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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
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... 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.
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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
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
*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
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
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
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
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
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
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
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
Laboratory Tests for Endocrine Disorders: 375 Medication: Vaginal, Administering, SKILL 2.29 158
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
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
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

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
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
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
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
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
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
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
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
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
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
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But here General Concha interceded by exclaiming: “Stop,
Manolito, stop the firing! For God’s sake remember we are in Her
Majesty’s palace!”
So the firing was stopped, and the little girls, alarmed at the
noise, fell into each other’s arms, and cried with fright, whilst the
Countess of Mina strove to still their fears. The noise of firing was
heard down the corridors and the staircases known by the names of
those of the Lions and the Ladies. General Dulce was not content
with quelling the invasion of the palace by firing down the chief
staircase to prevent the ascent of any interloper, but, leaving
Barrientos in command of half the Guard at that spot, he went with
the other half into the Salon of the Ambassadors, and there fired on
the insurgents from the windows, until the whole Plaza de la Armeria
was swept free from any more possible invaders of the royal abode.
In the meanwhile Boria, Don Diego Leon, and others, were
caught in the Campo del Moro, the gardens of the palace. No mercy
was shown to the would-be perpetrators of such a deed as the
kidnapping of the royal children, and Diego de Leon, who had been
covered with laurels for his brilliant services in the civil war, was shot
with his accomplices without demur.
In the meanwhile General Espartero, in his Palace of la Buena
Vista, was ignorant of the tragic scenes enacted at the palace until
they were over. Brought thither by the sound of firearms, he arrived
just as the insurrectionary force had been driven from the palace,
and hastening up the staircase stained with blood, he found the royal
children in their room weeping bitterly and much terrified, albeit at
the time of the alarming scene they had shown more courage than
could have been expected at such an early age. The Regent led the
little girls to a window of the palace to still the fears of the people,
who had hastened from all quarters at the noise of the firing, and the
halberdiers who had defended their young Queen and her sister so
bravely were all publicly applauded, promoted, and subsequently
given the Cross of San Fernando. The fact of gunshot penetrating
the royal apartment was unprecedented in history, and although the
halberdiers pressed into the room to protect the royal children, they
abstained from firing there on the invaders without, for fear of hurting
those in their charge. When the Cortes opened, Espartero escorted
the Princesses to the ceremony, and they were received with
enthusiastic demonstrations of loyalty.
A short time afterwards Argüelles had to insist on the Order of the
Palace, by which the French Ambassador was not allowed entry to
the palace without official permission from the Regent.
When the Infante Don Francisco and Luisa Carlota decided to go
to Spain to see what personal influence could do in obtaining power
over their nieces, the King of France did all he could to prevent the
fulfilment of the plan. Difficulties were put in the way of the illustrious
travellers having horses for the journey, but Luisa Carlota exclaimed:
“This new obstacle will not stop us, as, if we can’t get horses, we will
go on foot.”
The exiled Queen-mother did all she could to influence her
children against their aunt, and she placed within the leaves of a
book of fashions, which she sent them from Paris, a paper which ran
thus: “Do not trust that woman! She causes nothing but disgrace and
ruin. Her words are all lies; her protestations of friendship are
deceptions; her presence is a peril. Beware, my child. Your aunt
wants to get rule over your mind and your heart to deceive you, and
to claim an affection of which she is unworthy.”
It was in 1842 that, eluding the vigilance of the Countess of Mina,
the lady-in-chief of the royal children, Luisa Carlota managed to see
a good deal of her young niece Isabel. The Infanta constantly joined
the young Queen in her walks, and, not content with talking to the
young girl about her cousin Don Francisco, so as to make her think
of him as an eligible parti, she one day gave her niece a portrait of
her son in his uniform as Captain of the Hussars. This portrait
Isabella was seen to show to her little sister, and so annoyed was
the Marchioness of Belgida, the chief Lady-in-Waiting, at what she
considered the breach of confidence on the part of the Infanta, that
she resigned her post. Argüelles had striven to warn Luisa Carlota
against the imprudence of her course, for the question of the young
Queen’s marriage was one in which the dignity of the Government,
the honour of the Queen, and the good name of the Regent, had all
to be considered. Therefore any attempt to compromise the Queen
by forcing any opinion from her which could not be based on
experience was detrimental to all concerned. In the Cortes he said: “I
do not believe in absolute isolation for a young Queen, but I think
she ought to be surrounded by those who will give her a good
example of prudence and self-reflection.” On the day that the
Marchioness of Belgida’s resignation was accepted the widowed
Countess of Mina was raised to be a grandee of Spain of the first
order, and she was appointed to the post vacated by the Countess.
Then, in pursuance of the opinion of the Ministers, Espartero had the
Princesses taken to Zaragossa so as to prevent further intrigues
about the Queen’s marriage.
In the “Estafeta del Palacio Real,” Antonio Bermejo compares
Olozaga with Argüelles. “He was,” he says, “austere like Argüelles,
who might be a little brusque, but never had a word or a single
phrase left the lips of this old man which could sully the purity of a
Princess. Moreover, the new guardian of the Queen was so dense
that he let a book be circulated in the royal apartment, called
‘Theresa, the Philosopher,’ which was said to be at the root of much
of the light behaviour of our girls. Who allowed this book in the
palace? Whence came this vile work, calculated to pollute the throne
of San Ferdinand? Narvaez and Gonzalez Brabo saw the book lying
on a chimney-piece in the palace, and they indignantly cast it into the
fire. It was thus that people sought to shake the foundation of the
throne; it was thus that the seed of corruption was sown which
resulted in so much weakness and failure!”
CHAPTER VIII
MINISTERIAL DIFFICULTIES IN THE PALACE
1843
There is doubtless truth in the opinion that the wish of the

Government for the majority of the Queen to be declared at the age
of thirteen instead of fourteen proceeded from the desire of self-
interested personages to rid the country of the Regent, and hasten
the time when the power would be fully in the hands of the young
Sovereign, when it could be turned to the designs of the Moderates.
This project soon took form by the Ministry presenting a petition
to Isabella, saying:
“The nation wishes and desires to be governed by Your Majesty
yourself. Your Majesty will have heard the result of the vote taken in
the Cortes which is about to assemble, and there the oath required
by the Constitution from a constitutional monarch will be received by
the same Cortes.”
So on November 8, 1843, the proposal was carried by a majority
of 157 over 16, and Queen Isabel was endowed with full power as
Queen of the realm—a Queen of only thirteen years of age, whose
education had been grossly neglected, and who was inclined to
follow the dictates of an undisciplined sensual nature.
R E C E P T I O N O F I S A B E L L A I I . AT T H E E S C O R I A L
From a Painting by R. Benjumea
Don Salustiano de Olozaga was then appointed President of the

Ministry which had supported the deed, whilst Francisco Serrano,
who was subsequently to play such an important part in the history
of Spain, remained Minister of War, and Frias Minister of the Marine.
But on November 29 the nation was astounded by the publication
in the Gazette of the decree for the dissolution of the Government
which had put the full power in the young Queen’s hand.
The reason for this course was not far to seek. Olozaga was not
only anxious to free himself from a Parliament with a majority of
Moderates (Tories), but he wished to be freed from the influence of
Narvaez, who represented the influence of the Queen-mother in the
palace. It was the fact of this influence which had decided both
Cortina and Madoz to refuse office.
The fact of the Provisional Government having appointed
Olozaga guardian of the young Queen showed that he was known to
have great influence over her, and whilst holding that appointment he
had been flattered by the grant of the decoration of the Golden
Fleece. This distinction was declared by some to have been the
outcome of his own astuteness, and it certainly made him unpopular.
The decree for the dissolution of the Parliament was promptly
followed by incriminating whispers against the President of the
Council.
Mysterious allusions were made to Olozaga having been so
wanting in respect to his Queen that he insisted with undue force on
the dissolution of the Parliament, and when she objected and wished
to quit the apartment, he locked the door, and forcibly drew her back
to the table, where he made her sign the document.
“There are,” says Don Juan Rico y Amat, “those who say that this
report was got up by the Moderates on the exaggerated story of the
young Queen, as they wished to get him out of power; but this theory
is opposed by the difficulty of believing that a story which tended to
lessen the dignity of the Crown could have arisen only through
Isabella herself, and those acquainted with the Minister knew the
story was in accordance with his imperious, impetuous nature, well
known in the palace. It had, moreover, often been noticed that the
Prime Minister had entered the royal apartments with a freedom
unbefitting the respect due to royalty.”
Olozaga wrote to General Serrano, saying that the fact of the
Queen sending him a letter saying she would be glad to have the
decree, granted at the instance of Olozaga, returned to her, for the
rectification of the first lines, saying, “For grave reason of my own I
have just dissolved,” etc., showed the absurdity of the invention that
it had been obtained from her by force. “But if anybody,” continued
Olozaga, “still insists on such an idea, I will have the honour of
suggesting a means whereby the truth will be declared in my
presence.”
None of the Moderates surrounding the Queen had the courage
to seize the reins of government at this time of confusion, and
Narvaez himself, whose power in the palace was well known, and
whose position as Captain-General of Madrid would have assured
him of a large number of followers, hesitated to take the rudder of
the deserted ship.
Whilst all was hesitation in the audience chamber, a young man
suddenly made his appearance, and passed with fearless step and
bold bearing through the assembly of timorous people, right up to
within two steps to the throne in the Salon of Ambassadors, and
there assumed the leadership which was shunned by those who
could have claimed it, by exclaiming in a loud, commanding tone:
“The Queen before all! A revolution or I....” And thus by this splendid
coup the premiership was taken by Gonzalez Brabo, a man almost
unknown in Madrid, except for his talent as a journalist.
His paper, El Guirigay, had been prohibited for its gross attacks
on the Queen-mother, and his Liberal ideas were well known. The
splendid coolness and courage with which this young man thus
contravened the storm of revolution in the very palace itself was
calculated to arouse the hatred of the populace, who had looked to a
revolution as a reform in all the conditions which make life
burdensome.
Thus three days later, when Gonzalez Brabo crossed the Plaza
de Oriente for his audience with the Queen at the palace, his coach
was stopped by a mob, and the threatening attitude of the people
would have checked anyone less cool and determined in his course.
The day of the reopening of the Congress after its suspension for
the formation of the new Cabinet was a very anxious one, for it was
clearly seen that the Queen had either been treated with flagrant
disrespect or her report of the Minister’s conduct had been untrue.
The mace-bearers, with their plumed hats and their breasts
bearing the embroidered arms of the city, were standing in
statuesque immobility on their elevated places directly under the
canopy at the head of the chamber. Every seat was filled; the boxes
had their full complement of ladies, and outsiders and
representatives of the press crowded the gangways. The President
of the Congress sat at the official table, flanked by his officials, and
all was expectation when the slight, dapper figure of Brabo, dressed
in black and bearing the scarlet portfolio of office under his arm,
walked with determined step to the seat of honour on the black[15]
bench of the Ministers, and from thence returned the astonished
glances of the deputies with a scornful smile and a contemptuous
look. After waiting for the storm of dissentient remarks to subside,
the Minister rose to his feet, and in clear, concise tones declared that
he had been summoned by the Queen to the palace at 11.30 on
November 3, and, being admitted to the royal presence, he found
that the audience included all the staff of the gentiles hombres,
including General Domingo Dulce, who had distinguished himself so
bravely on the night of the attempted kidnapping of the little
Princesses; Don Maurice Carlos de Onis, President of the Senate;
the Duke of Rivas; the Count of Ezpeleta; the Marquis of
Peñaflorida, and the Marquis of San Felices, Secretary of the
Senate, with Don Pedro José Pidal, President of the Congress of
Deputies, the President of the Academy of Languages, etc. The
gathering also included the Patriarch of the Indias and the Notary of
the King. And it was in the presence of this august assembly that Her
Majesty had made the following declaration: “On the evening of the
28th of last month, Olozaga proposed my signing a decree for the
dissolution of the Cortes, and I replied that I did not wish to sign it,
having, among other reasons, the fact that this Cortes had declared
me to be of age. Olozaga insisted; I again objected, rising from my
seat and proceeding to the door at the left-hand side of the table.
Olozaga intercepted my passage and locked the door. Upon this I
turned to the other door, but he then stepped to that one, which he
also locked. Then, catching me by the dress, he made me sit down,
and seized me by the hand and forced me to sign the document.
Before leaving me he told me to say nothing of the occurrence to
anybody, but this I declined to promise.”
[15] The Ministerial seats are now upholstered in blue.
“Then,” continued Brabo, “at Her Majesty’s request, we all signed

the royal declaration, for its transmittance to the archives.”
It was with great dignity and cleverness that Olozaga followed the
statement of Brabo by refuting the points, holding his own as to his
innocence, and yet not incriminating the Queen of untruth. When the
unfortunate man had entered the Cortes with his brothers, cries of
“Death to him!” came from a box filled with officers of the regiment of
San Fernando, whilst shouts of “Viva!” came from other directions.
“Happen what may,” said Olozaga, “I deserve the confidence of
the Queen, which I won as a Minister;” and it was in a voice
trembling with emotion that he continued: “The life I have led justifies
me—the person of my heart, my daughter, my friends. My
colleagues have all found me always an upright man, incapable of
failing in my duties, and this opinion I cannot sacrifice to the Queen,
nor to God, nor to the Universe. Being a man of integrity, I must
show myself as such before the world, even if it were on the steps of
the scaffold itself.”
It is difficult to get an impartial opinion upon this episode, so
fraught with importance and so conclusive of the short-sighted policy
of putting the kingdom into the hands of a young girl of thirteen, who
was utterly inexperienced in the art of government, as the Regent
had lived away from the palace, and fate had sundered her from
mother, aunts, uncles, and relatives, who, in any other station of life,
might have aided her with their counsels. In the excitement of the
moment the Minister had doubtless treated the Queen as he would
his own daughter, and, keenly anxious to gain the decree which
would empower him to rid himself of the majority of Moderates in the
House, Olozaga had not stopped to consider how an exaggerated
report might colour his action to the tone of that of a man guilty of
gross lèse-majesté. The Queen was but a child in his eyes, and
when she demurred at the seeming cruelty and ingratitude of
dissolving a Cabinet which had been so favourable to the
anticipation of her majority, it is probably true that the Minister patted
her familiarly on the wrist, and said, with a smile of satisfaction and
superiority: “I will accustom My Lady to such cruelties!”
The return of the Queen-mother was now solemnly demanded by
a deputation of grandees, senators, and deputies. The necessity of
the young Queen having a person of experience at her side was
eloquently set forth; and those who were envious of the power of
Gonzalez Brabo eagerly advised a course which would curtail his
influence and lead to the supremacy of the Moderates. So Maria
Cristina returned to Spain on February 28, 1844, arriving at
Barcelona on March 4, and at Madrid on March 21.
However, Gonzalez Brabo managed to retain power under the
new state of affairs, albeit at the price of being termed a traitor by his
own party.
In spite of being accused of acting as a panderer to the
Moderates, Olozaga’s advice to the Queen to legalize the marriage
of her mother with Don Fernando Muñoz was a step of good policy.
The ceremony in the chapel of the royal palace was celebrated by
the Patriarch of the Indias.
The husband was endowed with the decorations and dignities of
his position, and the Queen published the following decree:
“With due regard to the weighty reasons set forth by my august

mother, Doña Maria Cristina de Bourbon, I have authorized her, after
listening to the counsel of my Ministry, to contract a marriage with
Don Fernando Muñoz, Duke of Rianzares, and I declare that the fact
of her contracting this marriage of conscience, albeit with a person of
unequal rank, in no way lessens my favour and love; and she is to
retain all the honours and prerogatives and distinctions due to her as
Queen-mother. But her husband is only to enjoy the honours,
prerogatives, and distinctions, due to his class and title; and the
children of this marriage are to remain subject to Article 12, of Law 9,
Title 11, Book 10, of the Novisima Recopilacion, being able to inherit
the free property of their parents according to the laws.
“Signed by the Royal Hand
and the Minister of Grace and Justice,
“Luis Mayans.
“Given in the Palace,
“October 11, 1844.”
Wherever the young Queen appeared with her sister in the

country, their simple, unsophisticated ways filled the people with love
and admiration. One day, being only accompanied by two Ladies-in-
Waiting, they went to a village fête not very far from San Sebastian.
“Do you come from San Sebastian?” asked the peasants, with
the freedom characteristic of the country-folk in Spain.
“Yes, we do,” replied the Queen.
“And do you belong to the military?”
“No,” said the Queen, repressing a smile, “we are not military
people.”
“But at least you are Castilians?”
“Yes,” returned the Queen promptly; “we are girls from Madrid.”
“And do you like this part?” queried the interlocutor.
“Very much,” replied the Queen. “It is very cheerful.”
“Well,” continued the peasant, with frank familiarity, “sit down a bit
and see the lads dance.”
“Thank you very much,” replied the Queen, “but we must be
going.”
“You will have noticed,” rejoined the peasant, “that the roads are
very bad, and you will get very tired. These mountains are only fit for
strong feet, and not little delicate ones like yours.”
“Never mind,” returned Isabel; “we like to accustom ourselves to
everything. You don’t know, then, who we are?”
“It is not easy to guess,” was the answer; “but you are certainly
daughters of people of position and money.”
Then Isabel said: “I am the Queen.”
“The Queen! the Queen!” cried the people with delight; and cider,
fruits, and cakes, were pressed upon the royal party.
The Queen and her sister received constant signs of affection in
the neighbourhood of Guipuzcoa. They went to Pampeluna to
receive the Duke and Duchess of Nemours and the Duke of Aumale,
the arrival of the distinguished French guests was celebrated in the
city by a magnificent banquet and bull-fight, and the distinguished
Frenchmen stayed with the Count of Ezpeleta.
The fall of Miraflores, the able Prime Minister, was heralded by
the evident desire of both the Queens for a change of Ministry, and
those who wished to compass the fall of the Prime Minister were
listened to by the royal ladies.
Miraflores found Queen Isabella alone one day in the palace, and
Her Majesty said to the Minister:
“I have heard that the scandal this afternoon in the Congress has
been so great that the President of the Congress put on his hat in his
want of consideration for the Court.”
Miraflores explained that this act proceeded from no want of
respect for the Cortes.
“Nevertheless it must be dissolved to-morrow,” was the reply.
Narvaez became Minister of War as well as President of the
Congress. The part played at the palace in the change of Ministries
is seen in the scene between Pacheco and the Queen-mother.
Maria Cristina remarked to the Minister that the Government
would not last long. Upon this Pacheco placed two ounces of gold
upon the mantelpiece, saying:
“I bet you that money that the Cabinet will not fall to-morrow as
you say.”
Whereupon the Queen took another two ounces from her purse,
and placing them beside those of the diplomat, she said:
“The bet is made: if the Ministry does not fall to-morrow, the
money is yours; if it does, it is mine.” And the Ministry did fall.
This insidious influence of the camarilla was daily becoming more
dangerous. Presumptuous and illegal, it held its sway over all that
was prudent and constitutional, and thus the intrigues of the palace
came between the Cortes and the throne, and the country and the
Queen, exercising power to the detriment of the national
representation, the throne, the nation, and the Sovereign. “The royal
palace,” says Don Antonio Bermejo, “was a gilded cage where men
were slaves to envy and idleness.”
CHAPTER IX
ROYAL MATRIMONIAL SCHEMES—HOW ISABELLA’S SISTER FLED FROM
PARIS IN 1848
1843–1848
Isabella’s marriage was now a burning subject of discussion and

intrigue. The objection offered to her marriage with one of the sons
of the Infanta Luisa Carlota was the hatred reigning between the
mother of the proposed bridegroom and Queen Maria Cristina.
Louis Philippe of France had also his own designs in these
marriage prospects, and would fain have united the Dauphin to the
young Queen. But, as we know, England put her veto upon this
alliance, as it would have upset the balance of European power; so
the French King had to be contented with the marriage of his
younger son, the Duke of Montpensier, with Isabel’s sister Luisa
Fernanda.
There was a strong party in favour of the Queen’s marriage with
the Count of Montemolin, son of Don Carlos, as this union would
have put an end to the rivalry reigning between these two branches
of the Royal Family.
But finally attention was turned to the sons of Don Francisco de
Paula as the most suitable candidates for the hand of the Queen.
Miraflores explains that it was natural for the Duke of Cadiz, the
eldest son of the Infante, to be preferred by the existing Cabinet in
Spain and the Queen-mother, as he was a quiet, judicious Prince,
who had accepted and fulfilled with honour the post of Colonel of a
cavalry regiment; whilst Don Henry was of a turbulent disposition,
whose conduct left much to be desired at the Court of the Queen-
mother, to whom he had written from Bayonne very disrespectfully,
and in Brussels he had distinguished himself by publishing ideas
which bordered on being revolutionary.
I S A B E L L A I I ., Q U E E N O F S PA I N
After a Painting by De Madrazo
Whilst the royal party was at Pampeluna a mysterious document

in French fell into the hands of the Minister of Foreign Affairs, signed
“Legitimista.” The document ran thus:
“To the Minister of Foreign Affairs.

“Before the Duc de Nemours and the Duc d’Aumale left Paris as
the emissaries of His Majesty the great ‘Père de famille,’ French
legitimists knew that the meeting at Pampeluna was merely a matter
of form. The Duc d’Aumale cannot be the husband of Doña Isabel;
his father knows it; M. Guizot and M. Bresson know it; and the
Queen, wife of the Citizen-King, knows it, and she is the most
strongly opposed to the union.
“The Duc de Montpensier will be the husband of the Infanta; this
is what is arranged, and what will take place. The Citizen Louis has
made a plan by which he thinks that in time Montpensier will occupy
the throne of Spain by the side of the immediate heiress, Luisa
Fernanda, because experienced doctors in medicine have declared
to Bresson that the Queen is very ill with an hereditary disease which
will take her to the grave. Why has not the Princess got it? That is a
mystery which time will reveal. Who will give his hand in marriage to
Queen Isabel? We hear that the candidature of Prince Henry is in
favour. But this illustrious youth cannot be the husband of the
Queen, neither can his brother, Don Francisco de Asis.
“The Minister whom I have the honour of addressing is ignorant
of the reason, and I can give it to him.
“The Minister must know that when Princess Luisa Carlota was
on her death-bed she did not, even in this sad moment, forget the
troubles of her sister; and impelled by conscientious scruples, she
sent for her illustrious sons, and, taking them each by the right hand,
she said these solemn words to them, in a sad tone and with a
tenderness which was truly Christian: ‘My sons, I wish to reach
heaven, I wish to quit you and the world without remorse, and
therefore I declare I repent having contributed through imprudent
affection to thwarting the legitimate succession of the Crown of
Spain, and this I swear on my salvation. So I command you as a
mother, as a Princess, and as a repentant sinner, to swear that
neither of you will aspire to the hand of Isabella.’”
Narvaez showed that this document was a fraud, as, at the death
of the Infanta, Don Henry was at some distance from Madrid, and
Francisco was at Pampeluna.
Isabella’s own feelings about her marriage were hardly taken into
consideration at all. As a matter of fact, she had been more inclined
to Prince Henry, the younger son of Doña Luisa Carlota, than to
Francisco, and it will be remembered that even as a child she had
admired the portrait of the Prince, which had been secretly sent by
the mother to the young Queen; but inclination had no part in the
negotiations, which were regulated entirely by self-interest and
policy, so the tide of influence was soon seen to be in favour of the
eldest son of Prince Francisco de Paula.
Don Henry was furious when he found he was left out in the cold
in the negotiation for the marriages of Isabella and her sister.
In a letter to Bulwer Lytton he writes:
“The old man at the Tuileries is very delighted and pleased. He

has written three letters full of hypocritical words, telling the great
Mama that she has drawn the first prize, and that she is very
fortunate to be marrying her daughters to Paquito (Francisco) and
Montpensier. A French fellow has arrived at the palace. You will
recollect that I told you before last night that, judging from the
appearance of things, you and I were going to have our noses put
out of joint.
“Istarez is very pleased. Cristina is delighted, and from what I
hear the weddings will take place very soon. When I see you I will
give you more particulars, which I cannot trust to the pen.”
The Queen-mother had been inclined to the idea of the Count of

Trapani, her brother, who had been educated in a Jesuit college at
Naples, as her son-in-law; but, as this idea had not been welcome to
the Government, attention had again been turned to one of the sons
of the Infante Don Francisco de Paula. Don Francisco, Duke of
Cadiz, the eldest, was favoured by France, whilst England gave
preference to Don Henry, Duke of Seville. As Miraflores says, it was
natural for the Queen-mother to prefer the eldest son of Don
Francisco, as he was a quiet Prince and one who had fulfilled his
duties with credit as Colonel of a cavalry regiment; whilst Don Henry
was of a more turbulent nature, and his antagonistic conduct to the
Queen-mother had excited some disturbance in the palace. In the
letters he sent from Brussels to Madrid he had manifested a
revolutionary spirit, which filled the Moderates with alarm. However,
poor Isabel preferred this hot-headed Prince to his more peaceful-
minded brother, and long were the arguments the young Queen held
with her mother against the project of her union with the elder
brother. Fortunately, however, the young Queen seemed somewhat
pleased with the appearance of Don Francisco, and at the fêtes
given in honour of the engagement she seemed very cheerful.
In an interview with Queen Maria Cristina, Bulwer Lytton said: “I
can understand your joy as a mother at seeing your eldest daughter
destined for a Prince who will make for the happiness of the royal
domestic hearth; but as to the marriage of the Infanta——”
Here Cristina interrupted him, saying: “It is decided that her union
with Montpensier will take place on the same day as that of the
Queen.”
The Duke of Rianzares had evidently favoured the alliance of the
Princess Luisa Fernanda with the Duke of Montpensier, for when the
matter was fully arranged Louis Philippe wrote to Queen Maria
Cristina:
“Please give my kind regards to the Duke of Rianzares, and
thank him for the part he has taken in the matter I have so much at
heart.”
So France and her supporters in Spain gained the day, and the
double wedding of the young sisters was fixed for October 10, 1846.
It was with all the magnificent state for which the Court of Spain is
famed that the reception by Isabel and Fernanda took place at the
palace (for the publication of the marriage contracts) in the Salon of
the Ambassadors. Alexandre Dumas was among the distinguished
Frenchmen accompanying the bridegroom of the Infanta Fernanda,
and the great author attended a bull-fight with the noblemen as
toreadors, and the fêtes all the week were of surpassing splendour.
The religious ceremony itself was held in the Church of Atocha
with all imaginable pomp and splendour. The Patriarch of the Indias
received the brides at the door of the church, and noticeable among
the French guests was Alexandre Dumas, author of “The Three
Musketeers.” All the Diplomatic Corps were there with the exception
of the English.
In the ceremony the Patriarch placed upon the open palms of the
Queen’s bridegroom the thirteen pieces of money pledged as his
dowry, which was then passed by the bridegroom to the hands of his
bride, saying, “This ring and this money I give you as a sign of
marriage,” and the Queen replied, “I accept them.”
The same ceremony was used with the Infanta and her
bridegroom, and then the prelate, with his mitre and crook, escorted
the royal couples to the altar, and there read the Mass. During the
Epistle the Patriarch presented the candles, veils, and conjugal yoke,
and at the conclusion of the Gospel the Patriarch turned to the
Queen and her bridegroom, and said to the latter: “I give Your
Majesty a companion, and not a servant; Your Majesty must love her
as Christ loves His Church.” And then the same words were said to
the other couple. The periodical which published this account of the
wedding remarked that the Queen and her husband looked smiling
and pleased, but the Infanta looked sad.
The attempt on the life of the Queen soon after her marriage
caused great excitement, and the trial of Angel de la Riva, a native of
Santiago, in Galicia, and editor of a paper called El Clamor Publico,
who was caught just after firing the shot, was followed with the
deepest interest.
The testimony of Don Manuel Matheu, officer of the Royal Guard
of Halberdiers, a man of thirty-five years of age, gives some idea of
the etiquette of the time.
He declared that on May 4, 1847, he was on duty, so when the
Queen returned from her drive he went as usual to receive her at the
foot of the staircase with his little company of six halberdiers, and a
Captain with a lamp, and two other attendants with their axes. On
descending from the carriage, Her Majesty said to him: “Do you
know that on passing through the Calle de Alcalá two shots were
fired at me.”
The officer returned: “Two shots at Your Majesty?”
“Yes,” was the reply; “you cannot doubt it; I saw them get down
from a carriage or cab.”
The Colonel was not aware if Her Majesty said an open carriage
or a shut one.
“I felt something,” she added, “pass over my forehead which hurt
me.”
“And as this was evident,” continued the officer, “I could but give
credit to Her Majesty’s words. Moreover, Her Highness the Infanta
Doña Maria Josefa added: ‘There is no doubt of the fact, for I myself
saw the men.’”
Then Her Majesty told the witness he was to inform the Ministers
of what had happened. This he did, leaving a message at the door of
the Secretary of State, and sending a halberdier to inform the
Minister of War.
It is not necessary to give further particulars of the long trial of the
accused. He was, as we know, first condemned to be beaten to
death, and being saved from this dreadful fate by the able defence of
Perez Hernandez, he was in November, 1847, condemned to twenty
years’ imprisonment. But on July 23, 1849, the Queen showed her
generous spirit by commuting the sentence to four years’ exile from
Madrid and all the royal resorts, as Her Majesty nobly gave full
benefit to the representation of the murderous lawyer’s madness, or
the influence exercised by others.
In the rapid and unexpected flight of the French Royal Family
from the Palace of the Tuileries, Princess Clementina, wife of the
Duke of Saxony, and the Duchess of Montpensier, were separated
from the King and Queen. When the Duke of Montpensier
accompanied his father to the carriages waiting for them in the Place
de la Concorde, he thought he would have no difficulty in returning to
fetch his wife, who had been confined for some days in her
apartments on account of her interesting condition of health. But the
crowds which had collected meanwhile in the gardens made it
impossible for the Prince to return to the palace. He had fortunately
left the Princess in the care of some of his suite and Monsieur Julio
de Lasteyrie, who was distinguished for his loyalty and popularity. So
the Duke mounted his horse and followed his father.
Directly Monsieur Lasteyrie saw that the palace was invaded, he
gave his arm to the Duchess of Montpensier, and in the confusion of
the moment they passed unnoticed from the gates and mingled with
the crowd. Monsieur de Lasteyrie hoped to arrive in time to put the
Princesses into the royal carriages, which, however, started off at a
gallop just as they arrived within sight of them.
So Lasteyrie escorted the royal ladies to the house of his mother.
In a few minutes Princess Clementina left the timely refuge, and
continued her way to the Trianon, where she met her father; whilst
the Duchess of Montpensier remained for the night under the
protection of Madame de Lasteyrie.
There she heard from her husband at Dreux that she was to join
him at the Castle of Eu, whither the King was going.
But the monarch found it impossible to get to this haven, so when
the young Princess arrived there the following day she found the
place deserted. Hearing an alarming rumour that a party of workmen
were coming to pillage the Palace of Eu, as they had ransacked the
one at Neuilly, the Duchess quietly left the place, and repaired to the
house of Monsieur Estancelin, a diplomat of the Bavarian Embassy.
Under the escort of this gentleman and that of General Thierry she
started off for Brussels. On passing through Abbeville, the sight of
the carriage attracted attention, and the people cried: “There are
royal fugitives in that coach!” Monsieur Estancelin put his head out of
the window, and, as his name was known in the district, he declared
that the lady was his wife, and he was going abroad with her. To put
the people off the scent, he then gave orders to the postilion to drive
to the house of a friend of his, well known for his republican opinions.
Arrived at the house, Estancelin whispered in the ear of his friend the
name and rank of the lady under his escort.
But the man, in fear of the consequences of the discovery of the
secret, declined to give his aid in the matter, in spite of all arguments
of both gentlemen in charge of the Princess, setting forth the
dreadful consequences of her being frightened or subjected to
imprisonment in her delicate condition.
It was all in vain; the republican declined to receive the Princess,
and they had to turn away from the door in despair, for several
people had gathered in front of the house, curious to see who could
be seeking shelter at such a late hour.
So Monsieur Estancelin bade General Thierry conduct the lady
out of the town by a particular gate leading to the bank of the river,
whilst he went in search of other friends, who might aid him to get
fresh horses and a carriage with which he would meet them.
So the poor Princess started forth with her military ally.
Unfortunately, the gate of the town led through a narrow exit only
meant for pedestrians. So they wandered along in the cold rain,
picking their way over the stones and rubbish of this out-of-the-way
road. The General, alarmed at the drenched condition of the
Princess and her evident exhaustion and fatigue, decided that he
had better let her sit on a stone to rest, whilst he went in search of a
guide or a refuge.
The officer hastened along the road, fearing to call the attention
of the enemy to the lady in his care, and yet anxious to get a guide to
the rendezvous appointed by Estancelin. Finally, to his delight, he
was accosted by a friend of Estancelin, who had sent him in search
of the couple, and, quickly returning to the Princess, they escorted
her to the carriage which was waiting on the highroad to Brussels.
“What dreadful adventures this awful night!” exclaimed General
Thierry, as the Duchess of Montpensier sought to recover one of her
shoes which had slipped off her weary wet feet in the mud.
“Never mind,” returned the brave Princess; “I prefer these
adventures to the monotony of the round table of work in the
sumptuous salons of the Tuileries.”
The relief with which the letter announcing the safety of her sister
was received by Queen Isabella can well be imagined, as in those
days the limited communication by telegraph was stopped on
account of the fog.
The fall of Louis Philippe relieved England of the fear of the upset
of the balance of European power from the astuteness with which he
had arranged the marriages of the Spanish Queen and her sister.
There was no doubt of the intentions which had led to the Duke
of Montpensier being the brother-in-law of the Queen, and the
unsuspicious girl was a prey to the reports which were spread by the
ambitious Orleanists.
CHAPTER X
A ROYAL QUARREL AND THE RECONCILIATION
It was soon seen that General Serrano’s influence with the Queen
surpassed the ordinary grade, and the Moderates were alarmed.
There were two parties in the royal palace—one on the side of
the Queen, and the other on that of the King; and the leaders of
these parties fostered the difference between the royal couple.
Francisco Pacheco, the King’s partisan, declared that a President
of the Congress was wanted who would give more independence to
the Crown, and who would receive the counsels of an intelligent
husband of the Sovereign; for the King-Consort should not be in a
position so secondary to that of the illustrious mother-in-law that she
can boast of having more power than he has.
When Isabella saw that Queen Maria Cristina’s influence in the
State was much resented by the Ministers, she advised her to go on
a visit to her daughter, the Duchess of Montpensier, and this counsel
was followed.
However, the want of union between the King and Queen was
soon evident to the world, and when it was announced that Isabella
was going to spend the rest of the summer at Aranjuez alone, whilst
the King remained in Madrid, it was seen that the Serrano influence
had become serious enough to cause a separation between the
royal couple. Isabella’s naturally good heart seemed softened when
she was leaving the palace, and it was evidently remorse which
prompted her to look anxiously back from the carriage, in search of a
glimpse of the husband at one of the windows of the royal pile. But
the coach rattled on, and the Queen’s search was in vain; whilst her
sad face, with its traces of tears, showed that things might have
been better had not the differences of the royal couple been
fostered, for their own ends, by intriguers of the camarilla.
Forsaken by his wife, Francisco followed the advice of his friends,
to enjoy himself in his own way; so he repaired to the Palace of the
Pardo, where banquets, hunting-parties, and other festivities
deadened his sense of injury at his wife’s conduct.
Those interested in the welfare of the land were disappointed
when the birthday of the Queen was celebrated by her holding a
reception alone at Aranjuez, whilst the King had a hunting expedition
at the Pardo. The Ministers came to the reception at Aranjuez, and
then promptly returned to the capital, leaving the Queen with her
trinity of Bulwer, Serrano, and Salamanca. General Salamanca was
at last sent by the King to Aranjuez to advise Isabella to return, but
she would not accept the condition of a change in the Serrano
position.
This refusal made the King decline to assist at the reception of
the Pope’s Nuncio at Aranjuez, and he was forbidden to return to the
royal Palace of Madrid.
Benavides, a courtier, anxious to heal this unhappy division in the
Royal Family, came to Francisco, and said:[16]
“This separation cannot go on; it is not good for the Queen or for
Your Majesty.”
[16] “Estafeta del Palacio Real,” Bermejo, vol. ii.
“That I can understand,” returned the King; “but she has chosen
to outrage my dignity as husband, and this when my demands are
not exaggerated. I know that Isabelita does not love me, and I
excuse her, because I know that our union was only for State
reasons, and not from inclination; and I am the more tolerant as I,
too, was unable to give her any affection myself. I have not objected
to the course of dissimulation, and I have always shown myself
willing to keep up appearances to avoid this disgraceful break; but
Isabelita, either from being more ingenuous or more vehement than I
am, could not fulfil this hypocritical duty—this sacrifice for the good
of the nation. I married because I had to marry, because the position
of King is flattering. I took the part, with its advantages. I have no
right to throw away the good fortune which I gained from the
arrangement. So I made up my mind to be tolerant, if they were
equally so with me, and I was never upset at the presence of a
favourite.”
Here the King was interrupted by Benavides saying:
“Allow me, Sire, to observe one thing. That which you now say
with regard to tolerance of a favourite is not in accordance with your
present line of conduct, for do you not demand the withdrawal of
General Serrano before agreeing to the reconciliation we are
asking?”
Then, with a singular calmness, the King returned:
“I do not deny that this Serrano is the main drawback to an
agreement with Isabelita, for the dismissal of the favourite would be
immediately followed by the reconciliation desired by my wife; but I
would have tolerated him, I would have exacted nothing, if he had
not hurt me personally by insulting me with unworthy names, failing
in respect to me, and not giving me proper consideration—and
therefore I hate him. He is a little Godoy, who has not known how to
behave; for he at least got over Charles IV. before rising to the
favour of my grandmother.”
The Minister of the Government listened with astonishment to the
King’s words. Don Francisco saw it, and continued:
“The welfare of fifteen million people demands this and other
sacrifices. I was not born for Isabelita, nor Isabelita for me, but the
country must think the contrary. I will be tolerant, but the influence of
Serrano must cease, or I will not make it up.”
Benavides replied that the Ministry deplored this unhappy
“influence,” which was getting burdensome to the Queen herself; but
Serrano had such a fatal ascendancy everywhere, and had won over
to his side the opposing elements, that any sudden step to put an
end to the evil would result in deplorable consequences for the
nation. “However, the Ministry has decided to get rid of this
pernicious influence,” continued Benavides. “It is seeking a way to
do so without a collision and its consequences; and one of the things
which would help to this course of the Cabinet would be the
immediate reconciliation of Your Majesties, as the preliminary to the
other steps which will lead to Serrano’s overthrow.”
The King refused. He said that his dignity demanded the
withdrawal of the “influence.” Fresh evident proofs had been given
that this hateful man was the cause of the Queen’s separation from
him, and therefore he was not inclined to go back from his word
about him.
So Pacheco and all the other Ministers, excepting Salamanca,
determined to resign if Serrano did not retire from the Court.
Benavides and Pacheco were among the deputation who
petitioned the favourite to agree to this step, but it was in vain. The
Ministers went backwards and forwards to La Granja without gaining
their purpose. Finally, in pursuance of the Pope’s advice, the Queen
decided to return to Madrid; and Salamanca, as Prime Minister, went
to the Escorial to report the fact to Bulwer.

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to provide skin care.

SKILL 12.7 Sequential

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

Delegation or Assignment Procedure step-by-step best practice

Antiembolism Devices 539

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

control procedures. When

oxygenation >> Maintaining

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

Patient Teaching …compatible

patient’s blood type must be Features teaching plans for

Review healthcare provider’s orders and patient’s nursing

Patient Teaching SKILL

or assigned to start kitblood

Prolonged immobilization has been associated with DVT in critically ill

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

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BOWEL INTERVENTIONS 261

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

Chapter 7 Intracranial CRITICAL THINKING OPTIONS FOR UNEXPECTED

There is doubtless truth in the opinion that the wish of the

From a Painting by R. Benjumea

Don Salustiano de Olozaga was then appointed President of the

“Then,” continued Brabo, “at Her Majesty’s request, we all signed

“With due regard to the weighty reasons set forth by my august

Wherever the young Queen appeared with her sister in the

Isabella’s marriage was now a burning subject of discussion and

After a Painting by De Madrazo

Whilst the royal party was at Pampeluna a mysterious document

“To the Minister of Foreign Affairs.

“The old man at the Tuileries is very delighted and pleased. He

The Queen-mother had been inclined to the idea of the Count of

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