Clinical Nursing Skills at a Glance (eBook)

Sarah Curr, Carol Fordham-Clarke (Herausgeber)

eBook Download: EPUB

2022
John Wiley & Sons (Verlag)
9781119035923 (ISBN)

Infos

Clinical Nursing Skills at a Glance is the must-have study and revision guide for pre-registration nursing students and newly qualified practitioners alike, providing a visual summary of the essential aspects of clinical nursing skills and procedures. The core platforms of professional practice applicable to nursing adults in a variety of clinical settings are emphasised throughout the text, including care planning, assessment, management, prioritisation and co-ordination of care.  

Designed to allow rapid reference to critical information, the book is divided into 12 sections organised around systems of the body, with each chapter describing a specific clinical skill. With high-quality images throughout, applications to practice, a review quiz, 'red flags' highlighting important aspects to consider in the clinical environment, and reflecting current NMC standards of proficiency for registered nurses, this new evidence-based guide: 

• Allows easy access to the necessary knowledge and skills required by nurses to provide quality care 
• Discusses general principles of care applicable to all, including verbal and non-verbal communication, record keeping, and admission and discharge procedures 
• Covers mandatory skills such as basic life support, infection control, and medicine management 
• Includes access to a companion website featuring interactive multiple-choice questions, case studies, and links to additional resources 

Offering superb illustrations, up-to-date information, and a reader-friendly approach, Clinical Nursing Skills at a Glance is an invaluable resource for pre-registration nursing students as well as newly qualified nurses, healthcare assistants, and allied healthcare professionals looking to expand their knowledge of nursing skills and procedures. 

Sarah Curr is a Lecturer in Nursing Education with a strong clinical skills and simulation focus at the Faculty of Nursing, Midwifery, and Palliative Care, King's College London, UK.

Carol Fordham-Clarke is a Lecturer and Clinical Skills Lead for Nursing at the Florence Nightingale School of Nursing & Midwifery, King's College London, UK.

Inhalt

Part 1

1 Introduction: the setup of_this book and_How to_Use It___2

Part 2 Principles of skills ___3

2 Care planning and the nursing process___4

3 Record keeping___6

4 Communication_- fundamentals___8

5 Communication_- de- escalation___10

6 Communication_- difficult conversations___12

7 Informed consent___14

8 Privacy and dignity___16

Part 3 Mandatory skills ___19

9 Moving and handling___20

10 Moving and_handling: turning in bed, transfers, and hoisting___22

11 Basic life support___24

12 The choking patient; the recovery position___26

13 Infection control___28

14 Medicine management___30

15 Injection technique___32

16 National early warning score (news) track and trigger system___34

Part 4 Neurological skills ___37

17 Assessing level of consciousness___38

18 Assessing pupil reaction and limb strength___40

19 Assessing cognition___42

20 Pain Assessment___44

21 Neurovascular Assessment___46

22 Assessing and managing seizures___48

Part 5 Respiratory skills ___51

23 Assessing and managing the airway___52

24 Respiratory assessment___54

25 Monitoring oxygen saturations___56

26 Arterial blood gas analysis___58

27 Chest auscultation___60

28 Peak Expiratory Flow Rate___62

29 Administering oxygen___64

30 Nebulisers and inhalers___66

31 Tracheostomy Care___68

32 Chest Drain Management___70

Part 6 Cardiovascular skills ___73

33 Taking a Pulse___74

34 Blood Pressure___76

35 Temperature Assessment___78

36 Non- invasive Circulatory Assessment___80

37 Central Venous Pressure Monitoring___82

38 Electrocardiogram___84

Part 7 Gastrointestinal skills ___87

39 Nutritional Screening___88

40 Supporting eating and drinking___90

41 Nasogastric Tube Insertion___92

42 Enteral feeding___94

43 Management of Diarrhoea___96

44 Management of Constipation___98

45 Administration of Suppositories and Enemas___100

46 Stoma care___102

Part 8 Genitourinary skills ___105

47 Urinalysis___106

48 Continence assessment___108

49 Urinary Catheterisation___110

50 Catheter Care___112

51 Catheter Removal___114

Part 9 Musculoskeletal skills __117

52 Assessing tone and ability to mobilise___118

53 Venous Thromboembolism Assessment and Risk Reduction___120

54 Anti- embolic Stockings___122

55 Musculoskeletal Minor Injuries: Assessment and Treatment___124

56 Falls_- Prevention, Assessment and Management___126

57 Stabilisation: neck collar___128

58 Care of the patient with spinal cord injuries_- log roll___130

Part 10 Integumentary skills ___133

59 Personal Hygiene___134

60 Personal Hygiene_- Mouth and Hair Care___136

61 Pressure Ulcer_- Prevention and Management___138

62 Venous Ulcer Assessment___140

63 Wound Dressing using Aseptic Non- touch Technique (ANTT)___142

64 Burns Management___144

65 Care after Death___146

66 Management of Surgical Drains___148

67 Suture and staple removal___150

Part 11 Endocrine skills ___153

68 Capillary Blood Glucose Monitoring___154

Part 12 Circulatory Skills ___157

69 Venepuncture___158

70 Cannulation___160

71 Intravenous fluid therapy___162

72 Fluid Balance Monitoring___164

73 Blood transfusions___166

Textauszug

17
Assessing level of consciousness

Figure 17.1 ACVPU recording.

Table 17.1 The ACVPU assessment tool.

Assessment	Response

Alert

The person is fully awake, eyes open, and able to move and respond appropriately

Confusion

Coherent but inappropriate, unoriented response

Voice

Any kind of response to the sound of voice, but without being fully awake

Pain	Any kind of response to a painful stimulus

Unresponsive

No eye, verbal, or motor responses to pain stimuli

Table 17.2 Structured assessment of Glasgow Coma Scale (GCS).

Check	For factors that can interfere with ability to communicate

Observe

Eye opening, verbal and motor response

Stimulate

Sound; a spoken or shouted request Pressure; on fingertip, trapezius or supraorbital notch

Rate	Record best response

Table 17.3 The Glasgow Coma Scale (GCS) assessment tool.

Source: Adapted from Teasdale et al. (2014).

Assessment	Rating	Score	Response

Eye response

Spontaneous

E4

Open before stimulus

To sound

E3

Open after spoken or shouted request

To pressure

E2

Open in response to application of pressure to the lateral aspect of the finger or fingernail (Figure 17.2)

None

E1

No opening at any time and no interfering factors. Ensure that pressure has increased over the 10‐second period and is an adequate pressure before recording as E1

Non‐testable

NT

Closed due to local factors, e.g. swelling

Verbal response

Orientated

V5

Orientated to name, place, and date

Confused

V4

Not orientated, communicates coherently

Words

V3

Intelligible single words

Sounds

V2

Moans and groans

None

V1

No audible response and interfering factor

Non‐testable

NT

Factors influencing communication

Motor response

Obeys commands

M6

Obeys two‐part request

Localising

M5

Brings hands above clavicle to central stimulus

Normal flexion

M4

Bends arm at elbow rapidly but does not appear abnormal

Abnormal flexion

M3

Bends arm at elbow abnormally

Extension

M2

Extends arm at elbow

None

M1

No movement in limbs and no interfering factors

Non‐testable

NT

Due to factors influencing movement, e.g. paralysis

NB: If there are different responses from the right and left sides of the body, record the best response.

Figure 17.2 Applying pressure: fingernail.

Figure 17.3 Applying pressure: trapezium pinch.

Figure 17.4 Applying pressure: supraorbital pressure.

Figure 17.5 Abnormal motor responses.

Background

• Level of consciousness measures a person's responsiveness to environmental stimuli and is a measure of overall neurological function.
• Consciousness is dependent upon arousal and awareness.
• Arousal is determined by a functioning reticular activating system (RAS) within the brain stem.
• Awareness is determined by the cerebral cortex processing information.
• Many factors can alter the level of consciousness, such as alcohol consumption, drugs, raised intracranial pressure, decreased oxygen or blood flow to the brain, hypoglycaemia, and electrolyte imbalance – in particular, sodium.
• Two tools are commonly used in clinical practice to assess consciousness: ACVPU (alert, confusion, verbal, pain, unresponsive) and Glasgow Coma Scale (GCS) (Kelly et al. 2005).

Influencing Factors

• Intoxication.
• Some drugs and medications.
• Existing disability.
• Post‐ictal (post‐seizure) drowsiness.
• Sleep disorders and consequent drowsiness.
• Eyes closed by swelling.
• Presence of endotracheal tube or tracheostomy.
• Communication problems.

Professional Approach

• Communicate clearly with the patient, and obtain informed consent when possible.
• Use the most appropriate assessment tool for the patient, remembering that a full neurological assessment includes:
  • GCS.
  • Limb movement and strength.
  • Pupil size and reaction to light (Chapter 18).
  • Full vital signs (Chapter 16).
• Be aware of the previous recording and baseline assessment.
• Accurate record keeping is essential, including areas that are unable to be assessed for a patient.
• Escalate changes in level of consciousness immediately to allow for early intervention.
• People sometimes require neurological observation at specific time intervals. It is important to be accurate with the required timings and follow local Trust guidance.

Equipment – The ACVPU Tool

• This is commonly used by following the section on the National Early Warning Score 2 (NEWS 2) chart (Royal College of Physicians 2017) (Figure 17.1).

Procedure – The ACVPU Tool

• The ACVPU is a tool for rapid assessment and is not suitable for a detailed assessment of consciousness.
• Responses can be alert (eyes opening), verbal (response to voice command) or motor (response to stimulus).
• “New confusion” is an additional response that has been added, which changed the abbreviation AVPU to ACVPU (Royal College of Physicians 2017) (Table 17.1).
• New confusion in an otherwise alert patient is a warning sign of serious underlying illness.

Equipment – Glasgow Coma Scale

• Refer to local neurological guidance.

Procedure – Glasgow Coma Scale

• This a structured assessment that must follow specific steps (Tables 17.2 and 17.3; Teasdale et al. 2014).
• Detailed scores for each response (as outlined in Table 17.3) are required and as they provide detailed information on consciousness they are more useful for diagnostic purposes.
• An overall total score of between 3 and 15 indicates severity (Table 17.3).

Procedure

• Where possible, explain the assessment to the patient to obtain informed consent.
• Initially assess for spontaneous behaviour.
• If the patient is not alert or awake, talk to them, asking them to open their eyes – this is to assess the arousal mechanisms in the brain stem (RAS).
• Table 17.3 details the full approach to follow for “eyes opening”.
• Then move to check for verbal response and thus level of consciousness.
• Check orientation by asking their name, where they are and the month (Table 17.3).
• Finally assess motor response by asking the patient to grasp and release your hand or open their mouth and stick their tongue out.
• If the patient does not obey commands and there is no response, apply increasing pressure to the trapezius muscle (Figure 17.3) for up to 10 seconds.
• If this stimulus does not elicit a localising response, apply pressure to the supraorbital notch (Figure 17.4) to distinguish between the motor responses: flexion, abnormal flexion, and extension (Figure 17.5).
• Remember to record eyes, verbal, and motor separately, as well as the total score (Table 17.3).
• Escalate as appropriate.

NB: When checking conscious level, ascertain that the patient can understand English (or the language you are speaking in).

Red Flags

• Avoid applying supraorbital pressure (as a central painful stimulus) if there are any injuries to the face.
• A GCS score ≤ 8 requires intubation to maintain the airway.
• Unconsciousness following a head...

Produkt-Details

• Erscheint lt. Verlag: 15.2.2022
• Reihe/Serie: At a Glance (Nursing and Healthcare)
• Reihe/Serie: Wiley Series on Cognitive Dynamic Systems
• Reihe/Serie: Wiley Series on Cognitive Dynamic Systems
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Pflege ► Ausbildung / Prüfung
• Schlagworte: clinical nurse guide • clinical nurse procedures </p> • clinical nurse reference • clinical nurse study guide • clinical nursing handbook • clinical nursing principles • clinical nursing revision guide • Clinical Skills • General Clinical Nursing • Klinische Fertigkeiten • Klinische Krankenpflege • Krankenpflege • <p>clinical nursing • Medical Science • Medizin • NMC proficiencies • nursing
• ISBN-13: 9781119035923 / 9781119035923