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vi TABLE OF CONTENTS
H
Skill 32 Hypothermia and Hyperthermia Blankets, 233
I
Skill 33 Using Incentive Spirometry, 238
Skill 34 Intradermal Injections, 241
Skill 35 Intramuscular Injections, 248
Skill 36 Intravenous Medications: Intermittent Infusion Sets and
Mini-Infusion Pumps, 259
Skill 37 Intravenous Medications: Intravenous Bolus, 270
Skill 38 Isolation Precautions, 280
M
Skill 39 Mechanical Lifts, 293
Skill 40 Metered-Dose Inhalers, 300
Skill 41 Moist Heat (Compress and Sitz Bath), 309
Skill 42 Mouth Care: Unconscious or Debilitated Patients, 316
N
Skill 43 Nail and Foot Care, 321
Skill 44 Nasoenteral Tube: Placement and Irrigation, 326
Skill 45 Nasogastric Tube for Gastric Decompression: Insertion and
Removal, 338
Skill 46 Negative-Pressure Wound Therapy, 345
O
Skill 47 Oral Medications, 354
Skill 48 Oral Medications: Medication Administration Through an
Enteral Feeding Tube, 364
Skill 49 Ostomy Care (Pouching), 372
Skill 50 Oxygen Therapy: Nasal Cannula, Oxygen Mask, T Tube, or
Tracheostomy Collar, 379
P
Skill 51 Parenteral Medication Preparation: Ampules and Vials, 386
Skill 52 Parenteral Medications: Mixing Medications in One
Syringe, 399
Skill 53 Patient-Controlled Analgesia, 408
Skill 54 Peripheral Intravenous Care: Dressing Care,
Discontinuation, 414
Skill 55 Peripheral Intravenous Care: Regulating Intravenous Flow
Rate, Changing Tubing and Solution, 421
Skill 56 Peripheral Intravenous Insertion, 432
TABLE OF CONTENTS vii
R
Skill 63 Rectal Suppository Insertion, 512
Skill 64 Respiration Assessment, 518
Skill 65 Restraint Application, 524
Skill 66 Restraint-Free Environment, 532
S
Skill 67 Seizure Precautions, 538
Skill 68 Sequential Compression Device and Elastic Stockings, 546
Skill 69 Specialty Beds: Air-Fluidized, Air-Suspension, and
Rotokinetic, 555
Skill 70 Sterile Gloving, 562
Skill 71 Sterile Technique: Donning and Removing Cap, Mask, and
Protective Eyewear, 571
Skill 72 Subcutaneous Injections, 578
Skill 73 Suctioning: Closed (in-Line), 587
Skill 74 Suctioning: Nasopharyngeal, Nasotracheal, and Artificial
Airway, 592
Skill 75 Suprapubic Catheter Care, 608
Skill 76 Suture and Staple Removal, 613
T
Skill 77 Topical Skin Applications, 620
Skill 78 Tracheostomy Care, 630
U
Skill 79 Urinary Catheter Insertion, 642
Skill 80 Urinary Catheter Care and Removal, 658
Skill 81 Urinary Catheter Irrigation, 667
Skill 82 Urinary Diversion: Pouching an Incontinent Urinary
Diversion, 674
V
Skill 83 Vaginal Instillations, 680
Skill 84 Venipuncture: Collecting Blood Specimens and Cultures by
Syringe and Vacutainer Method, 687
viii TABLE OF CONTENTS
W
Skill 85 Managing Wound Drainage Evacuation, 699
Skill 86 Wound Irrigation, 705
Bibliography, 714
Index, 740
SKILL 1
Acapella Device
The Acapella device is a handheld airway clearance device that uses
positive expiratory pressure (PEP) to stabilize airways and improve
aeration of the distal lung areas. There are two types: the blue device
for patients who cannot maintain their expiratory flow above 15 L/
min for greater than 3 seconds, and a green device for patients
who can maintain expiratory flow above or equal to 15 L/min for
at least 3 seconds. PEP stabilizes airways and improves aeration of
the distal lung areas. During exhalation, pressure from the airways is
transmitted to the Acapella device, which helps mucus dislodge from
the airway walls and as a result prevents airway collapse, accelerates
expiratory flow, and moves mucus toward the trachea (Strickland
et al., 2013). Some patients with cystic fibrosis may benefit more from
this device than from standard chest physiotherapy. However, cystic
fibrosis patients must receive some type of routine airway clearance
therapy daily.
Delegation Considerations
The skill of using an Acapella device can be delegated to nursing assistive
personnel (NAP). The nurse is responsible for performing respiratory
assessment, determining that the procedure is appropriate and that a
patient can tolerate it, and evaluating a patient’s response to the procedure.
The nurse directs the NAP to do the following:
■ Be alert for the patient’s tolerance of the procedure, such as
comfort level and changes in breathing pattern, and to
immediately report changes to the nurse.
■ Use specific patient precautions, such as positioning restrictions
related to disease or treatment.
Equipment
■ Stethoscope
■ Pulse oximeter
■ Water and glass
■ Chair
■ Tissues and paper bag
■ Clear, graduated, screw-top container
■ Suction equipment (if patient cannot cough and clear own
secretions)
■ Acapella device
■ Clean gloves
■ Patient education materials
1
2 SKILL 1 Acapella Device
Implementation
STEP RATIONALE
1 Complete preprocedure
protocol.
2 Prepare Acapella device (Fig.
1.1). Verify that the correct
device is used to match the
patient’s expiratory flow rate.
a Turn Acapella frequency This initial setting helps patient
adjustment dial adjust to device and benefit
counterclockwise to lowest from treatment.
resistance setting. As
patient improves or is more
proficient, adjust proper
resistance level upward by
turning dial clockwise.
b If aerosol drug therapy is
ordered, attach a nebulizer
to the end of the Acapella
valve.
3 Instruct patient to:
a Sit comfortably.
b Take in breath that is larger
than normal but not to fill
lungs completely.
c Place mouthpiece into the
mouth, maintaining tight
seal.
d Hold breath for 2 to 3
seconds.
e Try not to cough and to
exhale slowly for 3 to 4
seconds through the device
while it vibrates.
f Repeat cycle for 5 to 10
breaths as tolerated.
g Remove mouthpiece and
perform one or two “huff ”
coughs.
h Repeat Steps a through g as
ordered.
SKILL 1 Acapella Device 3
STEP RATIONALE
4 Auscultate lung fields; obtain
vital signs and pulse oximetry.
Inspect color, character, and
amount of sputum. Help
patient with oral hygiene.
5 Complete postprocedure
protocol.
Aquathermia and
Heating Pads
A water-flow pad such as an aquathermia pad, electric heating pads,
and commercial heat packs are common forms of dry heat therapy. The
aquathermia pad (water-flow pad) used in health care settings comprises
a waterproof rubber or plastic pad connected by two hoses to an electrical
control unit that has a heating element and motor. Distilled water
circulates through hollowed channels in the pad to the control unit
where water is heated (or cooled).
Dry heat devices are applied directly to the surface of the skin. For
this reason, extra precautions need to be taken to prevent burns and
skin and tissue injury (Igaki et al., 2014). A conventional heating pad
uses dry heat and is often used in the home care setting, but not in
health care settings. A cotton or flannel cloth must cover the heating
pad. The pad has a temperature-regulating unit for high, medium, or
low settings. Because it is easy to readjust temperature settings on heating
pads, instruct patients not to turn the setting higher once they have
adapted to the temperature.
Delegation Considerations
The skill of applying aquathermia and dry heat can be delegated to
nursing assistive personnel (NAP; see agency policy). The nurse must
assess and evaluate the condition of the skin and tissues in the area that
is treated and explain the purpose of the treatment. If there are risks or
expected complications, this skill cannot be delegated. The nurse directs
the NAP about the following:
■ Specific positioning and time requirements to keep the application
in place based on health care provider order or agency policy.
■ What to observe and report immediately, such as excessive redness
and pain during application.
■ Reporting when treatment is complete so the patient’s response
can be evaluated.
Equipment
■ Aquathermia or commercial heat pack
■ Distilled water (for aquathermia pad)
■ Bath towel or pillowcase
■ Tape ties or gauze roll
4
SKILL 2 Aquathermia and Heating Pads 5
Implementation
STEP RATIONALE
1 Complete preprocedure
protocol.
2 Check electric plugs and Prevents injury from accidental
cords for obvious fraying or electric shock.
cracking.
3 Determine patient’s or family Determines extent of health
members’ knowledge of teaching required.
procedure, including steps
for application and safety
precautions.
4 Apply dry heat device:
a For aquathermia Prevents heated surface from
(1) Cover or wrap area to touching patient’s skin directly
be treated with bath and increasing risk for injury
towel or enclose the to patient’s skin.
pad with pillowcase. Pad delivers dry, warm heat to
(2) Place pad over affected injured tissues. Pad should not
area (Fig. 2.1), and slip onto different body part.
secure with tape, tie, or Prevents exposure of patient to
gauze as needed. temperature extremes.
(3) Turn on aquathermia
unit and check
temperature setting.
SAFETY ALERT Do not pin the wrap to the pad, because this may cause a
leak in the device.
Continued
STEP RATIONALE
b For commercially prepared Activates chemicals within pack
heat pack, break pouch to warm outer surface. Pad
inside larger pack (follow delivers dry, warm heat to
manufacturer’s guidelines). injured tissues. Pad should not
slip onto different body part.
5 Monitor condition of skin Determines if heat exposure is
every 5 minutes during causing burn, blistering, or
application, and question injury to underlying skin.
patient regarding sensation of
burning.
6 After no more than 20 Heat therapy may reduce pain
minutes (or time ordered by and spasm and increase
health care provider), remove blood flow and compliance of
pad and store. soft-tissue structures (Brooks
et al., 2015).
7 Complete postprocedure
protocol.
8 Teach Back: To determine Determines patient and family
the patient and family’s caregiver level of understanding
understanding about safely of instructional topic.
using a heating pad. State: “I
want to be sure I explained
how to safely use a heating
pad at home. Can you explain
to me why you want a layer of
cloth between the heating pad
and your skin?” Revise your
instruction now or develop
a plan for revised patient
teaching if patient is not able
to teach back correctly.
Aspiration Precautions
Aspiration is the misdirection of oropharyngeal secretions or gastric
contents into the larynx and lower respiratory tract (Metheny, 2012).
You should suspect dysphagia if a patient has frequent drooling, loss of
food from the mouth during eating, pocketing food (holding food in
the cheek), and spitting pieces of food out. In addition, a patient might
experience choking or coughing when swallowing, a gurgling or wet-
sounding voice quality (e.g., hoarseness), and having the sensation of
food getting stuck in the throat after multiple attempts to swallow (Kyle,
2011; Mayo Clinic, 2014).
Silent or asymptomatic aspiration refers to passage of foods or liquids
into the trachea and lungs without producing a productive cough or
other signs consistent with aspiration (Garon et al., 2009). The more
subtle signs associated with silent aspiration include lack of speech,
depressed alertness, wet quality to voice, drooling, difficulty controlling
secretions, and absence of gag reflex.
The single most important measure to prevent aspiration is to place
the patient on nothing by mouth (NPO) until a dysphagia evaluation
by a certified speech language therapist (SLP) can be performed, then
a safe diet can resume. Early screening and intervention are crucial in
the prevention of aspiration and pneumonia.
Dysphagia management includes dietary modification by altering
the consistency of foods and liquids and is most effective when imple-
mented using an interprofessional approach. The SLP and registered
dietitian (RD) are central to dysphagia management.
The National Dysphagia Diet comprises four levels: dysphagia puree,
dysphagia mechanically altered, dysphagia advanced, and regular (Table
3.1). Thickened liquids are commonly prescribed to prevent aspiration
pneumonia (Frey and Ramsberger, 2011). Always read the label directions
when modifying liquids to prepare the desired thickness correctly. Appropri-
ate food choices and consistency of liquids are individualized and based
on which phase of swallowing is dysfunctional (Sura, 2012).
Delegation Considerations
The skill of following aspiration precautions while feeding a patient can
be delegated to nursing assistive personnel (NAP). However, the nurse
is responsible for the ongoing assessment of a patient’s risk for aspiration
and determination of positioning and any special feeding techniques.
The nurse directs the NAP to do the following:
■ Position patient upright (45 to 90 degrees preferred) or according
to medical restrictions during and after feeding.
8
SKILL 3 Aspiration Precautions 9
Equipment
■ Upright chair or bed in high-Fowler position
■ Thickening agents as designated by SLP (rice, cereal, yogurt,
gelatin, commercial thickener)
■ Tongue blade
■ Penlight
■ Oral hygiene supplies
■ Suction equipment
10 SKILL 3 Aspiration Precautions
■ Clean gloves
■ Pulse oximeter (optional)
Implementation
STEP RATIONALE
1 Complete preprocedure
protocol.
2 Perform a nutritional Patients with dysphagia alter
assessment. their eating patterns or choose
foods that do not provide
adequate nutrition (see Table
3.1).
3 Assess mental status, If orientation and
including alertness, command-following are
orientation, and ability to impaired, risk for aspiration is
follow simple commands. higher.
4 Determine if patient has an Performing an assessment
increased risk for aspiration, before feeding determines
and assess for signs and when referral to SLP is
symptoms of dysphagia necessary. Interventions to
(Box 3.1). Use a dysphagia minimize aspiration and
screening tool if available. possible pneumonia can be
implemented.
5 Apply clean gloves. Provide Risk for aspiration pneumonia
thorough oral hygiene, has been associated with poor
including brushing of oral hygiene (Eisenstadt, 2010).
tongue, before meal.
6 Observe patient during Indicates swallowing impairment
mealtime for signs of and possible aspiration.
dysphagia such as coughing, Chewing and sitting up for
dyspnea, or drooling. Note feeding accelerate onset of
during and at end of meal if fatigue. Fatigue increases risk
patient tires. for aspiration.
7 Indicate on patient’s chart Identifying patient as dysphagic
and Kardex that dysphagia/ reduces risk for his or her
aspiration risk is present. receiving oral nutrients without
supervision.
SKILL 3 Aspiration Precautions 11
When Observing the Patient or Giving Mouth Care, Look for the
Following:
■ Open mouth (weak lip closure)
■ Drooling liquids or solids
■ Poor oral hygiene/thrush
■ Facial weakness
■ Tongue weakness
■ Difficulty with secretions
■ Slurred, indistinct speech
■ Change in voice quality
■ Poor posture or head control
■ Weak involuntary cough
■ Delayed cough (up to 2 minutes after swallow)
■ General frailty
■ Confusion/dementia
■ No spontaneous swallowing movements
If any of the above is present, the patient may have swallowing
problems and need referral to an SLP.
STEP RATIONALE
8 Position patient upright (90 Position facilitates safe
degrees) in a chair or elevate swallowing and enhances
head of patient’s bed to a esophageal motility (Grodner
45- to 90-degree angle or to et al., 2012; Ney et al., 2009).
the highest position allowed Side-lying position is an option
by medical condition during if patient cannot have head
meal, or position in chair. elevated.
Continued
12 SKILL 3 Aspiration Precautions
STEP RATIONALE
9 Using penlight and tongue Pockets of food in the mouth
blade, gently inspect mouth indicate difficulty swallowing.
for pockets of food.
10 Optional: Apply pulse Pulse oximetry may be a reliable
oximeter to patient’s finger; method of diagnosis of
monitor during feeding. aspiration in most dysphagic
stroke patients (Lancaster,
2015).
11 Add thickener to thin liquids Thin liquids are difficult to
to create desired consistency control in the mouth and
per SLP evaluation. pharynx and are more easily
aspirated (Garcia et al., 2010).
12 Have patient assume a Chin-tuck or chin-down
chin-tuck position. Have position has traditionally been
patient swallow twice or used to help reduce aspiration
repeatedly, and monitor for (Eisenstadt, 2010). However,
swallowing and respiratory a study of 47 patients with a
difficulty. video fluoroscopic diagnosis
of aspiration found only 55%
avoided aspiration during the
chin-down posture (Terre &
Mearin, 2012). More research
is needed. Hyperextension of
neck makes it easier for food to
enter airway.
13 If patient cannot feed self, Small bites help patient’s ability
place 1 2 to 1 teaspoon of to swallow (Grodner et al.,
food on unaffected side of 2012).
mouth, allowing utensils to Provides a tactile cue to begin
touch the mouth or tongue. eating, avoids pocketing of
food on weaker side.
14 Provide verbal cueing while Verbal cueing keeps patient
feeding. Remind patient focused on normal swallowing
to chew and think about (Metheny, 2012). Positive
swallowing. Avoid mixing reinforcement enhances
food of different textures in patient’s confidence in ability
same mouthful. Alternate to swallow (Garcia and
liquids and bites of food. Chambers, 2010).
SKILL 3 Aspiration Precautions 13
STEP RATIONALE
Minimize distractions, and Single textures are easier to
do not rush patient. Use swallow than multiple textures.
sauces, condiments, and Alternating solids with liquids
gravies to facilitate cohesive removes food residue in mouth
food bolus formation. (Ney et al., 2009).
Environmental distractions and
conversations during mealtime
increase risk for aspiration
(Chang and Roberts, 2011).
Cohesive food bolus helps to
prevent pocketing or small
food particles from entering
the airway (Ney et al., 2009).
15 Ask patient to remain sitting Remaining upright after meals
upright for at least 30 to 60 or snack reduces chance of
minutes after the meal. aspiration by allowing food
particles remaining in pharynx
to clear (Frey and Ramsberger,
2011).
16 Complete postprocedure
protocol.
Assistive Device
Ambulation (Use of
Crutches, Cane,
and Walker)
An assistive device increases stability during ambulation; supports weak
extremities; or reduces the load on weight-bearing structures such as
hips, knees, or ankles. These devices range from standard canes, which
provide balance and minimal physical support, to crutches and walkers,
which are used by patients with weight-bearing limitations on one or
more of their legs.
A licensed physical therapist (PT) should be consulted to help
choose the proper assistive device, fit the device, and instruct the
patient on the correct technique for use. When helping a patient with
an assistive device ambulate, always have a gait belt on the patient
and stand slightly behind and to the side of the patient (on his or her
weak side).
Delegation Considerations
The skill of assisting patients with ambulation can be delegated to
nursing assistive personnel (NAP). The nurse directs the NAP to do the
following:
■ Have a patient dangle following lying in bed before ambulation.
■ Immediately return a patient to the bed or chair if he or she is
nauseated, dizzy, pale, or diaphoretic, and report these signs and
symptoms to the nurse immediately.
■ Apply safe, nonskid shoes on patient, and ensure that the
environment is free of clutter and there is no moisture on the
floor before ambulating patient.
Equipment
■ Ambulation device (crutch, walker, cane)
■ Safety device (gait belt)
■ Well-fitting, flat, nonskid shoes for patient
■ Goniometer (optional)
15
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rejtély marad. A mindennapi kérdésekre megvannak a szokásos
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Lefekvés előtt.
Parent úr 5
Borigó gazda fülbaja 58
Eladó 70
Az ismeretlen 79
Vallomás 87
A keresztelő 94
Veszedelmes játék 101
Az őrült 110
Vidéki pörösködések 119
A hajtű 125
Szalonkavadászat 133
A vonaton 145
Nyafinyaff 154
A felfedezés 165
A magányosság 171
Lefekvés előtt 178
A kis baka 187