Clinical Nursing Procedures: The Art of Nursing Practice Annamma Jacob, Rekha R, Jadhav Sonali Tarachand
Admission of a patient
hospital 58
labor room 534
Amniocentesis 530
complications 532
indications 530
preprocedural preparations 530
procedure 531
cerebral 455
complications 456
procedure 455
digital subtraction 457
postprocedural care 458
procedures 457
Antenatal abdominal examination 516
auscultation 519
inspection 516
palpation or Leopold's maneuvers 518
Antenatal assessment format 655
Antenatal exercises 521
Anthropometric measurements 617
Antimicrobial agents used in burns 351
Arterial puncture 364
Assessment of patient with gynecological problems 663
Assessment of postoperative cesarean section mothers 660
Assisting a patient to sitting position 130
Baby bath (tub bath) 632
Back massage 102
effleurage 103
massage pattern 103
petrissage 103
tapotement 104
Bag techniques 615
principles 316
purposes 316
types 316
capeline (head) bandage 318
circular turn 317
double spica of groin bandage 322
ear bandage 319
elbow bandage 318
eye bandage 319
finger bandage 320, 321
foot and ankle bandage 322
heel bandage 324
jaw bandage 320
knee bandage 318
shoulder (spica) 320
spica 317
spica of groin bandage 321
spica of hip 321
spiral reverse turn 317
spiral turn 317
stump bandage 322
thumb (spica) 320
newborn 599
patient in bed 84
Bed shampoo/hair wash performance 94
drying hair 96
massaging scalp 96
positioning patient 95
Bedpan 199
Benedict's solution 22
Binders 325
abdominal 325
breast binder 327
T binder 326
Bladder irrigation 197
Blood for routine examination 35
blood for peripheral smear 43
collection of blood for culture 41
measuring blood glucose level 38
Blood pressure measurement 11
auscutatory method 13
Blood transfusion 253
reactions 256
Blood types 257
Bolus medications through intravenous route 283
Bone marrow aspiration and biopsy 452
complications 454
contraindication 452
postprocedural care 454
procedure 453
Bowel wash/colonic lavage
contraindications 206
procedure 207
purposes 206
solutions used 206
temperature of the solution 206
Breast self-examination 52
palpation methods 53
special considerations 54
Breastfeeding 588
feeding techniques 589
health teaching to mother 590
Bronchoscopy 387
complications 388
postprocedure care 388
procedure 387
Can walking 336
Cardiac catheterization
contraindications 367
procedure 368
purposes 367
Cardiopulmonary resuscitation
indications 376
procedure 376
checking for carotid pulse 377
determining breathlessness 377
determining unresponsiveness 376
hands for chest compressions 379
head tilt-chin lift maneuver 378
jaw thrust maneuver 378
mouth to mouth respiration 378
sequence 376
when to stop CPR 379
Care of baby undergoing phototherapy 591
care and observation 592
Care of body after death
procedure 118
purposes 118
releasing body 120
Catheter care 193
Central venous pressure 259
Cervical swab 47
Checking height and weight 15, 619
Checking temperature 625
Chest physiotherapy 236
hand placement in vibration 237
percussion 237
Cleft lip and cleft palate 604
Cold compression 112
Collecting blood for peripheral smear 628
Collection of specimen 623
specimen for throat culture 624
specimen of sputum 624
specimens of pinworm 624
stool specimen 623
Colonoscopy 416
postprocedure care 417
procedure 416
Colostomy care 209
emptying colostomy bag without changing 211
steps of changing a colostomy bag 210
Colostomy irrigation 212
Comfort devices 99
Computerized axial tomography scan 445
Condom catheter 185
Crutch walking 338
follow-up activities 343
preparatory exercises 338
procedure 339
types of crutches 338
Cystoscopy 432
complications 433
postprocedural care 433
preprocedural preparation 432
procedure 433
Defibrillation and advanced cardiac life support 381
automated external defibrillator 383
automated external defibrillator 381
automatic implantable cardioverter defibrillator 381
direct current defibrillator 381
Dilatation and curettage 562
complications 563
contraindications 562
indications 562
postoperative care 563
procedure 562
Discharge of a patient from hospital 61
Disinfection of blood and body fluids spills 151
commonly used antiseptics and disinfectants 152
Domiciliary delivery
articles needed 635
contraindications 635
first stage of labor 636
second stage of labor 636
third stage of labor 637
Draping trolley and patient 487
Dressing a wound 630
Drug administration 264
Drug calculation formulae 646
Ear irrigation 461
Ear medication 286
Electrocardiogram 361
procedure 361
sites for chest lead placement 362
Electroconvulsive therapy 509
complications 511
contraindications 509
indications 509
procedure 509
administration of ECT 510
care after ECT 511
electrode placement 511
preparation 509
Electroencephalography 440
postprocedure care 441
procedure 440
Electromyography 442
postprocedural care 443
procedure 442
Endoscopic retrograde cholangiopancreatography 426
complications 427
postprocedural care 427
procedure 426
Endotracheal intubation 393
procedure 394
Endotracheal/tracheal suctioning 402
Enema administration 201
administration of evacuant enema 204
procedure 202
Episiotomy 552
complications 555
performing 553
suturing 554
types 552
Estimation of hemoglobin 626
Examination of placenta 549
cross-section of umbilical cord 550
fetal surface of placenta 550
maternal surface of placenta 550
Exchange transfusion 595
choice of donor blood 596
complications 597
indications 595
post transfusion care 597
procedure 596
Eye care 97
Eye irrigation 459
Eyes medication 288
Feeding a helpless patient 166
Forceps delivery
application of forceps 556
complications 559
procedure 557
types of forceps application 556
Fundal height 517
Gastric lavage or stomach wash 421
Gastric suctioing 411
Gastrointestinal fiberoscopy 413
complication 415
postprocedural care 414
procedures 414
Gastrostomy/jejunostomy tube 175
General preoperative assessment 479
Genital care/hygienic perineal care 90
female patient 91
male patient 92
Glasgow coma scale 438
Glucometer 38
Handwashing 614
Heimlich maneuver
adult 470
pediatrics 473
Hemoglobin testing paper 627
Hemoglobinometer 626
Hospital beds
cardiac 76
occupied 70
open/unoccupied 65
postoperative 74
Hot water bag 107
Ice cap 110
Immediate newborn care 573
Incentive spirometer 229
Induction of labor
contraindications 536
indications 536
medical induction 536
oxytocin induction 537
prostaglandin induction 538
surgical induction 538
Infant weighing scale 602
Injections 275
intradermal 278
administration 279
angle of needle insertion 279
procedure 278
intramuscular 280
angle of needle insertion 281
procedure 280
sites 281
z-track injection technique 282
subcutaneous 275
angle of needle insertion 276
common sites 275
procedure 275
Intake and output measurement 49
Intercostal drainage bottles 406
one bottle system 407
three bottle system 408
two bottle system 407
Intrauterine contraceptive devices
advantages 606
contraindications 606
insertion of copper T 607
side effects and complications 609
Intravenous infusion 246
changing an intravenous container, tubing and dressing 250
discontinuing an intravenous infusion 252
filling the drip chamber 248
priming the tube 248
setting the infusion pump 249
spiking the solution container 247
Intravenous pyelography 434
Involution of uterus 566, 567
Lap/leg bath 633
Latin terms used in medication orders 644
Liver biopsy 418
postprocedure care 419
procedure 419
types of biopsy
closed 418
open 418
Logrolling 127
variation: 2 nurses and turn sheet 128
Lumbar puncture 449
Magnetic resonance imaging scan 447
Management of patient in burns unit 463
exercises for post burn patients 469
fluid resuscitation in acute burns 466
Masking and sterile gowning 489
gowning 489
masking 489
removal of gown and mask 490
Measuring body temperature
common methods 2
contraindications 2
indications 2
procedure 3
purposes 2
Medical handwashing 146
from vial and ampoule 269
ampoule preparation 269
mixing insulins 273, 274
preparation from vial 271
vial containing a powder 273
into vagina 299
through nasogastric tube 301
Mental status examination 504
Metered dose inhalation 294
after care of the patient 296
procedure 294
Moving a patient up in bed 124
variation with two nurses and a turn sheet 125
Nail and foot care 87
Narco analysis/abreactive therapy 513
complications 514
procedure 514
Nasal drops 291
Nasogastric tube insertion 168
inserting tube 169
measuring length of tube 169
securing tube with tape 170
Nebulization therapy 239
Neonatal resuscitation 583
bag and mask ventilation 584
chest compressions 585
endotracheal intubation 586
positive pressure ventilation 584
resuscitation of the newborn in the delivery room 587
Newborn assessment 575
assessing for dislocation of hip 578
Babinski reflex 581
examination of head 576
head lag 581
measuring crown to heel length 575
Moro reflex 579
palmar grasp reflex 579
plantar grasp reflex 580
stepping reflex 580
symmetry of gluteal folds 578
tonic neck reflex 580
ventral suspension 581
Newborn assessment format 657
Newborn in incubator 593
Nonstress test
indications 523
procedure 524
Normal diet 164
Normal vaginal delivery 543
procedure 544
controlled cord traction (Brandt-Andrew's method) 547
controlling the crowning 545
delivery of posterior shoulder 547
downward traction of fetal head 546
preventing rapid extension of fetal head 545
Normal values 648
cerebrospinal fluid analysis 654
fecal analysis 654
hematology 649
serum, plasma and whole blood chemistries 651
urine chemistry 648
Nosocomial infections
common sites 154
preventive measures 154
preventive measures 155
body substance isolation 156
prevention of infection in susceptible patient 157
specific isolation practices 157
universal precautions 156
Nursing health history format 640
Operation theater 486
Oral hygiene and care
conscious patient 78
unconscious patient 81
Oral medication 265
Oropharyngeal suctioning 391
Oxygen saturation assessment 226
Oxygen tent 221
Oxygen therapy 216
cannula method 216
procedure 216
special precautions 218
mask method 219
Oxytocin challenge test
contraindications 526
indications 526
interpretations 527
procedure 526
Pacemaker implantation 370
permanent 372
complications 375
indications 373
postprocedure care 374
preparation of the patient 374
procedure 374
types 373
indications 370
postprocedure care 371
procedure 371
Papanicolaou smear 46
Paracentesis (abdominal) 428
procedure 429
Perineal care 564
Pinsite care in skeletal traction 334
Plaster of Paris application 329
Positions used in surgery 140, 493, 496
Fowler's 140
lateral/side lying 143, 495
lithotomy 145, 494
orthopneic 141
prone 142, 494
rose position/neck 495
Sim’s/semiprone 144
supine/dorsal recumbent/back lying 142, 494
Trendelenburg's 145, 495
Postnatal assessment format 658
Postnatal excercises
abdominal breathing 568
chest exercises 572
head and shoulder raising 569
head lift 569
knee and leg rolling 570
Postoperative exercises 497
controlled coughing 499
diaphragmatic (deep breathing) 498
leg exercise 501
turning 500
Postural drainage
contraindications 232
positions for drainage 233
procedure 234
Prenatal patient for ultrasound examination
transabdominal 528
transvaginal 529
Principles of body mechanics
advantages/benefits 122
factors affecting body alignment and activity 123
procedure 122
Process recording 507
Pulse assessment
common sites 6
procedure 8
purposes 6
Pulse oximeter 226
Range of motion exercises 136
illustrations 137, 138
Reagent strip 23
Rectal suppositories 297
Removal of chest drainage tubes 409
Renal biopsy
contraindications 436
postprocedural care 437
Respiration monitoring 10
Restraints 159
clove-hitch knot 160
elbow 161
jacket 159
mitten 160
swaddle wrapping 161
wrist 160
Sample collection of blood 33
Sclerotherapy (endoscopic) 430
postprocedural care 431
procedure 430
Segregation and disposal of biomedical waste 149
color coding and types of container 150
Sengstaken Blakemore tube 423
procedure for insertion 424
types 423
Sitz bath 105
positioning of patient 106
Skin preparation for surgery 481
sites for surgical preparation
abdominal 483
chest 483
flank 485
hand and forearm 485
head and neck 483
lateral neck 483
lower extremity 485
lower leg 485
lumbar spine 484
perineal 483
rectal 484
Skin traction 311
procedure for use 313
types 311, 312
Skull and spine X-rays 444
Slings 308
application 309
Splints 306
Sponge bath 610
Sponging of body 114
cold sponge 116
tepid sponge 114
Sputum for culture 45
Steam inhalation 223
Sterile gloving 491
removal of gloves 492
Stool specimen for routine examination
procedure 28
specimen for culture 30
Surgical scrub 476
Sutures and staples
procedure 352
specific instructions for staple removal 353
types of suturing 352
Test feed 182
Testicular self-examination 55
Thoracentesis 389
Throat swab for culture 31
Topical medications 303
Total parenteral nutrition 178
complications 180
indications 178
methods 178
procedure 179
Tracheostomy 396
postprocedural care 397
procedure 397
providing tracheostomy care 398
types of tracheostomy tube 397
Transfer of a patient 63, 131
bed to chair 131
bed to stretcher 133
hospital to hospital 63
unit to unit 63
Tube feeding 172
Turning a patient to lateral and prone position 126
Urinary catheterization 188
procedure 189
female 190
male 190
removing the catheter 195
Urine analysis 621
Urine specimen for routine examination 17
collecting urine specimen for culture 25
collection of 24 hours urine 27
procedure 17
purpose 17
special considerations 18
testing urine
albumin 24
glucose 22, 23
pH 19
specific gravity 20
Urometer 50
Use of urinal 184
Vaginal examination in labor 540
Venipuncture 242
common sites used 243
Ventouse extraction
contraindications 560
indications 560
procedure 560
Walker and cane 335
Weighing a newborn 602
Weights and measurements 645
dressing 346
dressing a burns wound 349
procedure 350
purposes 349
types 349
Wound irrigation 355
Wound swab for culture 32
Chapter Notes

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1Clinical Nursing Procedures: The Art of Nursing Practice
2Clinical Nursing Procedures: The Art of Nursing Practice
Editors Annamma Jacob MSc N Professor Bhagwan Mahaveer Jain College of Nursing Bangalore Formerly • Professor, St. Philomina's College of Nursing, Mother Teresa Road, Bangalore • Principal, Graduate School for Nurses, BNE, SIB, CMAI • Nurse Supervisor, Suburban Medical Center, Paramount, Southern California, USA • Assistant Director of Nursing, Al-Sabah Hospital, Ministry of Public Health, Kuwait • Sister Tutor, LT College of Nursing, SNDT Women's University, Mumbai • Junior Tutor, College of Nursing, CMC Hospital, Vellore, Tamil Nadu Rekha R MSc N Associate Professor Bhagwan Mahaveer Jain College of Nursing Bangalore, Karnataka Formerly • Lecturer and Asst. Professor, Sree Mookambika College of Nursing, Kanyakumari, Tamil Nadu Jadhav Sonali Tarachand MSc N, PG Diploma in Medical Law & Ethics Asst. Professor of Nursing Bhagwan Mahaveer Jain College of Nursing Bangalore, Karnataka Formerly • Lecturer in Medical Surgical Nursing, St. Marthas College of Nursing, Bangalore, Karnataka • Assistant Lecturer, Bharathi Vidyapeeth's College of Nursing, Pune, Maharashtra
3Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
EMCA House, 23/23B Ansari Road, Daryaganj
New Delhi 110 002, India
Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672
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Clinical Nursing Procedures: The Art of Nursing Practice
© 2006, Annamma Jacob, Rekha R, Jadhav Sonali Tarachand
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher.
First Edition: 2006
Typeset at JPBMP typesetting unit
Printed at Ajanta Offset4
Today's nursing practice has evolved through many changes influenced by advances in science and technology which has made medical care more complex. As modalities for diagnosing and treating illnesses and managing patients in different stages of health-illness continuum change, several nursing procedures are added and rewritten.
Use of specialized equipments, articles and assisting with advanced procedures have become a necessity in caring for patients. Several nursing procedures taught and practiced in yesteryears have become obsolete as a result of new knowledge of disease pathology and therapy.
The growing body of nursing research further challenges and stimulates nurses to acquire new knowledge and refine their critical thinking skills. Nursing education today aims to provide students a broad knowledge base which would help them provide expert and need-based care to clients with varying health problems. It is, therefore, essential that they master basic theories and skills and become equipped to further develop and refine their abilities to apply analytical thinking in clinical situations.
Nurse educators in India have always been faced with the need to have reference materials suited to present day practice standards. Books which meet the above criteria are written in the context of developed countries where advanced equipments and commercially prepared articles and materials are used for performing most nursing procedures. A procedure manual written in the Indian context, where health care facilities range from most advanced in the tertiary level multi-speciality hospitals in large cities to primary care centers in rural India has been a felt need.
This manual will help in preparing nurses who can demonstrate critical thinking and analytical ability, capable of making adaptations in varying situations. A manual of procedures that is relevant to the present day nursing practice in India has been a need, felt by nurse educators here. The book Clinical Nursing Procedures: The Art of Nursing Practice is an all-in-one compilation of nursing procedures.
Basic, Advanced and Community Health Nursing procedures are organized and presented in 15 chapters.
The editors and contributors have taken care to present the material in a concise, straight forward and simplified format in an easy to follow language and most importantly in the Indian context. Scientific rationale of every nursing action is included so as to enable nursing students and practicing nurses to use sound clinical judgement while emphasizing cognitive, interpersonal and psychomotor skills needed to carry out nursing procedures. Special considerations are included wherever additional explanations for deviations and adaptations are required.
The contents of the book include nursing procedures to be performed independently by nurses and interdependently by providing assistance to either health care professionals or clients themselves. Most nursing procedures prescribed for undergraduate education by Apex bodies in India are included.
A special feature of this book authored and contributed by Indian Nurses is the many illustrations and colour photographs which would aid to master and reinforce the skills of nursing students as well as practicing nurses.
The editors are confident that this book will prove to be an useful tool for undergraduate students as well as professional nurses working in different settings all over India.
Annamma Jacob
Rekha R
Jadhav Sonali Tarachand8
It takes more than great determination and sustained interest to write a book. For completion of the task, encouragement, support and cooperation of many are essential.
For the production of this book, the editors are deeply thankful to the administration of Bhagwan Mahaveer Jain College of Nursing. The President of Bhagwan Mahaveer Memorial Jain Trust, Mr. Sampathraj Gadia always encouraged us and provided the freedom and the facilities needed to the principal and senior faculty of the college to gather knowledge and teach professional nursing of high quality to their students. The members of BMMJ Trust, Mr. Parasmal Bansali and Mr. Phoolchand Jain did an excellent job of providing the library in the college with large collection of books and periodicals for reference. This greatly enhanced preparation of materials for the book.
As the idea of putting together all the nursing procedures taught to nursing students in the college emerged in the minds of the first group of faculty, the Chief Executive Officer of the Hospital and College of Nursing, Dr. Kishore Murthy offered great encouragement and support. The editors are thankful to Dr. Kishore Murthy.
Most of the faculty members who worked in the college of nursing, since its inception in 2003, contributed by way of writing and editing the procedures for the book. The editors thank each one of them for their contribution.
The nursing staff of BMJ Hospital whose practice standards needed updation for providing safe and effective nursing care to patients and the students of BMJ College of Nursing were our inspiration to embark on the task of preparing this manual of nursing procedures.
For the many photographs and illustrations included in the book, college and hospital staffs, their family members, students and patients offered themselves and their efforts, and we record our sincere thanks to everyone of them.
It was Miss Anuradha who in the final stages undertook the job of typing all the material in a professional manner. The preliminary work was done by Mrs. Vachala, Mrs. Sudheshna Mukherjee and Miss Sylvia Eileen. We thankfully acknowledge their contributions.
Finally but importantly, we once again acknowledge the administration of BMJ College of Nursing, the BMMJ Trust in honour of which this book may be published.