Clinical Nursing Skills A Concept-Based Approach, Volume III

For courses in concept-based nursing.

#1 curriculum choice for concept-based schools of nursing

Nursing: A Concept-Based Approach to Learning provides all of the core content and materials needed to deliver an effective concept-based program that develops practice-ready nurses. This three-volume series is the only concepts curriculum developed from the ground up as a cohesive, comprehensive learning system. An intentional instructional design and learning pattern fosters connections between concepts and a deep level of comprehension that can be applied broadly. Volume III, Clinical Skills: A Concept-Based Approach, presents more than 275 key nursing skills, with 250 minor skills embedded within them, that complement concepts in the first two volumes and support a concept-based approach. The 3rd edition of Volume III is a full-scale, cover-to-cover revision that brings the text in line with new evidence-based practice, care, and safety guidelines.

Barbara Callahan, MEd, RN, NCC, CHSE

Retired from Lenoir Community College in Kinston, North Carolina, Barbara Callahan was an Associate Degree Nursing Lead Instructor and coordinates simulation lab and clinical throughout the nursing curriculum. Her clinical background is concentrated in critical care and emergency care. As a Nurse Educator, she was the North Carolina State Training and Education Coordinator with the North Carolina Public Health Office of Preparedness and Response, the Continuing Education Coordinator for the Southwest Georgia AHEC, a Critical Care Transport clinician and the educator for a network of hospitals in southwest Georgia, and the Hospital Education Coordinator for the Medical Nursing Division at the University of Alabama Hospital. As a Nurse Manager, she provided leadership for a Medical/Surgical Department, an Emergency Department, and a Respiratory Intensive Care Unit. She maintains licensure/certification as a professional mental health counselor. As a speaker, she has provided a variety of presentations at state, regional, and local conferences in Florida, Virginia, Alabama, Georgia, and North Carolina. She participated in research projects targeting quality improvement of programs available for ongoing continuing education and nurses returning to active practice. Through pairing imagination and creativity with simulation technology, she developed and implemented an assortment of educational activities and clinical experiences for nursing students, including a simulation clinical site for all levels of students each semester, an emergency shelter site exercise, and a Within Prime Time rapid recognition and response program.

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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