By Pamela Barbara Lynn
This in actual fact written and abundantly illustrated textual content information the abilities pointed out in Taylor's basics of Nursing, 7th version and describes extra complicated talents. The systems and abilities are defined in a step by step demeanour that follows the nursing procedure structure, with motive, and comprises unforeseen events, which clarify tips to reply to unanticipated outcomes--a function detailed to this article.
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Extra info for Taylor's clinical nursing skills : a nursing process approach
3. Perform hand hygiene and put on PPE, if indicated. 4. Identify the patient. FIGURE A. Moving the Doppler tip until pulse is heard. 5. Close curtains around bed and close the door to the room, if possible. 6. Explain the procedure to the patient. 14. Remove the Doppler tip and turn the Doppler off. Wipe excess gel off of the patient’s skin with a tissue. 8. Select the appropriate peripheral site based on assessment data. 15. Place a small X over the spot where the pulse is located with an indelible pen, depending on facility policy.
Also verify the medical order for the application of a hypothermia blanket. Assess the patient’s vital signs, neurologic status, peripheral circulation, and skin integrity. Assess the equipment to be used, including the condition of cords, plugs, and cooling elements. Look for fluid leaks. Once the equipment is turned on, make sure there is a consistent distribution of cooling. NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses may include: • Hyperthermia • Risk for Impaired Skin Integrity • Risk for Injury • Ineffective Thermoregulation • Acute Pain OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when using a hypothermia blanket is that the patient maintains the desired body temperature.
The site must be exposed for pulse assessment. Exposing only the site keeps the patient warm and maintains his or her dignity. 8. Place your first, second, and third fingers over the artery (Figure 1). Lightly compress the artery so pulsations can be felt and counted. The sensitive fingertips can feel the pulsation of the artery. 9. Using a watch with a second hand, count the number of pulsations felt for 30 seconds (Figure 2). Multiply this number by 2 to calculate the rate for 1 minute. If the rate, rhythm, or amplitude of the pulse is abnormal in any way, palpate and count the pulse for 1 minute.
Taylor's clinical nursing skills : a nursing process approach by Pamela Barbara Lynn