Contents. Unit 1. How Nurses Think 5. Nursing Process: Diagnosis 26 Caring for the Nguyens 26

Transcription

1 Contents Unit 1 How Nurses Think 5 CHAPTER 1 Evolution of Nursing Thought & Action 7 Caring for the Nguyens 7 Critical Thinking and Clinical Reasoning 7 Knowledge Map 9 CHAPTER 2 Critical Thinking & Nursing Process 10 Caring for the Nguyens 10 Clinical Reasoning 11 Applying the Full-Spectrum Nursing Model 11 Critical Thinking and Clinical Reasoning 11 Knowledge Map 14 CHAPTER 3 Nursing Process: Assessment 15 Caring for the Nguyens 15 Practical Knowledge: Knowing How 16 Clinical Insights 16 Clinical Insight 3-1: Preparing for a Patient Interview 16 Clinical Insight 3-2: Conducting a Patient Interview 17 Clinical Insight 3-3: Closing a Patient Interview 18 Assessment Guidelines and Tools 18 Patient Assessment Tool Lawton Instrumental Activities of Daily Living (IADL) 18 Nursing Admission Data Form 19 Clinical Reasoning 22 Applying the Full-Spectrum Nursing Model 22 Critical Thinking and Clinical Reasoning 23 Knowledge Map 25 CHAPTER 4 Nursing Process: Diagnosis 26 Caring for the Nguyens 26 Practical Knowledge: Knowing How 27 Standardized Language 27 Descriptors for NANDA-I Nursing Diagnoses 27 Clinical Reasoning 28 Applying the Full-Spectrum Nursing Model 28 Critical Thinking and Clinical Reasoning 29 Knowledge Map 32 CHAPTER 5 Nursing Process: Planning Outcomes 33 Caring for the Nguyens 33 Practical Knowledge: Knowing How 34 Assessment Guidelines & Tools 34 Discharge Planning Form 34 Standardized Language 35 Clinical Reasoning 36 Applying the Full-Spectrum Nursing Model 36 Critical Thinking and Clinical Reasoning 37 Knowledge Map 39 CHAPTER 6 Nursing Process: Planning Interventions 40 Caring for the Nguyens 40 Clinical Reasoning 41 Applying the Full-Spectrum Nursing Model 41 Critical Thinking and Clinical Reasoning 41 Knowledge Map 44 xiii

2 xiv CONTENTS CHAPTER 7 Nursing Process: Implementation & Evaluation 45 Caring for the Nguyens 45 Practical Knowledge: Knowing How 46 Implementation and Evaluation Tools 46 The Five Rights of Delegation Checklist 46 NCSBN Delegation Grid 47 Evaluation Checklist 48 Clinical Reasoning 50 Applying the Full-Spectrum Nursing Model 50 Critical Thinking and Clinical Reasoning 51 Knowledge Map 53 CHAPTER 8 Evidence-Based Practice: Theory & Research 54 Caring for the Nguyens 54 Clinical Reasoning 55 Applying the Full-Spectrum Nursing Model 55 Critical Thinking and Clinical Reasoning 55 Knowledge Map 58 Unit 2 Factors Affecting Health 59 CHAPTER 9 Life Span: Infancy Through Middle Adulthood 61 Caring for the Nguyens 61 Practical Knowledge: Knowing How 62 Procedures 62 Procedure 9-1: Assessing for Abuse 63 Assessment Guidelines & Tools 67 Clinical Reasoning 68 Applying the Full-Spectrum Nursing Model 68 Critical Thinking and Clinical Reasoning 69 Knowledge Map 71 CHAPTER 10 Life Span: Older Adults 72 Caring for the Nguyens 72 Clinical Reasoning 73 Applying the Full-Spectrum Nursing Model 73 Critical Thinking and Clinical Reasoning 74 Knowledge Map 75 CHAPTER 11 Experiencing Health & Illness 76 Caring for the Nguyens 76 Practical Knowledge: Knowing How 77 Procedures 77 Procedure 11-1: Admitting a Patient to a Nursing Unit 77 Procedure 11-2: Transferring a Patient to Another Unit in the Agency 80 Procedure 11-3: Transferring a Patient to a Long-Term Care Facility 81 Procedure 11-4: Discharging a Patient From the Healthcare Facility 83 Clinical Insights 86 Clinical Insight 10-1: Preparing the Room for a Newly Admitted Patient 86 Forms 87 Discharge Assessment/Instructions 87 Patient Education Form 88 Clinical Reasoning 89 Applying the Full-Spectrum Nursing Model 89 Critical Thinking and Clinical Reasoning 89 Knowledge Map 91 CHAPTER 12 Stress & Adaptation 92 Caring for the Nguyens 93 Practical Knowledge: Knowing How 93 Clinical Insights 93 Clinical Insight 12-1: Dealing With Angry Patients 93 Clinical Insight 12-2: Crisis Intervention Guidelines 94 Assessment Guidelines and Tools 95 Standardized Language 97 Clinical Reasoning 98 Applying the Full-Spectrum Nursing Model 98 Critical Thinking and Clinical Reasoning 99 Knowledge Map 101

3 CONTENTS xv CHAPTER 13 Psychosocial Health & Illness 102 Caring for the Nguyens 102 Practical Knowledge: Knowing How 103 Clinical Insights 103 Clinical Insight 13-1: Assessing Self-Concept Problems 103 Clinical Insight 13-2: Performing a Self-Esteem Inventory 104 Clinical Insight 13-3: Identifying Depressed Patients Who Should Be Referred for Evaluation 105 Assessment Guidelines and Tools 106 Anxiety Assessment Guide 106 Depression Assessment Guide: Patient Health Questionnaire (PHQ-9) 107 Differentiating Depression and Dementia 108 Standardized Nursing Language 108 Anxiety-Related Diagnoses: Selected NOC Outcomes and NIC Interventions 109 Depression-Related Nursing Diagnoses: Selected NOC Outcomes and NIC Interventions 111 Clinical Reasoning 113 Applying the Full-Spectrum Nursing Model 113 Critical Thinking and Clinical Reasoning 113 Knowledge Map 117 CHAPTER 14 The Family 118 Caring for the Nguyens 119 Practical Knowledge: Knowing How 119 Clinical Insights 119 Clinical Insight 14-1: Conducting a Family Assessment 119 Assessment Guidelines and Tools 120 Assessing Family Developmental Tasks 120 Standardized Language 121 NOC Outcomes and NIC Interventions for Caregiver Role Strain 121 Clinical Reasoning 122 Applying the Full-Spectrum Nursing Model 122 Critical Thinking and Clinical Reasoning 122 Knowledge Map 124 CHAPTER 15 Culture & Ethnicity 125 Caring for the Nguyens 125 Practical Knowledge: Knowing How 126 Clinical Insights 126 Clinical Insight 15-1: Assessing for Biological Variations 126 Clinical Insight 15-2: Pain Perception in Selected Cultural Groups 127 Clinical Insight 15-3: Communicating With Clients Who Speak a Different Language 128 Assessment Guidelines and Tools 129 Obtaining Minimum Cultural Information 129 Cultural Assessment Using the Transcultural Assessment Model 130 Clinical Reasoning 131 Applying the Full-Spectrum Nursing Model 131 Critical Thinking and Clinical Reasoning 131 Knowledge Map 135 CHAPTER 16 Spirituality 136 Caring for the Nguyens 137 Practical Knowledge: Knowing How 137 Clinical Insights 137 Clinical Insight 16-1: Praying With Patients 137 S-P-I-R-I-T Assessment 139 Assessment Guidelines and Tools 140 The HOPE Approach to Spiritual Assessment: Examples of Questions 140 Standardized Nursing Language 140 Using Selected NIC Interventions and Activities to Support Spirituality 140 Clinical Reasoning 142 Applying the Full-Spectrum Nursing Model 142 Critical Thinking and Clinical Reasoning 143 Knowledge Map 144 CHAPTER 17 Loss, Grief, & Dying 145 Caring for the Nguyens 146 Practical Knowledge: Knowing How 146

4 xvi CONTENTS Clinical Insights 146 Clinical Insight 17-1: Communicating With People Who Are Grieving 146 Clinical Insight 17-2: Helping Families of Dying Patients 147 Clinical Insight 17-3: Caring for the Dying Person: Meeting Physiological Needs 148 Clinical Insight 17-4: Caring for the Dying Person: Meeting Psychological Needs 149 Clinical Insight 17-5: Providing Postmortem Care 150 Forms 152 Do Not Resuscitate Orders 152 Assessment Guidelines 153 Assessing Grief and Loss 153 Clinical Reasoning 155 Applying the Full-Spectrum Nursing Model 155 Critical Thinking and Clinical Reasoning 155 Knowledge Map 158 Unit 3 Essential Nursing Interventions 159 CHAPTER 18 Documenting & Reporting 161 Caring for the Nguyens 162 Practical Knowledge: Knowing How 163 Clinical Insights 163 Clinical Insight 18-1: Giving Oral Reports 163 Clinical Insight 18-2: Receiving Telephone and Verbal Orders 164 Clinical Insight 18-3: Guidelines for Documentation 164 Tables 269 Abbreviations Commonly Used in Healthcare 169 Charting Forms 171 Adult Admission History Electronic Screen 171 Intake and Output Sheet 172 Nursing Assessment Flowsheets Are Comprehensive Charting Documents 173 Clinical Reasoning 174 Applying the Full-Spectrum Nursing Model 174 Critical Thinking and Clinical Reasoning 174 Knowledge Map 176 CHAPTER 19 Teaching & Learning 177 Caring for the Nguyens 178 Practical Knowledge: Knowing How 179 Assessment Guidelines and Tools 179 Learning Assessment Guidelines 179 Clinical Reasoning 180 Applying the Full-Spectrum Nursing Model 180 Critical Thinking and Clinical Reasoning 180 Knowledge Map 183 CHAPTER 20 Measuring Vital Signs 184 Caring for the Nguyens 184 Practical Knowledge: Knowing How 185 Procedures 185 Procedure 20-1: Assessing Body Temperature 185 Procedure 20-1A: Taking an Axillary Temperature 186 Procedure 20-1B: Taking an Oral Temperature 186 Procedure 20-1C: Taking a Rectal Temperature 187 Procedure 20-1D: Taking a Temporal Artery Temperature 188 Procedure 20-1E: Taking a Tympanic Membrane Temperature 188 Procedure 20-1F: Taking a Skin Temperature Using a Chemical Strip Thermometer 189 Procedure 20-2: Assessing Peripheral Pulses 191 Procedure 20-2A: Assessing the Radial Pulse 191 Procedure 20-2B: Assessing the Brachial Pulse 192 Procedure 20-2C: Assessing the Carotid Pulse 192 Procedure 20-2D: Assessing the Dorsalis Pedis Pulse 192 Procedure 20-2E: Assessing the Femoral Pulse 193 Procedure 20-2F: Assessing the Posterior Tibial Pulse 193 Procedure 20-2G: Assessing the Popliteal Pulse 193 Procedure 20-2H: Assessing the Temporal Pulse 194 Procedure 20-3: Assessing the Apical Pulse 195 Procedure 20-4: Assessing for an Apical-Radial Pulse Deficit 197 Procedure 20-5: Assessing Respirations 198 Procedure 20-6: Measuring Blood Pressure 200 Procedure Variation A. Measuring Blood Pressure in the Forearm 202 Procedure Variation B. Measuring Blood Pressure in the Thigh 202 Procedure Variation C. Measuring Blood Pressure in the Calf 203 Procedure Variation D. Palpating the Blood Pressure 203

5 CONTENTS xvii Clinical Insights 204 Clinical Insight 20-1: Choosing a Blood Pressure Cuff Size 204 Clinical Insight 20-2: Taking an Accurate Blood Pressure 204 Forms 205 Graphic Flowsheet 205 Tables 206 Centigrade Fahrenheit Conversion Chart 206 Clinical Reasoning 206 Applying the Full-Spectrum Nursing Model 206 Critical Thinking and Clinical Reasoning 207 Knowledge Map 209 CHAPTER 21 Communication & Therapeutic Relationships 210 Caring for the Nguyens 210 Practical Knowledge: Knowing How 211 Clinical Insights 211 Clinical Insight 21-1: Enhancing Communication Through Nonverbal Behaviors 211 Clinical Insight 21-2: Technique for Assertive Communication 212 Clinical Insight 21-3: Communicating With SBAR 212 Clinical Insight 21-4: Communicating With Clients From Another Culture 212 Clinical Insight 21-5: Communicating With Clients Who Have Impaired Speech 213 Clinical Insight 21-6: Communicating With Clients Who Have Impaired Cognition or Consciousness 213 Assessment Guidelines and Tools 215 Communication 215 Clinical Reasoning 216 Applying the Full-Spectrum Nursing Model 216 Critical Thinking and Clinical Reasoning 216 Knowledge Map 218 CHAPTER 22 Health Assessment 219 Caring for the Nguyens 219 Practical Knowledge: Knowing How 220 Procedures 220 Procedure 22-1: Performing the General Survey 221 Procedure 22-2: Assessing the Skin 226 Procedure 22-3: Assessing the Hair 234 Procedure 22-4: Assessing the Nails 235 Procedure 22-5: Assessing the Head and Face 236 Procedure 22-6: Assessing the Eyes 238 Procedure 22-7: Assessing the Ears and Hearing 245 Procedure 22-8: Assessing the Nose and Sinuses 249 Procedure 22-9: Assessing the Mouth and Oropharynx 251 Procedure 22-10: Assessing the Neck 255 Procedure 22-11: Assessing the Breasts and Axillae 257 Procedure 22-12: Assessing the Chest and Lungs 260 Procedure 22-13: Assessing the Heart and Vascular System 265 Procedure 22-14: Assessing the Abdomen 271 Procedure 22-15: Assessing the Musculoskeletal System 277 Procedure 22-16: Assessing the Sensory-Neurological System 284 Procedure 22-17: Assessing the Male Genitourinary System 297 Procedure 22-18: Assessing the Female Genitourinary System 301 Procedure 22-19: Assessing the Anus and Rectum 305 Procedure 22-20: Brief Bedside Assessment 306 Clinical Insights 308 Clinical Insight 22-1: Performing Percussion 308 Clinical Insight 22-2: Performing Auscultation 309 Clinical Insight 22-3: Assisting With a Speculum Exam 309 Abnormal Atlas 312 Knowledge Map 316 CHAPTER 23 Promoting Asepsis & Preventing Infection 317 Caring for the Nguyens 317 Practical Knowledge: Knowing How 318 Procedures 318 Procedure 23-1: Hand Hygiene 318 Procedure 23-1A: Using Soap and Water 318 Procedure 23-1B: Using Alcohol-Based Handrubs 319 Procedure 23-2: Donning Personal Protective Equipment (PPE) 320 Procedure 23-3: Removing Personal Protective Equipment (PPE) 322 Procedure 23-4: Surgical Handwashing: Traditional Method 324

6 xviii CONTENTS Procedure 23-5: Surgical Handwashing: Brushless System 326 Procedure 23-6: Sterile Gown and Gloves (Closed Method) 328 Procedure 23-7: Sterile Gloves (Open Method) 331 Procedure 23-8: Sterile Fields 332 Procedure 23-8A: Setting Up a Sterile Field 332 Procedure 23-8B: Adding Supplies to a Sterile Field 333 Procedure 23-8C: Adding Sterile Solutions to a Sterile Field 334 Clinical Insights 335 Clinical Insight 23-1: Guidelines for Hand Hygiene 335 Clinical Insight 23-2: Providing a Clean Patient Environment 336 Clinical Insight 23-3: Following CDC Standard Precautions 337 Clinical Insight 23-4: Following Transmission-Based Precautions 339 Clinical Insight 23-5: Preventing the Transmission of Multidrug-Resistant Organisms (MDROs) 341 Clinical Insight 23-6: Maintaining a Protective Environment in Special Situations 342 Clinical Insight 23-7: Guidelines for Preparing and Maintaining Sterile Fields 343 Diagnostic Testing 344 Common Tests for Evaluating the Presence of or Risk for Infection 344 Clinical Reasoning 345 Applying the Full-Spectrum Nursing Model 345 Critical Thinking and Clinical Reasoning 345 Knowledge Map 347 CHAPTER 24 Promoting Safety 348 Caring for the Nguyens 349 Practical Knowledge: Knowing How 349 Procedures 350 Procedure 24-1: Using a Bed Monitoring Device 350 Procedure 24-2: Using Restraints 352 Clinical Insights 355 Clinical Insight 24-1: Preventing Needlestick Injury 355 Clinical Insight 24-2: What You Should Know About Using Restraints 356 Assessment Guidelines and Tools 357 Get Up and Go Test 357 The Timed Up & Go Test for Fall Risk Assessment 357 S.A.S. Safety Assessment Scale 358 Clinical Reasoning 359 Applying the Full-Spectrum Nursing Model 359 Critical Thinking and Clinical Reasoning 358 Knowledge Map 362 CHAPTER 25 Facilitating Hygiene 363 Caring for the Nguyens 363 Practical Knowledge: Knowing How 364 Procedures 364 Procedure 25-1: Bathing: Providing a Complete Bed Bath Using a Prepackaged Bathing Product 364 Procedure 25-2: Bathing: Providing a Towel Bath 369 Procedure 25-3: Bathing: Using a Basin and Water 370 Procedure 25-4: Providing Perineal Care 371 Procedure 25-5: Providing Foot Care 374 Procedure 25-6: Brushing and Flossing the Teeth 377 Procedure 25-7: Providing Denture Care 380 Procedure 25-8: Providing Oral Care for an Unconscious Patient 382 Procedure 25-9: Shampooing the Hair 384 Procedure 25-9A: Shampooing the Hair for a Patient on Bedrest Using Rinse-Free Shampoo 385 Procedure 25-9B: Shampooing the Hair Using Rinse-Free Shampoo Cap 385 Procedure 25-9C: Shampooing the Hair Using a Basin and Water 385 Procedure 25-10: Providing Beard and Mustache Care 387 Procedure 25-11: Shaving a Patient 389 Procedure 25-12: Removing and Caring for Contact Lenses 390 Procedure 25-13: Making an Unoccupied Bed 392 Procedure 25-14: Making an Occupied Bed 394 Procedure 25-15: Caring for Artificial Eyes 397 Procedure 25-16: Caring for Hearing Aids 398 Clinical Insights 401 Clinical Insight 25-1: Assisting With a Shower or Tub Bath 401 Clinical Insight 25-2: Bathing a Patient With Dementia 402 Assessment Guidelines and Tools 402 Guidelines for Assessing Hygiene 402 Clinical Reasoning 404 Applying the Full-Spectrum Nursing Model 404 Critical Thinking and Clinical Reasoning 404 Knowledge Map 408

7 CONTENTS xix CHAPTER 26 Administering Medications 409 Caring for the Nguyens 410 Practical Knowledge: Knowing How 410 Procedures 410 Medication Guidelines: Steps to Follow for All Medications (Regardless of Type or Route) 410 Procedure 26-1: Administering Oral Medication 414 Procedure 26-1A: Administering Medication Through an Enteral Tube 416 Procedure 26-2: Administering Ophthalmic Medication 419 Procedure 26-2A: Irrigating the Eyes 421 Procedure 26-3: Administering Otic Medication 422 Procedure 26-4: Administering Nasal Medication 424 Procedure 26-5: Administering Vaginal Medication 426 Procedure 26-6: Inserting a Rectal Suppository 428 Procedure 26-7: Applying Medication to Skin 430 Procedure 26-7A: Applying Topical Lotion, Cream, and Ointment 430 Procedure 26-7B: Applying Topical Aerosol Spray 430 Procedure 26-7C: Applying Prescribed Powder 430 Procedure 26-7D: Applying Transdermal Medication 431 Procedure 26-8: Administering Metered-Dose Inhaler (MDI) Medication 432 Procedure 26-9: Preparing, Drawing Up, and Mixing Medication 435 Procedure 26-9A: Drawing Up Medication From Ampules 435 Procedure 26-9B: Drawing Up Medication From Vials 437 Procedure 26-9C: Mixing Medication From Two Vials 439 Procedure 26-9D: Mixing Medication From One Ampule and One Vial 441 Procedure 26-9E: Using a Prefilled Cartridge and Single- Dose Vial For Intravenous Administration 442 Procedure 26-10: Recapping Needles Using a One-Handed Technique 443 Procedure 26-10A: Recapping Contaminated Needles 444 Procedure 26-10B: Recapping Sterile Needles 444 Procedure 26-11: Administering Intradermal Medication 445 Procedure 26-12: Administering Subcutaneous Medication 448 Procedure 26-13: Locating Intramuscular Injection Sites 451 Procedure 26-13A: Locating the Ventrogluteal Site 451 Procedure 26-13B: Locating the Deltoid Site 451 Procedure 26-13C: Locating the Vastus Lateralis Site 452 Procedure 26-13D: Locating the Rectus Femoris Site 453 Procedure 26-14: Administering an Intramuscular Injection 453 Procedure 26-14A: Intramuscular Injection: Traditional Method 454 Procedure 26-14B: Intramuscular Injection: Z-Track Method 455 Procedure 26-15: Adding Medications to Intravenous Fluid 457 Procedure 26-15A: Adding Medication to a New IV Bag or Bottle 457 Procedure 26-15B: Adding Medication to an Infusing IV 458 Procedure 26-16: Administering IV Push Medication 459 Procedure 26-16A: Administering IV Push Medications Through a Primary IV Line 459 Procedure 26-16B: Administering IV Push Medications Through an Intermittent Device (IV Lock) When No Extension Tubing Is Attached to the Venous Access Device 460 Procedure 26-16C: Administering IV Push Medications Through an Intermittent Device with IV Extension Tubing 461 Procedure 26-17: Administering Medications by Intermittent Infusion 463 Procedure 26-17A: Using a Volume-Control Administration Set 464 Procedure 26-17B: Using a Piggyback Administration Set With a Gravity Infusion 465 Procedure 26-17C: Using a Piggyback Administration Set With an Infusion Pump 466 Procedure 26-18: Administering Medication Through a Central Venous Access Device (CVAD) 467 Clinical Insights 471 Clinical Insight 26-1: Reusing Needles and Syringes: Home Care 471 Clinical Insight 26-2: Using Prefilled Unit-Dose Systems 472 Clinical Insight 26-3: Reconstituting Medication 473 Clinical Insight 26-4: Measuring Dosage When Changing Needles 474 Clinical Insight 26-5: Mixing Two Kinds of Insulin in One Syringe 475 Clinical Insight 26-6: Administering Anticoagulant Medication Subcutaneously 476 Clinical Insight 26-7: Taking Action After a Medication Error 477 Tables: Abbreviations 477 Common Medication-Related Abbreviations 477 Institute for Safe Medication Practices (ISMP) List of Error-Prone Abbreviations, Symbols, and Dose Designations 478 Measuring and Calculating Dosage 481

8 xx CONTENTS Medication Measurement Systems 481 Calculating Dosages 482 Clinical Reasoning 484 Applying the Full-Spectrum Nursing Model 484 Critical Thinking and Clinical Reasoning 485 Knowledge Map 489 Unit 4 Supporting Physiological Functioning 491 CHAPTER 27 Nutrition 493 Caring for the Nguyens 494 Practical Knowledge: Knowing How 494 Procedures 494 Procedure 27-1: Checking Fingerstick (Capillary) Blood Glucose Levels 494 Procedure 27-2: Inserting Nasogastric and Nasoenteric Tubes 498 Procedure 27-3: Administering Feedings Through Gastric and Enteric Tubes 502 Procedure 27-3A: Administering Feedings Through Gastric and Enteric Tubes Using an Open System: Syringe 504 Procedure 27-4: Removing a Nasogastric or Nasoenteric Tube 506 Procedure 27-5: Administering Parenteral Nutrition 508 Procedure 27-6: Administering Lipids 511 Clinical Insights 513 Clinical Insight 27-1: 10 Tips for Building Healthy Meals 513 Clinical Insight 27-2: Skinfold Measurement 514 Clinical Insight 27-3: Measuring Circumferences to Evaluate Body Composition 515 Clinical Insight 27-4: Interventions for Patients With Impaired Swallowing 515 Clinical Insight 27-5: Interventions for Patients Who Have Nausea 516 Clinical Insight 27-6: Assisting Patients With Meals 516 Clinical Insight 27-7: Checking Feeding Tube Placement 517 Clinical Insight 27-8: Monitoring Patients Receiving Enteral Nutrition 519 Clinical Insight 27-9: Preventing Infection in Patients Receiving Enteral Feedings 519 Clinical Insight 27-10: Monitoring and Other Interventions for Patients Receiving Parenteral Nutrition 520 Screening for Nutritional Problems 521 Subjective Global Assessment 521 Nutrition Screening Initiative (NSI), for Older Adults: Indications of Impaired Nutritional Status 521 Mini Nutritional Assessment 522 Focused Nutritional Assessment 522 Focused Nutritional Assessment 522 Diagnostic Testing 525 Tests Reflecting Nutritional Status: Norms 525 Clinical Reasoning 526 Applying the Full-Spectrum Nursing Model 526 Critical Thinking and Clinical Reasoning 526 Knowledge Map 529 CHAPTER 28 Urinary Elimination 530 Caring for the Nguyens 531 Practical Knowledge: Knowing How 531 Procedures 531 Procedure 28-1: Measuring Urine 531 Procedure 28-1A: Measuring Urine Output From a Bedpan or Urinal 532 Procedure 28-1B: Measuring Urine From an Indwelling Catheter 532 Procedure 28-1C: Measuring Post-Void Residual Urine Volume With a Portable Bladder Scanner 533 Procedure 28-2: Obtaining a Urine Specimen for Testing 534 Procedure 28-2A: Collecting a Clean-Catch Urine Specimen 535 Procedure 28-2B: Obtaining a Sterile Urine Specimen From a Catheter 536 Procedure 28-2C: Collecting a 24-Hour Urine Specimen 536 Procedure 28-3: Testing Urine at the Bedside 538 Procedure 28-3A: Dipstick Testing of Urine 538 Procedure 28-3B: Measuring Specific Gravity of Urine 538 Procedure 28-4: Inserting a Urinary Catheter 539 Procedure 28-4A: Intermittent Urinary Catheterization 540 Procedure 28-4B: Indwelling Urinary Catheterization 544 Procedure 28-5: Applying an External (Condom) Catheter 548 Procedure 28-6: Removing an Indwelling Catheter 551 Procedure 28-7: Irrigating the Bladder or Catheter 553 Procedure 28-7A: Intermittent Bladder or Catheter Irrigation 553 Procedure 28-7B: Continuous Bladder Irrigation 554

9 CONTENTS xxi Clinical Insights 556 Clinical Insight 28-1: Caring for a Patient With an Indwelling Catheter 556 Clinical Insight 28-2: Caring for Patients With Urinary Incontinence 558 Clinical Insight 28-3: Caring for Patients With Urinary Diversions 559 Clinical Insight 28-4: Teaching Clients About Clean, Intermittent Self-Catheterization 560 Assessment Guidelines and Tools 561 Urinary Elimination History Questions 561 Guidelines for Physical Assessment for Urinary Elimination 561 Diagnostic Testing 562 Urinalysis 562 Blood Studies: BUN and Creatinine 563 Studies of the Urinary System 564 Clinical Reasoning 565 Applying the Full-Spectrum Nursing Model 565 Critical Thinking and Clinical Reasoning 566 Knowledge Map 568 CHAPTER 29 Bowel Elimination 569 Caring for the Nguyens 569 Practical Knowledge: Knowing How 570 Procedures 570 Procedure 29-1: Testing Stool for Occult Blood 570 Procedure 29-2: Placing and Removing a Bedpan 572 Procedure 29-2A: Placing a Bedpan 573 Procedure 29-2B: Removing a Bedpan 574 Procedure 29-3: Administering an Enema 575 Procedure 29-3A: Administering a Cleansing Enema 575 Procedure 29-3B: Administering a Prepackaged Enema 577 Procedure 29-3C: Administering an Oil-Retention Enema 577 Procedure 29-3D: Administering a Return-Flow Enema 578 Procedure 29-4: Removing Stool Digitally 579 Procedure 29-5: Inserting a Rectal Tube 581 Procedure 29-6: Changing an Ostomy Appliance 582 Procedure 29-7: Irrigating a Colostomy 586 Procedure 29-8: Placing Fecal Drainage Devices 588 Procedure 29-8A: Applying an External Fecal Collection System 589 Procedure 29-8B: Inserting an Indwelling Fecal Drainage Device 590 Clinical Insights 592 Clinical Insight 29-1: Caring for a Patient With an Indwelling Fecal Drainage Device 592 Clinical Insight 29-2: Guidelines for Ostomy Care 593 Assessment Guidelines and Tools 594 Bowel Elimination 594 Diagnostic Testing 594 Direct Visualization Studies of the Gastrointestinal Tract 594 Indirect Visualization Studies of the Gastrointestinal Tract 595 Clinical Reasoning 596 Applying the Full-Spectrum Nursing Model 596 Critical Thinking and Clinical Reasoning 596 Knowledge Map 598 CHAPTER 30 Sensation, Perception, & Cognition 599 Caring for the Nguyens 599 Practical Knowledge: Knowing How 600 Procedures 600 Procedure 30-1: Performing Otic Irrigation 600 Clinical Insights 602 Clinical Insight 30-1: Seizure Precautions 602 Clinical Insight 30-2: Communicating With Visually Impaired Clients 604 Clinical Insight 30-3: Communicating With Hearing- Impaired Clients 604 Assessment Guidelines and Tools 605 Hearing Screening in Older Adults 605 Other Sensory Assessment Tools 605 Nursing History: Sensory Perceptual Status 605 Bedside Assessment of Sensory Function 606 Clinical Reasoning 607 Applying the Full-Spectrum Nursing Model 607 Critical Thinking and Clinical Reasoning 607 Knowledge Map 609 CHAPTER 31 Pain 610 Caring for the Nguyens 611 Practical Knowledge: Knowing How 611 Procedures 611 Procedure 30-1: Setting Up and Managing Patient- Controlled Analgesia by Pump 611 Clinical Insights 614 Clinical Insight 31-1: Caring for the Patient With an Epidural Catheter 614 Clinical Insight 31-2: Guidelines for Assessing Pain 615 Assessment Guidelines and Tools 616

10 xxii CONTENTS Pain Assessment 616 Pain Relief Diary 618 Richmond Agitation-Sedation Rating Scale 618 Clinical Reasoning 619 Applying the Full-Spectrum Nursing Model 619 Critical Thinking and Clinical Reasoning 619 Knowledge Map 621 CHAPTER 32 Physical Activity & Mobility 622 Caring for the Nguyens 623 Practical Knowledge: Knowing How 623 Procedures 623 Procedure 32-1: Moving and Turning Patients in Bed 623 Procedure 32-1A: Moving a Patient Up in Bed 624 Procedure 32-1B: Turning a Patient in Bed 625 Procedure 32-1C: Logrolling a Patient 626 Procedure 32-2: Transferring Patients 628 Procedure 32-2A: Transferring a Patient From Bed to Stretcher 628 Procedure 32-2B: Dangling a Patient at the Side of the Bed 629 Procedure 32-2C: Transferring a Patient From Bed to Chair 630 Procedure 32-3: Assisting With Ambulation 632 Procedure 32-3A: Assisting With Ambulation (One Nurse) 632 Procedure 32-3B: Assisting With Ambulation (Two Nurses) 633 Clinical Insights 635 Clinical Insight 32-1: Applying Principles of Body Mechanics 635 Clinical Insight 32-2: Using Common Positioning Devices 636 Clinical Insight 32-3: Tips for Performing Passive Range-of-Motion Exercises 638 Clinical Insight 32-4: Assisting With Physical Conditioning Exercises to Prepare for Ambulation 638 Clinical Insight 32-5: Sizing Walking Aids 639 Clinical Insight 32-6: Teaching Patients to Use Canes, Walkers, and Crutches 639 Assessment Guidelines and Tools 641 Assessing Activity and Exercise 641 Tables 643 Range of Motion at the Joints 643 Clinical Reasoning 648 Applying the Full-Spectrum Nursing Model 648 Critical Thinking and Clinical Reasoning 648 Knowledge Map 650 CHAPTER 33 Sexual Health 651 Caring for the Nguyens 652 Practical Knowledge: Knowing How 652 Clinical Insights 652 Clinical Insight 33-1: Providing Care After Sexual Assault 652 Clinical Insight 33-2: Guidelines for Taking a Sexual History 653 Clinical Insight 33-3: Teaching Your Patient to Use a Condom 654 Tables 654 Fertility Control Methods 654 Assessment Guidelines and Tools 656 Guidelines and Questions for Taking a Sexual History 656 Clinical Reasoning 658 Applying the Full-Spectrum Nursing Model 658 Critical Thinking and Clinical Reasoning 658 Knowledge Map 661 CHAPTER 34 Sleep & Rest 662 Caring for the Nguyens 662 Practical Knowledge: Knowing How 664 Procedures 664 Procedure 34-1: Giving a Back Massage 664 Assessment Guidelines and Tools 666 Questions for a Sleep History 666 Clinical Reasoning 667 Applying the Full-Spectrum Nursing Model 667 Critical Thinking and Clinical Reasoning 668 Knowledge Map 670 CHAPTER 35 Skin Integrity & Wound Healing 671 Caring for the Nguyens 672 Practical Knowledge: Knowing How 672 Procedures 672 Procedure 35-1: Obtaining a Wound Culture by Swab 673 Procedure 35-2: Performing a Sterile Wound Irrigation 675

11 CONTENTS xxiii Procedure 35-3: Taping a Dressing 678 Procedure 35-4: Removing and Applying Dry Dressings 680 Procedure 35-5: Removing and Applying Wet-to-Damp Dressings 682 Procedure 35-6: Applying a Negative Pressure Wound Therapy (NPWT) Device 685 Procedure 35-6A: Open-Pore Reticulated Polyurethane Foam Therapy (i.e., Vacuum-Assisted Closure [V.A.C.]) 687 Procedure 35-6B: Gauze Dressing Application (i.e., Chariker Jeter Method) 688 Procedure 35-7: Applying and Removing a Transparent Film Dressing 690 Procedure 35-8: Applying a Hydrating Dressing (Hydrocolloid or Hydrogel) 693 Procedure 35-9: Placing Skin Closures 695 Procedure 35-10: Applying Binders 697 Procedure 35-11: Applying Bandages 699 Procedure 35-12: Removing Sutures and Staples 703 Procedure 35-12A: Removing Sutures 703 Procedure 35-12B: Removing Staples 704 Procedure 35-13: Shortening a Wound Drain 705 Procedure 35-14: Emptying a Closed-Wound Drainage System 706 Clinical Insights 708 Clinical Insight 35-1: Applying Local Heat Therapy 708 Clinical Insight 35-2: Applying Local Cold Therapy 709 Assessment Guidelines and Tools 709 History Questions for Skin and Wound Assessment 709 Physical Examination: Wound Assessment 710 The Braden Scale for Predicting Pressure Sore Risk 711 The Norton Scale for Assessing Risk of Pressure Ulcers 712 The PUSH Tool for Evaluation of Pressure Ulcers 713 Diagnostic Testing 715 Tests for Assessing Wounds 715 Standardized Language 716 Selected Standardized Outcomes and Interventions for Skin and Wound Diagnoses 716 Clinical Reasoning 717 Applying the Full-Spectrum Nursing Model 717 Critical Thinking and Clinical Reasoning 718 Knowledge Map 721 CHAPTER 36 Oxygenation 722 Caring for the Nguyens 722 Practical Knowledge: Knowing How 723 Procedures 723 Procedure 36-1: Collecting a Sputum Specimen 723 Procedure 36-1A: Collecting an Expectorated Sputum Specimen 724 Procedure 36-1B: Collecting a Suctioned Sputum Specimen 725 Procedure 36-2: Monitoring Pulse Oximetry (Arterial Oxygen Saturation) 726 Procedure 36-3: Performing Percussion, Vibration, and Postural Drainage 728 Procedure 36-4: Administering Oxygen 731 Procedure 36-5: Performing Tracheostomy Care Using Sterile Technique 736 Procedure 36-6: Performing Tracheostomy Suctioning (Open System) 741 Procedure 36-7: Performing Tracheostomy or Endotracheal Suctioning (Inline Closed System) 744 Procedure 36-8: Performing Orotracheal and Nasotracheal Suctioning (Open System) 745 Procedure 36-9: Performing Upper Airway Suctioning 749 Procedure 36-10: Caring for Patients Requiring Mechanical Ventilation 752 Procedure 36-11: Setting Up Disposable Chest Drainage Systems 755 Procedure 36-12: Inserting an Oropharyngeal Airway 759 Procedure 36-13: Inserting a Nasopharyngeal Airway 760 Clinical Insights 762 Clinical Insight 36-1: Tips for Obtaining Accurate Pulse Oximetry Readings 762 Clinical Insight 36-2: Guidelines for Preventing Aspiration 762 Clinical Insight 36-3: Oxygen Therapy Safety Precautions 763 Clinical Insight 36-4: Caring for Patients With Endotracheal Airways 763 Clinical Insight 36-5: Managing Chest Tubes 764 Assessment Guidelines and Tools 765 Oxygenation 765 Diagnostic Testing 766 Lung Volumes and Capacities 766 Tests Related to Oxygenation 767 Reading a Tuberculin Skin Test Result 768 Clinical Reasoning 768 Applying the Full-Spectrum Nursing Model 768 Critical Thinking and Clinical Reasoning 769 Knowledge Map 771

12 xxiv CONTENTS CHAPTER 37 Circulation 772 Caring for the Nguyens 773 Practical Knowledge: Knowing How 773 Procedures 773 Procedure 37-1: Performing Cardiac Monitoring 774 Assessment Guidelines and Tools 776 Assessing Circulation 776 Diagnostic Testing 777 Tests Related to Circulation 777 Clinical Reasoning 777 Applying the Full-Spectrum Nursing Model 777 Critical Thinking and Clinical Reasoning 778 Knowledge Map 780 CHAPTER 38 Fluids, Electrolytes, & Acid Base Balance 781 Caring for the Nguyens 782 Practical Knowledge: Knowing Why 782 Procedures 783 Procedure 38-1: Initiating a Peripheral Intravenous Infusion 783 Procedure 38-2: Regulating the IV Flow Rate 788 Procedure 38-3: Setting Up and Using Volume-Control Pumps 790 Procedure 38-4: Changing IV Solutions and Tubing 793 Procedure 38-4A: Changing the IV Solution 793 Procedure 38-4B: Changing the IV Administration Tubing and Solution 794 Procedure 38-5: Changing IV Dressings 796 Procedure 38-5A: Peripheral IV Dressings 796 Procedure 38-5B: Central Line Dressings 797 Procedure 38-5C: PICC Line Dressings 798 Procedure 38-6: Converting a Primary Line to a Peripheral IV Lock 800 Procedure 38-7: Discontinuing a Peripheral IV 803 Procedure 38-8: Administering a Blood Transfusion 804 Procedure 38-8A: Administering Blood and Blood Products 805 Procedure 38-8B: Managing a Transfusion Reaction 807 Procedure 38-9: Assisting With Percutaneous Central Venous Catheter Placement 808 Clinical Insights 810 Clinical Insight 38-1: Assessing for Trousseau s and Chvostek s Signs 810 Clinical Insight 38-2: Guidelines for Measuring Intake and Output (I&O) 810 Clinical Insight 38-3: Guidelines for Selecting a Peripheral Venipuncture Site 812 Clinical Insight 38-4: Caring for Patients With a Central Venous Access Device (CVAD): CVC and PICC 813 Clinical Insight 38-5: Managing Infiltration and Extravasation 814 Assessment Guidelines and Tools 815 Assessing Fluids, Electrolytes, and Acid Base Balance 815 Diagnostic Testing 817 Assessing Fluid, Electrolyte, and Acid Base Balance 817 Clinical Reasoning 817 Applying the Full-Spectrum Nursing Model 817 Critical Thinking and Clinical Reasoning 818 Knowledge Map 821 Unit 5 Nursing Functions 823 CHAPTER 39 Perioperative Care 825 Caring for the Nguyens 825 Practical Knowledge: Knowing How 826 Procedures 826 Procedure 39-1: Teaching a Patient to Deep-Breathe, Cough, Move in Bed, and Perform Leg Exercises 826 Procedure 39-1A: Teaching a Patient to Deep-Breathe and Cough 827 Procedure 39-1B: Teaching a Patient to Move in Bed 827 Procedure 39-1C: Teaching Leg Exercises 828 Procedure 39-2: Applying Antiembolism Stockings 829 Procedure 39-3: Applying Sequential Compression Devices 832 Procedure 39-4: Managing Gastric Suction 834 Procedure 39-4A: Initial Equipment Setup 835 Procedure 39-4B: Emptying the Suction Container 835 Procedure 39-4C: Irrigating the Nasogastric Tubing 836 Procedure 39-4D: Providing Comfort Measures 836 Clinical Insights 839 Clinical Insight 39-1: Preoperative Teaching 839 Clinical Insight 39-2: Preparing a Room for a Patient s Return From Surgery 840 Clinical Insight 39-3: Creating an Operative Field 840 Assessment Guidelines and Tools 841

13 CONTENTS xxv Preoperative Assessment Topics 841 Example of a Preoperative Checklist 842 Example of a Surgical Safety Checklist 844 Intraoperative Care Questionnaire 844 Postanesthesia Assessment: Essential Elements 845 Diagnostic Testing 845 Common Preoperative Screening Tests 845 Standardized Language 846 Preoperative Patients: Selected Standardized Nursing Diagnoses, Outcomes, and Interventions 846 Intraoperative Patients: Selected Standardized Nursing Diagnoses, Outcomes, and Interventions 848 Postoperative Patients: Selected Standardized Nursing Diagnoses, Outcomes, and Interventions 851 Clinical Reasoning 855 Applying the Full-Spectrum Nursing Model 855 Critical Thinking and Clinical Reasoning 856 Knowledge Map 858 CHAPTER 40 Leading & Managing 859 Caring for the Nguyens 859 Clinical Reasoning 860 Applying the Full-Spectrum Nursing Model 860 Critical Thinking and Clinical Reasoning 860 Knowledge Map 863 CHAPTER 41 Nursing Informatics 864 Caring for the Nguyens 865 Practical Knowledge: Knowing How 865 Standardized Language 865 American Nurses Association Recognized Languages for Nursing 865 Clinical Reasoning 866 Applying the Full-Spectrum Nursing Model 866 Critical Thinking and Clinical Reasoning 867 Knowledge Map 870 CHAPTER 42 Promoting Health 871 Caring for the Nguyens 871 Assessment Guidelines and Tools 872 Health Promotion: Physical Fitness Assessment 872 Lifestyle and Risk Assessment 873 Life Stress Review 875 Selected Health Screening Activities 876 Standardized Language 877 Examples of NANDA-I Health Promotion Diagnoses 877 Selected NIC Health Promotion Interventions 877 Clinical Reasoning 879 Applying the Full-Spectrum Nursing Model 879 Critical Thinking and Clinical Reasoning 879 Knowledge Map 881 Unit 6 The Context for Nurses Work 883 CHAPTER 43 Community & Home Health Nursing 885 Caring for the Nguyens 886 Practical Knowledge: Knowing How 886 Clinical Insights 887 Clinical Insight 43-1: Safety Considerations in Home Care 887 Clinical Insight 43-2: Infection Control in the Home 888 Standardized Language 888 The Omaha System 888 Omaha System: Domains and Examples of Problem Labels 889 Omaha Problem Rating Scale for Outcomes 889 NIC Community Health Classes and Interventions 890 Omaha Intervention Categories and Examples of Targets 891 Clinical Care Classification System for Home Health Care 891 An Example of CCC Nursing Diagnoses and Interventions 892 Clinical Reasoning 892 Applying the Full-Spectrum Nursing Model 892 Critical Thinking and Clinical Reasoning 892 Knowledge Map 896 CHAPTER 44 Ethics & Values 897 Caring for the Nguyens 898 Practical Knowledge: Knowing How 898 Clinical Insights 899

14 xxvi CONTENTS Clinical Insight 44-1: Using the MORAL Model for Ethical Decision Making 899 Clinical Insight 44-2: Guidelines for Advocacy 899 Clinical Reasoning 900 Applying the Full-Spectrum Nursing Model 900 Critical Thinking and Clinical Reasoning 900 Knowledge Map 904 CHAPTER 45 Legal Accountability 905 Caring for the Nguyens 906 Practical Knowledge: Knowing How 906 Clinical Insights 906 Clinical Insight 45-1: Using Equipment Safely 906 Clinical Insight 45-2: Tips for Avoiding Malpractice 907 Clinical Insight 45-3: Guidelines for Documenting Care 907 Clinical Reasoning 908 Applying the Full-Spectrum Nursing Model 908 Critical Thinking and Clinical Reasoning 908 Knowledge Map 911 CHAPTER 46 Holistic Healing (on DavisPlus) Credits 912 References Cited 914 Index 1000