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Preface
Nursing: A Concept-Based Approach to Learning is the number while minimizing content overload. Further,
one choice for nursing schools employing a concept-based the model facilitates the transition from sage-
curriculum. The only true concept-based learning solution on-the-stage teaching to engaging students in
developed from the ground up, this three-volume learning the learning process by doing meaningful, collab-
suite equips you to deliver an effective concept-based pro- orative activities in lecture and the lab. Other benefits
gram and to develop practice-ready nurses. Available as a of conceptual learning in nursing programs –
digital or a print experience, this solution meets the needs of ■■ Concentrates on problems
today’s nursing student.
■■ Fosters systematic observations
Develops an understanding of relationships
What Makes Pearson’s Solution
■■

■■ Focuses on nursing actions and interdisciplinary efforts

Different? ■■ Challenges students to think like a nurse
Nurses perform skills that apply knowledge, psychomotor
dexterity, and critical thinking necessary for effective clinical
practice. Pearson’s Nursing: A Concept-Based Approach to New to This Edition
Learning, Third Edition, is the only resource solution to dedi- ■■ Learning Outcomes define measurable goals at the start
cate a volume exclusively to nursing skills. Showcasing 277 of each chapter and align with end-of-chapter NCLEX-
skills with nearly 250 minor skills embedded in them, Clini- style questions and the test bank.
cal Nursing Skills: A Concept-Based Approach to Learning, the ■■ Concept of … explains the chapter’s theory that under-
third volume in this suite, builds proficiency in the know- pins the skill.
how and the rationales to execute psychomotor skills, dele- ■■ Review Questions feature NCLEX-style questions that
gate appropriately, provide patient teaching, and support assess chapter-opening learning outcomes, answers, and
individualized nursing care. rationales and serve not only as a self-review, but also as
The previous edition of Clinical Nursing Skills: A Concept- preparation for the licensing exam.
Based Approach to Learning met the learning needs of tens of ■■ Enhanced eText, available via MyLab Nursing Concepts,
thousands of students and instructors in concept-based offers a rich and engaging learning experience with inter-
nursing programs. The Third Edition builds on that founda- active activities and exercises. Note: Access requires an
tion and Pearson’s commitment to excellence. We solicited adoption of MyLab Nursing Concepts.
and examined feedback on every skill and every feature that ■■ Instructor’s Resource Manual facilitates active learn-
you—our customer—recommended in order to produce the ing in the classroom, lab, and clinical environment with
best learning resource. This uniquely integrated solution class-tested interactive hands-on and cognitive exercises
provides students with a consistent design of content and to help students apply concepts and exemplars.
assessment that specifically supports a concept-based
■■ Test Bank offers test items written in NCLEX-like lan-
­curriculum.
guage.
Our goal for the Third Edition is to help students learn
the essential knowledge they will need for patient care. The ■■ Image Library provides all the text’s illustrations and
cover showcases a Möbius strip, which represents the rela- photos to enhance your PowerPoint presentations and
tionships among the concepts and how they are all intercon- other materials.
nected. By understanding important connections of ■■ New and Restructured Skills 277 major skills with
concepts, students are able to relate topics to broader nearly 250 additional assessment, teaching, or care skills
­contexts. embedded in them. For example, Skill 2.5 Hair: Caring for
includes the embedded skills of Assessing and Treating
Head Lice and Nits Infestation.
Why Teach Concept-Based Learning?
University and college nursing programs across the United
States and Canada evaluated how their programs can meet
More Changes for this Edition
the needs of today’s nursing students effectively. Nursing ■■ Integrates developmental ages across the lifespan
students felt overwhelmed by the amount of knowledge and throughout skills instead of having separate areas for dif-
skills they required to become proficient practitioners. As a ferent ages.
result, many programs moved or are moving to the model of ■■ Expands newborn, infant, and child procedural steps in
concept-based learning. A concept-based curriculum’s the skills.
streamlined approach helps nursing students to integrate ■■ Offers more photos and figures to improve learning
concepts, apply information, and use clinical reasoning through visual examples.

v
vi   Preface
■■ Identifies common advanced skills students may have
opportunities to observe or assist with following safety
Organization and Structure of Clinical
note perimeters – ex. “Paracentesis: Assisting” provides Nursing Skills, Third Edition
information about this procedure. Clinical Nursing Skills’ chapters, listed alphabetically, sup-
■■ Broadens teaching context to include the patient in the port concepts in volumes 1 and 2. Within each chapter, asso-
home environment after discharge. ciated skills appear in subgroups. Subgroups reflect the
sequence of thinking, such as assessment skills appearing
New Skills before intervention skills in the chapters. As an example, the
The following skills are new to the third edition: path for finding the skill about using a nasal cannula for
supplemental oxygen therapy is:
■■ Colostomy: Irrigating, Skill 4.19
■■ Fall Prevention: Assessing and Managing, Skill 15.2 ■■ Concept—Oxygenation, Chapter 11
■■ Suicide: Caring for Suicidal Patient, Skill 15.4 ■■ Subgroup—Supplemental Oxygen Therapy
■■ Skill—Oxygen Delivery Systems: Using, Skill 11.8
Revised and Restructured Skills ■■ VARIATIONS—Nasal Cannula/Simple Face Mask/­
The presentation of the following skills was re-envisioned Partial Rebreather Mask, etc.
for the third edition:
■■ Blood Transfusion: Administering, Skill 12.2 Skill Organization
■■ Body Mass Index (BMI): Assessing, Skill 10.1 ■■ Delegation or Assignment offers guidelines when it is
■■ Capillary Blood Specimen for Glucose: Measuring, appropriate to delegate or assign skills to unlicensed
Skill 8.4 assistive personnel (UAP).
■■ Cardiac Compressions, External: Performing, Skill 11.22 ■■ Equipment lists the apparatus required to perform the
skill.
■■ Closed Wound Drains: Maintaining, Skill 16.3
■■ Preparation includes safety, age, and cultural informa-
■■ Ear Medication: Administering, Skill 2.17
tion for working with various patients.
■■ Feeding, Continuous, Nasointestinal/Jejunostomy with a ■■ Procedure provides step-by-step best practice with
Small-Bore Tube: Administering, Skill 10.6
rationales.
■■ Implanted Vascular Access Devices: Managing, Skill 5.5 ■■ Photos and illustrations depict critical steps visually.
■■ Infusion Flow Rate Using Controller or IV Pump, Skill 5.7 ■■ Documentation demonstrates what data to capture
■■ Intracranial Pressure: Monitoring and Caring for, Skill 7.2 post-execution.
■■ Nasogastric Tube: Inserting, Skill 10.11 ■■ Variation Skills present alternative methods for per-
■■ Newborn: Assessing, Skill 14.23 forming select skills.
■■ Oxygen Delivery Systems: Using, Skill 11.8 ■■ Embedded Skills (as appropriate) provide useful skills
■■ Range-of-Motion Exercises: Assisting, Skill 9.2 to enhance learning (such as USING A DOPPLER
ULTRASOUND DEVICE in Skill 1.6, Pulse: Apical and
■■ Suctioning, Oropharyngeal and Nasopharyngeal: New- Peripheral, Obtaining).
born, Infant, Child, Adult, Skill 11.14
■■ Venipuncture: Initiating, Skill 5.15
 Chapter 12
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Perfusion
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Chapter at a Glance
Chapter Organization Maintaining Blood Volume
SKILL 12.1 Blood Products: Administering
SKILL 12.9
SKILL 12.10
ECG, 12-Lead: Recording
ECG, Leads: Applying

Chapter 12
For the Third Edition, as shown in the Chapter at a Glance listed at the beginning of each chapter,
SKILL 12.2
SKILL 12.3
Blood Transfusion: Administering
Direct Pressure: Applying
SKILL 12.11
SKILL 12.12
ECG, Strip: Interpreting
Pacemaker, Insertion: Assisting

Perfusion
SKILL 12.13 Pacemaker, Permanent: Teaching
SKILL 12.4 Pressure Dressing: Applying
each main section has a list of skills. SKILL 12.14 Pacemaker, Temporary: Maintaining
Antiembolism Devices SKILL 12.15 Temporary Cardiac Pacing, Transvenous,
Epicardial: Monitoring
SKILL 12.5 Antiembolism Stockings: Applying
SKILL 12.6 Pneumatic Compression Device: Applying Arterial Line
Chapter at a Glance
M12_NURS6834_03_SE_C12.indd Page 538 25/10/17 12:25 PM f-0051a
SKILL 12.7 Sequential Compression Devices: Applying
/203/PH03228/9780134616834_NA/NA_CLINICAL_NURSING_SKILLS_A_CONCEPT_BASED_APPROACH SKILL
... 12.16 Allen Test: Performing
Electrical Conduction in the Heart SKILL 12.17 Arterial Blood Pressure: Monitoring
Maintaining Blood Volume SKILL 12.9 ECG, SKILL
12-Lead: Recording
12.8 Automated External Defibrillator (AED): Adult,
SKILL 12.18 Arterial Blood Samples: Withdrawing
SKILL 12.10 ECG, Leads: Applying Using SKILL 12.19 Arterial Line: Caring for
SKILL 12.1 Blood Products: Administering
SKILL 12.11 ECG, Strip: Interpreting
SKILL 12.2 Blood Transfusion: Administering
SKILL 12.12 Pacemaker, Insertion: Assisting
538 12.3
SKILL Chapter Perfusion
12 Applying
Direct Pressure: Nursing students may observe or assist with the following skills only with faculty permission and while under direct supervision of faculty or another RN.
SKILL 12.13 Pacemaker, Permanent: Teaching
SKILL 12.4 Pressure Dressing: Applying
SKILL 12.6 Pneumatic Compression Device: Applying SKILL 12.14 Pacemaker, Temporary: Maintaining
(continued)
Antiembolism Devices
SKILL
SKILL
12.5theAntiembolism
5. Apply
●■ Remove
Stockings:
sleeve to the patient’s
12.6 Pneumatic Compression
sleeve from
Applying
leg.
plastic bag.Device: Applying
SKILL 12.15

Arterial Line
skin and
>>
Temporary Cardiac Pacing, Transvenous,

to provide skin care.

The Concept of Perfusion
Epicardial: Monitoring
10. Turn off machine at prescribed time intervals to assess

SKILL 12.7 Sequential

●■ Unfold sleeve and Compression Devices:toApplying
follow directions fit sleeve to SKILL 12.16 Allen Test: Performing
Perfusion is the immersion of body cells in a fluid. Tissue perfu- are carried away from the cells. When tissue perfusion is dimin-
patient’s leg. Leg is placed on white side (lining) of CAUTION!
Electrical
sleeve.Conduction
Markings on theinlining
theindicate
Heart the ankle and
SKILL 12.17 Arterialsion Bloodrefers to the Monitoring
Pressure: movement of solutes such as oxygen, nutri- ished or absent, cells do not receive adequate oxygen, nutri-
■■ Turn12.18
SKILL machine off ents,
Arterial and
immediately
Blood electrolytes
Samples: if the in the blood
patient
Withdrawing through
complains ofthe vascular system ents, or electrolytes. This may be manifested by a decrease in
SKILL popliteal
12.8 Automated
area. External Defibrillator (AED): Adult, to capillary networks. Tissue cells are bathed in solutes so they blood pressure, restlessness, confusion, cool extremities, pallor
SKILLnumbness or otherLine:
12.19 Arterial signsCaring
of DVT. for
●■ Place Using
patient’s leg on sleeve. Position back of knee can readily cross cell membranes. Waste products of cellular
■■ Follow hospital policy for amount of time alternating pneu-
or cyanosis of distal extremities, faint peripheral pulses, slowed
over popliteal opening. metabolic activity pass into the interstitial fluid from the cells and capillary refill, edema, or life-threatening conditions.
New! Each chapter contains The
●■ Starting at the side, wrap sleeve securely around
matic compression
Nursing students may observe or assist with the following skills only with faculty permission is
andimportant to keep
while under direct
devices are removed during the day. It
stockings
supervision on
of faculty most of
or another RN.the day to pre-
patient’s leg.
Concept of …, which explains the
●■ Attach Velcro straps securely.
vent clot formation.

>> ●■ Check the fit by placing two fingers between patient’s

chapter’s theoreticalofconcept
The Concept that
Perfusion
leg and sleeve to determine if sleeve fits properly. Read-
underpins the skill, and a dedicated
just Velcro as needed. Rationale: This is to ensure the
Learning Outcomes
11. To remove sleeve, turn power switch OFF, disconnect
tubing assembly from sleeve at connection site. Unwrap
sleeve from leg.
12.1 Give examples of priority safety considerations when 12.5 Differentiate the causes for different waves and intervals,
sleeve does not constrict circulation. preparing and administering a unit of blood to a patient. the P wave, the PR interval, the QRS wave, the T wave,
12. carried
When away the procedure is complete, perform handis hygiene,
list of Learning Outcomes. The out-
Perfusion
sion
●■ refers
is the
Attachtotubing
immersion
6. Turn the device on to begin.
the movement
of
and connect
body cells
of solutes
in a fluid.
such on
to plugs as leg
Tissue
oxygen,
sleeve
perfu-
nutri-
by
are
ishedlower the bed
or absent,
from
12.2
cells
the cells.
to do
Support
lowest
When thetissue
position,
not receive
devices and
adequate
(SCDs)
perfusion
benefits
leave
dimin-
of applying
patient
oxygen,
to promote
sequential compression
safe in the lower legs of
nutri-
circulation
and the QT interval when interpreting an electrocardio-
gram (ECG) pattern.
comes are reinforced by end-of-
ents, pushing
and electrolytes in the blood
ends firmly together. through the vascular system ents, and
or
13. Complete
comfortable.
electrolytes. This
pressure,documentation
may be manifested
an adult patient.
using forms,
by a decrease
cool checklists,
in 12.6 Examine the arterial insertion site for signs and symp-
to capillary
●■ Connect networks.
tubing Tissue
assemblycells plug
are bathed
to the incontroller
solutes soattheythe blood restlessness,
12.3 Summarize confusion, priority nursing or
extremities, elec- if SCDs are being
pallor
actions toms of bleeding, infection, or inflammation.
chapter review questions.
can readily cross cell membranes.
tubing assembly connector site. Waste products of cellular or tronic dropdown
cyanosis
additional
of distal listsused
extremities,
comments
supplemented
faint by
peripheral nurse’s
pulses, notes
slowed
on a patient, and the patient complains or of numbness 12.7 Explain why a transcutaneous pacemaker would be
metabolic activity pass into the interstitial fluid from the cells and
●■ Ensure tubing is free of kinks or twists. Rationale:
capillary refill, edema, andas appropriate,
or life-threatening
tingling conditions.
in one leg.including care, applied to a patient with a life-threatening dysrhythmia.
assessment, and patient response.
12.4 Explain proper placement of skin electrodes on the 12.8 Explain what a pacemaker spike indicates in an ECG
Kinks and twists can restrict airflow through system.
●■ Plug controller power cable into grounded electric out- patient being monitored on telemetry to avoid artifacts on monitor pattern.
the monitor screen.
Learning Outcomes
let and attach unit to bed frame.
●■ Turn controller power switch to ON. Confirm that alarms SAMPLE DOCUMENTATION
are audible. The following feature links some, but not all, of the concepts
12.1 Give examples of priority safety considerations when 12.5
[date] Differentiate
0720 Awake the causes for different
andtoalert, states she wavesready
and intervals,
●■ Check that pressure indicator lights are functioning related assessment. Theyisare for in alphabetical order.
presented
preparing and administering a unit of blood to a patient. the P wave, the PR interval, the QRS wave, the T wave,
properly.the Lower bedoftoapplying
lowest height. the andcompression device. Sleeves positioned,
12.2 Support
7. Monitor that
benefits
compression cycles
sequential compression
are correct.
devices (SCDs) to promote circulation in the lower legs of connected to compressor
gram (ECG) pattern. pumpEquipment provides a list
the QT interval when interpreting an electrocardio-
and turned on. 527
of tools required to execute
Skill Organization
8. Conduct
an adultneurovascular
patient. checks every 2–4 hr. Tolerated
12.6 Examine without complaint.
the arterial insertion R. Hosite for signs and symp-
9. Monitor
12.3 Summarize patient’s tolerance
priority nursingof device.
actions if SCDs are being toms of bleeding, infection, or inflammation.
used on a patient, and the patient complains of numbness 12.7 Explain why a transcutaneous pacemaker wouldthe
be skill.
and tingling in one leg. applied to a patient with a life-threatening dysrhythmia.
12.4 Explain proper placement of skin electrodes on the 12.8 Explain what a pacemaker spike indicates in an ECG
patient being monitored on telemetry to avoid artifacts on monitor pattern.
SKILL 12.7 Sequential Compression Devices: Applying
the monitor screen.
Preparation includes
The following feature links some, but not all, of the concepts
Sequential compression devices (SCDs) operate differently
related to assessment. They are presented in alphabetical order.
Equipment safety, age, and cultural
from pneumatic compression devices. SCDs use many inflat-
able compartments to compress the leg in a graduated
■■

■■
Single-use tape measure (to prevent cross-infection)
527
SCDs, including disposable sleeves, air pump, and tubing
information for working with
sequential fashion. The compartment closest to the foot
inflates first and the compartment closest to the thigh inflates various clients.
last. The amount of pressure also differs in each compart- Preparation
ment. The highest pressure is in the first compartment and
the lowest in the last one. This creates a “milking” action to
■■ Review healthcare provider’s orders and the patient’s nurs-
empty deeper veins of the lower leg to promote optimal ing plan of care.
Gather equipment and supplies.
Procedure provides
■■
blood flow.

Delegation or Assignment Procedure step-by-step best practice

The UAP often removes and reapplies SCDs when perform-
ing assigned or delegated hygiene care. The nurse should
1. Introduce self and verify the patient’s identity using two
identifiers. Explain to the patient what you are going to do,
with rationales.
check that the UAP knows the correct application process why it is necessary, and the procedure for applying the
for SCDs. Remind the UAP that the patient should not have sequential compression device. Rationale: The patient’s
SCDs removed for long periods of time because the purpose participation and comfort will be increased by under-
of the SCDs is to promote circulation. Note that state laws standing the reasons for applying the SCD.
for UAPs vary, so this task might be assigned to the UAP or 2. Perform hand hygieneM12_NURS6834_03_SE_C12.indd Page 539 25/10/17
and observe other appropriate 12:25 PM f-0051a
Photos and illustrations
/203/PH03228/9780134616834_NA/NA_CLINICAL_NURSING_SKILLS_A_CONCEPT_BASED_APPROACH
delegated. infection control procedures.
depict crucial steps visually.

Antiembolism Devices 539

Delegation or Assignment
SKILL 12.7 Sequential Compression Devices: Applying (continued)
offers guidelines, when
appropriate, to delegate 3. Provide for patient privacy and drape the patient appro-
priately. Assess legs for skin integrity and neurovascular
or assign skills to unlicensed status.
4. Prepare the patient. Position bed at correct height for pro-
assistive personnel. cedure.
●■ Place the patient in a dorsal recumbent or semi-Fowler

position.
●■ Measure the patient’s legs as recommended by the

manufacturer if a thigh-length sleeve is required. Ratio-

nale: Foot and knee-length sleeves come in just one
size; the thigh circumference determines the size
needed for a thigh-length sleeve.
5. Apply the sequential compression sleeves.
●■ Place a sleeve under each leg with the opening at the

knee ❶.
●■ Wrap the sleeve securely around the leg, securing the

Velcro tabs. Allow two fingers to fit between the leg and
sleeve ❷. Rationale: This amount of space ensures
that the sleeve does not impair circulation when inflated. ❷ Slip two fingers under wrap to ensure that it is not too tight.
Ensure that there is no overlapping or increases in the
SCD. Rationale: This prevents skin breakdown.
6. Connect the sleeves to the control unit and adjust the ●■ Turn on the control unit and adjust the alarms and
pressure as needed ❸. Reposition bed to lowest height. pressures as needed. The sleeve cooling control and
●■ Connect the tubing to the sleeves and control unit vii
alarm should be on; ankle pressure is usually set at
ensuring that arrows on the plug and the connector are 35–55 mmHg. Rationale: It is important to have the
in alignment and that the tubing is not kinked or twisted. sleeve cooling control on for comfort and to reduce
Rationale: Improper alignment or obstruction of the the risk of skin irritation from moisture under the
tubing by kinks or twists will interfere with operation of sleeve. Proper pressure settings prevent injury to the
 Maintaining Blood Volume 529
SKILL 12.1 Blood Products: Administering (continued)
Structures and Features
■■ Review patient’s record for allergies. 5. Identify rate at which blood component should infuse.
The Conceptsresults
■■ Anticipate are setofup consistently
infusing throughout the program. This
blood component: allows blood
6. Infusing students to antic- may produce adverse effects
components
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ipate●■ the learning
Fresh they will experience.
frozen plasma—given to buildSpecial features
up clotting recur in each
factors, thatchapter
can range as well,
from which
mild allergic manifestations to fatal
students can use
albumin, andfor learning and review. The basic structure of each
immune-globulins chapter(see
reactions is shown
steps 10 below
and 11 in Skill 12.2).
Platelets—given
with●■visuals to improve
and annotations coagulation
describing and prevent
the content. 7. When the procedure is complete, perform hand hygiene
bleeding 528 Chapter 12 Perfusion
and leave patient safe and comfortable.
Red blood cells (RBC)—given to build up red blood cell
●■ 8. Complete documentation using forms, checklists, or elec-
count for improved oxygenation and treatment ofConcepts anemia. Related
tronictodropdown lists supplemented by nurse’s notes or
Concepts Related to …
■■ Gather equipment and supplies.
M12_NURS6834_03_SE_C12.indd
Perfusion
Page 529 25/10/17 12:25 PM f-0051a additional comments as appropriate.
/203/PH03228/9780134616834_NA/NA_CLINICAL_NURSING_SKILLS_A_CONCEPT_BASED_APPROACH ...
­ nhanced for the Third Edition, the Concepts
E RELATIONSHIP TO
CONCEPT PERFUSION NURSING IMPLICATIONS
Related to feature links to more concepts,
Procedure Cognition Thought processing or mental ■■ Monitor oxygen saturation, vital signs, and orientation status
­relationships, and nursing implications. status is affected if blood volume is
Safety Considerations Rule out physical reasons cognition may change
■■

1. Introduce self to patient and verify the patient’s identity decreased.

using two identifiers. Explain to the patient you are going

Comfort Tissues not adequately oxygenated
In addition
manifest pain. to the usual blood
Monitor pain and for signs of local and systemic hypoxia
Maintaining
components Blood
■■
such as Volume
platelets and cryo- 529
Implement oxygen therapy as ordered
■■
to administer a blood product ordered by the healthcare precipitate, modified blood products are becoming more popular.
provider, SKILL 12.1 Blood and howProducts: canAdministering
Monitor oxygen saturations and vital signs
■■

why it is necessary, the patient Washed, irradiated,(continued) or leukocyte-removed blood is being used for
Fluids and Electrolytes Excess extracellular fluid volume Monitor fluid intake and output, vital signs, and oxygen saturation
■■

participate. Discuss how the results will be used in plan- patients

causes lung atcongestion
risk becauseand of Implement
multiple transfusions or a weakened
oxygen therapy as ordered
■■
impaired gas exchange.
ning further care or treatments.
■■ Review patient’s record for allergies.
immune system. Testing for cytomegalovirus asand
orderedmatching RBC or
5. Identify rate at which blood component
Administer medications
■■
should infuse.
2. Perform hand hygiene
■■ Anticipate and ofobserve
results infusing appropriate infection
blood component:
Intracranial Regulationhuman leukocyte
Blood flow 6.volume
Infusing
antigens
to brain is also
blood components
can Monitordone to pupils,
ensure
may produce
vital signs,
■■ safe and
sensorium, transfusions.
adverse effects
assess for motor or

control procedures. When

change infusing
intracranial pressurea blood
(ICP). product
sensory neurothat has
deficits undergone leukocyte
● ■ Fresh frozen plasma—given to build up clotting factors, that can range from mild allergic manifestations to fatal
Tissue Integrity reduction,
Wound healing remember
delayed without that it mustOxygen beis needed
filtered
■■
11 again
in Skillthrough
12.2). a standard
for cell metabolism; hyperbaric oxygen therapy
3. Provide for patient privacy.
albumin, and immune-globulins reactions
adequate perfusion to tissue. (see steps can be10 and
effective
●■ Platelets—given to improve coagulation and prevent
blood administration
7. When the procedure is complete, performthat
set in order to trap cellular debris handmayhygiene
have
4. Follow directions for proper administration of the blood accumulatedand since the patient
originalsafefiltration.
bleeding
product/component. leave and comfortable.

Safety Note!
countand Icon
for improved
●■

oxygenation >> Maintaining

Red blood cells (RBC)—given to build up red blood cell
…andDistinguishes
treatment
Blood
of anemia.Safety
Volume
Considerations
tronic dropdown lists supplemented…
by nurse’s notescrucial
Identifies or
8. Complete documentation using forms, checklists, or elec-

■■ Gather equipment and supplies. additional comments as appropriate.

skills that nursing students may observe or assist
Mostwith
peopleonly safety
in good health give littleinformation.
thought to their car- Preventing venous stasis is an important intervention to
diovascular function. Changing position frequently, ambu- reduce the risk of complications following surgery, trauma,
with faculty permission and while under direct supervision
ofSKILL 12.2
ProcedureBlood Transfusion: Administering
lating, and exercising usually maintain adequate or major medical problems. The use of antiembolism stock-
faculty or another RN. cardiovascular functioning. Immobility is detrimental to car- ings and sequential compression devices is an additional
diovascular function.
1. Introduce self to patient and verify the patient’s identity Safety Considerations
measure that can help prevent venous stasis.

Expected
using two identifiers. Explain to the patient youOutcomes
are going In addition to the usualfor
blood components such as platelets and cryo-
■■ 250 mL normal saline infusion
Safety Note! to administer
During a blood
scheduled product
clinical time,ordered
1. Early detection of bleeding occurs and loss of blood is
nursing by the healthcare
students
minimized. ■■ Venipuncture start kit containing
3. Blood volume and components stabilize after blood product
precipitate, modified bloodadministration productsasare
an 18- becoming
to
reflected 20-gauge more
in vital signs popular.
and needle
oxygen saturation
may have a learningprovider, why
opportunity to itobserve
is necessary,
or assistand
withhow
this the only
skill
2. Pressure patient can and bleeding
dressing is applied, Washed, irradiated, or leukocyte-removed
is controlled. assessment. blood is being used for
participate. Discuss
or catheter (if one is not already in place)
patients at risk because of multiple transfusions or a weakened or, if the blood is to
with faculty permission and with directhow the results
supervision willfaculty
from be used or in plan-
be administered
immune system. quickly,
Testingafor larger catheter and matching RBC or
cytomegalovirus
another RN. ning further care or treatments. SKILL 12.1 Blood
/203/PH03228/9780134616834_NA/NA_CLINICAL_NURSING_SKILLS_A_CONCEPT_BASED_APPROACH Products:
... Administering
■■ Alcohol human swabs leukocyte antigens is also done to ensure safe transfusions.
2. Perform hand hygiene and observe appropriate infection
control procedures. ■■ Tape When infusing a blood UAP. Theproduct that
nurse must hasthat
ensure undergone
the UAP knows leukocyte
what complica-
A blood transfusion transfers blood from a donor to a patient
Safety Note! During scheduled clinical
M12_NURS6834_03_SE_C12.indd
time, nursing
reduction, students that
remember Page it 25/10/17
tions
537 must be 12:25
or adverse filtered
signs can again
PM occur and
f-0051a through a standard
should report these to the
/203/PH03228/9780134616834_N
3. Provide for patient privacy. may have a learning opportunityClean
■ ■ to observegloves
or assist with this skill only
to replace blood volume lost from trauma, medical conditions,with faculty permission and with directblood administration
supervision
nurse. In some states, only RNs can
from faculty or set in order to trap cellular debris that may have
administer blood products.
4. Follow directions for proper administration
another RN. of the blood accumulated since the original filtration.
or surgical procedure. Whole blood contains red blood cells,
product/component.
Equipment
Antiembolism Devices
white blood cells, platelets, plasma, and electrolytes. The Preparation
537 ■■ Blood component

Patient Teaching …compatible

Blood products such as platelets, red blood cells, fresh frozen

patient’s blood type must be Features teaching plans for

plasma, and cryoprecipitate are processed components
with the donor’s
■■ IV solution of normal saline, 250 mL

Review healthcare provider’s orders and patient’s nursing

tockings: Applying
patients and tips to(continued)
assist patients in self-care.
Lifespan Considerations … Presents age-
blood type. Some patients who know they will need blood for
include albumin,
■ ■
removed from whole blood. Plasma processed components
plan
coagulation
of
factors,
care.
and immunoglobulins.
■■ Appropriate IV administration
■■ Filter, if indicated
kit

These products are given to patients who only require certain ■■ Clean gloves

a surgical procedure can donate their own blood, have it for specific
SKILL 12.2 Blood Transfusion: Administering
related ■■ Review patient’s
content to alert learners to differences in caring for
elements of blood treatments record for allergies.
such as increasing

Patient Teaching SKILL

patients. 12.5 Antiembolism Stockings: Applying (
stored in the healthcare facility’s blood bank, andoxygen-carrying
receive itcapacity■and promoting coagulation. Preparation
■ Verify patient’s signed informed consent is in the patient’s
■■ Review healthcare provider’s orders and patient’s nursing
later during surgery. This is called an autologous transfusion.
Delegation or Assignment record. plan of care.
■■ 250 mL normal saline for infusion
Wearing Safety Antiembolism Note! Stockings
During scheduled at Home Due to nursing
clinical time, the need for sterile
students Gather
■■technique andequipment and supplies.
technical complexity,
■■ Venipuncture
■■ Verify patient has signed informed consent to receive the

or assigned to start kitblood

containing
products. an 18- to 20-gauge needle
stockings, Delegation■■ Ensure or mayAssignment
the have aor
patient learning
caregiveropportunity
knows how to observe
to applyor assist with this skill only
antiem- ■ ■ Lifespan
administering blood products is not delegated
If the patient
or catheter
Considerations
has (if
the
anone intravenous
is not already solution
in place)infusing,
or, if thecheck
bloodthe is to Patient T
stockings. with faculty permission and with direct supervision from faculty or
bolism stockings. IV catheter size and IVquickly,
solution running. The only IV solution
OLDER be ADULTS
administered a larger catheter
on put the Due ■ to■ Reinforce
the need anotherfor RN.
sterile technique and technical complexity, Wearing Anti
the importance and the rationales for no wrinkles that■■is■■Because
appropriate
Alcohol the swabs to use when administering blood is normal
blood transfusion
and no rollingisdown not delegated or assigned to the UAP. The
of the stockings. elastic is quite strong in antiembolism stockings, ■■ Ensure the pa
antiembo- nurse■■must
saline. ■■ The preferred
Tapeadults
older may IVneed
catheter size isputting
assistance #18 to on#20
the gauge.
stockings.
Reinforceensure
A blood that the UAP
transfusion
the importance knows the
transfers
of removing what
blood complications
donor toora patient
from adaily
stockings bolism stockin
the stock- adverseand Clean gloves
■■Patients with arthritis may need to have another person put the
signs to replace
can occur
inspecting blood
the skin and volume
onshould lost from trauma, medical
the legs.report these to the nurse. In conditions, ■■ Reinforce the
sted. If so, stockings on for them.
some■■states,
Includeonlyor surgical
RNs can
instructions procedure.
administer
about: Wholeblood blood contains
or blood red blood cells,
products. CAUTION! Dextrose solution (which causes lysis of RBCs), and no rolling
t be evenly ■■ Preparation
Many older adults have circulation problems and wear antiembo-
white blood cells, platelets, plasma, and electrolytes. The
Ringer’s solution, medications and Reinforce the
to other
check additives,
for wrinkles and
in thehyper-
■■
●■ Laundering the stockings (air dry because putting them
n hinder— lism stockings. It is important stock-
patient’s blood type must be compatible with the donor’s alimentation ■■ Review healthcare provider’s orders and patient’s nursing
solutions arestocking
incompatible and inspectin
Equipment in a dryer can affect their elasticity.) ings and to see if the has rolledwith
down blood or blood
or twisted. If so,
blood type. Some patients who
●■ Needing two pairs of stockings to allow one pair to be know they will need blood for
components. plan ofit care. ■■ Include instru
heck facility correct immediately. Rationale: The stockings must be evenly
of the legs wornawhile
■■ Unit of whole surgical
blood procedure
(for
the other packed can
RBCs,
is being laundered.donate theirblood
or other own blood,
com- have it ■■ Review patient’s record for allergies.
distributed over the limb to promote—rather than hinder— ●■ Laundering

ponents, stored
see
●■ Replacing Skillthein the healthcare
12.1)
stockings when they facility’s blood
lose their bank, and receive it
elasticity. Verify patient’s signed informed consent is in the patient’s
■■circulation. in a dryer
n the heels
later during surgery. This is called an autologous transfusion. If the ■ ■ patient
record. does not have an IV solution infusing, check ●■ Needing tw
y assessed ■ ■ BloodReinforce
■ ■ administration knowledge setabout slipperiness of stockings if ■ ■ Stockings should be removed at least once a day (check facility
■■ IV pump worn(follow
without facility
slippers policy
or shoes. for device and method of con- facility■■policy)
policies.
Gather In some
soequipment
that a thoroughfacilities
and supplies. an infusion
assessment can bemustmadebe of running
the legs worn while
If theDelegation
patient is or Assignment
ambulatory, emphasize the need for foot- If
■■and the patient
feet. has
Rationale: an intravenous
Redness and solution
skin infusing,
breakdown on check
the heelsthe ●■ Replacing
the elastic trolling flow rate if IV pump not available; see Skill 5.7)
● ■
(continued on next page)
wearDue to prevent IV catheter
can size and
occur quickly and go IV undetected
solution running. The only IV
if not thoroughly solution
assessed ■■ Reinforce kn
are of them. to the falling.
need for sterile technique and technical complexity,
onthat is appropriate
a regular basis. to use when administering blood is normal worn without
blood transfusion is not delegated or assigned to the UAP. The
saline. The preferred IV catheter size is #18 to #20 gauge. ●■ If the patie
nurse must ensure that the UAP knows what complications or ■■ Provide information about the importance of wearing the elastic
stockings, how to wear them correctly, and how to take care of them. wear to pr
adverse signs can occur and should report these to the nurse. In
some states, only RNs can administer blood or blood products. CAUTION! Dextrose solution (which causes lysis of RBCs),
pression Device: Applying
viii Ringer’s solution, medications and other additives, and hyper-
Equipment alimentation solutions are incompatible with blood or blood
ble sleeve massive edema of the leg, dermatitis, gangrene, or pre- components.
■■ Unit of whole blood (for packed RBCs, or other blood com-
SKILL 12.6 Pneumatic Compression Device: Ap
 Delegation or Assignment ■■ If the patient has an intravenous solution infusing, check the
ompression Devices: Applying (continued)
Due to the need for sterile technique and technical complexity,
IV catheter size and IV solution running. The only IV solution
that is appropriate to use when administering blood is normal
blood transfusion is not delegated or assigned to the UAP. The
bed to lowest saline. The preferred IV catheter size is #18 to #20 gauge.
nurse must ensure that the UAP knows what complications or
■■ DVT within the past 6 months
atient safe and
adverse Caution! … Highlights key details
signs can occur and should report these to the nurse. In
Pulmonary embolism
■■
some states, only RNs can administer blood or blood products. CAUTION! Dextrose solution (which causes lysis of RBCs),
klists, or elec- for
■■ high-risk
Any condition situations
in which anwhen
increaseperforming
in venous return to the heart
Ringer’s solution, medications and other additives, and hyper-
rse’s notes or the skill.
might be detrimental
Equipment alimentation solutions are incompatible with blood or blood
ding baseline ■■ Local conditions such as dermatitis, gangrene, recent skin graft,
components.
CD.■■Note
Unit con- infected
of whole blood (forleg wound,RBCs,
packed or ulcer or other blood com-
n integrity and see Skill 12.1)
ponents,
us■per facility ■■ If the patient does not have an IV solution infusing, check
■ Blood administration set
■■ IV pump (follow facility policy for device and method of con- facility policies. In some facilities an infusion must be running
EVIDENCE-BASED
trolling flow rate PRACTICE
if IV pump not available;
Recommend Bed Rest for DVT?
see Skill 5.7)
Evidence-Based Practice … Provides sug­
(continued on next page)

Prolonged immobilization has been associated with DVT in critically ill

gestions for best practice from available, current evidence.
ed. SCD patients. However, the value and safety of mobilizing patients with
h. No acute DVT has been a concern, largely because of the potential for
venous thromboembolism (dislodging of the clot into the bloodstream)
toes. Both and life-threatening pulmonary embolism (PE). M01_NURS6834_03_SE_C01.indd Page 91 23/10/17 12:26 PM f-0051a /203/PH03228/9780134616834_NA/NA_CLINICAL_NURSING_SKILLS_A_CONCEPT_BASED_APPROACH
. Tolerating A number of studies have shown that patients with acute DVT
who use compression stockings and begin ambulating early after
initiation of anticoagulant therapy experience several benefits from
this approach. Benefits include reduced pain level, more rapid Critical Thinking Options for Unexpected Outcomes 91
reduction in edema, increased strength maintenance, and improved
EXPECTED OUTCOME UNEXPECTED OUTCOME POSSIBLE INTERVENTIONS
flexibility. Early ambulation in these patients, with careful monitoring
ealthcare pro- for any evidence of PE, resulted in no increase in incidence of PE.
General Assessment Patient’s weight varies more than ■■ Verify time of day weights were measured.
Height and weight are obtained and recorded. expected from one day to the next. ■■ Verify if same scale was used for both weights.
tingling or leg Conversely, bed rest and immobilization did not result in any reduc- ■■ Verify equipment’s reliability.
■■ Verify what clothing or linen was on the patient
tion in incidence of PE. Therefore, the current recommendation of when weighed on both days.
the American College of Chest Physicians is ambulation with com- ■■ Verify I&O record for sources of fluid loss or gain.
■■ Verify MAR for medications that alter fluid balance
pression as tolerated, after starting anticoagulation, in patients with (e.g., diuretics).
acute DVT. Vital Signs Fever develops. ■■ Verify possible sources of infection and take
Temperature is within normal range. preventive measures.
Source: Data from Christakou, A. (2015). Effectiveness of early mobilization in hospi- Notify healthcare provider as needed.
■■
talized patients with deep venous thrombosis. Retrieved from http://www. Implement cooling methods if temperature is
■■

hospitalchronicles.gr/index.php/hchr/article/view/553. dangerously high, such as tepid sponge bath,

cool oral fluids, ice packs, or antipyretic drugs as
(DVT), phlebitis, M12_NURS6834_03_SE_C12.indd Page 565 25/10/17 12:25 PM f-0051a
ordered.
/203/PH03228/9780134616834_NA/NA_CLINICAL_NURSING_SKILLS_A_CONCEPT_BASED_APPROACH
■■ Assess all vital signs. ...
cular disease Temperature is within normal range. Temperature remains elevated Request order to obtain culture of possible
■■
because of bacterial-produced sources of infection.
pyrogens. Give antipyretics and other drugs as ordered.
■■
Decrease room temperature and remove excess
■■
covers.
Critical Thinking Options for■Unexpected Outcomes 565
Critical Thinking Options
■ Give tepid sponge bath.

EXPECTED UNEXPECTED Temperature remains subnormal. ■■ Assess for blood clots; extreme low temperature

ction in for
theUnexpected
Heart Outcomes …
can cause vasoconstriction.
OUTCOME OUTCOME POSSIBLE INTERVENTIONS
■■ Implement measures to promote vasodilation
Arterial blood pressure Direct blood pressure Flick tubing system to remove
■■ tiny air bubbles
(application escaping the flush
of warmth).
monitoring system functions readings vary significantly. solution.
Demonstrates how evaluation can lead to reliably and accurately. ■■
■■ If extremity is ischemic, monitor that heat source
Recheck transducer and patientdoesposition to ensure
not exceed accurate data.
body temperature.
■■ Recalibrate transducer.
beat is termed ­further interventions
A junctional for unexpected
dysrhythmia outcomes.
occurs when there is a problem Pulse is palpated without difficulty. Apical, femoral, andsystem
■■ Flush
are absent.
carotidafter sampling Assess
pulses ■■ all vital signs and status of the patient.
and zeroing.
■■ Immediately call for the rapid response team.
■■ Keep flush bag adequately filled and cleared of air.
s been used in associated with the AV node as indicated by a change in the ■■ Initiate CPR immediately.
■■ Maintain bag external pressure at 300 mmHg.
■■ Check that connections are Use Doppler device to assess for presence of pulse.
■■
d interchange- PR interval. A ventricular dysrhythmia results from a prob- tightly secured.
Peripheral■pulse
Patient has decreased urinary ■ Suspect balloon migration. Assess for other signs and symptoms of
is absent. ■■
nce in cardiac lem with the ventricle and is indicated by an abnormality in output or develops signs of ■■ Maintain head-of-bed elevationcirculatory impairment.
at less than 45 degrees to prevent
ssified accord- the configuration of the QRS complex. Although many dys- Respiratory rate, rhythm, and depth
radial areocclusion.
artery within Apnea (absence of breathing)
kinking ■■ Assess patient for pulse.
and migration of catheter.
normal limits. occurs, may
■■ be intermittent.
Immobilize ■■ Begin
cannulated extremity torescue
preventbreathing
catheter at the rate of 12 per
migration.
al, ventricular, rhythmias have no clinical manifestations, many others Arterial blood samples are Arterial blood sample is ■■ Suspect arterial spasm; allow minute
spasm forofan adulttoorstop,
artery 20 per minute
then for a
attempt tochild.
dysrhythmia have serious consequences. A ventricular dysrhythmia is obtained.
Labored, difficult, or noisy unobtainable.
respirations are aspirate blood
Kussmaul respirations occurwith gentle■■pressure
(deep Implement using a 6-mL
orders for syringe
diabeticrather than
ketoacidosis, renal
assessed. and gasping Vacutainer.
breaths—more than failure, or septic shock.
trial dysrhyth- the most life threatening because it compromises cardiac ■■ Reposition patient’s arm, making sure there is no pressure at catheter
20 breaths/min).
l (SA) node or output. The presence of factors that can alter blood Blood pressureinsertion
readingsite.
is ■■ Verify that proper BP cuff size was used.
■■ Check that catheter is in artery (note waveform on oscilloscope), flush
configuration. pressure readings is identified. abnormally high without apparent
physiological catheter,
■■ Verify BP cuff was snug.
cause. then attempt to■obtain
■ Ask sample.
if patient has pain, was anxious, had just
consumed caffeine, or had just exercised.
■■ Verify blood pressure on both arms. The normal
difference from arm to arm is usually about 5 mmHg.
REVIEW Questions ■■ Ask patient to sit and rest for 15 minutes and

appropriately to 4. Monitor waveforms are distinct and readable. then retake blood pressure reading.
Accurate readings are of
taken by using
red the
blood cellsBlood pressure cannot ■■ Use thigh of lower extremity to obtain blood
be is prescribed
5. Patient’s cardiac rate is maintained through use of a pacemaker. 1. A client receiving
correct
a unit
BP cuffinto
sizethe
and
packed
procedure.What should the
begins
measured
to 5. A client 3-lead telemetry to monitor atrial fibrillation.
vomit 15 minutes transfusion. nurse doon upper extremity dueapproach
Which lead pressures.
should the nurse use to obtain the best
propriately and 6. Patient is prepared psychologically and physically for insertion of
New! Review Questions
the pacemaker. with
first?
1. Call for help.
2. Stop the transfusion.
to casts,
procedure.
dialysis shunt, or surgical
1. Lead I
Hypotension (systolic 2.
■■ Be sure to document site where blood pressure
assessment of this

Lead IIless
pressure
client’s atrial functioning?
reading was obtained.
Take all vital signs more frequently until condition
y. answers andis rationales
7. Pacemaker inserted withoutfeature NCLEX-style
complications. ■■
3. Provide an emesis basin. 3. Lead III
than 90 mmHg) develops. has stabilized.
4. Increase infusing normal saline. 4. Lead aVL Place patient in supine position with lower
questions that relate to chapter-opening learn-
■■
extremities elevated 45 degrees.
2. The nurse assigns the UAP to complete morning care for a client 6. The nurse notes■the following when analyzing a client’s cardiac
■ Assess cause of hypotension, and notify
ing outcomes. They serve not only as a self- with a sequential compression device. What information should
the nurse instruct the UAP to report to the nurse?
rhythm strip: atrial rate 60; ventricular rate 42; QRS width 0.10
healthcare provider.
seconds. Which■diagnostic test should the nurse anticipate to
■ Increase or administer fluids as ordered by
review, but also as preparation for the licensing 1. Presence of pulses in the client’s feet
2. Condition of the skin under the devices
determine the best treatment for this client’s rhythm?
1. Digoxin level ■■
healthcare provider.
Observe postoperative patients for signs of bleeding.
exam. Answers and rationales for the review 3. Amount of time the devices were turned off
4. Sensation and movement of the client’s feet
2. T3 and T4 levels
■■ Administer oxygen.
3. Arterial blood gases
questions can be found in Appendix A or in the 3. A new graduate is using an automated external defibrillator (AED)
4. Serum electrolyte levels

Pearson MyLab and eText. for a client who was discovered without a pulse. For which rea-
son should the charge nurse intervene?
7. The nurse visits the home of a client with a newly inserted per-
manent pacemaker. Which observation indicates that the client
1. Resuming CPR after discharging the AED would benefit from additional teaching about the device?
2. Loudly stating “Clear” before discharging the AED 1. Medical alert bracelet on the right wrist
3. Stopping compressions for the AED to analyze the client’s 2. Telephone transmission device installed
rhythm 3. Pacemaker information card in the wallet
4. Placing electrode pads below the right clavicle and above the 4. Cell phone in shirt pocket over the pacemaker
left nipple
8. A new graduate reports that a client’s arterial blood pressure
4. The nurse evaluates the ability of the UAP to complete a 12-lead monitor reading is 20 mmHg higher than the measurement from
electrocardiogram for a client. Which lead placement should the the previous shift. What should the nurse assess first to deter-
nurse correct before the measurement is recorded? mine the reason for the change in measurement?
1. Green lead placed on the client’s left leg 1. Calibration process
2. White lead placed on the client’s right wrist 2. Pressure bag setting
3. V2 placed at the fourth intercostal space, left sternal border 3. Arterial site dressing
4. V6 placed at the fifth intercostal space, left midclavicular line 4. Angle of the head of the bed

Note: For answers and rationales for the review questions, go to Appendix A or your Pearson MyLab Nursing and eText.
ix
Resources
Instructor Resources ■■ Skills Hub, The Skills Hub app meets students where
they are - on their smartphones and tablets - by provid-
■■ New! Instructor’s Resource Manual facilitates active ing procedural steps, skills videos, assessment, and pro-
learning in the classroom, lab, and clinical environment gress tracking in one mobile application. Access to Skills
with class-tested interactive hands-on and cognitive exer- Hub may be packaged with Pearson materials or pur-
cises to help students apply concepts and exemplars. chased as a standalone item.
■■ New! Test Bank offers test items written in NCLEX-like
language.
■■ New! Image Library provides all the text’s illustrations
and photos to enhance your PowerPoint presentations
and other materials.
■■ Skills Checklists deliver editable check-offs for each
skill to assess students’ competency, which can be used as
is or can be tailored to meet local requirements.

Student Resources
■■ New! Enhanced eText, available via MyLab Nursing Con-
cepts, offers a rich and engaging learning experience with
interactive activities and exercises. Note: Access requires
an adoption of MyLab Nursing Concepts.
■■ RealEHRprep with iCare, Developed as a partnership
between iCare and Pearson Education, RealEHRPrep
with iCare provides access to a real electronic health
record system developed by healthcare information tech-
nology, and documentation activities created by educa-
tion experts. Providing an environment that mirrors the
point-of-care, students can document assessments, plan
care, administer medications, communicate with other
healthcare providers, and more.
Access to RealEHRPrep with iCare may be packaged
with Pearson materials or purchased as a standalone item.

x
Acknowledgments
Foremost, my thanks to Pearson Education, Inc. for their Nursing, for her organizational skills and many
continued support of concept-based nursing education and contributions to this edition and its eText ver-
for the privilege of being one among so many involved in sion; Addy McCulloch and Laura Horowitz,
the production of this third edition of Volume 3 Clinical Development Editors, for their availability to
Nursing Skills. Much appreciation goes to Julie Alexander, respond to questions and offer suggestions from a dif-
Publisher, for her continued support and advocacy for con- ferent perspective; and Mary Siener (and team) for the inno-
cept-based learning; Lisa Rahn, Nursing Portfolio Manager/ vative cover, color scheme, and interior design of this
Editor, for her leadership, decision-making ability, and con- edition. A special thanks goes to my husband for supporting
sistent encouragement; Rachel Bedard, Development Editor, me to do what I enjoy doing. Thank you, Pearson folks, for
for guidance through the development process and for being promoting a culture of professionalism and team effort dur-
a great partner; Bianca Sepulveda, Content Producer in ing this fabulous adventure.
Barbara Callahan

Reviewers
Pearson thanks faculty who participated in pre-revision and manuscript reviews. We appreciate your thoughtful feedback,
insights, and recommendations.

Stephanie Bailey, BA, RN, MHS Ann Crawford, RN, PhD, CNS, CEN, Christine Kleckner, MA, MAN, RN
Nursing Instructor CPEN Instructor of Nursing
British Columbia Institute of Technology Professor, College of Nursing Minneapolis Community and Technical
Burnaby, BC, Canada University of Mary Hardin-Baylor College
Eleisa Bennett, RN, MSN Belton, TX Minneapolis, MN
Instructor of Associate Degree Nursing Christy Dean, DNP, MSN, FNP-BC, Lynn Lowery, RN, ADN, BSN, MSN
James Sprunt Community College CNE Professor of Nursing
Kenansville, NC Instructor of Nursing Delgado Community College
Wendy I. Buchanan, RN, ADN, BS, BSN, University of Louisiana at Lafayette New Orleans, LA
MSN-E Lafayette, LA Lauro Manolo, Jr., MSN
Instructor of Nursing Michelle De Lima, DNP, APRN, CNOR, Professor of Nursing
Southwestern Community College CNE Allan Hancock College
Sylva, NC Associate Professor of Nursing Santa Maria, CA
Marlena Bushway, PhD, MSNEd, RN, Delgado Community College Christy McDonald Lenahan, DNP, MSN,
CNE New Orleans, LA FNP-BC, CNE
Professor of Nursing James R. Fell, MSN, MBA, RN Assistant Professor of Nursing
New Mexico Junior College Assistant Professor of Nursing University of Louisiana Lafayette
Hobbs, NM The Breen School of Nursing, Lafayette, LA
Kathleen Campbell, MSN, BSN Ursuline University
Ellen Manieri, MN, MEd, RN,
Instructor of Nursing Pepper Pike, OH
CMSRN
Hudson Valley Community College Charlene Beach Gagliardi, RN, Professor of Nursing
Troy, NY MSN Delgado Community College, Charity
Darlene Clark, MS, RN Assistant Professor School of Nursing
Professor of Nursing Mount Saint Mary’s University New Orleans, LA
The Pennsylvania State University Los Angeles, CA Janice Martin, MSN, BSN
University Park, PA Cathryn Jackson, MSN, RN Professor of Nursing
Diane Cohen, MSN, RN Instructor of Nursing and Associate Southern Union State Community
Professor of Nursing Director of Undergraduate Programs College
MassBay Community College University of British Columbia Opelika, AL
Framingham, MA Vancouver, BC Canada Amy Mersiovsky, DNP, RN, BC
Ann Marie Cote, MSN, RN, CEN Carolyn Jones, BSN, MAEd, MSN Assistant Professor of Nursing
Professor of Nursing Professor of Nursing Scott and White College of Nursing,
Plymouth State University Craven Community College University of Mary Hardin-Baylor
Plymouth, NH New Bern, NC Belton, TX
xi
xii   Reviewers
Juleann H. Miller, PhD, RN, CNE St. Lawrence College School of Patricia Vasquez, MSN, RN
Professor of Nursing ­Baccalaureate Nursing Professor of Nursing
St. Ambrose University Kingston, ON Trinity Valley Community College
Davenport, IA Margaret Prydun, PhD, RN, CNE Athens, TX
Linda Mollino, MSN, RN Professor of Nursing Amanda Veesart, PhD, RN, CNE
Director of Career and Technical University of Mary Hardin-Baylor Assistant Professor/Program Director
Education (CTE) Programs Belton, TX Texas Tech University
Oregon Coast Community College Susan M. Randol, MSN, RN, CNE Lubbock, TX
Newport, OR Master Instructor of Nursing Molly H. Wells, BSN, RN-BC, CEN
Michelle Natrop, MSN, BSN University of Louisiana at Lafayette Instructor of Associate Degree Nursing
Instructor of Nursing Lafayette, LA Beaufort County Community College
Normandale Community College Marisue Rayno, EdD, RN Washington, NC
Bloomington, MN Professor of Nursing Teri Wisdorf, RN
Karen Neighbors, RN Luzerene County CC Professor of Nursing
Professor of Nursing Nanticoke, PA Century College
Trinity Valley Community College Lori-Ann D. Sarmiento, MSN, RN White Bear Lake, MN
Athens, TX Associate Professor of Nursing Lisa Zerby, MN, RN, CNOR
Denise Owens, MS, BSN, CCRN Guilford Technical Community College Adjunct Nursing Faculty
Instructor of Nursing Jamestown, NC Shoreline Community College
University of Maryland Lisa S. Smith, DNP, MSN, RN Shoreline, WA and
Baltimore, MD Instructor of Associate Degree Nursing Renton Technical College
Allison Peters, AA, ADN, BSN, MSN, DNP Sampson Community College Renton, WA
Professor of Nursing Clinton, NC Megan Zerillo, MSN, RN
University of Florida Tetsuya Umebayashi, DNP, RN Professor of Nursing
Gainesville, FL Director of Vocational Nursing Program University of Alabama
Katherine Poser, RN, BScN, MNEd Tarrant County College—Trinity River East Birmingham, AL
Professor of Nursing Fort Worth, TX

Technical Reviewers
Pearson gratefully thanks those who checked the accuracy and currency of the nursing skills content during the production
process. We appreciate you sharing your expertise and for your careful attention to detail.

Amanda Aird, RN, BScN James Sprunt Community College Lynn Perkins, PhD, MSN, RN
Instructor of Nursing Kenansville, NC Instructor of Nursing
St. Lawrence College School of Bacca- Sherrilyn Coffman, PhD, RN, COI Minneapolis Community and Technical
laureate Nursing Professor of Nursing College
Kingston, ON Nevada State College Minneapolis, MN
Stephanie Bailey, BA, RN, MHS Henderson, NV Katherine Poser, RN, BScN, MNEd
Nursing Instructor Ann Crawford, RN, PhD, CNS, CEN, Professor of Nursing
British Columbia Institute of Technology CPEN St. Lawrence College School of Bacca-
Burnaby, BC, Canada Professor, College of Nursing laureate Nursing
Eleisa Bennett, RN, MSN University of Mary Hardin-Baylor Kingston, ON
Instructor of Associate Degree Nursing Belton, TX
 Skills List by Key Word   xiii

SKILLS List by Key Word*

Items in black are major skills. Items in red are minor skills embedded within a major skill.
3-Lead or 5-Lead Electrode Telemetry Placement: 19 Bed or Chair Alarm, Exit Monitor Device: 648
Using, SKILL 12.10 Applying, SKILL 15.8
Abdomen: Assessing, SKILL 1.10 30 Bed Positions for Patient Care: Using, SKILL 9.7 402
Abdominal Binder: Applying, SKILL 16.2 663 Bedmaking: Occupied, Unoccupied, SKILL 2.2 103
Abuse: Newborn, Infant, Child, Older Adult, 636 Bedpan: Assisting, SKILL 4.6 239
Assessing for, SKILL 15.1
Biophysical Profile Criteria Scoring: Assessing, 595
After a Patient Falls: Assessing and Managing, 639 SKILL 14.5
SKILL 15.2
Bladder Irrigation: Continuous, SKILL 4.7 240
After Removal of Staple or Suture, Wound Care at 698
Bladder Irrigation: Providing, SKILL 4.8 241
Home: Teaching, SKILL 16.16
Bladder Scanner: Using, SKILL 4.1 228
Airway Obstruction: Clearing, SKILL 11.21 516
Blood Conservation Process: Using, SKILL 12.18 33
Airway, Nasopharyngeal: Inserting, SKILL 11.11 493
Blood Pressure: Newborn, Infant, Child, Adult, 11
Airway, Oropharyngeal: Inserting, SKILL 11.12 494
Obtaining, SKILL 1.5
Alcohol-Based Hand Rub: Using, SKILL 13.2 573
Blood Product Verification: Performing, 5
Allen Test: Performing, SKILL 12.16 556 SKILL 12.2
Altered Breathing Patterns and Sounds: 23 Blood Products: Administering, SKILL 12.1 528
Assessing, SKILL 1.8
Blood Specimen from Port: Obtaining, SKILL 5.5 304
Ambulating Patient: Assisting, SKILL 9.3 394
Blood Transfusion: Administering, SKILL 12.2 529
Amniocentesis: Assisting, SKILL 14.1 587
Blood Transfusion: Monitoring, SKILL 12.2 6
Amniotomy (Artificial Rupture of Membranes): 597
Blown Vein Occurs: Responding to, SKILL 5.15 332
Assisting, SKILL 14.7
BMI Table: Using, SKILL 10.1 437
Ankle-Brachial Index (ABI) Reading: Assessing, 673
SKILL 16.6 Body Mass Index (BMI): Assessing, SKILL 10.1 436
Antepartum Pelvic Examination: Assisting, 592 Body Mechanics: Using, SKILL 9.1 388
SKILL 14.3
Bowel Diversion Ostomy Appliance: Changing, 262
Antepartum, Maternal and Fetal: Assessing, 588 SKILL 4.18
SKILL 14.2
Bowel Routine, Develop Regular: Assisting, 261
Antiembolism Stockings: Applying, SKILL 12.5 534 SKILL 4.17
Anus: Assessing, SKILL 1.11 34 Breast Self-Examination: Teaching, SKILL 1.12 38
Apgar Score: Assessing, SKILL 14.21 621 Breastfeeding: Assisting, SKILL 14.16 612
Apgar Scoring and Interpretation: Using and 621 Breasts and Axilla: Assessing, SKILL 1.12 35
Treating, SKILL 14.21
Breath Sounds, Normal and Adventitious: 88
Appearance and Mental Status: Assessing, 3 Assessing, SKILL 1.27
SKILL 1.1
Calculating BMI with Formula: Using, SKILL 10.1 436
Apply Electrode Pads, Initiate Rhythm Analysis, 15
Calculating Calories, IV Infusion: Assessing, 307
Defibrillate as Indicated: Performing, SKILL 12.8
SKILL 5.7
Arterial Blood Gas (ABG) Values, Acid-Base 34
Calculating Flow Rate Manually: Using, SKILL 5.7 308
Imbalances: Using, SKILL 12.18
Calculating Fluid Balance for Exchanges and 280
Arterial Blood Pressure: Monitoring, SKILL 12.17 557
Cumulative Amounts: Performing, SKILL 4.25
Arterial Blood Samples: Withdrawing, 558
Calibrate (zero out) System: Performing, 31
SKILL 12.18
SKILL 12.17
Arterial Line: Caring for, SKILL 12.19 560
Cane: Assisting, SKILL 9.13 415
Arterial Ulcer Treatment: Assessing and 674
Capillary Blood Specimen for Glucose: 380
Performing, SKILL 16.6
Measuring, SKILL 8.4
Assistive Devices at Home: Using, SKILL 9.15 422
Cardiac Compressions, External: Performing, 518
Assistive Moving Patient Equipment: Using, 390 SKILL 11.22
SKILL 9.1
Cardiac Implantable Electronic Devices (CIEDs): 26
Automated Dispensing System: Using, 124 Assessing, SKILL 12.12
SKILL 2.10
Cardiac Rhythms, Dysrhythmias: Assessing and 21
Automated External Defibrillator (AED): Adult, 541 Treating, SKILL 12.11
Using, SKILL 12.8
Care as Dying Patient’s Condition Changes: 221
Bar-Code Medication Administration System: 323 Providing, SKILL 3.13
Using, SKILL 5.11
Care for Patient with Torso or Belt Restraint: 654
Bathing: Newborn, Infant, Child, Adult, SKILL 2.1 95 Providing, SKILL 15.12
(continued on next page)
*Related Concepts can be found in Nursing: A Concept-Based Approach to Learning, Volumes 1 and 2, Third Edition.
xiv    Skills List by Key Word
Care for Patient with Wrist or Ankle Restraint: 656 Coroner Cases, Precautions When Patient has 223
Providing, SKILL 15.13 Infectious Disease, Family Viewing the Body:
Providing Care (text)
Cast Care at Home: Teaching, SKILL 9.16 425
Cranial Nerves: Assessing, SKILL 1.22 69
Cast, Initial: Caring for, SKILL 9.16 422
Cast, Ongoing for Plaster and Synthetic: Caring 425 Crutch Gait Specific for Patient Needs: Teaching, 416
for, SKILL 9.17 SKILL 9.14

Casting Material: Selecting, SKILL 9.16 422 Crutches for Patient: Measuring, SKILL 9.14 420

Central Line Dressing: Changing, SKILL 5.2 296 Crutches: Assisting, SKILL 9.14 416

Central Line Infusion or Medication: 301 Deep Tendon Reflexes and Clonus: Assessing, 593
Administering, SKILL 5.4 SKILL 14.4

Central Line: Infusing Intravenous Fluids, 298 Dementia, Patient with: Bathing, SKILL 2.1 101
SKILL 5.3 Dentures, Artificial: Caring for, SKILL 2.7 119
Central Line: Managing, SKILL 5.4 300 Diabetes: Managing, SKILL 8.5 383
Changing Fecal Ostomy Pouch at Home: 276 Dialysis, Peritoneal: Catheter Insertion, Assisting, 277
Teaching, SKILL 4.22 SKILL 4.24
Changing Peritoneal Dialysis Catheter Site 282 Dialysis, Peritoneal: Procedures, Assisting, 279
Dressing at Home: Teaching, SKILL 4.25 SKILL 4.25
Characteristics of Chest Tube Drainage: 515 Diet, Therapeutic: Managing, SKILL 10.2 437
Assessing, SKILL 11.19
Direct Pressure: Applying, SKILL 12.3 532
Chest Drainage System Remains Closed and 510
Patent: Assessing and Monitoring, SKILL 11.18 Disposable Inner Cannula: Using, SKILL 11.17 508

Chest Physiotherapy: Preparing Patient, 478 Doppler to Measure Fetal Heart Rate: Using, 602
SKILL 11.4 SKILL 14.10

Chest Tube Drainage: Maintaining, SKILL 11.18 509 Doppler Ultrasound Device: Using, 20
SKILL 1.6
Chest Tube Drainage: Assessing, SKILL 11.18 511
Dosages: Calculating, SKILL 2.14 133
Chest Tube Insertion: Assisting, SKILL 11.19 512
Dressing, Alginate: Applying, SKILL 16.10 682
Chest Tube Removal: Assisting, SKILL 11.20 515
Dressing, Dry: Changing, SKILL 16.4 665
Circulation and Neurological Status, Cast: 424
Assessing, SKILL 9.16 Dressing, Hydrocolloid: Applying, SKILL 16.11 683
Circumcision: Caring for, SKILL 14.22 622 Dressing, Sterile: Changing, SKILL 16.5 668
Closed Intermittent Bladder Irrigation: Performing, 243 Dressing, Transparent: Applying, SKILL 16.12 686
SKILL 4.8
Dressing, Venous Ulcer: Changing, SKILL 16.6 671
Closed Wound Drain Care at Home: Teaching, 665
Dressing, Wet-to-Moist: Applying, SKILL 16.7 674
SKILL 16.3
Dry Cold: Applying, SKILL 3.8 210
Closed Wound Drains: Maintaining, SKILL 16.3 664
Dry Heat: Applying, SKILL 3.9 212
Colostomy: Irrigating, SKILL 4.19 265
During Circumcision and Post Circumcision: 622
Comfort Care, Child and Adult: Providing (text) 219
Providing Care, SKILL 14.22
Commode: Assisting, SKILL 4.9 244
Dying Patient: Physiological Needs, Managing, 219
Common Abbreviations/Symbols, Medication 129 SKILL 3.13
Administration: Using, SKILL 2.11
Ears: Hearing Acuity, Assessing: SKILL 1.13 39
Completion of Gowning: Performing, SKILL 13.5 13
Eating Assistance: Providing, SKILL 10.3 440
Complication of Mechanical Ventilator 492
Precautions: Applying, SKILL 11.10 ECG Waves, Intervals, Duration, Regularity: 20
Measuring and Assessing, SKILL 12.11
Complications of Phototherapy: Assessing and 630
Monitoring, SKILL 14.26 ECG, 12-Lead: Recording, SKILL 12.9 542

Compression Stocking Size: Measuring, 9 ECG, Leads: Applying, SKILL 12.10 543
SKILL 12.5 ECG, Strip: Interpreting, SKILL 12.11 546
Compression Therapy: Applying, SKILL 16.6 674 Elastic Bandage: Applying, SKILL 16.8 676
Confirm Rh Immune Globulin Indicated: 596 Electrical Safety for External Pacemaker: 25
Assessing, SKILL 14.6 Providing, SKILL 12.12
Continuous Ambulatory Peritoneal Dialysis (CAPD) 281 Electrical Stimulation: Using, SKILL 16.13 689
at Home: Teaching, SKILL 4.25
Electrode and Skin Care: Assessing and 18
Continuous Positive Airway Pressure (CPAP) or 487 Monitoring, SKILL 12.10
Biphasic Positive Airway Pressure (BiPAP):
Assessing, SKILL 11.8 Electrode Placement, 12-Lead ECG: Applying, 16
SKILL 12.9
Contraindications to Use of Sequential Compres- 14
sion Devices: Assessing, SKILL 12.7 Electromagnetic Interference Restrictions: 27
Teaching, SKILL 12.13
Conversion Drop Factors, IV Tubing Administra- 307
tion Sets: Using, SKILL 5.7 Electronic Blood Pressure Monitoring Device: 15
Using, SKILL 1.5
Cooling Blanket: Applying, SKILL 3.7 208
 Skills List by Key Word   xv
Empty Drainable Bowel Diversion Ostomy Pouch: 265 Gown Change for Patient with IV: Assisting, 100
Performing, SKILL 4.18 SKILL 2.1
Endocrine Disorders: Assessing, SKILL 8.1 373 Gravity Controller Device or Infusion Pump: Using, 308
SKILL 5.7
Endocrine Disorders: Complementary Health 376
Approaches, SKILL 8.2 Hair: Assessing, SKILL 1.16 53
Endotracheal Tube: Caring for, SKILL 11.13 496 Hair: Caring for, SKILL 2.5 113
Enema and Retention Enema: Administering, 267 Hand Hygiene: Performing, SKILL 6.1 341
SKILL 4.20
Head Lice and Nits Infestation: Assessing and 115
Enteric Contact Precautions: Using, SKILL 6.2 344 Treating, SKILL 2.5
Environmental Safety: Healthcare Facility, 644 Head-to-Toe Assessment: Performing (text) 3
Community, Home, SKILL 15.5
Healthcare Staff Safety: Providing, SKILL 15.5 645
Epidural: Assisting and Caring for Patient, 599
Healthy Eating on a Therapeutic Diet: Teaching, 439
SKILL 14.8
SKILL 10.2
Extremity and Pin Insertion Site Care: 430
Healthy Fluid Intake: Teaching, SKILL 5.1 295
Providing, 9.18
Healthy Nutrition at Home: Teaching, SKILL 10.5 445
Eyes and Contact Lenses: Caring for: SKILL 2.3 110
Hearing Acuity: Screening, SKILL 1.13 40
Eyes: Visual Acuity, Assessing, SKILL 1.14 44
Hearing Aid: Removing, Cleaning, and Inserting, 116
Failure of Pacemaker to Sense or Capture: 28
SKILL 2.6
Assessing, SKILL 12.14
Heart and Central Vessels: Assessing, SKILL 1.17 54
Fall Prevention When Ambulating: Assessing Risk, 395
SKILL 9.3 Heat and Cold Indications: Using (text) 208
Fall Prevention: Assessing and Managing, 638 Heat and Cold Physiological Effects: Using (text) 207
SKILL 15.2
Height: Newborn, Infant, Child, Adult, Measuring, 7
Fecal Impaction: Removing, SKILL 4.21 270 SKILL 1.2
Fecal Occult Blood Test (Hemoccult Test): 230 Hemodialysis: Central Venous Dual-Lumen 282
Performing, SKILL 4.2 Catheter, Caring for, SKILL 4.26
Fecal Ostomy and Skin: Assessing, SKILL 4.22 272 Hemodialysis: Procedures, Caring for, Assisting, 283
SKILL 4.27
Fecal Ostomy Pouch: Applying, SKILL 4.22 272
Huber Needle: Inserting, SKILL 5.5 304
Feeding, Continuous, Nasointestinal/Jejunostomy 446
with a Small-Bore Tube: Administering, Hydraulic Bathtub Chair: Using, SKILL 2.1 101
SKILL 10.6
Hydraulic Lift: Using, SKILL 9.4 396
Feeding, Gastrostomy or Jejunostomy Tubes: 449
Hygiene Care, Personal: Assisting (text) 100
Administering, SKILL 10.7
Hypoxia, Signs and Symptoms: Assessing, 490
Feet Care at Home: Teaching, SKILL 2.4 113
SKILL 11.9
Feet: Caring for, SKILL 2.4 111
Immobilizer, Mummy: Applying, SKILL 15.9 649
Fetal External Electronic: Monitoring, SKILL 14.9 600
Immobilizer, Papoose Board: Applying, 651
Fetal Heart Rate: Auscultating, SKILL 14.10 602 SKILL 15.10
Fetal Internal Scalp Electrode Placement: 602 Impending Clinical Death Manifestations: 219
Monitoring, SKILL 14.11 Assessing, SKILL 3.13
Fetal Scalp Electrode Contraindications: 603 Implanted Vascular Access Devices: Managing, 303
Assessing, SKILL 14.11 SKILL 5.5
Fetal Well-Being, Nonstress Test and Biophysical 594 Incentive Spirometer: Using, SKILL 11.5 479
Profile: Assessing, SKILL 14.5
Increased Intracranial Pressure: Assessing for, 366
Fire Safety: Healthcare Facility, Community, 646 SKILL 7.2
Home, SKILL 15.6
Induction of Labor with Oxytocin and Other 604
First Voiding and Output After Catheter Removal: 247 Agents: Assisting and Caring for Patient,
Assessing, SKILL 4.11 SKILL 14.12
Flow-Oriented or Volume-Oriented: Using, 479 Indwelling Catheter Care at Home: Teaching, 252
SKILL 11.5 SKILL 4.12
Fluid Intake and Output Sources: Assessing (text) 292 Inefficient Dilation of Vein: Intervening, SKILL 5.15 330
Fracture Bedpan: Using, SKILL 4.6 239 Infusing and Removing the Dialysate in Peritoneal 280
Dialysis: Performing, SKILL 4.25
Fresh Frozen Plasma, Platelets, and Red Blood 3
Cells, Modified Blood Products (Washed, Infusion Device: Discontinuing, SKILL 5.6 305
Irradiated, or Leukocyte-Removed Blood): Using,
Infusion Flow Rate Using Controller or IV Pump: 307
SKILL 12.1
Regulating, SKILL 5.7
Gastric Lavage: Performing, SKILL 10.8 452
Infusion Initiated, Peripheral Site or Central Line: 313
Genitals and Inguinal Area: Assessing, 49 Performing, SKILL 5.9
SKILL 1.15
Infusion Intermittent Device: Maintaining, 310
Glasgow Coma Scale: Using, SKILL 7.1 362 SKILL 5.8
(continued on next page)
xvi    Skills List by Key Word
Infusion Pump and “Smart” Pump: Using, 320 Locking Catheters, Saline or Heparin Solution: 312
SKILL 5.11 Using, SKILL 5.8
Infusion Syringe Pump: Using, SKILL 5.12 324 Logrolling Patient in Bed, SKILL 9.5 398
Infusion: Initiating, SKILL 5.9 313 Long-Term Mechanical Ventilation at Home: 492
Teaching, SKILL 11.10
Infusion: Maintaining, SKILL 5.10 318
Lumbar Puncture: Assisting, SKILL 7.3 366
Initiating Hemodialysis with Arteriovenous Fistula or 284
Graft: Assessing and Assisting, SKILL 4.27 Maintain Infusion System: Teaching, SKILL 5.10 320
Injection Sites for Medication, Parenteral Routes: 161 Maintaining Fluid Intake: Teaching, SKILL 5.1 293
Selecting (text)
Massage for Boggy Uterine Fundus: Performing, 620
Injection, Intradermal: Administering, SKILL 2.30 162 SKILL 14.20
Injection, Intramuscular: Administering, 164 Mealtime Fluid Portions: Assessing, SKILL 5.1 293
SKILL 2.31
Mealtime: Complementary Health Approaches, 442
Injection, Subcutaneous Anticoagulants: 168 SKILL 10.4
Administering, SKILL 2.33
Mean Arterial Blood Pressure: Obtaining, 35
Injection, Subcutaneous: Administering, 166 SKILL 12.19
SKILL 2.32
Medication Ampules: Removing, SKILL 2.13 132
Injection, Z-Track Method: Using, SKILL 2.34 170
Medication by Enteral Tube: Administering, 140
Inserting and Removing the Arterial Cannula: 35 SKILL 2.18
Assisting, SKILL 12.19
Medication Safety at Home: Teaching (text) 131
Insulin Injection: Using a Syringe, Pen, or Pump, 172
Medication Safety Measures: Performing, 129
SKILL 2.35
SKILL 2.11
Insulin Types and Therapeutic Actions: Using, 173
Medication to Intravenous Fluid Containers: 177
SKILL 2.35
Adding, SKILL 2.36
Intake and Output: Measuring, SKILL 5.1 293
Medication Using a Secondary Set: Administering 179
Intermittent Self-Catheterization at Home: 252 Intermittent Intravenous, SKILL 2.37
Teaching, SKILL 4.12
Medication Using IV Push: Administering 182
Intracranial Pressure: Monitoring and Caring for, 364 Intravenous, SKILL 2.38
SKILL 7.2
Medication Vials: Removing, SKILL 2.16 136
Intrapartum Vaginal Examination: Assisting, 609
Medication: Ear, Administering SKILL 2.17 138
SKILL 14.14
Medication: Eye, Administering SKILL 2.19 142
Intrapartum, Maternal and Fetal: Assessing, 606
SKILL 14.13 Medication: Inhaler, Dry Powder, Administering, 144
SKILL 2.20
Intubation, Maintenance, Extubation: Assisting, 497
SKILL 11.13 Medication: Inhaler, Metered-Dose, Administering, 145
SKILL 2.21
Irrigating the Colostomy at Home: Teaching, 267
SKILL 4.19 Medication: Nasal, Administering, SKILL 2.22 147
Isolation Precautions: Performing(text) 345 Medication: Nebulized, Non-Pressurized Aerosol 148
(NPA), Administering, SKILL 2.23
Isolation, Attire: Donning and Doffing, SKILL 6.3 346
Medication: Oral, Administering, SKILL 2.24 149
Isolation, Double-Bagging: Using, SKILL 6.5 352
Medication: Preparing and Administrating, 126
Isolation, Equipment, Specimens: Removing, 352
SKILL 2.11
SKILL 6.6
Medication: Rectal, Administering, SKILL 2.25 153
Isolation, Patient and Others: Caring for, 350
SKILL 6.4 Medication: Sublingual, Administering, 154
SKILL 2.26
Isolation, Transporting Patient Outside Room, 355
SKILL 6.7 Medication: Topical, Applying, SKILL 2.27 156
Jackson-Pratt or Hemovac Drain: Managing, 665 Medication: Transdermal Patch, Applying 157
SKILL 16.3 SKILL 2.28
Laboratory Tests for Endocrine Disorders: 375 Medication: Vaginal, Administering, SKILL 2.29 158
Assessing, SKILL 8.1
Medications to Relieve Pain: Administering, 204
Large-Volume and Small-Volume Enemas for 267 SKILL 3.5
Pediatric Patients: Administering, SKILL 4.20
Medications Using One Syringe: Mixing!, 134
Leg Drainage Bag or Urinary Drainage System: 256 SKILL 2.15
Applying, SKILL 4.14
Minimize Pain of Intradermal, Intramuscular, 161
Lifestyle/Behavioral Modification Strategies, 377 Subcutaneous Injections: Administering (text)
Endocrine Disorders: Teaching, SKILL 8.2
Modifications to Help Maintain Therapeutic Diets: 438
Lipid Side Effects with Lipid Infusion: Assessing, 464 Applying, SKILL 10.2
SKILL 10.13
Moist Pack and Tepid Sponges: Applying, 214
Lipids, IV Infusion: Providing, SKILL 10.13 463 SKILL 3.10
Lochia Amount Guide: Using, SKILL 14.17 616 Moist Wound Dressings: Selecting and Using, 684
SKILL 16.11
Lochia: Evaluating, SKILL 14.17 615
 Skills List by Key Word   xvii
Moisture-Retentive Dressings: Comparing, 685 Open-Suction and Closed-Suction System 502
SKILL 16.11 (In-Line Catheter): Using, SKILL 11.15
Monitor Fluid Intake and Output: Assessing, 294 Oral Suctioning, SKILL 11.14 499
SKILL 5.1
Orthopneic and Tripod Positions for Dyspnea: 477
Monitor for Complications: Assessing, SKILL 5.4 302 Using (text)
Monitor IV Fluid Type, Tubing, Infusion Rate, 318 Otoscope for Examination: Using, SKILL 1.13 41
Leaking: Assessing, SKILL 5.10
Oxygen Delivery Systems: Using, SKILL 11.8 484
Monitor IV Site for Complications: Assessing, 319
Oxygen Hood or Tent for Pediatric Patients: 488
SKILL 5.10
Using, SKILL 11.8
Mouth and Oropharynx: Assessing, SKILL 1.18 58
Oxygen Therapy: Assessing and Monitoring, 488
Mouth: Regular and for the Unconscious or 117 SKILL 11.8
Debilitated Patient, Caring for, SKILL 2.7
Oxygen, Portable Cylinder: Using, SKILL 11.9 488
Moving Patient Up in Bed, SKILL 9.6 400
Pacemaker Failure: Assessing, SKILL 12.14 27
Moving, Turning, and Lifting Body Mechanics: 389
Pacemaker, Insertion: Assisting, SKILL 12.12 550
Using, SKILL 9.1
Pacemaker, Permanent: Teaching, SKILL 12.13 552
Musculoskeletal Changes That Affect ROM: 393
Supporting, SKILL 9.2 Pacemaker, Temporary: Maintaining, SKILL 12.14 553
Musculoskeletal System: Assessing, SKILL 1.19 61 Pain Daily Diary: Using, SKILL 3.1 196
Nail Care, SKILL 2.4 112 Pain in Newborn, Infant, Child, or Adult: 190
Assessing, SKILL 3.1
Nails: Assessing, SKILL 1.20 64
Pain Rating Scales: Using, SKILL 3.1 195
Narcotic Control System: Using, SKILL 2.12 130
Pain Relief: Back Massage, SKILL 3.2 196
Nasal Cannula, Simple Face Mask, Partial 485
Rebreather Mask, Nonrebreather Mask, Venturi Pain Relief: Complementary Health Approaches, 198
Face Mask, Face Tent: Applying and Monitoring, SKILL 3.3
SKILL 11.8
Pain Relief: Transcutaneous Electrical Nerve 201
Nasal Speculum: Using, SKILL 1.23 76 Stimulation (TENS) Unit, Using, SKILL 3.4
Nasogastric Tube: Feeding, SKILL 10.9 453 Paracentesis: Assisting, SKILL 8.3 378
Nasogastric Tube: Flushing and Maintaining, 455 Parts of Medication Orders: Using, SKILL 2.11 129
SKILL 10.10
PASS: Using a Fire Extinguisher, SKILL 15.6 647
Nasogastric Tube: Inserting, SKILL 10.11 457
Patient with Dysphagia or Dementia: Assisting, 441
Nasogastric Tube: Removing, SKILL 10.12 461 SKILL 10.3
Neck: Assessing, SKILL 1.21 65 Patient-Controlled Analgesia (PCA) Pump: Using, 203
SKILL 3.5
Negative Pressure Wound Therapy: Using, 690
SKILL 16.14 Peak Expiratory Flow Rate: Measuring, 474
SKILL 11.2
Neonatal Incubator and Infant Radiant Warmer: 216
Using, SKILL 3.11 Penrose Drain: Managing, SKILL 16.9 680
Neurologic Status: Assessing, SKILL 1.22 67 Percutaneous Central Vascular Catheterization: 325
Assisting, SKILL 5.13
Newborn Thermoregulation: Assisting, 628
SKILL 14.25 Perineal-Genital Area: Caring for: SKILL 2.8 122
Newborn, Initial Bathing, SKILL 14.24 627 Peripheral Vascular System: Assessing, 77
SKILL 1.24
Newborn: Assessing, SKILL 14.23 623
Phototherapy Preparation to Newborn or Infant: 630
Newborn’s or Infant’s Head, Chest, and 8
Performing, SKILL 14.26
Abdomen: Measuring, SKILL 1.3
Phototherapy, Newborn, Infant: Providing, 630
NG Tube Feedings at Home: Teaching, 455
SKILL 14.26
SKILL 10.9
Physiological Tolerance and Contraindications to 207
Nonpharmacological Approaches to Pain: 202
Heat and Cold Therapies: Using (text)
Teaching (text)
PICC Line Dressing: Changing, SKILL 5.14 327
Nonstress Test Interpretation: Assessing, 595
SKILL 14.5 Pneumatic Compression Device: Applying, 537
SKILL 12.6
Nose and Sinuses: Assessing, SKILL 1.23 75
Positioning Child for Injections or Intravenous 166
Nose and Throat Specimen: Collecting, 473
Access (text)
SKILL 11.1
Positioning Patient in Bed, SKILL 9.7 401
Nutrition: Assessing, SKILL 10.5 443
Post Procedure Amniotomy Care: Assessing and 598
Nutritional Assessment Parameters: Using, 444
Monitoring, SKILL 14.7
SKILL 10.5
Postmortem Care: Providing, SKILL 3.14 221
Ongoing Care During Hemodialysis: Performing, 285
SKILL 4.27 Postoperative Care, Surgical Amputation: 699
Providing, SKILL 16.17
Open Bladder Irrigation with Two-Way Indwelling 243
Catheter: Performing, SKILL 4.8 Postpartum, Maternal: Assessing, SKILL 14.18 617

(continued on next page)

xviii    Skills List by Key Word
Postpartum, Perineum: Assessing, SKILL 14.19 618 Restraints, Torso and Belt: Applying, SKILL 15.12 653
Powdered Medications: Reconstituting, 138 Restraints, Wrist and Ankle: Applying, 654
SKILL 2.16 SKILL 15.13
PPE, Clean Gloves: Donning and Doffing, 356 Rh Immune Globulin: Administering, SKILL 14.6 596
SKILL 6.8
Rights of Medication Administration: Performing, 128
PPE, Face Masks: Donning and Doffing, 357 SKILL 2.11
SKILL 6.9
Risk Factors of Skin Care: Teaching, SKILL 2.1 102
Preoperative and Postoperative Care: Providing 567
Risk Level Assessment for Safety: Using, 643
(text)
SKILL 15.4
Preoperative Care, Surgical Amputation: 699
Risk of Patient for Skin Breakdown: Assessing, 693
Providing, SKILL 16.17
SKILL 16.15
Preoperative Patient Teaching, SKILL 13.1 568
Safety, Before, During, After Seizure Activity: 640
Pressure Dressing: Applying, SKILL 12.4 533 Applying, SKILL 15.3
Pressure Injury: Preventing and Caring for, 693 Salem Sump Tube: Using, SKILL 10.11 461
SKILL 16.15
Saline Lock Care at Home: Teaching, SKILL 5.8 313
Presurgery Hair Removal: Providing, SKILL 13.3 575
Saline Lock: Using, SKILL 2.37 181
Preventing Complications with Immobility: 429
Seizure Precautions at Home: Teaching, 642
Teaching, SKILL 9.18
SKILL 15.3
Preventing Constipation: Teaching, SKILL 4.17 262
Seizure Precautions: Implementing, SKILL 15.3 640
Preventing Postoperative Complications: 570
Self-Administration of Insulin by Patient: Teaching, 175
Teaching, SKILL 13.1
SKILL 2.35
Prevention of Central Line-Associated Blood- 326
Self-Care of Urinary Suprapubic Catheter at 260
stream Infection (CLABSI): Applying, SKILL 5.13
Home: Teaching, SKILL 4.16
Prolapsed Cord: Caring for Patient, SKILL 14.15 611
Sequential Compression Devices: Applying, 538
Promoting Healthy Bowel Training: Teaching, 262 SKILL 12.7
SKILL 4.17
Shampooing Hair, SKILL 2.5 114
Promoting Healthy Breathing: Teaching, 481
Shaving: Male Patient, SKILL 2.9 124
SKILL 11.6
Sitting on Side of Bed (Dangling): Assisting, 406
Promoting Healthy Skin at Home: Teaching, 683
SKILL 9.8
SKILL 16.10
Sitz Bath: Assisting, SKILL 3.12 217
Promoting Self-Care, Comfort, Safety: Teaching, 427
SKILL 9.17 Skin Lesions: Assessing, SKILL 1.25 81
Promoting Sleep at Home: Teaching, SKILL 3.6 206 Skin: Assessing, SKILL 1.25 79
Proper NG Tube Placement: Determining, 459 Skull and Face: Assessing, SKILL 1.26 84
SKILL 10.11
Sleep Promotion: Assisting, SKILL 3.6 205
Protective Isolation Precautions: Using (text) 344
Spacer with Metered-Dose Inhaler: Using, 146
Pulse Oximeter: Using, SKILL 1.7 21 SKILL 2.21
Pulse, Apical, and Peripheral: Obtaining, 16 Sputum Specimen: Collecting, SKILL 11.3 476
SKILL 1.6
Staff Recovery from Patient Suicide: Supporting, 643
Pursed-Lip Breathing, SKILL 11.6 481 SKILL 15.4
Quick-Result Urine Tests: Performing, SKILL 4.5 237 Staging a Pressure Injury: Performing, 694
SKILL 16.15
RACE: Priorities for Fire Safety, SKILL 15.6 647
Standard Precautions: Performing (text) 340
Radiant Warmer for Newborn: Using, 629
SKILL 14.25 Staple and Suture: Removing, SKILL 16.16 696
Range-of-Motion Exercises: Assisting, SKILL 9.2 390 Sterile Field: Maintaining, SKILL 13.4 576
Reactions to Blood Transfusion: Assessing and 5 Sterile Gown and Gloves: Donning (Closed 578
Treating, SKILL 12.2 Method), SKILL 13.5
Rectal Tube: Inserting, SKILL 4.23 276 Stool Specimen, Routine, Culture, and Ova, 229
Parasites: Obtaining SKILL 4.2
REEDA Scale to Evaluate Perineum: Using, 619
SKILL 14.19 Straight Catheter for Urine Specimen: Performing, 251
SKILL 4.12
Reflex Grading Scale: Using, SKILL 14.4 594
Stump: Positioning and Exercising, SKILL 16.17 698
Removal of Cord Clamp: Performing, 632
SKILL 14.27 Stump: Shrinking and Molding, SKILL 16.18 700
Rescue Breathing: Performing, SKILL 11.23 521 Suctioning at Home: Teaching, SKILL 11.14 501
Respirations: Newborn, Infant, Child, Adult, 22 Suctioning at Home: Teaching, SKILL 11.15 503
Obtaining, SKILL 1.8
Suctioning, Oropharyngeal and Nasopharyngeal: 498
Restraints and Alternatives: Caring for, 651 Newborn, Infant, Child, Adult, SKILL 11.14
SKILL 15.11
Suctioning, Tracheostomy or Endotracheal Tube, 502
Restraints for Infant or Child: Applying (text) 656 SKILL 11.15
 Skills List by Key Word   xix
Suicide: Caring for Suicidal Patient, SKILL 15.4 642 Universal Protocol for Preventing Wrong Site, 582
Wrong Procedure, and Wrong Person Surgery:
Supportive Devices for Patient Alignment: Using, 405
Using, SKILL 13.6
SKILL 9.7
Urinal: Assisting, SKILL, 4.10 245
Surgical Asepsis: Maintaining, SKILL 13.4 577
Urinary Catheter: Caring for and Removing, 246
Surgical Bed: Bedmaking, SKILL 2.2 109
SKILL 4.11
Surgical Hand Antisepsis and Scrubs, SKILL 13.2 572
Urinary Catheterization, Female and Male 250
Surgical Patient: Preparing, SKILL 13.6 580 Patients: Performing, SKILL 4.12
Surgical Safety Checklist: Using, SKILL 13.6 581 Urinary Catheterization: Performing, SKILL 4.12 248
Surgical Site: Preparing, SKILL 13.3 574 Urinary Diversion Pouch: Applying, SKILL 4.13 253
Surgical Wound: Caring for, SKILL 16.9 679 Urinary External Device: Applying, SKILL 4.14 255
Temperature: Newborn, Infant, Child, Adult, 24 Urinary Ostomy: Caring for, SKILL 4.15 257
Obtaining, SKILL 1.9
Urinary Stoma and Skin: Assessing, SKILL 4.13 254
Temperatures for Heat and Cold Applications: 208
Urinary Suprapubic Catheter: Caring for, 259
Using (text)
SKILL 4.16
Temporary Cardiac Pacing, Transvenous, 554
Urine Specimen Bag for Newborn or Infant: 236
Epicardial: Monitoring, SKILL 12.15
Using, SKILL 4.5
Terminating Hemodialysis Session: Assisting, 285
Urine Specimen, Clean-Catch, Closed Drainage 232
SKILL 4.27
System for Culture and Sensitivity: Obtaining,
Test for Fluid Leakage, Intrapartum: Assessing, 609 SKILL 4.3
SKILL 14.14
Urine Specimen, Ileal Conduit: Obtaining, 235
Testicular Self-Examination: Teaching, SKILL 1.15 53 SKILL 4.4
Testing for Pinworms at Home: Teaching, 232 Urine Specimen, Routine, 24-Hour: Obtaining, 236
SKILL 4.2 SKILL 4.5
Thermal and Electrical Injuries: Preventing, 647 Using Restraints at Home: Teaching (text) 656
SKILL 15.7
Using the Incentive Spirometer at Home: 480
Thoracentesis: Assisting, SKILL 11.7 482 Teaching, SKILL 11.5
Thorax and Lungs: Assessing, SKILL 1.27 85 Uterine Contractions: Monitoring, SKILL 14.13 24
Tonicity of IV Fluids: Using, SKILL 5.9 314 Uterine Fundus, After Vaginal or Caesarean Birth: 619
Assessing, SKILL 14.20
Topical Glue for Wound Closure: Using, 698
SKILL 16.16 Velcro Collar, One-Strip or Two-Strip Twill Ties 507
Method: Using, SKILL 11.17
Total Parental Nutrition (TPN), IV Infusion: 465
Providing, SKILL 10.14 Venipuncture Site: Selecting, SKILL 5.15 330
TPN Differences with Partial Parenteral 465 Venipuncture: Initiating, SKILL 5.15 329
Nutrition(PPN): Applying, SKILL 10.14
Ventilator Control Modes: Monitoring, 491
Tracheal Tube: Inflating the Cuff, SKILL 11.16 504 SKILL 11.10
Tracheostomy Care at Home: Teaching, 509 Ventilator, Mechanical: Caring for Patient, 490
SKILL 11.17 SKILL 11.10
Tracheostomy: Caring for, SKILL 11.17 505 Ventilator-Associated Pneumonia (VAP) 493
Precautions: Applying, SKILL 11.10
Traction Care at Home: Teaching, SKILL 9.18 431
Visual Acuity: Screening, SKILL 1.14 47
Traction, Skin and Skeletal: Caring for, SKILL 9.18 428
Volume-Control Infuser: Using, SKILL 2.37 181
Transcutaneous Pacing (TCP): Assessing, 29
SKILL 12.15 Walker: Assisting, SKILL 9.15 421
Transferring Patient Between Bed and Chair, 408 Wearing Antiembolic Stockings at Home: 11
SKILL 9.9 Teaching, SKILL 12.5
Transferring Patient Between Bed and Stretcher, 410 Weight: Newborn, Infant, Child, Adult Measuring, 10
SKILL 9.10 SKILL 1.4
Transporting: Newborn, Infant, Toddler, SKILL 9.11 411 Wound Care at Home: Teaching, SKILL 16.9 681
Troubleshooting Infusion Pump Alarm: Assessing, 307 Wound Cleansing or Irrigation: Performing, 666
SKILL 5.7 SKILL 16.4
Turning Patient: Lateral or Prone Position in Bed, 413 Wound Debridement: Performing, SKILL 16.6 672
SKILL 9.12
Wound Drainage Specimen: Obtaining, 661
Two-Insulin Solutions Mixed in One Syringe, 177 SKILL 16.1
SKILL 2.35
Wound: Irrigating, SKILL 16.19 701
Types of Wounds: Assessing (text) 660
Y-Set Infusion Tubing Set-Up: Preparing, 4
Umbilical Cord Clamp: Caring for, SKILL 14.27 631 SKILL 12.2
Contents
Chapter 1 Assessment 1 Chapter 2 Caring Interventions 93
GENERAL ASSESSMENT 3 BED CARE AND ACTIVITIES OF DAILY LIVING
SKILL 1.1 Appearance and Mental Status: Assessing 3 (ADLs) 95
SKILL 1.2 Height: Newborn, Infant, Child, Adult, SKILL 2.1 Bathing: Newborn, Infant, Child, Adult 95
Measuring 7 SKILL 2.2 Bedmaking: Occupied, Unoccupied 103
SKILL 1.3 Newborn’s or Infant’s Head, Chest, and Abdomen: SKILL 2.3 Eyes and Contact Lenses: Caring for 110
Measuring 8
SKILL 2.4 Feet: Caring for 111
SKILL 1.4 Weight: Newborn, Infant, Child, Adult,
Measuring 10 SKILL 2.5 Hair: Caring for 113
SKILL 2.6 Hearing Aid: Removing, Cleaning, and
VITAL SIGNS 10 Inserting 116
SKILL 1.5 Blood Pressure: Newborn, Infant, Child, Adult, SKILL 2.7 Mouth: Regular and Unconscious or Debilitated
Obtaining 11 Patient, Caring for 117
SKILL 1.6 Pulse, Apical and Peripheral: Obtaining 16 SKILL 2.8 Perineal-Genital Area: Caring for 122
SKILL 1.7 Pulse Oximeter: Using 21 SKILL 2.9 Shaving: Male Patient 124
SKILL 1.8 Respirations: Newborn, Infant, Child, Adult,
Obtaining 22 MEDICATION ADMINISTRATION SYSTEMS 124
SKILL 1.9 Temperature: Newborn, Infant, Child, Adult, SKILL 2.10 Automated Dispensing System: Using 124
Obtaining 24 SKILL 2.11 Medication: Preparing and Administering 126
SKILL 2.12 Narcotic Control System: Using 130
PHYSICAL ASSESSMENT 29
SKILL 1.10 Abdomen: Assessing 30
MEDICATION PREPARATION 131
SKILL 1.11 Anus: Assessing 34
SKILL 2.13 Ampule Medication: Removing 132
SKILL 1.12 Breasts and Axillae: Assessing 35
SKILL 2.14 Calculating Dosages 133
SKILL 1.13 Ears: Hearing Acuity, Assessing 39
SKILL 2.15 Mixing Medications in One Syringe 134
SKILL 1.14 Eyes: Visual Acuity, Assessing 44
SKILL 2.16 Vial Medication: Removing 136
SKILL 1.15 Genitals and Inguinal Area:
Assessing 49 MEDICATION ROUTES 138
SKILL 1.16 Hair: Assessing 53 SKILL 2.17 Ear Medication: Administering 138
SKILL 1.17 Heart and Central Vessels: Assessing 54 SKILL 2.18 Enteral Tube Medication: Administering 140
SKILL 1.18 Mouth and Oropharynx: Assessing 58 SKILL 2.19 Eye Medication: Administering 142
SKILL 1.19 Musculoskeletal System: Assessing 61 SKILL 2.20 Inhaler, Dry Powder Medication:
SKILL 1.20 Nails: Assessing 64 Administering 144
SKILL 1.21 Neck: Assessing 65 SKILL 2.21 Inhaler, Metered-Dose Medication:
Administering 145
SKILL 1.22 Neurologic Status: Assessing 67
SKILL 2.22 Nasal Medication: Administering 147
SKILL 1.23 Nose and Sinuses: Assessing 75
SKILL 2.23 Nebulized Medication, Non-pressurized Aerosol
SKILL 1.24 Peripheral Vascular System:
(NPA): Administering 148
Assessing 77
SKILL 2.24 Oral Medication: Administering 149
SKILL 1.25 Skin: Assessing 79
SKILL 2.25 Rectal Medication: Administering 153
SKILL 1.26 Skull and Face: Assessing 84
SKILL 2.26 Sublingual Medication: Administering 154
SKILL 1.27 Thorax and Lungs: Assessing 85
SKILL 2.27 Topical Medication: Applying 156
Physical Assessment for the Newborn 90
SKILL 2.28 Transdermal Patch Medication:
CRITICAL THINKING OPTIONS FOR UNEXPECTED Applying 157
OUTCOMES 90 SKILL 2.29 Vaginal Medication: Administering 158

Nursing students may observe or assist with these skills only with faculty permission and while under direct supervision of faculty or another RN.
xx
 Contents   xxi
PARENTERAL ROUTES 160 SKILL 4.3 Urine Specimen, Clean-Catch, Closed Drainage
System for Culture and Sensitivity: Obtaining 232
SKILL 2.30 Injection, Intradermal: Administering 162
SKILL 4.4 Urine Specimen, Ileal Conduit: Obtaining 235
SKILL 2.31 Injection, Intramuscular: Administering 164
SKILL 4.5 Urine Specimen, Routine, 24-Hour: Obtaining 236
SKILL 2.32 Injection, Subcutaneous: Administering 166
SKILL 2.33 Injection, Subcutaneous Anticoagulant: BLADDER INTERVENTIONS 238
Administering 168
SKILL 4.6 Bedpan: Assisting 239
SKILL 2.34 Injection, Z-Track Method: Using 170
SKILL 4.7 Bladder Irrigation: Continuous 240
SKILL 2.35 Insulin Injection: Using a Syringe, Pen,
SKILL 4.8 Bladder Irrigation: Providing 241
or Pump 172
SKILL 4.9 Commode: Assisting 244
SKILL 2.36 Intravenous Medication: Adding to Fluid
Container 177 SKILL 4.10 Urinal: Assisting 245
SKILL 2.37 Intravenous Medication, Intermittent: Using a SKILL 4.11 Urinary Catheter: Caring for and Removing 246
Secondary Set 179 SKILL 4.12 Urinary Catheterization: Performing 248
SKILL 2.38 Intravenous Medication, IV Push: SKILL 4.13 Urinary Diversion Pouch: Applying 253
Administering 182
SKILL 4.14 Urinary External Device: Applying 255
CRITICAL THINKING OPTIONS FOR UNEXPECTED SKILL 4.15 Urinary Ostomy: Caring for 257
OUTCOMES 184 SKILL 4.16 Urinary Suprapubic Catheter: Caring for 259

BOWEL INTERVENTIONS 261

Chapter 3 Comfort 189 SKILL 4.17 Bowel Routine, Develop Regular: Assisting 261
SKILL 4.18 Bowel Diversion Ostomy Appliance: Changing 262
ACUTE/CHRONIC PAIN MANAGEMENT 190
SKILL 4.19 Colostomy: Irrigating 265
SKILL 3.1 Pain in Newborn, Infant, Child, Adult:
Assessing 190 SKILL 4.20 Enema and Retention Enema: Administering 267

SKILL 3.2 Pain Relief: Back Massage 196 SKILL 4.21 Fecal Impaction: Removing 270

SKILL 3.3 Pain Relief: Complementary Health SKILL 4.22 Fecal Ostomy Pouch: Applying 272
Approaches 197 SKILL 4.23 Rectal Tube: Inserting 276
SKILL 3.4 Pain Relief: Transcutaneous Electrical Nerve
Stimulation (Tens) Unit, Using 200 DIALYSIS 277
SKILL 3.5 Patient-Controlled Analgesia (PCA) Pump: SKILL 4.24 Dialysis, Peritoneal: Catheter Insertion,
Using 203 Assisting 277

SKILL 3.6 Sleep Promotion: Assisting 205 SKILL 4.25 Dialysis, Peritoneal: Procedures, Assisting 279
SKILL 4.26 Hemodialysis: Central Venous Dual-Lumen
HEAT AND COLD APPLICATION 207 Catheter, Caring for 282
SKILL 3.7 Cooling Blanket: Applying 208 SKILL 4.27 Hemodialysis: Procedures, Caring for,
Assisting 283
SKILL 3.8 Dry Cold: Applying 210
SKILL 3.9 Dry Heat: Applying 212 CRITICAL THINKING OPTIONS FOR UNEXPECTED
SKILL 3.10 Moist Pack and Tepid Sponges: Applying 214 OUTCOMES 287
SKILL 3.11 Neonatal Incubator and Infant Radiant Warmer:
Using 216
Chapter 5 Fluids and
SKILL 3.12 Sitz Bath: Assisting 217
Electrolytes 291
END-OF-LIFE CARE 218
FLUID BALANCE MEASUREMENT 292
SKILL 3.13 Physiological Needs of the Dying Patient:
SKILL 5.1 Intake and Output: Measuring 293
Managing 219
SKILL 3.14 Postmortem Care: Providing 221 INTRAVENOUS THERAPY 296
SKILL 5.2 Central Line Dressing: Changing 296
CRITICAL THINKING OPTIONS FOR UNEXPECTED
OUTCOMES 223 SKILL 5.3 Central Line: Infusing Intravenous Fluids 298
SKILL 5.4 Central Line: Managing 300
SKILL 5.5 Implanted Vascular Access Devices: Managing 303
Chapter 4 Elimination 227 SKILL 5.6 Infusion Device: Discontinuing 305
ASSESSMENT: COLLECTING SPECIMENS 228 SKILL 5.7 Infusion Flow Rate Using Controller or IV Pump:
Regulating 307
SKILL 4.1 Bladder Scanner: Using 228
SKILL 5.8 Infusion Intermittent Device: Maintaining 310
SKILL 4.2 Stool Specimen, Routine, Culture, Ova, Parasites:
Obtaining 229 SKILL 5.9 Infusion: Initiating 313
xxii   Contents
SKILL 5.10 Infusion: Maintaining 318 Chapter 9 Mobility 387
SKILL 5.11 Infusion Pump and “Smart” Pump: Using 320
SKILL 5.12 Infusion Syringe Pump: Using 324 BALANCE AND STRENGTH 388
SKILL 5.13 Percutaneous Central Vascular Catheterization: SKILL 9.1 Body Mechanics: Using 388
Assisting 325 SKILL 9.2 Range-of-Motion Exercises: Assisting 390
SKILL 5.14 PICC Line Dressing: Changing 327
MOVING AND TRANSFERRING
SKILL 5.15 Venipuncture: Initiating 329 A PATIENT 394
CRITICAL THINKING OPTIONS FOR UNEXPECTED SKILL 9.3 Ambulating Patient: Assisting 394
OUTCOMES 334 SKILL 9.4 Hydraulic Lift: Using 396
SKILL 9.5 Logrolling Patient in Bed 398

Chapter 6 Infection 339 SKILL 9.6 Moving Patient Up in Bed 400

SKILL 9.7 Positioning Patient in Bed 401
MEDICAL ASEPSIS 340 SKILL 9.8 Sitting on Side of Bed (Dangling): Assisting 406
SKILL 6.1 Hand Hygiene: Performing 341 SKILL 9.9 Transferring Patient Between Bed and Chair 408

PERSONAL PROTECTIVE EQUIPMENT (PPE) AND SKILL 9.10 Transferring Patient Between Bed and
Stretcher 410
ISOLATION PRECAUTIONS 344
SKILL 9.11 Transporting: Newborn, Infant, Toddler 411
SKILL 6.2 Enteric Contact Precautions: Using 344
SKILL 9.12 Turning Patient: Lateral or Prone Position in
SKILL 6.3 Isolation, Attire: Donning and Doffing 346
Bed 413
SKILL 6.4 Isolation, Patient and Others: Caring for 350
SKILL 6.5 Isolation, Double-Bagging: Using 352 PATIENT ASSISTIVE DEVICES 414
SKILL 6.6 Isolation, Equipment, Specimens: Removing 352 SKILL 9.13 Cane: Assisting 415

SKILL 6.7 Isolation, Transporting Patient Outside SKILL 9.14 Crutches: Assisting 416
Room 355 SKILL 9.15 Walker: Assisting 421
SKILL 6.8 PPE, Clean Gloves: Donning and Doffing 356
TRACTION AND CAST CARE 422
SKILL 6.9 PPE, Face Masks: Donning and Doffing 357
SKILL 9.16 Cast, Initial: Caring for 422
CRITICAL THINKING OPTIONS FOR UNEXPECTED SKILL 9.17 Cast, Ongoing for Plaster and Synthetic: Caring
OUTCOMES 359 for 425
SKILL 9.18 Traction, Skin and Skeletal: Caring for 428

Chapter 7 Intracranial CRITICAL THINKING OPTIONS FOR UNEXPECTED

Regulation 361 OUTCOMES 432
SKILL 7.1 Glasgow Coma Scale: Using 362
SKILL 7.2 Intracranial Pressure: Monitoring and Chapter 10 Nutrition 435
Caring for 364
SKILL 7.3 Lumbar Puncture: Assisting 367 HEALTHY EATING HABITS 436
SKILL 10.1 Body Mass Index (BMI): Assessing 436
CRITICAL THINKING OPTIONS FOR UNEXPECTED SKILL 10.2 Diet, Therapeutic: Managing 437
OUTCOMES 369
SKILL 10.3 Eating Assistance: Providing 440
SKILL 10.4 Mealtime: Complementary Health
Chapter 8 Metabolism 371 Approaches 442
SKILL 10.5 Nutrition: Assessing 443
GENERAL METABOLISM 374
SKILL 8.1 Endocrine Disorders: Assessing 374 ENTERAL NUTRITION USING A FEEDING
SKILL 8.2 Endocrine Disorders: Complementary Health TUBE 446
Approaches 376 SKILL 10.6 Feeding, Continuous, Nasointestinal/Jejunostomy
SKILL 8.3 Paracentesis: Assisting 379 with a Small-Bore Tube: Administering 446
SKILL 10.7 Feeding, Gastrostomy or Jejunostomy Tube:
DIABETES CARE 380 Administering 449
SKILL 8.4 Capillary Blood Specimen for Glucose: SKILL 10.8 Gastric Lavage: Performing 452
Measuring 380
SKILL 10.9 Nasogastric Tube: Feeding 453
SKILL 8.5 Diabetes: Managing 383
SKILL 10.10 Nasogastric Tube: Flushing and Maintaining 455
CRITICAL THINKING OPTIONS FOR UNEXPECTED SKILL 10.11 Nasogastric Tube: Inserting 457
OUTCOMES 385 SKILL 10.12 Nasogastric Tube: Removing 461
Another random document with
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computer is used in more sophisticated work including speech
analysis, study of bioelectrical signals, and the simulation of
automata as in the “Hand” project. At the computing center of the
University of Michigan a second generation of computers is being
installed. Students in some one hundred different courses use these
computers, programming them with a language developed at the
University and called MAD, for Michigan Algorithm Decoder. These
are typical examples of perhaps two hundred schools using
computers.
That knowledge of computer techniques is essential for the
engineering graduate is evident in the fact that of a recent class of
such students at Purdue, 1,600 used the computer during the term.
Less known is the integration of computer courses in secondary
education. The Royal McBee Corporation teaches a special course
on the computer to youngsters at Staples High in Westport,
Connecticut. At the end of the first four-week session it was found
that the students, fifteen to seventeen years old, had learned faster
than adults. At New York’s St. Vincent Ferrer Catholic High School,
400 girls participated in a similar project conducted by Royal McBee.
Other high schools are following suit, and computers are expected to
appear in significant numbers in high schools before the end of
1962. Textbooks on computers, written for high-school students, are
available. As an example of the ability of young people in this field,
David Malin of Walter Johnson High School in Rockville, Maryland,
read his own paper on the use of computers to simulate human
thought processes to science experts attending the 1961 Eastern
Joint Computer Conference held in Washington, D.C.
The use of the computer in the classroom encompasses not only
colleges and high schools, but extends even to prisons. Twenty
inmates of a Pennsylvania state institution attended a pilot program
teaching computer techniques with a UNIVAC machine.
 Datamation

Seventeen-year-old David Malin who presented a paper on computers at the

Eastern Joint Computer Conference in 1961.

The United States is not alone in placing importance on the

computer in schools. Our Department of Commerce has published
details of Russian work in this direction, noting that it began in 1955
and places high priority on the training of specialists in computer
research, machine translation, automation, and so on. The
Department of Commerce feels that these courses, taught at the
graduate, undergraduate, and even high-school level, are of high
quality.
Teaching Machines
Thus far we have talked of the computer only as a tool to be
studied and not as an aid to learning in itself. In just a few years,
however, the “teaching machine” has become familiar in the press
and controversial from a number of standpoints, including those of
being a “dehumanizer” of the process of teaching and a threat to the
apple business!
Actually, the computer has functioned for some time outside the
classroom as a teaching machine. Early applications of analog
computers as flight simulators were true “teaching machines”
although perhaps the act was not as obvious as classroom use of a
computer to teach the three R’s. Even today, there are those who
insist that such use of the computer by the military or industry offers
more potential than an academic teaching machine. Assembly
workers have been taught by programmed audiovisual machines
such as Hughes Aircraft’s Videosonic trainer, and the government
has taught many technicians by computer techniques. A shrewd
observer, however, noting that the computer is called stupid, bluntly
points out that any untaught student is in the same category, and
that perhaps it takes one to teach one.
A strong motivation for looking to the machine as a public teaching
tool is the desperation occasioned by the growing shortage of
teachers. If the teaching machine could take over even some of the
more simple chores of the classroom, early advocates said, it would
be worth the effort.
Formal study of machine methods of teaching have a history of
forty years or more. In the 20’s, Sydney Pressey designed and built
automatic teaching—or more precisely, testing—machines at Ohio
State University. These were simply multiple-choice questions so
mechanized as to be answered by the push of a button rather than
with a pencil mark. A right answer advanced the machine to the next
question, while an error required the student to try again. Pressey
wisely realized the value in his machines; the student could proceed
at his own pace, and his learning was also stimulated by immediate
recognition of achievement. To further enforce this learning, some of
the teaching machines dispensed candy for a correct answer. Using
this criterion, it would seem that brighter students could be
recognized by their weight.
Unfortunately, Pressey’s teaching machines did not make a very
big splash in the academic world, because of a combination of
factors. The machines themselves had limitations in that they did not
present material to be learned but were more of the nature of a
posteriori testing devices. Too, educators were loath to adopt the
mechanized teachers for a variety of reasons, including skepticism,
inertia, economics, and others. However, machine scoring of
multiple-choice tests marked with special current-conducting pencils
became commonplace.
Another researcher, B. F. Skinner, commenced work on a different
kind of teaching machine thirty years ago at Harvard. Basically his
method consists of giving the subject small bits—not computer “bits,”
but the coincidence is interesting—of learning at a time, and
reinforcing these bits strongly and immediately. Skinner insists that
actual “recall” of information is more important than multiple-choice
“recognition,” and he asks for an answer rather than a choice. Called
“operant reinforcement,” the technique has been used not only on
man, but on apes, monkeys, rats, dogs, and surprisingly, pigeons.
During World War II, Dr. Skinner conducted “Project Pigeon” for
the military. In this unusual training program, the feathered students
were taught to peck at certain targets in return for which they
received food as a reward. This combination of apt pupils and
advanced teaching methods produced pigeons who could play ping-
pong. This was in the early days of missile guidance, and the
pigeons next went into training as a homing system for these new
weapons! To make guidance more reliable, not one but three
pigeons were to be carried in the nose of the device. Lenses in the
missile projected an image before each pigeon, who dutifully pecked
at his “target.” If the target was in the center of the cross hairs, the
missile would continue on its course; if off to one side, the pecking
would actuate corrective maneuvers. As Project “Orcon,” for Organic
Control, this work was carried on for some time after the end of the
war. Fortunately for the birds, however, more sophisticated, inorganic
guidance systems were developed.
The implications of the pigeon studies in time led to a new
teaching method for human beings. Shortly after Skinner released a
paper on his work in operant reinforcement with the pigeons, many
workers in the teaching field began to move in this direction. For
several years Skinner and James Holland have been using
machines of this type to teach some sections of a course in human
behavior to students at Radcliffe and Harvard. Rheem Califone
manufactures the DIDAK machine to Skinner’s specifications.
To the reasons advanced by those who see teacher shortages
looming, Skinner adds the argument that a machine can often teach
better. Too much time, he feels, has been spent on details that are
not basic to the problem. Better salaries for teachers, more teachers,
and more schools do not in themselves improve the actual teaching.
Operant reinforcement, Skinner contends, does get at the root of the
problem and, in addition to relieving the teacher of a heavy burden,
the teaching machine achieves better results in some phases of
teaching. It also solves another problem that plagues the educator
today. It is well known that not all of us can learn at the same rate.
Since it is economically and culturally impossible except in rare
cases to teach children in groups of equal ability, a compromise
speed must be established. This is fine for the “average” child, of
whom there may actually be none in the classroom; it penalizes the
fast student, and the slow student perhaps even more. The teaching
machine, its proponents feel, takes care of this difficulty and lets
each proceed at his own rate. Since speed in itself is no sure
indicator of intelligence, the slow child, left to learn as he can, may
reach heights not before dreamed possible for him.
Many educators agree that automated teaching is past due.
James D. Finn, Professor of Education at the University of Southern
California, deplores the lack of modern technology in teaching.
“Technology during the period from 1900 to 1950 only washed lightly
on the shores of instruction,” he says. “The cake of custom proved to
be too tough and the mass production state, at least 100 years
behind industry, was not entered except here and there on little
isolated islands.”

Educational Science Division,

U.S. Industries, Inc.

AutoTutor teaching machine has programs for teaching many subjects.

These little isolated islands are now getting bigger and closer
together. The Air Force has for some time trained technicians at
Keesler Field with U.S. Industries AutoTutor machines, and also
uses them at the Wright Air Development Center. The Post Office
Department has purchased fifty-five U.S. Industries’ Digiflex trainers.
Following this lead, public education is beginning to use teaching
machines. San Francisco has an electronic computer version that
not only teaches, tests, and coaches, but even sounds an alarm if
the student tries to “goof off” on any of the problems. The designers
of the machine selected a sure-fire intellectual acronym, PLATO, for
Programmed Logic for Automatic Teaching Operations. The System
Development Corporation, the operations firm that designed the
SAGE computer, calls its computer-controlled classroom teacher
simply CLASS. This machine uses a Bendix G-15 computer to teach
twenty youngsters at a time.
To show the awareness of the publishers of texts and other
educational material, firms like Book of Knowledge, Encyclopedia
Britannica Films, and TMI Grolier are in the “teaching machine”
business, and the McGraw-Hill Book Company and Thompson
Ramo Wooldridge, Inc., have teamed to produce computerized
teaching machines and the programs for them. Other publishers
using “programming” techniques in their books include Harcourt-
Brace with its 2600 series (for 2,600 programmed steps the student
must negotiate), Prentice-Hall, and D. C. Heath. Entirely new firms
like Learning, Incorporated, are now producing “programs” on many
subjects for teaching machines.
Subjects available in teaching machine form include algebra,
mathematics, trigonometry, slide rule fundamentals, electronics,
calculus, analytical geometry, plane geometry, probability theory,
electricity, Russian, German, Spanish, Hebrew, spelling, music
fundamentals, management science, and even Goren’s bridge for
beginners.
While many of these teaching machines are simply textbooks
programmed for faster learning, the conversion of such material into
computer-handled presentation is merely one of economics. For
example, a Doubleday TutorText book costs only a few dollars; an
automatic AutoTutor Mark II costs $1,250 because of its complex
searching facility that requires several thousand branching
responses. However, the AutoTutor is faster and more effective and
will operate twenty-four hours a day if necessary. With sufficient
demand the machine may be the cheaper in the long run.
 The System Development Corporation feels that its general
concept of automated group education will be feasible in the near
future despite the high cost of advanced electronic digital computers.
It cites pilot studies being conducted by the State of California on
data-processing for a number of schools through a central facility.
Using this same approach, a single central computer could serve
several schools with auxiliary lower-priced equipment. Even a
moderately large computer used in this way could teach a thousand
or more students simultaneously and individually, the Corporation
feels. After school hours, the computer can handle administrative
tasks.

System Development Corp.

The CLASS facility incorporates an administrative area, hallway, combined

observation and counseling area, and a large classroom area divided by a folding
wall.

In the CLASS system developed by the System Development

Corporation, the “branching” concept is used. In a typical lesson
program, if the student immediately answers that America was
discovered by Christopher Columbus, he will be told he is correct
and will then be branched to the next item. If he answers Leif
Ericson, the computer takes time out to enlighten the pupil on that
score. Next, it reinforces the correct date in the student’s mind
before asking another question. Although it would seem that a lucky
student could progress through the programmed lesson on
guesswork alone, the inexorable laws of probability rule this out. He
cannot complete the lesson until he has soaked up all the
information it is intended to impart. He can do this without an error, in
a very short time, or he can learn by the trial-and-error process,
whichever is better suited to his speed and mental ability.
Making up the program for the teaching machine is a difficult task
and requires the services of technical expert, psychologist, and
programmer. An English-like language is used in preparing a CLASS
program for the computer. Put on magnetic tape, the program goes
into the memory of the computer and is called out by proper
responses from the student as he progresses through the lesson.
 System Development Corp.

Students in CLASS are learning French in a group mode of automated instruction.

Complex as the programming is, entries from the student’s control

are processed into the computer in about one-tenth of a second, and
an answer is flashed back in about the same amount of time.
Remember that the CLASS computer is handling twenty students at
a time, and that in addition to teaching it is keeping a complete
record of how the student fared at each step of the lesson.
It is obvious that the binary or yes-no logic of the computer ties in
with the concept put forth by Skinner and others of presenting small
bits of information at a time. We can use the game of 20 Questions
as a good analogy. Even getting only simple yes-no answers, skilled
players can elicit an amazing amount of information in often far less
than the permitted number of questions. Thus even complex
subjects can be broken down into simple questions answerable by
discrete choices from the student.
The automated group education system of the System
Development Corporation is made up of the following components: a
digital computer to control and select the material presented and to
analyze responses, a magnetic tape storage unit, a typewriter for
printing out data analysis, a slide projector and screen for presenting
educational materials, and individual desks with keyboards for the
students’ responses.
We have pointed out that even though it is possible to break down
educational material into multiple-choice or yes-no answers to which
are assigned intrinsic values, the ideal system permits answers on a
linear scale. In other words, instead of picking what he considers the
most nearly correct, a student writes his own answer. Some experts
feel that the advances being made in optical scanning, or “reading”
techniques for computers, will result in linear programming of the
teaching machines within the next ten years. Such a development
will do much to alleviate the complaint that the machine exerts a rigid
mechanizing effect on the teaching process.
 While fear of displacement motivates some teachers to distrust the
machine, an honest belief that the human touch is necessary in the
schoolroom is also a large factor against acceptance. Yet these
same wary teachers generally use flash cards, flip charts, and other
mechanical aids with no qualms. The electronic computer is a logical
extension of audiovisual techniques, and in time the teacher will
come to accept it for what it is.
The human teacher will continue to be an indispensable element
in education, but he must recognize that as our technology becomes
more complex he will need more and more help. In 1960 there were
about 44 million students in our classrooms, and about 135,000 too
few teachers. By 1965 it is estimated there will be 48 million students
and 250,000 teachers fewer than we need. Parallel with this
development is the rapidly growing need for college graduates. One
large industrial firm which employs 150,000 hires only 300 college
graduates a year at present, but will need 7,000 when it automates
its plants. The pressure of need thus is forcing our educational
system to make use of the most efficient means of educating our
students.
Beyond simply taking its place with other aids, however, the
computer will make great changes in our basic concepts of teaching,
according to Dr. Skinner. He asks the question “Are the students who
learn in spite of a confusing presentation of a subject better for the
experience, or were they better students at the outset?” He
advances this argument to say that perhaps “easy” learning is
actually the best; that we would do well to analyze the behavior
called thinking and then produce it according to these specifications.
The traditional teacher finds the prospect alarming and questions the
soundness of minimizing failure and maximizing success.
There is not yet definite agreement by other psychologists with
Skinner’s contention that recall rather than recognition is the desired
method. Neither is it sure that the negative reinforcement of a
number of incorrect choices may result in remembering wrong
answers. And of course the division between rote learning and
creativity is an important consideration. The answers may well lie in
the computer, which when properly programmed is about the most
logical device we have available to us. Thus the machine may
determine the best teaching methods and then use them to teach us.
Regardless of these as yet unanswered questions, however, the
future of the teaching machine seems to be assured. One authority
has predicted that it will be a $100 million market by 1965.
An intriguing use of computer techniques in teaching is being
investigated by Corrigan Communications, which scores students
answering questions on telecourses. This work is being done with a
course in medicine, and with the rapid growth of educational
television the implications of combining it and teaching machine
techniques are of great importance.
Classroom teaching is not the only educational application for the
teaching machine. A computer-controlled library is an interesting
thought, with the patron requesting information from a central
computer and having it presented instantaneously on a viewing
screen in front of him. Such a system could conceivably have access
to a national library hookup, constantly updated with new material.
Such a service would also be available for use during school study
hall, or by the teacher during class.
Visitors to the World’s Fair in Seattle previewed the computerized
information center of the future. Called Library 21, it is considered a
prototype of the next century’s core libraries which will be linked to
smaller branches by communications networks. Many computers
were displayed, tied in with teaching machines, language
laboratories, and information from the Great Books, tailored to the
individual questioner’s sex, personality, and mental level. Also shown
was a photo process that reduces a 400-page book to the size of a
postage stamp for storage.
With this kind of progress, we can in the foreseeable future
request and receive up-to-date information of any kind of human
knowledge anywhere—in language we can understand. Another
computer application sure to come is that of handling
correspondence courses. The teaching of extension courses in the
home, through television and some sort of response link, has been
mentioned, and it is not impossible that the school as a physical
plant may one day no longer be necessary.
 International Business Machines Corp.

This system supplies legal information in minutes, with insertion of punched-card

query (top). Using inquiry words, computer prints citations of statutes (middle);
then, on request, full text (below).

Since the computer itself does not “teach,” but merely acts as a
go-between for the man who prepared the lesson or program and
the student who learns, it would seem that some of our teachers may
become programmers. The System Development Corporation has
broken the teaching machine program into three phases:
experimenting with the effects of many variables on teaching
machine effectiveness, developing a simplified teaching machine,
and finally, analyzing the educational system to find where and how
the machine fits. Research is still in the first phase, that of
experiment. But it is known that some programs produced so far
show better results than conventional teaching methods, and also
that teaching machines can teach any subject involving factual
information. Thus it is evident they will be useful in schools and also
in industry and military training programs.
Language
If man is to use the computer to teach himself, he must be able to
converse with it. In the early days of computers it was said with a
good deal of justification that the machine was not only stupid but
decidedly insular as well. In other words, man spoke to it in its own
language or not at all. A host of different languages, or “compilers”
as they are often called, were constructed and their originators beat
the drums for them. With tongues like ALGY, ALGOL, COBOL,
FACT, FLOWMATIC, FORTRAN, INTERCOM, IT, JOVIAL, LOGLAN,
MAD, PICE, and PROLAN, to name a few, the computer has
become a tower of Babel, and a programmer’s talents must include
linguistics.
One language called ALGOL, for Algorithmic Oriented Language,
had pretty smooth sailing, since it consists of algebraic and
arithmetic notation. Out of the welter of business languages a
compromise Common Business Oriented Language, or COBOL,
evolved. What COBOL does for programming computer problems is
best shown by comparing it with instructions once given the
machine. The sample below is typical of early machine language:
 SUBTRACT QUANTITY-SOLD FROM BALANCE-ON-HAND. IF BALANCE-ON-
HAND IS NOT LESS THAN REORDER-LEVEL THEN GO TO BALANCE-OK
ELSE COMPUTE QUANTITY-TO-BUY = TOTAL-SALES-3-MOS/3.

Recommended by a task force for the Department of Defense,

industry, and other branches of the government, COBOL
nevertheless has had a tough fight for acceptance, and there is still
argument and confusion on the language scene. New tongues
continue to proliferate, some given birth by ALGOL and COBOL
themselves. Examples of this generation are GECOM, BALGOL, and
TABSOL. One worthy attempt at a sort of machine Esperanto is
called a pun-inviting UNCOL, for Universal Computer-Oriented
Language and seems to be a try for the computer’s vote. One
harried machine-language user has suggested formation of an
“ALGOLICS Anonymous” group for others of his ilk, while another
partisan accuses his colleagues in Arizona of creating a new
language while “maddened by the scent of saguaro blossoms.”
 It was recently stated that perhaps by the time a decision is
ultimately reached as to which will be the general language, there
will be no need of it because by then the computer will have learned
to read and write, and perhaps to listen and to speak as well. Recent
developments bear out the contention.
Although it has used intermediate techniques, the computer has
proved it can do a lot with our language in some of the tasks it has
been given. Among these is the preparation of a Bible concordance,
listing principal words, frequency of appearance, and where they are
found. The computer tackled the same job on the poems of Matthew
Arnold. For this chore, Professor Stephen Maxfield Parrish of Cornell
worked with three colleagues and two technicians to program an IBM
704 data-processing system. In addition to compiling the list of more
than 10,000 words used most often by Arnold, the computer
arranged them alphabetically and also compiled an appendix listing
the number of times each word appeared. To complete the job, the
computer itself printed the 965-page volume. The Dead Sea Scrolls
and the works of St. Thomas Aquinas have also been turned over to
the computer for preparation of analytical indexes and
concordances.
At Columbia University, graduate student James McDonough gave
an IBM 650 the job of sleuthing the author of The Iliad and The
Odyssey. Since the computer can detect metric-pattern differences
otherwise practically undiscoverable, McDonough felt that the
machine could prove if Homer had written both poems, or if he had
help on either. Thus far he is sure the entire Iliad is the work of one
man, after computer analysis of its 112,000 words. The project is
part of his doctoral thesis. A recent article in a technical journal used
a title suggested by an RCA 501, and suspicion is strong that the
machines themselves are guilty of burning midnight kilowatts to
produce the acronyms that abound in the industry. The computer is
even beginning to prove its worth as an abstracter.
Other literary jobs the computer has done include the production
of a book of fares for the International Air Transport Association. The
computer compiled and then printed out this 420-page book which
gives shortest operating distances between 1,600 cities of the world.
Now newspapers are beginning to use computers to do the work of
typesetting. These excursions into the written language of human
beings, plus its experience as a poet and in translation from
language to language, have undoubtedly brought the computer a
long way from its former provincialism.
As pointed out, computer work with human language generally is
not accomplished without intermediate steps. For example, in one of
the concordances mentioned, although the computer required only
an hour to breeze through the work, a programmer had spent weeks
putting it in the proper shape. What is needed is a converter which
will do the work directly, and this is exactly what firms like Digitronics
supply to the industry. This computer-age Berlitz school has
produced converters for Merrill Lynch, Pierce, Fenner & Smith for
use in billing its stock-market customers, Wear-Ever as an order-
taking machine, Reader’s Digest for mailing-list work, and Schering
Corporation for rat-reaction studies in drug research, to mention a
few.
The importance of such converters is obvious. Prior to their use it
was necessary to type English manually into the correct code, a
costly and time-consuming business. Converters are not cheap, of
course, but they operate so rapidly that they pay for themselves in
short order. Merrill Lynch’s machine cost $120,000, but paid back
two-thirds of that amount in savings the first year. There is another
important implication in converter operation. It can get computer
language out of English—or Japanese, or even Swahili if the need
arises. A more recent Digitronics’ converter handles information in
English or Japanese.
If the computer has its language problems, man has them also, to
the nth degree. There are about 3,000 tongues in use today;
mercifully, scientific reports are published in only about 35 of these.
Even so, at least half the treatises published in the world cannot be
read by half the world’s scientists. Unfortunately, UNESCO estimates
that while 50 per cent of Russian scientists read English, less than 1
per cent of United States scientists return the compliment! The
ramifications of these facts we will take up a little later on; for now it
will be sufficient to consider the language barrier not only to science
but also to culture and the international exchange of good will that
can lead to and preserve peace. Esperanto, Io, and other tongues
have been tried as common languages. One recent comer to the
scientific scene is called Interlingua and seems to have considerable
merit. It is used in international medical congresses, with text totaling
300,000 words in the proceedings of one of these. But a truly
universal language is, like prosperity, always just around the corner.
Even the scientific community, recognizing the many benefits that
would accrue, can no more adopt Interlingua or another than it can
settle on the metric system of measurement. Our integration
problems are not those of race, color, and creed only.
Before Sputnik our interest in foreign technical literature was not
as keen as it has been since. One immediate result of the satellite
launching by the Russians was amendment of U.S. Public Law 480
to permit money from the sale of American farm equipment abroad
to be used for translation of foreign technical literature. We are vitally
concerned with Russia, but have also arranged for thousands of
pages of scientific literature from Poland, Yugoslavia, and Israel.
Communist China is beginning to produce scientific reports too, and
Japanese capability in such fields as electronics is evident in the fact
that the revolutionary “tunnel diode” was invented by Esaki in Japan.
It is understandable that we should be concerned with the output
of Russian literature, and much attention has been given to the
Russian-English translator developed by IBM for the Air Force. It is
estimated that the Russians publish a billion words a year, and that
about one-third of this output is technical in nature. Conventional
translating techniques, in addition to being tedious for the translators,
are hopelessly slow, retrieving only about 80 million words a year.
Thus we are falling behind twelve years each year! Outside of a
moratorium on writing, the only solution is faster translation.
The Air Force translator was a phenomenal achievement. Based
on a photoscopic memory—a glass disc 10 inches in diameter
capable of storing 55,000 words of Russian-English dictionary in
binary code—the system used a “one-to-one” method of translation.
The result initially was a translation at the rate of about 40 words per
minute of Russian into an often terribly scrambled and confusing