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Taylor’s Clinical Nursing Skills A Nursing Process Approach Fourth Edition Pamela Lynn, MSN, RN Instructor Gwynedd Mercy University Frances M. Maguire School of Nursing and Health Professions Gwynedd Valley, Pennsylvania
Publisher: Lisa McAllister Executive Editor: Sherry Dickinson Product Developmental Editor: Christine Abshire Developmental Editor: Sarah Kyle Editorial Assistant: Dan Reilly Marketing Manager: Dean Karampelas Production Project Manager: Cynthia Rudy Design Coordinator: Holly Reid McLaughlin Illustration Coordinator: Jennifer Clements Manufacturing Coordinator: Karin Duffield Prepress Vendor: Aptara, Inc. 4th Edition Copyright © 2015 Wolters Kluwer Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2008, 2005 by 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 Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services). 987654321 Printed in China Library of Congress Cataloging-in-Publication Data Lynn, Pamela (Pamela Barbara), 1961- author. Taylor’s clinical nursing skills : a nursing process approach / Pamela Lynn. – Fourth edition. p. ; cm. Clinical nursing skills Includes bibliographical references and index. ISBN 978-1-4511-9271-1 (alk. paper) I. Title. II. Title: Clinical nursing skills. [DNLM: 1. Nursing Process. 2. Nursing Care–methods. WY 100] RT51 610.73–dc23 2014021573 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contradictions, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. LWW.com
To past, present, and future nursing students and my family: Each one of you helps me to continue learning and caring every day.
Contributors and Reviewers Contributors to Previous Editions Denise Doliveira, MSN, CMSRN Professor of Nursing Sheryl Kathleen Buckner, RN, MS, CM Community College of Allegheny County, Boyce Campus Academic and Staff Developer, Case Manager, Clinical Instructor Monroeville, Pennsylvania University of Oklahoma, College of Nursing Oklahoma City, Oklahoma Jaime Huffman, PhD Unit III: Integrated Case Studies Assistant Professor Saginaw Valley State University Lynn Burbank, MSN, RN, CPNP University Center, Michigan Learning Resource Coordinator Dixon School of Nursing Kathryn Konrad, MS, RNC-OB, LCCE, FACCE Abington Memorial Hospital Instructor, Nursing Academic Programs Abington, Pennsylvania The University of Oklahoma College of Nursing Chapter 5: Medications Oklahoma City, Oklahoma Pamela Evans-Smith, MSN, FNP Catherine Leipold, MS, CCRN, APRN-BC Clinical Nursing Instructor Clinical Instructor University of Missouri University of Illinois–Urbana Columbia, Missouri Chicago, Illinois Mary Hermann, BSN, MSN, EdD Patricia Lisk, RN, MS, DACCE Professor Professor of Nursing Gwynedd Mercy University Dean of Nursing and Health Technologies Gwynedd Valley, Pennsylvania Germanna Community College Chapter 3: Health Assessment Locust Grove, Virginia Chapter 6: Perioperative Nursing Chapter 8: Skin Integrity and Wound Care April Magoteaux, PhD, RN, CNS, NHA, AC Chapter 11: Nutrition Associate Professor Chapter 15: Fluid, Electrolyte, and Acid–Base Balance Columbus State Community College Columbus, Ohio Connie J. Hollen, RN, MS Adjunct Instructor Marjorie Norquist, RN, MA, MPA, BSN University of Oklahoma, College of Nursing Professor Oklahoma City, Oklahoma Community College of Rhode Island Unit III: Integrated Case Studies Warwick, Rhode Island Loren Nell Melton Stein, RNC, MSN Valinda Pearson, PhD, RN, CRRN, CNE Adjunct Instructor Professor of Nursing University of Oklahoma, College of Nursing St, Catherine University Oklahoma City, Oklahoma Minneapolis, Minnesota Unit III: Integrated Case Studies Janette Petro, RN, MSN, BSN For a list of the contributors to the Student and Instructor Professor Community College of Allegheny County, Boyce Campus Resources accompanying this book, please visit . Monroeville, Pennsylvania Reviewers Amy Ragnone, MSN, MA, RN Professor Esther Levine Brill, PhD, APRN-BC (ANP), RN College of Southern Nevada Professor Las Vegas, Nevada Long Island University School of Nursing Brooklyn, New York iv
Contributors and Reviewers v Pamela Santarlasci, PhD, RN, CRNP, CNE Linda Tate, MSN, APRN-BC Assistant Professor Assistant Professor Delaware County Community College Arkansas State University Media, Pennsylvania Jonesboro, Arkansas Jeanine Speakman, MSN, BSN, ADN Robin Zachary, EdS, MSN, RN Assistant Professor Instructor of Nursing Victor Valley College Lincoln Memorial University Victorville, California Harrogate, Tennessee Donna Spivey, MSN, RN, CEN For a list of the reviewers of the Test Generator accompanying Nursing Program Director Lone Star College–Kingwood this book, please visit . Kingwood, Texas
Preface Taylor’s Clinical Nursing Skills: A Nursing Process every effort has been made to respect the differing needs Approach aims to help nursing students or graduate nurses of diverse curricula and students. Thus, each chapter stands incorporate cognitive, technical, interpersonal, and ethical/ on its own merit and may be read independently of others. legal skills into safe and effective patient care. This book is written to meet the needs of novice to advanced nurses. Unit I, Actions Basic to Nursing Care Many of the skills shown in this book may not be encoun- tered by the student while in school, but may be encountered This unit introduces the foundational skills used by nurses: once the graduate nurse has entered the workforce. maintaining asepsis, measuring vital signs, assessing health, promoting safety, administering medication, and caring for Because it emphasizes the basic principles of patient care, surgical patients. we believe this book can easily be used with any Funda- mentals text. However, this Skills book was specifically In Chapter 3, Health Assessment, revised physical assess- designed to accompany Fundamentals of Nursing: The ment content reflects the practice needs of beginning and gen- Art and Science of Person-Centered Nursing Care, Eighth eral nurses. Assessment procedures performed by advanced Edition, by Taylor, Lillis, and Lynn to provide a seamless practice professionals are clearly identified. Assessments learning experience. Some of the Skills and Guidelines for identified as advanced procedures and skills are available Nursing Care from the Taylor Fundamentals book may also on . be found in this book, but its content has been embellished here to: Unit II, Promoting Healthy Physiologic Responses r Highlight the nursing process r Emphasize unexpected situations that the nurse may This unit focuses on the physiologic needs of patients: hygiene; skin integrity and wound care; activity; comfort encounter, along with related interventions for how to and pain management; nutrition; urinary elimination; bowel respond to these unexpected situations elimination; oxygenation; fluid, electrolyte, and acid–base r Draw attention to critical actions within skills balance; neurologic care; cardiovascular care; and specimen r Illustrate specific actions within a skill through the use of collection. nearly 1,000 four-color photographs and illustrations r Highlight available best practice guidelines and/or Unit III, Integrated Case Studies research-based evidence to support the skills as available r Reference appropriate case study or studies included at Although nursing skills textbooks generally present con- the end of the book, emphasizing which case studies uti- tent in a linear fashion for ease of understanding, in real- lize and enhance the content of each chapter ity, many nursing skills are performed in combination for patients with complicated health needs. The integrated case Additionally, this book contains numerous higher-level studies in this unit are designed to challenge the reader to skills that are not addressed in the Taylor Fundamentals think critically and outside the norm, consider the mul- book. tiple needs of patients, and prioritize care appropriately— ultimately preparing the student and graduate nurse for com- LEARNING EXPERIENCE plex situations that may arise in everyday practice. This text and the entire Taylor Suite have been created with TEACHING/LEARNING PACKAGE the student’s experience in mind. Care has been taken to appeal to all learning styles. The student-friendly writing To facilitate mastery of this text’s content, a comprehensive style ensures that students will comprehend and retain infor- teaching/learning package has been developed to assist fac- mation. The extensive art program enhances understanding ulty and students. of important actions. Free video clips clearly demon- strate and reinforce important skill steps; as students watch Resources for Instructors and listen to the videos, comprehension increases. In addi- tion, each element of the Taylor Suite, which is described Tools to assist you with teaching your course are available later in the preface, coordinates to provide a consistent and cohesive learning experience. upon adoption of this text on at http://thepoint. ORGANIZATION lww.com/Lynn4e. Taylor’s Clinical Nursing Skills is organized into three r The Test Generator has over 500 NCLEX®-Style ques- units. Ideally, the text will be followed sequentially, but tions to help you put together exclusive new tests from a bank with questions spanning the book’s topics, which will assist you in assessing your students’ understanding of the material. vi
Preface vii r PowerPoint Presentations,QSPWJEFEGPSFBDICPPLDIBQ- BOETDJFODF EJSFDUFEUPIVNBOIFBMUIBOEXFMMCFJOH*U UFS FOIBODF UFBDIJOH CZ QSPWJEJOH LFZ WJTVBMT BOE SFJO- DIBMMFOHFT TUVEFOUT UP GPDVT PO UIF GPVS CMFOEFE TLJMMT GPSDJOH DPOUFOU 5IFTF QSPWJEF BO FBTZ XBZ GPS ZPV UP PG OVSTJOH DBSF XIJDI QSFQBSF TUVEFOUT UP DPNCJOF UIF JOUFHSBUF UIF UFYUCPPL XJUI ZPVS TUVEFOUT MFBSOJOH FYQF- IJHIFTU MFWFM PG TDJFOUJàD LOPXMFEHF BOE UFDIOPMPHJD SJFODF FJUIFSWJBTMJEFTIPXTPSIBOEPVUT TLJMMXJUISFTQPOTJCMF DBSJOHQSBDUJDF5IFUFYUJODMVEFT FOHBHJOHGFBUVSFTUPQSPNPUFDSJUJDBMUIJOLJOHBOEDPN- r Skills Lab Teaching PlansXBMLZPVUISPVHIFBDIDIBQ- QSFIFOTJPO UFS PCKFDUJWF CZ PCKFDUJWF BOE QSPWJEF B MFDUVSF PVUMJOF r Taylor’s Handbook of Clinical Nursing Skills, 2nd BOEUFBDIJOHHVJEFMJOFT*OBEEJUJPOUPPOFUFBDIJOHQMBO Edition, CZ 1BNFMB -ZOO 5IF TFDPOE FEJUJPO QSPWJEFT GPSFBDIDIBQUFS UIFSFJTPOFCPOVTUFBDIJOHQMBOUPBTTJTU TUSFBNMJOFETLJMMTDPOTJTUFOUXJUIUIPTFJOTaylor’s Clini- XJUIMBCTJNVMBUJPOT cal Nursing Skills, 'PVSUI &EJUJPO 1SFTFOUFE GPS RVJDL SFGFSFODFPSPOUIFHPSFWJFX TLJMMTBSFPSHBOJ[FEBMQIB- r A Master Checklist for Skills CompetencyJTQSPWJEFE CFUJDBMMZCZLFZXPSE UPIFMQZPVUSBDLZPVSTUVEFOUTQSPHSFTTPOBMMUIFTLJMMT r Taylor’s Video Guide to Clinical Nursing Skills, 3rd JOUIJTCPPL Edition. 8JUI NPSF UIBO IPVST PG WJEFP GPPUBHF UIJT VQEBUFETFSJFTGPMMPXTOVSTJOHTUVEFOUTBOEUIFJSJOTUSVD- r \"TBNQMFSyllabusJTQSPWJEFEUPIFMQZPVPSHBOJ[FZPVS UPST BT UIFZ QFSGPSN B SBOHF PG FTTFOUJBM OVSTJOH QSPDF- DPVSTF EVSFT *OTUJUVUJPOT DBO QVSDIBTF UIF WJEFPT PO FOIBODFE %7%PSBDDFTTUIFNPOMJOF r Journal ArticlesPGGFSBDDFTTUPDVSSFOUSFTFBSDIBWBJMBCMF r Skill Checklists for Taylor’s Clinical Nursing Skills,4th JO8PMUFST,MVXFSKPVSOBMT Edition. 5IJT DPMMFDUJPO PG DIFDLMJTUT XJUI DPOWFOJFOU QFSGPSBUFE QBHFT JT EFTJHOFE UP BDDPNQBOZ UIF 4LJMMT r WebCT/Blackboard-Ready Materials DBO CF BDDFTTFE UFYUCPPL BOE QSPNPUF QSPQFS UFDIOJRVF XIJMF JODSFBTJOH PO QMVTBDDFTTUPBMM4UVEFOU3FTPVSDFT JODMVE- TUVEFOUTDPOàEFODF JOH 8BUDI -FBSO WJEFP DMJQT 1SBDUJDF -FBSO BDUJWJ- UJFT BOE$PODFQUTJO\"DUJPO\"OJNBUJPOT r 5IFImage BankQSPWJEFTGSFFBDDFTTUPJMMVTUSBUJPOTBOE QIPUPTGSPNUIFUFYUCPPLGPSVTFJO1PXFS1PJOUQSFTFOUB- UJPOTBOEIBOEPVUT Resources for Students SIMULATION 7BMVBCMFMFBSOJOHUPPMTGPSTUVEFOUTBSFBWBJMBCMFPO BUIUUQUIFQPJOUMXXDPN-ZOOF vSim for Nursing | Fundamentals, a new virtual simu- r NCLEX®-Style Review QuestionsDPSSFTQPOEXJUIFBDI lationplatform available via $PEFWFMPQFE CZ CPPLDIBQUFSGPSSFWJFXPGJNQPSUBOUDPODFQUTBOEUPIFMQ QSBDUJDF GPS UIF /$-&9 FYBNJOBUJPO /FBSMZ RVFT- -BFSEBM .FEJDBM BOE 8PMUFST ,MVXFS vSim for Nursing | UJPOTBSFJODMVEFE Fundamentals IFMQT TUVEFOUT EFWFMPQ DMJOJDBM DPNQFUFODF r Watch & LearnWJEFPDMJQT Practice & LearnBDUJWJ- UJFT BOEConcepts in Action Animations EFNPO- BOE EFDJTJPONBLJOH TLJMMT BT UIFZ JOUFSBDU XJUI WJSUVBM TUSBUFJNQPSUBOUDPODFQUTSFMBUFEUPTLJMMT QBUJFOUT JO B TBGF SFBMJTUJD FOWJSPONFOU vSim for Nursing r Journal ArticlesPGGFSBDDFTTUPDVSSFOUSFTFBSDIBWBJMBCMF JO8PMUFST,MVXFSKPVSOBMT SFDPSETBOEBTTFTTFTTUVEFOUEFDJTJPOTUISPVHIPVUUIFTJNV- r \" Spanish–English Audio Glossary QSPWJEFT IFMQGVM MBUJPO UIFOQSPWJEFTBQFSTPOBMJ[FEGFFECBDLMPHIJHIMJHIU- UFSNT BOE QISBTFT GPS DPNNVOJDBUJOH XJUI QBUJFOUT XIP TQFBL4QBOJTI JOHBSFBTOFFEJOHJNQSPWFNFOU r Dosage Calculation QuizzesQSPWJEFPQQPSUVOJUJFTGPSTUV- A COMPREHENSIVE, DIGITAL, EFOUTUPQSBDUJDFNBUITLJMMTBOEDBMDVMBUFESVHEPTBHFT INTEGRATED COURSE SOLUTION Taylor Suite Resources -JQQJODPUU$PVSTF1PJOUJTUIFPOMZJOUFHSBUFEEJHJUBMDPVSTF TPMVUJPO GPS OVSTJOH FEVDBUJPO DPNCJOJOH UIF QPXFS 'SPN USBEJUJPOBM UFYUT UP WJEFP BOE JOUFSBDUJWF QSPEVDUT PG EJHJUBM DPVSTF DPOUFOU XJUI JOUFSBDUJWF SFTPVSDFT BOE UIF5BZMPS'VOEBNFOUBMT4LJMMTTVJUFJTUBJMPSFEUPGJUFWFSZ WJSUVBMTJNVMBUJPO1VMMJOHUIFTFSFTPVSDFTUPHFUIFSJOUPPOF MFBSOJOH TUZMF 5IJT JOUFHSBUFE TVJUF PG QSPEVDUT PGGFST TUV- TPMVUJPO UIFJOUFHSBUFEQSPEVDUPGGFSTBTFBNMFTTFYQFSJFODF EFOUT B TFBNMFTT MFBSOJOH FYQFSJFODF OPU GPVOE FMTFXIFSF GPSMFBSOJOH TUVEZJOH BQQMZJOH BOESFNFEJBUJOH-JQQJODPUU 5P MFBSO NPSF BCPVU BOZ TPMVUJPO XJUI UIF 5BZMPS TVJUF $PVSTF1PJOU QSPWJEFT B QFSTPOBMJ[FE MFBSOJOH FYQFSJFODF QMFBTFDPOUBDUZPVSMPDBM8PMUFST,MVXFSSFQSFTFOUBUJWF UIBUJTTUSVDUVSFEJOUIFXBZTUVEFOUTTUVEZ*UESJWFTTUVEFOUT UPJNNFEJBUFSFNFEJBUJPOJOUIFJSUFYU EJHJUBMDPVSTFDPOUFOU r Fundamentals of Nursing: The Art and Science of BOE JOUFSBDUJWF DPVSTF SFTPVSDFT TVDI BT DBTF TUVEJFT WJE- Person-Centered Nursing Care, 8th Edition, CZ $BSPM FPT BOE KPVSOBM BSUJDMFT BSF BMTP JNNFEJBUFMZ BWBJMBCMF JO 5BZMPS $BSPM -JMMJT BOE 1BNFMB -ZOO 5IJT USBEJUJPOBM UIFTBNFEJHJUBMMZJOUFHSBUFEDPVSTFTPMVUJPOUPIFMQFYQBOE 'VOEBNFOUBMT UFYU QSPNPUFT OVSTJOH BT BO FWPMWJOH BSU PO DPODFQUT BOE CSJOH UIFN UP MJGF 5IF 4NBSU4FOTF MJOLT GFBUVSF JODMVEFE UISPVHIPVU $PVSTF1PJOU JOUFHSBUFT BMM PG
viii Preface alized way. This unique offering creates an unparalleled learning experience for students. Contact your Wolters the content, offering immediate remediation and additional Kluwer sales representative for more information about the learning resources at the click of a mouse. With Lippincott Lippincott CoursePoint solution. CoursePoint, instructors can collaborate with students at any time, identify common misunderstandings, evaluate student Pamela Lynn, MSN, RN comprehension, and differentiate instruction as needed. And students can learn and retain course material in a person-
How to Use Taylor’s Clinical Nursing Skills FOCUS ON PATIENT CARE! Vital Signs Each chapter in Units I and II begins with FOCUSING ON PATIENT CARE a description of three real-world case scenarios that put the skills into context. This chapter will explain some of the skills related to vital signs needed to care for the These scenarios provide a framework for following patients: the chapter content to be covered. TYRONE JEFFRIES, age 5, is in the emergency department with a temperature of 101.3°F (38.9°C). GET READY TO LEARN! TOBY WHITE, age 26, has a history of asthma and is now breathing 32 times per minute. CARL GLATZ, age 58, has recently started taking medications to control his hypertension Before reading the chapter content, read (high blood pressure). the Learning Objectives. These roadmaps Refer to Focusing on Patient Care: Developing Clinical Reasoning at the end of the chapter help you understand what is important and to apply what you learn. why. Create your own learning outline or use them for self-testing. LEARNING OBJECTIVES Review the Key Terms lists to become After studying this chapter, you will be able to: familiar with new vocabulary presented 1. Assess body temperature via the oral, tympanic, temporal, axillary, and rectal throughout the narrative. Look for them in bold type throughout routes. the chapter. 2. Regulate an infant’s temperature using an overhead radiant warmer. 3. Regulate temperature using a cooling blanket. 4. Assess peripheral pulses by palpation. 5. Assess an apical pulse by auscultation. 6. Assess peripheral pulses using Doppler ultrasound. 7. Assess respiration. 8. Assess blood pressure by auscultation or using an automatic electronic blood pressure monitor. 9. Assess systolic blood pressure using Doppler ultrasound. KEY TERMS apnea: absence of breathing bell: (of stethoscope) hollowed, upright, curved portion used to auscultate low-pitched sounds, such as murmurs blood pressure: force of blood against arterial walls bradypnea: abnormally slow rate of breathing diaphragm: (of stethoscope) large, flat disk on the stethoscope used to auscultate high-pitched sounds, such as respiratory sounds 35 ix
x How to Use Taylor’s Clinical Nursing Skills ͖ǧ͖ TECHNIQUES FOR OBTAINING VITAL SIGNS OF INFANTS AND CHILDREN DEVELOP CRITICAL THINKING AND CLINICAL REASONING! r %VF UP UIF iGFBS GBDUPSu PG CMPPE QSFTTVSF NFBTVSF- r .BLFNFBTVSJOHWJUBMTJHOTBHBNF'PSJOTUBODF JG NFOU TBWF UIF CMPPE QSFTTVSF NFBTVSFNFOU GPS MBTU ZPV BSF VTJOH B UZNQBOJD UIFSNPNFUFS UIBU NBLFT Fundamentals Review. Because of the breadth and $IJMESFO BOE JOGBOUT PGUFO CFHJO UP DSZ EVSJOH CMPPE B DIJSQJOH TPVOE UFMM UIF DIJME ZPV BSF MPPLJOH GPS depth of nursing knowledge that must be absorbed, QSFTTVSFBTTFTTNFOU BOEUIJTNBZBGGFDUUIFSFTQJSBUJPO iCJSEJFTu JO UIF FBS 8IJMF BVTDVMUBUJOH UIF QVMTF nursing students and graduate nurses can easily become BOEQVMTFSBUFBTTFTTNFOU UFMM UIF DIJME ZPV BSF MJTUFOJOH GPS BOPUIFS UZQF PG overwhelmed. Thus, this book is designed to eliminate BOJNBM excessive content and redundancy and to better focus r 1FSGPSNBTNBOZUBTLTBTQPTTJCMFXIJMFUIFDIJMEJTTJU- the reader’s attention. To this end, each chapter in Units I UJOHPOUIFQBSFOUTMBQPSJOBDIBJSOFYUUPUIFQBSFOU r *GUIFDIJMEIBTBEPMMPSTUVGGFEBOJNBM QSFUFOEUPUBLF and II includes several boxes, tables, or figures that UIFEPMMTWJUBMTJHOTàSTU summarize important concepts that should be understood r -FU UIF DIJME TFF BOE UPVDI UIF FRVJQNFOU CFGPSF ZPV before performing a skill. For a more in-depth study of CFHJOUPVTFJU these concepts, readers are encouraged to refer to their Fundamentals textbook. Enhance Your Understanding, located at the end of each chapter, gives readers an opportunity to further their understanding and apply what they have learned. It includes three sections: Focusing on Patient Care: ENHANCE YOUR UNDERSTANDING Developing Clinical Reasoning asks readers to consider questions FOCUSING ON PATIENT CARE: DEVELOPING CLINICAL REASONING that reflect back to the opening scenarios for added cohesion Consider the case scenarios at the beginning of the chap- patient, Sheri Lawrence, moves her leg. You do not throughout the chapters. Readers are ter as you answer the following questions to enhance think that Sheri’s leg touched the glove, but you are challenged to apply the skills and use your understanding and apply what you have learned. not positive. What should you do? the new knowledge they have gained to “think through” learning exercises QUESTIONS 3. Edgar Barowski’s son is visiting and asks you why the designed to show how critical masks that are outside Edgar’s room are different from thinking and clinical reasoning can 1. While preparing the sterile table in the cardiac cath- the ones that people wear in the operating room. What result in a clinical judgment, leading eterization lab for Mr. Wilson, you realize that a sterile should you tell Edgar’s son? to a possible change in outcomes and bowl is missing. How can you obtain a sterile bowl? an impact on patient care. You can find suggested answers after the Bibliography at 2. While you are putting on sterile gloves in prepara- the end of this chapter. Suggested Answers for Focusing on tion for an indwelling urinary catheter insertion, your Patient Care: Developing Clinical Reasoning represent possible nursing INTEGRATED CASE STUDY TAYLOR SUITE RESOURCES care solutions to the problems. CONNECTION The answers can be found after the Explore these additional resources to enhance learning for bibliography section at the end of the The case studies in the back of the book are designed to this chapter: chapter. focus on integrating concepts. Refer to the following case r NCLEX-Style Questions and other resources on studies to enhance your understanding of the concepts Integrated Case Study Connection related to the skills in this chapter. , http://thePoint.lww.com/Lynn4e refers readers to the appropriate r Basic Case Studies: Tiffany Jones, page 1064; John r Skill Checklists for Taylor’s Clinical Nursing Skills, 4e case study or studies discussion in r Taylor’s Video Guide to Clinical Nursing Skills: Unit III, emphasizing which case Willis, page 1068. studies utilize and enhance the r Intermediate Case Studies: Tula Stillwater, page 1081; Asepsis content of that chapter. r Fundamentals of Nursing: Chapter 23, Asepsis and Gwen Galloway, page 1089; George Patel, page 1091. Infection Control New! Delegation Considerations assist students and decision-making information is provided in each skill graduate nurses in developing the critical decision- and Appendix A, using delegation guidelines based on making skills necessary to transfer responsibility for American Nurses Association (ANA) and National Council the performance of an activity to another individual and of State Boards of Nursing (NCSBN) principles and to ensure safe and effective nursing care. Delegation recommendations.
14 U N I T I Actions Basic to Nursing Care SKILL ͕ǧ͖ PERFORMING HAND HYGIENE USING SOAP AND WATER ȍHANDWASHINGȎ continued EVIDENCE IMPROVING THE USE OF HAND HYGIENE MEASURES FOR PRACTICE ▶ Prevention of health care–associated infections is a major challenge for health care providers. Hand hygiene is regarded as an effective preventive measure. This procedure is still not per- formed consistently in health care settings, however (The Joint Commission Center for Trans- forming Healthcare, 2012). Related Research Gould, D.J., Moralejo, D., Drey, N., & Chudleigh, J.H. (2011). Interventions to improve hand hygiene compliance in patient care. Cochrane Database of Systematic Reviews. Art. No.: CD005186. DOI: 10.1002/14651858.CD005186.pub3. Available http://summaries.cochrane. org/CD005186/methods-to-improve-healthcare-worker-hand-hygiene-to-decrease-infection-in- hospitals. The objective of this literature review was to assess the short- and longer-term success of strategies to improve hand hygiene compliance and to determine whether sustained increase in hand hygiene compliance can reduce rates of health care–associated infection. Four studies met the criteria for review: two from the original review and two from the update. Two studies evaluated simple education initiatives, one using a randomized clinical trial design and the other a controlled before and after design. Both measured hand hygiene compliance by direct observa- tion. The other two studies were both interrupted times series studies. One study presented three separate interventions within the same paper: simple substitutions of product and two multifac- eted campaigns, one of which included involving practitioners in making decisions about choice of hand hygiene products and the components of the hand hygiene program. The other study also presented two separate multifaceted campaigns, one of which involved application of social marketing theory. In these two studies follow-up data collection continued beyond 12 months, and a proxy measure of hand hygiene compliance (product use) was recorded. Microbiologi- cal data were recorded in one study. Hand hygiene compliance increased for one of the studies where it was measured by direct observation, but the results from the other study were not conclusive. Product use increased in the two studies in which it was reported, with inconsistent results reported for one initiative. Methicillin-resistant Staphylococcus aureus (MRSA) inci- dence decreased in the one study reporting microbiological data. The authors concluded there is little robust evidence to influence the choice of interventions to improve hand hygiene. They identified a need to undertake methodologically robust research to explore the effectiveness of soundly designed interventions to increase hand hygiene compliance. Relevance for Nursing Practice Effective hand hygiene is a mandatory part of nursing care. Nurses should consider undertaking studies related to improving hand hygiene compliance to ensure safe patient care. Such studies would also add to the body of knowledge to support evidence-based nursing practice. Refer to for additional research on related nursing topics. EVIDENCE HAND HYGIENE, RELIGION, AND CULTURE FOR PRACTICE ▶ Prevention of health care–associated infections is a major challenge for health care providers. Hand hygiene is regarded as an effective preventive measure. The WHO has prepared guidelines for hand hygiene and is studying the acceptability of these guidelines in different health care settings worldwide. Allegranzi, B., Memish, Z., Donaldson, L., et al. (2009). World Health Organization Global Patient Safety Challenge Task Force on Religious and Cultural Aspects of Hand Hygiene. Reli- gion and culture: Potential undercurrents influencing hand hygiene promotion in health care. American Journal of Infection Control, 37(1), 28–34. Refer to Skill 1-1 for detailed information related to this research, and refer to for additional research on related nursing topics.
C H A P T E R 1 Asepsis and Infection Control 15 ͕ǧ3 USING PERSONAL PROTECTIVE EQUIPMENT Personal protective equipment refers to specialized clothing or equipment worn by an employee for protection against infectious materials. PPE is used in health care settings to improve personnel safety in the health care environment through the appropriate use of PPE (CDC, 2004). This equipment includes clean (nonsterile) and sterile gloves, impervious gowns/aprons, surgical and high-efficiency particulate air (HEPA) masks, N95 disposable masks, face shields, and protective eyewear/goggles. Understanding the potential contamination hazards related to the patient’s diagnosis and con- dition and the institutional policies governing PPE is very important. The type of PPE used will vary based on the type of exposure anticipated and category of precautions: Standard Precautions and Transmission-Based Precautions, including Contact, Droplet, or Airborne Precautions. It is the nurse’s responsibility to enforce the proper wearing of PPE during patient care for members of the health care team. Refer to Fundamentals Review 1-4 and Fundamentals Review 1-5 for a summary of CDC-recommended practices for Standard and Transmission-based Precautions. Box 1-1 provides Guidelines for Effective Use of PPE. Due to the recent appearance of individuals in the United States who are positive for the Ebola virus, the CDC has issued revised guidelines for health care workers caring for these patients. The revised guidelines focus on repeated hands-on training with PPE before treating patients, avoidance of skin exposure when PPE is worn, and supervision by a trained monitor of the application and removal of PPE. The complete guideline is available at: http://www.cdc.gov/vhf/ebola/ hcp/procedures-for-ppe.html. Ĕĝ 1-1 GUIDELINES FOR EFFECTIVE USE OF PPE t 1VUPO11&CFGPSFDPOUBDUXJUIUIFQBUJFOU QSFGFSBCMZ t \"WPJEUPVDIJOHPSBEKVTUJOHPUIFS11& CFGPSFFOUFSJOHUIFQBUJFOUTSPPN t ,FFQHMPWFEIBOETBXBZGSPNZPVSGBDF t *GHMPWFTCFDPNFUPSOPSIFBWJMZTPJMFE SFNPWFBOE t $IPPTFBQQSPQSJBUF11&CBTFEPOUIFUZQFPGFYQPTVSF BOUJDJQBUFEBOEUZQFPGUSBOTNJTTJPOCBTFEQSFDBVUJPOT SFQMBDF1FSGPSNIBOEIZHJFOFCFGPSFQVUUJOHPOUIFOFX HMPWFT t 8IFOXFBSJOHHMPWFT XPSLGSPNiDMFBOwBSFBTUPiEJSUZwBSFBT t 1FSTPOBMHMBTTFTBSFOPUBTVCTUJUVUFGPSHPHHMFT t 5PVDIBTGFXTVSGBDFTBOEJUFNTXJUIZPVS11&BTQPTTJCMF \"EBQUFEGSPN$FOUFSTGPS%JTFBTF$POUSPMBOE1SFWFOUJPO $%$ F 6QEBUFE 1FSTPOBMQSPUFDUJWFFRVJQNFOUGPSIFBMUIDBSFQFSTPO OFM&YDFSQUFEGSPNHVJEFMJOFGPSJTPMBUJPOQSFDBVUJPOT1SFWFOUJOHUSBOTNJTTJPOPGJOGFDUJPVTBHFOUTJOIFBMUIDBSFTFUUJOHT\"WBJMBCMFXXXDEDHPW IJDQBDQEGJTPMBUJPO*TPMBUJPOQEG DELEGATION The application and use of PPE is appropriate for all health care providers. CONSIDERATIONS EQUIPMENT r(MPWFT r*NQFSWJPVTHPXO ASSESSMENT r.BTL TVSHJDBMPSQBSUJDVMBUFSFTQJSBUPS r 1SPUFDUJWFFZFXFBS EPFTOPUJODMVEFFZFHMBTTFT NURSING DIAGNOSIS Note: Equipment for PPE may vary depending on facility policy. OUTCOME Assess the situation to determine the necessity for PPE. In addition, check the patient’s chart for IDENTIFICATION AND information about a suspected or diagnosed infection or communicable disease. Determine the possi- PLANNING bility of exposure to blood and body fluids and identify the necessary equipment to prevent exposure. Refer to the infection control manual provided by your facility. Determine the related factors for the nursing diagnoses based on the patient’s current status. Appro- priate nursing diagnoses may include: r3JTLGPS*OGFDUJPO r%JBSSIFB r*OFGGFDUJWF1SPUFDUJPO The expected outcome to achieve when using PPE is prevention of microorganism transmission. Other outcomes that may be appropriate include the following: Patient and staff remain free of expo- sure to potentially infectious microorganisms; and patient verbalizes information about the rationale for use of PPE. (continued )
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