Clinical Nursing Skills: A Concept-Based Approach, Volume III

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

  • Barbara Callahan

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Overview

Nursing: A Concept-Based Approach to Learning provides the core content and materials needed to deliver an effective concept-based nursing program.

Published by Pearson (May 20th 2021) - Copyright © 2019

ISBN-13: 9780136873006

Subject: Nursing

Category: Upper-Level Titles

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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