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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


    A NURSING PROCESS APPROACH


    THIRD EDITION


    Pamela Lynn, MSN, RN


    Instructor


    School of Nursing


    Gwynedd-Mercy College


    Gwynedd Valley, Pennsylvania


    Marilee LeBon, BA


    Editor


    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


    Manufacturing Coordinator: Karin Duffield


    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


    as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval


    system without written permission from the copyright owner, except for brief quotations embodied in


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


    official duties as U.S. government employees are not covered by the above-mentioned copyright. To


    request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square, 2001


    Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at


    lww.com (products and services).


    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


    time of publication. However, in view of ongoing research, changes in government regulations, and the


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


    the package insert for each drug for any change in indications and dosage and for added warnings and


    precautions. This is particularly important when the recommended agent is a new or infrequently


    employed drug.


    Some drugs and medical devices presented in this publication have Food and Drug Administration


    (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health


    care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical


    practice.


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    Introduction


    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


    technique.


    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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