Professional Edition The Royal Marsden Manual of Clinical Nursing Procedures Ninth Edition Edited by Lisa Dougherty and Sara Lister The Royal Marsden Manual of Clinical Nursing Procedures Professional Edition The Royal Marsden Manual of Clinical Nursing Procedures Ninth Edition Edited by Lisa Dougherty OBE, RN, MSc, DClinP Nurse Consultant Intravenous Therapy The Royal Marsden NHS Foundation Trust and Sara Lister RN, PGDAE, BSc (Hons), MSc, MBACP Head of Pastoral Care and Psychological Support The Pastoral Care Centre The Royal Marsden NHS Foundation Trust This edition fi rst published 2015 © 2015 by The Royal Marsden NHS Foundation Trust Previous editions published 1992, 1996, 2000, 2004, 2008, 2011 Registered offi ce: J ohn Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offi ces: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offi ces, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identifi ed as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. 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No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloging-in-Publication Data Royal Marsden Hospital manual of clinical nursing procedures The Royal Marsden manual of clinical nursing procedures / edited by Lisa Dougherty and Sara Lister. – Ninth edition. p. ; cm. Preceded by: Royal Marsden Hospital manual of clinical nursing procedures / edited by Lisa Dougherty and Sara Lister. 8th ed. 2011. Includes bibliographical references and index. ISBN 978-1-118-74592-2 (pbk.) I. Dougherty, Lisa, editor. II. Lister, Sara E., editor. III. Title. [DNLM: 1. Nursing Care–methods. 2. Nursing Process. 3. Nursing Theory. 4. Patient Care Planning. WY 100.1] RT41 610.73--dc23 2014032706 A catalogue record for this book is available from the British Library. Wiley also publishes its books in a variety of electronic formats. 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Cover design by Design Deluxe Set in Lexia 9/10 by Aptara 1 2015 Brief table of contents Detailed table of contents vii Foreword to the ninth edition xiii Acknowledgements xiv List of contributors xv List of abbreviations xix Quick reference to the procedure guidelines xxiii How to use your manual xxvii 1 Introduction 1 Part One Managing the patient journey 7 2 Assessment and discharge 9 3 Infection prevention and control 49 Part Two Supporting the patient with human functioning 95 4 Communication 97 5 Elimination 133 6 Moving and positioning 207 7 Nutrition, fl uid balance and blood transfusion 253 8 Patient comfort and end-of-life care 331 9 Respiratory care 431 Part Three Supporting the patient through the diagnostic process 507 10 Interpreting diagnostic tests 509 11 Observations 595 Part Four Supporting the patient through treatment 673 12 Medicines management 675 13 Perioperative care 789 14 Vascular access devices: insertion and management 861 15 Wound management 935 Index 967 Detailed table of contents Brief table of contents v Prevention and management of inoculation injury 88 Foreword to the ninth edition xiii Management of waste in the healthcare environment 89 Acknowledgements xiv Management of soiled linen in the healthcare environment 91 List of contributors xv References 92 List of abbreviations xix Quick reference to the procedure guidelines xxiii Procedure guidelines for Chapter 3 How to use your manual xxvii 3.1 Hand washing 61 3.2 Hand decontamination using alcohol handrub 63 3.3 Putting on and removing non-sterile gloves 64 1 Introduction 3.4 Putting on and removing a disposable apron 66 1 3.5 Putting on and removing a disposable mask or Overview 2 respirator 67 3.6 Putting on or removing goggles or a face shield 68 Evidence-based practice 2 3.7 Surgical scrub technique 69 What is evidence-based practice? 2 3.8 Donning sterile gloves: open technique 71 Grading evidence in The Royal Marsden Manual of 3.9 Donning a sterile gown and gloves: Clinical Nursing Procedures 3 closed technique 73 Structure of the Manual 4 3.10 Aseptic technique example: changing a wound Structure of chapters 4 dressing 78 3.11 Source isolation: preparing an isolation room 83 Conclusion 4 3.12 Source isolation: entering the isolation room 84 References 4 3.13 Source isolation: leaving the isolation room 85 3.14 Source isolation: transporting infected patients outside the source isolation area 86 Part One 3.15 Protective isolation: preparing the room 87 3.16 Protective isolation: entering the isolation room 88 Managing the patient journey 7 3.17 Safe disposal of foul, infected or infested linen 92 2 Assessment and discharge 9 Part Two Overview 10 Supporting the patient with Inpatient assessment and the process of care 10 Observation 19 human functioning 95 Physical assessment/examination 19 Respiratory examination 21 4 Communication 97 Cardiovascular examination 26 Overview 98 Abdominal examination 30 Communication 98 Communication and discharge planning 34 References 45 Communicating with those who are worried or distressed 108 Procedure guidelines for Chapter 2 2.1 Respiratory examination 25 Informing patients 110 2.2 Cardiovascular examination 28 2.3 Abdominal examination 32 Communicating with those with specifi c psychological needs 113 Denial and collusion 113 3 Infection prevention and control 49 Anxiety 114 Panic attacks (acute anxiety) 115 Overview 50 Depression 116 Infection prevention and control 50 Anger, aggression and violence management 118 Delirium 121 Aseptic technique 78 Dementia 123 Acquired communication disorders 124 Source isolation 80 Websites and useful addresses 128 Protective isolation 86 References 128 The Royal Marsden Manual of Clinical Nursing Procedures 5 Elimination Positioning the patient: sitting in bed 214 133 Positioning the patient: side-lying 215 Overview 134 Positioning the patient: in a chair/wheelchair 217 Moving the patient from sitting to standing 218 Normal elimination 134 Walking 219 Vomiting 134 Insertion of a nasogastric drainage tube 135 Moving and positioning the unconscious patient 221 Removal of a nasogastric drainage tube 138 Moving and positioning the patient with an Urinary elimination 138 artifi cial airway 222 Faecal elimination 139 Assisting the patient with elimination 141 Moving and positioning the patient with respiratory compromise 225 Altered urinary elimination 144 Positioning to maximize ventilation/perfusion matching 225 Urinary incontinence 144 Positioning to minimize the work of breathing 227 Urinary catheterization 147 Positioning to maximize the drainage of secretions 228 Suprapubic catheterization 155 Intermittent catheterization 155 Moving and positioning the patient with Bladder irrigation 160 neurological impairment 230 Nephrostomy tubes 166 Moving and positioning of the patient with Surgical urinary diversions 170 actual or suspected spinal cord compression Altered faecal elimination 173 or spinal cord injury 235 Diarrhoea 173 Moving and positioning the patient with an Constipation 175 amputation 246 Enemas 179 Websites 249 Suppositories 183 References 249 Digital rectal examination 185 Digital removal of faeces 187 Procedure guidelines for Chapter 6 6.1 Positioning the patient: supine 213 Stoma care 189 6.2 Positioning the patient: sitting in bed 214 Complications 199 6.3 Positioning the patient: side-lying 215 Websites 199 6.4 Positioning the patient: lying down to sitting up 216 References 202 6.5 Positioning the patient: in a chair/wheelchair 218 Procedure guidelines for Chapter 5 6.6 Moving from sitting to standing: assisting the 5.1 Care of a patient who is vomiting 135 patient 219 5.2 Insertion of a nasogastric (NG) drainage tube 137 6.7 Assisting the patient to walk 220 5.3 Removal of a nasogastric tube 138 6.8 Positioning the unconscious patient or patient 5.4 Slipper bedpan use: assisting a patient 142 with an airway in supine 222 5.5 Commode use: assisting a patient 143 6.9 Positioning the unconscious patient or patient 5.6 Penile sheath application 145 with an airway in side-lying 224 5.7 Urinary catheterization: male 151 6.10 Positioning the patient to maximize V/Q 5.8 Urinary catheterization: female 153 matching with unilateral lung disease in a 5.9 Urinary catheterization: intermittent self-ventilating patient 226 self-catheterization patient guidance: male 156 6.11 Positioning the patient to maximize V/Q 5.10 Urinary catheterization: intermittent matching for widespread pathology in a self-catheterization patient guidance: female 157 self-ventilating patient 227 5.11 Urinary catheter bag: emptying 158 6.12 Positioning to maximize the drainage of 5.12 Urinary catheter removal 159 secretions 230 5.13 Commencing bladder irrigation 162 6.13 Positioning the neurological patient with 5.14 Care of the patient during bladder irrigation 164 tonal problems 233 5.15 Nephrostomy tube: weekly dressing and 6.14 Log rolling for suspected/confi rmed cervical bag change 167 spinal instability 237 5.16 Nephrostomy tube: removal of locking pigtail 6.15 Positioning for suspected/confi rmed cervical drainage system 169 spinal instability: pelvic twist to right 240 5.17 Continent urinary diversion stoma: 6.16 Log rolling for suspected/confi rmed self-catheterization 172 thoracolumbar spinal instability 242 5.18 Enema administration 181 6.17 Early mobilization of the patient in bed 243 5.19 Suppository administration 184 6.18 Positioning the pre-operative and post-operative 5.20 Digital rectal examination 186 amputation patient 247 5.21 Digital removal of faeces 188 5.22 Stoma siting 193 5.23 Stoma bag change 195 7 Nutrition, fl uid balance and blood 5.24 Stoma bridge or rod removal 196 transfusion 253 Overview 254 6 Moving and positioning 207 Fluid balance 254 Overview 208 Nutritional status 266 Moving and positioning: general principles 208 Provision of nutritional support: oral 272 Risk assessment: prevention of falls 212 Positioning the patient: in bed 213 Nutritional management of patients with dysphagia 277