LWBK545_FM_pi-xvi.qxd 8/7/10 12:51 PM Page iii LWBK545_FM_pi-xvi.qxd 8/7/10 12:51 PM Page i Taylor’s Clinical Nursing Skills A NURSING PROCESS APPROACH Third Edition Pamela Lynn, MSN, RN Instructor School of Nursing Gwynedd-Mercy College Gwynedd Valley, Pennsylvania LWBK545_FM_pi-xvi.qxd 8/16/10 9:21 PM Page ii Executive Acquisitions Editor: Carrie Brandon Product Managers:Helene T. Caprari and Michelle Clarke Design Coordinator:Holly Reid McLaughlin Art Director, Illustration: Brett MacNaughton Manufacturing Coordinator:Karin Duffield Prepress Vendor: Aptara, Inc. Third Edition Copyright ©2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright ©2008, 2005 by Lippincott Williams & Wilkins. All rights reserved. This book is protected by copy- right. No part of this book may be reproduced or transmitted in any form or by any means, including as photo- copies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. gov- ernment employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia, PA19103, via email at [email protected], or via our website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China Library of Congress Cataloging-in-Publication Data Lynn, Pamela Barbara, 1961- Taylor’s clinical nursing skills : a nursing process approach / Pamela Lynn.—3rd ed. p. ; cm. Other title: Clinical nursing skills Includes bibliographical references and index. ISBN 978-0-7817-9384-1 (alk. paper) 1. Nursing. I. Taylor, Carol, CSFN. II. Title. III. Title: Clinical nursing skill. [DNLM: 1. Nursing Process. 2. Nursing Care—methods. WY100] RT41.T398 2010 610.73—dc22 2010030026 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the author, editors, and publisher are not responsible for errors or omissions or for any con- sequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this infor- mation in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The author, 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 the time of publication. How- ever, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, 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 important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have US Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the healthcare provider to ascertain the FDAstatus of each drug or device planned for use in his or her clinical practice. LWW.com LWBK545_FM_pi-xvi.qxd 8/7/10 12:51 PM Page iii To John, Jenn, and Anna: The best support system anyone could ask for. LWBK545_FM_pi-xvi.qxd 8/7/10 12:51 PM Page iv Contributors and Reviewers CONTRIBUTOR TO THIS EDITION Lavonne M. Adams, PhD, RN, CCRN Dana M. Botz, RN, MSN Lynn Burbank, MSN, RN, CPNP Associate Professor of Nursing Nursing Instructor Learning Resource Coordinator Texas Christian University, Harris College North Hennepin Community College Dixon School of Nursing of Nursing & Health Sciences Brooklyn Park, Minnesota Abington Memorial Hospital Fort Worth, Texas Abington, Pennsylvania Ethel Bratt, RN, BScN CHAPTER5: MEDICATIONS Margarett Alexandre,MN, BN, RN Nursing Instructor Saskatchewan Institute of Applied Science Nursing Faculty CONTRIBUTOR TO THE Suffolk County Community College and Technology (SIAST) Brentwood, New York Regina, Saskatchewan SECOND EDITION Mary Hermann,BSN, MSN, EdD Nell Britton,MSN, RN, CNE Lyda C. Arévalo-Flechas, PhD, RN Assistant Professor Nursing Division New Student Coordinator Gwynedd Mercy College Assistant Professor Nursing Instructor Gwynedd Valley, Pennsylvania JAHF Claire M. Fagin Fellow Trident Technical College The University of Texas Health Science CHAPTER2: HEALTHASSESSMENT Charleston, South Carolina Center CHAPTER6: PERIOPERATIVENURSING San Antonio School of Nursing CHAPTER8: SKININTEGRITYANDWOUNDCARE Donna Bumpus,RN, MSN San Antonio, Texas CHAPTER11: NUTRITION Assistant Professor of Nursing CHAPTER15: FLUID, ELECTROLYTE, AND Lamar University ACID–BASEBALANCE Lisa Ayers, RN, MSN, CNE Beaumont, Texas Assistant Professor Harper College CONTRIBUTORS TO THE Joan Carlson,RN, MSN, CNE Palatine, Illinois FIRST EDITION Associate Professor Harper College Sheryl Kathleen Buckner, RN, MS, CM Helen Ballestas, PhD, RN, CRRN Palatine, Illinois Academic and Staff Developer, Case Assistant Professor of Nursing Manager, Clinical Instructor Adelphi University Julie Calvery Carman, MS, APN, University of Oklahoma, College of Nursing Garden City, New York FNP-BC Oklahoma City, Oklahoma Family Nurse Practitioner UNITIII: INTEGRATEDCASESTUDIES Jennifer Beck,PhD, RN, CNE Van Buren Family Medical Clinic Associate Professor of Nursing Van Buren, Arkansas Pamela Evans-Smith, MSN, FNP Our Lady of the Lake College Clinical Nursing Instructor Baton Rouge, Louisiana Dr. Veronica Clarke-Tasker,PhD, RN, University of Missouri MBA, MPH Columbia, Missouri Mary Bjorklund, RN, MSN, CPN Professor of Nursing Connie J. Hollen, RN, MS Professor, Associate Degree Nursing Howard University, College of Pharmacy, Lonestar College—Kingwood Nursing & Allied Health Sciences Adjunct Instructor University of Oklahoma, College of Nursing Kingwood, Texas Washington, DC Oklahoma City, Oklahoma John F. Conklin,RN, MSN, PhD UNITIII: INTEGRATEDCASESTUDIES Kathleen Blust,MSN, RN, BC Assistant Professor of Nursing and Professor of Nursing Department Chair Loren Nell Melton Stein,RNC, MSN Collin College State University of New York at Canton Adjunct Instructor McKinney, Texas Canton, New York University of Oklahoma, College of Nursing Oklahoma City, Oklahoma Sue Bodman, RN, MSN Kathryn Cooper, MSN, BSN UNITIII: INTEGRATEDCASESTUDIES Assistant Professor, Nursing Assistant Professor of Nursing Gloucester County College Union University REVIEWERS Sewell, New Jersey Germantown, Tennessee Faisal Aboul-Enein, DrPH, MSN, MPH, NP Carole Bomba, MSN, RN Gloria Coschigano,RN, MS, ACNS-BC Clinical Assistant Professor Assistant Professor of Nursing Associate Professor of Nursing Texas Women’s University Harper College Westchester Community College Houston, Texas Palatine, Illinois Valhalla, New York Robin Abrams, RN, MS, CDE Joanne Bonesteel, MS, RN Dale Crispell, MA, BS Nursing Faculty Nurse Faculty Instructor Alvin Community College Excelsior College SUNY Rockland Community College Alvin, Texas Albany, New York Suffern, New York iv LWBK545_FM_pi-xvi.qxd 8/7/10 12:51 PM Page v Maddie Diedo,MS, RN Mary Gers, MSN, CNS, RNC Linda Ann Kucher, BSN, MSN Professor Associate Professor Assistant Professor of Nursing Wayne County Community College District Director of Simulation and Technology Gordon College Detroit, Michigan Northern Kentucky University Barnesville, Georgia Highland Heights, Kentucky Evelyn Dogbey, PhD, APRN, BC Teresa Leon, MSN, RN, ACNS-BC Assistant Professor of Nursing Carol Girocco,MSN, RN Assistant Professor Temple University Professor, Associate Degree of Nursing New Mexico State University, School of Philadelphia, Pennsylvania Lonestar College—Montgomery Nursing Conroe, Texas Las Cruces, New Mexico Kathleen M. Reilly Dolin, RN, MSN, DNP Regina Gorski,RN, MSN, CNOR Mary Lewis, EdD, MBA, MSN, Associate Professor of Nursing Adjunct Faculty, Nursing ARNP-BC Northampton Community College Edison State College Associate Dean Health Professions/ Bethlehem, Pennsylvania Naples, Florida Director of Nursing Edison State College Lynda Dolphus, RN, MSN Joyce Heil,MSN, CMSRN, CNE Fort Myers, Florida Full-Time Nursing Faculty Nursing Faculty Wayne County Community College University of Pittsburgh Medical Center Shawne Llewellyn,MSN, RN District (UPMC), Shadyside School of Nursing Associate Degree Nursing Faculty Detroit, Michigan Pittsburgh, Pennsylvania First Level Curriculum Coordinator Clinical Coordinator David Dunham, DHEd(c), MS, RN, Beth Hickey, MSN, RN, CRRN, CAN Pitt Community College CRNI Assistant Professor Winterville, North Carolina Assistant Professor of Nursing Northern Kentucky University Director of Clinical Laboratories Highland Heights, Kentucky Hawaii Pacific University, College of Pamela Y. Mahon, PhD, NEA-BC, RN Nursing and Health Sciences Monica Holland,MS, RN Associate Professor Kaneohe, Hawaii Professor of Nursing City University of New York (CUNY), Oklahoma City Community College Hunter-Bellevue School of Nursing Carla Ferguson,BSN, MSN Oklahoma City, Oklahoma New York, New York Associate Professor of Nursing Oakton Community College Robin Johns,PhD, RN Deborah K. Martin, RN, MSN, Des Plaines, Illinois Associate Professor and Coordinator CCRN Medical College of Georgia, School of Instructor Cynthia Figueroa-Haas,PhD, ANP-BC Nursing at Athens St. Luke’s Hospital School of Nursing Clinical Assistant Professor Athens, Georgia Bethlehem, Pennsylvania University of Florida, Department of Adult and Elderly Nursing Fran E. Kamp, RN, MSN Janet Massoglia, MSN Gainesville, Florida Assistant Professor of Nursing Instructor Georgia Baptist College of Nursing of Delta College Karen Flanigan,RN, MS Mercer University University Center, Michigan Nursing Faculty Atlanta, Georgia Chandler-Gilbert Community College Connie McFadden, RN, BSN, MSN Mesa, Arizona Kathy Keister, PhD, MS, CNE, BSN, BS Assistant Professor Assistant Professor The Christ Hospital School of Nursing Jacqueline Frock,MSN, RN Wright State University, College of Cincinnati, Ohio Professor of Nursing Nursing & Health Oklahoma City Community College Dayton, Ohio Oklahoma City, Oklahoma Diane Monsivais, CRRN, MSN, PhD Teresa Kochera,BS, MSN Assistant Professor of Nursing Dawn Fucito, MS, RN, BC Assistant Professor of Nursing University of Texas at El Paso, School of Senior Nursing Instructor Macon State College Nursing Middlesex County College Macon, Georgia El Paso, Texas Edison, New Jersey Pamela Kohlbry, RN, MSN, PhD Claudia Mitchell, PhD(c), MSN, Patricia Gautreaux,MSN, M.Ed., RN Assistant Professor RN-BC Nursing Instructor California State University, San Marcos, Assistant Professor University of Southern Mississippi School of Nursing University of Cincinnati Hattiesburg, Mississippi San Marcos, California Cincinnati, Ohio v LWBK545_FM_pi-xvi.qxd 8/7/10 12:51 PM Page vi Susan Moore, BSN, MSN Carol Reid,RN, MS Kathy S. Taydus,RN, MSN Clinical Assistant Professor Instructor Assistant Professor University of Memphis, Loewenberg Century College Jamestown Community College School of Nursing Saint Paul, Minnesota Jamestown, New York Memphis, Tennessee Wanda Revis Ramesh Upadhyaya, PhD, RN, CRRN, Regina O’Drobinak Greenville Technical College MBA Nursing Faculty Greenville, South Carolina Clinical Instructor Ivy Tech Community College University of North Carolina, Greensboro, Gary, Indiana Hazel Ruff,MS, BS School of Nursing Instructor of Nursing Greensboro, North Carolina Penny R. Pak, RN, MSN Norfolk State University Associate Professor of Nursing Norfolk, Virginia Monica Taylor,RN, MSN Pasco Hernando Community College Professor of Nursing Dade City, Florida Cheryl Sadler,PhD, RN San Jacinto College Pasadena, Texas Associate Professor of Nursing Jerri Palmer,MA, RN University of Akron Polk State College Akron, Ohio Kathleen Thiede,MA, RN Winter Haven, Florida Nursing Faculty The College of St. Scholastica Kari Sand-Jecklin,EdD, MSN, RN, Duluth, Minnesota Caroline Peltz,RN, MSN, MSHSA AHN-BC Full-Time Nursing Faculty Associate Professor of Nursing Jeanne Ann Van Fossan, RN, MSN, NP Wayne County Community College West Virginia University Professor, Nursing District Morgantown, West Virginia West Virginia Northern Community College Detroit, Michigan Weirton, West Virginia Catherine Sikorski, RN, MSN Sharon Phelps,BSN, MSN Professor Barbara Vickers, RN, MS, CCRN Senior Faculty Specialist Macomb Community College Nursing Professor Chamberlain College of Nursing Clinton Township, Michigan Erie Community College—State St. Louis, Missouri University of New York (SUNY) Dolores Solosky,MSN, RN, CS Buffalo, New York Karen Piotrowski,MS, RN, BSN Nursing Faculty Nursing Faculty Oakland Community College Susan Waltz,RN, DNP D’Youville College Bloomfield Hills, Michigan Professor—School of Health Sciences Buffalo, New York Ivy Tech Community College of Indiana Jennifer Specht,BSN, MSN Columbus, Indiana Kimberly Plemmons,MSN Assistant Professor Faculty St. Luke’s School of Nursing at Moravian Julie Wells-Tsiatsos,MSN, RN Cabarrus College of Health Sciences College Nursing Instructor Concord, North Carolina Allentown, Pennsylvania St. Elizabeth College of Nursing Utica, New York Michelle Quigel,BSN, RN, CWOCN Mary Spica, RN, MS, CSE Certified Wound Ostomy Continence Nurse Assistant Professor of Nursing Kathleen S. Wilson, RN, MSN Holy Redeemer Hospital and Medical Christ College of Nursing & Health Nursing Professor Center Sciences Houston Community College Meadowbrook, Pennsylvania Cincinnati, Ohio Houston, Texas Loretta Quigley, MS, RN Amy Stegen, RN, MSN Robert Wyatt,MSN, RN Associate Dean Nursing Coordinator Assistant Professor of Nursing St. Joseph’s College of Nursing Davis Applied Technology College Jackson State Community College Syracuse, New York Kaysville, Utah Jackson, Tennessee Jennifer Rath, RN, BScN Kathleen Stevens, MN, BN, RN Patti Yudelson, RN, BS Nurse Technologist and Clinical Instructor Instructional Resource Centre Nursing Faculty Mohawk College of Applied Arts and Coordinator Wilson Technological Center, School of Technology Centre for Nursing Studies Practical Nursing Hamilton, Ontario St. John’s, Newfoundland Northport, New York vi LWBK545_FM_pi-xvi.qxd 8/7/10 12:51 PM Page vii Preface T curricula and students. Thus, each chapter stands on its own aylor’s Clinical Nursing Skills: A Nursing Process Approach merit and may be read independently of others. aims to help nursing students or graduate nurses incorporate cognitive, technical, interpersonal, and ethical/legal skills into Unit I,Actions Basic to Nursing Care safe and effective patient care. This book is written to meet the This unit introduces the foundational skills used by nurses: needs of novice to advanced nurses. Many of the skills shown measuring vital signs, assessing health, promoting safety, in this book may not be encountered by the student while in maintaining asepsis, administering medication, and caring school but may be encountered once the graduate nurse has for surgical patients. entered the workforce. Because it emphasizes the basic principles of patient care, Unit II,Promoting Healthy we believe this book can easily be used with any Fundamen- Physiologic Responses tals text. However, this Skills book was specifically designed to accompany Fundamentals of Nursing: The Art and Sci- This unit focuses on the physiologic needs of patients: ence of Nursing Care, Seventh Edition, by Taylor, Lillis, hygiene; skin integrity and wound care; activity; comfort; LeMone, and Lynn, to provide a seamless learning experi- nutrition; urinary elimination; bowel elimination; oxygena- ence. Some of the Skills and Guidelines for Nursing Care tion; fluid, electrolyte, and acid–base balance; neurologic from the Taylor Fundamentals book may also be found in care; cardiovascular care; and specimen collection. this book, but its content has been embellished here to: • Highlight the nursing process Unit III,Integrated Case Studies • Emphasize unexpected situations that the nurse may Although nursing skills textbooks generally present content encounter, along with related interventions for how to in a linear fashion for ease of understanding, in reality, many respond to these unexpected situations nursing skills are performed in combination for patients with • Draw attention to critical actions within skills complicated health needs. The integrated case studies in this unit are designed to challenge the reader to think critically, • Illustrate specific actions within a skill through the use of think outside the norm, consider the multiple needs of more than 1,000 four-color photographs and illustrations patients, and prioritize care appropriately—ultimately prepar- • Highlight available best practice guidelines and/or ing the student and graduate nurse for complex situations research-based evidence to support the skills as available that may arise in everyday practice. • Reference appropriate case study or studies included at the end of the book, emphasizing which case studies utilize and enhance the content of each chapter. FEATURES • Focusing on Patient Care.Each chapter in Units I and II Additionally, this book contains numerous higher-level skills begins with a description of three real-world case scenar- that are not addressed in the Taylor Fundamentals book. ios that put the skills into context. These scenarios provide a framework for the chapter content to be covered and are LEARNING EXPERIENCE followed by chapter Learning Objectivesand Key Terms. This text and the entire Taylor Suite have been created with the • Fundamentals Review.Because of the breadth and depth student’s experience in mind. Care has been taken to appeal to of nursing knowledge that must be absorbed, nursing stu- all learning styles. The student-friendly writing style ensures dents and graduate nurses can easily become overwhelmed. that students will comprehend and retain information. The Thus, this book is designed to eliminate excessive content extensive art program enhances understanding of important and redundancy and to focus the reader’s attention better. actions. Free video clips clearly demonstrate and reinforce To this end, each chapter in Units I and II includes several important skill steps; as students watch and listen to the videos, boxes, tables, or figures that summarize important concepts comprehension increases. In addition, each element of the that should be understood before performing a skill. For a Taylor Suite, which is described later in the preface, coordi- more in-depth study of these concepts, readers are encour- nates to provide a consistent and cohesive learning experience. aged to refer to their Fundamentals textbook. • Step-by-Step Skills.Each chapter presents a host of ORGANIZATION related step-by-step skills. The skills are presented in a Taylor’s Clinical Nursing Skills is organized into three units. concise, straightforward, and simplified two-column for- Ideally, the text will be followed sequentially, but every mat to facilitate competent performance of nursing effort has been made to respect the differing needs of diverse skills. vii LWBK545_FM_pi-xvi.qxd 8/23/10 1:35 PM Page viii • The nursing process framework is used to integrate • Concepts in Action Animations icons direct students to related nursing responsibilities for each of the five animations that bring physiologic and pathophys- steps: Assessment, *Nursing Diagnoses, Outcome iologic concepts to life and enhance student com- Identification and Planning, Implementation, Evalua- prehension. tion, and Documentation. • Photo Atlas Approach.When learning a new skill, it is • Scientific rationalesaccompany each nursing action often overwhelming to only readhow to perform a skill. to promote a deeper understanding of the basic princi- With more than 1,000 photographs, this book offers a ples supporting nursing care. pictorial guide to performing each skill. The skill will not • Nursing Alertsdraw attention to crucial information. only be learned but also remembered through the use of text with pictures. • Hand Hygieneicons alert you to this crucial step that is the best way to prevent the spread of • New!Enhance YourUnderstanding,located at the end of microorganisms. each chapter, gives readers an opportunity to review and apply what they have learned. It includes three sections: • Patient Identificationicons alert you to this crucial • Developing Critical Thinking Skills,a popular feature step ensuring the right patient receives the from the previous edition,asks readers critical thinking intervention and helping prevent errors. questions that reflect back to the opening scenarios for added cohesion throughout the chapters. Readers are • Documentation Guidelinesdirect students and gradu- challenged to apply the skills and use the new knowl- ate nurses in accurate documentation of the skill and edge they have gained to “think through” learning exer- their findings. Sample Documentationdemonstrates cises designed to show how critical thinking can have an proper documentation. impact on patient care and possibly change outcomes. • Special Considerations,including Infant, Child, • New! Suggested Answers forDeveloping Critical OlderAdultand Home Health Considerations(e.g., Thinking Skills represent possible nursing care solu- modifications and home care), appear throughout to tions to the problems. explain the varying needs of patients across the lifes- pan and in various settings. • New!Integrated Case Studiesrefer readers to the appropriate case study or studies discussion in Unit • Unexpected Situationsare provided after the explana- III, emphasizing which case studies utilize and tion of normal outcomes. Each situation is followed by enhance the content of that chapter. an explanation of how best to react, with rationales. This feature serves as a starting point for group discussion. TEACHING/LEARNING PACKAGE • New!EvidenceforPracticehighlights available best practice guidelines and/or research-based evidence to To facilitate mastery of this text’s content, a comprehensive support the skills as available. teaching/learning package has been developed to assist fac- • Skill Variationsprovide clear, start-to-finish instruc- ulty and students. tions for variations in equipment or technique. • Watch and Learnicons direct students to free video Resources for Instructors clips that show students how to perform a Tools to assist you with teaching your course are avail- skill. able upon adoption of this text on at http:// thePoint.lww.com/Lynn3e. Many of these tools are also • Practice and Learnicons direct students to free inter- included on the Instructor’s Resource DVD-ROM. active activities that allow students to apply skills to patient care. • An E-Bookon allows access to the book’s full text and images online. • The Test Generatorhas over 500 NCLEX®-Style ques- *Material related to nursing diagnoses is from Nursing Diagnoses–Definitions tions to help you put together exclusive new tests from a and Classification 2009–2011. Copyright ©2009, 2007, 2005, 2003, 2001, bank with questions spanning the book’s topics to help you 1998, 1996, 1994 by NANDAInternational. Used by arrangement with Wiley-Blackwell Publishing, a company of John Wiley & Sons, Inc. In in assessing your students’understanding of the material. order to make safe and effective judgments using NANDA-I nursing diag- • PowerPoint Presentations, provided for each book noses it is essential that nurses refer to the definitions and defining charac- teristics of the diagnoses listed in this work. chapter, enhance teaching, providing key visuals and viii