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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: Student Survival Skills
- Sprache: Englisch
Specifically designed for student nurses, Clinical Skills for Nurses provides a handy, portable introduction to both the knowledge and practical procedures that first year nursing students require. Giving you the knowledge behind the skill, this book will boost your confidence and competence for your clinical placements and time in the clinical skills lab.
Clinical Skills for Nurses covers the skills and procedures used most frequently in clinical practice, and includes Point of Care training; blood transfusion and tracheotomy care; continence and bowel care; and early patient assessment and response. This book uniquely incorporates words of wisdom and advice from real-life student nurses; in other words: developed by students, for students!
Special features:
- Tips, advice and words of wisdom from real-life students included throughout
- Pocket sized for portability on your clinical placement
- Clear, straightforward, and jargon-free
- Ties in with the NMC standards for pre-registration education and the Essential Skills Clusters
- Examples and questions based on real life nursing & healthcare examples
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Seitenzahl: 228
Veröffentlichungsjahr: 2013
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Contents
Cover
Half Title page
Title page
Copyright page
Preface
Introduction
Acknowledgements
Chapter 1: Performing Observations
Consent
Observation Charts
Body Temperature
Blood Pressure
Heart Rate
Respirations
Neurological Observations
Oxygen Saturation
Test your Knowledge
Chapter 2: Male Urethral Catheterisation
Policies and Procedures
Why is Urinary Catheterisation Performed?
Fluid Output
High-Risk Procedure
Personal Care and the Need for Strict Asepsis
Anatomy and Physiology
Catheterisation
Exclusion Criteria for Urethral Catheterisation
Catheter Material and Selection
Catheter Length and Design
Removing the Catheter
Drainage Bags and Securing Devices
Problems Associated with Catheterisation
How to Take a Catheter Sample of Urine
Emptying a Drainage Bag
Procedure for Male Urethral Catheterisation
Test your Knowledge
Chapter 3: Female Urethral Catheterisation
Why is Urinary Catheterisation Performed?
Anatomy and Physiology
Fluid Balance
Personal Care
Procedure for female Urethral Catheterisation
Test your Knowledge
Chapter 4: Bowel Care
Anatomy and Physiology of the Bowels
Assessment
The Bristol Stool Chart
Medication Review
Bowel Care Management
Exclusions and Contra-Indications
Risk Assessment
Digital Rectal Examination (DRE)
Administration of Enemas and/or Suppositories
Digital Removal of Faeces (DRF) in Adults
Digital Rectal Stimulation (DRS)
Autonomic Dysreflexia
The Procedures: Step by Step
Test your Knowledge
Chapter 5: Tracheostomy Care
Anatomy and Physiology
Tracheostomy Tubes
Suctioning Technique
Cuff Pressure Monitoring
Procedure for Cleaning and Dressing the Tracheostomy Stoma Site
Test your Knowledge
Chapter 6: Point-of-Care Training
Urinalysis
Faecal Occult Blood Test
Blood Lancing
Blood Glucose Testing
Test your Knowledge
Chapter 7: Blood Transfusion
Consent and Information Leaflets
Blood Transfusion Requests
Sample Collection
Collecting Blood that has Been Requested
Cold-Chain Requirements
Preparation/Administration
Product Specifications
Pre-Transfusion Check
Administration Procedure
Monitoring Procedure
What to Do if the Patient Experiences an Adverse Reaction
Safety
Test your Knowledge
Chapter 8: Venepuncture
What is Venepuncture?
Common Blood Tests
Policies, Procedures and Guidelines
Vicarious Liability
Keeping Updated
Equipment Used for Venepuncture
Written Requests
Available Veins
Skin Cleaning
Order of Draw
Labelling the Tubes
Potassium and Calcium
Paediatrics
Problems Associated with Venepuncture
Using a Tourniquet
Guidelines for the Venepuncture Procedure
Test your Knowledge
Chapter 9: Peripheral Cannulation
Selection of an Appropriate Cannula
The PVC Device
Approved Site
Vein Selection
Number of Attempts
Skin Preparation
Asepsis
Flushing
Documentation
Problems Associated with Cannulation
Removing the Cannula
Test your Knowledge
Chapter 10: Early Patient Assessment and Response
Situation, Background, Assessment, Recommendation (SBAR)
Early Warning Score (EWS)
Early Patient Assessment and Response (EPAR)
Test your Knowledge
Chapter 11: Intravenous Therapy
Possible Complications
procedure for The Administration of IV Fluids via Gravity
Test your Knowledge
Chapter 12: Basic Life Support
Responding to an Emergency Event
The Phonetic Alphabet
Paediatric Basic Life Support
Test your Knowledge
Answers to Activities, Questions and “Test Your Knowledge”
Appendix 1: The Bristol Observation Chart
Bibliography
Websites
Index
CLINICAL SKILLS FOR NURSES
Student Survival Skills Series
Survive your nursing course with these essential guides for all student nurses:
Calculation Skills for Nurses
Claire Boyd
9781118448892
Medicine Management Skills for Nurses
Claire Boyd
9781118448854
Clinical Skills for Nurses
Claire Boyd
9781118448779
This edition first published 2013 © 2013 by John Wiley & Sons, Ltd
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Library of Congress Cataloging-in-Publication Data Boyd, Claire. Clinical skills for nurses / Claire Boyd. p. ; cm. — (Student survival skills series) Includes bibliographical references and index. ISBN 978-1-118-44877-9 (pbk. : alk. paper) — ISBN 978-1-118-44876-2 (epub) — ISBN 978-1-118-44875-5 (epdf) — ISBN 978-1-118-44874-8 (emobi) I. Title. II. Series: Student survival skills series. [DNLM: 1. Nursing Care—methods—Handbooks. WY 49] 610.73 — dc232012047379
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Preface
Clinical Skills for Nurses is designed to assist the student healthcare worker in the field of clinical skills. All exercises are related to practice and the healthcare environment, from the acute hospital setting to the community, covering both adult and paediatric care.
The book looks at 12 clinical skills, requested by students like you, and gives a quick, snappy introduction to these skills in a non-threatening manner for you to gain a brief understanding and overview. You can then build on this foundation. For the present you may be permitted only to observe some of the skills that are covered, but that does not stop you from watching them being performed. This will be preparation for the day when you will be expected, often after a formal training event, to undertake them with your own patients.
I talk about ‘patients’ but the book applies to service users in the community setting as well. The paediatric nurse has not been forgotten, with information given throughout that incorporates this branch of nursing.
The book uses many activities and questions to check your understanding, and is laid out in a simple-to-follow, step-by-step approach. Each chapter ends with with a Test your knowledge section to relate everything learned to practice. The aim of this book is to start the individual on a journey through many healthcare-related exercises to build confidence and competence; from day one to qualification, and beyond. It has been compiled using quotes and tips from student nurses themselves; it is a book by students for students. I just wish a book like this had been around when I did my nursing training!
Claire Boyd Bristol October 2012
Introduction
Hello. My name is Claire and I am a Practice Development Trainer in a large NHS Trust. Let me tell you something about me: during one of my own clinical placements as a student nurse I was working in a doctor’s surgery and was invited to observe a minor surgical procedure, namely a mole removal. The room was very small and hot and as the doctor cut into the skin on the lady’s stomach, sounding very much like someone cutting into a cabbage, I felt very queasy. I was invited to take a closer look after the mole had been removed. I fainted while standing up, with my head laid down on the lady’s stomach, and my nose in the mole crevice. At first the doctor and practice nurse thought how vigilant I was, wanting to take such a close look at the surgical site, until they realised I had fainted, whereby I was dumped unceremoniously to one side on the floor and the patient soothed. Every time I cut into a cabbage and hear that noise I am taken back to my training days and remember this incident with huge embarrassment.
There will be many tears and much laughter throughout your own training and this book attempts to help you along the way, helping you to gain some of the skills you require to become an excellent health carer, something we should all be striving to achieve.
The table below shows the skills that student nurses may, or may not, be able to perform during placements and at which stage of their training. Note that this list varies from trust to trust and from university to university. These skills may also not be transferable between trusts, so students will need to access their own university’s and trust’s guidelines and only work within those parameters, to avoid breaking vicarious liability.
Skills may also require different degrees of supervision, and again this may vary between trusts and educational providers. The four degrees of supervision are:
The registered nurse retains accountability at all times for assessing an individual student’s knowledge, attitude and competence. But it is up to the student to check what skills they can perform, with:
the mentor,
trust policy,
the university decision-making framework.
With some skills students may only be able to undertake part of that skill. For example, in blood transfusion a student nurse may be permitted (according to local trust policy and university guidelines) to go and collect the blood from the pathology laboratory (after training and being deemed competent). Only in the third year, when about to qualify, may this same student nurse be permitted to undertake a patient’s observations while the blood is being transfused. A student nurse can never put up the blood products on the patient, not until they are qualified, and usually two nurses are involved in this process for safety reasons.
This book will therefore look at clinical skills you may or may not be permitted to be involved in, but which have been included to cover the wide range of students reading this book (from day one of your nurse training to the very last day). It is hoped that it will take you through your training, through all the tears and laughter this will involve (and there will be tears along the way!), giving you a good grounding in these clinical skills. They have been chosen by students themselves: they are the skills they wanted included in this book. I hope that I have made the writing style informal but brief, as though I am sitting beside you in your clinical placement. All the answers to the activities, questions and ‘test your knowledge’ exercises can be found at the back of the book.
Acknowledgements
First thanks go to the many wonderful student nurses I have taught in all the clinical skills. Believe me when I say that learning has been a two-way process. Again, as in other books in the Student Survival Skills Series, it is their tips and quotes that have made this book what it is.
Acknowledgements also go to North Bristol NHS Trust and to certain individuals in particular for making this book possible, namely Jane Hadfield (Head of Learning and Development), Dr Karen Mead (Lead Transfusion Practitioner), the Biochemistry Laboratory team, Nick Smith (Clinical Educator, High Dependency Unit) and the NBT tracheostomy working party, and all my friends and colleagues in the Staff Development Department.
Thanks also go to Magenta Styles, Executive Editor at Wiley-Blackwell, for first approaching me for this exciting project and then for her guidance and direction in writing this book. Catriona Cooper, Project Editor at Wiley-Blackwell and Dr Nik Prowse for his copy editing comments.
For Chapter 8, special thanks to BD Diagnostics (www.bd.com) for allowing reproduction of information and diagrams.
This book is dedicated to my loving family: my long-suffering husband Rob (for the photographs), Simon, Louise and David. Thank you for supporting me in this exciting project.
Chapter 1
PERFORMING OBSERVATIONS
LEARNING OUTCOMES
By the end of this chapter you will have an understanding of the theory and practice of performing respiration, temperature, heart rate and blood pressure clinical observations.
Performing observations of vital signs on patients is a fundamental healthcare task. Every time a set of observations are taken, valid consent must be obtained from the patient.
CONSENT
When a patient lacks the capacity to consent, as with all clinical skills, observations can be made if it is in the patient’s best interests. This is part of the UK Mental Capacity Act 2005, which is an Act of Parliament. Its primary purpose is to provide a legal framework for acting and making decisions on behalf of adults who lack the capacity to make particular decisions for themselves.
The three key factors when testing for valid consent are:
does the patient have enough information to make the decision?
does the patient have enough capacity to make the decision?
has the patient made a free choice?
All three tests must be met for you to have obtained valid consent.
OBSERVATION CHARTS
Observation charts have changed considerably over time, since the introduction of the Early Warning Score, whereby we are able to assess our patients and care for them before their condition becomes critical. We will look at Early Patient Assessment and Response (EPAR) in Chapter 10, but for now we will start with the basic vital signs, looking at how to perform these tasks.
All patients admitted to hospital should have a ‘manual’ set of essential observations recorded; this is known as a baseline. Any changes to this norm will trigger action. Of course, the patient could be so ill as to present with a set of abnormal readings, but it is still useful to monitor the patient on admission so that we can see when progress is being made with the patient’s condition.
BODY TEMPERATURE
Body temperature is measured using a calibrated clinical electronic thermometer or tympanic thermometer. In children’s nursing, ‘smart-material’ tempo dot thermometer strips are often used (see overleaf). Mercury glass thermometers are used very rarely in hospitals today. It is considered best practice to document the temperature recording on the observation chart as a solid dot, connecting these dots with a straight line. This is the same procedure as for documented recordings of all vital signs.
Tympanic membrane
The membrane in the eardrum separating the outer and middle ears.
The sites for recording body temperature are described below.
Oral:
the thermometer is placed in the posterior sublingual pocket, situated at the base of the tongue.
Axilla
: the thermometer is placed in the centre of the armpit, with the patient’s arm lying across their chest. The same site should be used for all recordings; that is, do not change armpits.
Rectum
: a special thermometer is inserted at least 4 cm into the anus of an adult, or 2–3 cm in infants. This provides the most accurate reading of all sites. Rectal temperature readings are usually about 1°C higher than readings taken in the ear.
Ear
: to take a temperature reading in the ear a device known as a tympanic membrane thermometer, which is covered with a disposable cuff, is inserted snugly into the ear canal (
Figure 1.1
). These devices use infrared light to measure body temperature. The same ear should be used each time for consistent results. Some clinical areas have reconfigured the display screen to show the oral temperature, but the device must still be placed in the ear.
Figure 1.1 A tympanic membrane thermometer
Single-use plastic-coated ‘smart-material’ strips are also used, often in paediatric care, which have heat-sensitive dots that change colour to indicate the temperature. The strip can be placed across the forehead or in the mouth as shown in Figure 1.2.
Figure 1.2 Tempo dot thermometer strips
Question 1.1 What are the reasons for recording an individual’s body temperature? List five, if you can.
Body Temperature Physiology
Body temperature is usually maintained between 36 and 37.5°C. A body temperature well above the normal range (41°C) is called hyperthermia and can result in convulsions. A temperature below normal temperature (35°C) is called hypothermia (Table 1.1).
Table 1.1 Hyperthermia and hypothermia
Condition
Possible causes
Hyperthermia
Heat stroke, malignancy, stroke or central nervous system damage
Hypothermia
Environmental exposure, medication and exposure of body and internal organs during surgery
Pyrexia is defined as a rise in body temperature, above the normal, usually caused by a viral or bacterial infection. Lay person’s terminology for this is ‘having a temperature’ (see Table 1.2).
Table 1.2 Pyrexia
Low-grade pyrexia
Normal to 38
°
C
Moderate- to high-grade pyrexia
38–40
°
C
Hyperpyrexia
40
°
C and above
Procedure to Obtain the Temperature Using a Tympanic Membrane Thermometer
In many clinical areas, staff must have undertaken training in the use of this equipment.
Documenting a Temperature Reading on an Observation Chart
Let’s look at the observation chart (Appendix 1). Just for the moment we will keep it simple (in Chapter 10 we go into the EWS or Early Warning Score system in more depth). You will notice that each of the sections for vital signs (temperature, respiratory rate, etc) are colour-coded. At the bottom of this document you will see what score each of the colours represents. Let’s say our patient has a temperature of 36.5°C, this is in the white section of the chart and scores zero. If this same patient had a score of 39.0°C it would be in the peach-coloured section and would generate a score of 2. Without going into any more detail yet, here are the actions we would perform with each score:
0–1
Continue with routine observations.
2–3
Report this information to the nurse in charge immediately.
4 and above
Re-check score. Inform the nurse in charge. Request a medical review within 15 minutes. Record the action taken.
Of course, we would usually do a full set of observations and tot up the scores for all the vital signs to get our final EWS score for that time.
BLOOD PRESSURE
Blood pressure is the force extended by the blood as it flows through the blood vessels, and increases with age, weight gain, stress and anxiety. Normal range for an adult is usually considered to be from 100/60 to 140/90 mmHg. The first figure is known as the systolic reading and the second figure is the diastolic reading. Although we record both figures on our observation chart, it is only the systolic reading that generates a score. Table 1.3 lists some of the terms you may hear in relation to the blood pressure reading.
Table 1.3 Terms related to the blood pressure reading
Normotension
Blood pressure within normal range
Hypotension
Blood pressure lower than normal range
Hypertension
Blood pressure higher than normal range
Of course, we should never lose sight of the fact that we are all individuals and have our own ‘normal’ range for the vital signs.
Blood pressure equipment
Sphygmomanometer
An instrument for measuring the blood pressure in the arteries.
Increasingly electronic sphygmomanometers (also known as automatic or oscillometric machinery; see Figure 1.3) are being used to monitor blood pressure, but these may not achieve the same level of accuracy as manual sphygmomanometers (also known as aneroid sphygmomanometers; see Figure 1.4). This is especially so in certain disease states, such as arrhythmias, pre-eclampsia and certain vascular diseases. Staff using these machines should be trained and assessed on how to use them correctly.
Figure 1.3 An automated blood pressure machine
Figure 1.4 An aneroid sphygmomanometer
Automated blood pressure machines should also not be used on patients with irregular heart rates or on patients with movement disorders, such as Parkinsonian tremors. These patients’ blood pressure recordings should be taken using a manual aneroid sphygmomanometer and stethoscope, which you will be shown how to use during your nurse training.
Medics may occasionally request that patients have a ‘lying and standing’ blood pressure recording, and this is exactly how it sounds: taking the blood pressure first while the patient is lying down, then when standing. Beware that the patient may experience postural hypotension and feel dizzy when standing.
Which arm was used to record the blood pressure should be documented in the care plan, due to variations in reading and consistency. Blood pressures should not be taken from a patient’s arms that are affected by arteriovenous fistulae, paralysis or breast surgery, or in which intravenous (IV) lines are situated.
Blood pressure cuffs should be the appropriate size to fit the patient, to ensure accurate measurement. The cuff should cover 80% of the circumference of the upper arm or appropriate limb and should be checked for latex if using on a latex-sensitive individual. Many latex-free cuffs are now available. These cuffs should also be wiped clean between patient use to avoid cross-contamination from patient to patient.
Some clinical areas may still have mercury sphygmomanometers, but these are being used much less frequently today due to the dangers of mercury spillage.
Activity 1.1
Our patient has had his blood pressure taken hourly. Plot these recordings for the last 5 hours on a copy of the observation chart shown in Appendix 1. Do any of these readings generate a score?
130/70 mmHg
140/70 mmHg
170/74 mmHg
190/90 mmHg
202/90 mmHg
Procedure to Obtain Blood Pressure Using an Aneroid Sphygmomanometer and Stethoscope
You will be shown how to perform this skill during your training, so don’t worry if you don’t understand the procedure yet. You will need plenty of practice.
HEART RATE
Heart rate varies according to age. We can see what the heart rate is by using the pulse rate, which is measured by palpating an artery that lies close to the surface of the body. The radial artery in the wrist is often the area of choice due to its accessibility. Normal pulse rates per minute are displayed in Table 1.4.
Table 1.4 Pulse rates at various ages
Age
Approximate range (beats per minute)
Newborn
120–160
1–12 months
80–140
12 months–2 years
80–130
2–6 years
75–120
6–12 years
75–110
Adolescent
60–100
Adult
60–100
Heart rate can be felt by feeling the pulse points, so sometimes it is referred to as the pulse rate.
Question 1.2 What are the sites of the major pulse points and where are they located on the body?
The sites of the major pulse points can be viewed in the Figure 1.5.
Figure 1.5 Pulse points (Smith and Roberts, 2011)
The pulse should be taken for one full minute, assessing for rate, regularity and volume. Patients with a known or suspected irregular heart rate should have a manual reading taken each time this observation is performed.
Activity 1.2
A patient is on hourly observations. Plot the following heart-rate recordings (shown in beats per minute, bpm) on a copy of the observation chart. Do any of the readings generate an EWS score?
80 bpm
88 bpm
102 bpm
90 bpm
82 bpm
An abnormally fast heart rate (over 100 beats per minute in adults) is known as tachycardia. This may be caused by raised body temperature, physical/emotional stress or heart disease, as well as certain drugs.
An abnormally slow heart rate (less than 60 beats per minute) is known as bradycardia. This may be caused by low body temperature and certain drugs. Very fit athletes also tend to have low pulse rates.
Procedure to Obtain a Pulse Reading
RESPIRATIONS
On the Bristol Observation Chart, the respiratory rate section is at the top, showing how crucial this recording is. A change in a patient’s respiratory rate is a sensitive predictor of deterioration, and can be a precursor to an adverse event, such as a cardiac arrest, up to 4 hours prior to its occurrence. Trends in respiratory rate on a chart are therefore very important.
The respiratory system supplies the body with oxygen and removes the carbon dioxide through the rhythmic expansion and deflation of the lungs. Each respiration consists of an inhalation, exhalation and pause.
Ventilation is the act of breathing, with air moving in and out of the respiratory tract. Ventilation is under involuntary control
