BOOK
AACN Procedure Manual for High Acuity, Progressive, and Critical Care - E-Book
(2016)
Additional Information
Book Details
Abstract
The AACN Procedure Manual for High Acuity, Progressive, and Critical Care, 7th Edition, authored by the American Association of Critical-Care Nurses, is the authoritative reference to procedures performed in high acuity, progressive, and critical care settings. It visually guides you through procedures unique to the adult critical care environment, including those performed by advanced practice nurses, in an illustrated, step-by-step format. This edition features 17 new procedures, new illustrations, and updated content throughout, reflecting the latest evidence-based guidelines and national and international protocols.
- Authored by the American Association of Critical-Care Nurses, the foremost authority in critical care nursing, the AACN Procedure Manual is the most authoritative reference to procedures performed by nurses in high acuity, progressive, and critical care settings.
- Comprehensive coverage includes all procedures commonly performed by nurses in high acuity, progressive, and critical care settings, including those performed by advanced practice nurses (indicated by an AP icon).
- A straightforward step-by-step organization uses consistent headings to make following a procedure (and finding the various supporting elements) quick and easy.
- Rationales for all interventions in patient and family education, assessment, patient preparation, procedure, and monitoring help you understand the reason for every step.
- The level of evidence is provided when an evidence base exists to substantiate an intervention, giving insight into the strength of information available.
- Advanced practice procedures are clearly identified with an AP icon so you can judge whether a procedure is within your scope of practice.
- Alphabetical Procedure Index inside the front cover provides quick access to the procedures.
- Written by more than 100 expert critical care nurses and extensively reviewed by more than 100 experts in critical care nursing to ensure the accuracy and currency of each procedure.
- Bulleted lists, tables, and detailed illustrations throughout ensure that content is easy to reference and digest.
- NEW! Updated content throughout reflects the latest evidence-based guidelines and national and international protocols.
- NEW! 17 new procedures reflect major additions to nursing practice in high acuity, progressive, and critical care settings.
- NEW! Engaging new illustrations of procedures, equipment, and techniques are integrated throughout.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | cover | ||
| Inside Front Cover | ifc1 | ||
| AACN Procedure Manual for High Acuity, Progressive, and Critical Care | iii | ||
| Copyright Page | iv | ||
| Section Editors | v | ||
| Contributors | vi | ||
| Reviewers | xiii | ||
| Preface | xvii | ||
| Acknowledgments | xix | ||
| Table Of Contents | xx | ||
| Unit I Pulmonary System | 1 | ||
| One Airway Management | 1 | ||
| Procedure 1 Combitube Insertion and Removal | 1 | ||
| Purpose: | 1 | ||
| Prerequisite Nursing Knowledge | 1 | ||
| Equipment | 2 | ||
| Patient and Family Education | 2 | ||
| Patient Assessment and Preparation | 2 | ||
| Patient Assessment | 2 | ||
| Patient Preparation | 3 | ||
| Procedure for Combitube Insertion | 3 | ||
| Procedure for Combitube Removal | 6 | ||
| Expected Outcomes | 6 | ||
| Unexpected Outcomes | 6 | ||
| Patient Monitoring and Care | 7 | ||
| Documentation | 7 | ||
| References and Additional Readings | 7 | ||
| References | 7.e1 | ||
| Additional Readings | 7.e1 | ||
| Procedure 2 Endotracheal Intubation (Perform) | 8 | ||
| Purpose: | 8 | ||
| Prerequisite Nursing Knowledge | 8 | ||
| Equipment | 10 | ||
| Patient and Family Education | 10 | ||
| Patient Assessment and Preparation | 11 | ||
| Patient Assessment | 11 | ||
| Patient Preparation | 11 | ||
| Procedure for Performing Endotracheal Intubation | 12 | ||
| Expected Outcomes | 21 | ||
| Unexpected Outcomes | 21 | ||
| Patient Monitoring and Care | 21 | ||
| Documentation | 22 | ||
| References and Additional Readings | 22 | ||
| References | 22.e1 | ||
| Procedure 3 Endotracheal Intubation (Assist) | 23 | ||
| Purpose: | 23 | ||
| Prerequisite Nursing Knowledge | 23 | ||
| Equipment | 24 | ||
| Patient and Family Education | 25 | ||
| Patient Assessment and Preparation | 25 | ||
| Patient Assessment | 25 | ||
| Patient Preparation | 25 | ||
| Procedure for Performing Endotracheal Intubation | 26 | ||
| Expected Outcomes | 30 | ||
| Unexpected Outcomes | 30 | ||
| Patient Monitoring and Care | 31 | ||
| Documentation | 31 | ||
| References and Additional Readings | 31 | ||
| References | 31.e1 | ||
| Procedure 4 Endotracheal Tube Care and Oral Care Practices for Ventilated and Non-ventilated Patients | 32 | ||
| Purpose: | 32 | ||
| Prerequisite Nursing Knowledge | 32 | ||
| Equipment | 33 | ||
| Patient and Family Education | 33 | ||
| Patient Assessment and Preparation | 33 | ||
| Patient Assessment | 33 | ||
| Patient Preparation | 33 | ||
| Procedure for Endotracheal Tube and Oral Care for Ventilated Patients | 34 | ||
| Procedure for Oral Care: Non-ventilated Patients | 37 | ||
| Expected Outcomes | 37 | ||
| Unexpected Outcomes | 37 | ||
| Patient Monitoring and Care | 38 | ||
| Documentation | 39 | ||
| References and Additional Readings | 39 | ||
| References | 39.e1 | ||
| Procedure 5 Extubation/Decannulation (Perform) | 40 | ||
| Purpose: | 40 | ||
| Prerequisite Nursing Knowledge | 40 | ||
| Equipment | 40 | ||
| Patient and Family Education | 40 | ||
| Patient Assessment and Preparation | 41 | ||
| Patient Assessment | 41 | ||
| Patient Preparation | 41 | ||
| Procedure for Performing Extubation and Decannulation | 41 | ||
| Expected Outcomes | 42 | ||
| Unexpected Outcomes | 42 | ||
| Patient Monitoring and Care | 42 | ||
| Documentation | 43 | ||
| References and Additional Readings | 43 | ||
| References | 43.e1 | ||
| Additional Readings | 43.e1 | ||
| Procedure 6 Extubation/Decannulation (Assist) | 44 | ||
| Purpose: | 44 | ||
| Prerequisite Nursing Knowledge | 44 | ||
| Equipment | 44 | ||
| Patient and Family Education | 44 | ||
| Patient Assessment and Preparation | 45 | ||
| Patient Assessment | 45 | ||
| Patient Preparation | 45 | ||
| Procedure for Assisting with Extubation and Decannulation | 45 | ||
| Expected Outcomes | 45 | ||
| Unexpected Outcomes | 45 | ||
| Patient Monitoring and Care | 46 | ||
| Documentation | 46 | ||
| References and Additional Readings | 46 | ||
| References | 46.e1 | ||
| Additional Readings | 46.e1 | ||
| Procedure 7 King Airway Insertion and Removal | 47 | ||
| Purpose: | 47 | ||
| Prerequisite Nursing Knowledge | 47 | ||
| Equipment | 48 | ||
| Patient and Family Education | 48 | ||
| Patient Assessment and Preparation | 48 | ||
| Patient Assessment | 48 | ||
| Patient Preparation | 48 | ||
| Procedure for King Airway Insertion | 49 | ||
| Procedure for King Airway Removal | 51 | ||
| Expected Outcomes | 51 | ||
| Unexpected Outcomes | 51 | ||
| Patient Monitoring and Care | 51 | ||
| Documentation | 52 | ||
| References and Additional Readings | 52 | ||
| References | 52.e1 | ||
| Additional Reading | 52.e1 | ||
| Procedure 8 Laryngeal Mask Airway | 53 | ||
| Purpose: | 53 | ||
| Prerequisite Nursing Knowledge | 53 | ||
| Equipment | 55 | ||
| Patient and Family Education | 56 | ||
| Patient Assessment and Preparation | 56 | ||
| Patient Assessment | 56 | ||
| Patient Preparation | 56 | ||
| Procedures for Laryngeal Mask Airway (LMA Supreme) Insertion | 56 | ||
| Procedures for Laryngeal Mask Airway (LMA Supreme) Correct Position | 59 | ||
| Procedures for Laryngeal Mask Airway (LMA Supreme) Removal | 60 | ||
| Expected Outcome | 60 | ||
| Unexpected Outcomes | 60 | ||
| Patient Monitoring and Care | 61 | ||
| Documentation | 61 | ||
| References and Additional Readings | 61 | ||
| References | 61.e1 | ||
| Additional Readings | 61.e1 | ||
| Procedure 9 Nasopharyngeal and Oral Airway Insertion | 62 | ||
| Purpose: | 62 | ||
| Prerequisite Nursing Knowledge | 62 | ||
| Nasopharyngeal Airway | 62 | ||
| Oropharyngeal Airway | 62 | ||
| Equipment | 62 | ||
| Patient and Family Education | 64 | ||
| Patient Assessment and Preparation | 64 | ||
| Patient Assessment | 64 | ||
| Patient Preparation | 64 | ||
| Procedure for Nasopharyngeal Airway Insertion | 65 | ||
| Procedure for Oropharyngeal Airway Insertion | 66 | ||
| Expected Outcomes | 67 | ||
| Unexpected Outcomes | 67 | ||
| Patient Monitoring and Care | 67 | ||
| Documentation | 68 | ||
| References and Additional Readings | 68 | ||
| References | 68.e1 | ||
| Additional Readings | 68.e1 | ||
| Procedure 10 Suctioning | 69 | ||
| Purpose: | 69 | ||
| Prerequisite Nursing Knowledge | 69 | ||
| Equipment | 70 | ||
| Patient and Family Education | 71 | ||
| Patient Assessment and Preparation | 71 | ||
| Patient Assessment | 71 | ||
| Patient Preparation | 71 | ||
| Procedure for Endotracheal or Tracheostomy Tube Suctioning | 71 | ||
| Expected Outcomes | 77 | ||
| Unexpected Outcomes | 77 | ||
| Patient Monitoring and Care | 77 | ||
| Documentation | 77 | ||
| References and Additional Readings | 78 | ||
| References | 78.e1 | ||
| Additional Readings | 78.e2 | ||
| Procedure 11 Surgical Cricothyrotomy (Perform) | 79 | ||
| Purpose: | 79 | ||
| Prerequisite Nursing Knowledge | 79 | ||
| Contraindications | 79 | ||
| Absolute | 79 | ||
| Relative | 79 | ||
| Equipment | 79 | ||
| Patient and Family Education | 79 | ||
| Patient Assessment and Preparation | 80 | ||
| Patient Assessment | 80 | ||
| Patient Preparation | 80 | ||
| Procedure for Surgical Cricothyrotomy | 80 | ||
| Expected Outcomes | 83 | ||
| Unexpected Outcomes | 83 | ||
| Patient Monitoring and Care | 83 | ||
| Documentation | 84 | ||
| References and Additional Readings | 84 | ||
| References | 84.e1 | ||
| Procedure 12 Surgical Cricothyrotomy (Assist) | 85 | ||
| Purpose: | 85 | ||
| Prerequisite Nursing Knowledge | 85 | ||
| Contraindications | 85 | ||
| Absolute | 85 | ||
| Relative | 85 | ||
| Equipment | 85 | ||
| Patient and Family Education | 85 | ||
| Patient Assessment and Preparation | 86 | ||
| Patient Assessment | 86 | ||
| Patient Preparation | 86 | ||
| Procedure for Assisting with Surgical Cricothyrotomy | 86 | ||
| Expected Outcomes | 88 | ||
| Unexpected Outcomes | 88 | ||
| Patient Monitoring and Care | 88 | ||
| Documentation | 88 | ||
| References and Additional Readings | 88 | ||
| References | 88.e1 | ||
| Procedure 13 Tracheostomy Cuff and Tube Care | 89 | ||
| Purpose: | 89 | ||
| Prerequisite Nursing Knowledge | 89 | ||
| Equipment | 92 | ||
| Patient and Family Education | 93 | ||
| Patient Assessment and Preparation | 93 | ||
| Patient Assessment | 93 | ||
| Patient Preparation | 93 | ||
| Procedure for Tracheostomy Cuff and Tube Care | 94 | ||
| Expected Outcomes | 98 | ||
| Unexpected Outcomes | 98 | ||
| Patient Monitoring and Care | 99 | ||
| Documentation | 102 | ||
| References and Additional Readings | 102 | ||
| References | 102.e1 | ||
| Additional Reading | 102.e1 | ||
| Two Special Pulmonary Procedures | 103 | ||
| Procedure 14 Continuous End-Tidal Carbon Dioxide Monitoring | 103 | ||
| Purpose: | 103 | ||
| Prerequisite Nursing Knowledge | 103 | ||
| Equipment | 104 | ||
| Patient and Family Education | 104 | ||
| Patient Assessment and Preparation | 104 | ||
| Patient Assessment | 104 | ||
| Patient Preparation | 104 | ||
| Procedure for Continuous End-Tidal Carbon Dioxide Monitoring | 105 | ||
| Expected Outcomes | 106 | ||
| Unexpected Outcomes | 106 | ||
| Patient Monitoring and Care | 106 | ||
| Documentation | 110 | ||
| References and Additional Readings | 110 | ||
| References | 110.e1 | ||
| Additional Readings | 110.e1 | ||
| Procedure 15 Continuous Lateral Rotation Therapy | 111 | ||
| Purpose: | 111 | ||
| Prerequisite Nursing Knowledge | 111 | ||
| Equipment | 112 | ||
| Patient and Family Education | 112 | ||
| Patient Assessment and Preparation | 112 | ||
| Patient Assessment | 112 | ||
| Patient Preparation | 112 | ||
| Procedure Continuous Lateral Rotational Therapy | 112 | ||
| Expected Outcomes | 113 | ||
| Unexpected Outcomes | 113 | ||
| Patient Monitoring and Care | 113 | ||
| Documentation | 114 | ||
| References and Additional Readings | 115 | ||
| References | 115.e1 | ||
| Additional Readings | 115.e1 | ||
| Procedure 16 Continuous Venous Oxygen Saturation Monitoring | 116 | ||
| Purpose: | 116 | ||
| Prerequisite Nursing Knowledge | 116 | ||
| Equipment | 117 | ||
| Patient and Family Education | 118 | ||
| Patient Assessment and Preparation | 118 | ||
| Patient Assessment | 118 | ||
| Patient Preparation | 119 | ||
| Procedure for Continuous Mixed Venous Oxygen Saturation Monitoring | 119 | ||
| Expected Outcomes | 121 | ||
| Unexpected Outcomes | 121 | ||
| Patient Monitoring and Care | 122 | ||
| Documentation | 122 | ||
| References and Additional Readings | 122 | ||
| References | 122.e1 | ||
| Additional Readings | 122.e1 | ||
| Procedure 17 Extracorporeal Life Support (ECLS) and Extracorporeal Membrane Oxygenation (ECMO) | 123 | ||
| Purpose: | 123 | ||
| Prerequisite Nursing Knowledge | 123 | ||
| Equipment | 124 | ||
| Patient and Family Education | 124 | ||
| Patient Assessment and Preparation | 125 | ||
| Patient Assessment | 125 | ||
| Patient Preparation | 125 | ||
| Procedure for Extracorporeal Life Support and Extracorporeal Membrane Oxygenation | 125 | ||
| Expected Outcomes | 130 | ||
| Unexpected Outcomes | 130 | ||
| Patient Monitoring and Care | 130 | ||
| Documentation | 132 | ||
| References and Additional Readings | 133 | ||
| References | 133.e1 | ||
| Additional Readings | 133.e1 | ||
| Procedure 18 Oxygen Saturation Monitoring with Pulse Oximetry | 134 | ||
| Purpose: | 134 | ||
| Prerequisite Nursing Knowledge | 134 | ||
| Equipment | 135 | ||
| Patient and Family Education | 136 | ||
| Patient Assessment and Preparation | 136 | ||
| Patient Assessment | 136 | ||
| Patient Preparation | 136 | ||
| Procedure for Oxygen Saturation Monitoring with Pulse Oximetry | 136 | ||
| Expected Outcomes | 139 | ||
| Unexpected Outcomes | 139 | ||
| Patient Monitoring and Care | 140 | ||
| Documentation | 140 | ||
| References and Additional Readings | 141 | ||
| References | 141.e1 | ||
| Additional Readings | 141.e1 | ||
| Procedure 19 Pronation Therapy | 142 | ||
| Purpose: | 142 | ||
| Prerequisite Nursing Knowledge | 142 | ||
| Equipment | 144 | ||
| Patient and Family Education | 144 | ||
| Patient Assessment and Preparation | 144 | ||
| Patient Assessment | 144 | ||
| Patient Preparation | 145 | ||
| Procedure for Preparation for Manual Prone Therapy | 147 | ||
| Procedure for Manual Pronation Therapy: The Five-Step Method to Prone the Patient (see Fig. 19-1) | 148 | ||
| Procedure for Automated Pronation Therapy (Using the RotoProne Therapy System; see Fig. 19-3) | 151 | ||
| Procedure for Manual Pronation Therapy With the Vollman Prone Positioner (VPP) (the device is no longer manufactured; see Fig. 19-4) | 155 | ||
| Expected Outcomes | 160 | ||
| Unexpected Outcomes | 160 | ||
| Patient Monitoring and Care | 160 | ||
| Documentation | 163 | ||
| References and Additional Readings | 163 | ||
| References | 163.e1 | ||
| Three Thoracic Cavity Management | 164 | ||
| Procedure 20 Autotransfusion | 164 | ||
| Purpose: | 164 | ||
| Prerequisite Nursing Knowledge | 164 | ||
| Equipment | 164 | ||
| Patient and Family Education | 164 | ||
| Patient Assessment and Preparation | 165 | ||
| Patient Assessment | 165 | ||
| Patient Preparation | 165 | ||
| Procedure for Autotransfusion | 165 | ||
| Expected Outcomes | 166 | ||
| Unexpected Outcomes | 166 | ||
| Patient Monitoring and Care | 166 | ||
| Documentation | 167 | ||
| References and Additional Readings | 167 | ||
| References | 167.e1 | ||
| Procedure 21 Chest Tube Placement (Perform) | 168 | ||
| Purpose: | 168 | ||
| Prerequisite Nursing Knowledge | 168 | ||
| Equipment | 169 | ||
| Patient and Family Education | 170 | ||
| Patient Assessment and Preparation | 170 | ||
| Patient Assessment | 170 | ||
| Patient Preparation | 170 | ||
| Procedure for Performing Pleural Chest Tube Placement | 171 | ||
| Expected Outcomes | 176 | ||
| Unexpected Outcomes | 176 | ||
| Patient Monitoring and Care | 176 | ||
| Documentation | 177 | ||
| References and Additional Readings | 177 | ||
| References | 177.e1 | ||
| Additional Readings | 177.e1 | ||
| Procedure 22 Chest Tube Placement (Assist) | 178 | ||
| Purpose: | 178 | ||
| Prerequisite Nursing Knowledge | 178 | ||
| Equipment | 179 | ||
| Patient and Family Education | 179 | ||
| Patient Assessment and Preparation | 179 | ||
| Patient Assessment | 179 | ||
| Patient Preparation | 180 | ||
| Procedure for Assisting with Pleural Chest Tube Placement | 180 | ||
| Expected Outcomes | 182 | ||
| Unexpected Outcomes | 182 | ||
| Patient Monitoring and Care | 182 | ||
| Documentation | 183 | ||
| References and Additional Readings | 183 | ||
| References | 183.e1 | ||
| Additional Readings | 183.e1 | ||
| Procedure 23 Chest Tube Removal (Perform) | 184 | ||
| Purpose: | 184 | ||
| Prerequisite Nursing Knowledge | 184 | ||
| Equipment | 185 | ||
| Patient and Family Education | 185 | ||
| Patient Assessment and Preparation | 185 | ||
| Patient Assessment | 185 | ||
| Patient Preparation | 185 | ||
| Procedure for Performing Chest Tube Removal | 186 | ||
| Expected Outcomes | 188 | ||
| Unexpected Outcomes | 188 | ||
| Patient Monitoring and Care | 188 | ||
| Documentation | 189 | ||
| References and Additional Readings | 189 | ||
| References | 189.e1 | ||
| Procedure 24 Chest Tube Removal (Assist) | 190 | ||
| Purpose: | 190 | ||
| Prerequisite Nursing Knowledge | 190 | ||
| Equipment | 191 | ||
| Patient and Family Education | 191 | ||
| Patient Assessment and Preparation | 191 | ||
| Patient Assessment | 191 | ||
| Patient Preparation | 191 | ||
| Procedure for Assisting with Chest Tube Removal | 192 | ||
| Expected Outcomes | 193 | ||
| Unexpected Outcomes | 193 | ||
| Patient Monitoring and Care | 193 | ||
| Documentation | 194 | ||
| References and Additional Readings | 194 | ||
| References | 194.e1 | ||
| Procedure 25 Closed Chest-Drainage System | 195 | ||
| Purpose: | 195 | ||
| Prerequisite Nursing Knowledge | 195 | ||
| Equipment | 197 | ||
| Disposable Setup (Wet and Dry Systems) | 197 | ||
| Patient and Family Education | 197 | ||
| Patient Assessment and Preparation | 197 | ||
| Patient Assessment | 197 | ||
| Patient Preparation | 198 | ||
| Procedure for Dry Suction Closed Chest-Drainage Systems | 198 | ||
| Procedure for Wet Suction Closed Chest-Drainage Systems | 199 | ||
| Expected Outcomes | 200 | ||
| Unexpected Outcomes | 200 | ||
| Patient Monitoring and Care | 201 | ||
| Documentation | 204 | ||
| References and Additional Readings | 205 | ||
| References | 205.e1 | ||
| Additional Readings | 205.e1 | ||
| Procedure 26 Needle Thoracostomy (Perform) | 206 | ||
| Purpose: | 206 | ||
| Prerequisite Nursing Knowledge | 206 | ||
| Equipment | 206 | ||
| Patient and Family Education | 206 | ||
| Patient Assessment and Preparation | 207 | ||
| Patient Assessment | 207 | ||
| Patient Preparation | 207 | ||
| Procedure for Performing Needle Thoracostomy | 208 | ||
| Expected Outcomes | 209 | ||
| Unexpected Outcomes | 209 | ||
| Patient Monitoring and Care | 209 | ||
| Documentation | 210 | ||
| References and Additional Readings | 210 | ||
| References | 210.e1 | ||
| Procedure 27 Thoracentesis (Perform) | 211 | ||
| Purpose: | 211 | ||
| Prerequisite Nursing Knowledge | 211 | ||
| Equipment | 212 | ||
| Patient and Family Education | 212 | ||
| Patient Assessment and Preparation | 212 | ||
| Patient Assessment | 212 | ||
| Patient Preparation | 213 | ||
| Procedure for Diagnostic and Therapeutic Thoracentesis | 214 | ||
| Expected Outcomes | 219 | ||
| Unexpected Outcomes | 219 | ||
| Patient Monitoring and Care | 220 | ||
| Documentation | 220 | ||
| References and Additional Readings | 221 | ||
| References | 221.e1 | ||
| Additional Readings | 221.e1 | ||
| Procedure 28 Thoracentesis (Assist) | 222 | ||
| Purpose: | 222 | ||
| Prerequisite Nursing Knowledge | 222 | ||
| Equipment | 222 | ||
| Patient and Family Education | 223 | ||
| Patient Assessment and Preparation | 223 | ||
| Patient Assessment | 223 | ||
| Patient Preparation | 223 | ||
| Procedure for Assisting with Diagnostic and Therapeutic Thoracentesis | 224 | ||
| Expected Outcomes | 225 | ||
| Unexpected Outcomes | 225 | ||
| Patient Monitoring and Care | 225 | ||
| Documentation | 226 | ||
| References and Additional Readings | 226 | ||
| References | 226.e1 | ||
| Additional Readings | 226.e1 | ||
| Four Ventilatory Management | 227 | ||
| Procedure 29 Invasive Mechanical Ventilation (Through an Artificial Airway) | 227 | ||
| Purpose: | 227 | ||
| Prerequisite Nursing Knowledge | 227 | ||
| Equipment | 231 | ||
| Patient and Family Education | 231 | ||
| Patient Assessment and Preparation | 232 | ||
| Patient Assessment | 232 | ||
| Patient Preparation | 233 | ||
| Procedure for Invasive Mechanical Ventilation (Through an Artificial Airway): Volume and Pressure Modes | 233 | ||
| Expected Outcomes | 244 | ||
| Unexpected Outcomes | 244 | ||
| Patient Monitoring and Care | 245 | ||
| Documentation | 248 | ||
| References and Additional Readings | 248 | ||
| References | 248.e1 | ||
| Additional Readings | 248.e3 | ||
| Procedure 30 Noninvasive Positive Pressure Ventilation | 249 | ||
| Purpose: | 249 | ||
| Prerequisite Nursing Knowledge | 249 | ||
| Indications for Noninvasive Positive Pressure Ventilation | 250 | ||
| Contraindications for Use of Noninvasive Positive Pressure Ventilation | 251 | ||
| Absolute Contraindications | 251 | ||
| Relative Contraindications | 251 | ||
| Noninvasive Positive Pressure Ventilation Interfaces | 251 | ||
| Modes of Noninvasive Positive Pressure Ventilation | 251 | ||
| Equipment | 251 | ||
| Patient and Family Education | 252 | ||
| Patient Assessment and Preparation | 253 | ||
| Patient Assessment | 253 | ||
| Patient Preparation | 253 | ||
| Procedure for Noninvasive Ventilation (CPAP and Bilevel Ventilation) | 253 | ||
| Expected Outcomes | 256 | ||
| Unexpected Outcomes | 256 | ||
| Patient Monitoring and Care | 257 | ||
| Documentation | 259 | ||
| References and Additional Readings | 260 | ||
| References | 260.e1 | ||
| Additional Readings | 260.e2 | ||
| Procedure 31 Manual Self-Inflating Resuscitation Bag-Valve Device | 261 | ||
| Purpose: | 261 | ||
| Prerequisite Nursing Knowledge | 261 | ||
| Equipment | 261 | ||
| Patient and Family Education | 262 | ||
| Patient Assessment and Preparation | 262 | ||
| Patient Assessment | 262 | ||
| Patient Preparation | 263 | ||
| Procedure for Manual Self-Inflating Resuscitation Bag | 263 | ||
| Expected Outcomes | 266 | ||
| Unexpected Outcomes | 266 | ||
| Patient Monitoring and Care | 267 | ||
| Documentation | 267 | ||
| References and Additional Readings | 267 | ||
| References | 267.e1 | ||
| Additional Reading | 267.e1 | ||
| Procedure 32 Peripheral Nerve Stimulators | 268 | ||
| Purpose: | 268 | ||
| Prerequisite Nursing Knowledge | 268 | ||
| Equipment | 269 | ||
| Patient and Family Education | 269 | ||
| Patient Assessment and Preparation | 269 | ||
| Patient Assessment | 269 | ||
| Patient Preparation | 269 | ||
| Procedures for Peripheral Nerve Stimulators | 270 | ||
| Expected Outcomes | 275 | ||
| Unexpected Outcomes | 275 | ||
| Patient Monitoring and Care | 275 | ||
| Documentation | 276 | ||
| References and Additional Readings | 276 | ||
| References | 276.e1 | ||
| Procedure 33 Weaning Mechanical Ventilation | 277 | ||
| Purpose: | 277 | ||
| Prerequisite Nursing Knowledge | 277 | ||
| Other Criteria That May Be Used for Evaluation of Weaning Readiness | 278 | ||
| Methods of Ventilator Weaning | 279 | ||
| Equipment | 280 | ||
| Patient and Family Education | 280 | ||
| Patient Assessment | 281 | ||
| Patient Preparation | 281 | ||
| Procedure for Ventilator Weaning | 282 | ||
| Expected Outcomes | 282 | ||
| Unexpected Outcomes | 285 | ||
| Patient Monitoring and Care | 285 | ||
| Documentation | 285 | ||
| References and Additional Readings | 285 | ||
| References | 285.e1 | ||
| Additional Readings | 285.e3 | ||
| Unit II Cardiovascular System | 286 | ||
| Five Cardiac Emergencies | 286 | ||
| Procedure 34 Automated External Defibrillation | 286 | ||
| Purpose: | 286 | ||
| Prerequisite Nursing Knowledge | 286 | ||
| Equipment | 287 | ||
| Patient and Family Education | 288 | ||
| Patient Assessment and Preparation | 288 | ||
| Patient Assessment | 288 | ||
| Patient Preparation | 288 | ||
| Procedure for Automated External Defibrillation | 288 | ||
| Expected Outcomes | 291 | ||
| Unexpected Outcomes | 291 | ||
| Patient Monitoring and Care | 291 | ||
| Documentation | 292 | ||
| References and Additional Readings | 292 | ||
| References | 292.e1 | ||
| Procedure 35 Cardioversion | 293 | ||
| Purpose: | 293 | ||
| Prerequisite Nursing Knowledge | 293 | ||
| Equipment | 293 | ||
| Patient and Family Education | 294 | ||
| Patient Assessment and Preparation | 294 | ||
| Patient Assessment | 294 | ||
| Patient Preparation | 294 | ||
| Procedure for Cardioversion | 295 | ||
| Expected Outcomes | 300 | ||
| Unexpected Outcomes | 300 | ||
| Patient Monitoring and Care | 301 | ||
| Documentation | 301 | ||
| References and Additional Readings | 301 | ||
| References | 301.e1 | ||
| Procedure 36 Defibrillation (External) | 302 | ||
| Purpose: | 302 | ||
| Prerequisite Nursing Knowledge | 302 | ||
| Equipment | 302 | ||
| Patient and Family Education | 303 | ||
| Patient Assessment and Preparation | 303 | ||
| Patient Assessment | 303 | ||
| Patient Preparation | 303 | ||
| Procedure for Defibrillation (External) | 304 | ||
| Expected Outcomes | 307 | ||
| Unexpected Outcomes | 307 | ||
| Patient Monitoring and Care | 308 | ||
| Documentation | 309 | ||
| References and Additional Readings | 309 | ||
| References | 309.e1 | ||
| Procedure 37 Defibrillation (Internal) Perform | 310 | ||
| Purpose: | 310 | ||
| Prerequisite Nursing Knowledge | 310 | ||
| Equipment | 310 | ||
| Patient and Family Education | 310 | ||
| Patient Assessment and Preparation | 310 | ||
| Patient Assessment | 310 | ||
| Patient Preparation | 310 | ||
| Procedure for Internal Defibrillation | 311 | ||
| Expected Outcomes | 315 | ||
| Unexpected Outcomes | 315 | ||
| Patient Monitoring and Care | 315 | ||
| Documentation | 316 | ||
| References and Additional Readings | 316 | ||
| References | 316.e1 | ||
| Procedure 38 Defibrillation (Internal) Assist | 317 | ||
| Purpose: | 317 | ||
| Prerequisite Nursing Knowledge | 317 | ||
| Equipment | 317 | ||
| Patient and Family Education | 317 | ||
| Patient Assessment and Preparation | 317 | ||
| Patient Assessment | 317 | ||
| Patient Preparation | 317 | ||
| Procedure for Defibrillation Internal | 318 | ||
| Expected Outcomes | 320 | ||
| Unexpected Outcomes | 320 | ||
| Patient Monitoring and Care | 320 | ||
| Documentation | 321 | ||
| References and Additional Readings | 321 | ||
| References | 321.e1 | ||
| Procedure 39 Emergent Open Sternotomy (Perform) | 322 | ||
| Purpose: | 322 | ||
| Prerequisite Nursing Knowledge | 322 | ||
| Equipment | 322 | ||
| Patient and Family Education | 323 | ||
| Patient Assessment and Preparation | 323 | ||
| Patient Assessment | 323 | ||
| Patient Preparation | 323 | ||
| Procedure for Performing Emergent Open Sternotomy | 324 | ||
| Expected Outcomes | 327 | ||
| Unexpected Outcomes | 327 | ||
| Patient Monitoring and Care | 327 | ||
| Documentation | 328 | ||
| References and Additional Readings | 328 | ||
| References | 328.e1 | ||
| Additional Readings | 328.e1 | ||
| Procedure 40 Emergent Open Sternotomy (Assist) | 329 | ||
| Purpose: | 329 | ||
| Prerequisite Nursing Knowledge | 329 | ||
| Equipment | 329 | ||
| Patient and Family Education | 329 | ||
| Patient Assessment and Preparation | 330 | ||
| Patient Assessment | 330 | ||
| Patient Preparation | 330 | ||
| Procedure for Assisting with Emergent Open Sternotomy | 330 | ||
| Expected Outcomes | 333 | ||
| Unexpected Outcomes | 333 | ||
| Patient Monitoring and Care | 333 | ||
| Documentation | 333 | ||
| References and Additional Readings | 334 | ||
| References | 334.e1 | ||
| Additional Reading | 334.e1 | ||
| Procedure 41 External Wearable Cardioverter-Defibrillator | 335 | ||
| Purpose: | 335 | ||
| Prerequisite Nursing Knowledge | 335 | ||
| Equipment | 336 | ||
| Patient and Family Education | 336 | ||
| Patient Assessment and Preparation | 337 | ||
| Patient Assessment | 337 | ||
| Patient Preparation | 337 | ||
| Procedure for External Wearable Cardioverter-Defibrillator | 337 | ||
| Expected Outcomes | 338 | ||
| Unexpected Outcomes | 338 | ||
| Patient Monitoring and Care | 338 | ||
| Documentation | 339 | ||
| References and Additional Readings | 339 | ||
| References | 339.e1 | ||
| Procedure 42 Pericardiocentesis (Perform) | 340 | ||
| Purpose: | 340 | ||
| Prerequisite Nursing Knowledge | 340 | ||
| Equipment | 340 | ||
| Patient and Family Education | 341 | ||
| Patient Assessment and Preparation | 341 | ||
| Patient Assessment | 341 | ||
| Patient Preparation | 341 | ||
| Procedure for Performing Pericardiocentesis | 342 | ||
| Expected Outcomes | 346 | ||
| Unexpected Outcomes | 346 | ||
| Patient Monitoring and Care | 346 | ||
| Documentation | 348 | ||
| References and Additional Readings | 348 | ||
| References | 348.e1 | ||
| Additional Reading | 348.e1 | ||
| Procedure 43 Pericardiocentesis (Assist) | 349 | ||
| Purpose: | 349 | ||
| Prerequisite Nursing Knowledge | 349 | ||
| Equipment | 349 | ||
| Patient and Family Education | 350 | ||
| Patient Assessment and Preparation | 350 | ||
| Patient Assessment | 350 | ||
| Patient Preparation | 350 | ||
| Procedure for Assisting With Pericardiocentesis | 351 | ||
| Expected Outcomes | 353 | ||
| Unexpected Outcomes | 353 | ||
| Patient Monitoring and Care | 353 | ||
| Documentation | 355 | ||
| References and Additional Readings | 355 | ||
| References | 355.e1 | ||
| Additional Reading | 355.e1 | ||
| Six Cardiac Pacemakers | 356 | ||
| Procedure 44 Atrial Electrogram | 356 | ||
| Purpose: | 356 | ||
| Prerequisite Nursing Knowledge | 356 | ||
| Equipment | 356 | ||
| Patient and Family Education | 357 | ||
| Patient Assessment and Preparation | 357 | ||
| Patient Assessment | 357 | ||
| Patient Preparation | 357 | ||
| Procedure for Atrial Electrogram | 357 | ||
| Expected Outcomes | 364 | ||
| Unexpected Outcomes | 364 | ||
| Patient Monitoring and Care | 364 | ||
| Documentation | 365 | ||
| References and Additional Readings | 365 | ||
| References | 365.e1 | ||
| Additional Reading | 365.e1 | ||
| Procedure 45 Atrial Overdrive Pacing (Perform) | 366 | ||
| Purpose: | 366 | ||
| Prerequisite Nursing Knowledge | 366 | ||
| Equipment | 367 | ||
| Patient and Family Education | 367 | ||
| Patient Assessment and Preparation | 367 | ||
| Patient Assessment | 367 | ||
| Patient Preparation | 367 | ||
| Procedure for Performing Atrial Overdrive Pacing | 368 | ||
| Expected Outcomes | 370 | ||
| Unexpected Outcomes | 370 | ||
| Patient Monitoring and Care | 371 | ||
| Documentation | 372 | ||
| References and Additional Readings | 372 | ||
| References | 372.e1 | ||
| Additional Reading | 372.e1 | ||
| Procedure 46 Epicardial Pacing Wire Removal | 373 | ||
| Purpose: | 373 | ||
| Prerequisite Nursing Knowledge | 373 | ||
| Equipment | 373 | ||
| Patient and Family Education | 373 | ||
| Patient Assessment and Preparation | 373 | ||
| Patient Assessment | 373 | ||
| Patient Preparation | 374 | ||
| Procedure for Epicardial Pacing Wire Removal | 374 | ||
| Expected Outcomes | 375 | ||
| Unexpected Outcomes | 375 | ||
| Patient Monitoring and Care | 375 | ||
| Documentation | 376 | ||
| References and Additional Readings | 376 | ||
| References | 376.e1 | ||
| Procedure 47 Implantable Cardioverter-Defibrillator | 377 | ||
| Purpose: | 377 | ||
| Prerequisite Nursing Knowledge | 377 | ||
| Equipment | 380 | ||
| Patient and Family Education | 380 | ||
| Patient Assessment and Preparation | 381 | ||
| Patient Assessment | 381 | ||
| Patient Preparation | 381 | ||
| Procedure for Implantable Cardioverter-Defibrillator | 383 | ||
| Expected Outcomes | 386 | ||
| Unexpected Outcomes | 386 | ||
| Patient Monitoring and Care | 387 | ||
| Documentation | 387 | ||
| References and Additional Readings | 387 | ||
| References | 387.e1 | ||
| Additional Readings | 387.e1 | ||
| Procedure 48 Permanent Pacemaker (Assessing Function) | 388 | ||
| Purpose: | 388 | ||
| Prerequisite Nursing Knowledge | 388 | ||
| Equipment | 391 | ||
| Patient and Family Education | 391 | ||
| Patient Assessment and Preparation | 391 | ||
| Patient Assessment | 391 | ||
| Patient Preparation | 392 | ||
| Procedure for Assessing Function of Permanent Pacemaker | 392 | ||
| Expected Outcomes | 397 | ||
| Unexpected Outcomes | 397 | ||
| Patient Monitoring and Care | 397 | ||
| Documentation | 397 | ||
| References and Additional Readings | 398 | ||
| References | 398.e1 | ||
| Additional Readings | 398.e1 | ||
| Procedure 49 Temporary Transcutaneous (External) Pacing | 399 | ||
| Purpose: | 399 | ||
| Prerequisite Nursing Knowledge | 399 | ||
| Equipment | 399 | ||
| Patient and Family Education | 400 | ||
| Patient Assessment and Preparation | 400 | ||
| Patient Assessment | 400 | ||
| Patient Preparation | 400 | ||
| Procedure for Temporary Transcutaneous (External) Pacing | 401 | ||
| Expected Outcomes | 404 | ||
| Unexpected Outcomes | 404 | ||
| Patient Monitoring and Care | 404 | ||
| Documentation | 406 | ||
| References and Additional Readings | 406 | ||
| References | 406.e1 | ||
| Additional Reading | 406.e1 | ||
| Procedure 50 Temporary Transvenous Pacemaker Insertion (Perform) | 407 | ||
| Purpose: | 407 | ||
| Prerequisite Nursing Knowledge | 407 | ||
| Equipment | 408 | ||
| Patient and Family Education | 409 | ||
| Patient Assessment and Preparation | 409 | ||
| Patient Assessment | 409 | ||
| Patient Preparation | 409 | ||
| Procedure for Performing Temporary Transvenous Pacemaker Insertion | 410 | ||
| Expected Outcomes | 413 | ||
| Unexpected Outcomes | 413 | ||
| Patient Monitoring and Care | 413 | ||
| Documentation | 414 | ||
| References and Additional Readings | 415 | ||
| References | 415.e1 | ||
| Additional Readings | 415.e1 | ||
| Procedure 51 Temporary Transvenous and Epicardial Pacing | 416 | ||
| Purpose: | 416 | ||
| Prerequisite Nursing Knowledge | 416 | ||
| Equipment | 419 | ||
| Patient and Family Education | 419 | ||
| Patient Assessment and Preparation | 420 | ||
| Patient Assessment | 420 | ||
| Patient Preparation | 420 | ||
| Procedure for Temporary Transvenous and Epicardial Pacing | 420 | ||
| Expected Outcomes | 428 | ||
| Unexpected Outcomes | 428 | ||
| Patient Monitoring and Care | 428 | ||
| Documentation | 429 | ||
| References and Additional Readings | 430 | ||
| References | 430.e1 | ||
| Additional Readings | 430.e1 | ||
| Seven Circulatory Assist Devices | 431 | ||
| Procedure 52 Intraaortic Balloon Pump Management | 431 | ||
| Purpose: | 431 | ||
| Prerequisite Nursing Knowledge | 431 | ||
| Equipment | 432 | ||
| Patient and Family Education | 433 | ||
| Patient Assessment and Preparation | 433 | ||
| Patient Assessment | 433 | ||
| Patient Preparation | 433 | ||
| Procedure for Assisting with IAB Catheter Insertion | 434 | ||
| Procedure for Timing of the IABP | 437 | ||
| Procedure for Balloon-Pressure Waveform | 441 | ||
| Procedure for Troubleshooting | 442 | ||
| Procedure for Weaning and IAB Catheter Removal | 445 | ||
| Expected Outcomes | 446 | ||
| Unexpected Outcomes | 446 | ||
| Patient Monitoring and Care | 446 | ||
| Documentation | 449 | ||
| References and Additional Readings | 449 | ||
| References | 449.e1 | ||
| Additional Readings | 449.e1 | ||
| Procedure 53 Ventricular Assist Devices | 450 | ||
| Purpose: | 450 | ||
| Prerequisite Nursing Knowledge | 450 | ||
| Equipment | 451 | ||
| Patient and Family Education | 452 | ||
| Patient Assessment and Preparation | 452 | ||
| Patient Assessment | 452 | ||
| Patient Preparation | 453 | ||
| Procedure for Ventricular Assist Devices (Temporary/Short Term) | 453 | ||
| Procedure for (Durable/Long Term) | 458 | ||
| Procedure for Acute Driveline Dressing | 463 | ||
| Procedure for Chronic Driveline Dressing | 464 | ||
| Expected Outcomes | 465 | ||
| Unexpected Outcomes | 465 | ||
| Patient Monitoring and Care | 465 | ||
| Documentation | 466 | ||
| References and Additional Readings | 466 | ||
| References | 466.e1 | ||
| Additional Readings | 466.e1 | ||
| Eight Electrocardiographic Leads and Cardiac Monitoring | 467 | ||
| Procedure 54 Cardiac Monitoring and Electrocardiographic Leads | 467 | ||
| Purpose: | 467 | ||
| Prerequisite Nursing Knowledge | 467 | ||
| Equipment | 470 | ||
| Patient and Family Education | 470 | ||
| Patient Assessment and Preparation | 470 | ||
| Patient Assessment | 470 | ||
| Patient Preparation | 470 | ||
| Procedure for Cardiac Monitoring: Hardwire and Telemetry | 471 | ||
| Expected Outcomes | 475 | ||
| Unexpected Outcomes | 475 | ||
| Patient Monitoring and Care | 476 | ||
| Documentation | 476 | ||
| References and Additional Readings | 476 | ||
| References | 476.e1 | ||
| Additional Readings | 476.e1 | ||
| Procedure 55 Extra Electrocardiographic Leads | 477 | ||
| Purpose: | 477 | ||
| Prerequisite Nursing Knowledge | 477 | ||
| Equipment | 478 | ||
| Patient and Family Education | 478 | ||
| Patient Assessment and Preparation | 478 | ||
| Patient Assessment | 478 | ||
| Patient Preparation | 479 | ||
| Procedure for Extra Electrocardiographic Leads | 479 | ||
| Expected Outcomes | 484 | ||
| Unexpected Outcomes | 484 | ||
| Patient Monitoring and Care | 484 | ||
| Documentation | 485 | ||
| References and Additional Readings | 485 | ||
| References | 485.e1 | ||
| Additional Reading | 485.e1 | ||
| Procedure 56 ST-Segment Monitoring (Continuous) | 486 | ||
| Purpose: | 486 | ||
| Prerequisite Nursing Knowledge | 486 | ||
| Equipment | 488 | ||
| Patient and Family Education | 488 | ||
| Patient Assessment and Preparation | 489 | ||
| Patient Assessment | 489 | ||
| Patient Preparation | 489 | ||
| Procedure for Continuous ST-Segment Monitoring | 489 | ||
| Expected Outcomes | 491 | ||
| Unexpected Outcomes | 491 | ||
| Patient Monitoring and Care | 492 | ||
| Documentation | 492 | ||
| References and Additional Readings | 493 | ||
| References | 493.e1 | ||
| Additional Readings | 493.e1 | ||
| Procedure 57 Twelve-Lead Electrocardiogram | 494 | ||
| Purpose: | 494 | ||
| Prerequisite Nursing Knowledge | 494 | ||
| Equipment | 494 | ||
| Patient and Family Education | 494 | ||
| Patient Assessment and Preparation | 495 | ||
| Patient Assessment | 495 | ||
| Patient Preparation | 495 | ||
| Procedure for 12-Lead Electrocardiogram | 496 | ||
| Expected Outcomes | 499 | ||
| Unexpected Outcomes | 499 | ||
| Patient Monitoring and Care | 500 | ||
| Documentation | 500 | ||
| References and Additional Readings | 500 | ||
| References | 500.e1 | ||
| Additional Readings | 500.e1 | ||
| Nine Hemodynamic Monitoring | 501 | ||
| Procedure 58 Arterial Catheter Insertion (Perform) | 501 | ||
| Purpose: | 501 | ||
| Prerequisite Nursing Knowledge | 501 | ||
| Equipment | 502 | ||
| Patient and Family Education | 502 | ||
| Patient Assessment and Preparation | 502 | ||
| Patient Assessment | 502 | ||
| Patient Preparation | 503 | ||
| Procedure for Performing Arterial Catheter Insertion | 503 | ||
| Expected Outcomes | 506 | ||
| Unexpected Outcomes | 506 | ||
| Patient Monitoring and Care | 506 | ||
| Documentation | 507 | ||
| References and Additional Readings | 507 | ||
| References | 507.e1 | ||
| Additional Readings | 507.e1 | ||
| Procedure 59 Arterial Catheter Insertion (Assist), Care, and Removal | 508 | ||
| Purpose: | 508 | ||
| Prerequisite Nursing Knowledge | 508 | ||
| Equipment | 509 | ||
| Patient and Family Education | 510 | ||
| Patient Assessment and Preparation | 510 | ||
| Patient Assessment | 510 | ||
| Patient Preparation | 510 | ||
| Procedure for Assisting With Insertion of an Arterial Catheter | 511 | ||
| Procedure for Troubleshooting an Overdamped Waveform | 514 | ||
| Procedure for Troubleshooting an Underdamped Waveform | 516 | ||
| Procedure for Arterial Catheter Dressing Change | 517 | ||
| Procedure for Removal of the Arterial Catheter | 518 | ||
| Expected Outcomes | 518 | ||
| Unexpected Outcomes | 518 | ||
| Patient Monitoring and Care | 519 | ||
| Documentation | 521 | ||
| References and Additional Readings | 522 | ||
| References | 522.e1 | ||
| Additional Readings | 522.e1 | ||
| Procedure 60 Arterial Pressure–Based Cardiac Output Monitoring | 523 | ||
| Purpose: | 523 | ||
| Prerequisite Nursing Knowledge | 523 | ||
| Equipment | 524 | ||
| Patient and Family Education | 524 | ||
| Patient Assessment and Preparation | 524 | ||
| Patient Assessment | 524 | ||
| Patient Preparation | 524 | ||
| Procedure for Arterial Pressure–Based Cardiac Output Monitoring | 525 | ||
| Expected Outcomes | 527 | ||
| Unexpected Outcomes | 527 | ||
| Patient Monitoring and Care | 528 | ||
| Documentation | 528 | ||
| References and Additional Readings | 529 | ||
| References | 529.e1 | ||
| Additional Readings | 529.e1 | ||
| Procedure 61 Blood Sampling from an Arterial Catheter | 530 | ||
| Purpose: | 530 | ||
| Prerequisite Nursing Knowledge | 530 | ||
| Equipment | 530 | ||
| Patient and Family Education | 530 | ||
| Patient Assessment and Preparation | 530 | ||
| Patient Assessment | 530 | ||
| Patient Preparation | 530 | ||
| Procedure for Blood Sampling From an Arterial Catheter | 531 | ||
| Expected Outcomes | 538 | ||
| Unexpected Outcomes | 538 | ||
| Patient Monitoring and Care | 538 | ||
| Documentation | 538 | ||
| References and Additional Readings | 539 | ||
| References | 539.e1 | ||
| Additional Readings | 539.e1 | ||
| Procedure 62 Blood Sampling from a Central Venous Catheter | 540 | ||
| Purpose: | 540 | ||
| Prerequisite Nursing Knowledge | 540 | ||
| Equipment | 540 | ||
| Patient and Family Education | 540 | ||
| Patient Assessment and Preparation | 540 | ||
| Patient Assessment | 540 | ||
| Patient Preparation | 540 | ||
| Procedure for Blood Sampling from Central Venous Catheters | 541 | ||
| Expected Outcomes | 546 | ||
| Unexpected Outcomes | 546 | ||
| Patient Monitoring and Care | 546 | ||
| Documentation | 547 | ||
| References and Additional Readings | 547 | ||
| References | 547.e1 | ||
| Additional Readings | 547.e1 | ||
| Procedure 63 Blood Sampling from a Pulmonary Artery Catheter | 548 | ||
| Purpose: | 548 | ||
| Prerequisite Nursing Knowledge | 548 | ||
| Equipment | 548 | ||
| Patient and Family Education | 548 | ||
| Patient Assessment and Preparation | 548 | ||
| Patient Assessment | 548 | ||
| Patient Preparation | 548 | ||
| Procedure for Blood Sampling from a Pulmonary Artery Catheter | 549 | ||
| Expected Outcomes | 551 | ||
| Unexpected Outcomes | 551 | ||
| Patient Monitoring and Care | 552 | ||
| Documentation | 552 | ||
| References and Additional Readings | 552 | ||
| References | 552.e1 | ||
| Additional Readings | 552.e1 | ||
| Procedure 64 Cardiac Output Measurement Techniques (Invasive) | 553 | ||
| Purpose: | 553 | ||
| Prerequisite Nursing Knowledge | 553 | ||
| Equipment | 557 | ||
| Patient and Family Education | 558 | ||
| Patient Assessment and Preparation | 558 | ||
| Patient Assessment | 558 | ||
| Patient Preparation | 559 | ||
| Procedure for Measurement of Cardiac Output With the Closed or Open Thermodilution Method | 559 | ||
| Procedure for Closed-Method of Syringe Preparation and Cardiac Output Determination | 561 | ||
| Procedure for Open Method of Syringe Preparation and Cardiac Output Determination | 563 | ||
| Procedure for Measurement of Cardiac Output With Continuous Cardiac Output Method | 565 | ||
| Expected Outcomes | 567 | ||
| Unexpected Outcomes | 567 | ||
| Patient Monitoring and Care | 567 | ||
| Documentation | 568 | ||
| References and Additional Readings | 568 | ||
| References | 568.e1 | ||
| Additional Readings | 568.e2 | ||
| Procedure 65 Central Venous Catheter Removal | 569 | ||
| Purpose: | 569 | ||
| Prerequisite Nursing Knowledge | 569 | ||
| Equipment | 569 | ||
| Patient and Family Education | 569 | ||
| Patient Assessment and Preparation | 569 | ||
| Patient Assessment | 569 | ||
| Patient Preparation | 569 | ||
| Procedure for Central Venous Catheter Removal | 570 | ||
| Expected Outcomes | 572 | ||
| Unexpected Outcomes | 572 | ||
| Patient Monitoring and Care | 572 | ||
| Documentation | 573 | ||
| References and Additional Readings | 573 | ||
| References | 573.e1 | ||
| Additional Readings | 573.e1 | ||
| Procedure 66 Central Venous Catheter Site Care | 574 | ||
| Purpose: | 574 | ||
| Prerequisite Nursing Knowledge | 574 | ||
| Equipment | 574 | ||
| Patient and Family Education | 574 | ||
| Patient Assessment and Preparation | 574 | ||
| Patient Assessment | 574 | ||
| Patient Preparation | 574 | ||
| Procedure for Central Venous Catheter Site Care | 575 | ||
| Expected Outcomes | 576 | ||
| Unexpected Outcomes | 576 | ||
| Patient Monitoring and Care | 576 | ||
| Documentation | 576 | ||
| References and Additional Readings | 577 | ||
| References | 577.e1 | ||
| Additional Readings | 577.e1 | ||
| Procedure 67 Central Venous/Right Atrial Pressure Monitoring | 578 | ||
| Purpose: | 578 | ||
| Prerequisite Nursing Knowledge | 578 | ||
| Equipment | 578 | ||
| Patient and Family Education | 578 | ||
| Patient Assessment and Preparation | 578 | ||
| Patient Assessment | 578 | ||
| Patient Preparation | 579 | ||
| Procedure for Central Venous/Right-Atrial Pressure Monitoring | 579 | ||
| Expected Outcomes | 581 | ||
| Unexpected Outcomes | 581 | ||
| Patient Monitoring and Care | 582 | ||
| Documentation | 583 | ||
| References and Additional Readings | 583 | ||
| References | 583.e1 | ||
| Additional Readings | 583.e1 | ||
| Procedure 68 Esophageal Cardiac Output Monitoring | 584 | ||
| Purpose: | 584 | ||
| Prerequisite Nursing Knowledge | 584 | ||
| Equipment | 585 | ||
| Patient and Family Education | 585 | ||
| Patient Assessment and Preparation | 585 | ||
| Patient Assessment | 585 | ||
| Patient Preparation | 585 | ||
| Procedure for Esophageal Cardiac Output Monitoring: Perform | 586 | ||
| Expected Outcomes | 588 | ||
| Unexpected Outcomes | 588 | ||
| Patient Monitoring and Care | 588 | ||
| Documentation | 588 | ||
| References and Additional Readings | 589 | ||
| Additional Readings | 589.e1 | ||
| Procedure 69 Esophageal Cardiac Output Monitoring | 590 | ||
| Purpose: | 590 | ||
| Prerequisite Nursing Knowledge | 590 | ||
| Equipment | 590 | ||
| Patient and Family Education | 590 | ||
| Patient Assessment and Preparation | 591 | ||
| Patient Assessment | 591 | ||
| Patient Preparation | 592 | ||
| Procedure for Esophageal Cardiac Output Monitoring: Assist, Care, and Removal | 592 | ||
| Expected Outcomes | 594 | ||
| Unexpected Outcomes | 594 | ||
| Patient Monitoring and Care | 594 | ||
| Documentation | 595 | ||
| References and Additional Readings | 595 | ||
| Additional Readings | 595.e1 | ||
| Procedure 70 Noninvasive Cardiac Output Monitoring | 596 | ||
| Purpose: | 596 | ||
| Prerequisite Nursing Knowledge | 596 | ||
| Equipment | 596 | ||
| Patient and Family Education | 597 | ||
| Patient Assessment and Preparation | 597 | ||
| Patient Assessment | 597 | ||
| Patient Preparation | 597 | ||
| Procedure for Noninvasive Cardiac Output Monitoring | 597 | ||
| Expected Outcomes | 599 | ||
| Unexpected Outcomes | 599 | ||
| Patient Monitoring and Care | 599 | ||
| Documentation | 599 | ||
| References and Additional Readings | 600 | ||
| References | 600.e1 | ||
| Procedure 71 Pulmonary Artery Catheter Insertion (Perform) | 601 | ||
| Purpose: | 601 | ||
| Prerequisite Nursing Knowledge | 601 | ||
| Equipment | 603 | ||
| Patient and Family Education | 603 | ||
| Patient Assessment and Preparation | 603 | ||
| Patient Assessment | 603 | ||
| Patient Preparation | 604 | ||
| Procedure for Performing Pulmonary Artery Catheter Insertion | 604 | ||
| Expected Outcomes | 607 | ||
| Unexpected Outcomes | 607 | ||
| Patient Monitoring and Care | 607 | ||
| Documentation | 608 | ||
| References and Additional Readings | 608 | ||
| References | 608.e1 | ||
| Additional Readings | 608.e1 | ||
| Procedure 72 Pulmonary Artery Catheter Insertion (Assist) and Pressure Monitoring | 609 | ||
| Purpose: | 609 | ||
| Prerequisite Nursing Knowledge | 609 | ||
| Equipment | 612 | ||
| Patient and Family Education | 612 | ||
| Patient Assessment and Preparation | 613 | ||
| Patient Assessment | 613 | ||
| Patient Preparation | 613 | ||
| Procedure for Assisting With Pulmonary Artery Catheter Insertion and Pressure Monitoring | 613 | ||
| Expected Outcomes | 626 | ||
| Unexpected Outcomes | 626 | ||
| Patient Monitoring and Care | 626 | ||
| Documentation | 629 | ||
| References and Additional Readings | 629 | ||
| References | 629.e1 | ||
| Additional Readings | 629.e1 | ||
| Procedure 73 Pulmonary Artery Catheter Removal | 630 | ||
| Purpose: | 630 | ||
| Prerequisite Nursing Knowledge | 630 | ||
| Equipment | 630 | ||
| Patient and Family Education | 630 | ||
| Patient Assessment and Preparation | 631 | ||
| Patient Assessment | 631 | ||
| Patient Preparation | 631 | ||
| Procedure for Pulmonary Artery Catheter Removal | 631 | ||
| Expected Outcomes | 634 | ||
| Unexpected Outcomes | 634 | ||
| Patient Monitoring and Care | 635 | ||
| Documentation | 636 | ||
| References and Additional Readings | 636 | ||
| References | 636.e1 | ||
| Additional Readings | 636.e1 | ||
| Procedure 74 Pulmonary Artery Catheter and Pressure Lines, Troubleshooting | 637 | ||
| Purpose: | 637 | ||
| Prerequisite Nursing Knowledge | 637 | ||
| Equipment | 637 | ||
| Patient and Family Education | 638 | ||
| Patient Assessment and Preparation | 638 | ||
| Patient Assessment | 638 | ||
| Patient Preparation | 638 | ||
| Procedure for Pulmonary Artery Catheter and Pressure Lines, Troubleshooting | 638 | ||
| Expected Outcomes | 651 | ||
| Unexpected Outcomes | 651 | ||
| Patient Monitoring and Care | 651 | ||
| Documentation | 652 | ||
| References and Additional Readings | 652 | ||
| References | 652.e1 | ||
| Additional Readings | 652.e1 | ||
| Procedure 75 Single-Pressure and Multiple-Pressure Transducer Systems | 653 | ||
| Purpose: | 653 | ||
| Prerequisite Nursing Knowledge | 653 | ||
| Equipment | 653 | ||
| Patient and Family Education | 653 | ||
| Patient Assessment and Preparation | 653 | ||
| Patient Assessment | 653 | ||
| Patient Preparation | 654 | ||
| Procedure for Single-Pressure and Multiple-Pressure Transducer Systems | 655 | ||
| Expected Outcomes | 661 | ||
| Unexpected Outcomes | 661 | ||
| Patient Monitoring and Care | 662 | ||
| Documentation | 663 | ||
| References and Additional Readings | 663 | ||
| References | 663.e1 | ||
| Additional Readings | 663.e2 | ||
| Ten Special Cardiac Procedures | 664 | ||
| Procedure 76 Femoral Arterial and Venous Sheath Removal | 664 | ||
| Purpose: | 664 | ||
| Prerequisite Nursing Knowledge | 664 | ||
| Equipment | 664 | ||
| Patient and Family Education | 665 | ||
| Patient Assessment and Preparation | 665 | ||
| Patient Assessment | 665 | ||
| Patient Preparation | 665 | ||
| Procedure for Arterial and Venous Sheath Removal | 666 | ||
| Expected Outcomes | 670 | ||
| Unexpected Outcomes | 670 | ||
| Patient Monitoring and Care | 670 | ||
| Documentation | 671 | ||
| References and Additional Readings | 671 | ||
| References | 671.e1 | ||
| Additional Readings | 671.e2 | ||
| Procedure 77 Radial Arterial Sheath Removal | 672 | ||
| Purpose: | 672 | ||
| Prerequisite Nursing Knowledge | 672 | ||
| Equipment | 672 | ||
| Patient and Family Education | 672 | ||
| Patient Assessment and Preparation | 673 | ||
| Patient Assessment | 673 | ||
| Patient Preparation | 673 | ||
| Procedure for Radial Arterial Sheath Removal | 673 | ||
| Expected Outcomes | 676 | ||
| Unexpected Outcomes | 676 | ||
| Patient Monitoring and Care | 676 | ||
| Documentation | 677 | ||
| References and Additional Readings | 677 | ||
| References | 677.e1 | ||
| Additional Readings | 677.e1 | ||
| Procedure 78 Pericardial Catheter Management | 678 | ||
| Purpose: | 678 | ||
| Prerequisite Nursing Knowledge | 678 | ||
| Equipment | 678 | ||
| Patient and Family Education | 679 | ||
| Patient Assessment and Preparation | 679 | ||
| Patient Assessment | 679 | ||
| Patient Preparation | 679 | ||
| Procedure for Pericardial Catheter Management | 680 | ||
| Expected Outcomes | 691 | ||
| Unexpected Outcomes | 691 | ||
| Patient Monitoring and Care | 691 | ||
| Documentation | 692 | ||
| References and Additional Readings | 692 | ||
| References | 692.e1 | ||
| Procedure 79 Thenar Tissue Oxygen Saturation Monitoring | 693 | ||
| Purpose: | 693 | ||
| Prerequisite Nursing Knowledge | 693 | ||
| Equipment | 693 | ||
| Patient and Family Education | 693 | ||
| Patient Assessment and Preparation | 693 | ||
| Patient Assessment | 693 | ||
| Patient Preparation | 694 | ||
| Procedure for Thenar Tissue Oxygenation (Sto2) Monitoring | 695 | ||
| Expected Outcomes | 696 | ||
| Unexpected Outcomes | 696 | ||
| Patient Monitoring and Care | 696 | ||
| Documentation | 697 | ||
| References and Additional Readings | 697 | ||
| References | 697.e1 | ||
| Additional Reading | 697.e1 | ||
| Procedure 80 Transesophageal Echocardiography (Assist) | 698 | ||
| Purpose: | 698 | ||
| Prerequisite Nursing Knowledge | 698 | ||
| Equipment | 699 | ||
| Patient and Family Education | 700 | ||
| Patient Assessment and Preparation | 700 | ||
| Patient Assessment | 700 | ||
| Patient Preparation | 701 | ||
| Procedure for Transesophageal Echocardiography (Assist) | 701 | ||
| Expected Outcomes | 703 | ||
| Unexpected Outcomes | 703 | ||
| Patient Monitoring and Care | 704 | ||
| Documentation | 706 | ||
| References and Additional Readings | 706 | ||
| References | 706.e1 | ||
| Additional Readings | 706.e1 | ||
| Eleven Vascular Access | 707 | ||
| Procedure 81 Arterial Puncture | 707 | ||
| Purpose: | 707 | ||
| Prerequisite Nursing Knowledge | 707 | ||
| Equipment | 707 | ||
| Patient and Family Education | 708 | ||
| Patient Assessment and Preparation | 708 | ||
| Patient Assessment | 708 | ||
| Patient Preparation | 708 | ||
| Procedure for Arterial Puncture | 709 | ||
| Expected Outcomes | 713 | ||
| Unexpected Outcomes | 713 | ||
| Patient Monitoring and Care | 713 | ||
| Documentation | 713 | ||
| References and Additional Readings | 713 | ||
| References | 713.e1 | ||
| Procedure 82 Central Venous Catheter Insertion (Perform) | 714 | ||
| Purpose: | 714 | ||
| Prerequisite Nursing Knowledge | 714 | ||
| Equipment | 714 | ||
| Patient and Family Education | 718 | ||
| Patient Assessment and Preparation | 718 | ||
| Patient Assessment | 718 | ||
| Patient Preparation | 719 | ||
| Procedure for Performing Central Venous Catheter Insertion | 719 | ||
| Expected Outcomes | 729 | ||
| Unexpected Outcomes | 729 | ||
| Patient Monitoring and Care | 729 | ||
| Documentation | 730 | ||
| References and Additional Readings | 730 | ||
| References | 730.e1 | ||
| Additional Readings | 730.e1 | ||
| Procedure 83 Central Venous Catheter Insertion (Assist) | 731 | ||
| Purpose: | 731 | ||
| Prerequisite Nursing Knowledge | 731 | ||
| Equipment | 731 | ||
| Patient and Family Education | 732 | ||
| Patient Assessment and Preparation | 732 | ||
| Patient Assessment | 732 | ||
| Patient Preparation | 732 | ||
| Procedure for Assisting with Central Venous Catheter Insertion | 733 | ||
| Expected Outcomes | 735 | ||
| Unexpected Outcomes | 735 | ||
| Patient Monitoring and Care | 736 | ||
| Documentation | 736 | ||
| References and Additional Readings | 737 | ||
| References | 737.e1 | ||
| Additional Readings | 737.e1 | ||
| Procedure 84 Implantable Venous Access Device | 738 | ||
| Purpose: | 738 | ||
| Prerequisite Nursing Knowledge | 738 | ||
| Equipment | 738 | ||
| Patient and Family Education | 739 | ||
| Patient Assessment and Preparation | 739 | ||
| Patient Assessment | 739 | ||
| Patient Preparation | 739 | ||
| Procedure for Implantable Venous Access Device: Access, Deaccess, and Care | 740 | ||
| Expected Outcomes | 746 | ||
| Unexpected Outcomes | 746 | ||
| Patient Monitoring and Care | 746 | ||
| Documentation | 747 | ||
| References and Additional Readings | 747 | ||
| References | 747.e1 | ||
| Additional Readings | 747.e1 | ||
| Procedure 85 Intraosseous Devices | 748 | ||
| Purpose: | 748 | ||
| Prerequisite Nursing Knowledge | 748 | ||
| Equipment | 750 | ||
| Patient and Family Education | 750 | ||
| Patient Assessment and Preparation | 751 | ||
| Patient Assessment | 751 | ||
| Patient Preparation | 751 | ||
| Procedure for Intraosseous Access | 751 | ||
| Expected Outcomes | 756 | ||
| Unexpected Outcomes | 756 | ||
| Patient Monitoring and Care | 756 | ||
| Documentation | 756 | ||
| References and Additional Readings | 757 | ||
| References | 757.e1 | ||
| Additional Readings | 757.e1 | ||
| Procedure 86 Midline Catheters | 758 | ||
| Purpose: | 758 | ||
| Prerequisite Nursing Knowledge | 758 | ||
| Equipment | 758 | ||
| Patient and Family Education | 759 | ||
| Patient Assessment and Preparation | 759 | ||
| Patient Assessment | 759 | ||
| Patient Preparation | 759 | ||
| Procedure for Peripherally Inserted Central Catheter | 760 | ||
| Expected Outcomes | 763 | ||
| Unexpected Outcomes | 763 | ||
| Patient Monitoring and Care | 763 | ||
| Documentation | 764 | ||
| References and Additional Readings | 765 | ||
| References | 765.e1 | ||
| Additional Readings | 765.e1 | ||
| Procedure 87 Peripherally Inserted Central Catheter | 766 | ||
| Purpose: | 766 | ||
| Prerequisite Nursing Knowledge | 766 | ||
| Equipment | 767 | ||
| Patient and Family Education | 768 | ||
| Patient Assessment and Preparation | 768 | ||
| Patient Assessment | 768 | ||
| Patient Preparation | 769 | ||
| Procedure for Peripherally Inserted Central Catheter | 770 | ||
| Expected Outcomes | 775 | ||
| Unexpected Outcomes | 775 | ||
| Patient Monitoring and Care | 775 | ||
| Documentation | 777 | ||
| References and Additional Readings | 777 | ||
| References | 777.e1 | ||
| Additional Readings | 777.e1 | ||
| Unit III Neurologic System | 778 | ||
| Twelve Neurologic Monitoring | 778 | ||
| Procedure 88 Bispectral Index Monitoring | 778 | ||
| Purpose: | 778 | ||
| Prerequisite Nursing Knowledge | 778 | ||
| Equipment | 784 | ||
| Patient and Family Education | 784 | ||
| Patient Assessment and Preparation | 784 | ||
| Patient Assessment | 784 | ||
| Patient Preparation | 785 | ||
| Procedure for Bispectral Index Monitoring | 785 | ||
| Expected Outcomes | 789 | ||
| Unexpected Outcomes | 789 | ||
| Patient Monitoring and Care | 789 | ||
| Documentation | 790 | ||
| References and Additional Readings | 791 | ||
| References | 791.e1 | ||
| Additional Readings | 791.e2 | ||
| Procedure 89 Brain Tissue Oxygen Monitoring | 792 | ||
| Purpose: | 792 | ||
| Prerequisite Nursing Knowledge | 792 | ||
| Patient and Family Education | 796 | ||
| Patient Assessment and Preparation | 796 | ||
| Patient Assessment | 796 | ||
| Patient Preparation | 797 | ||
| Equipment | 797 | ||
| For the RAUMEDIC Neurovent-PTO Monitoring System | 797 | ||
| For the Integra Licox Pto2 Monitor | 797 | ||
| Procedure for Brain Tissue Oxygen Monitoring for the Integra Licox Pto2 Monitor: Insertion (Assist) and Care | 797 | ||
| Procedure for Brain Tissue Oxygen Monitoring for the Integra Licox CMP Monitor: Insertion (Assist) and Care | 801 | ||
| Procedure for Brain Tissue Oxygen Monitoring for the RAUMEDIC NEUROVENT-PTO Monitor: Insertion (Assist) and Care | 804 | ||
| Expected Outcomes | 809 | ||
| Unexpected Outcomes | 809 | ||
| Patient Monitoring and Care | 809 | ||
| Documentation | 810 | ||
| References and Additional Readings | 810 | ||
| References | 810.e1 | ||
| Additional Readings | 810.e1 | ||
| Procedure 90 Cerebral Blood Flow Monitoring | 811 | ||
| Purpose: | 811 | ||
| Prerequisite Nursing Knowledge | 811 | ||
| Equipment | 816 | ||
| Patient and Family Education | 816 | ||
| Patient Assessment and Preparation | 816 | ||
| Patient Assessment | 816 | ||
| Patient Preparation | 816 | ||
| Procedure for Cerebral Blood Flow Monitoring: Insertion (Assist), Care, Troubleshooting, and Removal | 817 | ||
| Expected Outcomes | 820 | ||
| Unexpected Outcomes | 820 | ||
| Patient Monitoring and Care | 821 | ||
| Documentation | 821 | ||
| References and Additional Readings | 822 | ||
| References | 822.e1 | ||
| Additional Readings | 822.e1 | ||
| Procedure 91 Cerebral Microdialysis | 823 | ||
| Purpose: | 823 | ||
| Prerequisite Nursing Knowledge | 823 | ||
| Equipment | 824 | ||
| Patient and Family Education | 824 | ||
| Patient Assessment and Preparation | 824 | ||
| Patient Assessment | 824 | ||
| Patient Preparation | 824 | ||
| Procedure for Performing Cerebral Microdialysis | 824 | ||
| Expected Outcomes | 827 | ||
| Unexpected Outcomes | 827 | ||
| Patient Monitoring and Care | 827 | ||
| Documentation | 828 | ||
| References and Additional Readings | 828 | ||
| References | 828.e1 | ||
| Procedure 92 Intracranial Bolt and Fiberoptic Catheter Insertion (Assist), Intracranial Pressure Monitoring, Care, Troubleshooting, and Removal | 829 | ||
| Purpose: | 829 | ||
| Prerequisite Nursing Knowledge | 829 | ||
| Equipment | 831 | ||
| Patient and Family Education | 831 | ||
| Patient Assessment and Preparation | 831 | ||
| Patient Assessment | 831 | ||
| Patient Preparation | 831 | ||
| Procedure for Intracranial Bolt and Fiberoptic Catheter Insertion (Assist), Intracranial Pressure Monitoring, Care, Troubleshooting, and Removal | 832 | ||
| Expected Outcomes | 833 | ||
| Unexpected Outcomes | 833 | ||
| Patient Monitoring and Care | 833 | ||
| Documentation | 834 | ||
| References and Additional Readings | 834 | ||
| References | 834.e1 | ||
| Additional Reading | 834.e1 | ||
| Procedure 93 Intraventricular/Fiberoptic Catheter Insertion (Assist), Monitoring, Nursing Care, Troubleshooting, and Removal | 835 | ||
| Purpose: | 835 | ||
| Prerequisite Nursing Knowledge | 835 | ||
| Equipment | 836 | ||
| Patient and Family Education | 836 | ||
| Patient Assessment and Preparation | 836 | ||
| Patient Assessment | 836 | ||
| Patient Preparation | 837 | ||
| Procedure for Combination Intraventricular/Fiberoptic Catheter Insertion (Assist), Monitoring, Nursing Care, Troubleshooting, and Removal | 837 | ||
| Expected Outcomes | 839 | ||
| Unexpected Outcomes | 839 | ||
| Patient Monitoring and Care | 840 | ||
| Documentation | 841 | ||
| References and Additional Readings | 841 | ||
| References | 841.e1 | ||
| Procedure 94 Intraventricular Catheter with External Transducer for Cerebrospinal Fluid Drainage and Intracranial Pressure Monitoring | 842 | ||
| Purpose: | 842 | ||
| Prerequisite Nursing Knowledge | 842 | ||
| Equipment | 843 | ||
| Patient and Family Education | 843 | ||
| Patient Assessment and Preparation | 844 | ||
| Patient Assessment | 844 | ||
| Patient Preparation | 844 | ||
| Procedure for Pressure Monitoring and Drainage | 844 | ||
| Expected Outcomes | 844 | ||
| Unexpected Outcomes | 851 | ||
| Patient Monitoring and Care | 852 | ||
| Documentation | 853 | ||
| References and Additional Readings | 855 | ||
| References | 855.e1 | ||
| Additional Readings | 855.e2 | ||
| Procedure 95 Lumbar Subarachnoid Catheter Insertion (Assist) for Cerebrospinal Fluid Drainage and Pressure Monitoring | 856 | ||
| Purpose: | 856 | ||
| Prerequisite Nursing Knowledge | 856 | ||
| Equipment | 857 | ||
| Patient and Family Education | 857 | ||
| Patient Assessment and Preparation | 857 | ||
| Patient Assessment | 857 | ||
| Patient Preparation | 857 | ||
| Procedure for Lumbar Subarachnoid Catheter Insertion (Assist) | 858 | ||
| Procedure for Troubleshooting Lumbar Subarachnoid Catheter Insertion (Assist) | 861 | ||
| Procedure for Removal of a Lumbar Subarachnoid Catheter (Assist) | 861 | ||
| Expected Outcomes | 862 | ||
| Unexpected Outcomes | 862 | ||
| Patient Monitoring and Care | 862 | ||
| Documentation | 864 | ||
| References and Additional Readings | 864 | ||
| References | 864.e1 | ||
| Additional Reading | 864.e2 | ||
| Thirteen Special Neurologic Procedures | 865 | ||
| Procedure 96 Lumbar Puncture (Perform) | 865 | ||
| Purpose: | 865 | ||
| Prerequisite Nursing Knowledge | 865 | ||
| Equipment | 865 | ||
| Patient and Family Education | 866 | ||
| Patient Assessment and Preparation | 866 | ||
| Patient Assessment | 866 | ||
| Patient Preparation | 866 | ||
| Procedure for Lumbar Puncture (Perform) | 867 | ||
| Expected Outcomes | 871 | ||
| Unexpected Outcomes | 871 | ||
| Patient Monitoring and Care | 871 | ||
| Documentation | 872 | ||
| References and Additional Readings | 872 | ||
| References | 872.e1 | ||
| Additional Readings | 872.e1 | ||
| Procedure 97 Lumbar Puncture (Assist) | 873 | ||
| Purpose: | 873 | ||
| Prerequisite Nursing Knowledge | 873 | ||
| Equipment | 873 | ||
| Patient and Family Education | 873 | ||
| Patient Assessment and Preparation | 874 | ||
| Patient Assessment | 874 | ||
| Patient Preparation | 874 | ||
| Procedure for Lumbar Puncture (Assist) | 874 | ||
| Expected Outcomes | 877 | ||
| Unexpected Outcomes | 877 | ||
| Patient Monitoring and Care | 878 | ||
| Documentation | 878 | ||
| References and Additional Readings | 879 | ||
| References | 879.e1 | ||
| Additional Readings | 879.e1 | ||
| Procedure 98 Pupillometer | 880 | ||
| Purpose: | 880 | ||
| Prerequisite Nursing Knowledge | 880 | ||
| Equipment | 880 | ||
| Patient and Family Education | 881 | ||
| Patient Assessment and Preparation | 881 | ||
| Patient Assessment | 881 | ||
| Patient Preparation | 881 | ||
| Procedure for Automated Pupillometer Use | 882 | ||
| Expected Outcomes | 884 | ||
| Unexpected Outcomes | 884 | ||
| Patient Monitoring and Care | 884 | ||
| Documentation | 884 | ||
| References and Additional Readings | 884 | ||
| References | 884.e1 | ||
| Procedure 99 RotoRest Lateral Rotation Surface | 885 | ||
| Purpose: | 885 | ||
| Prerequisite Nursing Knowledge | 885 | ||
| Equipment | 886 | ||
| Patient and Family Education | 887 | ||
| Patient Assessment and Preparation | 887 | ||
| Patient Assessment | 887 | ||
| Patient Preparation | 887 | ||
| Procedure for Lateral Rotation Therapy | 888 | ||
| Expected Outcomes | 890 | ||
| Unexpected Outcomes | 890 | ||
| Patient Monitoring and Care | 891 | ||
| Documentation | 892 | ||
| References and Additional Readings | 892 | ||
| References | 892.e1 | ||
| Procedure 100 Thermoregulation | 893 | ||
| Purpose: | 893 | ||
| Prerequisite Nursing Knowledge | 893 | ||
| Equipment | 896 | ||
| Patient and Family Education | 896 | ||
| Patient Assessment and Preparation | 896 | ||
| Patient Assessment | 896 | ||
| Patient Preparation | 897 | ||
| Procedure for External Warming/Cooling Devices | 898 | ||
| Procedure for Intravascular Warming/Cooling Devices | 901 | ||
| Expected Outcomes | 902 | ||
| Unexpected Outcomes | 902 | ||
| Patient Monitoring and Care | 902 | ||
| Documentation | 903 | ||
| References and Additional Readings | 903 | ||
| References | 903.e1 | ||
| Fourteen Traction Management | 904 | ||
| Procedure 101 Cervical Tongs or Halo Ring | 904 | ||
| Purpose: | 904 | ||
| Prerequisite Nursing Knowledge | 904 | ||
| Equipment | 905 | ||
| Patient and Family Education | 905 | ||
| Patient Assessment and Preparation | 906 | ||
| Patient Assessment | 906 | ||
| Patient Preparation | 906 | ||
| Procedure for Assisting With Application of Tongs or Halo Ring for Cervical Traction | 906 | ||
| Expected Outcomes | 908 | ||
| Unexpected Outcomes | 908 | ||
| Patient Monitoring and Care | 908 | ||
| Documentation | 910 | ||
| References and Additional Readings | 910 | ||
| References | 910.e1 | ||
| Additional Readings | 910.e1 | ||
| Procedure 102 Cervical Traction Maintenance | 911 | ||
| Purpose: | 911 | ||
| Prerequisite Nursing Knowledge | 911 | ||
| Equipment | 911 | ||
| Patient and Family Education | 911 | ||
| Patient Assessment and Preparation | 911 | ||
| Patient Assessment | 911 | ||
| Patient Preparation | 912 | ||
| Procedure for Traction Maintenance | 912 | ||
| Expected Outcomes | 913 | ||
| Unexpected Outcomes | 913 | ||
| Patient Monitoring and Care | 913 | ||
| Documentation | 916 | ||
| References and Additional Readings | 916 | ||
| References | 916.e1 | ||
| Additional Reading | 916.e1 | ||
| Procedure 103 Halo Ring and Vest Care | 917 | ||
| Purpose: | 917 | ||
| Prerequisite Nursing Knowledge | 917 | ||
| Equipment | 917 | ||
| Patient and Family Education | 918 | ||
| Patient Assessment and Preparation | 918 | ||
| Patient Assessment | 918 | ||
| Patient Preparation | 919 | ||
| Procedure for Halo Ring and Vest Care | 919 | ||
| Expected Outcomes | 922 | ||
| Unexpected Outcomes | 922 | ||
| Patient Monitoring and Care | 922 | ||
| Documentation | 924 | ||
| References and Additional Readings | 924 | ||
| References | 924.e1 | ||
| Additional Reading | 924.e1 | ||
| Procedure 104 Pin-Site Care | 925 | ||
| Purpose: | 925 | ||
| Prerequisite Nursing Knowledge | 925 | ||
| Equipment | 925 | ||
| Patient and Family Education | 925 | ||
| Patient Assessment and Preparation | 926 | ||
| Patient Assessment | 926 | ||
| Patient Preparation | 926 | ||
| Procedure for Pin-Site Care: Cervical Tong and Halo Pins | 926 | ||
| Expected Outcomes | 927 | ||
| Unexpected Outcomes | 927 | ||
| Patient Monitoring and Care | 927 | ||
| Documentation | 928 | ||
| References and Additional Readings | 928 | ||
| References | 928.e1 | ||
| Additional Readings | 928.e1 | ||
| Fifteen Pain Management | 929 | ||
| Procedure 105 Epidural Catheters | 929 | ||
| Purpose: | 929 | ||
| Prerequisite Nursing Knowledge | 929 | ||
| Equipment | 929 | ||
| Patient and Family Education | 930 | ||
| Patient Assessment and Preparation | 931 | ||
| Patient Assessment | 931 | ||
| Patient Preparation | 931 | ||
| Procedure for Pain Management: Epidural Catheters (Assisting With Insertion and Initiating Continuous Infusion) | 931 | ||
| Procedure for Epidural Catheter (Bolus Dose Administration) Without a Continuous Infusion | 934 | ||
| Procedure for Assisting With Removal of the Epidural Catheter | 936 | ||
| Expected Outcomes | 937 | ||
| Unexpected Outcomes | 937 | ||
| Patient Monitoring and Care | 937 | ||
| Documentation | 940 | ||
| References and Additional Readings | 940 | ||
| References | 940.e1 | ||
| Additional Readings | 940.e1 | ||
| Procedure 106 Patient-Controlled Analgesia | 941 | ||
| Purpose: | 941 | ||
| Prerequisite Nursing Knowledge | 941 | ||
| Equipment | 943 | ||
| Patient and Family Education | 943 | ||
| Patient Assessment and Preparation | 944 | ||
| Patient Assessment | 944 | ||
| Patient Preparation | 944 | ||
| Procedure for Initiating Intravenous Patient-Controlled Analgesia | 944 | ||
| Expected Outcomes | 946 | ||
| Unexpected Outcomes | 946 | ||
| Patient Monitoring and Care | 946 | ||
| Documentation | 947 | ||
| References and Additional Readings | 947 | ||
| References | 947.e1 | ||
| Additional Readings | 947.e2 | ||
| Procedure 107 Peripheral Nerve Blocks | 948 | ||
| Purpose: | 948 | ||
| Prerequisite Nursing Knowledge | 948 | ||
| Equipment | 951 | ||
| Patient and Family Education | 951 | ||
| Patient Assessment and Preparation | 951 | ||
| Patient Assessment | 951 | ||
| Patient Preparation | 952 | ||
| Procedure for Peripheral Nerve Blocks | 952 | ||
| Expected Outcomes | 954 | ||
| Unexpected Outcomes | 954 | ||
| Patient Monitoring and Care | 955 | ||
| Documentation | 957 | ||
| References and Additional Readings | 957 | ||
| References | 957.e1 | ||
| Additional Readings | 957.e1 | ||
| Unit IV Gastrointestinal System | 958 | ||
| Sixteen Special Gastrointestinal Procedures | 958 | ||
| Procedure 108 Esophagogastric Tamponade Tube | 958 | ||
| Purpose: | 958 | ||
| Prerequisite Nursing Knowledge | 958 | ||
| Equipment | 958 | ||
| Patient and Family Education | 960 | ||
| Patient Assessment and Preparation | 960 | ||
| Patient Assessment | 960 | ||
| Patient Preparation | 960 | ||
| Procedure for Inserting Esophagogastric Tamponade Tube | 961 | ||
| Expected Outcomes | 967 | ||
| Unexpected Outcomes | 967 | ||
| Patient Monitoring and Care | 967 | ||
| Documentation | 967 | ||
| References and Additional Readings | 969 | ||
| References | 969.e1 | ||
| Additional Readings | 969.e1 | ||
| Procedure 109 Focused Assessment with Sonography in Trauma | 970 | ||
| Purpose: | 970 | ||
| Prerequisite Nursing Knowledge | 970 | ||
| Equipment | 975 | ||
| Patient and Family Education | 975 | ||
| Patient Assessment and Preparation | 975 | ||
| Patient Assessment | 975 | ||
| Patient Preparation | 975 | ||
| Procedure FAST and Extended FAST | 976 | ||
| Expected Outcomes | 978 | ||
| Unexpected Outcomes | 978 | ||
| Patient Monitoring and Care | 979 | ||
| Documentation | 979 | ||
| References and Additional Readings | 979 | ||
| References | 979.e1 | ||
| Additional Readings | 979.e1 | ||
| Procedure 110 Gastric Lavage in Hemorrhage and Overdose | 980 | ||
| Purpose: | 980 | ||
| Prerequisite Nursing Knowledge | 980 | ||
| Equipment | 981 | ||
| Patient and Family Education | 981 | ||
| Patient Assessment and Preparation | 981 | ||
| Patient Assessment | 981 | ||
| Patient Preparation | 982 | ||
| Procedure for Gastric Lavage in Hemorrhage and Overdose | 982 | ||
| Expected Outcomes | 985 | ||
| Unexpected Outcomes | 985 | ||
| Patient Monitoring and Care | 986 | ||
| Documentation | 988 | ||
| References and Additional Readings | 988 | ||
| References | 988.e1 | ||
| Additional Readings | 988.e1 | ||
| Procedure 111 Endoscopic Therapy | 989 | ||
| Purpose: | 989 | ||
| Prerequisite Nursing Knowledge | 989 | ||
| Equipment | 989 | ||
| Patient and Family Education | 990 | ||
| Patient Assessment and Preparation | 990 | ||
| Patient Assessment | 990 | ||
| Patient Preparation | 990 | ||
| Procedure for Assisting With Endoscopic Therapy | 991 | ||
| Expected Outcomes | 994 | ||
| Unexpected Outcomes | 994 | ||
| Patient Monitoring and Care | 994 | ||
| Documentation | 996 | ||
| References and Additional Readings | 996 | ||
| References | 996.e1 | ||
| Additional Readings | 996.e1 | ||
| Procedure 112 Intraabdominal Pressure Monitoring | 997 | ||
| Purpose: | 997 | ||
| Prerequisite Nursing Knowledge | 997 | ||
| Equipment | 998 | ||
| Patient/Family Education | 998 | ||
| Patient Assessment and Preparation | 998 | ||
| Patient Assessment | 998 | ||
| Patient Preparation | 1000 | ||
| Procedure for Intraabdominal Pressure Monitoring | 1001 | ||
| Procedure for Intraabdominal Pressure Monitoring With the AbViser (Convatec) Bladder Pressure Monitoring System With AutoValve (Fig. 112-4) | 1003 | ||
| Procedure for Intraabdominal Pressure Monitoring With the Foley Manometer LV System | 1007 | ||
| Expected Outcomes | 1009 | ||
| Unexpected Outcomes | 1009 | ||
| Patient Monitoring and Care | 1009 | ||
| Documentation | 1010 | ||
| References and Additional Readings | 1010 | ||
| References | 1010.e1 | ||
| Additional Readings | 1010.e1 | ||
| Procedure 113 Nasogastric and Orogastric Tube Insertion, Care, and Removal | 1011 | ||
| Purpose: | 1011 | ||
| Prerequisite Nursing Knowledge | 1011 | ||
| Equipment | 1011 | ||
| Patient and Family Education | 1011 | ||
| Patient Assessment and Preparation | 1011 | ||
| Patient Assessment | 1011 | ||
| Patient Preparation | 1012 | ||
| Procedure for NG or OG Tube Insertion | 1012 | ||
| Procedure for NG or OG Tube Removal | 1016 | ||
| Expected Outcomes | 1017 | ||
| Unexpected Outcomes | 1017 | ||
| Patient Monitoring and Care | 1017 | ||
| Documentation | 1018 | ||
| References and Additional Readings | 1019 | ||
| References | 1019.e1 | ||
| Additional Reading | 1019.e1 | ||
| Procedure 114 Molecular Adsorbent Recirculating System (MARS) | 1020 | ||
| Purpose: | 1020 | ||
| Prerequisite Nursing Knowledge | 1020 | ||
| Equipment | 1021 | ||
| Patient and Family Education | 1021 | ||
| Patient Assessment and Preparation | 1021 | ||
| Patient Assessment | 1021 | ||
| Patient Preparation | 1022 | ||
| Procedure for Molecular Adsorbent Recirculating System (MARS) | 1022 | ||
| Expected Outcomes | 1026 | ||
| Unexpected Outcomes | 1026 | ||
| Patient Monitoring and Care | 1026 | ||
| Documentation | 1029 | ||
| References and Additional Readings | 1029 | ||
| References | 1029.e1 | ||
| Procedure 115 Paracentesis (Perform) | 1030 | ||
| Purpose: | 1030 | ||
| Prerequisite Nursing Knowledge | 1030 | ||
| Equipment | 1031 | ||
| Patient and Family Education | 1031 | ||
| Patient Assessment and Preparation | 1031 | ||
| Patient Assessment | 1031 | ||
| Patient Preparation | 1032 | ||
| Procedure for Performing Paracentesis | 1032 | ||
| Expected Outcomes | 1034 | ||
| Unexpected Outcomes | 1034 | ||
| Patient Monitoring and Care | 1035 | ||
| Documentation | 1035 | ||
| References and Additional Readings | 1035 | ||
| References | 1035.e1 | ||
| Additional Readings | 1035.e1 | ||
| Procedure 116 Paracentesis (Assist) | 1036 | ||
| Purpose: | 1036 | ||
| Prerequisite Nursing Knowledge | 1036 | ||
| Equipment | 1037 | ||
| Patient and Family Education | 1037 | ||
| Patient Assessment and Preparation | 1037 | ||
| Patient Assessment | 1037 | ||
| Patient Preparation | 1037 | ||
| Procedure for Assisting With Paracentesis | 1038 | ||
| Expected Outcomes | 1039 | ||
| Unexpected Outcomes | 1039 | ||
| Patient Monitoring and Care | 1039 | ||
| Documentation | 1040 | ||
| References and Additional Readings | 1040 | ||
| References | 1040.e1 | ||
| Additional Readings | 1040.e1 | ||
| Procedure 117 Peritoneal Lavage (Perform) | 1041 | ||
| Purpose: | 1041 | ||
| Prerequisite Nursing Knowledge | 1041 | ||
| Equipment | 1042 | ||
| Patient and Family Education | 1042 | ||
| Patient Assessment and Preparation | 1042 | ||
| Patient Assessment | 1042 | ||
| Patient Preparation | 1042 | ||
| Procedure for Performing Peritoneal Lavage | 1043 | ||
| Expected Outcomes | 1046 | ||
| Unexpected Outcomes | 1046 | ||
| Patient Monitoring and Care | 1046 | ||
| Documentation | 1047 | ||
| References and Additional Readings | 1047 | ||
| References | 1047.e1 | ||
| Additional Readings | 1047.e1 | ||
| Procedure 118 Peritoneal Lavage (Assist) | 1048 | ||
| Purpose: | 1048 | ||
| Prerequisite Nursing Knowledge | 1048 | ||
| Equipment | 1049 | ||
| Patient and Family Education | 1049 | ||
| Patient Assessment and Preparation | 1049 | ||
| Patient Assessment | 1049 | ||
| Patient Preparation | 1049 | ||
| Procedure for Assisting With Peritoneal Lavage | 1050 | ||
| Expected Outcomes | 1052 | ||
| Unexpected Outcomes | 1052 | ||
| Patient Monitoring and Care | 1052 | ||
| Documentation | 1053 | ||
| References and Additional Readings | 1053 | ||
| References | 1053.e1 | ||
| Additional Readings | 1053.e1 | ||
| Unit V Renal System | 1054 | ||
| Seventeen Renal Replacement | 1054 | ||
| Procedure 119 Continuous Renal Replacement Therapies | 1054 | ||
| Purpose: | 1054 | ||
| Prerequisite Nursing Knowledge | 1054 | ||
| Equipment | 1057 | ||
| Patient and Family Education | 1058 | ||
| Patient Assessment and Preparation | 1058 | ||
| Patient Assessment | 1058 | ||
| Patient Preparation | 1058 | ||
| Procedure for Initiation and Termination of Continuous Renal Replacement Therapy | 1059 | ||
| Expected Outcomes | 1064 | ||
| Unexpected Outcomes | 1064 | ||
| Patient Monitoring and Care | 1064 | ||
| Documentation | 1066 | ||
| References and Additional Readings | 1066 | ||
| References | 1066.e1 | ||
| Additional Readings | 1066.e1 | ||
| Procedure 120 Hemodialysis | 1067 | ||
| Purpose: | 1067 | ||
| Prerequisite Nursing Knowledge | 1067 | ||
| Equipment | 1068 | ||
| Patient and Family Education | 1069 | ||
| Patient Assessment and Preparation | 1069 | ||
| Patient Assessment | 1069 | ||
| Patient Preparation | 1069 | ||
| Procedure for Hemodialysis | 1070 | ||
| Expected Outcomes | 1077 | ||
| Unexpected Outcomes | 1077 | ||
| Patient Monitoring and Care | 1077 | ||
| Documentation | 1079 | ||
| References and Additional Readings | 1079 | ||
| References | 1079.e1 | ||
| Additional Readings | 1079.e1 | ||
| Procedure 121 Peritoneal Dialysis | 1080 | ||
| Purpose: | 1080 | ||
| Prerequisite Nursing Knowledge | 1080 | ||
| Equipment | 1081 | ||
| Patient and Family Education | 1081 | ||
| Patient Assessment and Preparation | 1081 | ||
| Patient Assessment | 1081 | ||
| Patient Preparation | 1082 | ||
| Procedure for Peritoneal Dialysis | 1082 | ||
| Expected Outcomes | 1085 | ||
| Unexpected Outcomes | 1085 | ||
| Patient Monitoring and Care | 1085 | ||
| Documentation | 1087 | ||
| References and Additional Readings | 1087 | ||
| References | 1087.e1 | ||
| Additional Readings | 1087.e1 | ||
| Unit VI Hematologic System | 1088 | ||
| Eighteen Fluid Management | 1088 | ||
| Procedure 122 Use of a Massive Infusion Device and a Pressure Infusor Bag | 1088 | ||
| Purpose: | 1088 | ||
| Prerequisite Nursing Knowledge | 1088 | ||
| Equipment | 1089 | ||
| Patient and Family Education | 1090 | ||
| Patient Assessment and Preparation | 1090 | ||
| Patient Assessment | 1090 | ||
| Patient Preparation | 1091 | ||
| Procedure for Use of Massive Infusion Device | 1091 | ||
| Procedure for Pressure Infusor Bag Use | 1095 | ||
| Expected Outcomes | 1097 | ||
| Unexpected Outcomes | 1097 | ||
| Patient Monitoring and Care | 1097 | ||
| Documentation | 1099 | ||
| References and Additional Readings | 1099 | ||
| References | 1099.e1 | ||
| Additional Readings | 1099.e1 | ||
| Nineteen Special Hematologic Procedures | 1100 | ||
| Procedure 123 Apheresis and Therapeutic Plasma Exchange (Assist) | 1100 | ||
| Purpose: | 1100 | ||
| Prerequisite Nursing Knowledge | 1100 | ||
| Equipment | 1105 | ||
| Patient and Family Education | 1105 | ||
| Patient Assessment and Preparation | 1106 | ||
| Patient Assessment | 1106 | ||
| Patient Preparation | 1106 | ||
| Procedure for Assisting With Apheresis/Plasmapheresis | 1107 | ||
| Expected Outcomes | 1108 | ||
| Unexpected Outcomes | 1108 | ||
| Patient Monitoring and Care | 1108 | ||
| Documentation | 1109 | ||
| References and Additional Readings | 1109 | ||
| References | 1109.e1 | ||
| Additional Readings | 1109.e1 | ||
| Procedure 124 Bone Marrow Biopsy and Aspiration (Perform) | 1110 | ||
| Purpose: | 1110 | ||
| Prerequisite Nursing Knowledge | 1110 | ||
| Equipment | 1111 | ||
| Patient and Family Education | 1111 | ||
| Patient Assessment and Preparation | 1112 | ||
| Patient Assessment | 1112 | ||
| Patient Preparation | 1112 | ||
| Procedure for Performing Bone Marrow Aspiration and Biopsy | 1113 | ||
| Expected Outcomes | 1117 | ||
| Unexpected Outcomes | 1117 | ||
| Patient Monitoring and Care | 1117 | ||
| Documentation | 1118 | ||
| References and Additional Readings | 1118 | ||
| References | 1118.e1 | ||
| Procedure 125 Bone Marrow Biopsy and Aspiration (Assist) | 1119 | ||
| Purpose: | 1119 | ||
| Prerequisite Nursing Knowledge | 1119 | ||
| Equipment | 1120 | ||
| Patient and Family Education | 1120 | ||
| Patient Assessment and Preparation | 1121 | ||
| Patient Assessment | 1121 | ||
| Patient Preparation | 1121 | ||
| Procedure for Assisting With Bone Marrow Aspiration and Biopsy | 1122 | ||
| Expected Outcomes | 1123 | ||
| Unexpected Outcomes | 1123 | ||
| Patient Monitoring and Care | 1123 | ||
| Documentation | 1124 | ||
| References and Additional Readings | 1124 | ||
| References | 1124.e1 | ||
| Unit VII Integumentary System | 1125 | ||
| Twenty Burn Wound Management | 1125 | ||
| Procedure 126 Burn Wound Care | 1125 | ||
| Purpose: | 1125 | ||
| Prerequisite Nursing Knowledge | 1125 | ||
| Equipment | 1130 | ||
| Patient and Family Education | 1130 | ||
| Patient Assessment and Preparation | 1131 | ||
| Patient Assessment | 1131 | ||
| Patient Preparation | 1131 | ||
| Procedure for Care of Burn Wounds | 1132 | ||
| Expected Outcomes | 1133 | ||
| Unexpected Outcomes | 1133 | ||
| Patient Monitoring and Care | 1134 | ||
| Documentation | 1135 | ||
| References and Additional Readings | 1135 | ||
| References | 1135.e1 | ||
| Additional Readings | 1135.e1 | ||
| Procedure 127 Donor-Site Care | 1136 | ||
| Purpose: | 1136 | ||
| Prerequisite Nursing Knowledge | 1136 | ||
| Equipment | 1137 | ||
| Patient and Family Education | 1137 | ||
| Patient Assessment and Preparation | 1138 | ||
| Patient Assessment | 1138 | ||
| Patient Preparation | 1138 | ||
| Procedure for Care of Donor Sites | 1138 | ||
| Expected Outcomes | 1140 | ||
| Unexpected Outcomes | 1140 | ||
| Patient Monitoring and Care | 1140 | ||
| Documentation | 1141 | ||
| References and Additional Readings | 1141 | ||
| References | 1141.e1 | ||
| Additional Reading | 1141.e1 | ||
| Procedure 128 Skin-Graft Care | 1142 | ||
| Purpose: | 1142 | ||
| Prerequisite Nursing Knowledge | 1142 | ||
| Equipment | 1144 | ||
| Patient and Family Education | 1144 | ||
| Patient Assessment and Preparation | 1145 | ||
| Patient Assessment | 1145 | ||
| Patient Preparation | 1145 | ||
| Procedure for Care of Skin Grafts | 1146 | ||
| Expected Outcomes | 1147 | ||
| Unexpected Outcomes | 1147 | ||
| Patient Monitoring and Care | 1148 | ||
| Documentation | 1149 | ||
| References and Additional Readings | 1149 | ||
| References | 1149.e1 | ||
| Additional Readings | 1149.e1 | ||
| Twenty-One Special Integumentary Procedures | 1150 | ||
| Procedure 129 Intracompartmental Pressure Monitoring | 1150 | ||
| Purpose: | 1150 | ||
| Prerequisite Nursing Knowledge | 1150 | ||
| Equipment | 1151 | ||
| Patient and Family Education | 1151 | ||
| Patient Assessment and Preparation | 1152 | ||
| Patient Assessment | 1152 | ||
| Patient Preparation | 1152 | ||
| Procedure for Intracompartmental Pressure Monitoring | 1152 | ||
| Expected Outcomes | 1154 | ||
| Unexpected Outcomes | 1154 | ||
| Patient Monitoring and Care | 1154 | ||
| Documentation | 1155 | ||
| References and Additional Readings | 1155 | ||
| References | 1155.e1 | ||
| Additional Readings | 1155.e1 | ||
| Procedure 130 Suture and Staple Removal | 1156 | ||
| Purpose: | 1156 | ||
| Prerequisite Nursing Knowledge | 1156 | ||
| Equipment | 1156 | ||
| Patient and Family Education | 1156 | ||
| Patient Assessment and Preparation | 1156 | ||
| Patient Assessment | 1156 | ||
| Patient Preparation | 1157 | ||
| Procedure for Suture Removal | 1157 | ||
| Procedure for Staple Removal | 1159 | ||
| Expected Outcomes | 1160 | ||
| Unexpected Outcomes | 1160 | ||
| Patient Monitoring and Care | 1160 | ||
| Documentation | 1160 | ||
| References and Additional Readings | 1161 | ||
| References | 1161.e1 | ||
| Additional Readings | 1161.e1 | ||
| Procedure 131 Wound Closure | 1162 | ||
| Purpose: | 1162 | ||
| Prerequisite Nursing Knowledge | 1162 | ||
| Equipment | 1166 | ||
| Patient and Family Education | 1166 | ||
| Patient Assessment and Preparation | 1166 | ||
| Patient Assessment | 1166 | ||
| Patient Preparation | 1166 | ||
| Procedure for Wound Closure | 1167 | ||
| Expected Outcomes | 1170 | ||
| Unexpected Outcomes | 1170 | ||
| Patient Monitoring and Care | 1170 | ||
| Documentation | 1171 | ||
| References and Additional Readings | 1172 | ||
| References | 1172.e1 | ||
| Additional Readings | 1172.e1 | ||
| Twenty-Two Wound Management | 1173 | ||
| Procedure 132 Cleaning, Irrigating, Culturing, and Dressing an Open Wound | 1173 | ||
| Purpose: | 1173 | ||
| Prerequisite Nursing Knowledge | 1173 | ||
| Equipment | 1175 | ||
| Patient and Family Education | 1176 | ||
| Patient Assessment and Preparation | 1176 | ||
| Patient Assessment | 1176 | ||
| Patient Preparation | 1176 | ||
| Procedure for Cleaning, Irrigating, Culturing, and Dressing an Open Wound | 1177 | ||
| Expected Outcomes | 1181 | ||
| Unexpected Outcomes | 1181 | ||
| Patient Monitoring and Care | 1181 | ||
| Documentation | 1182 | ||
| References and Additional Readings | 1182 | ||
| References | 1182.e1 | ||
| Additional Readings | 1182.e1 | ||
| Procedure 133 Débridement | 1183 | ||
| Purpose: | 1183 | ||
| Prerequisite Nursing Knowledge | 1183 | ||
| Equipment | 1184 | ||
| Patient and Family Education | 1184 | ||
| Patient Assessment and Preparation | 1184 | ||
| Patient Assessment | 1184 | ||
| Patient Preparation | 1185 | ||
| Procedure for Débridement: Pressure Ulcers, Burns, and Wounds | 1185 | ||
| Expected Outcomes | 1188 | ||
| Unexpected Outcomes | 1188 | ||
| Patient Monitoring and Care | 1188 | ||
| Documentation | 1188 | ||
| References and Additional Readings | 1189 | ||
| References | 1189.e1 | ||
| Additional Readings | 1189.e1 | ||
| Procedure 134 Drain Removal | 1190 | ||
| Purpose: | 1190 | ||
| Prerequisite Nursing Knowledge | 1190 | ||
| Equipment | 1190 | ||
| Patient and Family Education | 1190 | ||
| Patient Assessment and Preparation | 1190 | ||
| Patient Assessment | 1190 | ||
| Patient Preparation | 1190 | ||
| Procedure for Drain Removal | 1191 | ||
| Expected Outcomes | 1191 | ||
| Unexpected Outcomes | 1191 | ||
| Patient Monitoring and Care | 1191 | ||
| Documentation | 1192 | ||
| References and Additional Readings | 1192 | ||
| References | 1192.e1 | ||
| Additional Readings | 1192.e1 | ||
| Procedure 135 Fecal Containment Devices and Bowel Management Systems | 1193 | ||
| Purpose: | 1193 | ||
| Prerequisite Nursing Knowledge | 1193 | ||
| Equipment | 1194 | ||
| Patient and Family Education | 1195 | ||
| Patient Assessment and Preparation | 1195 | ||
| Patient Assessment | 1195 | ||
| Patient Preparation | 1195 | ||
| Procedure for Fecal Containment Device and Bowel Management System (BMS) | 1195 | ||
| Expected Outcomes | 1198 | ||
| Unexpected Outcomes | 1198 | ||
| Patient Monitoring and Care | 1198 | ||
| Documentation | 1199 | ||
| References and Additional Readings | 1199 | ||
| References | 1199.e1 | ||
| Additional Readings | 1199.e1 | ||
| Procedure 136 Negative-Pressure Wound Therapy | 1200 | ||
| Purpose: | 1200 | ||
| Prerequisite Nursing Knowledge | 1200 | ||
| Equipment | 1201 | ||
| Patient and Family Education | 1202 | ||
| Patient Assessment and Preparation | 1202 | ||
| Patient Assessment | 1202 | ||
| Patient Preparation | 1202 | ||
| Procedure for Negative-Pressure Wound Therapy | 1203 | ||
| Expected Outcomes | 1206 | ||
| Unexpected Outcomes | 1206 | ||
| Patient Monitoring and Care | 1207 | ||
| Documentation | 1209 | ||
| References and Additional Readings | 1209 | ||
| References | 1209.e1 | ||
| Procedure 137 Wound Management with Excessive Drainage | 1210 | ||
| Purpose: | 1210 | ||
| Prerequisite Nursing Knowledge | 1210 | ||
| Equipment | 1210 | ||
| Patient and Family Education | 1210 | ||
| Patient Assessment and Preparation | 1211 | ||
| Patient Assessment | 1211 | ||
| Patient Preparation | 1211 | ||
| Procedure for Management of Wound Exudate With Drains and Pouches | 1211 | ||
| Expected Outcomes | 1214 | ||
| Unexpected Outcomes | 1214 | ||
| Patient Monitoring and Care | 1214 | ||
| Documentation | 1215 | ||
| References and Additional Readings | 1215 | ||
| References | 1215.e1 | ||
| Additional Readings | 1215.e1 | ||
| Unit VIII Nutrition | 1216 | ||
| Procedure 138 Percutaneous Endoscopic Gastrostomy (PEG), Gastrostomy, and Jejunostomy Tube Care | 1216 | ||
| Purpose: | 1216 | ||
| Prerequisite Nursing Knowledge | 1216 | ||
| Equipment | 1216 | ||
| Patient and Family Education | 1217 | ||
| Patient Assessment and Preparation | 1217 | ||
| Patient Assessment | 1217 | ||
| Patient Preparation | 1217 | ||
| Procedure for Percutaneous Endoscopic Gastrostomy (PEG), Gastrostomy, or Jejunostomy Tube Care | 1218 | ||
| Expected Outcomes | 1219 | ||
| Unexpected Outcomes | 1219 | ||
| Patient Monitoring and Care | 1219 | ||
| Documentation | 1220 | ||
| References and Additional Readings | 1220 | ||
| References | 1220.e1 | ||
| Additional Readings | 1220.e1 | ||
| Procedure 139 Small-Bore Feeding Tube Insertion and Care | 1221 | ||
| Purpose: | 1221 | ||
| Prerequisite Nursing Knowledge | 1221 | ||
| Equipment | 1221 | ||
| Patient and Family Education | 1221 | ||
| Patient Assessment and Preparation | 1222 | ||
| Patient Assessment | 1222 | ||
| Patient Preparation | 1222 | ||
| Procedure for Small-Bore Feeding Tube Insertion and Care | 1222 | ||
| Expected Outcomes | 1225 | ||
| Unexpected Outcomes | 1225 | ||
| Patient Monitoring and Care | 1225 | ||
| Documentation | 1225 | ||
| References and Additional Readings | 1226 | ||
| References | 1226.e1 | ||
| Additional Readings | 1226.e1 | ||
| Procedure 140 Small-Bore Feeding Tube Insertion Using an Electromagnetic Guidance System (CORTRAK 2 Enteral Access System EAS) | 1227 | ||
| Purpose: | 1227 | ||
| Prerequisite Nursing Knowledge | 1227 | ||
| Equipment | 1227 | ||
| Patient and Family Education | 1227 | ||
| Patient Assessment and Preparation | 1227 | ||
| Patient Assessment | 1227 | ||
| Patient Preparation | 1228 | ||
| Procedure for Small-Bore Feeding Tube Insertion Using an Electromagnetic Guidance System (CORTRAK 2 Enteral Access System [EAS]) | 1229 | ||
| Expected Outcomes | 1234 | ||
| Unexpected Outcomes | 1234 | ||
| Patient Monitoring and Care | 1234 | ||
| Documentation | 1235 | ||
| References and Additional Readings | 1235 | ||
| References | 1235.e1 | ||
| Additional Readings | 1235.e1 | ||
| Unit IX Calculating Medication Doses | 1236 | ||
| Procedure 141 Calculating Doses, Flow Rates, and Administration of Continuous Intravenous Infusions | 1236 | ||
| Purpose: | 1236 | ||
| Prerequisite Nursing Knowledge | 1236 | ||
| Equipment | 1237 | ||
| Patient and Family Education | 1237 | ||
| Patient Assessment and Preparation | 1238 | ||
| Patient Assessment | 1238 | ||
| Patient Preparation | 1238 | ||
| Procedure for Calculating Doses and Flow Rates and Administering Continuous Intravenous Infusions | 1239 | ||
| Expected Outcomes | 1240 | ||
| Unexpected Outcomes | 1240 | ||
| Patient Monitoring and Care | 1240 | ||
| Documentation | 1241 | ||
| References and Additional Readings | 1241 | ||
| References | 1241.e1 | ||
| Additional Readings | 1241.e1 | ||
| Index | 1242 | ||
| A | 1242 | ||
| B | 1245 | ||
| C | 1247 | ||
| D | 1253 | ||
| E | 1255 | ||
| F | 1259 | ||
| G | 1259 | ||
| H | 1260 | ||
| I | 1261 | ||
| J | 1263 | ||
| K | 1263 | ||
| L | 1264 | ||
| M | 1265 | ||
| N | 1266 | ||
| O | 1267 | ||
| P | 1268 | ||
| Q | 1273 | ||
| R | 1273 | ||
| S | 1274 | ||
| T | 1276 | ||
| U | 1280 | ||
| V | 1280 | ||
| W | 1281 | ||
| X | 1282 | ||
| Y | 1282 | ||
| Z | 1282 |