Essential Clinical Skills: Enrolled Nurses, 5th Edition
By Joanne Tollefson, Gayle Watson, Eugenie Jelly and Karen Tambree
Contents:
Guide to the text v
Guide to the online resources viii
Introduction x
New to this edition xi
About the authors xiv
Acknowledgements xv
PART 1
HAND HYGIENE 1
1.1 Hand hygiene 2
PART 2
ASSESSMENT 6
2.1 Head-to-toe assessment 7
2.2 Risk assessment and risk management 12
2.3 Temperature, pulse and respiration (TPR)
measurement 18
2.4 Blood pressure measurement 23
2.5 Pulse oximetry 28
2.6 Blood glucose measurement 31
2.7 Neurological observation 35
2.8 Neurovascular observation 40
2.9 Pain assessment 44
2.10 12-lead ECG recording 49
PART 3
ACTIVITIES OF DAILY LIVING 53
3.1 Professional workplace skills – including
time management, rounding and personal
stress management 54
3.2 Bedmaking 60
3.3 Assisting the patient to ambulate 64
3.4 Assisting the patient with
eating and drinking 68
3.5 Assisting the patient to maintain personal
hygiene and grooming needs – sponge
(bed bath) with oral hygiene, hair wash
in bed, eye and nasal care 72
3.6 Assisting the patient to maintain personal
hygiene and grooming – assisted shower
(chair or trolley), undressing/dressing,
shaving, hair and nail care 79
3.7 Assisting the patient with elimination –
urinary and bowel elimination 86
3.8 Urine specimen collection and urinalysis 91
3.9 Faeces assessment and specimen collection 95
3.10 Assisting the patient with colostomy care 99
3.11 Patient comfort – pain management
(non-pharmacological interventions – heat and cold) 103
3.12 Positioning of a dependent patient 107
3.13 Preventing and managing pressure injuries 111
3.14 Active and passive exercises 115
3.15 Deep breathing and coughing, and use
of incentive spirometer 121
PART 4
ASEPSIS AND WOUND CARE 125
4.1 Aseptic technique – establishing a general or
critical aseptic field 126
4.2 Simple dry dressing using a general aseptic field 132
4.3 Wound irrigation 138
4.4 Wound swab 143
4.5 Packing a wound – ‘wet-to-moist’ dressing 147
4.6 Negative pressure wound therapy (NPWT)
dressing 152
4.7 Suture and staple removal 157
4.8 Drain removal and shortening 162
4.9 Gowning and gloving (open and closed) 168
4.10 Surgical scrub (surgical hand wash) 173
4.11 Chest drains and underwater seal drainage
(UWSD) management 177
PART 5
MEDICATION 182
5.1 Medication administration – oral, sublingual,
buccal, topical and rectal 183
5.2 Medication administration – eye drops or
ointment, and eye care 192
5.3 Medication administration – injections 196
5.4 Medication therapy – inhaled medication
(metered-dose inhalers and nebulisers) 205
5.5 Medication administration – via an
enteral tube 209
PART 6
INTRAVENOUS CARE 214
6.1 Venepuncture 215
6.2 Peripheral intravenous cannula (PIVC) –
assisting with establishment 220
6.3 Peripheral intravenous cannula (PIVC)
and therapy (PIVT) management 224
6.4 Removal of a peripheral intravenous
cannula (PIVC) 231
6.5 Intravenous medication administration –
adding medication to PIVC fluid bag 235
6.6 Intravenous medication administration –
adding medication to a burette 240
6.7 Intravenous medication administration –
injection (bolus) 245
6.8 Central venous access device (CVAD)
dressing 250
6.9 Blood transfusion management 254
PART 7
DOCUMENTATION 260
7.1 Documentation 261
7.2 Nursing care plans 265
7.3 Clinical handover – change of shift 269
7.4 Admission, discharge and patient transfer 273
7.5 Health teaching 279
7.6 Nursing informatics 284
PART 8
SPECIFIC NURSING CARE 288
8.1 Oxygen therapy (includes peak flow meter) 289
8.2 Preoperative care 296
8.3 Recovery room care and handover 302
8.4 Postoperative care 308
8.5 Nasogastric tube – gastric drainage 314
8.6 Catheterisation (urinary) 318
8.7 Catheter care (including hourly urine
measurement) 324
8.8 Suctioning of oral cavity 329
8.9 Tracheostomy care 333
8.10 Assist a patient to use CPAP in the
general ward or community 338
8.11 Nasogastric tube insertion 342
8.12 Enteral feeding (nasogastric and
gastrostomy tube) 347
8.13 Infection control – standard and
transmission-based precautions 353
8.14 Care of the unconscious patient 360
8.15 Palliative care and end-of-life care 365
PART 9
MENTAL HEALTH CARE 371
9.1 Mental state examination 372
9.2 Establishing a ‘therapeutic relationship’
in the mental health setting 377
9.3 Management of a client with challenging
behaviour (aggressive or violent) 382
9.4 Assist with the management of a client in
seclusion 388
9.5 Electroconvulsive therapy (ECT) –
client care pre- and post-treatment 393
Appendix 398
Index 407