4076 fm i-xxvi - fa davis cms...

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Contents

Unit 1How Nurses Think 5

C H A P T E R 1Evolution of Nursing Thought & Action 7Caring for the Nguyens 7

Critical Thinking and Clinical Reasoning 7

Knowledge Map 9

C H A P T E R 2Critical Thinking & Nursing Process 10Caring for the Nguyens 10Clinical Reasoning 11

Applying the Full-Spectrum Nursing Model 11Critical Thinking and Clinical Reasoning 11

Knowledge Map 14

C H A P T E R 3Nursing Process: Assessment 15Caring for the Nguyens 15Practical Knowledge: Knowing How 16Clinical Insights 16Clinical 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 18Patient Assessment Tool—Lawton Instrumental

Activities of Daily Living (IADL) 18Nursing Admission Data Form 19

Clinical Reasoning 22Applying the Full-Spectrum Nursing Model 22Critical Thinking and Clinical Reasoning 23

Knowledge Map 25

C H A P T E R 4Nursing Process: Diagnosis 26Caring for the Nguyens 26Practical Knowledge: Knowing How 27Standardized Language 27

Descriptors for NANDA-I Nursing Diagnoses 27


Knowledge Map 32

C H A P T E R 5Nursing Process: Planning Outcomes 33Caring for the Nguyens 33Practical Knowledge: Knowing How 34Assessment Guidelines & Tools 34

Discharge Planning Form 34

Standardized Language 35Clinical Reasoning 36


Knowledge Map 39

C H A P T E R 6Nursing Process: Planning Interventions 40Caring for the Nguyens 40Clinical Reasoning 41


Knowledge Map 44

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C H A P T E R 7Nursing Process: Implementation &Evaluation 45Caring for the Nguyens 45Practical Knowledge: Knowing How 46Implementation and Evaluation Tools 46

The Five Rights of Delegation—Checklist 46NCSBN Delegation Grid 47Evaluation Checklist 48


Knowledge Map 53

C H A P T E R 8Evidence-Based Practice: Theory &Research 54Caring for the Nguyens 54Clinical Reasoning 55


Knowledge Map 58

Unit 2Factors Affecting Health 59

C H A P T E R 9Life Span: Infancy Through MiddleAdulthood 61Caring for the Nguyens 61Practical Knowledge: Knowing How 62Procedures 62Procedure 9-1: Assessing for Abuse 63

Assessment Guidelines & Tools 67Clinical Reasoning 68


Knowledge Map 71

C H A P T E R 10Life Span: Older Adults 72Caring for the Nguyens 72Clinical Reasoning 73


Knowledge Map 75

C H A P T E R 11Experiencing Health & Illness 76Caring for the Nguyens 76Practical Knowledge: Knowing How 77Procedures 77Procedure 11-1: Admitting a Patient to a Nursing

Unit 77Procedure 11-2: Transferring a Patient to Another

Unit in the Agency 80Procedure 11-3: Transferring a Patient to a Long-Term

Care Facility 81Procedure 11-4: Discharging a Patient From the

Healthcare Facility 83

Clinical Insights 86Clinical Insight 10-1: Preparing the Room for a Newly

Admitted Patient 86

Forms 87Discharge Assessment/Instructions 87Patient Education Form 88


Knowledge Map 91

C H A P T E R 12Stress & Adaptation 92Caring for the Nguyens 93Practical Knowledge: Knowing How 93Clinical Insights 93Clinical Insight 12-1: Dealing With Angry Patients 93

Clinical Insight 12-2: Crisis Intervention Guidelines 94

Assessment Guidelines and Tools 95Standardized Language 97Clinical Reasoning 98


Knowledge Map 101

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C H A P T E R 13Psychosocial Health & Illness 102Caring for the Nguyens 102Practical Knowledge: Knowing How 103Clinical Insights 103Clinical 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 106Anxiety Assessment Guide 106Depression Assessment Guide: Patient HealthQuestionnaire (PHQ-9) 107Differentiating Depression and Dementia 108Standardized Nursing Language 108

Anxiety-Related Diagnoses: Selected NOC Outcomes and NIC Interventions 109

Depression-Related Nursing Diagnoses: Selected NOCOutcomes and NIC Interventions 111


Knowledge Map 117

C H A P T E R 14The Family 118Caring for the Nguyens 119Practical Knowledge: Knowing How 119Clinical Insights 119Clinical Insight 14-1: Conducting a Family

Assessment 119

Assessment Guidelines and Tools 120Assessing Family Developmental Tasks 120

Standardized Language 121NOC Outcomes and NIC Interventions for Caregiver

Role Strain 121


Knowledge Map 124

C H A P T E R 15Culture & Ethnicity 125Caring for the Nguyens 125Practical Knowledge: Knowing How 126Clinical Insights 126Clinical 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 129Obtaining Minimum Cultural Information 129Cultural Assessment Using the Transcultural Assessment

Model 130


Knowledge Map 135

C H A P T E R 16Spirituality 136Caring for the Nguyens 137Practical Knowledge: Knowing How 137Clinical Insights 137Clinical Insight 16-1: Praying With Patients 137

S-P-I-R-I-T Assessment 139

Assessment Guidelines and Tools 140The HOPE Approach to Spiritual Assessment: Examples of Questions 140Standardized Nursing Language 140Using Selected NIC Interventions and Activities to Support Spirituality 140Clinical Reasoning 142Applying the Full-Spectrum Nursing Model 142Critical Thinking and Clinical Reasoning 143Knowledge Map 144

C H A P T E R 17Loss, Grief, & Dying 145Caring for the Nguyens 146Practical Knowledge: Knowing How 146

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Clinical Insights 146Clinical 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 152Do Not Resuscitate Orders 152

Assessment Guidelines 153Assessing Grief and Loss 153


Knowledge Map 158

Unit 3Essential Nursing Interventions 159

C H A P T E R 18Documenting & Reporting 161Caring for the Nguyens 162Practical Knowledge: Knowing How 163Clinical Insights 163Clinical Insight 18-1: Giving Oral Reports 163

Clinical Insight 18-2: Receiving Telephone and VerbalOrders 164

Clinical Insight 18-3: Guidelines for Documentation 164

Tables 269Abbreviations Commonly Used in Healthcare 169

Charting Forms 171Adult Admission History Electronic Screen 171Intake and Output Sheet 172Nursing Assessment Flowsheets Are Comprehensive

Charting Documents 173


Knowledge Map 176

C H A P T E R 19Teaching & Learning 177Caring for the Nguyens 178Practical Knowledge: Knowing How 179Assessment Guidelines and Tools 179

Learning Assessment Guidelines 179


Knowledge Map 183

C H A P T E R 20Measuring Vital Signs 184Caring for the Nguyens 184Practical Knowledge: Knowing How 185Procedures 185Procedure 20-1: Assessing Body Temperature 185Procedure 20-1A: Taking an Axillary Temperature 186Procedure 20-1B: Taking an Oral Temperature 186Procedure 20-1C: Taking a Rectal Temperature 187Procedure 20-1D: Taking a Temporal Artery

Temperature 188Procedure 20-1E: Taking a Tympanic Membrane

Temperature 188Procedure 20-1F: Taking a Skin Temperature Using a

Chemical Strip Thermometer 189

Procedure 20-2: Assessing Peripheral Pulses 191Procedure 20-2A: Assessing the Radial Pulse 191Procedure 20-2B: Assessing the Brachial Pulse 192Procedure 20-2C: Assessing the Carotid Pulse 192Procedure 20-2D: Assessing the Dorsalis Pedis Pulse 192Procedure 20-2E: Assessing the Femoral Pulse 193Procedure 20-2F: Assessing the Posterior Tibial Pulse 193Procedure 20-2G: Assessing the Popliteal Pulse 193Procedure 20-2H: Assessing the Temporal Pulse 194

Procedure 20-3: Assessing the Apical Pulse 195Procedure 20-4: Assessing for an Apical-Radial Pulse

Deficit 197Procedure 20-5: Assessing Respirations 198Procedure 20-6: Measuring Blood Pressure 200Procedure Variation A. Measuring Blood Pressure in the

Forearm 202Procedure Variation B. Measuring Blood Pressure in the

Thigh 202Procedure Variation C. Measuring Blood Pressure in

the Calf 203Procedure Variation D. Palpating the Blood Pressure 203

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Clinical Insights 204Clinical Insight 20-1: Choosing a Blood Pressure

Cuff Size 204

Clinical Insight 20-2: Taking an Accurate Blood Pressure 204

Forms 205Graphic Flowsheet 205

Tables 206Centigrade–Fahrenheit Conversion Chart 206


Knowledge Map 209

C H A P T E R 21Communication & TherapeuticRelationships 210Caring for the Nguyens 210Practical Knowledge: Knowing How 211Clinical Insights 211Clinical Insight 21-1: Enhancing Communication

Through Nonverbal Behaviors 211

Clinical Insight 21-2: Technique for AssertiveCommunication 212

Clinical Insight 21-3: Communicating With SBAR 212

Clinical Insight 21-4: Communicating With Clients FromAnother Culture 212

Clinical Insight 21-5: Communicating With Clients WhoHave Impaired Speech 213

Clinical Insight 21-6: Communicating With Clients WhoHave Impaired Cognition or Consciousness 213

Assessment Guidelines and Tools 215Communication 215


Knowledge Map 218

C H A P T E R 22Health Assessment 219Caring for the Nguyens 219Practical Knowledge: Knowing How 220Procedures 220Procedure 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 VascularSystem 265

Procedure 22-14: Assessing the Abdomen 271

Procedure 22-15: Assessing the Musculoskeletal System 277

Procedure 22-16: Assessing the Sensory-NeurologicalSystem 284

Procedure 22-17: Assessing the Male GenitourinarySystem 297

Procedure 22-18: Assessing the Female GenitourinarySystem 301

Procedure 22-19: Assessing the Anus and Rectum 305

Procedure 22-20: Brief Bedside Assessment 306

Clinical Insights 308Clinical 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 312Knowledge Map 316

C H A P T E R 23Promoting Asepsis & PreventingInfection 317Caring for the Nguyens 317Practical Knowledge: Knowing How 318Procedures 318Procedure 23-1: Hand Hygiene 318Procedure 23-1A: Using Soap and Water 318Procedure 23-1B: Using Alcohol-Based Handrubs 319

Procedure 23-2: Donning Personal Protective Equipment(PPE) 320

Procedure 23-3: Removing Personal ProtectiveEquipment (PPE) 322

Procedure 23-4: Surgical Handwashing: TraditionalMethod 324

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Procedure 23-5: Surgical Handwashing: Brushless System 326

Procedure 23-6: Sterile Gown and Gloves (ClosedMethod) 328

Procedure 23-7: Sterile Gloves (Open Method) 331

Procedure 23-8: Sterile Fields 332Procedure 23-8A: Setting Up a Sterile Field 332Procedure 23-8B: Adding Supplies to a Sterile Field 333Procedure 23-8C: Adding Sterile Solutions to a Sterile

Field 334

Clinical Insights 335Clinical Insight 23-1: Guidelines for Hand Hygiene 335

Clinical Insight 23-2: Providing a Clean PatientEnvironment 336

Clinical Insight 23-3: Following CDC Standard Precautions 337

Clinical Insight 23-4: Following Transmission-BasedPrecautions 339

Clinical Insight 23-5: Preventing the Transmission ofMultidrug-Resistant Organisms (MDROs) 341

Clinical Insight 23-6: Maintaining a ProtectiveEnvironment in Special Situations 342

Clinical Insight 23-7: Guidelines for Preparing andMaintaining Sterile Fields 343

Diagnostic Testing 344Common Tests for Evaluating the Presence of or

Risk for Infection 344


Knowledge Map 347

C H A P T E R 24Promoting Safety 348Caring for the Nguyens 349Practical Knowledge: Knowing How 349Procedures 350Procedure 24-1: Using a Bed Monitoring Device 350

Procedure 24-2: Using Restraints 352

Clinical Insights 355Clinical Insight 24-1: Preventing Needlestick Injury 355

Clinical Insight 24-2: What You Should Know About Using Restraints 356

Assessment Guidelines and Tools 357Get Up and Go Test 357The Timed Up & Go Test for Fall Risk Assessment 357S.A.S. Safety Assessment Scale 358


Knowledge Map 362

C H A P T E R 25Facilitating Hygiene 363Caring for the Nguyens 363Practical Knowledge: Knowing How 364Procedures 364Procedure 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 UnconsciousPatient 382

Procedure 25-9: Shampooing the Hair 384Procedure 25-9A: Shampooing the Hair for a Patient on

Bedrest—Using Rinse-Free Shampoo 385Procedure 25-9B: Shampooing the Hair Using Rinse-Free

Shampoo Cap 385Procedure 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 ContactLenses 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 401Clinical 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 402Guidelines for Assessing Hygiene 402


Knowledge Map 408

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C H A P T E R 26Administering Medications 409Caring for the Nguyens 410Practical Knowledge: Knowing How 410Procedures 410Medication Guidelines: Steps to Follow for AllMedications (Regardless of Type or Route) 410Procedure 26-1: Administering Oral Medication 414Procedure 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 430Procedure 26-7A: Applying Topical Lotion, Cream, and

Ointment 430Procedure 26-7B: Applying Topical Aerosol Spray 430Procedure 26-7C: Applying Prescribed Powder 430Procedure 26-7D: Applying Transdermal Medication 431

Procedure 26-8: Administering Metered-Dose Inhaler(MDI) Medication 432

Procedure 26-9: Preparing, Drawing Up, and MixingMedication 435

Procedure 26-9A: Drawing Up Medication From Ampules 435

Procedure 26-9B: Drawing Up Medication From Vials 437Procedure 26-9C: Mixing Medication From Two Vials 439Procedure 26-9D: Mixing Medication From One Ampule

and One Vial 441Procedure 26-9E: Using a Prefilled Cartridge and Single-

Dose Vial—For Intravenous Administration 442

Procedure 26-10: Recapping Needles Using a One-HandedTechnique 443

Procedure 26-10A: Recapping Contaminated Needles 444Procedure 26-10B: Recapping Sterile Needles 444

Procedure 26-11: Administering Intradermal Medication 445

Procedure 26-12: Administering SubcutaneousMedication 448

Procedure 26-13: Locating Intramuscular Injection Sites 451

Procedure 26-13A: Locating the Ventrogluteal Site 451Procedure 26-13B: Locating the Deltoid Site 451Procedure 26-13C: Locating the Vastus Lateralis Site 452Procedure 26-13D: Locating the Rectus Femoris Site 453

Procedure 26-14: Administering an IntramuscularInjection 453

Procedure 26-14A: Intramuscular Injection: TraditionalMethod 454

Procedure 26-14B: Intramuscular Injection: Z-Track Method 455

Procedure 26-15: Adding Medications to IntravenousFluid 457

Procedure 26-15A: Adding Medication to a New IV Bag orBottle 457

Procedure 26-15B: Adding Medication to an Infusing IV 458

Procedure 26-16: Administering IV Push Medication 459Procedure 26-16A: Administering IV Push Medications

Through a Primary IV Line 459Procedure 26-16B: Administering IV Push Medications

Through an Intermittent Device (IV Lock) When NoExtension Tubing Is Attached to the Venous Access Device 460

Procedure 26-16C: Administering IV Push MedicationsThrough an Intermittent Device with IV Extension Tubing 461

Procedure 26-17: Administering Medications byIntermittent Infusion 463

Procedure 26-17A: Using a Volume-Control AdministrationSet 464

Procedure 26-17B: Using a Piggyback Administration SetWith a Gravity Infusion 465

Procedure 26-17C: Using a Piggyback Administration SetWith an Infusion Pump 466

Procedure 26-18: Administering Medication Through aCentral Venous Access Device (CVAD) 467

Clinical Insights 471Clinical 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 ChangingNeedles 474

Clinical Insight 26-5: Mixing Two Kinds of Insulin in OneSyringe 475

Clinical Insight 26-6: Administering AnticoagulantMedication Subcutaneously 476

Clinical Insight 26-7: Taking Action After a MedicationError 477

Tables: Abbreviations 477Common Medication-Related Abbreviations 477Institute for Safe Medication Practices (ISMP) List of

Error-Prone Abbreviations, Symbols, and DoseDesignations 478

Measuring and Calculating Dosage 481

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Medication Measurement Systems 481Calculating Dosages 482


Knowledge Map 489

Unit 4Supporting Physiological Functioning 491

C H A P T E R 27Nutrition 493Caring for the Nguyens 494Practical Knowledge: Knowing How 494Procedures 494Procedure 27-1: Checking Fingerstick (Capillary) Blood

Glucose Levels 494

Procedure 27-2: Inserting Nasogastric and NasoentericTubes 498

Procedure 27-3: Administering Feedings Through Gastricand Enteric Tubes 502

Procedure 27-3A: Administering Feedings Through Gastricand Enteric Tubes Using an Open System: Syringe 504

Procedure 27-4: Removing a Nasogastric or NasoentericTube 506

Procedure 27-5: Administering Parenteral Nutrition 508

Procedure 27-6: Administering Lipids 511

Clinical Insights 513Clinical Insight 27-1: 10 Tips for Building Healthy

Meals 513

Clinical Insight 27-2: Skinfold Measurement 514

Clinical Insight 27-3: Measuring Circumferences toEvaluate Body Composition 515

Clinical Insight 27-4: Interventions for Patients WithImpaired Swallowing 515

Clinical Insight 27-5: Interventions for Patients WhoHave 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 ReceivingEnteral Nutrition 519

Clinical Insight 27-9: Preventing Infection in PatientsReceiving Enteral Feedings 519

Clinical Insight 27-10: Monitoring and OtherInterventions for Patients Receiving ParenteralNutrition 520

Screening for Nutritional Problems 521Subjective Global Assessment 521Nutrition Screening Initiative (NSI), for Older Adults:

Indications of Impaired Nutritional Status 521Mini Nutritional Assessment 522

Focused Nutritional Assessment 522Focused Nutritional Assessment 522

Diagnostic Testing 525Tests Reflecting Nutritional Status: Norms 525


Knowledge Map 529

C H A P T E R 28Urinary Elimination 530Caring for the Nguyens 531Practical Knowledge: Knowing How 531Procedures 531Procedure 28-1: Measuring Urine 531Procedure 28-1A: Measuring Urine Output From a Bedpan

or Urinal 532Procedure 28-1B: Measuring Urine From an Indwelling

Catheter 532Procedure 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 Froma Catheter 536

Procedure 28-2C: Collecting a 24-Hour Urine Specimen536

Procedure 28-3: Testing Urine at the Bedside 538Procedure 28-3A: Dipstick Testing of Urine 538Procedure 28-3B: Measuring Specific Gravity of Urine 538

Procedure 28-4: Inserting a Urinary Catheter 539Procedure 28-4A: Intermittent Urinary

Catheterization 540Procedure 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 553Procedure 28-7A: Intermittent Bladder or Catheter

Irrigation 553Procedure 28-7B: Continuous Bladder Irrigation 554

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Clinical Insights 556Clinical Insight 28-1: Caring for a Patient With an

Indwelling Catheter 556

Clinical Insight 28-2: Caring for Patients With UrinaryIncontinence 558

Clinical Insight 28-3: Caring for Patients With UrinaryDiversions 559

Clinical Insight 28-4: Teaching Clients About Clean,Intermittent

Self-Catheterization 560Assessment Guidelines and Tools 561

Urinary Elimination History Questions 561Guidelines for Physical Assessment for Urinary

Elimination 561

Diagnostic Testing 562Urinalysis 562Blood Studies: BUN and Creatinine 563Studies of the Urinary System 564


Knowledge Map 568

C H A P T E R 29Bowel Elimination 569Caring for the Nguyens 569Practical Knowledge: Knowing How 570Procedures 570Procedure 29-1: Testing Stool for Occult Blood 570

Procedure 29-2: Placing and Removing a Bedpan 572Procedure 29-2A: Placing a Bedpan 573Procedure 29-2B: Removing a Bedpan 574

Procedure 29-3: Administering an Enema 575Procedure 29-3A: Administering a Cleansing Enema 575Procedure 29-3B: Administering a Prepackaged Enema 577Procedure 29-3C: Administering an Oil-Retention

Enema 577Procedure 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 588Procedure 29-8A: Applying an External Fecal Collection

System 589Procedure 29-8B: Inserting an Indwelling Fecal Drainage

Device 590

Clinical Insights 592Clinical 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 594Bowel Elimination 594

Diagnostic Testing 594Direct Visualization Studies of the Gastrointestinal

Tract 594Indirect Visualization Studies of the Gastrointestinal

Tract 595


Knowledge Map 598

C H A P T E R 30Sensation, Perception, & Cognition 599Caring for the Nguyens 599Practical Knowledge: Knowing How 600Procedures 600Procedure 30-1: Performing Otic Irrigation 600

Clinical Insights 602Clinical Insight 30-1: Seizure Precautions 602

Clinical Insight 30-2: Communicating With VisuallyImpaired Clients 604

Clinical Insight 30-3: Communicating With Hearing-Impaired Clients 604

Assessment Guidelines and Tools 605Hearing Screening in Older Adults 605Other Sensory Assessment Tools 605Nursing History: Sensory Perceptual Status 605Bedside Assessment of Sensory Function 606


Knowledge Map 609

C H A P T E R 31Pain 610Caring for the Nguyens 611Practical Knowledge: Knowing How 611Procedures 611Procedure 30-1: Setting Up and Managing Patient-

Controlled Analgesia by Pump 611

Clinical Insights 614Clinical 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

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Pain Assessment 616Pain Relief Diary 618Richmond Agitation-Sedation Rating Scale 618


Knowledge Map 621

C H A P T E R 32Physical Activity & Mobility 622Caring for the Nguyens 623Practical Knowledge: Knowing How 623Procedures 623Procedure 32-1: Moving and Turning Patients in

Bed 623Procedure 32-1A: Moving a Patient Up in Bed 624Procedure 32-1B: Turning a Patient in Bed 625Procedure 32-1C: Logrolling a Patient 626

Procedure 32-2: Transferring Patients 628Procedure 32-2A: Transferring a Patient From Bed to

Stretcher 628Procedure 32-2B: Dangling a Patient at the Side of the

Bed 629Procedure 32-2C: Transferring a Patient From Bed to

Chair 630

Procedure 32-3: Assisting With Ambulation 632Procedure 32-3A: Assisting With Ambulation

(One Nurse) 632Procedure 32-3B: Assisting With Ambulation

(Two Nurses) 633Clinical Insights 635

Clinical Insight 32-1: Applying Principles of BodyMechanics 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 641Assessing Activity and Exercise 641

Tables 643Range of Motion at the Joints 643


Knowledge Map 650

C H A P T E R 33Sexual Health 651Caring for the Nguyens 652Practical Knowledge: Knowing How 652Clinical Insights 652Clinical Insight 33-1: Providing Care After Sexual

Assault 652

Clinical Insight 33-2: Guidelines for Taking a SexualHistory 653

Clinical Insight 33-3: Teaching Your Patient to Use aCondom 654

Tables 654Fertility Control Methods 654

Assessment Guidelines and Tools 656Guidelines and Questions for Taking a Sexual

History 656


Knowledge Map 661

C H A P T E R 34Sleep & Rest 662Caring for the Nguyens 662Practical Knowledge: Knowing How 664Procedures 664Procedure 34-1: Giving a Back Massage 664

Assessment Guidelines and Tools 666Questions for a Sleep History 666


Knowledge Map 670

C H A P T E R 35Skin Integrity & Wound Healing 671Caring for the Nguyens 672Practical Knowledge: Knowing How 672Procedures 672Procedure 35-1: Obtaining a Wound Culture by

Swab 673

Procedure 35-2: Performing a Sterile Wound Irrigation 675

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Procedure 35-3: Taping a Dressing 678

Procedure 35-4: Removing and Applying Dry Dressings 680

Procedure 35-5: Removing and Applying Wet-to-DampDressings 682

Procedure 35-6: Applying a Negative Pressure WoundTherapy (NPWT) Device 685

Procedure 35-6A: Open-Pore Reticulated PolyurethaneFoam 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 TransparentFilm 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 703Procedure 35-12A: Removing Sutures 703Procedure 35-12B: Removing Staples 704

Procedure 35-13: Shortening a Wound Drain 705

Procedure 35-14: Emptying a Closed-Wound DrainageSystem 706

Clinical Insights 708Clinical Insight 35-1: Applying Local Heat Therapy 708

Clinical Insight 35-2: Applying Local Cold Therapy 709

Assessment Guidelines and Tools 709History Questions for Skin and Wound Assessment 709Physical Examination: Wound Assessment 710The Braden Scale for Predicting Pressure Sore Risk 711The Norton Scale for Assessing Risk of Pressure

Ulcers 712The PUSH Tool for Evaluation of Pressure Ulcers 713

Diagnostic Testing 715Tests for Assessing Wounds 715

Standardized Language 716Selected Standardized Outcomes and Interventions

for Skin and Wound Diagnoses 716


Knowledge Map 721

C H A P T E R 36Oxygenation 722Caring for the Nguyens 722Practical Knowledge: Knowing How 723

Procedures 723Procedure 36-1: Collecting a Sputum Specimen 723Procedure 36-1A: Collecting an Expectorated Sputum

Specimen 724Procedure 36-1B: Collecting a Suctioned Sputum

Specimen 725

Procedure 36-2: Monitoring Pulse Oximetry (ArterialOxygen Saturation) 726

Procedure 36-3: Performing Percussion, Vibration, and Postural Drainage 728

Procedure 36-4: Administering Oxygen 731

Procedure 36-5: Performing Tracheostomy Care UsingSterile Technique 736

Procedure 36-6: Performing Tracheostomy Suctioning (Open System) 741

Procedure 36-7: Performing Tracheostomy orEndotracheal Suctioning (Inline Closed System) 744

Procedure 36-8: Performing Orotracheal andNasotracheal Suctioning (Open System) 745

Procedure 36-9: Performing Upper Airway Suctioning 749

Procedure 36-10: Caring for Patients RequiringMechanical Ventilation 752

Procedure 36-11: Setting Up Disposable Chest DrainageSystems 755

Procedure 36-12: Inserting an Oropharyngeal Airway 759

Procedure 36-13: Inserting a Nasopharyngeal Airway 760

Clinical Insights 762Clinical 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 WithEndotracheal Airways 763

Clinical Insight 36-5: Managing Chest Tubes 764

Assessment Guidelines and Tools 765Oxygenation 765

Diagnostic Testing 766Lung Volumes and Capacities 766Tests Related to Oxygenation 767Reading a Tuberculin Skin Test Result 768


Knowledge Map 771

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C H A P T E R 37Circulation 772Caring for the Nguyens 773Practical Knowledge: Knowing How 773Procedures 773Procedure 37-1: Performing Cardiac Monitoring 774

Assessment Guidelines and Tools 776Assessing Circulation 776

Diagnostic Testing 777Tests Related to Circulation 777


Knowledge Map 780

C H A P T E R 38Fluids, Electrolytes, & Acid–Base Balance 781Caring for the Nguyens 782Practical Knowledge: Knowing Why 782Procedures 783Procedure 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-ControlPumps 790

Procedure 38-4: Changing IV Solutions and Tubing 793Procedure 38-4A: Changing the IV Solution 793Procedure 38-4B: Changing the IV Administration Tubing

and Solution 794

Procedure 38-5: Changing IV Dressings 796Procedure 38-5A: Peripheral IV Dressings 796Procedure 38-5B: Central Line Dressings 797Procedure 38-5C: PICC Line Dressings 798

Procedure 38-6: Converting a Primary Line to aPeripheral IV Lock 800

Procedure 38-7: Discontinuing a Peripheral IV 803

Procedure 38-8: Administering a Blood Transfusion 804Procedure 38-8A: Administering Blood and Blood

Products 805Procedure 38-8B: Managing a Transfusion Reaction 807

Procedure 38-9: Assisting With Percutaneous CentralVenous Catheter Placement 808

Clinical Insights 810Clinical Insight 38-1: Assessing for Trousseau’s and

Chvostek’s Signs 810

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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 CentralVenous Access Device (CVAD): CVC and PICC 813

Clinical Insight 38-5: Managing Infiltration andExtravasation 814

Assessment Guidelines and Tools 815Assessing Fluids, Electrolytes, and Acid–Base

Balance 815

Diagnostic Testing 817Assessing Fluid, Electrolyte, and Acid–Base Balance 817


Knowledge Map 821

Unit 5Nursing Functions 823

C H A P T E R 39Perioperative Care 825Caring for the Nguyens 825Practical Knowledge: Knowing How 826Procedures 826Procedure 39-1: Teaching a Patient to Deep-Breathe,

Cough, Move in Bed, and Perform Leg Exercises 826Procedure 39-1A: Teaching a Patient to Deep-Breathe and

Cough 827Procedure 39-1B: Teaching a Patient to Move in Bed 827Procedure 39-1C: Teaching Leg Exercises 828

Procedure 39-2: Applying Antiembolism Stockings 829

Procedure 39-3: Applying Sequential CompressionDevices 832

Procedure 39-4: Managing Gastric Suction 834Procedure 39-4A: Initial Equipment Setup 835Procedure 39-4B: Emptying the Suction Container 835Procedure 39-4C: Irrigating the Nasogastric Tubing 836Procedure 39-4D: Providing Comfort Measures 836

Clinical Insights 839Clinical Insight 39-1: Preoperative Teaching 839

Clinical Insight 39-2: Preparing a Room for a Patient’sReturn From Surgery 840

Clinical Insight 39-3: Creating an Operative Field 840

Assessment Guidelines and Tools 841

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CONTENTS xxv

Preoperative Assessment Topics 841Example of a Preoperative Checklist 842Example of a Surgical Safety Checklist 844Intraoperative Care Questionnaire 844Postanesthesia Assessment: Essential Elements 845

Diagnostic Testing 845Common Preoperative Screening Tests 845

Standardized Language 846Preoperative Patients: Selected Standardized Nursing

Diagnoses, Outcomes, and Interventions 846Intraoperative Patients: Selected Standardized Nursing

Diagnoses, Outcomes, and Interventions 848Postoperative Patients: Selected Standardized Nursing

Diagnoses, Outcomes, and Interventions 851


Knowledge Map 858

C H A P T E R 40Leading & Managing 859Caring for the Nguyens 859Clinical Reasoning 860


Knowledge Map 863

C H A P T E R 41Nursing Informatics 864Caring for the Nguyens 865Practical Knowledge: Knowing How 865Standardized Language 865

American Nurses Association Recognized Languages for Nursing 865


Knowledge Map 870

C H A P T E R 42Promoting Health 871Caring for the Nguyens 871Assessment Guidelines and Tools 872

Health Promotion: Physical Fitness Assessment 872Lifestyle and Risk Assessment 873Life Stress Review 875

Selected Health Screening Activities 876

Standardized Language 877Examples of NANDA-I Health Promotion

Diagnoses 877Selected NIC Health Promotion Interventions 877


Knowledge Map 881

Unit 6The Context for Nurses’ Work 883

C H A P T E R 43Community & Home Health Nursing 885Caring for the Nguyens 886Practical Knowledge: Knowing How 886Clinical Insights 887Clinical Insight 43-1: Safety Considerations in Home

Care 887

Clinical Insight 43-2: Infection Control in the Home 888

Standardized Language 888The Omaha System 888Omaha System: Domains and Examples of Problem

Labels 889Omaha Problem Rating Scale for Outcomes 889NIC Community Health Classes and Interventions 890Omaha Intervention Categories and Examples of

Targets 891Clinical Care Classification System for Home Health

Care 891An Example of CCC Nursing Diagnoses and

Interventions 892


Knowledge Map 896

C H A P T E R 44Ethics & Values 897Caring for the Nguyens 898Practical Knowledge: Knowing How 898Clinical Insights 899

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Clinical Insight 44-1: Using the MORAL Model for EthicalDecision Making 899

Clinical Insight 44-2: Guidelines for Advocacy 899


Knowledge Map 904

C H A P T E R 45Legal Accountability 905Caring for the Nguyens 906Practical Knowledge: Knowing How 906Clinical 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


Knowledge Map 911

C H A P T E R 46Holistic Healing (on DavisPlus)

Credits 912References Cited 914Index 1000

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