joanne essential clinical skills -...

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EssentialClinical Skillse n r o l l e d |d i v i s i o n 2 n u r s e s

Joanne Tollefson

Toni Bishop

Eugenie Jelly

Gayle Watson

Karen Tambree

e d i t i o n 2

BISHOP_TOLLEFSON 9780170197182 CVR FINAL ART.indd 1 10/10/12 10:28 AM

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CONTENTSIntroduction vii

About the authors xi

Acknowledgements xii

Resources guide xiii

PART 1 GENERAL CARE 11.1 Hand hygiene 2

1.2 Bedmaking 6

1.3 Assisting the patient to ambulate 9

1.4 Assisting the patient with eating and

drinking 13

1.5 Assisting the patient to maintain

personal hygiene – bed bath or

assisted shower, undressing/dressing,

oral hygiene, eye and nasal care,

shaving, hair and nail care 16

1.6 Assisting the patient with elimination

(including urinalysis and urine specimen

collection, perineal care, ostomy care

and stool assessment) 24

1.7 Patient comfort – pain management

(non-pharmacological interventions –

heat and cold) 31

1.8 Positioning of a dependent patient and

pressure area care 35

1.9 Range of motion exercises 39

PART 2 DOCUMENTATION 432.1 Documentation 44

2.2 Clinical handover 48

2.3 Admissions and discharge 51

2.4 Health teaching 55

PART 3 ASSESSMENT 613.1 Basic assessment 62

3.2 Temperature, pulse and respiration

(TPR) measurement 66

3.3 Blood pressure measurement 70

3.4 Pulse oximetry 74

3.5 Blood glucose measurement 77

3.6 Mental status assessment 81

3.7 Neurological observation 85

3.8 Neurovascular observation 90

3.9 Pain assessment 94

3.10 12-Lead ECG recording 98

PART 4 MEDICATION 1034.1 Medication administration – oral,

topical and suppositories 104

4.2 Medication administration – eye drops

or ointment administration 111

4.3 Medication administration – injections 115

PART 5 ASEPSIS 1255.1 Aseptic technique 126

5.2 Dry dressing 130

5.3 Wound irrigation, wound swabs 134

5.4 Packing a wound 138

5.5 Suture, clip and staple removal 142

5.6 Drain removal and shortening 146

PART 6 ACUTE CARE 1516.1 Catheterisation (urinary) 152

6.2 Nasogastric tube insertion and feeding,

gastric drainage and gastric

tube feeding 158

6.3 Oxygen therapy via nasal cannula or

various masks including nebulisers,

metered dose inhalers and peak

flow meters 165

6.4 Pre-operative care 172

6.5 Post-operative care 177

6.6 Recovery room care and handover 183

6.7 Suctioning of oral cavity 188

6.8 Tracheostomy care 192

6.9 Electro-convulsive therapy (ECT) –

patient care pre and post treatment 197

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PART 7 INTRAVENOUS CARE 2017.1 Venipuncture 202

7.2 Intravenous therapy (IVT) – assisting

with establishment 207

7.3 Intravenous therapy (IVT) management 213

7.4 Intravenous medication

administration – IV container 217


administration – burette 220


administration – bolus 224

7.7 Blood transfusion management 228

PART 8 SPECIFIC SKILLS 2338.1 Isolation nursing 234

8.2 Gowning and gloving 237

8.3 Surgical scrub 240

8.4 Chest drains/underwater seal drainage

management 244

8.5 Care of the unconscious patient 248

Appendix:

ANMC National Competency Standards

for the Enrolled Nurse (2002) 252

Index 274

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Thoroughly wet hands and apply soap

Do not touch the inside or outside of the sink. The sink is contaminated and touching will transfer micro-organisms onto the nurse’s hands. Wet hands to above the wrists, keeping hands lower than elbows toprevent water from flowing onto the arms and, when contaminated, back onto the clean hands. Add liquidsoap or an antimicrobial cleanser. Five millilitres is sufficient to be effective; less does not effectivelyremove microbes. More soap would be wasteful of resources. If only bar soap is available, lather and rinsethe bar to remove microbes before you start to wash your hands, and do not put the bar down until youare ready to rinse. Lather hands to above the wrists.

Clean under the fingernails

Under the nails is a highly soiled area and high concentrations of microbes on hands come from beneathfingernails. The area under the nails should be cleansed of debris with either a nail brush or an orangestick, usually during the first hand wash of the day. If the nails become soiled during the shift, thiscleaning will need to be done again. Some authors suggest cleansing the nails prior to washing; otherssuggest that during washing is more effective. Cleaning this area under flowing water is most effective forremoving debris.

Wash hands

Lather and wash your hands for a period of not less than 15 to 30 seconds before care or after care iftouching ‘clean’ objects (clean materials, limited patient contact such as pulse-taking), and one to twominutes if engaged in ‘dirty’ activities (Larsen & Lusk, 2006) such as direct contact with excreta orsecretions. A surgical hand wash will take 3–6 minutes depending on policies.

Rub one hand with the other, using vigorous movements since friction is effective in dislodging dirt andmicro-organisms. Pay particular attention to palms, backs of hands, knuckles and webs of fingers. Dirtand micro-organisms lodge in creases. Lather and scrub up over the wrist, and onto the lower forearm ifdoing a longer wash to remove dirt and micro-organisms from this area. The wrists and forearms areconsidered less contaminated than the hands, so they are scrubbed after the hands to prevent themovement of micro-organisms from a more contaminated to a less contaminated area. Repeat thewetting, lathering with additional soap and rubbing if hands have been heavily contaminated.

Rinse hands

For social washing, rinse the hands and fingers under running water to wash micro-organisms and dirt.For clinical and surgical washes, hands are rinsed first, and are held higher than the elbows to allowwater to run off the elbows and so prevent contamination of the clean forearms and hands. Rinse well toprevent residual soap from irritating the skin.

Dry hands

Using paper towels, pat the fingers, hands and forearms well to dry the skin and prevent chapping. Damphands are a source of microbial growth and transfer, as well as contributing to chapping and then lesionsof the hands.

Turn off taps

Using dry paper towels, turn hand-manipulated taps off, taking care not to contaminate hands on the sinkor taps. Carefully discard paper towels so that hands are not contaminated. Turn off other types of tapswith foot, knee or elbow as appropriate. After several washes, hand lotion should be applied to preventchapping. Frequent hand hygiene can be very drying and chapped skin becomes a reservoir for micro-organisms.

Apply alcohol-based hand rub as required

Hands must be visibly clean and dry prior to using the ABHR. Hand hygiene using a waterless, alcohol-based rub has been demonstrated to reduce the microbial load on hands when 3 mL of the 60–80%ethanol based solution is vigorously rubbed over all hand and finger surfaces (pay the same attention tothe palms, back of the hands, finger webs, knuckles and wrists as during the traditional hand wash) for10–30 seconds. The use of such a rub is effective for minimally contaminated hands. It increases

CHAPTER 1.1 Hand hygiene 3


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ESSENTIAL SKILLS COMPETENCY

BLOOD PRESSURE MEASUREMENT

Demonstrates the ability to effectively measure blood pressure

(Numbers indicate ANMC National Competency Standardsfor the Enrolled Nurse, 2002)

Y(Satisfactory)

D(Requires Development)

1. Identifies indication (4.1, 7.1, 8.1)

2. Evidence of effective communication with the patient; e.g. givespatient a clear explanation of procedure, and assesses patient (3.1,3.3, 3.4, 6.1, 7.1, 8.2)

3. Gathers equipment (7.1, 7.4)

● sphygmomanometer (aneroid or mercury manometer, automatedmanometer)

● stethoscope● alcowipes

4. Demonstrates problem-solving abilities; e.g. prepares environment(6.1, 7.1, 8.1)

5. Performs hand hygiene (7.1, 8.1)

6. Positions and prepares patient (7.1)

7. Applies the cuff (7.1)

8. Performs a preliminary palpatory systolic determination (7.1, 8.1)

9. Positions the stethoscope appropriately (7.1)

10. Auscultates the patient’s blood pressure (7.1)

11. Removes the cuff (7.1, 8.1)

12. Cleans, replaces and disposes of equipment appropriately (8.1, 9.2,10.2)

13. Documents and reports relevant information (1.1, 1.3, 1.4, 1.5, 6.1,7.2, 7.3, 8.1)

14. Demonstrates ability to link theory to practice (5.1, 5.2)

CHAPTER 3.3 Blood pressure measurement 73


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Tracheostomy careIdentify indications

A tracheostomy is the surgical creation of a stoma in the upper airway to facilitate airway management. Itmay be carried out to bypass any upper respiratory tract obstruction or trauma, or in patients requiringlong-term ventilation (Dougherty & Lister, 2008). It is generally a temporary measure. Tracheostomy caremaintains airway patency by removing dried secretions. It keeps the skin around the site clean to helpprevent infections of the stoma site and lower airway, and to prevent skin breakdown. Tracheostomysuctioning is an advanced skill for the Enrolled Nurse.

Tracheostomy tubes are chosen individually for each patient and vary in their composition, number ofparts, shape and size. The diameter should be smaller than the trachea so it lies comfortably in thelumen. The length and curve are important so that dislodgement during coughing or head turning isavoided. The tube may be cuffed or uncuffed. Cuffs seal the space between the trachea and tube, allowingfor mechanical ventilation. Long-term tracheostomy tubes have three parts: an inner cannula (smooth tubewith the locking device), an outer cannula (with a flange, cuff and pilot tube) and an obdurator (with a

6.8

Figure 6.8.1 A tracheostomy with the cuff inflated

Figure 6.8.2 Tracheostomy parts

Obturator

Outercannula

Faceplate

Slit for tracheostomy ties

Cuff

Innercannula

Pilotballoon

192 PART 6 Acute care


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