The Royal Marsden Manual of Clinical Nursing Procedures, Professional Edition

Now in its tenth edition, The Royal Marsden Manual of Clinical Nursing Procedures has been the definitive, market-leading guide to clinical nursing skills for over three decades. This internationally best-selling title sets the gold standard for nursing care; providing the procedures, rationale, and guidance required by qualified nurses to deliver clinically effective, patient-focused care with expertise and confidence. 

With over two-hundred detailed procedures, this comprehensive manual presents the evidence and underlying theory alongside full-colour illustrations and photographs, and includes coverage of infection prevention and control, perioperative care, wound management, nutrition, diagnostic testing, discharge, medicines management, and much more. Loved and trusted by millions for over thirty years, The Royal Marsden Manual of Clinical Nursing Procedures continues to be a truly indispensable guide for nursing practice. 

• Written by nurses for nurses
• Empowers nurses to become informed, skilled practitioners
• Reflects current procedures and changes in modern adult nursing practice
• All procedures are supported by up to date evidence, including detailed rationales for each step of each procedure
• Considers the clinical governance around the procedures and nursing practice

NEW to the Tenth Edition:

• Each chapter is linked to the NMC 2018 ‘Future Nurse: Standards of Proficiency for Registered Nurses’ guidance
• Includes a brand-new chapter on ‘Self Care and Wellbeing,’ helping nurses to care for themselves emotionally and physically

The Royal Marsden Manual is also available online, fully searchable, and annotatable. www.rmmonline.co.uk

Sara Lister, Head of Pastoral Care, Psychological Support, and PALS, The Royal Marsden Hospital NHS Foundation Trust, UK.

Justine Hofland, Divisional Clinical Nurse Director - Cancer Services, The Royal Marsden NHS Foundation Trust, UK.

Brief table of contents v

Foreword to the tenth edition xv

Preface xvii

Acknowledgements xix

List of contributors xxi

Quick reference to the procedure guidelines xxv

How to use your manual xxix

1 The context of nursing 1

Overview 2

Background 2

Context of nursing 2

Evidence-based practice 7

Structure of the manual 8

Structure of the chapters 9

Finally 9

References 10

Part One Managing the patient journey 13

2 Admissions and assessment 14

Overview 16

Inpatient assessment and the process of care 16

Observation 24

Physical assessment 24

3 Discharge care and planning 45

Overview 46

Discharge care and planning 46

Discharging patients from hospital: internal procedures 47

Interface between primary and secondary care: external processes 53

Informal carers 58

The role of voluntary services 62

References 62

4 Infection prevention and control 64

Overview 66

Infection prevention and control 66

Hand hygiene 75

Personal protective equipment (PPE) 87

Specific patient-related procedures 101

Isolation procedures 105

Environmental hygiene and the management of waste in the healthcare environment 111

Prevention and management of inoculation injury 118

Websites 119

References 119

4.1 Hand washing 79

4.2 Hand decontamination using an alcohol-based handrub 80

4.3 Surgical scrub technique using soap and water 82

4.4 Surgical scrub technique using an alcohol-based handrub 84

4.5 Putting on and removing non-sterile gloves 88

4.6 Applying and removing a disposable apron 89

4.7 Putting on and removing a disposable mask or respirator 91

4.8 Putting on or removing goggles or a face-shield 93

4.9 Donning a sterile gown and gloves: closed technique 94

4.10 Donning sterile gloves: open technique 98

4.11 Aseptic technique example: changing a wound dressing 102

4.12 Source isolation: preparing an isolation room 106

4.13 Source isolation: entering an isolation room 107

4.14 Source isolation: leaving an isolation room 108

4.15 Source isolation: transporting infected patients outside a source isolation area 108

4.16 Protective isolation: preparing an isolation room 109

4.17 Protective isolation: entering an isolation room 110

4.18 Cleaning a hard surface without recontamination 112

4.19 Safe disposal of foul, infected or infested linen 117

Part Two Supporting patients with human functioning 123

5 Communication, psychological wellbeing and safeguarding 124

Overview 126

Communication 126

Providing information and making shared decisions 138

Communicating with specific populations 141

Psychological wellbeing 147

Safeguarding, mental capacity and the Mental Health Act 169

Websites 187

References 187

6 Elimination 194

Overview 196

Normal elimination 196

Altered urinary elimination 200

Altered faecal elimination 237

Stoma care 257

Websites 272

References 272

6.1 Slipper bedpan use: assisting a patient 198

6.2 Commode use: assisting a patient 199

6.3 Penile sheath application 202

6.4 Urinary catheterization: male 208

6.5 Urinary catheterization: female 210

6.6 Changing a suprapubic catheter 214

6.7 Urinary catheterization: intermittent self-catheterization patient guidance: male 216

6.8 Urinary catheterization: intermittent self-catheterization patient guidance: female 217

6.9 Urinary catheter bag: emptying 219

6.10 Urinary catheter removal 219

6.11 Commencing bladder irrigation 223

6.12 Nephrostomy tube: weekly dressing and bag change and sample collection 227

6.13 Nephrostomy tube: flushing technique 229

6.14 Nephrostomy tube: removal of locking pigtail drainage system 230

6.15 Flushing externalized ureteric stents 232

6.16 Removal of externalized ureteric stents 233

6.17 Continent urinary diversion stoma: self-catheterization 236

6.18 Insertion of a faecal management system 240

6.19 Insertion of a nasogastric drainage tube 247

6.20 Removal of a nasogastric drainage tube 249

6.21 Enema administration 250

6.22 Suppository administration 252

6.23 Digital rectal examination 254

6.24 Digital removal of faeces 256

6.25 Stoma siting 263

6.26 Stoma bag change 264

6.27 Obtaining a clean-catch urine sample from an ileal conduit 265

6.28 Stoma bridge or rod removal 266

7 Moving and positioning 278

Overview 280

Moving and positioning: general principles 280

Moving and positioning an unconscious patient 293

Moving and positioning a patient with an artificial airway 294

Moving and positioning a patient with respiratory compromise 298

Moving and positioning a patient with neurological impairment 301

Moving and positioning a patient with actual or suspected spinal cord compression or spinal cord injury 313

Moving and positioning a patient with raised intracranial pressure 325

Moving and positioning a patient with an amputation 326

Websites 329

References 329

7.1 Positioning a patient: supine 284

7.2 Positioning a patient: sitting up in bed 285

7.3 Positioning a patient: side-lying 286

7.4 Positioning a patient: lying down to sitting up 288

7.5 Moving a patient from sitting to standing: assisting the patient 289

7.6 Positioning a patient: in a chair or wheelchair 291

7.7 Assisting a patient to walk 292

7.8 Positioning an unconscious patient or a patient with an artificial airway in supine 295

7.9 Positioning an unconscious patient or a patient with an artificial airway in side-lying 296

7.10 Positioning a neurological patient with tonal problems in bed 309

7.11 Positioning a neurological patient with tonal problems in a chair 312

7.12 Application of a two-piece cervical collar 318

7.13 Log rolling a patient with suspected or confirmed cervical spinal instability (above T6) 319

7.14 Log rolling a patient with suspected or confirmed thoracolumbar spinal instability (T7 and below) 321

7.15 Early mobilization of a patient with spinal considerations 323

7.16 Positioning a patient with an amputation 327

8 Nutrition and fluid balance 334

Overview 336

Fluid balance 336

Nutritional status 351

Provision of nutritional support: Oral 359

Nutritional management of patients with dysphagia 364

Enteral tube feeding 365

Parenteral nutrition 385

Websites 389

References 389

8.1 Fluid input: measurement 345

8.2 Fluid output: monitoring/measuring output if the patient is catheterized 346

8.3 Fluid output: monitoring/measuring output if the patient is not catheterized 347

8.4 Fluid output: monitoring/measuring output from drains 347

8.5 Fluid output: monitoring/measuring output from gastric outlets, nasogastric tubes or gastrostomy 348

8.6 Fluid output: monitoring/measuring output from bowels 349

8.7 Fluid output: monitoring/measuring output from stoma sites 349

8.8 Measuring the weight and height of a patient 356

8.9 Feeding an adult patient 362

8.10 Nasogastric intubation with tubes using an internal guidewire or stylet 369

8.11 Removal of a nasogastric tube 374

8.12 Percutaneous endoscopically placed gastrostomy (PEG) tube care 375

8.13 Radiologically inserted gastrostomy (RIG) tube care 376

8.14 Removal of T-fasteners 377

8.15 Changing the balloon water and checking the volume of a balloon gastrostomy 378

8.16 Jejunostomy feeding tube care including dressing change 379

8.17 Insertion of a silicone gastrostomy stoma plug 380

8.18 Enteral feeding tubes: administration of feed using an enteral feeding pump 381

8.19 Enteral feeding tubes: administration of medication 384

8.20 Enteral feeding tubes: unblocking 386

9 Patient comfort and supporting personal hygiene 394

Overview 396

Personal hygiene 396

Sleep promotion in a hospitalized patient 407

Patient environment 409

Eye care 413

Ear care 423

Mouth care 427

Websites 439

References 439

9.1 Bedbathing a patient 401

9.2 Washing a patient’s hair in bed 403

9.3 Shaving the face: wet shave 405

9.4 Shaving the face: dry electric shaver 406

9.5 Making an unoccupied bed 410

9.6 Making an occupied bed 412

9.7 Eye swabbing 417

9.8 Eye irrigation 418

9.9 Artificial eye care: insertion 420

9.10 Artificial eye care: removal 420

9.11 Contact lens removal: hard lenses 421

9.12 Contact lens removal: soft lenses 422

9.13 Irrigation of the external auditory canal using an electronic irrigator 425

9.14 Mouth care 436

9.15 Mouth care for a patient with dentures 437

10 Pain assessment and management 446

Overview 448

Pain 448

Pain management 456

Regional analgesia: local anaesthetic nerve blocks and infusions 462

Epidural analgesia 469

Entonox administration 481

Non-pharmacological methods of managing pain 485

References 491

10.1 Pain assessment 455

10.2 Peripheral nerve catheter removal 464

10.3 Epidural sensory blockade: assessment 475

10.4 Epidural exit site dressing change 475

10.5 Epidural catheter removal 479

10.6 Entonox administration 484

10.7 Preparation for acupuncture and actions post-treatment 490

11 Symptom control and care towards the end of life 496

Overview 498

End-of-life care 498

Symptom control 515

Verification and certification of death 526

Care after death (last offices) 528

Websites 534

References 534

11.1 Management of dyspnoea (breathlessness) 516

11.2 Care of a patient who is vomiting 519

11.3 Abdominal paracentesis 523

11.4 Terminal sedation 526

11.5 Verification of death 527

11.6 Care after death 529

12 Respiratory care, CPR and blood transfusion 538

Overview 540

Respiratory therapy 540

Oxygen therapy 542

High-flow oxygen via a nasal cannula 551

Humidification 553

Non-invasive ventilation 555

Chest drain management 562

Tracheostomy and laryngectomy care 578

Basic life support 607

Transfusion of blood and blood components 620

Websites 645

References 645

12.1 Oxygen therapy 546

12.2 High-flow oxygen therapy 552

12.3 Continuous positive airway pressure (CPAP) 559

12.4 Chest drain: assisting insertion 567

12.5 Chest drainage: suction 572

12.6 Chest drain: changing the bottle 573

12.7 Chest drain: removal 576

12.8 Tracheostomy: dressing and tube tape/tie change 587

12.9 Tracheostomy: suctioning a patient (single-use suction catheter) 590

12.10 Tracheostomy: changing an inner cannula 592

12.11 Tracheostomy: changing a tube 594

12.12 Tracheostomy: insertion and removal of a speaking valve 597

12.13 Tracheostomy: decannulation 599

12.14 Tracheostomy: emergency management 601

12.15 Laryngectomy care 605

12.16 Insertion of an oropharyngeal airway 616

12.17 Basic life support 617

12.18 Blood product request 634

12.19 Blood sampling: pre-transfusion 635

12.20 Blood components: collection and delivery to the clinical area 636

12.21 Blood component administration 638

Part Three Supporting patients through the diagnostic process 653

13 Diagnostic tests 654

Overview 656

Diagnostic tests 656

Blood sampling 660

Venepuncture: obtaining blood samples from a peripheral vein 662

CVAD sampling: sampling from a central venous access device 671

Arterial blood sampling 675

Blood cultures 683

Antimicrobial drug assay 687

Cerebrospinal fluid obtained by lumbar puncture 689

Semen collection and analysis 694

Cervical screening 697

Specimen collection: swab sampling 701

Specimen collection: urine sampling 710

Specimen collection: faecal sampling 715

Specimen collection: respiratory tract secretion sampling 717

Specimen collection: pleural fluid 722

Endoscopic investigations 723

Liver biopsy 728

Radiological investigations: X-ray 730

Magnetic resonance imaging (MRI) 730

Computed tomography (CT) 732

Websites 733

References 733

13.1 Venepuncture 666

13.2 Central venous access devices: taking a blood sample for vacuum sampling 672

13.3 Central venous access devices: taking a blood sample for syringe sampling 673

13.4 Arterial puncture: radial artery 678

13.5 Arterial blood gas sampling: arterial cannula 680

13.6 Blood cultures: peripheral (winged device collection method) 684

13.7 Blood cultures: central venous access device 686

13.8 Blood sampling: antimicrobial drug assay 688

13.9 Lumbar puncture 692

13.10 Semen collection 696

13.11 Cervical uterine smear using liquid-based cytology 699

13.12 Swab sampling: ear 702

13.13 Swab sampling: eye 703

13.14 Swab sampling: nose 704

13.15 Swab sampling: penis 705

13.16 Swab sampling: rectum 705

13.17 Swab sampling: skin 706

13.18 Swab sampling: throat 707

13.19 Swab sampling: vagina 708

13.20 Swab sampling: wound 709

13.21 Urine sampling: midstream specimen of urine: male 711

13.22 Urine sampling: midstream specimen of urine: female 712

13.23 Urine sampling: catheter specimen of urine 713

13.24 Urine sampling: sampling from an ileal conduit 713

13.25 Urine sampling: 24-hour urine collection 714

13.26 Faecal sampling 716

13.27 Sputum sampling 719

13.28 Nasopharyngeal wash: syringe method 719

13.29 Nasopharyngeal wash: vacuum-assisted aspirate method 721

14 Observations 740

Overview 742

Observations 742

Pulse (heart rate) 744

Electrocardiogram (ECG) 751

Blood pressure 758

Respiration and pulse oximetry 766

Peak flow 777

Temperature 781

Urinalysis 788

Blood glucose 793

Neurological observations 800

References 814

14.1 Pulse measurement 749

14.2 Electrocardiogram (ECG) 755

14.3 Blood pressure measurement (manual) 763

14.4 Respiratory assessment and pulse oximetry 775

14.5 Peak flow reading using a manual peak flow meter 780

14.6 Tympanic temperature measurement 786

14.7 Urinalysis: reagent strip 792

14.8 Blood glucose monitoring 797

14.9 Neurological observations and assessment 811

Part Four Supporting patients through treatment 819

15 Medicines optimization: ensuring quality and safety 820

Overview 822

Medicines management 822

Self-administration of medicines 833

Controlled drugs 835

Routes of administration 843

Parenteral administration (injections and infusions) 869

Infiltration and extravasation 918

Websites 932

References 932

15.1 Medication: controlled drug administration 841

15.2 Medication: oral drug administration 849

15.3 Medication: topical applications 851

15.4 Medication: transdermal applications 853

15.5 Medication: vaginal administration 855

15.6 Medication: administration by inhalation using a metered dose or dry powder inhaler 858

15.7 Medication: administration by inhalation using a nebulizer 860

15.8 Medication: eye administration 864

15.9 Medication: nasal drop administration 866

15.10 Medication: ear drop administration 868

15.11 Medication: single-dose ampoule: solution preparation 872

15.12 Medication: single-dose ampoule: powder preparation 873

15.13 Medication: multidose vial: powder preparation using a venting needle 874

15.14 Medication: multidose vial: powder preparation using the equilibrium method 876

15.15 Medication: injection administration 877

15.16 Medication: intradermal injection 879

15.17 Medication: subcutaneous injection 882

15.18 Medication: subcutaneous infusion of fluids 885

15.19 Medication: subcutaneous administration using a CME Medical T34 syringe pump (previously McKinley) 886

15.20 Medication: intramuscular injection 891

15.21 Inserting an intraosseous needle 894

15.22 Removing an intraosseous needle 897

15.23 Medication: continuous infusion of intravenous drugs 909

15.24 Medication: intermittent infusion of intravenous drugs 911

15.25 Medication: injection (bolus or push) of intravenous drugs 914

15.26 Extravasation management: peripheral cannula 925

15.27 Extravasation: performing flush-out following an extravasation 928

16 Perioperative care 940

Overview 942

Pre-operative care 942

Intraoperative care 977

Post-operative care 1001

16.1 Measuring and applying antiembolic stockings 963

16.2 Pre-operative care: checking that the patient is fully prepared for surgery 975

16.3 Caring for the patient in the anaesthetic room 979

16.4 Operating theatre procedure: maintaining the safety of a patient during surgery 992

16.5 Handover in the post-anaesthetic care unit (PACU): scrub nurse or operating department practitioner to recovery practitioner 996

16.6 Safe management of patients in the post-operative care unit (PACU) 997

16.7 Drainage systems: changing the dressing around the drain site for both open and closed drains 1006

16.8 Closed drainage systems: changing a vacuum bottle 1007

16.9 Wound drain removal: closed drainage system 1008

16.10 Wound drain shortening for open drainage systems 1010

16.11 Wound drain shortening for closed drainage systems 1012

17 Vascular access devices: insertion and management 1028

Overview 1030

Vascular access devices 1030

Peripheral cannulas 1046

Midline catheters 1068

Peripherally inserted central catheters 1073

Short-term percutaneous central venous catheters (non-tunnelled) 1090

Skin-tunnelled catheters 1097

Implanted ports 1102

Arterial cannulas 1110

References 1117

17.1 Central venous catheter: insertion site dressing change 1042

17.2 Vascular access devices: maintaining patency 1043

17.3 Central venous access devices: unblocking an occlusion 1043

17.4 Peripheral cannula insertion 1053

17.5 Ultrasound-guided peripheral cannula insertion 1059

17.6 Midline catheter insertion 1069

17.7 PICC insertion using modified Seldinger technique (MST) with ultrasound 1082

17.8 PICC removal 1089

17.9 Short-term central venous catheter (non-cuffed and non-tunnelled) insertion into the internal jugular vein 1092

17.10 Short-term central venous catheter (non-cuffed and non-tunnelled): removal 1096

17.11 Central venous catheter (skin tunnelled): surgical removal 1099

17.12 Implanted arm PORT insertion using modified Seldinger technique (MST) with ultrasound guidance and ECG technology 1104

17.13 Implanted ports: insertion and removal of non-coring needles 1107

17.14 Arterial cannula insertion: preparation and setting up of monitoring set 1112

17.15 Arterial cannula: removal 1114

18 Wound management 1128

Overview 1130

Wounds 1130

Pressure ulcers 1143

Surgical wounds 1152

Negative pressure wound therapy 1154

Websites 1157

References 1157

18.1 Dressing a wound 1142

18.2 Suture removal 1153

18.3 Clip removal 1153

18.4 Negative pressure wound therapy 1155

Part Five Looking after ourselves so we can support patients 1161

19 Self-care and wellbeing 1162

Overview 1164

Self-care and wellbeing 1164

Mindfulness 1172

Eating and drinking 1173

Physical wellbeing and musculoskeletal health 1175

Websites 1181

References 1181

19.1 Working at low or floor level 1178

19.2 Working with a patient lying in a bed or on another raised supportive surface 1179

19.3 Carrying out clinical procedures in a seated posture (e.g. cannulation) 1180

19.4 Working in a seated position: office work 1180

Appendix: Standards of Proficiency for Registered Nurses 1183

List of abbreviations 1185

Index 1189

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