Royal Marsden Manual of Clinical Nursing Procedures, Professional Edition

Sara Lister, Head of Pastoral Care, Psychological Support, and PALS, The Royal Marsden Hospital NHS Foundation Trust, UK.Justine Hofland, Divisional Clinical Nurse Director - Cancer Services, The Royal Marsden NHS Foundation Trust, UK.Hayley Grafton, Chief Nursing Information Officer, The Royal Marsden NHS Foundation Trust, UK.

"...an excellent resource to improve and enhance clinical practice." (Nursing Standard)"...a worldwide 'oracle' for all clinical nursing procedures." (Cancer Nursing Practice)"Any nurse...will find a good reason to dip into this book at some time." (Nursing Times)"...a pleasure to read and difficult to put down." (Emergency Nurse)

• Brief table of contents vForeword to the tenth edition xvPreface xviiAcknowledgements xixList of contributors xxiQuick reference to the procedure guidelines xxvHow to use your manual xxix1 The context of nursing 1Overview 2Background 2Context of nursing 2Evidence-based practice 7Structure of the manual 8Structure of the chapters 9Finally 9References 10Part One Managing the patient journey 132 Admissions and assessment 14Overview 16Inpatient assessment and the process of care 16Observation 24Physical assessment 243 Discharge care and planning 45Overview 46Discharge care and planning 46Discharging patients from hospital: internal procedures 47Interface between primary and secondary care: external processes 53Informal carers 58The role of voluntary services 62References 624 Infection prevention and control 64Overview 66Infection prevention and control 66Hand hygiene 75Personal protective equipment (PPE) 87Specific patient-related procedures 101Isolation procedures 105Environmental hygiene and the management of waste in the healthcare environment 111Prevention and management of inoculation injury 118Websites 119References 1194.1 Hand washing 794.2 Hand decontamination using an alcohol-based handrub 804.3 Surgical scrub technique using soap and water 824.4 Surgical scrub technique using an alcohol-based handrub 844.5 Putting on and removing non-sterile gloves 884.6 Applying and removing a disposable apron 894.7 Putting on and removing a disposable mask or respirator 914.8 Putting on or removing goggles or a face-shield 934.9 Donning a sterile gown and gloves: closed technique 944.10 Donning sterile gloves: open technique 984.11 Aseptic technique example: changing a wound dressing 1024.12 Source isolation: preparing an isolation room 1064.13 Source isolation: entering an isolation room 1074.14 Source isolation: leaving an isolation room 1084.15 Source isolation: transporting infected patients outside a source isolation area 1084.16 Protective isolation: preparing an isolation room 1094.17 Protective isolation: entering an isolation room 1104.18 Cleaning a hard surface without recontamination 1124.19 Safe disposal of foul, infected or infested linen 117Part Two Supporting patients with human functioning 1235 Communication, psychological wellbeing and safeguarding 124Overview 126Communication 126Providing information and making shared decisions 138Communicating with specific populations 141Psychological wellbeing 147Safeguarding, mental capacity and the Mental Health Act 169Websites 187References 1876 Elimination 194Overview 196Normal elimination 196Altered urinary elimination 200Altered faecal elimination 237Stoma care 257Websites 272References 2726.1 Slipper bedpan use: assisting a patient 1986.2 Commode use: assisting a patient 1996.3 Penile sheath application 2026.4 Urinary catheterization: male 2086.5 Urinary catheterization: female 2106.6 Changing a suprapubic catheter 2146.7 Urinary catheterization: intermittent self-catheterization patient guidance: male 2166.8 Urinary catheterization: intermittent self-catheterization patient guidance: female 2176.9 Urinary catheter bag: emptying 2196.10 Urinary catheter removal 2196.11 Commencing bladder irrigation 2236.12 Nephrostomy tube: weekly dressing and bag change and sample collection 2276.13 Nephrostomy tube: flushing technique 2296.14 Nephrostomy tube: removal of locking pigtail drainage system 2306.15 Flushing externalized ureteric stents 2326.16 Removal of externalized ureteric stents 2336.17 Continent urinary diversion stoma: self-catheterization 2366.18 Insertion of a faecal management system 2406.19 Insertion of a nasogastric drainage tube 2476.20 Removal of a nasogastric drainage tube 2496.21 Enema administration 2506.22 Suppository administration 2526.23 Digital rectal examination 2546.24 Digital removal of faeces 2566.25 Stoma siting 2636.26 Stoma bag change 2646.27 Obtaining a clean-catch urine sample from an ileal conduit 2656.28 Stoma bridge or rod removal 2667 Moving and positioning 278Overview 280Moving and positioning: general principles 280Moving and positioning an unconscious patient 293Moving and positioning a patient with an artificial airway 294Moving and positioning a patient with respiratory compromise 298Moving and positioning a patient with neurological impairment 301Moving and positioning a patient with actual or suspected spinal cord compression or spinal cord injury 313Moving and positioning a patient with raised intracranial pressure 325Moving and positioning a patient with an amputation 326Websites 329References 3297.1 Positioning a patient: supine 2847.2 Positioning a patient: sitting up in bed 2857.3 Positioning a patient: side-lying 2867.4 Positioning a patient: lying down to sitting up 2887.5 Moving a patient from sitting to standing: assisting the patient 2897.6 Positioning a patient: in a chair or wheelchair 2917.7 Assisting a patient to walk 2927.8 Positioning an unconscious patient or a patient with an artificial airway in supine 2957.9 Positioning an unconscious patient or a patient with an artificial airway in side-lying 2967.10 Positioning a neurological patient with tonal problems in bed 3097.11 Positioning a neurological patient with tonal problems in a chair 3127.12 Application of a two-piece cervical collar 3187.13 Log rolling a patient with suspected or confirmed cervical spinal instability (above T6) 3197.14 Log rolling a patient with suspected or confirmed thoracolumbar spinal instability (T7 and below) 3217.15 Early mobilization of a patient with spinal considerations 3237.16 Positioning a patient with an amputation 3278 Nutrition and fluid balance 334Overview 336Fluid balance 336Nutritional status 351Provision of nutritional support: Oral 359Nutritional management of patients with dysphagia 364Enteral tube feeding 365Parenteral nutrition 385Websites 389References 3898.1 Fluid input: measurement 3458.2 Fluid output: monitoring/measuring output if the patient is catheterized 3468.3 Fluid output: monitoring/measuring output if the patient is not catheterized 3478.4 Fluid output: monitoring/measuring output from drains 3478.5 Fluid output: monitoring/measuring output from gastric outlets, nasogastric tubes or gastrostomy 3488.6 Fluid output: monitoring/measuring output from bowels 3498.7 Fluid output: monitoring/measuring output from stoma sites 3498.8 Measuring the weight and height of a patient 3568.9 Feeding an adult patient 3628.10 Nasogastric intubation with tubes using an internal guidewire or stylet 3698.11 Removal of a nasogastric tube 3748.12 Percutaneous endoscopically placed gastrostomy (PEG) tube care 3758.13 Radiologically inserted gastrostomy (RIG) tube care 3768.14 Removal of T-fasteners 3778.15 Changing the balloon water and checking the volume of a balloon gastrostomy 3788.16 Jejunostomy feeding tube care including dressing change 3798.17 Insertion of a silicone gastrostomy stoma plug 3808.18 Enteral feeding tubes: administration of feed using an enteral feeding pump 3818.19 Enteral feeding tubes: administration of medication 3848.20 Enteral feeding tubes: unblocking 3869 Patient comfort and supporting personal hygiene 394Overview 396Personal hygiene 396Sleep promotion in a hospitalized patient 407Patient environment 409Eye care 413Ear care 423Mouth care 427Websites 439References 4399.1 Bedbathing a patient 4019.2 Washing a patient’s hair in bed 4039.3 Shaving the face: wet shave 4059.4 Shaving the face: dry electric shaver 4069.5 Making an unoccupied bed 4109.6 Making an occupied bed 4129.7 Eye swabbing 4179.8 Eye irrigation 4189.9 Artificial eye care: insertion 4209.10 Artificial eye care: removal 4209.11 Contact lens removal: hard lenses 4219.12 Contact lens removal: soft lenses 4229.13 Irrigation of the external auditory canal using an electronic irrigator 4259.14 Mouth care 4369.15 Mouth care for a patient with dentures 43710 Pain assessment and management 446Overview 448Pain 448Pain management 456Regional analgesia: local anaesthetic nerve blocks and infusions 462Epidural analgesia 469Entonox administration 481Non-pharmacological methods of managing pain 485References 49110.1 Pain assessment 45510.2 Peripheral nerve catheter removal 46410.3 Epidural sensory blockade: assessment 47510.4 Epidural exit site dressing change 47510.5 Epidural catheter removal 47910.6 Entonox administration 48410.7 Preparation for acupuncture and actions post-treatment 49011 Symptom control and care towards the end of life 496Overview 498End-of-life care 498Symptom control 515Verification and certification of death 526Care after death (last offices) 528Websites 534References 53411.1 Management of dyspnoea (breathlessness) 51611.2 Care of a patient who is vomiting 51911.3 Abdominal paracentesis 52311.4 Terminal sedation 52611.5 Verification of death 52711.6 Care after death 52912 Respiratory care, CPR and blood transfusion 538Overview 540Respiratory therapy 540Oxygen therapy 542High-flow oxygen via a nasal cannula 551Humidification 553Non-invasive ventilation 555Chest drain management 562Tracheostomy and laryngectomy care 578Basic life support 607Transfusion of blood and blood components 620Websites 645References 64512.1 Oxygen therapy 54612.2 High-flow oxygen therapy 55212.3 Continuous positive airway pressure (CPAP) 55912.4 Chest drain: assisting insertion 56712.5 Chest drainage: suction 57212.6 Chest drain: changing the bottle 57312.7 Chest drain: removal 57612.8 Tracheostomy: dressing and tube tape/tie change 58712.9 Tracheostomy: suctioning a patient (single-use suction catheter) 59012.10 Tracheostomy: changing an inner cannula 59212.11 Tracheostomy: changing a tube 59412.12 Tracheostomy: insertion and removal of a speaking valve 59712.13 Tracheostomy: decannulation 59912.14 Tracheostomy: emergency management 60112.15 Laryngectomy care 60512.16 Insertion of an oropharyngeal airway 61612.17 Basic life support 61712.18 Blood product request 63412.19 Blood sampling: pre-transfusion 63512.20 Blood components: collection and delivery to the clinical area 63612.21 Blood component administration 638Part Three Supporting patients through the diagnostic process 65313 Diagnostic tests 654Overview 656Diagnostic tests 656Blood sampling 660Venepuncture: obtaining blood samples from a peripheral vein 662CVAD sampling: sampling from a central venous access device 671Arterial blood sampling 675Blood cultures 683Antimicrobial drug assay 687Cerebrospinal fluid obtained by lumbar puncture 689Semen collection and analysis 694Cervical screening 697Specimen collection: swab sampling 701Specimen collection: urine sampling 710Specimen collection: faecal sampling 715Specimen collection: respiratory tract secretion sampling 717Specimen collection: pleural fluid 722Endoscopic investigations 723Liver biopsy 728Radiological investigations: X-ray 730Magnetic resonance imaging (MRI) 730Computed tomography (CT) 732Websites 733References 73313.1 Venepuncture 66613.2 Central venous access devices: taking a blood sample for vacuum sampling 67213.3 Central venous access devices: taking a blood sample for syringe sampling 67313.4 Arterial puncture: radial artery 67813.5 Arterial blood gas sampling: arterial cannula 68013.6 Blood cultures: peripheral (winged device collection method) 68413.7 Blood cultures: central venous access device 68613.8 Blood sampling: antimicrobial drug assay 68813.9 Lumbar puncture 69213.10 Semen collection 69613.11 Cervical uterine smear using liquid-based cytology 69913.12 Swab sampling: ear 70213.13 Swab sampling: eye 70313.14 Swab sampling: nose 70413.15 Swab sampling: penis 70513.16 Swab sampling: rectum 70513.17 Swab sampling: skin 70613.18 Swab sampling: throat 70713.19 Swab sampling: vagina 70813.20 Swab sampling: wound 70913.21 Urine sampling: midstream specimen of urine: male 71113.22 Urine sampling: midstream specimen of urine: female 71213.23 Urine sampling: catheter specimen of urine 71313.24 Urine sampling: sampling from an ileal conduit 71313.25 Urine sampling: 24-hour urine collection 71413.26 Faecal sampling 71613.27 Sputum sampling 71913.28 Nasopharyngeal wash: syringe method 71913.29 Nasopharyngeal wash: vacuum-assisted aspirate method 72114 Observations 740Overview 742Observations 742Pulse (heart rate) 744Electrocardiogram (ECG) 751Blood pressure 758Respiration and pulse oximetry 766Peak flow 777Temperature 781Urinalysis 788Blood glucose 793Neurological observations 800References 81414.1 Pulse measurement 74914.2 Electrocardiogram (ECG) 75514.3 Blood pressure measurement (manual) 76314.4 Respiratory assessment and pulse oximetry 77514.5 Peak flow reading using a manual peak flow meter 78014.6 Tympanic temperature measurement 78614.7 Urinalysis: reagent strip 79214.8 Blood glucose monitoring 79714.9 Neurological observations and assessment 811Part Four Supporting patients through treatment 81915 Medicines optimization: ensuring quality and safety 820Overview 822Medicines management 822Self-administration of medicines 833Controlled drugs 835Routes of administration 843Parenteral administration (injections and infusions) 869Infiltration and extravasation 918Websites 932References 93215.1 Medication: controlled drug administration 84115.2 Medication: oral drug administration 84915.3 Medication: topical applications 85115.4 Medication: transdermal applications 85315.5 Medication: vaginal administration 85515.6 Medication: administration by inhalation using a metered dose or dry powder inhaler 85815.7 Medication: administration by inhalation using a nebulizer 86015.8 Medication: eye administration 86415.9 Medication: nasal drop administration 86615.10 Medication: ear drop administration 86815.11 Medication: single-dose ampoule: solution preparation 87215.12 Medication: single-dose ampoule: powder preparation 87315.13 Medication: multidose vial: powder preparation using a venting needle 87415.14 Medication: multidose vial: powder preparation using the equilibrium method 87615.15 Medication: injection administration 87715.16 Medication: intradermal injection 87915.17 Medication: subcutaneous injection 88215.18 Medication: subcutaneous infusion of fluids 88515.19 Medication: subcutaneous administration using a CME Medical T34 syringe pump (previously McKinley) 88615.20 Medication: intramuscular injection 89115.21 Inserting an intraosseous needle 89415.22 Removing an intraosseous needle 89715.23 Medication: continuous infusion of intravenous drugs 90915.24 Medication: intermittent infusion of intravenous drugs 91115.25 Medication: injection (bolus or push) of intravenous drugs 91415.26 Extravasation management: peripheral cannula 92515.27 Extravasation: performing flush-out following an extravasation 92816 Perioperative care 940Overview 942Pre-operative care 942Intraoperative care 977Post-operative care 100116.1 Measuring and applying antiembolic stockings 96316.2 Pre-operative care: checking that the patient is fully prepared for surgery 97516.3 Caring for the patient in the anaesthetic room 97916.4 Operating theatre procedure: maintaining the safety of a patient during surgery 99216.5 Handover in the post-anaesthetic care unit (PACU): scrub nurse or operating department practitioner to recovery practitioner 99616.6 Safe management of patients in the post-operative care unit (PACU) 99716.7 Drainage systems: changing the dressing around the drain site for both open and closed drains 100616.8 Closed drainage systems: changing a vacuum bottle 100716.9 Wound drain removal: closed drainage system 100816.10 Wound drain shortening for open drainage systems 101016.11 Wound drain shortening for closed drainage systems 101217 Vascular access devices: insertion and management 1028Overview 1030Vascular access devices 1030Peripheral cannulas 1046Midline catheters 1068Peripherally inserted central catheters 1073Short-term percutaneous central venous catheters (non-tunnelled) 1090Skin-tunnelled catheters 1097Implanted ports 1102Arterial cannulas 1110References 111717.1 Central venous catheter: insertion site dressing change 104217.2 Vascular access devices: maintaining patency 104317.3 Central venous access devices: unblocking an occlusion 104317.4 Peripheral cannula insertion 105317.5 Ultrasound-guided peripheral cannula insertion 105917.6 Midline catheter insertion 106917.7 PICC insertion using modified Seldinger technique (MST) with ultrasound 108217.8 PICC removal 108917.9 Short-term central venous catheter (non-cuffed and non-tunnelled) insertion into the internal jugular vein 109217.10 Short-term central venous catheter (non-cuffed and non-tunnelled): removal 109617.11 Central venous catheter (skin tunnelled): surgical removal 109917.12 Implanted arm PORT insertion using modified Seldinger technique (MST) with ultrasound guidance and ECG technology 110417.13 Implanted ports: insertion and removal of non-coring needles 110717.14 Arterial cannula insertion: preparation and setting up of monitoring set 111217.15 Arterial cannula: removal 111418 Wound management 1128Overview 1130Wounds 1130Pressure ulcers 1143Surgical wounds 1152Negative pressure wound therapy 1154Websites 1157References 115718.1 Dressing a wound 114218.2 Suture removal 115318.3 Clip removal 115318.4 Negative pressure wound therapy 1155Part Five Looking after ourselves so we can support patients 116119 Self-care and wellbeing 1162Overview 1164Self-care and wellbeing 1164Mindfulness 1172Eating and drinking 1173Physical wellbeing and musculoskeletal health 1175Websites 1181References 118119.1 Working at low or floor level 117819.2 Working with a patient lying in a bed or on another raised supportive surface 117919.3 Carrying out clinical procedures in a seated posture (e.g. cannulation) 118019.4 Working in a seated position: office work 1180Appendix: Standards of Proficiency for Registered Nurses 1183List of abbreviations 1185Index 1189