Clinical Nursing Procedures : The Art of Nursing Practice

1. Health Assessment 1
1.1: Measuring Body Temperature 2
1.2: Assessment of Pulse 6
1.3: Assessing Respiration 10
1.4: Monitoring Blood Pressure 11
1.5: Checking Height and Weight of a Patient 15
1.6: Collecting Urine Specimen for Routine Examination 17
1.7: Testing Urine for pH 19
1.8: Checking Specific Gravity of Urine 20
1.9(A): Testing Urine for Glucose (Benedict’s Solution) 22
1.9(B): Testing Urine for Glucose (Reagent Strip or Tape) 23
1.10: Testing Urine for Albumin 24
1.11: Collecting Urine Specimen for Culture 25
1.12: Collection of 24 Hours Urine 27
1.13: Collecting Stool Specimen for Routine Examination 28
1.14: Collecting Stool Specimen for Culture 30
1.15: Collecting Throat Swab for Culture 31
1.16: Collecting Wound Swab for Culture 33
1.17: Protocol for Sample Collection of Blood 34
1.18: Collecting Blood for Routine Examination 36
1.19: Measuring Blood for Glucose Level Using Glucometer 38
1.20: Collection of Blood for Culture 41
1.21: Collecting Blood for Peripheral Smear 43
1.22: Collection of Sputum for Culture 45
1.23: Assisting with Obtaining a Papanicolaou Smear 46
1.24: Measuring Intake and Output 49
1.25: Teaching Breast Self-examination (BSE) 52
1.26: Teaching Testicular Self-examination (TSE) 54
2. Client Care: Hygiene and Comfort 57
2.1: Admission of a Patient in Hospital 58
2.2: Discharge of a Patient from Hospital 60
2.3: Transfer of a Patient from Unit to Unit and Hospital to Hospital 62
2.4: Preparing an Open/Unoccupied Bed 64
2.5: Preparing an Occupied Bed 69
2.6: Preparing a Postoperative Bed 72
2.7: Preparing a Cardiac Bed 74
2.8: Assisting in Oral Hygiene for a Conscious Patient 75
2.9: Performing Oral Care for an Unconscious Patient 78
2.10: Bathing a Patient in Bed 81
2.11: Performing Nail and Foot Care 84
2.12: Providing Genital Care/Hygienic Perineal Care 87
2.13: Providing a Bed Shampoo/Hair Wash 90
2.14: Performing Eye Care 93
2.15: Performing Eye Irrigation 94
2.16: Performing Ear Irrigation 96
xiv Clinical Nursing Procedures: The Art of Nursing Practice
2.17: Use of Comfort Devices 98
2.18: Providing Back Massage 100
2.19: Providing Sitz Bath 103
2.20: Application of Hot Water Bag 105
2.21: Application of an Ice Cap 108
2.22: Application of Cold Compress 110
2.23: Giving a Tepid Sponge 112
2.24: Giving a Cold Sponge 114
2.25: Care of Body After Death 116
3. Safety, Body Mechanics and Prevention of Infection 119
3.1: Practicing Principles of Body Mechanics 120
3.2: Moving a Patient up in Bed 122
3.3: Turning a Patient to Lateral or Prone Position 124
3.4: Logrolling a Patient 126
3.5: Assisting a Patient to Sitting Position 129
3.6: Transferring a Patient from Bed to Chair 130
3.7: Transferring a Patient Between a Bed and a Stretcher 131
3.8: Providing Range of Motion Exercises 133
3.9: Positioning of the Patient in Bed 137
3.10: Performing Medical Handwashing 143
3.11: Policies for Segregation and Disposal of Biomedical Waste 147
3.12: Disinfection of Blood and Body Fluids Spills 149
3.13: Prevention of Nosocomial Infections 151
3.14: Applying Restraints 156
3.15: Positioning and Restraining Children for Procedures 160
4. Nutrition 163
4.1: Serving Normal Diet 164
4.2: Feeding Helpless Patient 166
4.3: Insertion of a Nasogastric Tube 168
4.4: Administration of Nasogastric Tube Feeding 171
4.5: Feeding Through a Gastrostomy/Jejunostomy Tube 174
4.6: Administration of Total Parenteral Nutrition 177
4.7: Performing a Test Feed 181
5. Elimination 183
5.1: Assisting with the Use of a Urinal 184
5.2: Applying a Condom Catheter 185
5.3: Performing a Urinary Catheterization 187
5.4: Performing Catheter Care 192
5.5: Removing an Indwelling Urinary Catheter 194
5.6: Performing a Bladder Irrigation 196
5.7: Assisting with the Use of a Bedpan 198
5.8: Administering an Enema 200
5.9: Performing a Bowel Wash/Colonic Lavage 206
5.10: Performing Colostomy Care 209
5.11: Performing Colostomy Irrigation 212
Contents xv
6. Oxygenation 2
xvi Clinical Nursing Procedures: The Art of Nursing Practice
10. Skin Integrity and Wound Care 335
10.1: Performing a Wound Dressing 336
10.2: Dressing a Burn Wound 339
10.3: Removal of Sutures and Staples 342
10.4: Performing Wound Irrigation 345
11. Advanced Clinical Procedures 349
11.1: Recording an Electrocardiogram (Ecg) 350
11.2: Preparation of Patient and Assisting with Exercise Stress Test 353
11.3: Preparation of Patient and Assisting with Cardiac Catheterization 357
11.4: Preparation of Patient and Assisting with Pacemaker Implantation 360
11.5: Performing a Cardiopulmonary Resuscitation (Cpr) 366
11.6(A): Performing Defibrillation and Advanced Cardiac Life Support (ACLS) 370
11.6(B): Advanced Cardiac Life Support Algorithm 374
11.7: Performing a Heimlich Maneuver 375
11.8: Assisting with Arterial Puncture 378
11.9: Preparation for and Assisting with Digital Subtraction Angiography 381
11.10: Preparation for and Assisting with Cerebral Angiography 383
11.11(A): Assisting with Insertion of Central Venous Catheter 385
11.11(B): Flushing a Central Venous Catheter 389
11.11(C): Measuring Central Venous Pressure (CVP) 390
11.11(D): Changing Dressing at Central Venous Catheter Insertion Site 393
11.11(E): Changing the Central Venous Tubing 394
11.12: Assisting with Bronchoscopy 395
11.13: Assisting with Endotracheal Intubation 397
11.14: Assisting with Tracheostomy 400
11.15: Providing Tracheostomy Care 402
11.16: Performing Endotracheal/Tracheal Suctioning 405
11.17: Performing Oropharyngeal Sunctioning 409
11.18: Assisting with Thoracentesis 411
11.19: Connecting and Changing Intercostal Drainage (Icd) Bottles 414
11.20: Assisting with Removal of Chest Drainage Tubes 417
11.21: Performing Gastric Suctioning 419
11.22: Assisting with Upper Gastrointestinal Endoscopy 421
11.23: Assisting with Endoscopic Sclerotherapy 424
11.24: Assisting with Insertion of Sengstaken-Blakemore Tube/Balloon Tamponade 426
11.25: Performing a Gastric Lavage or Stomach Wash 429
11.26: Preparation of Patient and Assisting with Barium Studies (Upper GI Series) 431
11.27: Preparation of Patient and Assisting with Barium Enema 433
11.28: Preparation of Patient and Assisting with Colonoscopy 435
11.29: Preparation of Patient and Assisting with Proctoscopy 437
11.30: Assisting in Abdominal Paracentesis 439
11.31: Preparation for Ultrasonography 441
11.32: Assisting with Liver Biopsy 442
11.33: Assisting with Endoscopic Retrograde Cholangiopancreatography (ERCP) 445
11.34: Preparation for kub X-ray 448
11.35: Assisting with Intravenous Pyelography (IVP) 449
11.36: Assisting with Renal Biopsy 451
11.37: Preparation of Patient and Assisting with Cystoscopy 453
Contents xvii
11.38: Preparation for Skull and Spine X-ray 455
11.39: Preparation of Patient and Assisting with Electroencephalography (EEG) 456
11.40: Assessment of Consciousness Using Glasgow Coma Scale (GCS) 457
11.41: Assisting with Lumbar Puncture 459
11.42: Assisting with Computerized Axial Tomography Scan 462
11.43: Assisting with Magnetic Resonance Imaging (Mri) Scan 464
11.44: Assisting with Bone Marrow Aspiration and Biopsy 466
11.45: Preparation of Patient for Electromyography (EMG) 469
11.46(A): Admission and Initial Management of Patient in Burns Unit 471
11.46(B): Fluid Resuscitation in Acute Burns 474
11.47: Providing Exercises for Postburn Patients 476
11.48: Preparing Patient for Mammography 477
12. Operating Room and Related Procedures 479
12.1: Performing a Surgical Scrub 480
12.2: Conducting a General Preoperative Assessment and Checklist 483
12.3: Performing Skin Preparation for Surgery 485
12.4: Preparing an Operation Theater Trolley and Patient Before Surgery 490
12.5: Applying Mask and Sterile Gown 493
12.6: Performing Sterile Gloving 495
12.7: Positioning Patients for Surgery 497
12.8: Assisting with Postoperative Exercises 500
13. Mental Health Nursing 505
13.1: Admitting a Patient in Psychiatric Unit 506
13.2: Discharging a Patient from Psychiatric Unit 507
13.3: Performing Mental Status Examination (MSE) 508
13.4: Conducting Process Recording 510
13.5: Preparing Patient and Assisting with Electroconvulsive Therapy (ECT) 511
13.6: Preparing Patient and Assisting with Chemical Convulsive Therapy 514
13.7: Assisting with Hypnosis Therapy 516
13.8: Assisting with Insulin Subcoma Therapy 518
13.9: Assisting with Narcoanalysis/Abreactive Therapy 519
14. Maternal and Child Nursing 521
14.1: Performing an Antenatal Abdominal Examination and Palpation 522
14.2: Teaching Antenatal Exercises 527
14.3: Performing a Nonstress Test (NST) 529
14.4: Performing an Oxytocin Challenge Test 532
14.5: Preparing a Prenatal Patient for Ultrasound Examination 534
14.6: Assisting with an Amniocentesis 536
14.7: Admitting a Client to Labor Room 540
14.8: Assisting with Induction of Labor 542
14.9: Performing Vaginal Examination for a Patient in Labor 546
14.10: Conducting a Normal Vaginal Delivery 549
14.11: Performing an Examination of Placenta 554
14.12: Performing and Suturing an Episiotomy 557
xviii Clinical Nursing Procedures: The Art of Nursing Practice
14.13: Assisting with Forceps Delivery 561
14.14: Assisting with Ventouse Extraction 565
14.15: Assisting with Dilatation and Curettage Procedure 567
14.16: Providing Perineal Care 569
14.17: Measuring Involution of Uterus 571
14.18: Teaching Postnatal Excercises 573
14.19: Assisting in Insertion of Intrauterine Contraceptive Device (Copper-T) 577
14.20: Providing Immediate Newborn Care 581
14.21: Performing a Newborn Assessment 583
14.22: Performing Neonatal Resuscitation 591
14.23: Assisting with Breastfeeding 596
14.24: Care of Baby Undergoing Phototherapy 599
14.25: Care of Newborn in Incubator (Isolette) 601
14.26: Assisting in Exchange Transfusion 603
14.27: Bathing a Newborn 606
14.28: Giving Sponge Bath to a Newborn 609
14.29: Weighing a Newborn 611
14.30: Feeding Infants with Cleft Lip and Cleft Palate 613
14.31: Administering Nasogastric/Orogastric Tube Feed for Children 615
14.32: Growth Assessment for Children (Anthropometry) 617
14.33: Cardiopulmonary Resuscitation for Children 622
14.34: Performing Heimlich Maneuver for Children 625
14.35: Collecting Urine Specimen from Infants 627
15. Community Health Nursing 629
15.1: Performing Handwashing at Home 630
15.2: Performing Bag Techniques at Home 631
15.3: Taking Anthropometric Measurements 633
15.4: Checking Weight and Height 635
15.5: Performing Urine Analysis 639
15.6: Collection of Specimens for Laboratory Investigations 641
15.7: Checking Temperature at Home 643
15.8A: Estimation of Hemoglobin at Home Using Hemoglobinometer 644
15.8B: Estimation of Hemoglobin Level Using Hemoglobin Testing Paper 645
15.9: Collecting Blood for Peripheral Smear 646
15.10: Dressing a Wound at Home 647
15.11A: Giving a Baby Bath/Tub Bath 649
15.11B: Giving a Lap/Leg Bath 650
15.12: Conducting a Domiciliary Delivery 652
16. Special Topics 655
16.1: Legal Aspects of Nursing Practice 656
16.2: Ethics in Nursing Practice 664
Appendices 673
Bibliography 705
Index 707