Skills in

Ninth Edition

Clinical Nursing
Audrey Berman, PhD, RN
Professor, School of Nursing
Samuel Merritt University
Oakland, California

Shirlee J. Snyder, EdD, RN

Retired Dean and Professor, Nursing
Nevada State College
Henderson, Nevada

A01_BERM1444_09_SE_FM.indd 1 19/11/2019 18:56

 Senior Vice President, Product Management: Adam Jaworski Full Service Project Management and Composition: SPi Global
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The authors and publisher have exerted every effort to ensure that drug selections and dosages set forth in this text are in accord with current
recommendations and practice at time of publication. However, in view of ongoing research, changes in government regulations, and the
constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package inserts of all drugs for any
change in indications of dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new
and/or infrequently employed drug.

Library of Congress Cataloging-in-Publication Data

Berman, Audrey, author.
Skills in clinical nursing / Audrey Berman and Shirlee Snyder. — Ninth edition.
  p.; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-13-542144-4
ISBN-10: 0-13-542144-6
I. Snyder, Shirlee, author. II. Title.
[DNLM: 1. Nursing Care—Handbooks. 2. Nursing Process—Handbooks. WY 49]
  RT41
  610.73—dc23
  2014043489
ScoutAutomatedPrintCode

ISBN-10: 0-13-542144-6
ISBN-13: 978-0-13-542144-4

A01_BERM1444_09_SE_FM.indd 2 19/11/2019 18:56

 Dedication

Audrey again dedicates this book to her child, Jordanna Elise MacIntyre, who has
evolved and matured just as has the book itself. Also, like the book, Jordanna seeks
to—and will—make the world a healthier and better place.

Shirlee again dedicates this book to her husband, Terry J. Schnitter, for his continual
love and support; to the nurses, present and future, who contribute to the nursing
profession; to her step-children ( Kelly and Steven), grandchildren (Ashley, Brady, and
Ryan), and first great-grandchild (Oliver); to her younger brother, Dan Snyder, and his
wonderful family; and in memory of her older brother, Ted Snyder, who is missed by
his loving and caring family.

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 Acknowledgments
Special thanks to those without whom this edition would not have been possible:

• Teri Zak, Development Editor, whose unfailing energy, intelligence, memory, expe-
rience, and professionalism supported each aspect of the book’s creation.
• John Goucher, Product Manager, for his support for enhancing and marketing
this book.
• Michael Giacobbe, Pearson Content Producer, and Meghan DeMaio and Patty
Donovan, SPi editorial project managers, whose efforts ensured a quality and
timely production.
• The reviewers, who provided many helpful comments.

iv

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 Thank You
We extend thanks to our contributors from previous editions, who gave their time, effort,
and expertise to the development and writing of chapters and resources that helped
foster our goal of preparing student nurses for clinical practice.

C ONTR IB UTORS TO TH E SEVENT H E DIT IO N

Janet Adams, MSN, RT (AART), RN Kathleen Kunkler, MS, BSN Janice L. Reilly, EdD, MSN, RN-BC
Southeast Missouri State University Capital University Immaculata University
Cape Girardeau, MO Columbus, OH Immaculata, PA
Betty M. L. Bedner, RN, MSN/Ed Lora McDonald McGuire, MS, BSN Melissa Schmidt, PhD, MSN, BSN
University of Pittsburgh Bradford Joliet Junior College Tompkins Cortland Community College
Pittsburgh, PA Joliet, IL Dryden, NY
Annette Gunderman, DEd, MSN, RN Gail Rattigan, MSN, RN, FNP-BC Ruby Wertz, MSHA, BSN, RN
Associate Professor of Nursing Nevada State College School of Nursing Nevada State College School of Nursing
Bloomsburg University Henderson, NV Henderson, NV
Bloomsburg, PA

REVIEWERS OF THE NINTH EDITION

We would like to express our sincere thanks to the educators who reviewed chapters of this text. Their insights, com-
ments, suggestions, criticisms, and encouragement contributed to making this a more useful and relevant tool for
students.
Andrea Ackermann, PhD, RN, CNE Karen Cooper, MSN, RN, CNE Christy Lenahan, DNP, MSN, FNP-BC, CNE
Mount Saint Mary College Tyler Junior College University of Louisiana at Lafayette
Newburgh, NY Tyler, TX Lafayette, LA
Lynn Barton, MSN, RN, CNS Sally Davis, RN, MSN, CNE Catharine Muskus, MS, RN, FNP-BC, CNE
Oregon Coast Community College Western Technical College Rasmussen College
Newport, OR La Crosse, WI Ocala, FL
Mitzi Bass, MPH, MSN, RN Jenny Elbracht, RN, MSN Susan Randol, MSN, RN, CNE
Baltimore City Community College Nebraska Methodist College University of Louisiana Lafayette
Baltimore, MD Omaha, NE Lafayette, LA
Wendy Batch-Wilson, DNP, RN Tracy George, DNP, APRN-BC, CNE Jackie Reils, MSN, RN
Cuyahoga Community College Francis Marion University Western Technical College
Cleveland, OH Florence, SC La Crosse, WI
Kellie Bryant, DNP, WHNP Ruth Henderson, RN, MSN, CCRN Linda Shubert, MSN, RN
New York University Medical University of South Carolina Jacksonville University
New York, NY Charleston, SC Jacksonville, FL
Christie Cavallo, MSN, RN Katherine Houle, RN, MSN, CPAN
University of Tennessee Health Science Center Gillette Children’s Specialty Healthcare
Memphis, TN St. Paul, MN

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 Preface
The skills performed by nurses exemplify the integration this step of the nursing process for the skills in this book
of the knowledge, psychomotor dexterity, attitude, and because the focus is on the skill and no specific client
critical thinking necessary for effective clinical practice assessment data are included. Application of nursing
in the 21st century. The ninth edition of Skills in ­Clinical diagnoses is reflected in each end-of-unit feature on the
­Nursing has been revised and updated to reflect the nursing process.
changes in practice that have occurred since the previous • As a component of the planning phase, information
edition. It includes: about when it is and is not appropriate to assign each
• The 161 most important skills performed by nurses, skill to assistive personnel (AP).
including all common variations, organized from the • Implementation steps, including client teaching, obser-
simple to the more complex. All skills have been revised vation of standard infection prevention precautions, and
to reflect current clinical practice. client record documentation. Rationales are indicated
• More than 800 illustrations. Skills in Clinical Nursing is by italic type.
intended as a primary textbook for nursing education • Considerations in evaluation of the skill, focusing on
programs and as a reference for practicing nurses. Con- steps indicated for follow-up and communication with
tent was selected based on feedback from reviewers of other members of the healthcare team.
previous editions, market surveys, and the extensive
teaching and practice experience of the authors. HIGHLIGHTS OF THE 9TH ED IT I ON
• Emphasis on QSEN! The delivery of high-quality and
All content was reviewed by practicing clinical nurses
safe nursing practice is imperative for every nurse.
who provided invaluable firsthand knowledge of current
This edition has incorporated QSEN competencies and
practice.
specified expectations into the narrative. This content
highlights relevant information in patient-centered care,
F O R M AT teamwork and collaboration, and safety.
Each chapter contains concise introductory material, plac- • Updated art! Many new photos and drawings
ing the skills in perspective to client anatomy, physiology,
• Current CDC and WHO definitions and guidelines
and pathophysiology, and provides an overview of the
rationale and purpose of the skills. The presentation of • 2019 National Patient Safety Goals (NPSGs) for hospi-
each skill follows the steps of the nursing process: tals and long-term care
• Current CMS guidelines for use of restraints
• A review of the assessment data required before per-
forming the skill. • Healthy People 2020 objectives for cholesterol, hyperten-
sion, and diabetes
• During diagnosing, the second phase of the nursing
process, the nurse uses critical thinking skills to inter- • Updated Infusion Nurses Society guidelines
pret specific assessment data and identify the client’s • Updated nursing standards and references (ANA,
strengths and problems. The authors did not include NPSG, and so on)

vi

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 Features of the Ninth Edition
704 Unit 8 • Wounds and Injury Care

NURSING PROCESS: SUTURES AND STAPLES

Skills in Clinical Removing Sutures and Staples

Nursing ASSESSMENT
Assess:
continues to be a definitive

SKILL 31.6
• Appearance of the suture line
resource for the most • Factors contraindicating suture removal (e.g., nonuniformity of closure, inflammation, presence of drainage).

commonly performed PLANNING

nursing skills. This skills Before removing skin sutures, verify (a) the orders for suture removal Equipment
(many times only alternate interrupted sutures or staples are removed • Waterproof bag
book is designed as an one day and the remaining sutures or staples are removed a day or • Sterile gloves
two later); (b) when the client may bathe or shower; and (c) whether a
easy reference for both dressing is to be applied following the suture removal. Some primary
• Sterile dressing equipment including:
• Sterile suture scissors or staple remover
the classroom and clinical care providers prefer no dressing; others prefer a small, light gauze • Gauze squares
dressing to prevent friction by clothing. • Sterile hemostat or forceps
practice! Assignment • Sterile butterfly tape or Steri-Strips (optional)
Skills are organized in a Removal of sutures or staples requires application of knowledge and • Tape, if a dressing is to be applied
problem-solving and is not assigned to AP.
nursing process framework
and include step-by-step IMPLEMENTATION Cut the suture. Rationale: Sutures are cut as close to the
Performance skin as possible on one side of the visible part because
instructions. 1. Prior to performing the procedure, introduce yourself and verify the visible suture material is contaminated with skin
the client’s identity using agency protocol. Explain to the client bacteria and must not be pulled beneath the skin during
what you are going to do, why it is necessary, and how to removal. Suture material that is beneath the skin is consid-
participate. Inform the client that suture removal may produce ered free from bacteria.
slight discomfort, such as a pulling or stinging sensation, but • With the forceps or hemostat, pull the suture out in
should not be painful. one piece. Inspect carefully to make sure that all suture
2. Perform hand hygiene and observe other appropriate infection material is removed. Rationale: Suture material left
prevention procedures. beneath the skin acts as a foreign body and causes
3. Provide for client privacy. inflammation.
4. Apply clean gloves, remove any dressings, and clean the inci- • Discard the suture onto a piece of sterile gauze or into
sion (see Skill 31.4). the moisture-resistant bag, being careful not to contami-
Easy-to-find RAT ION A LES provide a • Clean the suture line with an antimicrobial solution before nate the forceps tips. Sometimes, the suture sticks to the
better understanding of why critical and after suture or staple removal. Rationale: This is gener- forceps and needs to be removed by wiping the tips on a
ally done as a prophylactic measure to prevent infection. sterile gauze.
steps are performed. 5. Remove the sutures or staples. Staples
• Apply sterile gloves. • Place the lower tips of the sterile staple remover under
Plain Interrupted Sutures the staple.
• Grasp the suture at the knot with a pair of forceps. • Squeeze the handles together until they are completely
• Place the curved tip of the suture scissors under the closed. ❷ Rationale: Pressing the handles together causes
suture as close to the skin as possible, either on the the staple to bend in the middle and pulls the edges of the
side opposite the knot ❶ or directly under the knot. staple out of the skin. Do not lift the staple remover when
squeezing the handles.

CR ITIC A L S T EPS are visually

­represented with full-color
­photos and illustrations.

❶ Removing a skin suture.

Bojan Fatur/Getty Images. ❷ Removing surgical clips or staples.

M31B_BERM1444_09_SE_C31.indd 704 14/11/2019 18:55

vii

A01_BERM1444_09_SE_FM.indd 7 19/11/2019 18:56

 450 Unit 5 • Medication Administration

Administering Intermittent Intravenous Medications—continued

9. After infusion of the secondary IV medication bag, regulate the • When the medication has been infused, disconnect the
rate of the primary solution by adjusting the clamp or IV pump IV tubing, maintaining sterility of the end of the IV tubing.
infusion rate. Some infusion pumps will do this automatically. • Insert the second saline syringe into the port and flush at the

SKILL 17.8
10. Leave the secondary piggyback bag and tubing in place for same rate that the drug was injected until the entire drug dose
future administration or discard as appropriate. has been cleared from the infusion system and vascular access
11. Document relevant data. device lumen. Rationale: This clears the tubing and maintains
• Record the date, time, medication, dose, route, and patency. Clamp the saline lock after flushing, if appropriate.
solution; assessment of the IV site, if appropriate; and the • Dispose of syringes in the appropriate container.
client’s response. Variation: Adding a Medication to a Volume-Control Infusion
• Record the volume of fluid of the medication infusion bag
• Withdraw the required dose of the medication into a syringe.
on the client’s intake and output record.
VAR IATIO NS present alternative Variation: Using a Saline Lock
• Ensure that there is sufficient fluid in the volume-control fluid
chamber to dilute the medication. Generally, at least 50 mL of
methods of ­performing certain skills. Intermittent infusion devices ❺ may be attached to an IV catheter to fluid is used. Check the directions from the drug manufacturer
allow medications to be administered intravenously without requiring or consult the pharmacist.
a continuous IV infusion. The device may also have a port at one end • Close the inflow to the fluid chamber by adjusting the upper
of the lock and a needleless injection cap at the other end, with the roller or slide clamp above the fluid chamber; also ensure that
extension tubing between the two ends. ❻ the clamp on the air vent of the chamber is open.
• Prepare two normal saline prefilled syringes (10 mL each). • Clean the medication port on the volume-control fluid chamber
• Spike the medication bag with minidrip (60 gtt/mL) IV tubing. with an antiseptic swab.
• Attach the needleless adapter to the tubing, prime the tubing, • Inject the medication into the port of the appropriately filled
and close the clamp. volume-control set (i.e., the ordered amount of solution).
• Clean the needleless injection port of the saline lock with an • Gently rotate the fluid chamber until the fluid is well mixed.
antiseptic swab. Open the saline lock clamp, if appropriate. • Regulate the flow by adjusting the lower roller clamp below the
Insert the first saline syringe into the port, flush 1 to 2 mL, fluid chamber.
376 Unit 5 • Medication Administration and then gently aspirate to check for patency. Flush the remain- • Attach a medication label to the volume-control fluid
ing volume slowly, noting any resistance, swelling, pain, or burning. chamber.
Rationale: This ensures placement of the IV in the vein. • Document relevant data and monitor the client and the
and may
After connecting the IVbe either
tubing to theharmless
injection port or potentially
of the lock, harmful. For
infusion.
administer the medication, regulating the drip rate to allow medication
example, digitalis increases the strength
to infuse for the appropriate time period. Macrodrip (10 to 20 gtt/mL)
of myocardial
tubing maycontractions (desired
also be used if using an IV pumpeffect), but
to regulate the it can have the side effect
flow.
of nausea and vomiting. Some side effects are tolerated
for the drug’s therapeutic effect; more severe side effects,
also called adverse effects or reactions, may justify the
discontinuation of a drug. The nurse should monitor for
dose-related side or adverse effects and report these to the
448 healthcare provider
Unit 5 • Medication who may discontinue the medication
Administration
or change the dosage.
the primary infusion container so that the medication is and older clients when the volume administered is criti-
administered through the client’s IV line. Volume-control cal and must be carefully monitored. Skill 17.8 provides

Medication Orders
sets are frequently used to infuse solutions into children additional information.

NURSING
❺ Intermittent infusion devicePROCESS: INTERMITTENT ❻INTRAVENOUS
with an injection port. Intermittent infusion deviceINFUSIONS
with an injection port and extension tubing.
A physician usually determines the client’s medication
Administering
EVALUATIONneeds andIntermittent
orders medications, Intravenous althoughMedications
in some Usingsettings a Secondary Piggyback Set
• Conduct appropriate follow-up such as desired effect of • Compare to previous findings, if available.
nurse
medication,
ASSESSMENT anypractitioners and
adverse reactions or side physician
effects, or change assistants
• Report (PAs)
significantcan
deviations from normal to the primary
now
•in vital
Inspect andorder
signs. drugs.
palpate the State
IV insertion site forlaw
• Reassess status of the IV lock site and patency of the
determines
signs of infection, whether
•care provider.ifnurse
Determine the client has allergies to the medication(s).
infiltration, or a dislocated catheter. • Check the compatibility of the medication, primary IV fluid, and
practitioners and PAs have prescriptive ability and the
SKILL 17.8

•IV Inspect
infusion.the surrounding skin for redness, pallor, or swelling. any medication(s) in the primary IV bag.
• classes
Palpate of drug
the surrounding forforwhich
tissues they
tenderness, mayand
coldness, prescribe. Also,specific
• Determine eachdrug action, side effects, normal dosage,
the presence of edema, which could indicate leakage of the recommended administration time, and peak action time.
health
IV fluid into theagency
tissues. will have its own policies. Usually
• Check patency the
of the IV line by assessing flow rate.
order
Intravenous Push
• Take is forwritten,
vital signs although
baseline data telephone
if the medication being and
intoverbal orders
a vein by venipuncture or into an existing IV line
administered is particularly potent. through an injection port or through an IV lock.
arepush
Intravenous acceptable in issome
(IVP) or bolus the IVagencies. Nursing
administration of students need
There are two major disadvantages to this method of
ASSIG NME N T highlights guidelines to know
an PLANNING
undiluted the agency
drug directly policiescirculation.
into the systemic about medication
drug orders.Any error in administration cannot
administration:
It isAssignment Equipment
for when it is appropriate and how to usedInwhen
some a medication
hospitals, cannot
for be diluted oronly
example, in an licensed nurses
be•corrected after are
the drug has entered the client, and the
The administration of intermittent IV medications
emergency situation. An IVP can be introduced directly involves the appli- Client’s MAR or computer printout
assign skills to a
­ ssistive personnel (AP). cationpermitted to accept
of nursing knowledge and critical telephone drug may be irritating to the lining of the blood vessels.
and
thinking. Check the verbal
state’s orders. It ismedication-infused bag with correct label
• Pharmacy-prepared
nurse practice act to verify the scope of practice for the LPN/LVN as • Short secondary administration set
strongly recommended thatpolicy
health agencies haveswabs solid
Figure 15.1 ■ Some controlled substances are kept in specially it relates to IV medication administration. Agency also must • Antiseptic for disinfection of needleless connector or
designed packages or plastic containers that are sectioned and guidelines
be checked inThisplace
and followed. toassigned
skill is not reduce orTheeliminate
to AP. nurse, errors occur-
injection port
however, can inform the AP of the intended therapeutic effects and • Needleless adapter, syringe, and saline if medication is
numbered. specificring fromof verbal
side effects the medication orders.
and directForthe example,
AP to report for incompatible
all verbal withor
the primary infusion
specific
M17_BERM1444_09_SE_C17.indd 450 telephone orders
client observations thefornurse
to the nurse follow-up.must first write down the
19/09/19 7:00 PM

order and then read it back, verbatim, to the prescribing

IMPLEMENTATION
Included on the inventory record are the controlled Preparation care provider. of the solution to exit the tubing to ensure that the client
• Check the MAR. receives the full dose of medication.
substances wasted during preparation. When a portion or • Check the label on the medication carefully against the • Clamp the secondary tubing.
SAFE TY ALERT S correlate to the National
all of a controlled substance dose is discarded, the nurse MAR to make sure that the correct medication is being • Attach the appropriate label to the secondary tubing.

must askPatient Safety

a second nurseGoals and identify
to witness other
the discarding
prepared.
of the • Confirm that the dosage is correct. Safety Alert! SAFETY
Note: Per the Infusion Nurses’ Society (2016), all primary
and secondary administration sets used for intermittent
c
­ rucial safety information.
unused medication. Both nurses must sign the control • Ensure medication compatibility with the primary infusion administration should be replaced every 24 hours.
Encourage the prescribing care provider to provide
solution. • cor- up subsequent medication bags when
When setting
inventory form. • Consult rect spellingif required,
a pharmacist, of a drug, using
to confirm aids such
compatibility primary
of the as “B as in boy.” and secondary fluids are compatible:
It
drugs and solutions being mixed. • Use the back priming method for administering the next
In most agencies, counts of controlled substances • Organize is also important for the provider to pronounce numbers dose with the same administration set.
the equipment. medication
are taken at the end of each shift. The count total should • Remove separately.
the medicationFor bag example, 30 minutes 16 should•be
the number
from the refrigerator Lower the previous medication infusion bag below the
stated
primary IV bag.
before administration, if appropriate.
match the total at the end of the last shift minus the num- Performance as “one six” to avoid confusion with the number• 60. Open the clamp of the medication bag.
• Allow the solution from the primary IV bag to backfill
ber used. If the totals do not match and the discrepancy 1. Perform hand hygiene and observe other appropriate infection the secondary IV tubing and one-third to one-half of the
cannot be resolved, it must be reported immediately to prevention procedures. secondary tubing chamber. ❶ Rationale: This method
2. Provide for client privacy. of priming the secondary tubing allows for no loss of
the nurse manager, nursing supervisor, and pharmacy 3. Prepare the client.
Policies about primary care providers’ orders vary
medication.
according to agency policy. In facilities that use a com- • Prior to performing the procedure, introduce yourself • Detach the empty container and insert spike into the
viii
puterized dispensing system, manual counts are not
considerably from agency to agency. For example,
and verify the client’s identity using agency protocol.
Rationale: This ensures that the right client receives the
a cli- bag.
new medication
• Clamp the secondary IV tubing.
ent’smedication.
orders may be automatically canceled after surgery
required because the dispensing system runs a continu- • right
or an examination involving an anesthetic Clinical
If not previously assessed, take the appropriate assessment agent. The Alert pri-
ous count; however, discrepancies must still be reported measures necessary for the medication.
mary
4. Explain the care
purposeprovider
of the medicationmust andthen write
how it will help, new orders.
and accounted for. Each IV medication bag requires its own secondary tubing. Medi-
Mostthatagencies
using language the client canalso haveInclude
understand.
relevant information about the effects of the medication.
lists of abbreviations
cation from the IVoffi-
infusion bag remains in the secondary tubing. It
is important, therefore, when hanging subsequent IV infusion bags
cially Information
Rationale: accepted canfor useacceptance
facilitate in the agency.
of and To prevent medica-
to hang the same medication on the same secondary tubing. This
A01_BERM1444_09_SE_FM.indd 8 adherence to the therapy.
tion errors, The Joint Commission mandates that
avoids theagencies
mixing of incompatible medications. 19/11/2019 18:56
5. Assemble the secondary piggyback infusion:
 272 Unit 3 • Assisting with Client Hygiene and Comfort

Managing Pain with a PCA IV Pump—continued

260 Unit 3 • Assisting with Client Hygiene and Comfort
EVALUATION
PR ACTICE GUIDELIN ES provide
• Conduct appropriate follow-up: • Compare to previous findings, if available.
instant access
• Pain status summaries • Report significant deviations from normal to the primary care
PRACTICEprovider.
GUIDELINES Strategies for Colleague Accountability in Pain Management
SKILL 9.2

• Respiratory rate and character

of common
• Amount of ­
pmedication
rocedures used and
What do we do if the healthcare team does not respond positively Cite recommendations from evidence-based clinical practice
•
clinical practice.
• Frequency of use
to a client’s report of pain? guidelines (e.g., American Pain Society, Agency for Health
Care Policy and Research), The Joint Commission standards,
• Speak up! Inappropriate professional behavior will persist if not
organization-specific documents (e.g., mission statement,
challenged. If necessary, file an “incident” or “variance” report for patient bill of rights, practice standards), or relevant research
persistent patterns or unacceptable violations of standards of and quality reports. As necessary, distribute or post with key
LIFESPAN CONSIDERATIONS PCA Pump care. These types of behaviors (ignoring reports of pain, failing to passages highlighted.
treat or mistreating people with pain) are not only unethical, but
CHILDREN • Involve key committees, managers, and administrators in
legallyOLDER ADULTS
indefensible because a standard of care is not being met.
• Include the parents in teaching. Carefully monitoroffor drug side effects. studying and addressing the problem from a cost, quality,
• Clarify•that the sensation pain is subjective and that profes-
• Assess the child’s ability to understand and use the client • Use cautiously for individuals with impaired pulmonary or renal competency, and credentialing perspective.
sionals have a duty to believe clients’ reports of their symptoms.
control button. Pasero and McCaffery (2011) report that “PCA function.
has been used effectively and safely in developmentally normal • Assess the client’s cognitive and physical ability to use the client
children as young as 4 years old” (p. 314). control button.
• Use distraction techniques to avoid dislodging or disconnection
by the child.
• Use pediatric elbow immobilizers (no-nos, Snuggle Wraps) if Reducing Misconceptions About Pain Preventing Pain
distraction is not effective in keeping the child from playing with
tubing and ports.
Reducing a client’s misconceptions about pain and its A preventive approach to pain management involves the
treatment will remove one of the barriers to optimal pain provision of measures to treat the pain before it occurs
relief. The nurse should explain to the client that pain is or before itC becomes
L I ENT Tsevere.
EACH IPreemptive
N G CO N SIanalgesia
D E R ATIisO NtheS
a highly individual experience and that the client is the administration giveoftips analgesics
and toolsbeforetosurgery
help to decrease or
clients
CLIENT TEACHING CONSIDERATIONS
only one who really experiences the pain, although others relieve pain after surgery and reduce the need for opioid
Client Self-Management of Pain can understand andthe
(i.e., push empathize.
button) 5 to 10 Misconceptions
times to receive the are alsoamountpain control.
same
facilitate self-care and wellness.
Choose a time to teach the client about pain management when dealt
the with when of medication
the nurse (10 mg andmorphine
clientequivalent)
discuss theythe would
context receive Some authors, however, believe the term “preventive”
pain is controlled so that the client is able to focus on the teaching. in a standard “shot.”
of pain control as part of the healing process. For exam-
• Describe the use of the pain scale and encourage the client to
analgesia better explains the assumption of the practice—
Teaching the client about self-management of pain can include
ple, clients may respond refuse
in order pain medicineunderstanding.
to demonstrate out of concern for that the only way to prevent central sensitization might
the following:
addiction, • explaining
Explore a variety that the pain is more
of nonpharmacologic paintolerable as
relief techniques be to block any pain and afferent signals from the surgical
272 Unit 3 • the Assisting is with Client Hygiene useand Comfortpain relief
• Demonstrate the operation of the PCA pump and explain that
long as theythat remain client
totally willing to This
still. learn and to promote
misconception over- wound from the time of incision until final wound healing
the client can safely push the button without fear of overmedi- and optimize functioning.
states the• risk
cating. Sometimes it helps clients who are reluctant to repeat-
of addiction (estimated at less than 5% of
Explain to the client the need to notify staff when ambulation is
(Polomano et al., 2017).
edly push the button to know that they must dose themselves clients
Managing without a history
Pain
desired for of
(e.g.,with substance
bathrooma PCA ifabuse
use), IV when treated
Pump—continued
applicable. Nurses can use a preemptive approach by providing
for acute pain), while underestimating the risks associated an analgesic around the clock (ATC) and supplementing
with immobility (e.g., atelectasis, muscle atrophy, pressure
EVALUATION with as-needed (prn) doses after surgery or prior to pain-
Nonpharmacologic Approaches injuries,
• Conduct client
infections).by focusing
appropriate follow-up:attention on tactile stimuli and away ful procedures
• Compare (e.g., dressing
to previous findings, if changes,
available. physical therapy).
• Painfromstatus
the painful sensations, thus reducing pain percep- • Report
This significant
strategy deviations
prevents from
the normal toand
windup the primary care
sensitization
Nonpharmacologic pain management consists of a variety• Respiratory
SKILL 9.2

rate and character

tion. Selected cutaneous stimulation techniques include: provider.
of physical, cognitive-behavioral, and lifestyle pain manage- (described earlier in Box 9.2) that spreads, intensifies, and
Clinical
• Amount Alert!
of medication used
prolongs pain.
ment strategies that target the body, mind, spirit, and social• Frequency 1. Massage.of use Varying styles and degrees of pressure are
interactions (Table 9.6). Physical modalities include cutane- So what if you used,areincluding
fooled by a client’sSwedish
lymphatic, self-report (seeofSkill
pain?9.4), Thai,
ous stimulation, ice or heat, immobilization or therapeutic Evidence suggests craniosacral, 5%deep of people
tissue, ice reporting
massage,pain and hot arestones.
LIFE SPAN
exercises, C ON S IDERAT
transcutaneous IONnerve
electrical S stimulation, dishonest
and
ing everyone,
2.and seeking some
Application
you willpads,
of heat
not short-change
secondary
and cold.gain. IncludesBy believ-
warm baths, Multimodal Pain Management
­present age-related
acupuncture. content to
Mind–body (cognitive-behavioral) interven- heating ice bags, hot the 95% compresses,
or cold of people and
Multimodal pain management incorporates both pharma-
tions include distracting activities, relaxation techniques LIFESPAN
who CONSIDERATIONS
so desperately
warm orneed
coldto sitzhave PCA
help
baths Pump
controlling
(see Chaptertheir 8 pain,).
alert you to d
­ ifferences in caring
and imagery (see Skills 9.5 and 9.6), meditation, biofeed- providing them with competent, compassionate, and appro- cologic and nonpharmacologic approaches to achieve
CHILDREN 3. Acupressure. Based on the ancient Chinese system OLDER of
for clients. priate nursing care based on the bestADULTS possible outcomes for the client. Multimodal
back, hypnosis, cognitive reframing, emotional counsel- • Include the acupuncture,
parents in teaching. thisthe best available
technique uses the information.
fingers to apply • Carefully monitor for drug side effects.
ing, prayer and spiritual activities, and energy-directed analgesia combines analgesics from two or more drug
• Assess the pressure to specific
child’s ability to understand pointsand along meridians
use the client through-• Use cautiously for individuals with impaired pulmonary or renal
approaches such as therapeutic touch or Reiki. Lifestylecontrol button. out the Paserobody. and McCaffery (2011) report that “PCA
classes and a variety of delivery approaches for the anal-
function.
management approaches include symptom monitoring, Reducinghas been Fear
used andand
effectively
4. Contralateral Anxiety
safely in developmentally
stimulation. This technique normal gesics
is the appli-• Assess thattheresult
client’sincognitive
reducing, and often
and physical eliminating,
ability the
to use the client
stress management, exercise, nutrition, disability manage- children ascation
youngof asany
4 yearsof the old”above
(p. 314).cutaneous modalities need
to the for opioids.
control button. This is also referred to as opioid-sparing
It •is Use
important to help relieve strong emotions capable therapy. Multimodal pain therapies include therapies
ment, and other approaches needed by many clients with distraction exacttechniques
location on to avoid dislodging or disconnection
the opposite side of the body.
of amplifying
by the child.pain (e.g., anxiety, anger, and fear). When that are independent of or in addition to pharmacologic
persistent pain that has drastically changed their life. •
clients Usehave no
pediatric opportunity
elbow immobilizers to talk about
(no-nos,
Additional physical approaches to pain management their
Snuggle pain
Wraps) and
if
therapy and include nonpharmacologic therapies such
distraction is nottheireffective in keeping the child from playing with
Physical Interventions associated fears, perceptions and
include immobilizing a painful body part through bracing
tubing and ports.
reactions to the as yoga, massage, biofeedback, acupuncture, mind–body
The goals of physical intervention include providing com- pain can be intensified. Often, these emotions
with splints and supportive devices and transcutaneous are related therapies, and physical therapies. The literature reflects
fort, altering physiologic responses to reduce pain percep- to uncertaintyelectricalaboutnerve the future, feeling
stimulation (TENS). mistreated
See Table 9.7 in fortheadditional
that multimodal pain management is effective for both
tion, and optimizing functioning. Cutaneous stimulation past, or having
information unmet expectations.
regarding By providing
nonpharmacologic accu-
physical interven-
acute and chronic pain (ANA, 2016; Chou et al., 2016;
can provide effective temporary pain relief. It distracts CLIENT
rate TEACHING
theinformation,
tions. Skill the9.3 CONSIDERATIONS
nurse
describescan reduce
how tomany manage of athe
TENSclient’s
unit. Polomano et al., 2017).
fears or anxiety; and clarifying expectations can minimize
ne and Comfort Client Self-Management of Pain (i.e., push the button) 5 to 10 times to receive the same amount
frustration and anger. Specifically, client education about
the
Choose a time to teach the client about pain management when the
range of pain that is considered normal for the condi- Pharmacologic
in a standard “shot.”
Approaches
of medication (10 mg morphine equivalent) they would receive
pain is controlled so that the client is able to focus on the teaching.
tion as well asthethe
Teaching types
client aboutof discomforts
self-management thatofsignal a poten-
C L I NI C A L A L ERT
pain can include Pharmacologic
• Describe the use
S highlight approaches can involve
of the pain scale
important the use
and encourage theof nonopi-
client to
Clinical Alert!
M09_BERM1444_09_SE_C09.indd 272 04/10/2019 19:06
e pain assessment tial
thefor problems will help alleviate this fear and anxiety.
following:
­information such
oidsrespond
such as
as high-risk
• Explore
in nonsteroidal
order to demonstrate understanding.drugs (NSAIDs),
anti-inflammatory
situations. pain relief techniques
a variety of nonpharmacologic
vel, and cognitive • Demonstrate the operation of the PCA pump and explain that that the client is willing to learn and use to promote pain relief

ain intensity scales Emphasize to the client that, at times, treatment may need the client can safely push the button without fear of overmedi- and optimize functioning.
cating. Sometimes it helps clients who are reluctant to repeat- • Explain to the client the need to notify staff when ambulation is
to balance the demands of providing pain reduction with edly push the button to know that they must dose themselves desired (e.g., for bathroom use), if applicable.
mining the client’s
functional improvement. Too much pain medicine might
sistency for nurses M09_BERM1444_09_SE_C09.indd 260 04/10/2019 19:06
impair alertness or gait; too muchNonpharmacologic
pain impairs alertness Approaches client by focusing attention on tactile stimuli and away
and children) and
and ability to move. Thus, a client may have to tolerate
Nonpharmacologic mild
pain management consists of a variety from the painful sensations, thus reducing pain percep-
tion. Selected cutaneous stimulation techniques include:
pain in order to do what is necessary to maximize
of physical, function-and lifestyle pain manage-
cognitive-behavioral,
ating scales (NRS) ment strategies that target the body, mind, spirit, and social
ing and recovery (e.g., cough, deep-breathe, walk). 1. Massage. Varying styles and degrees of pressure are
dicating “no pain” interactions (Table 9.6). Physical modalities include cutane- used, including lymphatic, Swedish (see Skill 9.4), Thai,
ous stimulation, ice or heat, immobilization or therapeutic craniosacral, deep tissue, ice massage, and hot stones.
“worst pain imag- exercises, transcutaneous electrical nerve stimulation, and 2. Application of heat and cold. Includes warm baths,
(0–10) rating scale acupuncture. Mind–body (cognitive-behavioral) interven- heating pads, ice bags, hot or cold compresses, and
tions include distracting activities, relaxation techniques warm or cold sitz baths (see Chapter 8 ).
of word modifiers Not all clients understand or relate to numerical
and imagery (see Skills 9.5pain
and 9.6), meditation, biofeed- 3. Acupressure. Based on the ancient Chinese system of
ho find it difficult rating scales. These include preverbal children,
back, hypnosis, cognitiveolder
reframing, emotional counsel- acupuncture, this technique uses the fingers to apply
For example, after adults with impairments in cognition
ing, prayer and spiritual activities, and energy-directed
or communication, pressure to specific points along meridians through- ix
approaches such as therapeutic touch or Reiki. Lifestyle out the body.
pain nor the worst and clients who do not speak English. Givenapproaches
management the diversityinclude symptom monitoring, 4. Contralateral stimulation. This technique is the appli-
stress management, exercise, nutrition, disability manage- cation of any of the above cutaneous modalities to the
client if it is mild of pain and behaviors among clients spanning a broad
ment, and other approaches needed by many clients with exact location on the opposite side of the body.
(ratings in the 4–6 range of ages and physical and mental persistentcapabilities, it is changed their life.
pain that has drastically
Additional physical approaches to pain management
ange). unrealistic
A01_BERM1444_09_SE_FM.indd 9
to believe a single pain Physical Interventions be
assessment tool can include immobilizing a painful body part through bracing
19/11/2019 18:56
 544 Unit 6 • Nutrition and Elimination

FOCUS ON CLINICAL WHAT IF Urinary Catheterization Using an Indwelling Catheter

THINKING! Check orders of the primary care provider

UNIQUE! What If . . . concept maps Inform the client

visually represent the flow of a skill

Perform hand hygiene, apply clean gloves, perform peri care, perform hand hygiene
and present options for unexpected
outcomes. Assemble the equipment

WHAT IF the female client cannot independently

Position the client, perform hand hygiene
assume a dorsal recumbent position?

Open the catheterization kit

THEN position in a Sims’ THEN have another person
position (side-lying support and hold the client’s
with upper leg flexed
legs in position.
Apply sterile gloves at the hip and knee
to expose the
perineal area).

Organize the supplies in the kit

Lubricate the catheter, attach the prefilled syringe

WHAT IF the labia tissue becomes slippery and

the labia drop back into normal position? Cleanse the meatus

WHAT IF the catheter THEN the catheter

touches the labia is considered
THEN repeat the cleansing process Insert the catheter until contaminated
during insertion?
as the area has become contaminated. urine flows through it
and a new sterile
catheter needs
to be inserted.
WHAT IF no urine is obtained after Advance the catheter
the appropriate length WHAT IF the client c/o
inserting the catheter? discomfort when the THEN immediately
balloon is being withdraw the
inflated? instilled fluid,
Inflate the balloon
Try advancing the catheter advance the
WHAT IF there is catheter, and
resistance when attempt to inflate
If no urine . . . check if the catheter is in the vagina Pull gently on the catheter inflating the balloon? the balloon again.

Secure the catheter tubing to the client and hang the bag below the level of the bladder

If the catheter is in the vagina

Remove the used equipment and make the client comfortable

THEN leave the catheter in place and insert Perform hand hygiene
a new sterile catheter into the urethra.

Document

552 Unit 6 • Nutrition and Elimination

Chapter 20 Review
FO CU SING ON C LIN IC A L T HIN K IN G
at the end of every chapter promotes
­critical thinking with application-­
FOCUSING ON CLINICAL THINKING
M20_BERM1444_09_SE_C20.indd 544 19/09/19 7:01 PM
oriented scenarios and questions. Consider This
1. An older male client requests that the urinal be left in place 4. Following a transurethral resection of the prostate gland (TURP),
between his legs at all times. How would you respond, and significant bleeding may occur. The primary care provider may
why? order “irrigate catheter prn.” How would you determine if the
2. Needing to use the urinal every 30–60 minutes around the clock catheter requires irrigating?
has exhausted an 85-year-old man. However, he voids only 5. The hospitalized client’s urostomy bag was last emptied 4 hours
15–30 mL each time. Is an external urinary device an appropri- ago at 4:00 a.m. It now contains 100 mL. Is this acceptable? If
ate solution? not, what steps would you take?
3. While removing an indwelling catheter, only about 75% of the Answers to Focusing on Clinical Thinking questions are available on the faculty resources site. Please
consult with your instructor.
amount of balloon fluid indicated on the catheter is retrieved.
How would you proceed?

TEST YOUR KNOWLEDGE

1. Which terms are acceptable for use in documenting the process 5. While preparing a client for thoracic surgery, the nurse prepares
of emptying the urinary bladder? Select all that apply. to insert an indwelling urinary catheter. Which is the least appro-
1. Urination priate indication for inserting a retention catheter?
2. Voiding 1. Accurate measurement of intake and output
3. Maturation 2. Avoidance of soiling of the surgical incision and dressing
4. Micturition 3. Avoidance of urine retention and bladder distention
5. Incontinence 4. Client’s inability to void normally postoperatively secondary
2. The nurse is obtaining a urinary elimination history. Which should to anesthesia
x be emphasized due to likely influence on urinary elimination?
1. Cardiovascular system disease
6. When inserting a Foley catheter as opposed to a straight cath-
eter, the nurse must complete which action?
2. Integumentary system disease 1. Perform hand hygiene.
3. Immune system disease 2. Obtain a collection bag and tubing.
4. Respiratory system disease 3. Apply sterile gloves.
3. The nurse is preparing to assist a male client with using a urinal. 4. Lubricate the tip of the catheter prior to insertion.
In what order would the nurse perform this procedure? Place the 7. The nurse is caring for a client with an indwelling urinary catheter
following steps of the procedure in the proper order. in place. What is the nurse’s primary concern when caring for
A01_BERM1444_09_SE_FM.indd 10 1. Place the urinal between the client’s legs. this client? 19/11/2019 18:56
2. Pull the curtain around the bed or close the door to the 1. Maintain the client on bed rest to prevent backflow of urine
 Chapter 20 Review
FOCUSING ON CLINICAL THINKING
Consider This
1. An older male client requests that the urinal be left in place 4. Following a transurethral resection of the prostate gland (TURP),
between his legs at all times. How would you respond, and significant bleeding may occur. The primary care provider may
why? order “irrigate catheter prn.” How would you determine if the
2. Needing to use the urinal every 30–60 minutes around the clock catheter requires irrigating?
has exhausted an 85-year-old man. However, he voids only 5. The hospitalized client’s urostomy bag was last emptied 4 hours
15–30 mL each time. Is an external urinary device an appropri- ago at 4:00 a.m. It now contains 100 mL. Is this acceptable? If
ate solution? not, what steps would you take?
3. While removing an indwelling catheter, only about 75% of the Answers to Focusing on Clinical Thinking questions are available on the faculty resources site. Please
consult with your instructor.
amount of balloon fluid indicated on the catheter is retrieved.
How would you proceed?

TE ST YOUR K N OW LEDGE
helps you prepare for the
NCLEX-RN® exam. Alternate-
TEST YOUR KNOWLEDGE
style questions are included. 1. Which terms are acceptable for use in documenting the process 5. While preparing a client for thoracic surgery, the nurse prepares
of emptying the urinary bladder? Select all that apply. to insert an indwelling urinary catheter. Which is the least appro-
1. Urination priate indication for inserting a retention catheter?
2. Voiding 1. Accurate measurement of intake and output
3. Maturation 2. Avoidance of soiling of the surgical incision and dressing
4. Micturition 3. Avoidance of urine retention and bladder distention
5. Incontinence 4. Client’s inability to void normally postoperatively secondary
2. The nurse is obtaining a urinary elimination history. Which should to anesthesia
be emphasized due to likely influence on urinary elimination? 6. When inserting a Foley catheter as opposed to a straight cath-
1. Cardiovascular system disease eter, the nurse must complete which action?
2. Integumentary system disease 1. Perform hand hygiene.
3. Immune system disease 2. Obtain a collection bag and tubing.
4. Respiratory system disease 3. Apply sterile gloves.
3. The nurse is preparing to assist a male client with using a urinal. 4. Lubricate the tip of the catheter prior to insertion.
In what order would the nurse perform this procedure? Place the 7. The nurse is caring for a client with an indwelling urinary catheter
following steps of the procedure in the proper order. in place. What is the nurse’s primary concern when caring for
1. Place the urinal between the client’s legs. this client?
2. Pull the curtain around the bed or close the door to the 1. Maintain the client on bed rest to prevent backflow of urine
room. from the drainage bag back into the bladder.
3. Apply clean gloves. 2. Encourage fluids to produce urine output.
4. Rinse the urinal and return it to the client’s bedside. 3. Reduce the risk of infection.
5. Remove the urinal. 4. Reduce the risk of skin breakdown.
4. The nurse is caring for a client with benign prostatic hyperplasia 8. The nurse is teaching a client with a urinary diversion how to
and urinary retention. Which catheter would be the best choice reduce the odor of urine. The nurse recognizes that the client
for this client? needs further teaching when the client says:
1. Foley catheter 1. “I will soak my reusable pouch in diluted vinegar solution to
2. Robinson catheter reduce the smell of urine.”
3. Condom catheter 2. “If I drink plenty of fluids, that will help to reduce the urine
4. Coudé catheter smell.”
3. “I can put some baking soda in the pouch to make my urine
less acidic.”
4. “I can buy deodorant drops to put in the pouch and that will
lessen the smell of urine.”

UNIT
3
Applying the Nursing
Process
M20_BERM1444_09_SE_C20.indd 552 19/09/19 7:01 PM

This unit looks at comfort and hygiene skills including bathing, bedmaking, infection
control, heat and cold applications, and pain management. Comfort and hygiene
needs are highly personal, and the nurse must consider the client’s wishes, culture,
and unique requirements when planning and providing care. The client should be END -O F -UNI T Applying the Nursing Process
involved as much as possible in both decision making and care delivery to increase
his or her well-being and autonomy.
activities provide the opportunity to think
through themes and competencies presented
CLIENT: John AGE: 42 Years across chapters in a unit and think critically to
CURRENT MEDICAL DIAGNOSIS: Fractured Left Femur and Left Ulna link theory to nursing practice.
Medical History: John fell asleep while driving home from his Personal and Social History: John lives with his wife in a three-
night shift job and was involved in a collision with another vehicle. story townhouse in the suburbs of a major city. He works the night
He fractured his left femur, requiring placement of pins and traction. shift in a department store. His wife is a high school chemistry
He also fractured his left ulna, which was casted with a synthetic teacher. She is 18 weeks pregnant with their first child. The parents
cast following closed reduction surgery. He has multiple abrasions and siblings of both John and his wife live within a 30-mile radius
and lacerations. A laceration above his left ear required sutures and of their home. As a result, John has many visitors including family,
has become infected with a methicillin-resistant Staphylococcus friends, and coworkers.
aureus (MRSA) infection. He was placed on contact precautions.
John has an infusing IV with a patient-controlled analgesia (PCA)
pump for pain management in his right arm via a percutaneous
intravenous central catheter (PICC).

Questions 5. John tells the nurse he usually showers every day and washes
Assessment his hair in the shower. The nurse, developing his plan of care,
1. The nurse is assessing John for pain, which he ranks as a 6 on a includes interventions to shampoo his hair three times a week.
0–10 scale. What other information will the nurse assess? For what outcomes would the nurse have associated this
2. The nurse offers John a back massage to help him relax as a intervention?
nonpharmacologic pain management technique. What assess-
ments will the nurse perform while providing the back massage? Implementation
6. The nurse initiates contact isolation for John to reduce the risk of
Analysis spreading MRSA. Describe the components of contact isolation
3. List two possible nursing diagnoses that can be identified from to be used for this client.
the medical-personal history and assessment data above. 7. What type of client hygiene interventions would the nurse
include in John’s plan of care?
Planning
4. The nurse plans care for John to include applications of ice Evaluation
to his fractured left arm to manage pain and edema. What 8. Describe the steps to take if the outcomes have not been met or
expected outcomes would the nurse include in the plan of care have been only partially met.
related to this intervention? Applying the Nursing Process suggested answers are available on the faculty resources
site. Please consult with your instructor.

xi
284

M09_BERM1444_09_SE_C09.indd 284 04/10/2019 19:06

A01_BERM1444_09_SE_FM.indd 11 19/11/2019 18:56

 Contents
Acknowledgments iv SKILL 3.1 Assessing Body Temperature 43
Pulse 46
Thank You v Factors Affecting Pulse Rate 46, Pulse Assessment Sites 46
Preface vi SKILL 3.2 Assessing Peripheral Pulses 47
SKILL 3.3 Assessing an Apical Pulse 50
Features of the Ninth Edition vii SKILL 3.4 Assessing an Apical–Radial Pulse 52
Respirations 54
Factors Affecting Respirations 54, Assessing Respirations 54
UNIT 1 Fundamental Care 1
SKILL 3.5 Assessing Respirations 55

CHAPTER 1 Essential Skills 2 Blood Pressure 57

Factors Affecting Blood Pressure 57, Blood Pressure Assessment
Creating and Maintaining the Healing Environment 2
Sites 57, Measuring Blood Pressure 58
Delegation 4 SKILL 3.6 Assessing Blood Pressure 59
Standard Precautions 5 Oxygen Saturation 64
SKILL 1.1 Using Standard Precautions 5
Factors Affecting Oxygen Saturation Readings 64
Hand Hygiene 7 SKILL 3.7 Assessing Oxygen Saturation
SKILL 1.2 Performing Hand Washing 8 (Pulse Oximeter) 64
Personal Protective Equipment 10
Gloves 10, Gowns 10, Face Masks, Face Shields, and Eyewear 11
SKILL 1.3 Applying and Removing Personal Protective CHAPTER 4 Health Assessment 70
Equipment (Gown, Mask, Eyewear, Gloves) 11 Nursing Health History 71
Disposal of Soiled Equipment and Supplies 13 Physical Health Examination 73
Bagging 13, Linens 13, Laboratory Specimens 14, Dishes and Examination Techniques 73, Auscultation 76
­Utensils 14, Blood Pressure Equipment 14, Disposable Needles,
General Survey 76
Syringes, and Sharps 14
General Appearance and Mental Status 76, Vital Signs 76,
Documentation 14 Height and Weight 76
SKILL 4.1 Assessing Appearance and Mental Status 77
CHAPTER 2 Infection Prevention 18
Integument 79
Chain of Infection 19 Skin 79
Method of Transmission 19, Breaking the Chain of Infection 20,
SKILL 4.2 Assessing the Skin 81
Reducing Risks for Infection 20
Hair 84
Maintaining Surgical Asepsis 22 SKILL 4.3 Assessing the Hair 84
Sterile Field 22 Nails 85
SKILL 2.1 Establishing and Maintaining a Sterile Field 24 SKILL 4.4 Assessing the Nails 86
Sterile Gloves 27
Head 87
SKILL 2.2 Applying and Removing Sterile Gloves 28 Skull and Face 87
Caring for Clients with Known or Suspected Infections 29 SKILL 4.5 Assessing the Skull and Face 87
Standard Precautions (see Chapter 1 ) 30, Transmission-Based Eyes and Vision 88
Precautions (see Skill 2.3) 30
SKILL 4.6 Assessing the Eye Structures and
SKILL 2.3 Implementing Transmission-Based Visual Acuity 90
Precautions 30 Ears and Hearing 94
SKILL 4.7 Assessing the Ears and Hearing 94
UNIT 2 Health Assessment 37 Nose and Sinuses 97
SKILL 4.8 Assessing the Nose and Sinuses 97
CHAPTER 3 Vital Signs 38 Mouth and Oropharynx 98
Body Temperature 39 SKILL 4.9 Assessing the Mouth and Oropharynx 99
Factors Affecting Body Temperature 39, Alterations in Body ­Temperature 39, Neck 102
Body Temperature Assessment Sites 40, Types of Thermometers 41 SKILL 4.10 Assessing the Neck 103

xii

A01_BERM1444_09_SE_FM.indd 12 19/11/2019 18:56

 Thorax and Lungs 105 Sputum, Nose, and Throat Specimens 172
Chest Wall Landmarks 105, Chest Shape and Size 106, SKILL 5.8 Collecting a Sputum Specimen 173
Breath Sounds 107 Nose and Throat Specimens 174
SKILL 4.11 Assessing the Thorax and Lungs 108 SKILL 5.9 Obtaining Nose and Throat Specimens 174
The Cardiovascular and Peripheral Vascular Systems 112 Wound Drainage Specimen 176
Heart 112, Central ­Vessels 114 Kinds of Wound Drainage 176
SKILL 4.12 Assessing the Heart and Central Vessels 114 SKILL 5.10 Obtaining a Wound Drainage Specimen 177
Peripheral Vascular System 117 Assisting with Procedures 178
SKILL 4.13 Assessing the Peripheral Vascular System 118 Aspiration and Biopsy Procedures 178
Breasts and Axillae 120 Lumbar Puncture 182, Abdominal Paracentesis 182, ­Thoracentesis 184,
SKILL 4.14 Assessing the Breasts and Axillae 121 Bone Marrow Biopsy 185, Liver Biopsy 186
Abdomen 124 Care of Clients Receiving ­Contrast Media 187
SKILL 4.15 Assessing the Abdomen 126
Musculoskeletal System 130 UNIT 3 Assisting with ­Client Hygiene and
SKILL 4.16 Assessing the Musculoskeletal System 130
Comfort 191
Neurologic System 133
SKILL 4.17 Assessing the Neurologic System 133
CHAPTER 6 Client Hygiene 192
Female Genitals and Inguinal Area 140 Bathing and Skin Care 193
SKILL 4.18 Assessing the Female Genitals and Inguinal
Categories of Baths 193, Long-Term Care Setting 195
Area 141
SKILL 6.1 Bathing an Adult Client 196
Male Genitals and Inguinal Area 143
Perineal-Genital Care 201
SKILL 4.19 Assessing the Male Genitals and Inguinal
SKILL 6.2 Providing Perineal-Genital Care 201
Area 143
Oral Hygiene 203
Anal Area 145
Clients at Risk 204, Special Oral Hygiene 204
SKILL 4.20 Assessing the Anus 145
SKILL 6.3 Brushing and Flossing the Teeth 205
Fluid Balance 146
SKILL 6.4 Providing Special Oral Care for an Unconscious
Daily Weights 148, Vital Signs 148, Fluid Intake and Output 148
or Debilitated Client 208
SKILL 4.21 Assessing Intake and Output 148
Hair Care 210
Brushing and Combing Hair 210, Shampooing the Hair 211
CHAPTER 5 Diagnostic Testing 154 Beard and Mustache Care 212
Diagnostic Testing Phases 154 SKILL 6.5 Providing Hair Care 212
Pretest 154, Intratest 155, Posttest 155 Foot Care 213
Specimen Collection 155 SKILL 6.6 Providing Foot Care 214
Blood Tests 155 Ears 215
SKILL 5.1 Withdrawing Venous Blood (Phlebotomy) 156 Cleaning the Ears 215, Care of Hearing Aids 216
Capillary Blood Glucose 159 SKILL 6.7 Removing, Cleaning, and Inserting a Hearing
SKILL 5.2 Obtaining a Capillary Blood Specimen to Measure Aid 218
Blood Glucose 160
Stool Specimens 162 CHAPTER 7 Bedmaking 222
SKILL 5.3 Obtaining and Testing a Stool Specimen 163 Supporting a Hygienic and Comfortable
Urine Specimens 165 Environment 222
Routine Urine Specimen 165, Timed Urine Specimen 165, Clean-Catch Room Temperature 222, Ventilation 222, Noise 222,
or Midstream Urine Specimen 165 Urine Tests 166, Collecting a Routine Hospital Beds 223, Mattresses 224, Side Rails 224, Footboard or
Urine Specimen 166 ­Footboot 225, Intravenous Rods 225, Trapeze 225
SKILL 5.4 Collecting a Routine Urine Specimen 166 Making Beds 225
Collecting a Timed Urine ­Specimen 168 Unoccupied Bed 225
SKILL 5.5 Collecting a Timed Urine Specimen 168 SKILL 7.1 Changing an Unoccupied Bed 226
Collecting a Urine Specimen for Culture and Sensitivity by Occupied Bed 229
Clean Catch 169 SKILL 7.2 Changing an Occupied Bed 230
SKILL 5.6 Collecting a Urine Specimen for Culture and
Sensitivity by the Clean-Catch Method 169 CHAPTER 8 Heat and Cold Measures 234
SKILL 5.7 Performing Urine Testing 171 Guidelines for Applying Heat and Cold 234
xiii

A01_BERM1444_09_SE_FM.indd 13 19/11/2019 18:56

 Adaptation of Temperature Receptors 234, Rebound SKILL 10.5 Assisting a Client to Sit on the Side of the
Phenomenon 235, Systemic Effects 235, Tolerance and Bed (Dangling) 303
Contraindications 236, The Mind–Body Connection 236 Transferring Clients 304
SKILL 8.1 Applying Dry Heat Measures: Electric Heating SKILL 10.6 Transferring Between Bed and Chair 306
Pad, Aquathermia Pad, Disposable Hot Pack 237 Transferring Between Bed and Stretcher 308
SKILL 8.2 Applying Dry Cold Measures: Ice Bag, Ice Collar, SKILL 10.7 Transferring Between Bed and Stretcher 309
Ice Glove, Disposable Cold Pack 239
Lifting Devices 310
Compresses and Moist Packs 240
SKILL 10.8 Using a Mobile Floor-Based Hydraulic Lift 311
SKILL 8.3 Applying Compresses and Moist Packs 241
Specialized Beds 312
CHAPTER 9 Pain Assessment and Management 244
CHAPTER 11 Mobilizing the Client 316
The Nature of Pain 245
Assisting Clients to Use Wheelchairs 316
Types of Pain 245
SKILL 11.1 Assisting the Client to Use a Wheelchair 317
Location 245, Duration 246, Intensity 246, Etiology 246
Ambulation 319
Concepts Associated with Pain 246
SKILL 11.2 Assisting the Client to Ambulate 320
Factors Affecting the Pain Experience 248
Assisting Clients to Use Mechanical Aids for Walking 322
Ethnic and Cultural Values 248, Developmental Stage 248, Environment
SKILL 11.3 Assisting the Client to Use a Cane 324
and Support People 249, Previous Pain Experiences 250, Meaning of
SKILL 11.4 Assisting the Client to Use Crutches 325
Pain 250, Emotional Responses to Pain 250
SKILL 11.5 Assisting the Client to Use a Walker 329
Pain Assessment 250
Pain History 251, Observation of Behavioral and P­ hysiologic
CHAPTER 12 Fall Prevention, Restraints, and Seizure
Responses 254, Daily Pain Diary 255, Settings 255
Precautions 332
SKILL 9.1 Assessing the Client in Pain 256
Preventing Falls 332
Barriers to Pain Management 257 SKILL 12.1 Using a Bed or Chair Exit Safety Monitoring
Key Strategies in Pain Management 259 Device 335
Acknowledging and Accepting the Client’s Pain 259, Assisting Support
Restraining Clients 336
People 259, Reducing Misconceptions About Pain 260, Reducing Fear
Selecting a Restraint 338
and Anxiety 260, Preventing Pain 260
SKILL 12.2 Applying Restraints 340
Multimodal Pain Management 260
Seizure Precautions 343
Pharmacologic Approaches 260
SKILL 12.3 Implementing Seizure Precautions 343
SKILL 9.2 Managing Pain with a PCA IV Pump 271
Nonpharmacologic Approaches 272
CHAPTER 13 Maintaining Joint Mobility 348
SKILL 9.3 Managing a TENS Unit 274
SKILL 9.4 Providing a Back Massage 275 Range-of-Motion Exercises 349
SKILL 9.5 Teaching Progressive Muscle Relaxation 279 Active Range of Motion 349, Passive Range of Motion 350,
SKILL 9.6 Assisting with Guided Imagery 280 Active-Assistive Range of Motion 351
SKILL 13.1 Performing Passive Range-of-Motion
Exercises 351
UNIT 4 Mobility and Safety 285 Continuous Passive Motion Devices 359

CHAPTER 10 Positioning the Client 286

Body Mechanics 286 UNIT 5 Medication Administration 363
Preventing Musculoskeletal Disorders 287, Elements of Body
Movement 287, Principles of Body Mechanics 288 CHAPTER 14 Drug Calculations 364
Positioning Clients in Bed 290 Systems of Measurement 364
Fowler’s Position 292, Orthopneic Position 293, Dorsal Recumbent Metric System 364
­Position 293, Prone Position 293, Lateral Position 294, Converting Units of Weight and Measure 365
Sims’ Position 294 Converting Weights Within the Metric System 365, Converting Units of
SKILL 10.1 Supporting the Client’s Position in Bed 295 Volume 365, Converting Units of Weight 365
Moving and Turning Clients in Bed 298 Methods of Calculating Dosages 366
SKILL 10.2 Moving a Client Up in Bed 299 Basic Formula 366, Ratio and Proportion Method 367, Fractional
SKILL 10.3 Turning a Client to the Lateral or Prone Position Equation Method 367, Dimensional Analysis Method 367, Calculation
in Bed 301 for Individualized Drug Dosages 368
SKILL 10.4 Logrolling a Client 302 Calculating Intravenous Flow Rates 369
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 Calculating Milliliters per Hour 370, Calculating Drops per Minute 371, Subcutaneous Injections 433
Calculating IV Flow Rates Based on Time 371, Calculating IV Flow Rates SKILL 17.5 Administering a Subcutaneous Injection 434
Based on Body Weight and Time 371 Intramuscular Injections 436, Intramuscular Injection Technique 438
SKILL 17.6 Administering an Intramuscular Injection 440
CHAPTER 15 Administering Oral and Enteral Intravenous Medications 444
Medications 374 Large-Volume Infusions 444
Legal Aspects of Drug Administration 375 SKILL 17.7 Adding Medications to Intravenous Fluid
Containers 444
Effects of Drugs 376
Intermittent Intravenous Infusions 446
Medication Orders 376 SKILL 17.8 Administering Intermittent Intravenous
Types of Medication Orders 377, Essential Parts of a Drug
Medications Using a Secondary Piggyback Set 448
Order 377, Communicating a Medication Order 379
Intravenous Push 450
Routes of Administration 380 SKILL 17.9 Administering Intravenous Medications
Oral 380, Sublingual 380, Buccal 380, Enteral 380 Using IV Push 451
Administering Medications Safely 380
Medication Administration Errors 382, Medication Reconciliation 382, CHAPTER 18 Administering Intravenous
Medication Dispensing Systems 383, Process of Administering Therapy 456
Medications 384, Oral Medications 386 Intravenous Infusions 456
SKILL 15.1 Administering Oral Medications 387 Common Types of Solutions 456, Peripheral Venous Access Site
Nasogastric and Gastrostomy Medications 391 ­Selection 457, Intravenous Infusion Equipment 458
SKILL 15.2 Administering Medications by Enteral Tube 393 Starting an Intravenous Infusion 463
SKILL 18.1 Inserting a Short Peripheral Catheter 463
CHAPTER 16 Administering Topical Medications 400 Establishing Intravenous Infusions 467
Dermatologic Medications 400 SKILL 18.2 Establishing an Intravenous Infusion 468
Transdermal Medications 401 Regulating Intravenous Flow Rates 470
SKILL 16.1 Administering Dermatologic Medications 402 Milliliters per Hour 470, Drops per Minute 470
Ophthalmic Medications 403 SKILL 18.3 Using an Electronic Infusion Device 472
SKILL 16.2 Administering Ophthalmic Medications 403 Maintaining Infusions 473
Otic Medications 405 SKILL 18.4 Maintaining Infusions 474
SKILL 16.3 Administering Otic Medications 406 Intermittent Infusion Devices 476
Nasal Medications 408 SKILL 18.5 Changing a Short Peripheral Catheter to an
SKILL 16.4 Administering Nasal Medications 408 Intermittent Infusion Device 476
Inhaled Medications 409 Discontinuing Infusions 478
SKILL 16.5 Administering Metered-Dose Inhaler SKILL 18.6 Discontinuing an IV Infusion and Removing a
Medications 411 Short Peripheral Catheter 478
Vaginal Medications 412 Blood Transfusions 480
SKILL 16.6 Administering Vaginal Medications 413 Transfusion Reactions 480, Blood Administration 481
SKILL 18.7 Initiating, Maintaining, and Terminating a Blood
Rectal Medications 414
Transfusion 482
SKILL 16.7 Administering Rectal Medications 415
Central Vascular Access Devices 486
CHAPTER 17 Administering Parenteral Types of CVADs 486, Complications Associated with CVADs 486
Medications 418 SKILL 18.8 Managing Central Vascular Access Devices 487
Changing CVAD Dressings 489
Equipment 418
SKILL 18.9 Performing CVAD Dressing Changes 490
Syringes 418, Needles 422
Implanted Vascular Access Devices 491
Preventing Needlestick Injuries 422 SKILL 18.10 Working with Implanted Vascular Access Devices 491
Preparing Injectable Medications 424
Ampules and Vials 424
SKILL 17.1 Preparing Medications from Ampules 426 UNIT 6 Nutrition and Elimination 497
SKILL 17.2 Preparing Medications from Vials 428
Mixing Medications in One Syringe 429 CHAPTER 19 Feeding Clients 498
SKILL 17.3 Mixing Medications Using One Syringe 429 Nutrition 498
Intradermal Injections 431 Altered Nutrition 499, Nutritional Assessment 500, Assisting Clients with
SKILL 17.4 Administering an Intradermal Injection for Special Diets 502, Stimulating the Appetite 504, Assisting Clients with
Skin Tests 431 Meals 504
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 SKILL 19.1 Assisting an Adult to Eat 506 UNIT 7 Circulatory and ­Ventilatory
Enteral Nutrition 507 Support 583
Enteral Access Devices 508
SKILL 19.2 Inserting a Nasogastric Tube 510 CHAPTER 23 Promoting Circulation 584
Testing Feeding Tube Placement 513, Enteral Feedings 513
Preventing Venous Stasis 584
SKILL 19.3 Administering a Tube Feeding 514
Antiemboli Stockings 584
SKILL 19.4 Administering an Intermittent Gastrostomy or
SKILL 23.1 Applying Antiemboli Stockings 585
Jejunostomy Feeding 517
Sequential Compression Devices 587
SKILL 19.5 Removing a Nasogastric Tube 519
SKILL 23.2 Applying a Sequential Compression Device 588
Managing Clogged Feeding Tubes 521
Parenteral Nutrition 521 CHAPTER 24 Breathing Exercises 592
SKILL 19.6 Providing Total Parenteral Nutrition 522
Promoting Oxygenation 592
CHAPTER 20 Assisting with Urinary Elimination 526 Deep Breathing and Coughing 593
SKILL 24.1 Teaching Abdominal (Diaphragmatic)
The Urinary System 526
Breathing 594
Urinary Control 527
Incentive Spirometry 596
Bladder Scanning 528
SKILL 24.2 Using an Incentive Spirometer 597
Urinals 528
Guidelines for the Care of Urinals 528 CHAPTER 25 Oxygen Therapy 602
SKILL 20.1 Assisting with a Urinal 529 Oxygen Therapy 602
Applying an External Urinary Device 530 Safety Precautions for Oxygen Therapy 604
SKILL 20.2 Applying an External Urinary Device 531 Oxygen Delivery Equipment 604
Urinary Catheterization 532 Cannula 604, Face Mask 605, Face Tent 606, Transtracheal
SKILL 20.3 Performing Indwelling Urinary Catheter 607
Catheterization 536 SKILL 25.1 Administering Oxygen by Cannula, Face Mask,
Catheter Care and Removal 543 or Face Tent 608
SKILL 20.4 Performing Catheter Care and Removal 544 Peak Expiratory Flow 610
Urinary Irrigations 545 SKILL 25.2 Measuring Peak Expiratory Flow 610
SKILL 20.5 Performing Bladder Irrigation 545 Noninvasive Positive Pressure Ventilation 611
Urinary Diversion 547
SKILL 20.6 Performing Urinary Ostomy Care 548 CHAPTER 26 Suctioning 614
Oropharyngeal and Nasopharyngeal Airways 614
CHAPTER 21 Assisting with Fecal Elimination 552 Endotracheal Tubes 615
Defecation 552
Tracheostomy 616
Feces 552, Factors That Affect Defecation 553
Upper-Airway Suctioning 616
Bedpans 555
Tracheostomy or Endotracheal Tube Suctioning 617
Guidelines for the Care of Bedpans 556 Open Suction System 617
SKILL 21.1 Assisting with a Bedpan 556
SKILL 26.1 Oral, Oropharyngeal, Nasopharyngeal, and
Enemas 557 ­N asotracheal Suctioning 618
SKILL 21.2 Administering an Enema 559 Closed Suction System 620, Complications of Suctioning 621
Fecal Impaction 561 SKILL 26.2 Suctioning a Tracheostomy or Endotracheal
Removing a Fecal Impaction Digitally 562 Tube 621
SKILL 21.3 Removing a Fecal Impaction 562
Bowel Diversion Ostomies 563 CHAPTER 27 Caring for the Client with a
SKILL 21.4 Changing a Bowel Diversion Ostomy Appliance 567 Tracheostomy 626
Tracheostomy 626
CHAPTER 22 Caring for the Client with Peritoneal Tracheostomy Tubes 626
Dialysis 574 Tracheostomy Care 628
Peritoneal Dialysis 574 Tracheostomy Dressing and Ties 628
SKILL 22.1 Assisting with Peritoneal Dialysis Catheter SKILL 27.1 Providing Tracheostomy Care 628
Insertion 575 Humidification 632, Facilitating Communication 632
Performing Peritoneal Dialysis 577 SKILL 27.2 Capping a Tracheostomy Tube with a Speaking
SKILL 22.2 Conducting Peritoneal Dialysis Procedures 577 Valve 633
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 CHAPTER 28 Caring for the Client on Mechanical SKILL 31.4 Cleaning a Sutured Wound and Changing a
Ventilation 636 Dressing on a Wound with a Drain 697
Wound Drainage Systems 700
Mechanical Ventilation 636
SKILL 31.5 Maintaining Closed Wound Drainage 701
Characteristics of Positive Pressure Ventilators 637, Complications of
Sutures and Staples 702
Mechanical Ventilation 637
SKILL 31.6 Removing Sutures and Staples 704
SKILL 28.1 Caring for the Client on a Mechanical
Irrigating a Wound 706
Ventilator 637
SKILL 31.7 Irrigating a Wound 706
Removing the Client from a Ventilator 642 Sitz Baths 707
Removing the Endotracheal Tube 642
SKILL 31.8 Assisting with a Sitz Bath 708
SKILL 28.2 Weaning the Client from a Ventilator 643 Packing a Wound 709
SKILL 31.9 Performing a Damp-to-Damp Dressing
CHAPTER 29 Caring for the Client with Chest Tube Change 709
Drainage 648 SKILL 31.10 Using Alginates on Wounds 710
Chest Tubes 648 Negative Pressure Wound Therapy 712
Drainage Systems 649 Bandages and Binders 713
Assisting with Chest Tubes 651 SKILL 31.11 Applying Bandages and Binders 714
SKILL 29.1 Assisting with Chest Tube Insertion 651
Managing a Client with Chest Drainage 654 CHAPTER 32 Orthopedic Care 720
SKILL 29.2 Maintaining Chest Tube Drainage 654 Casts 720
Chest Tube Removal 659 Cast Materials 720, Padding Materials 721, Types of Casts 722
SKILL 29.3 Assisting with Chest Tube Removal 659 Care for Clients with Casts 723
SKILL 32.1 Providing Initial Cast Care 723
CHAPTER 30 Administering Emergency Measures to SKILL 32.2 Providing Ongoing Cast Care 725
the H
­ ospitalized Client 662 Traction 729
Rapid Response Teams 662 Purposes of Traction 729, Types of Traction 729, Traction
Equipment 729
Emergency Measures 663
Obstructed Airway 664 SKILL 32.3 Caring for Clients in Skeletal Traction 732
SKILL 30.1 Clearing an Obstructed Airway 665 Orthoses 733
Respiratory Arrest 668
SKILL 30.2 Performing Rescue Breathing 668 CHAPTER 33 Performing Perioperative
Pulselessness and Cardiac Arrest 672 Care 736
SKILL 30.3 Administering External Cardiac Preparing a Client for Surgery 736
Compressions 672 Preoperative Consent 737, Preoperative Assessment 737, Planning for
Automated External Defibrillation 676 Home Care 738, Physical Preparation 738
SKILL 30.4 Administering Automated External Preoperative Teaching 742
Defibrillation 676 SKILL 33.1 Conducting Preoperative Teaching 743
Intraoperative Phase 746
Surgical Hand Antisepsis 746
UNIT 8 Wounds and Injury Care 681 SKILL 33.2 Performing a Surgical Hand Antisepsis
Scrub 747
CHAPTER 31 Performing Wound and Pressure Preparing for the Postoperative Client 749
Injury Care 682
Postoperative Phase 750
Types of Wounds 682 Immediate Postanesthetic Care 750
Pressure Injuries 683, Preventing Pressure Injuries 683
Ongoing Postoperative Nursing Care 751
SKILL 31.1 Assessing Wounds and Pressure Injuries 688
Suction 754
Dressing Wounds 690 SKILL 33.3 Managing Gastrointestinal Suction 755
Dressing Materials 690, Dressing Changes 691, Transparent Wound
Barriers 693, Hydrocolloid Dressings 693 CHAPTER 34 End-of-Life Care 760
SKILL 31.2 Applying a Transparent Wound Barrier or Hydro-
Definitions of Death 760
colloid Dressing 693
SKILL 31.3 Performing a Dry Dressing Change 695 Death-Related Religious and Cultural Practices 761
Treating Wounds 696 Helping Clients Die with Dignity 761
Wound Care and Surgical Dressings 696 Hospice and Palliative Care 762
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 SKILL 34.1 Meeting the Physiologic Needs of the Dying APPENDIX A Answers to Test Your Knowledge 773
Client 763
Care of the Client After Death 766 GLOSSARY 799
SKILL 34.2 Performing Postmortem Care 767 INDEX 810
Caring for the Caregiver 768

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