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Taylor's Handbook of Clinical Nursing Skills
Taylor's Handbook of Clinical Nursing Skills
Copyright © All rights reserved. This book is protected by copyright. No part of it may be
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permission of the publisher, except for brief quotations embodied in critical articles and
reviews and testing and evaluation
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accompanying textbook. Materials appearing in this book prepared by individuals as part of
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Care has been taken to confirm the accuracy of the information presented and to describe
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for errors or omissions or for any consequences from the application of the information in
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publication.
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
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ment regulations, and the constant flow of information relating to drug therapy and drug re
actions, the reader is urged to check the package insert for each drug for any change in
indications and dosage and for added warnings and precautions. This is particularly impor
tant when the recommended agent is a new or infrequently employed drug.
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sponsibility of the healthcare provider to ascertain the FDA status of each drug or device
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Contributors and Reviewers
Beaumont, Texas
CONTRIBUTORS
Patti Simmons, RN, MN,
Lynn Burbank, RN, CPNP, MSN
CHPN Assistant Professor of
Learning Resource Coordinator
Nursing North Georgia College
Dixon School of Nursing
and State University
Abington Memorial
Dahlonega, Georgia
Hospital Abington,
Pennsylvania
Diane E. Witt, RN, PhD,
Medications
CNP Assistant Professor
REVIEWERS
School of Nursing
Rose A. Harding, MSN, RN Minnesota State
Instructor University Mankato,
Lamar University Minnesota
JoAnne Gay Dishman
Department of Nursing
iv
Preface
Taylor’s Handbook of Clinical Nursing Skills is a quick-reference
guide to basic and advanced nursing skills. It outlines step-by-step
instructions and reinforces the cognitive and technical knowledge
needed to perform skills safely and effectively. The convenient
handbook format is helpful for student review in the lab or clinical
setting and as a reference for graduate nurses in practice.
LEARNING EXPERIENCE
This text and the entire Taylor Suite have been created with the
student’s experience in mind. Care has been taken to appeal to all
learning styles. The student-friendly writing style ensures that students
will comprehend and retain information. The extensive art program
enhances understand
ing of important actions. In addition, each element of the Taylor Suite,
which is described later in the preface, coordinates the information to
provide a consistent and cohesive learning experience.
ORGANIZATION
In general, the content of this book provides streamlined skills
consistent with those in Taylor’s Clinical Nursing Skills, 3rd Edition.
Skills are or ganized alphabetically, based on the main word(s) of the
skill, allowing the user to access the information about the desired skill
quickly and easily.
FEATURES
• Step-by-Step Skills. Each skill is presented in a concise, straight
forward, and simplified two-column format to facilitate competent
performance of nursing skills.
• The nursing process framework is used to integrate related nursing
responsibilities for each of the five steps.
• Scientific rationales accompany each nursing action to promote a
deeper understanding of the basic principles supporting nursing
care.
yg
• Hand hygiene icons alert you to this crucial step that is the best
wa
way to prevent the spread
of microorganisms.
• Patient i
• Patient identification icons alert you to this crucial step ensuring
the
the right patient receives the intervention and helping pre
ve
vent errors.
v
• Documentation guidelines direct students and graduate nurses in
accurate documentation of the skill and their findings.
• General considerations appear throughout to explain the varying
needs of patients across the lifespan and in various settings. • Photos.
Key steps are clarified and reinforced with pictures.
vi
versions for purchase by schools. Student versions of the videos are
available on DVD/DVD-ROM or online through thePoint.
Contact your sales representative or check out LWW.com/Nursing
for more details and ordering information.
vii
Acknowledgments
This edition is the work of many talented people. I would like to ac
knowledge the hard work of all who have contributed to the completion
of this project. Thanks to Carol Taylor, Carol Lillis, and Priscilla
LeMone for offering generous support and encouragement. You have
been excel lent mentors.
The work of this book was skillfully coordinated by my dedicated
Product Manager, Michelle Clarke, in the Nursing Education division
of Lippincott Williams & Wilkins. I am grateful to you for your
patience, support, unending encouragement, and total commitment. My
thanks to Jean Rodenberger, Executive Acquisitions Editor, for her
hard work and guidance throughout most of the project. Thank you to
the members of the production department, who patiently pulled
everything together to form a completed book: Helen Ewan, Director
of Nursing Production; Cindy Rudy, Vendor Manager; Holly Reid
McLaughlin, Design Coordi nator; and Brett MacNaughton, Illustration
Coordinator.
A special thanks to my colleagues at Gwynedd-Mercy College, who
offer unending support and professional guidance.
Finally, I would like to gratefully acknowledge my family, for their
love, understanding, and encouragement. Their support was essential
during the long hours of research and writing.
viii
Contents
3 Ambulation: Crutches,
A Assisting a Patient with
1 Ambulation, Assisting Using 9
with 1 4 Ambulation: Walker,
Assisting a Patient with
2 Ambulation: Cane, Assisting a
Using 14
Patient with Using 5
5 Antiembolism Stockings.
Applying and Arterial Blood Gas
Removing 18 Analysis 96
6 Arterial and Femoral Lines, 20 Blood Specimen,
Removing 23 Obtaining from an
Arterial Line–Stopcock
System 104
B
21 Blood Specimen, Using
7 Back Massage, Giving 27 8 Venipuncture to Collect for
Bath: Bed, Giving 32 Routine Testing 111
9 Bath: Sitz, Assisting 22 Blood Specimen: Venous,
with 44 Obtaining for Culture and
10 Bed Making, Sensitivity 120
Occupied 47 23 Blood Transfusing,
11 Bed Making, Administering 128
Unoccupied 52
12 Bedpan, Assisting with the C
Use of 59
24 Cardiac Monitor,
13 Bed Scale, Using 66 Applying 134
14 Bladder Volume, Assessing 25 Cardiopulmonary
Using a Bladder Ultrasound Resuscitation (CPR),
Scanner 71 Performing 140
15 Blood Glucose Testing, 26 Cast Application,
Obtaining a Capillary Assisting 146
Sample 75 27 Cast Care 151
16 Blood Pressure, Assessing 28 Central Venous Access
Brachial Artery Device (CVAD):
Auscultated 80 Accessing an Implanted
17 Blood Pressure, Assessing Port 156
Using a Doppler
29 Central Venous Access
Ultrasound 87
Device (CVAD): Changing Site
18 Blood Pressure, Assessing Dressing and
Using an Electronic Flushing 162
Automated Device 92
19 Blood Specimen, Obtaining
ix
30 Central Venous Access 32 Cervical Collar, Applying a
Device (CVAD): Two-Piece 175
Deaccessing an Implanted
33 Chest Tube: Providing Care
Port 168
of a Chest Drainage
31 Central Venous Access System 179
Device (CVAD): Removing a
34 Chest Tube: Assisting with
Peripherally Inserted
Removal 187
Central Catheter
(PICC) 172 35 Cold Therapy,
Applying 189 Automated External
36 Colostomy, Irrigating 194 (Emergency) 256
37 Comfort, Promoting 49 Denture Care,
Patient 198 Providing 261
38 Commode, Assisting with 50 Digital Removal of
the Use of 207 Stool 265
39 Compress, Applying a 51 Drain: Hemovac, Caring
Warm 211 for 269
40 Condom Catheter, 52 Drain: Jackson-Pratt,
Applying 217 Caring for 275
41 Contact Lenses, 53 Drain: Penrose, Caring
Removing 222 for 281
42 Continuous Closed Bladder 54 Drain: T-tube, Caring
Irrigation (CBI), for 287
Administering 226 55 Dressing: Cleaning a
43 Continuous Passive Motion Wound and Applying a
Device (CPM), Dry, Sterile 293
Applying 230 56 Dressing: Hydrocolloid,
44 Continuous Wound Applying 299
Perfusion Pain 57 Dressing: Changing a
Management 234 Peripheral Venous
45 Cooling Blanket, Access 305
Using 240 58 Dressing: Saline
D Moistened, Applying 309
46 Deep Breathing Exercises:
Coughing and E
Splinting 245
59 Ear Drops,
47 Defibrillation, Performing Instilling 315
Manual External
60 Ear Irrigation,
(Emergency,
Administering 321
Asynchronous) 250
48 Defibrillation, Performing
x
61 Eating, Assisting 65 Endotracheal Tube: Open
Patient 326 System, Suctioning 353
62 Electrocardiogram (ECG), 66 Enema: Large
Obtaining 331 Volume Cleansing,
63 Endotracheal Tube, Administering 361
Securing 339 67 Enema: Retention,
64 Endotracheal Tube: Administering 367
Closed System, 68 Enema: Small
Suctioning 346 Volume Cleansing,
Administering 372
69 Epidural Analgesia, H
Caring for a Patient
Receiving 377 81 Hand Hygiene: Alcohol
Based Hand Rub,
70 External Fixation, Caring
Performing 436
for a Patient with 383
82 Hand Hygiene: Hand
71 Eye Drops, Washing with Soap and
Instilling 387 Water 438
72 Eye Irrigation, 83 Heating Pad, Applying an
Administering 394 External 441
84 Hemodialysis Access
F (Arteriovenous Fistula or
73 Fall Prevention 397 74 Fecal Graft), Caring for 445
Incontinence Pouch, Applying
403 I
75 Fiber Optic Intracranial 85 Incentive Spirometer,
Catheter, Caring for a Teaching a Patient to
Patient with 406 Use 448
76 Figure-Eight Bandage, 86 Inhaler: Dry Powder,
Applying 410 Administering Medication
77 Forced-Air Warming via 452
Device, Applying 414 87 Inhaler: Metered-Dose,
G Administering Medication
78 Gastric Tube: Administering via 458
a Tube Feeding 417 88 Injection: Intradermal,
79 Gastric Tube: Caring Administering 464
for a Gastrostomy 89 Injection: Intramuscular,
Tube 428 Administering 471
80 Gloves: Putting on 90 Injection: Subcutaneous,
Sterile and Removing Administering 478
Soiled 432
xi
91 Insulin Pump, 94 IV Infusion: Changing an
Administering Continuous IV Solution Container and
Subcutaneous via 486 Administration
92 IV Access: Initiating a Set 507
Peripheral Venous Access IV 95 IV Infusion: Monitoring
Infusion 493 an IV Site and
93 IV Access: Capping for Infusion 514
Intermittent Use and
Flushing a Peripheral L
Venous Access Device 503
Oral 566
96 Leg Exercises 518 97
105 Medication: Removing
Logrolling a Patient 521
from an Ampule 573
106 Medication: Removing
M
from a Vial 578
98 Medication: Administering 107 Medication: Transdermal
Medications via a Gastric Patch, Applying 584
Tube 525
108 Medication: Vaginal Cream,
99 Medication: IV Infusion, Administering 590
Administering Medications by
109 Montgomery Straps,
Intravenous Bolus or
Applying 596
Push Through an
Intravenous Infusion 533 110 Moving a Patient Up in
Bed 601
100 Medication: IV Infusion,
Administering a Piggyback
Intravenous of N
Medication 539
111 Nasal Swab,
101 Medication: IV Infusion, Obtaining 605
Administering an
112 Nasopharyngeal Swab,
Intermittent Intravenous
Obtaining 609
Infusion of Medication
via a Mini-Infusion 113 Nasogastric Tube,
Pump 546 Insertion 613
102 Medication: IV Infusion, 114 Nasogastric Tube,
Administering an Irrigating 621
Intermittent Intravenous 115 Nasogastric Tube,
Infusion of Medication via Removing 625
a Volume-Control
116 Nasopharyngeal Airway,
Administration Set 552
Inserting 629
103 Medication: Mixing
117 Nebulizer, Administering
Medications from Two
Medication via Small
Vials in One Syringe 559
Volume 633
104 Medication: Administering
xii
118 Negative Pressure Wound 122 Oropharyngeal Airway,
Therapy, Applying 639 Inserting 660
119 Nose Drops, 123 Ostomy: Changing and
Instilling 646 Emptying Appliance 664
124 Ostomy: Changing Urinary
O Stoma Appliance on an
120 Oral Care, Assisting the Ileal Conduit 672
Patient 651 125 Oxygen Administration:
121 Oral Care, Providing for the Using an Oxygen
Dependent Patient 656 Hood 678
126 Oxygen Administration: 136 Pulse: Peripheral Using
Administering Oxygen by Palpation, Assessing 731
Mask 681 137 Pulse: Periperhal Using
127 Oxygen Administration: Portable Doppler
Administering Oxygen by Ultrasound, Assessing 735
Nasal Cannula 685 138 Pulse Oximeter, Using 738
128 Oxygen Administration:
Using an Oxygen R
Tent 688
139 Radiant Warmer (Overhead),
Monitoring Temperature
P Using an 744
129 Pacemaker: Using 140 Range-of-Motion
an External Exercises, Providing 747
(Transcutaneous) 692 141 Rectal Suppository,
130 Patient-Controlled Administering 752
Analgesia (PCA), Caring 142 Respiration, Assessing 757
for a Patient 143 Restraints, Implementing
Receiving 699 Alternatives to the Use
131 Peritoneal Dialysis Catheter: of 760
Caring for a 706 144 Restraint, Applying an
132 Personal Protective Elbow 764
Equipment (PPE),
Using 710 145 Restraint, Applying an
Extremity 768
133 Pneumatic Compression
Devices, Applying 715 146 Restraint, Applying a
Mummy 772
134 Postoperative Patient Care,
Providing when Patient 147 Restraint, Applying a
Returns to Room 719 Waist 776
135 Pulse: Apical Using 148 Resuscitation: Using a
Auscultation, Handheld Bag and
Assessing 727 Mask 780
xiii
S Sterile Items 806
149 Seizure Precautions and 155 Sterile Field: Preparing
Management 784 Using a Commercially
Prepared Sterile Kit or
150 Shaving, Assisting the
Tray 810
Patient 790
156 Sterile Field: Preparing
151 Shampooing a Patient’s
Using a Packaged Sterile
Hair in Bed 793
Drape 814
152 Sling, Applying 798
157 Stool Culture: Collecting a
153 Sputum for Culture, Stool Specimen 817
Collecting 801
158 Stool Culture: Testing for
154 Sterile Field: Adding Occult Blood 820
159 Suctioning the Bed to Chair 895
Nasopharyngeal and 170 Transferring a Patient
Oropharyngeal from Bed to
Airways 826 Stretcher 901
160 Staples, Removing 171 Transferring a Patient
Surgical 836 Using a Powered
161 Sutures, Removing 841 Full-Body Sling
Lift 906
172 Turning a Patient in Bed,
T
Assisting 914
162 Temperature, Assessing
Body 845
U
163 TENS Unit, Applying and
Caring for Patient 173 Urinal, Assisting with the
Using 855 Use of 919
164 Tracheostomy Care, 174 Urinary Catheter: Female,
Providing 859 Catheterizing the Urinary
165 Tracheostomy Care: Bladder 923
Open System, 175 Urinary Catheter: Male,
Suctioning 871 Catheterizing the Urinary
166 Traction: Halo, Caring for Bladder 933
a Patient in 878 176 Urinary Catheter:
167 Traction: Skeletal, Irrigation, Performing
Caring for a Patient Intermittent Closed
in 884 Catheter 944
168 Traction: Skin, Applying 177 Urinary Catheter:
Skin Traction and Indwelling Catheter,
Caring for a Patient Removing an 948
in 889
169 Transferring a Patient from
xiv
178 Urinary Catheter: V
Suprapubic, Caring
181 Ventriculostomy (Closed
for 952
Fluid-Filled System) 966
179 Urine Specimen,
Collecting (Clean Catch,
Midstream) for Urinalysis W
and Culture 956 182 Wound Culture,
180 Urine Specimen: Collecting 970
Indwelling Urinary 183 Wound Irrigation,
Catheter, Obtaining Performing 977
from 962
xv
Assisting a Patient with Ambulation 1
Walking exercises most of the body’s muscles and increases joint flexi
bility. It improves respiratory and gastrointestinal function. Ambulating
also reduces the risk for complications of immobility. However, even a
short period of immobility can decrease a person’s tolerance for ambu
lating. If necessary, make use of appropriate equipment and assistive
devices to aid in patient movement and handling.
EQUIPMENT
• Gait belt, as necessary • Nonskid shoes or slippers •
Nonsterile gloves and/or other necessary, if available
PPE, as indicated • Additional staff for assistance,
as needed
ASSESSMENT GUIDELINES
• Stand-assist device, as
• Assess the patient’s ability to walk and the need for assistance.
Review the patient’s record for conditions that may affect
ambulation.
• Perform a pain assessment before the time for the activity. If the
patient reports pain, administer the prescribed medication in
sufficient time to allow for the full effect of the analgesic.
• Take vital signs and assess the patient for dizziness or lightheadedness
with position changes.
NURSING DIAGNOSES
• Impaired Physical Mobility
• Impaired Walking
• Deficient Knowledge
• Impaired Bed Mobility
• Acute Pain
• Activity Intolerance
• Chronic Pain
• Fatigue
IMPLEMENTATION
ACTION RATIONALE
ACTION RATIONALE
ACTION RATIONALE
• The patient ambulates safely for the prescribed distance and time and
remains free from falls or injury.
• The patient exhibits increasing muscle strength, joint
mobility. • The patient exhibits increasing independence.
• The patient remains free of any signs and symptoms of immobility.
Assisting a Patient with Ambulation Using a Cane 5
DOCUMENTATION
• Document the activity, any observations, the patient’s tolerance of the
procedure, and the distance walked. Document the use of transfer
aids and number of staff required for transfer.
GENERAL CONSIDERATIONS
• Secure all equipment, such as indwelling urinary catheters, drains, or
IV infusions, to a pole for ambulation.
• Do not carry equipment while helping the patient. Your hands should
be free to provide support.
Skill • 2 Assisting a Patient with Ambulation
Using a Cane
Canes are useful for patients who can bear weight but need support for
balance. They are also useful for patients who have decreased strength
in one leg. Canes provide an additional point of support during ambula
tion. Canes are made of wood or metal and often have a rubberized cap
on the tip to prevent slipping. Canes come in three variations: single
ended canes with half-circle handles (recommended for patients requir
ing minimal support and for those who will be using stairs frequently);
single-ended canes with straight handles (recommended for patients
with hand weakness because the handgrip is easier to hold, but not
recom mended for patients with poor balance); canes with three (tripod)
or four prongs (quad cane) or legs to provide a wide base of support
(recom mended for patients with poor balance). The cane should rise
from the floor to the height of the person’s waist, and the elbow should
be flexed about 30 degrees when holding the cane. The patient holds
the cane in the hand opposite the weak or injured leg.
EQUIPMENT
• Cane of appropriate size with
rubber tip ASSESSMENT GUIDELINES
• Nonskid shoes or slippers • • Stand-assist aid, if necessary
Nonsterile gloves and/or other and available
PPE, as indicated • Gait belt, based on assessment
• Take vital signs and assess the patient for dizziness or light
headedness with position changes.
• Assess for muscle strength in the legs and arms.
• Assess the patient’s knowledge regarding the use of a cane.
NURSING DIAGNOSES
• Impaired Walking
• Deficient Knowledge
• Acute Pain
• Activity Intolerance
• Chronic Pain
• Risk for Falls
IMPLEMENTATION
ACTION RATIONALE
ACTION RATIONALE
8. Tell the patient to advance the weaker foot for ward, parallel
cane 4 to 12 inches (10 to 30 with the cane.
cm) and then, while sup porting 9. While supporting his or her
his or her weight on the stronger weight on the weaker leg and the
leg and the cane, advance the cane, have the patient advance
the stronger leg support and balance.
forward ahead of the cane
(heel slightly beyond the tip
of the cane).
10. Tell the patient to move the
weaker leg forward until it is Moving in this manner provides
even with the stronger leg, and support and balance.
then advance the cane again.
11. Continue with ambulation for
the planned distance and time.
Return the patient to the bed or
chair, based on the patient’s
This motion provides support
tolerance and condition,
and balance.
ensuring the patient’s com
fort. Make sure call bell and
other necessary items are
Continued ambulation promotes
within easy reach.
activity. Adhering to the planned
12. Clean the distance and patient’s tolerance
transfer aids, per prevents the patient from becom
fac ing fatigued.
facility policy, if
not
ind
indicated for single
pa Proper cleaning of equipment
patient use. Remove between patient use prevents the
PP spread of microorganisms.
PPE, if used. Perform Removing PPE properly reduces
hand hyg the risk for infection transmis
hand hygiene. sion and contamination of other
items. Hand hygiene prevents the
spread of microorganisms.
EVALUATION
Moving in this manner provides
• The patient uses the cane to ambulate safely and is free from falls or
injury.
• The patient demonstrates proper use of the cane.
• The patient exhibits increased muscle strength, joint mobility, and
independence.
Assisting a Patient with Ambulation Using Crutches 9
DOCUMENTATION
• Document the activity, any observations, the patient’s ability to use
the cane, the patient’s tolerance of the procedure, and the distance
walked. Document the use of transfer aids and the number of staff
required for transfer.
GENERAL CONSIDERATIONS
• Patients with bilateral weakness should not use a cane. Crutches or a
walker would be more appropriate.
• To climb stairs, the patient should advance the stronger leg up the
stair first, followed by the cane and weaker leg. To descend, reverse
the process.
• When less support is required from the cane, the patient can advance
the cane and weaker leg forward simultaneously while the stronger
leg supports the patient’s weight.
• Teach patients to position their canes within easy reach when they sit
down so that they can rise easily.
Crutches enable a patient to walk and remove weight from one or both
legs. The patient uses the arms to support the body weight. Crutches
can be used for the short or the long term. This section discusses
short-term crutch use. Crutches must be fitted to each person. Have the
patient stand up straight with the palm of the hand pressed against the
body under the arm. The hand should fit between the top of the
crutches and the armpit. When using crutches, the elbow should be
slightly bent at about 30 degrees and the hands, not the armpits, should
support the patient’s weight. Weight on the armpits can cause nerve
damage. If anything needs to be carried, it is best to use a backpack
(University of Iowa, 2006). The procedure for crutch walk ing is
usually taught by a physical therapist, but it is important for the nurse
to be knowledgeable about the patient’s progress and the gait being
taught. Be prepared to guide the patient at home or in the hospital after
the initial teaching is completed. Remind the patient that the support of
body weight should come primarily on the hands and arms while using
the crutches. There are a number of different ways to walk using
crutches, based on how much weight the patient is allowed to bear on
one or both legs.
EQUIPMENT
• Crutches with axillary pads, • Nonskid shoes or slippers
hand grips, and rubber suction • Nonsterile gloves and/or other
tips PPE, as indicated
• Stand-assist device, as necessary, if available
10 Assisting a Patient with Ambulation Using Crutches
ASSESSMENT GUIDELINES
• Review the patient’s record and nursing plan of care to determine the
reason for using crutches and instructions for weight-bearing. Check
for specific instructions from Physical Therapy.
• Perform a pain assessment before the time for the activity. If the
patient reports pain, administer the prescribed medication in
sufficient time to allow for the full effect of the analgesic.
• Determine the patient’s knowledge regarding the use of crutches and
assess the patient’s ability to balance on the crutches.
• Assess for muscle strength in the legs and arms.
• Determine the appropriate gait for the patient to use.
NURSING DIAGNOSES
• Impaired Walking
• Deficient Knowledge
• Acute Pain
• Activity Intolerance
• Chronic Pain
• Risk for Falls
IMPLEMENTATION
ACTION RATIONALE
ACTION RATIONALE
ACTION RATIONALE
DOCUMENTATION
• Document the activity, any observations, the patient’s ability to use
the crutches, the patient’s tolerance of the procedure, and the distance
walked. Document the use of transfer aids and number of staff
required for transfer.
GENERAL CONSIDERATIONS
• Crutches can be used when climbing stairs. The patient grasps both
crutches as one on one side of the body and uses the stair railing.
Have the patient stand in the tripod position facing the stairs. The
patient transfers his or her weight to the crutches and holds the rail
ing. The patient places the unaffected leg on the first stair tread. The
patient then transfers his or her weight to the unaffected leg, moving
up onto the stair tread. The patient moves the crutches and affected
leg up to the stair tread and continues to the top of the stairs. Using
this process, the crutches always support the affected leg.
• Long-term use of the swing-to gait can lead to atrophy of the hips and
legs. Include appropriate exercises in the patient’s plan of care to
avoid this complication.
• Patients should not lean on the crutches. Prolonged pressure on the
axillae can damage the brachial nerves, causing brachial nerve palsy,
with resulting loss of sensation and inability to move the upper
extremities.
• Patients using crutches should perform arm- and
shoulder-strengthening exercises to aid with crutch walking.
14 Assisting a Patient with Ambulation Using a Walker
EQUIPMENT
• Walker, adjusted to the appro • Additional staff for assistance,
priate height as needed
• Nonskid shoes or slippers • • Stand-assist device, as neces
Nonsterile gloves and/or other sary, if available
PPE, as indicated • Gait belt
ASSESSMENT GUIDELINES
• Assess the patient’s ability to walk and the need for assistance.
Review the patient’s record for conditions that may affect
ambulation.
• Perform a pain assessment before the time for the activity. If the
patient reports pain, administer the prescribed medication in suffi
cient time to allow for the full effect of the analgesic.
• Take vital signs and assess the patient for dizziness or lightheaded
ness with position changes.
• Assess the patient’s knowledge regarding the use of a walker. Ensure
that the walker is at the appropriate height for the patient.
NURSING DIAGNOSES
• Risk for Falls
• Impaired Walking
• Deficient Knowledge
• Risk for Injury
• Activity Intolerance
• Acute Pain
• Chronic Pain
• Fatigue
• The patient demonstrates proper use of the walker and states the need
for the walker.
• The patient’s level of independence increases.
• The patient demonstrates increasing muscle strength and joint
mobility.
• The patient remains free of complications of immobility.
IMPLEMENTATION
ACTION RATIONALE
ACTION RATIONALE
6. Assist the patient to the side Having the patient sit on the side
of the bed, if necessary. Have of the bed minimizes the risk for
the patient sit on the side of blood pressure changes (ortho
the bed. Assess for dizziness static hypotension) that can
or lightheadedness. Have the occur with position change.
patient stay seated until he or Assessing patient complaints
she feels secure. helps prevent injury.
7. Assist the patient to put on Doing so ensures safety and
footwear and a robe, if warmth.
desired.
8. Wrap the gait belt around the Gait belts improve the caregiv
patient’s waist, based on er’s grasp, reducing the risk of
assessed need and facility musculoskeletal injuries to staff
policy. and the patient and provide for a
firmer grasp if patient should
lose his or her balance.
9. Place the walker directly in Proper positioning with the
front of the patient. Ask the walker ensures balance. Standing
patient to push himself or within the walker and holding the
herself off the bed or chair; hand grips firmly provide stabil
make use of the stand-assist ity when moving the walker and
device or assist the patient to helps ensure safety. Positioning
stand. Once the patient is to the side and slightly behind the
standing, have him or her patient encourages the patient to
hold the walker’s hand grips stand and walk erect. It also
firmly and equally. Stand places the nurse in a safe position
slightly behind the patient, if the patient should lose his or
on one side. her balance or begin to fall.
10. Have the patient move the Having all four feet of the walker
walker forward 6 to 8 inches and on the floor provides a broad
set it down, making sure all four base of support. Moving the
feet of the walker stay on the walker and stepping forward
floor. Then, tell the patient to moves the center of gravity
step forward with either foot into toward the walker, ensuring
the walker, supporting himself or balance and pre venting tipping
herself on his or her arms. of the walker.
Follow through with the other
leg.
11. Move the walker forward
again, and continue the same Moving the walker promotes
pattern. Continue with ambu activity. Continuing for the
lation for the planned distance planned distance and time pre
and time (FIGURE 1). Return vents the patient from becoming
the patient to the bed or chair fatigued.
Assisting a Patient with Ambulation Using a Walker 17
ACTION RATIONALE
based
on the patient’s tolerance
and condition, ensuring that the
patient is comfortable and the
call bell is within reach.
• The patient uses the walker to ambulate safely and remains free of
injury. • The patient exhibits increasing muscle strength and joint
mobility. • The patient exhibits increasing independence.
• The patient remains free from complications of immobility.
DOCUMENTATION
• Document the activity, any observations, the patient’s ability to use
the walker, the patient’s tolerance of the procedure, and the distance
walked. Document the use of transfer aids and number of staff
required for transfer.
18 Applying and Removing Antiembolism Stockings
GENERAL CONSIDERATIONS
• Never use a walker on the stairs.
• The patient should wear nonskid shoes or slippers.
• Some walkers have wheels on the front legs. These walkers are best
for patients with a gait that is too fast for a walker without wheels
and for patients who have difficulty lifting a walker. This type of
walker is rolled forward while the patient walks as normally as
possible. Because lifting repeatedly is not required, energy
expenditure and stress to the back and upper extremities is lower
than with a standard walker (Mincer, 2007).
• Keep in mind, walkers often prove to be difficult to maneuver
through doorways and congested areas.
• Advise the patient to check the walker before use for signs of dam
age, frame deformity, or loose or missing parts.
• Teach patients to use the arms of the chair or a stand-assist device for
leverage when getting up from a chair. Explain to patients that they
should not pull on the walker to get up; the walker could tip or
become unbalanced.
Antiembolism stockings are often used for patients at risk for deep-vein
thrombosis and pulmonary embolism, and to help prevent phlebitis.
They are made of elastic material and are available in either knee-high
or thigh-high length. By applying pressure, antiembolism stockings
increase the velocity of blood flow in the superficial and deep veins and
improve venous valve function in the legs, promoting venous return to
the heart. A medical order is required for their use. Be prepared to
apply the stockings in the morning before the patient is out of bed and
while the patient is supine. If the patient is sitting or has been up and
about, have the patient lie down with legs and feet elevated for at least
15 minutes before applying the stockings. Otherwise, the leg vessels are
congested with blood, reducing the effectiveness of the stockings.
EQUIPMENT
• Elastic antiembolism stockings • Talcum powder (optional)
in ordered length in correct size. • Skin cleanser, basin,
See Assessment for appro priate towel • Nonsterile gloves
measurement procedure. • • Additional PPE as indicated
Measuring tape
ASSESSMENT GUIDELINES
• Assess the skin condition and neurovascular status of the legs. Report
any abnormalities before continuing with the application of the
Applying and Removing Antiembolism Stockings 19
NURSING DIAGNOSES
• Ineffective Peripheral Tissue Perfusion
• Risk for Impaired Skin Integrity
• Excess Fluid Volume
• Risk for Injury
IMPLEMENTATION
ACTION RATIONALE
1. Review the medical record the use of elastic
and medical orders to deter sto
mine the need for antiembo stockings.
lism stockings. Reviewing the medical record
2. Perform hand and order validates the correct
hygiene. Put on patient and correct procedure.
on PPE, as
indicated. Hand hygiene and PPE prevent
the spread of microorganisms.
PPE is required based on trans
mission precautions.
3 Identify
3. Identify the Patient identification validates
patient. Explain the correct patient and correct
wh procedure. Discussion and expla
what you are going to nation allay anxiety and prepare
do the patient for what to expect.
do and the rationale for
the
20 Applying and Removing Antiembolism Stockings
ACTION RATIONALE
ACTION RATIONALE
ACTION RATIONALE
DOCUMENTATION
• Document the patient’s leg measurements as a baseline. Document
the application of the stockings, size stocking applied, skin and leg
assessment, and neurovascular assessment.
GENERAL CONSIDERATIONS
• Remove stockings once every shift for 20 to 30 minutes. Wash and
air-dry, as necessary, according to manufacturer’s directions. • Assess
at least every shift for skin color, temperature, sensation, swell ing, and
the ability to move. If complications are evident, remove the stockings
and notify the physician or primary care provider. • Evaluate stockings
to ensure the top or toe opening does not roll with movement. Rolled
stocking edges can cause excessive pressure and interfere with
circulation.
• Despite the use of elastic stockings, a patient may develop deep-vein
thrombosis or phlebitis. Unilateral swelling, redness, tenderness,
pain, and warmth are possible indicators of these complications.
Notify the primary care provider of the presence of any symptoms.
Removing Arterial and Femoral Lines 23
EQUIPMENT
• Sterile gloves • For femoral line: small sandbag
• Clean gloves (5 to 10 pounds), wrapped in
• Goggles or face shield towel or pillowcase
• Sterile gauze pads • Emergency medications (e.g.,
• Waterproof protective pad atropine, for a vasovagal
• Sterile suture removal set response with femoral line
• Transparent dressing removal) for emergency
• Alcohol pads response, per facility policy
• Hypoallergenic tape and guidelines
• Indelible pen
ASSESSMENT GUIDELINES
• Review the patient’s medical record and plan of care for information
about discontinuation of the arterial or femoral line.
• Assess the patient’s coagulation status, including laboratory studies,
to reduce the risk of complications secondary to impaired clotting
ability. • Assess the patient’s understanding of the procedure.
• Inspect the site for leakage, bleeding, or hematoma.
• Assess skin color and temperature and assess distal pulses for
strength and quality. Mark distal pulses with an ‘X’ for easy
identification after the procedure.
• Assess patient’s blood pressure; systolic blood pressure should be
less than 180 mm Hg before catheter is removed.
NURSING DIAGNOSES
• Risk for Injury
• Risk for Infection
• Impaired Skin Integrity
• Anxiety
IMPLEMENTATION
ACTION RATIONALE
1. Verify the order for removal alarms and then turn off the
of arterial or femoral line in flow
the patient’s medical record. This ensures that the correct
2. Gather all equipment and intervention is performed on the
bring to bedside. correct patient.
Having equipment available
3. Perform hand saves time and facilitates accom
hygiene and pu plishment of procedure.
put on PPE, if Hand hygiene and PPE prevent
in the spread of microorganisms.
indicated. PPE is required based on trans
mission precautions.
4. Identify Identifying the patient ensures
4. Identify the patient. the right patient receives the
intervention and helps prevent
errors.
ACTION RATIONALE
ACTION RATIONALE
DOCUMENTATION
• Document the time the line was removed and how long pressure was
applied.
• Document site assessment every 5 minutes while pressure is being
applied (second nurse can do this).
• Document assessment of peripheral circulation, appearance of site,
type of dressing applied, the timed assessments, patient’s response,
and any medications given.
GENERAL CONSIDERATIONS
• Sometimes, a culture of the catheter tip is ordered to aid in identify
ing the source of infection. If ordered, place the catheter tip on a 4
4 sterile gauze pad. After the bleeding is under control and the dress
ing is secure, hold the catheter over the sterile container. Cut the tip
of the catheter with sterile scissors and allow it to fall into the sterile
container. Label the specimen and send it to the laboratory.
EQUIPMENT
• Massage lubricant or lotion, • Bath blanket
warmed • Towel
• Pain assessment tool and/or • Nonsterile gloves, if indicated
scale • Powder, if not • Additional PPE, as indicated
contraindicated
28 Giving a Back Massage
ASSESSMENT GUIDELINES
• Review the patient’s medical record and plan of care for information
about the patient’s status and contraindications to back massage.
Question the patient about any conditions that might require modifi
cations or that might contraindicate a massage. Inquire about any
allergies, such as to lotions or scents.
• Ask if the patient has any preferences for lotion or has his or her own
lotion. • Assess the patient’s level of pain.
• Check the patient’s medication administration record for the time an
analgesic was last administered. If appropriate, administer an
analgesic early enough so that it has time to take effect.
NURSING DIAGNOSES
• Acute Pain
• Deficient Knowledge
• Chronic Pain
• Anxiety
• Disturbed Sleep Pattern
• Risk for Impaired Skin Integrity
• Activity Intolerance
IMPLEMENTATION
ACTION RATIONALE
ACTION RATIONALE
ACTION RATIONALE
ACTION RATIONALE
movements that eventually plan of care, as appropriate.
become lighter in pressure.
DOCUMENTATION
• Document pain assessment and other significant assessments. Docu
ment the use of, and length of time of, massage, and patient response.
Record alternative treatments to consider, if appropriate.
GENERAL CONSIDERATIONS
• Before giving a back massage, assess the patient’s body structure and
skin condition, and tailor the duration and intensity of the massage
accordingly. If you are giving a back massage at bedtime, have the
patient ready for bed beforehand so the massage can help him or her
fall asleep.
32 Giving a Bed Bath
• If the patient has oily skin, substitute a talcum powder or lotion of the
patient’s choice. However, to avoid aspiration, do not use powder if the
patient has an endotracheal or tracheal tube in place. Avoid using
powder and lotion together because this may lead to skin maceration.
• When massaging the patient’s back, stand with one foot slightly for
ward and your knees slightly bent to allow effective use of your arm
and shoulder muscles.
A bed bath may be considered a partial bed bath if the patient is well
enough to perform most of the bath, and the nurse needs to assist with
washing areas that the patient cannot reach easily. A partial bath may
also refer to bathing only those body parts that absolutely have to be
cleaned, such as the perineal area and any soiled body parts. Many of
the bedside skin-cleaning products available today do not require
rinsing. After cleaning the body part, dry it thoroughly. Refer to the
accompany
ing skill variations for the procedures related to perineal cleansing and a
bath using a disposable self-contained bathing system.
EQUIPMENT
• Washbasin and warm water • Washcloths (2)
• Personal hygiene supplies • Bath blanket
(deodorant, lotion) • Gown or pajamas
• Skin-cleaning agent • Bedpan or urinal
• Emollient and skin barrier, as • Laundry bag
indicated • Nonsterile gloves; other PPE as
• Towels (2) indicated
ASSESSMENT GUIDELINES
NURSING DIAGNOSES
• Bathing Self-Care Deficit
• Risk for Infection
Giving a Bed Bath 33
IMPLEMENTATION
ACTION RATIONALE
ACTION RATIONALE
ACTION RATIONALE
ACTION RATIONALE
ACTION RATIONALE
area
and any abdominal folds
or creases.
24. Return the bath blanket to its attention to the areas between
original position and expose the toes. Apply appropriate
far leg. Place towel under the far emollient.
leg. Using firm
strokes, wash, rinse, if neces
sary, and dry the leg from 26. Repeat Actions 21 and 22 for
ankle to knee and knee to the other leg and foot.
groin. Apply appropriate
27. Make sure the patient is cov
emollient.
ered with the bath blanket.
Change water and washcloth at
25. Wash, rinse if necessary, and
this point, or earlier, if
dry the foot. Pay particular
necessary.
28. Assist patient to prone or 2009). Use of emollients is rec
side-lying position. Put on ommended to restore and main
gloves, if not applied earlier. tain skin integrity (Voegeli,
Position bath blanket and towel 2008a; Watkins, 2008; Brown &
to expose only the Butcher, 2005).
back and buttocks.
29. Wash, rinse, if necessary, and
dry back and buttocks area. The bath blanket maintains
Pay particular attention to warmth and privacy. Clean,
cleansing between gluteal warm water prevents chilling and
folds, and observe for any maintains patient comfort.
redness or skin breakdown
in the sacral area. Positioning the towel and bath
blanket protects the patient’s pri
30. If not contraindicated, give
vacy and provides warmth.
patient a backrub. Back
Gloves prevent contact with
massage may be given also
body fluids.
after perineal care. Apply
The towel protects linens and
prevents the patient from feeling Fecal material near the anus may
uncomfortable from a damp or be a source of microorganisms.
wet bed. Washing from ankle to Prolonged pressure on the sacral
groin with firm strokes promotes area or other bony prominences
venous return. Use of emollients may compromise circulation and
is recommended to restore and lead to development of decubitus
maintain skin integrity (Voegeli, ulcer.
2008a; Watkins, 2008; Brown & A backrub improves circulation
Butcher, 2005). to the tissues and is an aid to
Drying of the feet is important to relaxation. A backrub may be
prevent irritation, possible skin contraindicated in patients with
breakdown, and infections (NIA,
38 Giving a Bed Bath
ACTION RATIONALE
ACTION RATIONALE
EVALUATION
DOCUMENTATION
• Record any significant observations and communication on the
patient’s chart. Document the condition of the patient’s skin. Record
the procedure, amount of assistance given, and patient participation.
Document the application of skin care products, such as a skin
barrier.
GENERAL CONSIDERATIONS
• To remove the gown from a patient with an IV line, take the gown off
the uninvolved arm first and then thread the IV tubing and bottle or
bag through the arm of the gown. To replace the gown, place the
clean gown on the unaffected arm first and thread the IV tubing and
bottle or bag from inside the arm of the gown on the involved side.
Never disconnect IV tubing to change a gown, because this causes a
break in a sterile system and could introduce infection.
• Lying flat in bed during the bed bath may be contraindicated for cer
tain patients. The position may have to be modified to accommodate
their needs.
• Incontinent patients require special attention to perineal care. Patients
with urinary or fecal incontinence are at risk for perineal skin dam
age. This damage is related to moisture, changes in the pH of the
skin, overgrowth of bacteria and infection of the skin, and erosion of
perineal skin from friction on moist skin. Skin care for these patients
should include measures to reduce overhydration (excess exposure to
moisture), reduce contact with ammonia and bacteria, and reduce
friction. Remove soil and irritants from the skin during routine
hygiene, as well as cleansing when the skin becomes exposed to irri
tants. Avoid using soap and excessive force for cleaning. The use of
perineal skin cleansers, moisturizers, and moisture barriers are rec
ommended for skin care for the incontinent patient. These products
help promote healing and prevent further skin damage.
40 Giving a Bed Bath
Skill Variation
A sitz bath can help relieve pain and discomfort in the perineal area,
such as after childbirth or surgery, and can increase circulation to the
tissues, promoting healing.
EQUIPMENT
• Clean gloves • Adjustable IV pole
• Additional PPE, as • Disposable sitz bath bowl with
indicated • Towel water bag
ASSESSMENT GUIDELINES
NURSING DIAGNOSES
• Acute Pain
• Risk for Infection
• Risk for Hypothermia
• Impaired Tissue Integrity
Assisting with a Sitz Bath 45
OUTCOME IDENTIFICATION AND PLANNING
Expected outcomes may include:
• Patient verbalizes an increase in comfort.
• Patient experiences a decrease in healing time, maintains normal
body temperature, remains free of any signs and symptoms of infec
tion, and exhibits signs and symptoms of healing.
IMPLEMENTATION
ACTION RATIONALE
ACTION RATIONALE
ACTION RATIONALE
EVALUATION
DOCUMENTATION
• Document administration of the sitz bath, including water tempera
ture and duration. Document patient response, and assessment of
perineum before and after administration.
EQUIPMENT
• One large flat sheet • One fitted • Bedside chair
sheet • Drawsheet (optional) • • Waterproof protective pad
Blankets (optional)
• Bedspread • Disposable gloves
• Pillowcases • Additional PPE, as indicated
• Linen hamper or bag
48 Making an Occupied Bed
ASSESSMENT GUIDELINES
• Assess the patient’s preferences regarding linen changes.
• Assess for any precautions or activity restrictions for the
patient.
• Check for any patient belongings that may have accidentally
been placed in the bed linens, such as eyeglasses or prayer
cloths.
• Note the presence and position of any tubes or drains that the patient
may have.
NURSING DIAGNOSES
• Risk for Impaired Skin Integrity
• Risk for Activity Intolerance
• Impaired Physical Mobility
• Impaired Bed Mobility
• Impaired Transfer Ability
IMPLEMENTATION
ACTION RATIONALE
1. Check chart for limitations on do
the patient’s physical activity. do.
This facilitates patient coopera
2. Assemble equipment and tion, determines level of activity,
arrange on bedside chair in and promotes patient safety.
the order the items will be Organization facilitates perfor
used. mance of the task.
3. Perform hand
hygiene. Put on Hand hygiene and PPE prevent
on PPE, as the spread of microorganisms.
indicated. PPE is required based on trans
mission precautions.
ACTION RATIONALE
ACTION RATIONALE
ACTION RATIONALE
ACTION RATIONALE
• The bed linens are changed without any injury to the patient or
nurse. • The patient verbalizes feelings of increased comfort after the
bed is changed.
DOCUMENTATION
• Changing of bed linens does not need to be documented. The use of a
specialty bed, or bed equipment, such as Balkan frame or foot cradle,
should be documented. Document any significant observations and
communication.
Usually bed linens are changed after the bath, but some agencies
change linens only when soiled. If the patient can get out of bed, the
bed should be made while it is unoccupied to decrease stress on the
patient and the nurse. The following procedure explains how to make
the bed using a fitted bottom sheet. Some facilities do not provide fitted
bottom sheets, or sometimes a fitted bottom sheet may not be available.
If this is the case, refer to the accompanying Skill Variation for using a
flat bottom sheet, instead of a fitted sheet.
Making an Unoccupied Bed 53
EQUIPMENT
• One large flat sheet • Linen hamper or bag
• One fitted sheet • Bedside chair
• Drawsheet (optional) • Waterproof protective pad
• Blankets (optional)
• Bedspread • Disposable gloves
• Pillowcases • Additional PPE, as indicated
ASSESSMENT GUIDELINES
NURSING DIAGNOSES
• Risk for Impaired Skin Integrity
• Risk for Activity Intolerance
• Impaired Physical Mobility
IMPLEMENTATION
ACTION RATIONALE
ACTION RATIONALE
ACTION RATIONALE
ACTION RATIONALE
16. Move to the other side of the Working on one side of the bed
bed and follow the same pro at a time saves energy and is
cedure for securing top more efficient.
sheets under the foot of the
bed and making a cuff.
17. Place the pillows on the bed. Opening linens by shaking them
Open each pillowcase in the causes organisms to be carried
same manner as you opened on air currents. Covering the pil
other linens. Gather the pil low while it rests on the bed
lowcase over one hand reduces strain on the nurse’s
toward the closed end. Grasp arms and back.
the pillow with the hand
inside the pillowcase. Keep a
firm hold on the top of the
pillow and pull the cover
onto the pillow. Place the pil
low at the head of the bed. Having linens opened makes it
18. Fan-fold or pie-fold the top more convenient for the patient
linens. to get into bed.
The patient will be able to call
19. Secure the signal device on for assistance as necessary. Pro
the bed, according to agency motes patient comfort and
policy. safety.
20. Raise side rail and lower bed. Promotes patient comfort and
safety.
21. Dispose of soiled linen Deters the spread of
according to agency policy. microorganisms.
22. Remove any Removing PPE properly reduces
other PPE, if us the risk for infection transmis
used. Perform sion and contamination of other
hand items. Hand hygiene prevents the
hy spread of microorganisms.
hygiene.
EVALUATION
• The bed linens are changed without any injury to the patient or nurse.
DOCUMENTATION
• Changing of bed linens does not need to be documented. The use of a
specialty bed, or bed equipment, such as Balkan frame or foot cradle,
should be documented.
Making an Unoccupied Bed 57
Skill
EQUIPMENT
• Bedpan (regular or • Additional PPE, as indicated •
fracture) • Toilet tissue Cover for bedpan or urinal (dis
• Disposable clean gloves posable waterproof pad or cover)
60 Assisting With the Use of a Bedpan
ASSESSMENT GUIDELINES
• Assess the patient’s normal elimination habits. Determine why the
patient needs to use a bedpan, (e.g., a medical order for strict bed rest
or immobilization).
• Assess the patient’s degree of limitation and ability to help with
activity. Assess for activity limitations, such as hip surgery or spinal
injury, which would contraindicate certain actions by the patient.
• Check for the presence of drains, dressings, intravenous fluid infu
sion sites/equipment, traction, or any other devices that could inter
fere with the patient’s ability to help with the procedure or that could
become dislodged.
• Assess the characteristics of the urine and the patient’s skin.
NURSING DIAGNOSES
• Impaired Physical Mobility
• Deficient Knowledge
• Impaired Urinary Elimination
• Functional Urinary Incontinence
• Toileting Self-Care Deficit
on PPE, if
Assisting With the Use of a Bedpan 61
ACTION RATIONALE
4. Identify the
patient.
y and assess the patient’s abil
ity to assist with the proce
dure, as well as personal
hygiene preferences.
6. Unless contraindicated, apply
5. Close curtains powder to the rim of the bed
around bed pan. Place bedpan and cover
5 Cl on chair next to bed. Put on
and close the door to the gloves.
room, if possible. Discuss the
procedure with the patient
logue encourages patient
participation and allows for indi
vidualized nursing care.
ACTION RATIONALE
13. Remove
gloves and addi
tio Hand hygiene deters the spread
tional PPE, if used. of microorganisms. Gloves pre
Pe vent exposure to blood and body
Perform hand hygiene. fluids. Having the bed at the
proper height prevents back and
muscle strain. Proper disposal of
Removing the Bedpan
soiled tissue prevents transmis
i sion of microorganisms.
14. Perform hand hygiene and
put on gloves and additional
PPE, as indicated. Adjust bed to
comfortable working
height, usually elbow height
of the caregiver (VISN 8
Patient Safety Center, 2009).
Have a receptacle, such as
plastic trash bag, handy for
discarding tissue.
Having the bedpan in the proper
position prevents spills onto the
bed, ensures patient comfort, and
prevents injury to the skin from a
misplaced bedpan.