Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Approach

406 Pages · 2011 · 1.31 MB · English

  • Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Approach

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    Skill Checklists for

    Taylor’s Clinical

    Nursing Skills



    Pamela Lynn, MSN, RN


    School of Nursing

    Gwynedd-Mercy College

    Gwynedd Valley, Pennsylvania

    Marilee LeBon, BA


    Brigantine, New Jersey LWBK681-FM_pi-xii.qxd 9/16/10 2:35 AM Page ii Aptara

    Executive Acquisitions Editor: Carrie Brandon

    Product Manager: Helene T. Caprari

    Design Coordinator: Holly McLaughlin

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    Prepress Vendor: Aptara, Inc.

    3rd edition

    Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.

    Copyright © 2008, 2005 Lippincott Williams & Wilkins. All rights reserved. This book is protected by

    copyright. No part of this book may be reproduced or transmitted in any form or by any means, including

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    critical articles and reviews. Materials appearing in this book prepared by individuals as part of their

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    9 8 7 6 5 4 3 2 1

    Printed in the United States of America.

    ISBN: 978-0-7817-9518-0

    Care has been taken to confirm the accuracy of the information presented and to describe generally

    accepted practices. However, the authors, editors, and publisher are not responsible for errors or omis-

    sions or for any consequences from application of the information in this book and make no warranty,

    expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the pub-

    lication. Application of this information in a particular situation remains the professional responsibility

    of the practitioner; the clinical treatments described and recommended may not be considered absolute

    and universal recommendations.

    The authors, editors, and publisher have exerted every effort to ensure that drug selection and

    dosage set forth in this text are in accordance with the current recommendations and practice at the

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    constant flow of information relating to drug therapy and drug reactions, the reader is urged to check

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    Developing clinical competency is a major challenge for each fundamentals student. To facilitate the mastery

    of nursing skills, we are happy to provide Skill Checklists for each skill in Taylor Clinical Nursing Skills:

    A Nursing Process Approach, 3rd edition. The skill checklists follow each step of the skill to provide a

    complete evaluative tool. Students can use the checklists to facilitate self-evaluation, and faculty will find them

    useful in measuring and recording student performance. Three-hole punched and perforated, these checklists

    can be easily reproduced and brought to the simulation laboratory or clinical area. The checklists are designed

    to record an evaluation of each step of the skill.

    • Checkmark in the “Excellent” column denotes mastering the procedure.

    • Checkmark in the “Satisfactory” column indicates use of the recommended technique.

    • Checkmark in the “Needs Practice” column indicates use of some but not all of each recommended


    The Comments section allows you to highlight suggestions that will improve skills. Space is available at the top

    of each checklist to record a final pass/fail evaluation, date, and the signature of the student and evaluating

    faculty member.

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    List of Skills by Chapter

    Chapter 1 Vital Signs

    Skill 1-1: Assessing Body Temperature 1

    Skill1-2: Monitoring Temperature Using an Overhead Radiant Warmer 5

    Skill1-3: Using a Cooling Blanket 6

    Skill1-4: Assessing a Peripheral Pulse by Palpation 8

    Skill1-5: Assessing the Apical Pulse by Auscultation 9

    Skill1-6: Assessing Respiration 10

    Skill1-7: Assessing Brachial Artery Blood Pressure 11

    Chapter 2 Health Assessment

    Skill2-1: Performing a General Survey 14

    Skill2-2: Using a Bed Scale 16

    Skill2-3: Assessing the Skin, Hair, and Nails 18

    Skill2-4: Assessing the Head and Neck 20

    Skill2-5: Assessing the Thorax and Lungs 23

    Skill2-6: Assessing the Cardiovascular System 25

    Skill2-7: Assessing the Abdomen 27

    Skill2-8: Assessing the Neurologic, Musculoskeletal, and Peripheral Vascular Systems 29

    Chapter 3 Safety

    Skill3-1: Fall Prevention 32

    Skill3-2: Implementing Alternatives to the Use of Restraints 34

    Skill3-3: Applying an Extremity Restraint 36

    Skill3-4: Applying a Waist Restraint 38

    Skill3-5: Applying an Elbow Restraint 40

    Skill3-6: Applying a Mummy Restraint 42

    Chapter 4 Asepsis and Infection Control

    Skill4-1: Performing Hand Hygiene Using Soap and Water (Handwashing) 43

    Skill4-2: Performing Hand Hygiene Using an Alcohol-Based Hand Rub 44

    Skill4-3: Preparing a Sterile Field Using a Packaged Sterile Drape 45

    Skill4-4: Preparing a Sterile Field Using a Commercially Prepared Sterile Kit or Tray 46

    Skill4-5: Adding Sterile Items to a Sterile Field 48

    Skill4-6: Putting on Sterile Gloves and Removing Soiled Gloves 50

    Skill4-7: Using Personal Protective Equipment 52

    Chapter 5 Medications

    Skill5-1: Administering Oral Medications 54

    Skill5-2: Administering Medications via a Gastric Tube 57

    Skill5-3: Removing Medication from an Ampule 60

    Skill5-4: Removing Medication from a Vial 62

    Skill5-5: Mixing Medications From Two Vials in One Syringe 64

    Skill5-6: Administering an Intradermal Injection 66

    Skill5-7: Administering a Subcutaneous Injection 69

    Skill5-8: Administering an Intramuscular Injection 72

    Skill5-9: Administering Continuous Subcutaneous Infusion: Applying an Insulin Pump 75

    Skill5-10: Administering Medications by Intravenous Bolus or Push Through an Intravenous Infusion 78

    Skill5-11: Administering a Piggyback Intermittent Intravenous Infusion of Medication 81

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    vi Contents

    Skill5-12: Administering an Intermittent Intravenous Infusion of Medication via a Mini-infusion Pump 84

    Skill5-13: Administering an Intermittent Intravenous Infusion of Medication via a Volume-Control

    Administration Set 87

    Skill5-14: Introducing Drugs Through a Medication or Drug-Infusion Lock Using the Saline Flush

    (Intermittent Peripheral Venous Access Device) 90

    Skill5-15: Applying a Transdermal Patch 93

    Skill5-16: Instilling Eye Drops 95

    Skill5-17: Administering an Eye Irrigation 98

    Skill5-18: Instilling Ear Drops 100

    Skill5-19: Administering an Ear Irrigation 102

    Skill5-20: Instilling Nose Drops 104

    Skill5-21: Administering a Vaginal Cream 106

    Skill5-22: Administering a Rectal Suppository 109

    Skill5-23: Administering Medication via a Metered-Dose Inhaler (MDI) 111

    Skill5-24: Administering Medication via a Small-Volume Nebulizer 113

    Skill5-25: Administering Medication via a Dry Powder Inhaler 115

    Chapter 6 Perioperative Nursing

    Skill6-1: Providing Preoperative Patient Care: Hospitalized Patient 117

    Skill6-2: Deep Breathing Exercises, Coughing, and Splinting 120

    Skill6-3: Leg Exercises 122

    Skill6-4: Providing Preoperative Patient Care: Hospitalized Patient (Day of Surgery) 123

    Skill6-5: Providing Postoperative Care When Patient Returns to Room 125

    Skill6-6: Applying a Forced-Air Warming Device 128

    Chapter 7 Hygiene

    Skill7-1: Giving a Bed Bath 129

    Skill7-2: Assisting the Patient With Oral Care 132

    Skill7-3: Providing Oral Care for the Dependent Patient 134

    Skill7-4: Providing Denture Care 135

    Skill7-5: Removing Contact Lenses 136

    Skill7-6: Shampooing a Patient’s Hair in Bed 137

    Skill7-7: Assisting the Patient to Shave 139

    Skill7-8: Making an Unoccupied Bed 140

    Skill7-9: Making an Occupied Bed 142

    Chapter 8 Skin Integrity and Wound Care

    Skill8-1: Cleaning a Wound and Applying a Dry, Sterile Dressing 144

    Skill8-2: Applying a Saline-Moistened Dressing 147

    Skill8-3: Applying a Hydrocolloid Dressing 149

    Skill8-4: Performing Irrigation of a Wound 151

    Skill8-5: Collecting a Wound Culture 153

    Skill8-6: Applying Montgomery Straps 155

    Skill8-7: Caring for a Penrose Drain 157

    Skill8-8: Caring for a T-Tube Drain 159

    Skill8-9: Caring for a Jackson-Pratt Drain 162

    Skill8-10: Caring for a Hemovac Drain 164

    Skill8-11: Applying Negative Pressure Wound Therapy 166

    Skill8-12: Removing Sutures 169

    Skill8-13: Removing Surgical Staples 171

    Skill8-14: Applying an External Heating Pad 173

    Skill8-15: Applying a Warm Compress 175

    Skill8-16: Assisting With a Sitz Bath 177

    Skill8-17: Applying Cold Therapy 178

    Chapter 9 Activity

    Skill9-1: Assisting a Patient With Turning in Bed 180

    Skill9-2: Moving a Patient Up in Bed With the Assistance of Another Nurse 182

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    Contents vii

    Skill9-4: Transferring a Patient From the Bed to a Chair 186

    Skill9-5: Transferring a Patient Using a Powered Full-Body Sling Lift 188

    Skill9-6: Providing Range-of-Motion Exercises 190

    Skill9-7: Assisting a Patient With Ambulation 192

    Skill9-8: Assisting a Patient With Ambulation Using a Walker 194

    Skill9-9: Assisting a Patient With Ambulation Using Crutches 196

    Skill9-10: Assisting a Patient With Ambulation Using a Cane 198

    Skill9-11: Applying and Removing Antiembolism Stockings 199

    Skill9-12: Applying Pneumatic Compression Devices 201

    Skill9-13: Applying a Continuous Passive Motion Device 203

    Skill9-14: Applying a Sling 205

    Skill9-15: Applying a Figure-Eight Bandage 206

    Skill9-16: Assisting With Cast Application 208

    Skill9-17: Caring for a Cast 210

    Skill9-18: Applying Skin Traction and Caring for a Patient in Skin Traction 212

    Skill9-19: Caring for a Patient in Skeletal Traction 214

    Skill9-20: Caring for a Patient With an External Fixation Device 216

    Chapter 10 Comfort

    Skill10-1: Promoting Patient Comfort 218

    Skill10-2: Giving a Back Massage 222

    Skill10-3: Applying and Caring for a Patient Using a TENS Unit 224

    Skill10-4: Caring for a Patient Receiving Patient-Controlled Analgesia 226

    Skill10-5: Caring for a Patient Receiving Epidural Analgesia 228

    Skill10-6: Caring for a Patient Receiving Continuous Wound Perfusion Pain Management 230

    Chapter 11 Nutrition

    Skill11-1: Assisting a Patient With Eating 232

    Skill11-2: Inserting a Nasogastric (NG) Tube 234

    Skill11-3: Administering a Tube Feeding 237

    Skill11-4: Removing a Nasogastric Tube 240

    Skill11-5: Caring for a Gastrostomy Tube 241

    Chapter 12 Urinary Elimination

    Skill12-1: Assisting With the Use of a Bedpan 243

    Skill12-2: Assisting With the Use of a Urinal 245

    Skill12-3: Assisting With the Use of a Bedside Commode 247

    Skill12-4: Assessing Bladder Volume Using an Ultrasound Bladder Scanner 249

    Skill12-5: Applying an External Condom Catheter 251

    Skill12-6: Catheterizing the Female Urinary Bladder 253

    Skill12-7: Catheterizing the Male Urinary Bladder 256

    Skill12-8: Removing an Indwelling Catheter 259

    Skill12-9: Performing Intermittent Closed Catheter Irrigation 260

    Skill12-10: Administering a Continuous Closed Bladder Irrigation 262

    Skill12-11: Emptying and Changing a Stoma Appliance on an Ileal Conduit 264

    Skill12-12: Caring for a Suprapubic Urinary Catheter 266

    Skill12-13: Caring for a Peritoneal Dialysis Catheter 268

    Skill12-14: Caring for a Hemodialysis Access (Arteriovenous Fistula or Graft) 270

    Chapter 13 Bowel Elimination

    Skill13-1: Administering a Large-Volume Cleansing Enema 271

    Skill13-2: Administering a Small-Volume Cleansing Enema 273

    Skill13-3: Administering a Retention Enema 275

    Skill13-4: Digital Removal of Stool 277

    Skill13-5: Applying a Fecal Incontinence Pouch 279

    Skill13-6: Changing and Emptying an Ostomy Appliance 280

    Skill13-7: Irrigating a Colostomy 282

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    viii Contents

    Chapter 14 Oxygenation

    Skill14-1: Using a Pulse Oximeter 286

    Skill14-2: Teaching Patient to Use an Incentive Spirometer 288

    Skill14-3: Administering Oxygen by Nasal Cannula 290

    Skill14-4: Administering Oxygen by Mask 291

    Skill14-5: Using an Oxygen Tent 292

    Skill14-6: Suctioning the Nasopharyngeal and Oropharyngeal Airways 293

    Skill14-7: Inserting an Oropharyngeal Airway 296

    Skill14-8: Suctioning an Endotracheal Tube: Open System 298

    Skill14-9: Suctioning an Endotracheal Tube: Closed System 301

    Skill14-10: Securing an Endotracheal Tube 304

    Skill14-11: Suctioning the Tracheostomy: Open System 307

    Skill14-12: Providing Tracheostomy Care 310

    Skill14-13: Providing Care of a Chest Drainage System 313

    Skill14-14: Assisting With Removal of a Chest Tube 315

    Skill14-15: Using a Handheld Resuscitation Bag and Mask 316

    Chapter 15 Fluid, Electrolyte, and Acid–Base Balance

    Skill15-1: Initiating a Peripheral Venous Access IV Infusion 318

    Skill15-2: Changing an IV Solution Container and Administration Set 322

    Skill15-3: Monitoring an IV Site and Infusion 325

    Skill15-4: Changing a Peripheral Venous Access Dressing 327

    Skill15-5: Capping for Intermittent Use and Flushing a Peripheral Venous Access Device 329

    Skill15-6: Administering a Blood Transfusion 330

    Skill15-7: Changing the Dressing and Flushing Central Venous Access Devices 333

    Skill15-8: Accessing an Implanted Port 335

    Skill15-9: Deaccessing an Implanted Port 337

    Skill15-10: Removing a Peripherally Inserted Central Catheter (PICC) 339

    Chapter 16 Cardiovascular Care

    Skill16-1: Obtaining an Electrocardiogram (ECG) 340

    Skill16-2: Applying a Cardiac Monitor 343

    Skill16-3: Obtaining an Arterial Blood Sample From an Arterial Line–Stopcock System 345

    Skill16-4: Removing Arterial and Femoral Lines 347

    Skill16-5: Performing Cardiopulmonary Resuscitation (CPR) 349

    Skill16-6: Performing Emergency Automated External Defibrillation 351

    Skill16-7: Performing Emergency Manual External Defibrillation (Asynchronous) 353

    Skill16-8: Using an External (Transcutaneous) Pacemaker 355

    Chapter 17 Neurologic Care

    Skill17-1: Logrolling a Patient 358

    Skill17-2: Applying a Two-Piece Cervical Collar 360

    Skill17-3: Employing Seizure Precautions and Seizure Management 362

    Skill17-4: Caring for a Patient in Halo Traction 364

    Skill17-5: Caring for a Patient with an External Ventriculostomy (Intraventricular Catheter–Closed

    Fluid-Filled System) 366

    Skill17-6: Caring for a Patient With a Fiber Optic Intracranial Catheter 368

    Chapter 18 Laboratory Specimen Collection

    Skill18-1: Testing Stool for Occult Blood 369

    Skill18-2: Collecting a Stool Specimen for Culture 371

    Skill18-3: Obtaining a Capillary Blood Sample for Glucose Testing 372

    Skill18-4: Obtaining a Nasal Swab 374

    Skill18-5: Obtaining a Nasopharyngeal Swab 376

    Skill18-6: Collecting a Sputum Specimen for Culture 378

    Skill18-7: Collecting a Urine Specimen (Clean Catch, Midstream) for Urinalysis and Culture 380

    Skill18-8: Obtaining a Urine Specimen From an Indwelling Urinary Catheter 382

    Skill18-9: Using Venipuncture to Collect a Venous Blood Sample for Routine Testing 384

    Skill18-10: Obtaining a Venous Blood Specimen for Culture and Sensitivity 387

    Skill18-11: Obtaining an Arterial Blood Specimen for Blood Gas Analysis 390

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