Nursing Procedures

589 Pages·2015·12.59 MB·English

~

A vance
Practice
Nursing Procedures

Margaret R. Colyar

Advanced
Practice
Nursing Procedures

Margaret R. Colyar, DSN, APRN, C-FNP
Family Nurse Practitioner
Hannibal Clinic
Hannibal, Missouri

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F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com

Copyright © 2015 by F. A. Davis Company

Copyright © 2015 by F. A. Davis Company. All rights reserved. This book is protected by copyright.
No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from
the publisher.

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Publisher, Nursing: Joanne Patzek DaCunha, RN, MSN
Senior Acquisitions Editor: Susan R. Rhyner
Content Development Manager: Darlene Pedersen
Content Project Manager: Christina L. Snyder
Design and Illustration Manager: Carolyn O’Brien

As new scientific information becomes available through basic and clinical research, recommended
treatments and drug therapies undergo changes. The author(s) and publisher have done everything
possible to make this book accurate, up to date, and in accord with accepted standards at the time of
publication. The author(s), editors, and publisher are not responsible for errors or omissions or for
consequences from application of the book, and make no warranty, expressed or implied, in regard to
the contents of the book. Any practice described in this book should be applied by the reader in
accordance with professional standards of care used in regard to the unique circumstances that may
apply in each situation. The reader is advised always to check product information (package inserts) for
changes and new information regarding dose and contraindications before administering any drug.
Caution is especially urged when using new or infrequently ordered drugs.

Library of Congress Control Number 2014959076

Authorization to photocopy items for internal or personal use, or the internal or personal use of
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This book is lovingly dedicated to Stephen Colyar, Andrea Brown,
Michelle Bailey, and Courtney Kaul.

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v

Preface

The new nurse practitioner and the practicing nurse practitioner in the ambulatory
care setting must be prepared to perform an increasing array of skills competently
to meet patient care needs. The inspiration for this book came when, on graduating
from a nurse practitioner program, I found no procedural resources directed toward
the needs of the nurse practitioner in ambulatory care. The need to perform many
procedures—those not taught in my nurse practitioner program—was apparent. The
physician I practiced with required a knowledge base in procedural skills greater than
the one I possessed. Fortunately, this physician was willing to teach me the necessary
procedures. This improved care to our patients and decreased the necessity to refer
many patients for procedures easily performed in the ambulatory care (outpatient)
setting.
This text was developed to assist in the many demands on the newly graduated
nurse practitioner and the nurse practitioner currently in practice. We believe the
procedures outlined will improve the marketability of the nurse practitioner and
serve as a good reference tool for family and/or adult nurse practitioners in an
ambulatory care setting. Prerequisites for this book are basic anatomy and physiology,
microbiology, pharmacology, principles of aseptic technique, and basic nursing skills.
This book would be an appropriate text for incorporation of procedural techniques
throughout a family or an adult nurse practitioner curriculum. It also would be
appropriate for an elective on minor surgery and diagnostic procedures and inter-
pretation. Another potential use for this book would be as part of the protocol/
guidelines in the nurse practitioner’s practice.
Many procedures performed by primary care physicians are not currently appro-
priate for the nurse practitioner to perform. The procedures in this book were chosen
based on a comprehensive study of types of procedures currently used in the nurse
practitioner’s practice. Many of the procedures can be used in any ambulatory
setting. Twenty-eight new procedures have been added to this edition: Suture selec-
tion, ulcer debridement, compartment syndrome and pressure testing, bladder cath-
eterization, breast examination, administration of vaginal medications and condoms,
Nexplanon insertion and removal, vaginal examination, fetal assessment, Leopold’s
maneuver, fundal assessment, obstetric ultrasound, emergency delivery, teaching
breast feeding, eye drop insertion, laryngoscopy, nasal lavage, cardiac stress testing,
type of pacemakers, defibrillation, assessing for respiratory distress, pulmonary stress
test, hemoccult, urea breath test, perianal skin tags and external hemorrhoidal skin
tabs, pilonidal cyst, prostate massage, and rectal prolapsed reduction.
Some of the procedures need specialized equipment, and some use equip-
ment commonly found in any office. A few of the procedures—flexible chest tube
insertion, circumcision, colposcopy, endometrial biopsy, IUD insertion and re-
moval, lumbar puncture, occipital nerve block, paracentesis, sigmoidoscopy, and

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vi Preface

thrombosed hemorrhoid removal—require additional training. They are included
for reference only. Check with your State Board of Nursing if you are unsure whether
or not a certain procedure may be performed by nurse practitioners in the state in
which you practice.
The major theme of this book is clinical application of knowledge and clinical
skills. There are seven sections in the book. These sections are based on body systems
for ease of classification. Each major section begins with diagnostic procedures the
nurse practitioner performs with the basis for their interpretation. Next in each
section, listed in alphabetical order, are procedures performed in an ambulatory care
setting.
Each procedure contains seven parts. First, an Overview is presented, outlining
causes, incidence, and other specific information intrinsic to each procedure. The
Health Promotion/Prevention section gives tips to the nurse practitioner to pass on to
the client to help promote health or prevent the need for the procedure in the future.
Options lists one to four methods of performing the procedure and gives a choice of
how to perform the procedure. The Rationale section gives reasons to perform the
procedure. Indications tell the nurse practitioner when the procedure should be
performed, and Contraindications tells the nurse practitioner when not to perform
the procedure. The Procedure section lists the necessary equipment and gives step-
by-step instructions for performing each procedure listed under Options. Client
Instructions assist the nurse practitioner with postprocedure instructions, listing what
the client must and must not do to have an optimal recovery period. At the end of
each is the Bibliography for further information gathering.
We hope you will find this text to be a good learning tool and a great resource
in your practice.

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vii

Acknowledgments

We acknowledge the following people for their contributions, assistance, and patience
while compiling this book: Joanne DaCunha, RN, MSN, Nursing Acquisitions
Editor at F.A. Davis, for believing in the merits of this book, and Denise Melomo,
artist, for her expertise in sketching the line drawings from which the illustrations
in this book were made.
Many colleagues at Tri County Family Health Care in Madison, Florida, and
Family Health Service in Ocala, Florida, were instrumental in this book. Colleagues
at Rapides Regional Medical Center, Alexandria, Louisiana; Jackson Parish Hospital,
Jonesboro, Louisiana; and Stansbury Medical Center, Stansbury Park, Utah, posed
for the photographs in the book. These models include Linda Alby, Steve Colyar,
Hugh Gentry, Cindy Grappe, Aleene Hale, Lane Helm, Debra Lefler, Anne Martin,
and Shaneal Wright.

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viii

Contributors

Tracy Call-Schmidt, MS, C-FNP
Pain Management Specialist
Salt Lake City, Utah

Margaret Colyar, DSN, APRN, C-FNP
Hannibal Clinic
Hannibal, Missouri

Cynthia Ehrhardt, RN, ARNP, MSN,
FNP-CS
Adjunct Faculty
University of Central Florida
Ocala, Florida

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ix

Contents

Section One: DERMATOLOGICAL PROCEDURES, 1
Diagnostic Testing
1. Punch Biopsy, 1
2. Skin Biopsy, 5
3. Wood’s Light Examination, 11

Procedures
4. Abscesses—Incision and Drainage: Furuncle, Felon, Paronychia,
Pilonidal Cyst, Perianal Cyst, 13
5. Bites: Ants, Arthropods (Spiders), Bees, and Wasps, 20
6. Bites—Cats, Dogs, and Humans, 24
7. Burns—Debridement, 27
8. Digital Nerve Block, 34
9. Fishhook Removal, 36
10. Nail Removal, 41
11. Ring Removal, 48
12. Sebaceous Cyst Removal, 54
13. Skin Closure—Dermabond Application, 59
14. Skin Lesion Removal—Cautery and Cryosurgery, 62
15. Skin Lesion Removal—Keloids, Moles, Corns, Calluses, 68
16. Skin Tag (Acrochordon) Removal, 73
17. Soft Tissue Aspiration, 79
18. Staple Insertion, 82
19. Staple Removal, 84
20. Steri-Strip Application, 87
21. Subungual Hematoma Excision, 89
22. Suture Insertion, 94
23. Suture Selection, 101
24. Suture Removal, 103
25. Tick Removal, 107
26. Topical Hemostatic Agent Application, 114
27. Ulcer Debridement, 117

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x Contents

Section Two: MUSCULOSKELETAL PROCEDURES, 121
Diagnostic Testing
28. Bone Marrow Aspiration and Biopsy, 121
29. Lumbar Puncture, 126
30. X-Ray Interpretation—Bones, 131
31. Arthrocentesis, 135
32. Compartment Syndrome Assessment, 138

Procedures
33. Clavicle Immobilization Techniques: Clavicle Strap, Figure Eight, Sling
and Swath, 143
34. Crutch Walking, 146
35. Dislocation Reduction, 152
36. Ganglion Cyst Aspiration and Injection, 166
37. Intra-Articular and Bursa Corticosteroid Injection, 170
38. Sling Application, 180
39. Splinting and Taping, 183
40. Trigger Point Injection, 202

Section Three: GENITOURINARY AND BREAST
PROCEDURES, 205
Diagnostic Testing
41. Bladder Catheterization Insertion and Removal, 205
42. Breast Biopsy—Fine Needle Aspiration, 211
43. Breast Examination, 214
44. Colposcopy—Endocervical Curettage and Cervical Biopsy, 221
45. Endometrial Biopsy, 227
46. Specimen Collection—Gram Stain, Wet Mount (Saline and KOH), 230
47. Specimen Collection—Papanicolaou (Pap) Smear, 234

Procedures
48. Administration of Vaginal Medications and Condoms, 240
49. Bartholin Cyst Abscess—Incision and Drainage, 243
50. Cervical Cap Fitting, Insertion, and Removal, 246
51. Cervical Lesions—Cryotherapy, 249
52. Circumcision and Dorsal Penile Nerve Block, 252
53. Condyloma Acuminata Removal, 258
54. Diaphragm Fitting, Insertion, and Removal, 263

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Contents xi

55. IUD Fitting, Insertion, and Removal, 266
56. Nexplanon Insertion, 274
57. Nexplanon Removal, 277
58. Paracervical Nerve Block, 279
59. Pessary Insertion, 281

Diagnostic Testing
60. Vaginal Examination, 285
61. Vasectomy, 289
62. At-Risk Fetal Assessment—Third Trimester Testing, 294
63. Leopold's Maneuver, 297
64. Fundal Assessment, 300
65. Obstetric Ultrasound, 302

Procedures
66. Emergency Delivery, 305
67. Teaching Breastfeeding, 308

Section Four: HEAD: EYES, EARS, NOSE, AND MOUTH, 313
Diagnostic Testing
68. Audiometry Testing, 313
69. Occipital Nerve Block, 317
70. Tympanometry, 321
71. Visual Function Evaluation—Snellen, Illiterate E, Pictorial, 330

Procedures—Eyes

72. Corneal Abrasion and Foreign Body Removal—Eye, 335
73. Eye Drop Insertion, 341
74. Eye Irrigation, 345
75. Eye Trauma Stabilization, 348
76. Eyebrow Laceration Repair, 354
77. Eyelid Eversion, 358

Procedures—Ears/Nose
78. Auricular Hematoma Evacuation, 360
79. Cerumen Impaction Removal—Irrigation of the Ear and Curette
Technique, 363
80. Ear Piercing, 367
81. Epistaxis Control, 370

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xii Contents

Procedures—Mouth
82. Laryngoscopy—Indirect and Direct Flexible, 380
83. Nasal Lavage (Irrigation), 383
84. Removal of Foreign Body—Ear and Nose, 387
85. Frenotomy for Ankyloglossia, 390
86. Lip Laceration Repair, 393
87. Tongue Laceration Repair, 396
88. Tooth Avulsion and Fracture, 399

Section Five: CARDIOVASCULAR PROCEDURES, 403
Diagnostic Testing
89. Doppler Technique, 403
90. Electrocardiogram (EKG) Interpretation, 406
91. Electrocardiogram (EKG) Lead Placement, 424
92. Holter Monitor Application—Continuous 24-Hour Ambulatory Cardiac
Monitoring, 427
93. Stress Testing (Stress EKG), 430
94. Types of Pacemakers, 435

Procedures
95. Arterial Puncture, 437
96. Blood Culture Specimen Collection, 441
97. Capillary Blood Collection—Heel/Finger Stick, 445
98. Central Venous Catheter Access (Portacath), 447
99. Defibrillation, 451
100. Unna’s Boot Application, 453
101. Venipuncture, 457

Section Six: RESPIRATORY PROCEDURES, 463

102. Aerosol/Inhalation Administration (Nebulizer), 463
103. Assessing Respiratory Distress, 466
104. Peak Flowmeter, 469
105. Pulmonary Function Testing (Spirometry), 472
106. Pulmonary Stress Test, 476
107. X-Ray Interpretation—Chest, 480

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Contents xiii

Procedures
108. Chest Tubes for Emergency Transport, 488
109. Flail Chest Stabilization—With or Without Open Chest Wound, 491
110. Stab/Penetrating Wound Stabilization, 496

Section Seven: GASTROINTESTINAL PROCEDURES, 499
Diagnostic Testing
111. Anoscopy, 499
112. Hemoccult, 502
113. Flexible Sigmoidoscopy, 504
114. Urea Breath Test, 512
115. X-Ray Interpretation—Abdominal, 514

Procedures
116. Abdominal Paracentesis, 521
117. Gastric Lavage, 524
118. Inguinal Hernia Reduction, 529
119. Nasogastric Tube Insertion, 532
120. Percutaneous Endoscopic Gastrostomy (PEG) Tube Reinsertion, 534
121. Perianal Skin Tags/External Hemorrhoidal Skin Tags, 539
122. Pilonidal Cyst/Abscess Incision and Drainage (I&D), 541
123. Prostate Massage, 544
124. Rectal Prolapse Reduction, 547
125. Thrombosed Hemorrhoid Removal, 549

Glossary, 553
Index, 563

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