Continuous positive airway pressure use 211 Fecal impaction removal, digital 300 Continuous renal replacement therapy 214 Fecal occult blood tests 302 Crede’s maneuver 217 Feeding 303 Cricothyrotomy, assisting 218 Feeding tube insertion and removal 307 Crutch use 220 Femoral compression 309 Foot care 311 Foreign body obstruction and management 312 D Functional assessment 315 Defibrillation 223 Discharge 228 G Documentation 230 Doppler use 232 Gastric lavage 317 Droplet precautions 233 Gastrostomy feeding button care and Drug and alcohol specimen collection 236 reinsertion 319 Dying patient care 239 H E Hair care 321 Eardrop instillation 241 Halo-vest traction management 322 Ear irrigation 242 Hand hygiene 325 Elastic bandage application 244 Hearing aid care 328 Electrical bone growth stimulation 247 Heat application 329 Electrocardiogram, 12-lead 249 Height and weight measurement 332 Electrocardiogram, right chest lead 251 Hemodialysis 334 Electrocardiogram, posterior chest lead 253 Hemoglobin testing, bedside 341 Electrocardiogram, signal-averaged 255 Hip arthroplasty care 342 Endoscopic therapy, assisting 256 Hour-of-sleep care 344 LWBK1103-FM_i-xvi.qxd 7/19/12 6:10 AM Page vii CONTENTS vii Humidifier therapy 345 L Hyperthermia-hypothermia blanket use 348 Laryngeal mask airway insertion 451 Laser therapy, assisting 454 Latex allergy protocol 457 I Lipid emulsion administration 459 IM injection 351 Low-air-loss therapy bed use 461 Impaired swallowing and aspiration Lumbar puncture, assisting 462 precautions 355 Implanted port use 358 Incentive spirometry 366 M Incontinence device application, male 368 Manual ventilation 465 Incontinence management, fecal 370 Massive infusion device use 467 Incontinence management, urinary 371 Mechanical traction management 469 Indwelling urinary catheter care and removal 374 Mechanical ventilation, positive pressure 472 Indwelling urinary catheter insertion 377 Metered-dose inhaler use 476 Indwelling urinary catheter irrigation 382 Mixed venous oxygen saturation monitoring 478 Intermittent infusion device drug administration 384 Moderate sedation 480 Intermittent infusion device insertion 385 Mucus clearance device 482 Intermittent positive-pressure breathing 388 Intermittent urinary catheterization 389 Internal fixation management 392 N Intra-abdominal pressure monitoring 395 Nasal irrigation 483 Intra-aortic balloon counterpulsation 397 Nasal medication administration 485 Intracranial pressure monitoring 403 Nasal packing, assisting 487 Intradermal injection 409 Nasoenteric-decompression tube care 490 Intraosseous infusion 412 Nasoenteric-decompression tube insertion and Intrapleural drug administration 414 removal 492 Iontophoresis 418 Nasogastric tube care 494 IV bolus injection 419 Nasogastric tube drug instillation 496 IV catheter insertion and removal 421 Nasogastric tube insertion and removal 498 IV catheter maintenance 431 Nasopharyngeal airway insertion and care 503 IV infusion rates and manual control 436 Nebulizer therapy 504 IV pump use 438 Negative-pressure wound therapy 508 IV secondary line infusion 442 Nephrostomy and cystostomy tube dressing IV therapy preparation 443 changes 511 Neurologic assessment 513 Nutritional screening 518 J Jugular venous oxygen saturation monitoring 447 O Ommaya reservoir drug infusion 521 K Oral care 524 Knee arthroplasty postprocedure care 449 Oral drug administration 529 LWBK1103-FM_i-xvi.qxd 7/19/12 6:10 AM Page viii viii CONTENTS Organ donor, identification 531 S Oronasopharyngeal suction 533 Seizure management 641 Oropharyngeal airway insertion and care 535 Self-catheterization 644 Oxygen administration 537 Sequential compression therapy 645 Sexual assault examination 648 P Sharp debridement 650 Shaving 651 Pain management 542 Sitz bath 652 Parenteral nutrition administration 546 Skin biopsy 654 Parenteral nutrition monitoring 552 Skin graft care 655 Passive range-of-motion exercises 554 Skin staple and clip removal 658 Patient-controlled analgesia 557 Soaks 660 Pericardiocentesis, assisting 560 Spiritual care 661 Perineal care 563 Splint application 664 Peripherally inserted central catheter use 564 Sponge bath 666 Peripheral nerve stimulation 572 Sputum collection 667 Peritoneal dialysis 575 Standard precautions 669 Peritoneal lavage, assisting 579 Sterile technique, basic 671 Permanent pacemaker care 582 Stool specimen collection 674 Personal protective equipment 585 ST-Segment monitoring 675 Pneumatic antishock garment application 586 Stump and prosthesis care 677 Postmortem care 588 Subcutaneous injection 680 Postoperative care 589 Subdermal drug implants 683 Preoperative care 593 Surgical drain removal 684 Preoperative skin preparation 594 Surgical wound management 685 Pressure dressing application 597 Suture removal 688 Pressure ulcer care 598 Swab specimen collection 691 Progressive ambulation 604 Synchronized cardioversion 695 Prone positioning 606 Protective environment guidelines 609 Pulmonary artery pressure and pulmonary artery wedge T pressure monitoring 610 Temperature assessment 697 Pulse amplitude monitoring 613 Therapeutic bath 700 Pulse assessment 614 Thoracentesis, assisting 702 Pulse oximetry 617 Thoracic electrical bioimpedance monitoring 704 Tilt table 705 R Topical skin drug application 706 Radiation implant therapy 620 Tracheal cuff–pressure measurement 708 Radiation therapy, external 623 Tracheal suctioning, intubated patient 710 Radioactive iodine therapy 624 Tracheostomy and ventilator speaking valve 715 Rectal suppositories and ointments 626 Tracheostomy care 717 Rectal tube insertion and removal 628 Tracheotomy, assisting 722 Respiration assessment 629 Transabdominal tube feeding and care 725 Restraint application 631 Transcranial Doppler monitoring 729 Ring removal 635 Transcutaneous electrical nerve stimulation 732 Rotation beds 638 LWBK1103-FM_i-xvi.qxd 7/19/12 6:10 AM Page ix CONTENTS ix Transcutaneous pacing 734 Transdermal drug application 736 Transducer system setup 739 Transfer within a facility 741 Transfusion of blood and blood products 742 Transfusion reaction management 747 Transvenous pacing 751 Traumatic wound management 754 T-tube care 756 Tub baths and showers 759 Tube feedings 760 U Ultraviolet light therapy 765 Unna’s boot application 768 Urinary diversion stoma care 769 Urine collection, 12- or 24-hour timed 773 Urine glucose and ketone tests 774 Urine pH 775 Urine specimen collection 776 Urine straining, for calculi 779 V Vaginal medication administration 780 Venipuncture 781 Ventricular assist device care 784 Ventricular drain insertion, assisting 786 Volume-control set preparation 788 W Walkers 790 Water intoxication assessment 792 Wound dehiscence and evisceration management 793 Wound irrigation 795 Z Z-track injection 797 Index 801 LWBK1103-FM_i-xvi.qxd 7/19/12 6:10 AM Page x
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