Mosby's Pocket Guide to Nursing Skills & Procedures

683 Pages·2014·12.36 MB·English

by  Anne Griffin Perry

The Joint Commission Offcial “Do Not Use” List*
of Abbreviations
ABBREVIATION PREFERRED TERM
U (unit) Write “unit”
IU (international unit) Write “international unit”
Q.D., QD, q.d., qd (daily) Write “daily”
Q.O.D., QOD, q.o.d. qod (every Write “every other day”
other day)
Trailing zero (X.0 mg)† Write X mg
Lack of leading zero (.X mg) Write 0.X mg
MS Write “morphine sulfate”
MSO4 and MgSO4 Write “magnesium sulfate”
Additional Abbreviations, Acronyms, and Symbols
(for possible future inclusion in the Offcial “Do Not Use” List)
> (greater than) Write “greater than”
< (less than) Write “less than”
Abbreviations for drug names Write drug names in full
Apothecary units Use metric units
@ Write “at”
cc Write “mL”
µg Write “mcg” or “micrograms”
In 2004, The Joint Commission created its “do not use” list of
abbreviations as part of the requirements for meeting a National
Patient Safety Goal. In 2010, NPSG.02.02.01 was integrated into the
Information Management standards as elements of performance 2 and
3 under IM.02.02.01.
http://www.jointcommission.org/assets/1/18/Do_Not_Use_List.pdf
*Applies to all orders and all medication-related documentation that
is handwritten (including free-text computer entry) or on preprinted
forms.
†Exception: A “trailing zero“ may be used only where required to
demonstrate the level of precision of the value being reported, such
as for laboratory results, imaging studies that report size of lesions, or
catheter/tube sizes. It may not be used in medication orders or other
medication-related documentation.
Mosby’s Pocket Guide to
Nursing Skills
& Procedures
EIGHTH EDITION
Anne Griffn Perry, EdD, RN, FAAN
Interim Dean and Professor
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
Subject Matter Expert
Paul L. Desmarais, PhD, RN, CCRN
Lecturer
College of Nursing
University of Central Florida
Orlando, Florida
3251 Riverport Lane
St. Louis, Missouri 63043
MOSBY’S POCKET GUIDE TO NURSING SKILLS 978-0-323-18741-1
AND PROCEDURES
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
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. Details on how to seek permission, further information
about the Publisher’s permissions policies and our arrangements with
organizations such as the Copyright Clearance Center and the Copyright
Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this feld are constantly changing. As new
research and experience broaden our understanding, changes in research
methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience
and knowledge in evaluating and using any information, methods,
compounds, or experiments described herein. In using such information
or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identifed, 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 practitioners, relying on their own experience and
knowledge of their patients, 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,
contributors, or editors, assume any liability for any injury and/or damage
to persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
Previous editions copyrighted 2011, 2007, 2003, 1998, 1994, 1990, 1986
International Standard Book Number 978-0-323-18741-1
Content Development Manager, Education: Jean Sims Fornango
Associate Content Development Specialist: Savannah Davis
Publishing Services Manager: Deborah L. Vogel
Senior Project Manager: Jodi M. Willard
Design Direction: Brian Salisbury
Printed in China
Last digit is the print number:
9 8 7 6 5 4 3 2 1
P R E F A C E
Mosby’s Pocket Guide to Nursing Skills and Procedures, eighth edition, is
a practical, portable reference for students and practitioners in the
clinical setting. Grouped alphabetically, 85 commonly performed skills
are presented in a clear, step-by-step format that includes:
■ Purpose for performing each skill
■ Guidelines to help students in delegating tasks to assistive
personnel
■ List of equipment required
■ Rationales to explain why specifc techniques are used
■ Full-color photographs and drawings to provide visual
reinforcement
In addition, Safety Alerts are included in the skills to highlight impor-
tant information about patient safety and effective performance.
Current Standard Precautions guidelines from the Centers for Disease
Control and Prevention are incorporated throughout. Preprocedure
and postprocedure protocols are conveniently located on the inside
back cover.
Features of This Edition
■ Glove logo identifes when gloves should be worn.
■ Information is completely updated for every skill and procedure.
■ Unexpected Outcomes and Related Interventions present
commonly occurring complications and the appropriate responses
for patient care.
■ Completely updated, full-color illustrations throughout.
This pocket guide is also available in formats compatible with handheld
electronic devices. For a more complete discussion of information pre-
sented in this book, refer to Perry and Potter: Clinical Nursing Skills and
Techniques, eighth edition.
iii
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C ON T E N T S
A
Skill 1 Acapella Device, 1
Skill 2 Apical-Radial Pulse, 4
Skill 3 Aquathermia and Heating Pads, 6
Skill 4 Aspiration Precautions, 10
Skill 5 Assistive Device Ambulation (Use of Crutches, Cane, and
Walker), 16
Skill 6 Automated External Defbrillator, 31
B
Skill 7 Bladder Volume Measurement, 36
Skill 8 Blood Administration, 39
Skill 9 Blood Glucose Testing, 48
Skill 10 Blood Pressure by Auscultation: Upper Extremities, Lower
Extremities, Palpation, 54
Skill 11 Blood Pressure: Automatic, 65
C
Skill 12 Central Venous Access Device Care: Central Venous
Catheter, Ports, 68
Skill 13 Chest Tube Care, 83
Skill 14 Cold Applications, 99
Skill 15 Condom Catheter, 105
Skill 16 Continuous Passive Motion Machine, 110
Skill 17 Continuous Subcutaneous Infusion, 114
D
Skill 18 Dressings: Dry and Moist-to-Dry, 121
Skill 19 Dressings: Hydrocolloid, Hydrogel, Foam, or Alginate, 131
Skill 20 Dressings: Transparent, 140
E
Skill 21 Ear Drop Administration, 145
Skill 22 Ear Irrigations, 149
Skill 23 Enemas, 153
Skill 24 Enteral Nutrition via a Gastrostomy or Jejunostomy
Tube, 161
Skill 25 Enteral Nutrition via a Nasoenteric Feeding Tube, 168
Skill 26 Epidural Analgesia, 176
Skill 27 Eye Irrigation, 184
Skill 28 Eye Medications: Drops and Ointment, 188
F
Skill 29 Fall Prevention in a Health Care Facility, 195
Skill 30 Fecal Impaction: Removing Digitally, 204
v
vi Contents
H
Skill 31 Hypothermia and Hyperthermia Blankets, 208
I
Skill 32 Incentive Spirometery, 212
Skill 33 Intradermal Injections, 214
Skill 34 Intramuscular Injections, 221
Skill 35 Intravenous Medications: Intermittent Infusion Sets and
Mini-Infusion Pumps, 230
Skill 36 Intravenous Medications: Intravenous Bolus, 241
Skill 37 Isolation Precautions, 250
M
Skill 38 Mechanical Lifts, 262
Skill 39 Metered-Dose Inhalers, 268
Skill 40 Moist Heat (Compress and Sitz Bath), 276
Skill 41 Mouth Care: Unconscious or Debilitated Patients, 283
N
Skill 42 Nail and Foot Care, 288
Skill 43 Nasoenteral Tube: Placement and Irrigation, 293
Skill 44 Nasogastric Tube for Gastric Decompression: Insertion
and Removal, 304
Skill 45 Negative-Pressure Wound Therapy, 312
O
Skill 46 Oral Medications, 320
Skill 47 Oral Medications: Nasogastric Tube Administration, 330
Skill 48 Ostomy Care (Pouching), 337
Skill 49 Oxygen Therapy: Nasal Cannula, Oxygen Mask, T Tube, or
Tracheostomy Collar, 342
P
Skill 50 Parenteral Medication Preparation: Ampules
and Vials, 348
Skill 51 Parenteral Medications: Mixing Medications in One
Syringe, 358
Skill 52 Patient-Controlled Analgesia, 366
Skill 53 Peripheral Intravenous Care: Dressing Care,
Discontinuation, 372
Skill 54 Peripheral Intravenous Care: Regulating Intravenous Flow
Rate, Changing Tubing and Solution, 379
Skill 55 Peripheral Intravenous Insertion, 389
Skill 56 Peripherally Inserted Central Catheter Care, 408
Contents vii
Skill 57 Postoperative Exercises, 417
Skill 58 Pressure Bandages (Applying), 428
Skill 59 Pressure Ulcer Risk Assessment, 433
Skill 60 Pressure Ulcer Treatment, 443
Skill 61 Pulse Oximetry, 453
R
Skill 62 Rectal Suppository Insertion, 459
Skill 63 Respiration Assessment, 465
Skill 64 Restraint Application, 471
Skill 65 Restraint-Free Environment, 479
S
Skill 66 Seizure Precautions, 484
Skill 67 Sequential Compression Device and Elastic
Stockings, 491
Skill 68 Specialty Beds: Air-Fluidized, Air-Suspension, and
Rotokinetic, 497
Skill 69 Sterile Gloving, 505
Skill 70 Sterile Technique: Donning and Removing Cap, Mask, and
Protective Eyewear, 512
Skill 71 Subcutaneous Injections, 517
Skill 72 Suctioning: Closed (In-Line), 525
Skill 73 Suctioning: Nasopharyngeal, Nasotracheal, and Artifcial
Airway, 529
Skill 74 Suprapubic Catheter Care, 543
Skill 75 Suture and Staple Removal, 548
T
Skill 76 Topical Skin Applications, 555
Skill 77 Tracheostomy Care, 563
U
Skill 78 Urinary Catheter Insertion, 572
Skill 79 Urinary Catheter Care and Removal, 587
Skill 80 Urinary Catheter Irrigation, 595
Skill 81 Urinary Diversion: Pouching an Incontinent Urinary
Diversion, 603
V
Skill 82 Vaginal Instillations, 608
Skill 83 Venipuncture: Collecting Blood Specimens and Cultures by
Syringe and Vacutainer Method, 615
viii Contents
W
Skill 84 Wound Drainage Devices: Jackson-Pratt, Hemovac, 626
Skill 85 Wound Irrigation, 631
Appendix: Overview of CDC Hand Hygiene Guidelines, 637
Bibliography, 640