(Test Bank) Fundamentals of Nursing

Lillis,Taylor, 8

Nursing

Test Bank

8th Edition

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Test Bank for Fundamentals of Nursing, The downloadable file consists of 170 pages, and the total size of the file is 1.07 MB. Purchase now only for highly discounted price.

Author(s): Lillis, Taylor

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Skill Checklists for Fundamentals of Nursing THE ART AND SCIENCE OF NURSING CARELWBK680-FM._i-x.qxd 9/3/10 5:30 PM Page i Aptara IncLWBK680-FM._i-x.qxd 9/3/10 5:30 PM Page ii Aptara IncSkill Checklists for Fundamentals of Nursing THE ART AND SCIENCE OF NURSING CARE SEVENTH EDITION Carol R. Taylor, PhD, MSN, RN Center for Clinical Bioethics Professor of Nursing Georgetown University Washington, DC Carol Lillis, MSN, RN Faculty Emerita, Assistant to the Provost Delaware County Community College Media, Pennsylvania Priscilla LeMone, DSN, RN, FAAN Associate Professor Emerita, Sinclair School of Nursing University of Missouri-Columbia Columbia, Missouri Adjunct Associate Professor, College of Nursing The Ohio State University Columbus, Ohio Pamela Lynn, MSN, RN Instructor School of Nursing Gwynedd-Mercy College Gwynedd Valley, Pennsylvania Marilee LeBon, BA Editor Brigantine, New JerseyLWBK680-FM._i-x.qxd 9/3/10 5:30 PM Page iii Aptara IncExecutive Acquisitions Editor: Carrie Brandon Senior Product Manager: Betsy Gentzler Design Coordinator: Holly McLaughlin Manufacturing Coordinator: Karin DuffieldPrepress Vendor: Aptara, Inc. 7th editionCopyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2008, 2005, 2001 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 anymeans, including as photocopies or scanned-in or other electronic copies, or utilized by any informationstorage and retrieval system without written permission from the copyright owner, except for briefquotations embodied in critical articles and reviews. Materials appearing in this book prepared byindividuals 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 TwoCommerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at lww .com (products and services). 9 8 7 6 5 4 3 2 1 Printed in the United States of America.ISBN: 978-0-7817-9385-8 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 omissions or for any consequences from application of the information in this book and make nowarranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contentsof the publication. Application of this information in a particular situation remains the professionalresponsibility of the practitioner; the clinical treatments described and recommended may not beconsidered 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 thetime of publication. However, in view of ongoing research, changes in government regulations, and theconstant flow of information relating to drug therapy and drug reactions, the reader is urged to checkthe package insert for each drug for any change in indications and dosage and for added warnings andprecautions. This is particularly important when the recommended agent is a new or infrequentlyemployed 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 careprovider to ascertain the FDA status of each drug or device planned for use in his or her clinicalpractice. LWW.comLWBK680-FM._i-x.qxd 9/3/10 5:30 PM Page iv Aptara IncvIntroduction Developing clinical competency is an important challenge for each fundamentals nursing student. To facilitate the mastery of nursing skills, we are happy to provide skill checklists for each skill included in Fundamentals of Nursing: The Art and Science of Nursing Care , Seventh Edition. 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 follow each step of the skill to provide a complete evaluative tool. They are designed to record an evaluation of each step of the procedure. • 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 evaluat- ing faculty member.LWBK680-FM._i-x.qxd 9/3/10 5:30 PM Page v Aptara IncLWBK680-FM._i-x.qxd 9/3/10 5:30 PM Page vi Aptara IncList of Skills by Chapter Chapter 24 Vital Signs Skill 24-1: Assessing Body Temperature 1 Skill 24-2: Assessing a Peripheral Pulse by Palpation 5 Skill 24-3: Assessing Respiration 6 Skill 24-4: Assessing a Brachial Artery Blood Pressure 7 Chapter 26 Safety, Security, and Emergency Preparedness Skill 26-1: Applying an Extremity Restraint 9 Chapter 27 Asepsis and Infection Control Skill 27-1: Performing Hand Hygiene Using Soap and Water (Handwashing) 11 Skill 27-2: Using Personal Protective Equipment 12 Skill 27-3: Preparing a Sterile Field and Adding Sterile Items to a Sterile Field 14 Skill 27-4: Putting on Sterile Gloves and Removing Soiled Gloves 17 Chapter 29 Medications Skill 29-1: Administering Oral Medications 19 Skill 29-2: Removing Medication from an Ampule 21 Skill 29-3: Removing Medication From a Vial 23 Skill 29-4: Mixing Medications From Two Vials in One Syringe 25 Skill 29-5: Administering an Intradermal Injection 27 Skill 29-6: Administering a Subcutaneous Injection 30 Skill 29-7: Administering an Intramuscular Injection 33 Skill 29-8: Administering Medications by Intravenous Bolus or Push Through an Intravenous Infusion 36 Skill 29-9: Administering a Piggyback Intermittent Intravenous Infusion of Medication 38 Skill 29-10: Introducing Drugs Through a Medication or Drug-Infusion Lock (Intermittent PeripheralVenous Access Device) Using the Saline Flush 41 Chapter 30 Perioperative Nursing Skill 30-1: Providing Preoperative Patient Care: Hospitalized Patient 44 Skill 30-2: Providing Postoperative Care When Patient Returns to Room 47 Chapter 31 Hygiene Skill 31-1: Giving a Bed Bath 50 Skill 31-2: Assisting the Patient With Oral Care 53 Skill 31-3: Providing Oral Care for the Dependent Patient 55 Skill 31-4: Making an Unoccupied Bed 56 Skill 31-5: Making an Occupied Bed 58 Chapter 32 Skin Integrity and Wound Care Skill 32-1: Cleaning a Wound and Applying a Dry, Sterile Dressing 60 Skill 32-2: Applying a Saline-Moistened Dressing 63 Skill 32-3: Performing Irrigation of a Wound 65 Skill 32-4: Caring for a Jackson-Pratt Drain 67 Skill 32-5: Caring for a Hemovac Drain 69 Skill 32-6: Collecting a Wound Culture 71 Skill 32-7: Applying Negative-Pressure Wound Therapy 73 viiLWBK680-FM._i-x.qxd 9/3/10 5:30 PM Page vii Aptara Incviii List of Skills by Chapter Skill 32-8: Applying an External Heating Pad 76 Skill 32-9: Applying a Warm Compress 77 Chapter 33 Activity Skill 33-1: Applying and Removing Antiembolism Stockings 79 Skill 33-2: Assisting a Patient With Turning in Bed 81 Skill 33-3: Moving a Patient Up in Bed With the Assistance of Another Nurse 83 Skill 33-4: Transferring a Patient From the Bed to a Stretcher 85 Skill 33-5: Transferring a Patient From the Bed to a Chair 87 Skill 33-6: Providing Range-of-Motion Exercises 89 Chapter 35 Comfort Skill 35-1: Giving a Back Massage 91 Chapter 36 Nutrition Skill 36-1: Inserting a Nasogastric (NG) Tube 93 Skill 36-2: Administering a Tube Feeding 96 Skill 36-3: Removing a Nasogastric Tube 99 Skill 36-4: Obtaining a Capillary Blood Sample for Glucose Testing 100 Chapter 37 Urinary Elimination Skill 37-1: Assessing Bladder Volume Using an Ultrasound Bladder Scanner 102 Skill 37-2: Assisting With the Use of a Bedpan 104 Skill 37-3: Assisting With the Use of a Urinal 106 Skill 37-4: Applying an External Condom Catheter 108 Skill 37-5: Catheterizing the Female Urinary Bladder 110 Skill 37-6: Catheterizing the Male Urinary Bladder 113 Skill 37-7: Performing Intermittent Closed Catheter Irrigation 116 Skill 37-8: Administering a Continuous Closed Bladder Irrigation 118 Skill 37-9: Emptying and Changing a Stoma Appliance on an Ileal Conduit 120 Skill 37-10: Caring for a Hemodialysis Access (Arteriovenous Fistula or Graft) 122 Skill 37-11: Caring for a Peritoneal Dialysis Catheter 123 Chapter 38 Bowel Elimination Skill 38-1: Administering a Large-Volume Cleansing Enema 125 Skill 38-2: Irrigating a Nasogastric Tube Connected to Suction 127 Skill 38-3: Changing and Emptying an Ostomy Appliance 129 Chapter 39 Oxygenation Skill 39-1: Using a Pulse Oximeter 131 Skill 39-2: Suctioning the Nasopharyngeal and Oropharyngeal Airways 133 Skill 39-3: Administering Oxygen by Nasal Cannula 136 Skill 39-4: Administering Oxygen by Mask 137 Skill 39-5: Suctioning the Tracheostomy: Open System 138 Skill 39-6: Providing Tracheostomy Care 141 Chapter 40 Fluid, Electrolyte, and Acid–Base Balance Skill 40-1: Initiating a Peripheral Venous Access IV Infusion 144 Skill 40-2: Changing an IV Solution Container and Administration Set 148 Skill 40-3: Monitoring an IV Site and Infusion 151 Skill 40-4: Changing a Peripheral Venous Access Dressing 153 Skill 40-5: Capping for Intermittent Use and Flushing a Peripheral Venous Access Device 155 Skill 40-6: Administering a Blood Transfusion 156LWBK680-FM._i-x.qxd 9/3/10 5:30 PM Page viii Aptara IncList of Skills in Alphabetical Order Skill 33-1 Antiembolism Stockings, Applying and Removing 79 Skill 35-1 Back Massage, Giving a 91 Skill 33-2 Bed, Assisting a Patient With Turning in 81 Skill 31-5 Bed, Making an Occupied 58 Skill 31-4 Bed, Making an Unoccupied 56 Skill 37-2 Bedpan, Assisting With the Use of a 104 Skill 31-1 Bed Bath, Giving a 50 Skill 37-8 Bladder Irrigation, Administering a Continuous Closed 118 Skill 37-1 Bladder Volume Using an Ultrasound Bladder Scanner, Assessing 102 Skill 24-4 Blood Pressure, Assessing Brachial Artery 7 Skill 40-6 Blood Transfusion, Administering a 156 Skill 37-4 Catheter, Applying an External Condom 108 Skill 37-11 Catheter, Caring for a Peritoneal Dialysis 123 Skill 37-7 Catheter Irrigation, Performing Intermittent Closed 116 Skill 37-5 Catheterizing the Female Urinary Bladder 110 Skill 37-6 Catheterizing the Male Urinary Bladder 113 Skill 32-9 Compress, Applying a Warm 77 Skill 32-5 Drain, Caring for a Hemovac 69 Skill 32-4 Drain, Caring for a Jackson-Pratt 67 Skill 32-2 Dressing, Applying a Saline-Moistened 63 Skill 29-10 Drug-Infusion Lock (Intermittent Peripheral Venous Access Device) Using the Saline Flush, Introducing Drugs Through a Medication or 41 Skill 38-1 Enema, Administering a Large-Volume Cleansing 125 Skill 33-6 Exercises, Providing Range-of-Motion 89 Skill 27-4 Gloves, Putting on Sterile Gloves and Removing Soiled 17 Skill 36-4 Glucose Testing, Obtaining a Capillary Blood Sample for 100 Skill 27-1 Hand Hygiene, Performing: Using Soap and Water (Handwashing) 11 Skill 32-8 Heating Pad, Applying an External 76 Skill 37-10 Hemodialysis Access (Arteriovenous Fistula or Graft), Caring for a 122 Skill 29-6 Injection, Administering a Subcutaneous 30 Skill 29-5 Injection, Administering an Intradermal 27 Skill 29-7 Injection, Administering an Intramuscular 33 Skill 29-8 Intravenous Infusion, Administering Medications by Intravenous Bolus or Push Through an 36 Skill 29-9 Intravenous Infusion of Medication, Administering a Piggyback Intermittent 38 Skill 40-1 IV Infusion, Initiating a Peripheral Venous Access 144 Skill 40-3 IV Site and Infusion, Monitoring an 151 Skill 40-2 IV Solution Container and Administration Set, Changing an 148 Skill 29-2 Medication, Removing From an Ampule 21 Skill 29-3 Medication, Removing From a Vial 23 Skill 29-1 Medications, Administering Oral 19 Skill 29-4 Medications, Mixing From Two Vials in One Syringe 25 Skill 33-3 Moving a Patient Up in Bed With the Assistance of Another Nurse 83 Skill 36-1 Nasogastric (NG) Tube, Inserting a 93 Skill 38-2 Nasogastric Tube Connected to Suction, Irrigating a 127 Skill 36-3 Nasogastric Tube, Removing a 99 Skill 39-2 Nasopharyngeal and Oropharyngeal Airways, Suctioning the 133 Skill 31-2 Oral Care, Assisting the Patient With 53 Skill 31-3 Oral Care for the Dependent Patient, Providing 55 Skill 38-3 Ostomy Appliance, Changing and Emptying an 129 ixLWBK680-FM._i-x.qxd 9/3/10 5:30 PM Page ix Aptara Incx List of Skills in Alphabetical Order Skill 39-4 Oxygen by Mask, Administering 137 Skill 39-3 Oxygen by Nasal Cannula, Administering 136 Skill 40-5 Peripheral Venous Access Device, Capping for Intermittent Use and Flushing a 155 Skill 40-4 Peripheral Venous Access Dressing, Changing a 153 Skill 27-2 Personal Protective Equipment, Using 12 Skill 30-2 Postoperative Care When Patient Returns to Room, Providing 47 Skill 30-1 Preoperative Patient Care: Hospitalized Patient, Providing 44 Skill 24-2 Pulse by Palpation, Assessing a Peripheral 5 Skill 39-1 Pulse Oximeter, Using a 131 Skill 24-3 Respiration, Assessing 6 Skill 26-1 Restraint, Applying an Extremity 9 Skill 27-3 Sterile Field, Preparing and Adding Sterile Items to a 14 Skill 37-9 Stoma Appliance on an Ileal Conduit, Emptying and Changing a 120 Skill 24-1 Temperature, Assessing Body 1 Skill 39-6 Tracheostomy Care, Providing 141 Skill 39-5 Tracheostomy: Open System, Suctioning the 138 Skill 33-5 Transferring a Patient From the Bed to a Chair 87 Skill 33-4 Transferring a Patient From the Bed to a Stretcher 85 Skill 36-2 Tube Feeding, Administering a 96 Skill 37-3 Urinal, Assisting With the Use of a 106 Skill 32-1 Wound, Cleaning a, and Applying a Dry Sterile Dressing 60 Skill 32-3 Wound, Performing Irrigation of a 65 Skill 32-6 Wound Culture, Collecting a 71 Skill 32-7 Wound Therapy, Applying Negative-Pressure 73LWBK680-FM._i-x.qxd 9/16/10 2:39 AM Page x Aptara1 Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th edition Name Date Unit Position Instructor/Evaluator: Position SKILL 24-1 Assessing Body Temperature Goal: The patient’s temperature is assessed accurately without injury and the patient experiences only minimal discomfort. Comments 1. Check medical order or nursing care plan for frequency of measurement and route. More frequent temperature meas- urement may be appropriate based on nursing judgment. Bring necessary equipment to the bedside stand or overbed table. 2. Perform hand hygiene and put on PPE, if indicated. 3. Identify the patient. 4. Close curtains around bed and close door to room if possi- ble. Discuss procedure with patient and assess patient’s ability to assist with the procedure. 5. Ensure the electronic or digital thermometer is in working condition. 6. Put on gloves if appropriate or indicated. 7. Select the appropriate site based on previous assessment data. 8. Follow the steps as outlined below for the appropriate type of thermometer. 9. When measurement is completed, remove gloves, if worn. Remove additional PPE, if used. Perform hand hygiene. Measuring a Tympanic Membrane Temperature 10. If necessary, push the “on” button and wait for the “ready” signal on the unit. 11. Slide disposable cover onto the tympanic probe. 12.Insert the probe snugly into the external ear using gentle but firm pressure, angling the thermometer toward the patient’s jaw line. Pull pinna up and back to straighten the ear canal in an adult. 13. Activate the unit by pushing the trigger button. The reading is immediate (usually within 2 seconds). Note the reading. 14. Discard the probe cover in an appropriate receptacle by pushing the probe-release button or use rim of cover to remove from probe. Replace the thermometer in its charger, if necessary. Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care , 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.LWBK680-c24_p01-08.qxd 9/3/10 5:24 PM Page 1 Aptara Inc2 Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care , 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.SKILL 24-1 Assessing Body Temperature (Continued) Comments Assessing Oral Temperature 10. Remove the electronic unit from the charging unit, and remove the probe from within the recording unit. 11. Cover thermometer probe with disposable probe cover and slide it on until it snaps into place. 12.Place the probe beneath the patient’s tongue in the poste- rior sublingual pocket. Ask the patient to close his or her lips around the probe. 13.Continue to hold the probe until you hear a beep. Note the temperature reading. 14. Remove the probe from the patient’s mouth. Dispose of the probe cover by holding the probe over an appropriate receptacle and pressing the probe release button. 15. Return the thermometer probe to the storage place within the unit. Return the electronic unit to the charging unit, if appropriate. Assessing Rectal Temperature 10. Adjust the bed to a comfortable working height, usually elbow height of the caregiver (VISN 8, 2009). Put on non- sterile gloves. 11. Assist the patient to a side-lying position. Pull back the covers enough to expose only the buttocks. 12. Remove the rectal probe from within the recording unit of the electronic thermometer. Cover the probe with a dispos- able probe cover and slide it into place until it snaps in place. 13.Lubricate about 1 /H11033of the probe with a water-soluble lubricant. 14. Reassure the patient. Separate the buttocks until the anal sphincter is clearly visible. 15.Insert the thermometer probe into the anus about 1.5 /H11033in an adult or 1 /H11033in a child. 16. Hold the probe in place until you hear a beep, then carefully remove the probe. Note the temperature reading on the display. 17. Dispose of the probe cover by holding the probe over an appropriate waste receptacle and pressing the release button. 18. Using toilet tissue, wipe the anus of any feces or excess lubricant. Dispose of the toilet tissue. Remove gloves and discard them.LWBK680-c24_p01-08.qxd 9/3/10 5:24 PM Page 2 Aptara Inc3 Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care , 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.SKILL 24-1 Assessing Body Temperature (Continued) Comments 19. Cover the patient and help him or her to a position of comfort. 20. Place the bed in the lowest position; elevate rails as needed. 21. Return the thermometer to the charging unit. Assessing Axillary Temperature 10. Move the patient’s clothing to expose only the axilla. 11. Remove the probe from the recording unit of the electronic thermometer. Place a disposable probe cover on by sliding it on and snapping it securely. 12.Place the end of the probe in the center of the axilla. Have the patient bring the arm down and close to the body. 13. Hold the probe in place until you hear a beep, and then carefully remove the probe. Note the temperature reading. 14. Cover the patient and help him or her to a position of comfort. 15. Dispose of the probe cover by holding the probe over an appropriate waste receptacle and pushing the release button. 16. Place the bed in the lowest position and elevate rails as needed. Leave the patient clean and comfortable. 17. Return the electronic thermometer to the charging unit. Assessing Temporal Artery Temperature 10. Brush the patient’s hair aside if it is covering the temporal artery area. 11. Apply a probe cover. 12. Hold the thermometer like a remote, with your thumb on the red “ON” button. Place the probe flush on the center of the forehead, with the body of the instrument sideways (not straight up and down), so it is not in the patient’s face. 13. Depress the “ON” button. Keep the button depressed throughout the measurement. 14. Slowly slide the probe straight across the forehead, midline, to the hairline. The thermometer will click; fast clicking indicates a rise to a higher temperature, slow click- ing indicates the instrument is still scanning, but not find- ing any higher temperature.LWBK680-c24_p01-08.qxd 9/3/10 5:24 PM Page 3 Aptara Inc4 Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care , 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.SKILL 24-1 Assessing Body Temperature (Continued) Comments 15. Brush hair aside if it is covering the ear, exposing the area of the neck under the ear lobe. Lift the probe from the forehead and touch on the neck just behind the ear lobe, in the depression just below the mastoid. 16. Release the button and read the thermometer measurement. 17. Hold the thermometer over a waste receptacle. Gently push the probe cover with your thumb against the proximal edge to dispose of probe cover. 18. Instrument will automatically turn off in 30 seconds, or press and release the power button.LWBK680-c24_p01-08.qxd 9/3/10 5:24 PM Page 4 Aptara Inc5 Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th edition Name Date Unit Position Instructor/Evaluator: Position SKILL 24-2 Assessing a Peripheral Pulse by Palpation Goal: The patient’s pulse is assessed accurately without injury and the patient experiences only minimal discomfort. Comments 1. Check medical order or nursing care plan for frequency of pulse assessment. More frequent pulse measurement may be appropriate based on nursing judgment. 2. Perform hand hygiene and put on PPE, if indicated. 3. Identify the patient. 4. Close curtains around bed and close door to room if possi- ble. Discuss procedure with patient and assess patient’s ability to assist with the procedure. 5. Put on gloves as appropriate. 6. Select the appropriate peripheral site based on assessment data. 7. Move the patient’s clothing to expose only the site chosen. 8. Place your first, second, and third fingers over the artery. Lightly compress the artery so pulsations can be felt and counted. 9. Using a watch with a second hand, count the number of pulsations felt for 30 seconds. Multiply this number by 2 to calculate the rate for 1 minute. If the rate, rhythm, or amplitude of the pulse is abnormal in any way, palpate and count the pulse for 1 minute. 10. Note the rhythm and amplitude of the pulse. 11. When measurement is completed, remove gloves, if worn. Cover the patient and help him or her to a position of comfort. 12. Remove additional PPE, if used. Perform hand hygiene. Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care , 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.LWBK680-c24_p01-08.qxd 9/3/10 5:24 PM Page 5 Aptara Inc6 Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care , 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th edition Name Date Unit Position Instructor/Evaluator: Position SKILL 24-3 Assessing Respiration Goal: The patient’s respirations are assessed accurately without injury and the patient experiences only minimal discomfort. Comments 1.While your fingers are still in place for the pulse measurement, after counting the pulse rate, observe the patient’s respirations. 2. Note the rise and fall of the patient’s chest. 3. Using a watch with a second hand, count the number of res- pirations for 30 seconds. Multiply this number by 2 to cal- culate the respiratory rate per minute. 4.If respirations are abnormal in any way, count the respira- tions for at least 1 full minute. 5. Note the depth and rhythm of the respirations. 6. When measurement is completed, remove gloves, if worn. Cover the patient and help him or her to a position of com- fort. 7. Remove additional PPE, if used. Perform hand hygiene.LWBK680-c24_p01-08.qxd 9/3/10 5:24 PM Page 6 Aptara Inc7 Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th edition Name Date Unit Position Instructor/Evaluator: Position SKILL 24-4 Assessing a Brachial Artery Blood Pressure Goal: The patient’s blood pressure is measured accurately with minimal discomfort to the patient. Comments 1. Check physician’s order or nursing care plan for frequency of blood pressure measurement. More frequent measurement may be appropriate based on nursing judgment. 2. Perform hand hygiene and put on PPE, if indicated. 3. Identify the patient. 4. Close curtains around bed and close door to room if possi- ble. Discuss procedure with patient and assess patient’s ability to assist with the procedure. Validate that the patient has relaxed for several minutes. 5. Put on gloves, if appropriate or indicated. 6. Select the appropriate arm for application of the cuff. 7. Have the patient assume a comfortable lying or sitting posi- tion with the forearm supported at the level of the heart and the palm of the hand upward. If the measurement is taken in the supine position, support the arm with a pillow. In the sitting position, support the arm yourself or by using the bedside table. If the patient is sitting, have the patient sit back in the chair so that the chair supports his or her back. In addition, make sure the patient keeps the legs uncrossed. 8. Expose the brachial artery by removing garments, or move a sleeve, if it is not too tight, above the area where the cuff will be placed. 9. Palpate the location of the brachial artery. Center the bladder of the cuff over the brachial artery, about midway on the arm, so that the lower edge of the cuff is about 2.5 to 5 cm (1 /H11033–2/H11033) above the inner aspect of the elbow. Line the artery marking on the cuff up with the patient’s brachial artery. The tubing should extend from the edge of the cuff nearer the patient’s elbow. 10. Wrap the cuff around the arm smoothly and snugly, and fasten it. Do not allow any clothing to interfere with the proper placement of the cuff. 11. Check that the needle on the aneroid gauge is within the zero mark. If using a mercury manometer, check to see that the manometer is in the vertical position and that the mercury is within the zero level with the gauge at eye level. Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care , 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.LWBK680-c24_p01-08.qxd 9/3/10 5:24 PM Page 7 Aptara Inc8 Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care , 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.SKILL 24-4 Assessing a Brachial Artery Blood Pressure (Continued) Comments Estimating Systolic Pressure 12. Palpate the pulse at the brachial or radial artery by press- ing gently with the fingertips. 13. Tighten the screw valve on the air pump. 14.Inflate the cuff while continuing to palpate the artery. Note the point on the gauge where the pulse disappears. 15. Deflate the cuff and wait 1 minute. Obtaining Blood Pressure Measurement 16. Assume a position that is no more than 3 feet away from the gauge. 17. Place the stethoscope earpieces in your ears. Direct the ear- pieces forward into the canal and not against the ear itself. 18. Place the bell or diaphragm of the stethoscope firmly but with as little pressure as possible over the brachial artery. Do not allow the stethoscope to touch clothing or the cuff. 19. Pump the pressure 30-mm Hg above the point at which the systolic pressure was palpated and estimated. Open the valve on the manometer and allow air to escape slowly (allowing the gauge to drop 2-3 mm per second). 20.Note the point on the gauge at which the first faint, but clear, sound appears that slowly increases in intensity. Note this number as the systolic pressure. Read the pressure to the closest 2 mm Hg. 21. Do not reinflate the cuff once the air is being released to recheck the systolic pressure reading. 22.Note the point at which the sound completely disappears. 23. Allow the remaining air to escape quickly. Repeat any sus- picious reading, but wait at least 1 minute. Deflate the cuff completely between attempts to check the blood pressure. 24. When measurement is completed, remove the cuff. Remove gloves, if worn. Cover the patient and help him or her to a position of comfort. 25. Remove additional PPE, if used. Perform hand hygiene. 26. Clean the diaphragm of the stethoscope with the alcohol wipe. Clean and store the sphygmomanometer, according to facility policy.LWBK680-c24_p01-08.qxd 9/3/10 5:24 PM Page 8 Aptara Inc9 Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th edition Name Date Unit Position Instructor/Evaluator: Position SKILL 26-1 Applying an Extremity Restraint Goal: The patient is constrained by the restraint, remains free from injury, and the restraint does not interfere with therapeutic devices. Comments 1. Determine need for restraints. Assess patient’s physical condition, behavior, and mental status. 2. Confirm agency policy for application of restraints. Secure an order from the primary care provider, or validate that the order has been obtained within the past 24 hours. 3. Perform hand hygiene and put on PPE, if indicated. 4. Identify the patient. 5. Explain reason for use to patient and family. Clarify how care will be given and how needs will be met. Explain that restraint is a temporary measure. 6. Include the patient’s family and/or significant others in the plan of care. 7. Apply restraint according to manufacturer’s directions: a. Choose the least restrictive type of device that allows the greatest possible degree of mobility. b. Pad bony prominences. c. Wrap the restraint around the extremity with the soft part in contact with the skin. If hand mitt is being used, pull over hand with cushion to the palmar aspect of hand. Secure in place with the Velcro® straps. 8.Ensure that two fingers can be inserted between the restraint and patient’s wrist or ankle. 9. Maintain restrained extremity in normal anatomic position. Use a quick-release knot to tie the restraint to the bed frame, not side rail. The restraint may also be attached to chair frame. The site should not be readily accessible to patient. 10. Remove PPE, if used. Perform hand hygiene. 11. Assess the patient at least every hour or according to facil- ity policy. Assessment should include: the placement of the restraint, neurovascular assessment of the affected extrem- ity, and skin integrity. In addition, assess for signs of sensory deprivation such as increased sleeping, daydream- ing, anxiety, panic, and hallucinations. Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care , 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.LWBK680-c26-p09-10.qxd 9/3/10 5:24 PM Page 9 Aptara Inc10 Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care , 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.SKILL 26-1 Applying an Extremity Restraint (Continued) Comments 12.Remove restraint at least every 2 hours, or according to agency policy and patient need. Perform range-of-motion exercises. 13. Evaluate patient for continued need of restraint. Reapply restraint only if continued need is evident and order is still valid. 14. Reassure patient at regular intervals. Provide continued explanation of rationale for interventions, reorientation if necessary, and plan of care. Keep call bell within easy reach.LWBK680-c26-p09-10.qxd 9/3/10 5:24 PM Page 10 Aptara Inc11 Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th edition Name Date Unit Position Instructor/Evaluator: Position SKILL 27-1 Performing Hand Hygiene Using Soap and Water (Handwashing) Goal: The hands will be free of visible soiling and transient microorganisms will be eliminated. Comments 1. Gather the necessary supplies. Stand in front of the sink. Do not allow your clothing to touch the sink during the washing procedure. 2. Remove jewelry, if possible, and secure in a safe place. A plain wedding band may remain in place. 3. Turn on water and adjust force. Regulate the temperature until the water is warm. 4. Wet the hands and wrist area. Keep hands lower than elbows to allow water to flow toward fingertips. 5. Use about 1 teaspoon of liquid soap from dispenser or rinse bar of soap and lather thoroughly. Cover all areas of hands with the soap product. Rinse soap bar again and return to soap rack. 6. With firm rubbing and circular motions, wash the palms and backs of the hands, each finger, the areas between the fingers, and the knuckles, wrists, and forearms. Wash at least 1 inch above area of contamination. If hands are not visibly soiled, wash to 1 inch above the wrists 7. Continue this friction motion for at least 15 seconds. 8. Use fingernails of the opposite hand or a clean orangewood stick to clean under fingernails. 9. Rinse thoroughly with water flowing toward fingertips. 10. Pat hands dry with a paper towel, beginning with the fin- gers and moving upward toward forearms, and discard it immediately. Use another clean towel to turn off the faucet. Discard towel immediately without touching other clean hand. 11. Use oil-free lotion on hands, if desired. Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care , 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.LWBK680-c27-p11-18.qxd 9/3/10 5:24 PM Page 11 Aptara Inc12 Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care , 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th edition Name Date Unit Position Instructor/Evaluator: Position SKILL 27-2 Using Personal Protective Equipment Goal: The transmission of microorganisms is prevented. Comments 1. Check medical record and nursing plan of care for type of precautions and review precautions in infection-control manual. 2. Plan nursing activities before entering patient’s room. 3. Perform hand hygiene. 4. Provide instruction about precautions to patient, family members, and visitors. 5. Put on gown, gloves, mask, and protective eyewear, based on the type of exposure anticipated and category of isolation precautions. a. Put on the gown, with the opening in the back. Tie gown securely at neck and waist. b. Put on the mask or respirator over your nose, mouth, and chin. Secure ties or elastic bands at the middle of the head and neck. If respirator is used, perform a fit check. Inhale; the respirator should collapse. Exhale; air should not leak out. c. Put on goggles. Place over eyes and adjust to fit. Alternately, a face shield could be used to take the place of the mask and goggles. d. Put on clean disposable gloves. Extend gloves to cover the cuffs of the gown. 6. Identify the patient. Explain the procedure to the patient. Continue with patient care as appropriate. Remove PPE 7. Remove PPE: Except for respirator, remove PPE at the doorway or in anteroom. Remove respirator after leaving the patient room and closing door. a. If impervious gown has been tied in front of the body at the waistline, untie waist strings before removing gloves. b. Grasp the outside of one glove with the opposite gloved hand and peel off, turning the glove inside out as you pull it off. Hold the removed glove in the remaining gloved hand. LWBK680-c27-p11-18.qxd 9/3/10 5:24 PM Page 12 Aptara Inc13 Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Fundamentals of Nursing: The Art and Science of Nursing Care , 7th edition, by Carol Taylor, Carol Lillis, Priscilla LeMone, Pamela Lynn, and Marilee LeBon.SKILL 27-2 Using Personal Protective Equipment (Continued) Comments c. Slide fingers of ungloved hand under the remaining glove at the wrist, taking care not to touch the outer surface of the glove. d. Peel off the glove over the first glove, containing the one glove inside the other. Discard in appropriate container. e. To remove the goggles or face shield: Handle by the headband or ear pieces. Lift away from the face. Place in designated receptacle for reprocessing or in an appropri- ate waste container. f. To remove gown: Unfasten ties, if at the neck and back. Allow the gown to fall away from shoulders. Touching only the inside of the gown, pull away from the torso. Keeping hands on the inner surface of the gown, pull from arms. Turn gown inside out. Fold or roll into a bundle and discard. g. To remove mask or respirator: Grasp the neck ties or elastic, then top ties or elastic and remove. Take care to avoid touching front of mask or respirator. Discard in waste container. If using a respirator, save for future use in the designated area. 8. Perform hand hygiene immediately after removing all PPE.LWBK680-c27-p11-18.qxd 9/3/10 5:24 PM Page 13 Aptara Inc