The Royal Marsden manual of clinical nursing procedures

著者

• Lister, Sara
• Hofland, Justine
• Grafton, Hayley
• The Royal Marsden NHS Foundation Trust

書誌事項

The Royal Marsden manual of clinical nursing procedures

edited by Sara Lister, Justine Hofland, Hayley Grafton

Wiley, 2020

10th ed, professional ed

• : pbk

注記

Includes bibliographical references and index

内容説明・目次

内容説明

Now in its tenth edition, The Royal Marsden Manual of Clinical Nursing Procedures has been the definitive, market-leading guide to clinical nursing skills for over three decades. This internationally best-selling title sets the gold standard for nursing care; providing the procedures, rationale, and guidance required by qualified nurses to deliver clinically effective, patient-focused care with expertise and confidence. With over two-hundred detailed procedures, this comprehensive manual presents the evidence and underlying theory alongside full-colour illustrations and photographs, and includes coverage of infection prevention and control, perioperative care, wound management, nutrition, diagnostic testing, discharge, medicines management, and much more. Loved and trusted by millions for over thirty years, The Royal Marsden Manual of Clinical Nursing Procedures continues to be a truly indispensable guide for nursing practice. Written by nurses for nurses Empowers nurses to become informed, skilled practitioners Reflects current procedures and changes in modern adult nursing practice All procedures are supported by up to date evidence, including detailed rationales for each step of each procedure Considers the clinical governance around the procedures and nursing practice NEW to the Tenth Edition: Each chapter is linked to the NMC 2018 'Future Nurse: Standards of Proficiency for Registered Nurses' guidance Includes a brand-new chapter on 'Self Care and Wellbeing,' helping nurses to care for themselves emotionally and physically The Royal Marsden Manual is also available online, fully searchable, and annotatable. www.rmmonline.co.uk

目次

Brief table of contents v Foreword to the tenth edition xv Preface xvii Acknowledgements xix List of contributors xxi Quick reference to the procedure guidelines xxv How to use your manual xxix 1 The context of nursing 1 Overview 2 Background 2 Context of nursing 2 Evidence-based practice 7 Structure of the manual 8 Structure of the chapters 9 Finally 9 References 10 Part One Managing the patient journey 13 2 Admissions and assessment 14 Overview 16 Inpatient assessment and the process of care 16 Observation 24 Physical assessment 24 3 Discharge care and planning 45 Overview 46 Discharge care and planning 46 Discharging patients from hospital: internal procedures 47 Interface between primary and secondary care: external processes 53 Informal carers 58 The role of voluntary services 62 References 62 4 Infection prevention and control 64 Overview 66 Infection prevention and control 66 Hand hygiene 75 Personal protective equipment (PPE) 87 Specific patient-related procedures 101 Isolation procedures 105 Environmental hygiene and the management of waste in the healthcare environment 111 Prevention and management of inoculation injury 118 Websites 119 References 119 4.1 Hand washing 79 4.2 Hand decontamination using an alcohol-based handrub 80 4.3 Surgical scrub technique using soap and water 82 4.4 Surgical scrub technique using an alcohol-based handrub 84 4.5 Putting on and removing non-sterile gloves 88 4.6 Applying and removing a disposable apron 89 4.7 Putting on and removing a disposable mask or respirator 91 4.8 Putting on or removing goggles or a face-shield 93 4.9 Donning a sterile gown and gloves: closed technique 94 4.10 Donning sterile gloves: open technique 98 4.11 Aseptic technique example: changing a wound dressing 102 4.12 Source isolation: preparing an isolation room 106 4.13 Source isolation: entering an isolation room 107 4.14 Source isolation: leaving an isolation room 108 4.15 Source isolation: transporting infected patients outside a source isolation area 108 4.16 Protective isolation: preparing an isolation room 109 4.17 Protective isolation: entering an isolation room 110 4.18 Cleaning a hard surface without recontamination 112 4.19 Safe disposal of foul, infected or infested linen 117 Part Two Supporting patients with human functioning 123 5 Communication, psychological wellbeing and safeguarding 124 Overview 126 Communication 126 Providing information and making shared decisions 138 Communicating with specific populations 141 Psychological wellbeing 147 Safeguarding, mental capacity and the Mental Health Act 169 Websites 187 References 187 6 Elimination 194 Overview 196 Normal elimination 196 Altered urinary elimination 200 Altered faecal elimination 237 Stoma care 257 Websites 272 References 272 6.1 Slipper bedpan use: assisting a patient 198 6.2 Commode use: assisting a patient 199 6.3 Penile sheath application 202 6.4 Urinary catheterization: male 208 6.5 Urinary catheterization: female 210 6.6 Changing a suprapubic catheter 214 6.7 Urinary catheterization: intermittent self-catheterization patient guidance: male 216 6.8 Urinary catheterization: intermittent self-catheterization patient guidance: female 217 6.9 Urinary catheter bag: emptying 219 6.10 Urinary catheter removal 219 6.11 Commencing bladder irrigation 223 6.12 Nephrostomy tube: weekly dressing and bag change and sample collection 227 6.13 Nephrostomy tube: flushing technique 229 6.14 Nephrostomy tube: removal of locking pigtail drainage system 230 6.15 Flushing externalized ureteric stents 232 6.16 Removal of externalized ureteric stents 233 6.17 Continent urinary diversion stoma: self-catheterization 236 6.18 Insertion of a faecal management system 240 6.19 Insertion of a nasogastric drainage tube 247 6.20 Removal of a nasogastric drainage tube 249 6.21 Enema administration 250 6.22 Suppository administration 252 6.23 Digital rectal examination 254 6.24 Digital removal of faeces 256 6.25 Stoma siting 263 6.26 Stoma bag change 264 6.27 Obtaining a clean-catch urine sample from an ileal conduit 265 6.28 Stoma bridge or rod removal 266 7 Moving and positioning 278 Overview 280 Moving and positioning: general principles 280 Moving and positioning an unconscious patient 293 Moving and positioning a patient with an artificial airway 294 Moving and positioning a patient with respiratory compromise 298 Moving and positioning a patient with neurological impairment 301 Moving and positioning a patient with actual or suspected spinal cord compression or spinal cord injury 313 Moving and positioning a patient with raised intracranial pressure 325 Moving and positioning a patient with an amputation 326 Websites 329 References 329 7.1 Positioning a patient: supine 284 7.2 Positioning a patient: sitting up in bed 285 7.3 Positioning a patient: side-lying 286 7.4 Positioning a patient: lying down to sitting up 288 7.5 Moving a patient from sitting to standing: assisting the patient 289 7.6 Positioning a patient: in a chair or wheelchair 291 7.7 Assisting a patient to walk 292 7.8 Positioning an unconscious patient or a patient with an artificial airway in supine 295 7.9 Positioning an unconscious patient or a patient with an artificial airway in side-lying 296 7.10 Positioning a neurological patient with tonal problems in bed 309 7.11 Positioning a neurological patient with tonal problems in a chair 312 7.12 Application of a two-piece cervical collar 318 7.13 Log rolling a patient with suspected or confirmed cervical spinal instability (above T6) 319 7.14 Log rolling a patient with suspected or confirmed thoracolumbar spinal instability (T7 and below) 321 7.15 Early mobilization of a patient with spinal considerations 323 7.16 Positioning a patient with an amputation 327 8 Nutrition and fluid balance 334 Overview 336 Fluid balance 336 Nutritional status 351 Provision of nutritional support: Oral 359 Nutritional management of patients with dysphagia 364 Enteral tube feeding 365 Parenteral nutrition 385 Websites 389 References 389 8.1 Fluid input: measurement 345 8.2 Fluid output: monitoring/measuring output if the patient is catheterized 346 8.3 Fluid output: monitoring/measuring output if the patient is not catheterized 347 8.4 Fluid output: monitoring/measuring output from drains 347 8.5 Fluid output: monitoring/measuring output from gastric outlets, nasogastric tubes or gastrostomy 348 8.6 Fluid output: monitoring/measuring output from bowels 349 8.7 Fluid output: monitoring/measuring output from stoma sites 349 8.8 Measuring the weight and height of a patient 356 8.9 Feeding an adult patient 362 8.10 Nasogastric intubation with tubes using an internal guidewire or stylet 369 8.11 Removal of a nasogastric tube 374 8.12 Percutaneous endoscopically placed gastrostomy (PEG) tube care 375 8.13 Radiologically inserted gastrostomy (RIG) tube care 376 8.14 Removal of T-fasteners 377 8.15 Changing the balloon water and checking the volume of a balloon gastrostomy 378 8.16 Jejunostomy feeding tube care including dressing change 379 8.17 Insertion of a silicone gastrostomy stoma plug 380 8.18 Enteral feeding tubes: administration of feed using an enteral feeding pump 381 8.19 Enteral feeding tubes: administration of medication 384 8.20 Enteral feeding tubes: unblocking 386 9 Patient comfort and supporting personal hygiene 394 Overview 396 Personal hygiene 396 Sleep promotion in a hospitalized patient 407 Patient environment 409 Eye care 413 Ear care 423 Mouth care 427 Websites 439 References 439 9.1 Bedbathing a patient 401 9.2 Washing a patient's hair in bed 403 9.3 Shaving the face: wet shave 405 9.4 Shaving the face: dry electric shaver 406 9.5 Making an unoccupied bed 410 9.6 Making an occupied bed 412 9.7 Eye swabbing 417 9.8 Eye irrigation 418 9.9 Artificial eye care: insertion 420 9.10 Artificial eye care: removal 420 9.11 Contact lens removal: hard lenses 421 9.12 Contact lens removal: soft lenses 422 9.13 Irrigation of the external auditory canal using an electronic irrigator 425 9.14 Mouth care 436 9.15 Mouth care for a patient with dentures 437 10 Pain assessment and management 446 Overview 448 Pain 448 Pain management 456 Regional analgesia: local anaesthetic nerve blocks and infusions 462 Epidural analgesia 469 Entonox administration 481 Non-pharmacological methods of managing pain 485 References 491 10.1 Pain assessment 455 10.2 Peripheral nerve catheter removal 464 10.3 Epidural sensory blockade: assessment 475 10.4 Epidural exit site dressing change 475 10.5 Epidural catheter removal 479 10.6 Entonox administration 484 10.7 Preparation for acupuncture and actions post-treatment 490 11 Symptom control and care towards the end of life 496 Overview 498 End-of-life care 498 Symptom control 515 Verification and certification of death 526 Care after death (last offices) 528 Websites 534 References 534 11.1 Management of dyspnoea (breathlessness) 516 11.2 Care of a patient who is vomiting 519 11.3 Abdominal paracentesis 523 11.4 Terminal sedation 526 11.5 Verification of death 527 11.6 Care after death 529 12 Respiratory care, CPR and blood transfusion 538 Overview 540 Respiratory therapy 540 Oxygen therapy 542 High-flow oxygen via a nasal cannula 551 Humidification 553 Non-invasive ventilation 555 Chest drain management 562 Tracheostomy and laryngectomy care 578 Basic life support 607 Transfusion of blood and blood components 620 Websites 645 References 645 12.1 Oxygen therapy 546 12.2 High-flow oxygen therapy 552 12.3 Continuous positive airway pressure (CPAP) 559 12.4 Chest drain: assisting insertion 567 12.5 Chest drainage: suction 572 12.6 Chest drain: changing the bottle 573 12.7 Chest drain: removal 576 12.8 Tracheostomy: dressing and tube tape/tie change 587 12.9 Tracheostomy: suctioning a patient (single-use suction catheter) 590 12.10 Tracheostomy: changing an inner cannula 592 12.11 Tracheostomy: changing a tube 594 12.12 Tracheostomy: insertion and removal of a speaking valve 597 12.13 Tracheostomy: decannulation 599 12.14 Tracheostomy: emergency management 601 12.15 Laryngectomy care 605 12.16 Insertion of an oropharyngeal airway 616 12.17 Basic life support 617 12.18 Blood product request 634 12.19 Blood sampling: pre-transfusion 635 12.20 Blood components: collection and delivery to the clinical area 636 12.21 Blood component administration 638 Part Three Supporting patients through the diagnostic process 653 13 Diagnostic tests 654 Overview 656 Diagnostic tests 656 Blood sampling 660 Venepuncture: obtaining blood samples from a peripheral vein 662 CVAD sampling: sampling from a central venous access device 671 Arterial blood sampling 675 Blood cultures 683 Antimicrobial drug assay 687 Cerebrospinal fluid obtained by lumbar puncture 689 Semen collection and analysis 694 Cervical screening 697 Specimen collection: swab sampling 701 Specimen collection: urine sampling 710 Specimen collection: faecal sampling 715 Specimen collection: respiratory tract secretion sampling 717 Specimen collection: pleural fluid 722 Endoscopic investigations 723 Liver biopsy 728 Radiological investigations: X-ray 730 Magnetic resonance imaging (MRI) 730 Computed tomography (CT) 732 Websites 733 References 733 13.1 Venepuncture 666 13.2 Central venous access devices: taking a blood sample for vacuum sampling 672 13.3 Central venous access devices: taking a blood sample for syringe sampling 673 13.4 Arterial puncture: radial artery 678 13.5 Arterial blood gas sampling: arterial cannula 680 13.6 Blood cultures: peripheral (winged device collection method) 684 13.7 Blood cultures: central venous access device 686 13.8 Blood sampling: antimicrobial drug assay 688 13.9 Lumbar puncture 692 13.10 Semen collection 696 13.11 Cervical uterine smear using liquid-based cytology 699 13.12 Swab sampling: ear 702 13.13 Swab sampling: eye 703 13.14 Swab sampling: nose 704 13.15 Swab sampling: penis 705 13.16 Swab sampling: rectum 705 13.17 Swab sampling: skin 706 13.18 Swab sampling: throat 707 13.19 Swab sampling: vagina 708 13.20 Swab sampling: wound 709 13.21 Urine sampling: midstream specimen of urine: male 711 13.22 Urine sampling: midstream specimen of urine: female 712 13.23 Urine sampling: catheter specimen of urine 713 13.24 Urine sampling: sampling from an ileal conduit 713 13.25 Urine sampling: 24-hour urine collection 714 13.26 Faecal sampling 716 13.27 Sputum sampling 719 13.28 Nasopharyngeal wash: syringe method 719 13.29 Nasopharyngeal wash: vacuum-assisted aspirate method 721 14 Observations 740 Overview 742 Observations 742 Pulse (heart rate) 744 Electrocardiogram (ECG) 751 Blood pressure 758 Respiration and pulse oximetry 766 Peak flow 777 Temperature 781 Urinalysis 788 Blood glucose 793 Neurological observations 800 References 814 14.1 Pulse measurement 749 14.2 Electrocardiogram (ECG) 755 14.3 Blood pressure measurement (manual) 763 14.4 Respiratory assessment and pulse oximetry 775 14.5 Peak flow reading using a manual peak flow meter 780 14.6 Tympanic temperature measurement 786 14.7 Urinalysis: reagent strip 792 14.8 Blood glucose monitoring 797 14.9 Neurological observations and assessment 811 Part Four Supporting patients through treatment 819 15 Medicines optimization: ensuring quality and safety 820 Overview 822 Medicines management 822 Self-administration of medicines 833 Controlled drugs 835 Routes of administration 843 Parenteral administration (injections and infusions) 869 Infiltration and extravasation 918 Websites 932 References 932 15.1 Medication: controlled drug administration 841 15.2 Medication: oral drug administration 849 15.3 Medication: topical applications 851 15.4 Medication: transdermal applications 853 15.5 Medication: vaginal administration 855 15.6 Medication: administration by inhalation using a metered dose or dry powder inhaler 858 15.7 Medication: administration by inhalation using a nebulizer 860 15.8 Medication: eye administration 864 15.9 Medication: nasal drop administration 866 15.10 Medication: ear drop administration 868 15.11 Medication: single-dose ampoule: solution preparation 872 15.12 Medication: single-dose ampoule: powder preparation 873 15.13 Medication: multidose vial: powder preparation using a venting needle 874 15.14 Medication: multidose vial: powder preparation using the equilibrium method 876 15.15 Medication: injection administration 877 15.16 Medication: intradermal injection 879 15.17 Medication: subcutaneous injection 882 15.18 Medication: subcutaneous infusion of fluids 885 15.19 Medication: subcutaneous administration using a CME Medical T34 syringe pump (previously McKinley) 886 15.20 Medication: intramuscular injection 891 15.21 Inserting an intraosseous needle 894 15.22 Removing an intraosseous needle 897 15.23 Medication: continuous infusion of intravenous drugs 909 15.24 Medication: intermittent infusion of intravenous drugs 911 15.25 Medication: injection (bolus or push) of intravenous drugs 914 15.26 Extravasation management: peripheral cannula 925 15.27 Extravasation: performing flush-out following an extravasation 928 16 Perioperative care 940 Overview 942 Pre-operative care 942 Intraoperative care 977 Post-operative care 1001 16.1 Measuring and applying antiembolic stockings 963 16.2 Pre-operative care: checking that the patient is fully prepared for surgery 975 16.3 Caring for the patient in the anaesthetic room 979 16.4 Operating theatre procedure: maintaining the safety of a patient during surgery 992 16.5 Handover in the post-anaesthetic care unit (PACU): scrub nurse or operating department practitioner to recovery practitioner 996 16.6 Safe management of patients in the post-operative care unit (PACU) 997 16.7 Drainage systems: changing the dressing around the drain site for both open and closed drains 1006 16.8 Closed drainage systems: changing a vacuum bottle 1007 16.9 Wound drain removal: closed drainage system 1008 16.10 Wound drain shortening for open drainage systems 1010 16.11 Wound drain shortening for closed drainage systems 1012 17 Vascular access devices: insertion and management 1028 Overview 1030 Vascular access devices 1030 Peripheral cannulas 1046 Midline catheters 1068 Peripherally inserted central catheters 1073 Short-term percutaneous central venous catheters (non-tunnelled) 1090 Skin-tunnelled catheters 1097 Implanted ports 1102 Arterial cannulas 1110 References 1117 17.1 Central venous catheter: insertion site dressing change 1042 17.2 Vascular access devices: maintaining patency 1043 17.3 Central venous access devices: unblocking an occlusion 1043 17.4 Peripheral cannula insertion 1053 17.5 Ultrasound-guided peripheral cannula insertion 1059 17.6 Midline catheter insertion 1069 17.7 PICC insertion using modified Seldinger technique (MST) with ultrasound 1082 17.8 PICC removal 1089 17.9 Short-term central venous catheter (non-cuffed and non-tunnelled) insertion into the internal jugular vein 1092 17.10 Short-term central venous catheter (non-cuffed and non-tunnelled): removal 1096 17.11 Central venous catheter (skin tunnelled): surgical removal 1099 17.12 Implanted arm PORT insertion using modified Seldinger technique (MST) with ultrasound guidance and ECG technology 1104 17.13 Implanted ports: insertion and removal of non-coring needles 1107 17.14 Arterial cannula insertion: preparation and setting up of monitoring set 1112 17.15 Arterial cannula: removal 1114 18 Wound management 1128 Overview 1130 Wounds 1130 Pressure ulcers 1143 Surgical wounds 1152 Negative pressure wound therapy 1154 Websites 1157 References 1157 18.1 Dressing a wound 1142 18.2 Suture removal 1153 18.3 Clip removal 1153 18.4 Negative pressure wound therapy 1155 Part Five Looking after ourselves so we can support patients 1161 19 Self-care and wellbeing 1162 Overview 1164 Self-care and wellbeing 1164 Mindfulness 1172 Eating and drinking 1173 Physical wellbeing and musculoskeletal health 1175 Websites 1181 References 1181 19.1 Working at low or floor level 1178 19.2 Working with a patient lying in a bed or on another raised supportive surface 1179 19.3 Carrying out clinical procedures in a seated posture (e.g. cannulation) 1180 19.4 Working in a seated position: office work 1180 Appendix: Standards of Proficiency for Registered Nurses 1183 List of abbreviations 1185 Index 1189

「Nielsen BookData」 より

詳細情報

• NII書誌ID(NCID): BC04052503
• ISBN:
  • 9781119634386
• 出版国コード: us
• タイトル言語コード: eng
• 本文言語コード: eng
• 出版地: Hoboken, NJ
• ページ数/冊数: [xxix], 1231 p.
• 大きさ: 28 cm
• 分類:
  • DC23 : 610.73
• 件名:
  • LCSH : Nursing -- Technique -- Handbooks, manuals, etc
  • BLSH : Nursing Process
  • BLSH : Nursing Theory
  • BLSH : Nursing Care -- methods
  • BLSH : HEALTH & FITNESS -- Holism. bisacsh