LIA ST RA AU SA GA M GE PL L E EA PA R GE NI S NG EN OF C TY Joanne Tollefson Toni Bishop Eugenie Jelly ER Essential Clinical Skills Gayle Watson PR OP Karen Tambree e n r o l l e d d i v i s i o n 2 n u r s e s This publication has been endorsed by Royal College of Nursing, Australia, according to approved criteria. edition 2 BISHOP_TOLLEFSON 9780170197182 CVR FINAL ART.indd 1 10/10/12 10:28 AM
CONTENTS Introduction About the authors Acknowledgements Resources guide vii xi xii xiii PART 1 GENERAL CARE 1 1.1 Hand hygiene 2 1.2 Bedmaking 6 1.3 Assisting the patient to ambulate 9 1.4 Assisting the patient with eating and drinking 13 1.5 Assisting the patient to maintain personal hygiene bed bath or assisted shower, undressing/dressing, oral hygiene, eye and nasal care, shaving, hair and nail care 16 1.6 Assisting the patient with elimination (including urinalysis and urine specimen collection, perineal care, ostomy care and stool assessment) 24 1.7 Patient comfort pain management (non-pharmacological interventions heat and cold) 31 1.8 Positioning of a dependent patient and pressure area care 35 1.9 Range of motion exercises 39 PART 2 DOCUMENTATION 43 2.1 Documentation 44 2.2 Clinical handover 48 2.3 Admissions and discharge 51 2.4 Health teaching 55 PART 3 ASSESSMENT 61 3.1 Basic assessment 62 3.2 Temperature, pulse and respiration (TPR) measurement 66 3.3 Blood pressure measurement 70 3.4 Pulse oximetry 74 3.5 Blood glucose measurement 77 3.6 Mental status assessment 81 3.7 Neurological observation 85 3.8 Neurovascular observation 90 3.9 Pain assessment 94 3.10 12-Lead ECG recording 98 PART 4 MEDICATION 103 4.1 Medication administration oral, topical and suppositories 104 4.2 Medication administration eye drops or ointment administration 111 4.3 Medication administration injections 115 PART 5 ASEPSIS 125 5.1 Aseptic technique 126 5.2 Dry dressing 130 5.3 Wound irrigation, wound swabs 134 5.4 Packing a wound 138 5.5 Suture, clip and staple removal 142 5.6 Drain removal and shortening 146 PART 6 ACUTE CARE 151 6.1 Catheterisation (urinary) 152 6.2 Nasogastric tube insertion and feeding, gastric drainage and gastric tube feeding 158 6.3 Oxygen therapy via nasal cannula or various masks including nebulisers, metered dose inhalers and peak flow meters 165 6.4 Pre-operative care 172 6.5 Post-operative care 177 6.6 Recovery room care and handover 183 6.7 Suctioning of oral cavity 188 6.8 Tracheostomy care 192 6.9 Electro-convulsive therapy (ECT) patient care pre and post treatment 197 v
PART 7 INTRAVENOUS CARE 201 7.1 Venipuncture 202 7.2 Intravenous therapy (IVT) assisting with establishment 207 7.3 Intravenous therapy (IVT) management 213 7.4 Intravenous medication administration IV container 217 7.5 Intravenous medication administration burette 220 7.6 Intravenous medication administration bolus 224 7.7 Blood transfusion management 228 PART 8 SPECIFIC SKILLS 233 8.1 Isolation nursing 234 8.2 Gowning and gloving 237 8.3 Surgical scrub 240 8.4 Chest drains/underwater seal drainage management 244 8.5 Care of the unconscious patient 248 Appendix: ANMC National Competency Standards for the Enrolled Nurse (2002) 252 Index 274 vi CONTENTS
Thoroughly wet hands and apply soap Do not touch the inside or outside of the sink. The sink is contaminated and touching will transfer microorganisms onto the nurse s hands. Wet hands to above the wrists, keeping hands lower than elbows to prevent water from flowing onto the arms and, when contaminated, back onto the clean hands. Add liquid soap or an antimicrobial cleanser. Five millilitres is sufficient to be effective; less does not effectively remove microbes. More soap would be wasteful of resources. If only bar soap is available, lather and rinse the bar to remove microbes before you start to wash your hands, and do not put the bar down until you are ready to rinse. Lather hands to above the wrists. Clean under the fingernails Under the nails is a highly soiled area and high concentrations of microbes on hands come from beneath fingernails. The area under the nails should be cleansed of debris with either a nail brush or an orange stick, usually during the first hand wash of the day. If the nails become soiled during the shift, this cleaning will need to be done again. Some authors suggest cleansing the nails prior to washing; others suggest that during washing is more effective. Cleaning this area under flowing water is most effective for removing debris. Wash hands Lather and wash your hands for a period of not less than 15 to 30 seconds before care or after care if touching clean objects (clean materials, limited patient contact such as pulse-taking), and one to two minutes if engaged in dirty activities (Larsen & Lusk, 2006) such as direct contact with excreta or secretions. A surgical hand wash will take 3 6 minutes depending on policies. Rub one hand with the other, using vigorous movements since friction is effective in dislodging dirt and micro-organisms. Pay particular attention to palms, backs of hands, knuckles and webs of fingers. Dirt and micro-organisms lodge in creases. Lather and scrub up over the wrist, and onto the lower forearm if doing a longer wash to remove dirt and micro-organisms from this area. The wrists and forearms are considered less contaminated than the hands, so they are scrubbed after the hands to prevent the movement of micro-organisms from a more contaminated to a less contaminated area. Repeat the wetting, lathering with additional soap and rubbing if hands have been heavily contaminated. Rinse hands For social washing, rinse the hands and fingers under running water to wash micro-organisms and dirt. For clinical and surgical washes, hands are rinsed first, and are held higher than the elbows to allow water to run off the elbows and so prevent contamination of the clean forearms and hands. Rinse well to prevent residual soap from irritating the skin. Dry hands Using paper towels, pat the fingers, hands and forearms well to dry the skin and prevent chapping. Damp hands are a source of microbial growth and transfer, as well as contributing to chapping and then lesions of the hands. Turn off taps Using dry paper towels, turn hand-manipulated taps off, taking care not to contaminate hands on the sink or taps. Carefully discard paper towels so that hands are not contaminated. Turn off other types of taps with foot, knee or elbow as appropriate. After several washes, hand lotion should be applied to prevent chapping. Frequent hand hygiene can be very drying and chapped skin becomes a reservoir for microorganisms. Apply alcohol-based hand rub as required Hands must be visibly clean and dry prior to using the ABHR. Hand hygiene using a waterless, alcoholbased rub has been demonstrated to reduce the microbial load on hands when 3 ml of the 60 80% ethanol based solution is vigorously rubbed over all hand and finger surfaces (pay the same attention to the palms, back of the hands, finger webs, knuckles and wrists as during the traditional hand wash) for 10 30 seconds. The use of such a rub is effective for minimally contaminated hands. It increases CHAPTER 1.1 Hand hygiene 3
ESSENTIAL SKILLS COMPETENCY BLOOD PRESSURE MEASUREMENT Demonstrates the ability to effectively measure blood pressure Y (Numbers indicate ANMC National Competency Standards (Satisfactory) for the Enrolled Nurse, 2002) 1. Identifies indication (4.1, 7.1, 8.1) 2. Evidence of effective communication with the patient; e.g. gives patient a clear explanation of procedure, and assesses patient (3.1, 3.3, 3.4, 6.1, 7.1, 8.2) 3. Gathers equipment (7.1, 7.4) sphygmomanometer (aneroid or mercury manometer, automated manometer) stethoscope alcowipes 4. Demonstrates problem-solving abilities; e.g. prepares environment (6.1, 7.1, 8.1) 5. Performs hand hygiene (7.1, 8.1) 6. Positions and prepares patient (7.1) 7. Applies the cuff (7.1) 8. Performs a preliminary palpatory systolic determination (7.1, 8.1) 9. Positions the stethoscope appropriately (7.1) 10. Auscultates the patient s blood pressure (7.1) 11. Removes the cuff (7.1, 8.1) 12. Cleans, replaces and disposes of equipment appropriately (8.1, 9.2, 10.2) 13. Documents and reports relevant information (1.1, 1.3, 1.4, 1.5, 6.1, 7.2, 7.3, 8.1) 14. Demonstrates ability to link theory to practice (5.1, 5.2) D (Requires Development) CHAPTER 3.3 Blood pressure measurement 73
6.8 Figure 6.8.1 Figure 6.8.2 Tracheostomy care Identify indications A tracheostomy is the surgical creation of a stoma in the upper airway to facilitate airway management. It may be carried out to bypass any upper respiratory tract obstruction or trauma, or in patients requiring long-term ventilation (Dougherty & Lister, 2008). It is generally a temporary measure. Tracheostomy care maintains airway patency by removing dried secretions. It keeps the skin around the site clean to help prevent infections of the stoma site and lower airway, and to prevent skin breakdown. Tracheostomy suctioning is an advanced skill for the Enrolled Nurse. Tracheostomy tubes are chosen individually for each patient and vary in their composition, number of parts, shape and size. The diameter should be smaller than the trachea so it lies comfortably in the lumen. The length and curve are important so that dislodgement during coughing or head turning is avoided. The tube may be cuffed or uncuffed. Cuffs seal the space between the trachea and tube, allowing for mechanical ventilation. Long-term tracheostomy tubes have three parts: an inner cannula (smooth tube with the locking device), an outer cannula (with a flange, cuff and pilot tube) and an obdurator (with a A tracheostomy with the cuff inflated Tracheostomy parts Cuff Obturator Outer cannula Faceplate Slit for tracheostomy ties Pilot balloon Inner cannula 192 PART 6 Acute care