Checklists for Clinical Nursing Skills

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_ 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 , or via our website at (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. LWW.com LWBK681-FM_ 9/4/10 12:53 AM Page iii MCGH146-c01_ 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. iii LWBK681-FM_ 9/4/10 12:53 AM Page iv MCGH146-c01_ LWBK681-FM_ 9/4/10 12:53 AM Page v MCGH146-c01_ 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 v LWBK681-FM_ 9/4/10 12:53 AM Page vi MCGH146-c01_ 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 Skill9-3: Transferring a Patient From the Bed to a Stretcher 184 LWBK681-FM_ 9/4/10 12:53 AM Page vii MCGH146-c01_ 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 Skill13-8: Irrigating a Nasogastric Tube Connected to Suction 284 LWBK681-FM_ 9/4/10 12:53 AM Page viii MCGH146-c01_ 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