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Nursing Skills , 2nd edition

Open Resources for Nursing (Open RN) ; Editors: Kimberly Ernstmeyer , MSN, RN, CNE, CHSE, APNP-BC and Elizabeth Christman , DNP, RN, CNE.

Contributors

Open Resources for Nursing (Open RN) ; Editors: Kimberly Ernstmeyer , MSN, RN, CNE, CHSE, APNP-BC 1 and Elizabeth Christman , DNP, RN, CNE.

Affiliations

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/.

This is the second edition of the Open RN Nursing Skills OER textbook. This free online textbook is an open educational resource with CC-BY 4.0 licensing that has been developed for prelicensure nursing students. It is designed for use in both practical/vocational nursing programs, as well as for first-year courses in programs preparing students to become registered nurses. An additional Open RN OER textbook, “Nursing Advanced Skills,” includes advanced skills such as intravenous infusion, blood product administration, management of central lines and chest tube systems, basic electrocardiogram interpretation, and nasogastric/feeding tube insertion. The Open RN project is supported by a $2.5 million Open Resources for Nursing (Open RN) grant from the Department of Education and is licensed under CC-BY 4.0 creative commons license. More information about the Open RN project can be found at cvtc.edu/OpenRN.

The second edition has been updated according to the 2023 NCLEX-PN and NCLEX-RN Test Plans, and additional NCLEX Next Generation-style learning activities have been added to each chapter. It is aligned with the Wisconsin Technical College System (WTCS) statewide nursing curriculum for the Nursing Skills course (543-102). View a list of updates made to the second edition based on the 2023 NCLEX Test Plans and suggestions received from WTCS nursing faculty.

This Open RN Nursing Skills OER textbook focuses on the development of evidence-based clinical skills and physical assessment across the life span routinely performed by entry-level nurses. Techniques related to obtaining a health history and basic physical assessment using a body systems approach are described and include sample skills checklists and instructor demonstration videos. Mathematical calculations and conversions related to clinical skills are also included. The first edition of Open RN Nursing Skills received an OE Award for Excellence from OE Global. For more information, visit the 2020 OE Awards for Excellence site.

Several free, online, interactive learning activities are included in each chapter to encourage students to apply the nursing process while analyzing assessment findings and performing nursing skills. Additionally, in this second edition, NCLEX Next-Generation style questions are included in each chapter, with formative feedback immediately provided, to encourage the development of clinical judgment based on the NCSBN Clinical Judgment Measurement Model.

This online book can be downloaded as a PDF or other formats for offline use. The online version is required for interaction with the learning activities included in each chapter.

Contents

• Preface
• Standards & Conceptual Approach
• Chapter 1 General Survey
  • 1.1. GENERAL SURVEY INTRODUCTION
  • 1.2. INITIATING PATIENT INTERACTION
  • 1.3. VITAL SIGNS
  • 1.4. BASIC CONCEPTS
  • 1.5. EXPECTED VERSUS UNEXPECTED FINDINGS
  • 1.6. SAMPLE DOCUMENTATION
  • 1.7. CHECKLIST FOR GENERAL SURVEY
  • 1.8. LEARNING ACTIVITIES
  • I. GLOSSARY
  • 2.1. HEALTH HISTORY INTRODUCTION
  • 2.2. HEALTH HISTORY BASIC CONCEPTS
  • 2.3. COMPONENTS OF A HEALTH HISTORY
  • 2.4. DEMOGRAPHIC AND BIOLOGICAL DATA
  • 2.5. REASON FOR SEEKING HEALTH CARE
  • 2.6. CURRENT AND PAST MEDICAL HISTORY
  • 2.7. FAMILY HEALTH HISTORY
  • 2.8. FUNCTIONAL HEALTH AND ACTIVITIES OF DAILY LIVING
  • 2.9. REVIEW OF BODY SYSTEMS
  • 2.10. SAMPLE DOCUMENTATION
  • 2.11. CHECKLIST FOR OBTAINING A HEALTH HISTORY
  • 2.12. LEARNING ACTIVITIES
  • II. GLOSSARY
  • CHAPTER RESOURCES A: SAMPLE HEALTH HISTORY FORM
  • 3.1. BLOOD PRESSURE INTRODUCTION
  • 3.2. BLOOD PRESSURE BASICS
  • 3.3. BLOOD PRESSURE ASSESSMENT
  • 3.4. SAMPLE DOCUMENTATION
  • 3.5. CHECKLIST FOR MANUAL BLOOD PRESSURE
  • 3.6. SUPPLEMENTARY VIDEO OF BLOOD PRESSURE ASSESSMENT
  • 3.7. LEARNING ACTIVITIES
  • III. GLOSSARY
  • 4.1. ASEPTIC TECHNIQUE INTRODUCTION
  • 4.2. ASEPTIC TECHNIQUE BASIC CONCEPTS
  • 4.3. ASEPTIC TECHNIQUE
  • 4.4. STERILE FIELDS
  • 4.5. CHECKLIST FOR HAND HYGIENE WITH SOAP AND WATER
  • 4.6. CHECKLIST FOR HAND HYGIENE WITH ALCOHOL-BASED HAND SANITIZER
  • 4.7. CHECKLIST FOR PERSONAL PROTECTIVE EQUIPMENT (PPE)
  • 4.8. CHECKLIST FOR APPLYING AND REMOVING STERILE GLOVES
  • 4.9. ASEPSIS LEARNING ACTIVITIES
  • IV. GLOSSARY
  • 5.1. MATH CALCULATIONS INTRODUCTION
  • 5.2. MATH BASIC CONCEPTS
  • 5.3. MILITARY TIME
  • 5.4. EQUIVALENCIES
  • 5.5. ROUNDING
  • 5.6. USING DIMENSIONAL ANALYSIS
  • 5.7. CONVERSIONS
  • 5.8. TABLET DOSAGE
  • 5.9. LIQUID CONCENTRATIONS
  • 5.10. RECONSTITUTED MEDICATION
  • 5.11. WEIGHT-BASED CALCULATIONS
  • 5.12. SAFE DOSAGE RANGE
  • 5.13. INTRAVENOUS INFUSIONS
  • 5.14. IV INFUSION BY GRAVITY
  • 5.15. IV INFUSION BY PUMP
  • 5.16. IV COMPLETION TIME
  • 5.17. MULTI-STEP CALCULATIONS
  • 5.18. LEARNING ACTIVITIES
  • V. GLOSSARY
  • 6.1. NEUROLOGICAL ASSESSMENT INTRODUCTION
  • 6.2. BASIC NEUROLOGICAL CONCEPTS
  • 6.3. NEUROLOGICAL EXAM
  • 6.4. ASSESSING MENTAL STATUS
  • 6.5. ASSESSING CRANIAL NERVES
  • 6.6. ASSESSING SENSORY FUNCTION
  • 6.7. ASSESSING MOTOR STRENGTH
  • 6.8. ASSESSING CEREBELLAR FUNCTION
  • 6.9. ASSESSING REFLEXES
  • 6.10. NEUROLOGICAL ASSESSMENT
  • 6.11. SAMPLE DOCUMENTATION
  • 6.12. CHECKLIST FOR NEUROLOGICAL ASSESSMENT
  • 6.13. LEARNING ACTIVITIES
  • VI. GLOSSARY
  • 7.1. HEAD AND NECK ASSESSMENT INTRODUCTION
  • 7.2. HEAD AND NECK BASIC CONCEPTS
  • 7.3. COMMON CONDITIONS OF THE HEAD AND NECK
  • 7.4. HEAD AND NECK ASSESSMENT
  • 7.5. SAMPLE DOCUMENTATION
  • 7.6. CHECKLIST FOR HEAD AND NECK ASSESSMENT
  • 7.7. SUPPLEMENTARY VIDEO ON HEAD AND NECK ASSESSMENT
  • 7.8. LEARNING ACTIVITIES
  • VII. GLOSSARY
  • 8.1. EYE AND EAR ASSESSMENT INTRODUCTION
  • 8.2. EYE AND EAR BASIC CONCEPTS
  • 8.3. EYE AND EAR ASSESSMENT
  • 8.4. SAMPLE DOCUMENTATION
  • 8.5. CHECKLIST FOR EYE AND EAR ASSESSMENT
  • 8.6. SUPPLEMENTARY VIDEO ON EYE ASSESSMENT
  • 8.7. LEARNING ACTIVITIES
  • VIII. GLOSSARY
  • 9.1. CARDIOVASCULAR ASSESSMENT INTRODUCTION
  • 9.2. CARDIOVASCULAR BASIC CONCEPTS
  • 9.3. CARDIOVASCULAR ASSESSMENT
  • 9.4. SAMPLE DOCUMENTATION
  • 9.5. CHECKLIST FOR CARDIOVASCULAR ASSESSMENT
  • 9.6. SUPPLEMENTARY VIDEOS ON CARDIOVASCULAR ASSESSMENT
  • 9.7. LEARNING ACTIVITIES
  • IX. GLOSSARY
  • 10.1. RESPIRATORY ASSESSMENT INTRODUCTION
  • 10.2. RESPIRATORY BASIC CONCEPTS
  • 10.3. RESPIRATORY ASSESSMENT
  • 10.4. SAMPLE DOCUMENTATION
  • 10.5. CHECKLIST FOR RESPIRATORY ASSESSMENT
  • 10.6. SUPPLEMENTARY VIDEOS ON RESPIRATORY ASSESSMENT
  • 10.7. LEARNING ACTIVITIES
  • X. GLOSSARY
  • 11.1. OXYGEN THERAPY INTRODUCTION
  • 11.2. BASIC CONCEPTS OF OXYGENATION
  • 11.3. OXYGENATION EQUIPMENT
  • 11.4. NURSING PROCESS RELATED TO OXYGEN THERAPY
  • 11.5. SAMPLE DOCUMENTATION
  • 11.6. CHECKLIST FOR OXYGEN THERAPY
  • 11.7. SUPPLEMENTARY VIDEOS ON OXYGEN THERAPY
  • 11.8. LEARNING ACTIVITIES
  • XI. GLOSSARY
  • 12.1. ABDOMINAL ASSESSMENT INTRODUCTION
  • 12.2. GASTROINTESTINAL BASICS
  • 12.3. GASTROINTESTINAL AND GENITOURINARY ASSESSMENT
  • 12.4. SAMPLE DOCUMENTATION
  • 12.5. CHECKLIST FOR ABDOMINAL ASSESSMENT
  • 12.6. SUPPLEMENTARY VIDEO ON ABDOMINAL ASSESSMENT
  • 12.7. LEARNING ACTIVITIES
  • XII. GLOSSARY
  • 13.1. MUSCULOSKELETAL ASSESSMENT INTRODUCTION
  • 13.2. MUSCULOSKELETAL BASIC CONCEPTS
  • 13.3. COMMON MUSCULOSKELETAL CONDITIONS
  • 13.4. MUSCULOSKELETAL ASSESSMENT
  • 13.5. SAMPLE DOCUMENTATION
  • 13.6. CHECKLIST FOR MUSCULOSKELETAL ASSESSMENT
  • 13.7. LEARNING ACTIVITIES
  • XIII. GLOSSARY
  • 14.1. INTEGUMENTARY ASSESSMENT INTRODUCTION
  • 14.2. BASIC INTEGUMENTARY CONCEPTS
  • 14.3. COMMON INTEGUMENTARY CONDITIONS
  • 14.4. INTEGUMENTARY ASSESSMENT
  • 14.5. SAMPLE DOCUMENTATION
  • 14.6. CHECKLIST FOR INTEGUMENTARY ASSESSMENT
  • 14.7. LEARNING ACTIVITIES
  • XIV. GLOSSARY
  • 15.1. ADMINISTRATION OF ENTERAL MEDICATIONS INTRODUCTION
  • 15.2. BASIC CONCEPTS OF ADMINISTERING MEDICATIONS
  • 15.3. ASSESSMENTS RELATED TO MEDICATION ADMINISTRATION
  • 15.4. CHECKLIST FOR ORAL MEDICATION ADMINISTRATION
  • 15.5. CHECKLIST FOR RECTAL MEDICATION ADMINISTRATION
  • 15.6. CHECKLIST FOR ENTERAL TUBE MEDICATION ADMINISTRATION
  • 15.7. SUPPLEMENTARY VIDEOS
  • 15.8. LEARNING ACTIVITIES
  • XV. GLOSSARY
  • 16.1. ADMINISTRATION OF MEDICATIONS VIA OTHER ROUTES INTRODUCTION
  • 16.2. BASIC CONCEPTS
  • 16.3. CHECKLIST FOR TRANSDERMAL, EYE, EAR, INHALATION, AND VAGINAL ROUTES MEDICATION ADMINISTRATION
  • 16.4. LEARNING ACTIVITIES
  • XVI. GLOSSARY
  • 17.1. ENTERAL TUBE MANAGEMENT INTRODUCTION
  • 17.2. BASIC CONCEPTS OF ENTERAL TUBES
  • 17.3. ASSESSMENTS RELATED TO ENTERAL TUBES
  • 17.4. SAMPLE DOCUMENTATION
  • 17.5. CHECKLIST FOR NG TUBE ENTERAL FEEDING BY GRAVITY WITH IRRIGATION
  • 17.6. CHECKLIST FOR NG SUCTION
  • 17.7. LEARNING ACTIVITIES
  • XVII. GLOSSARY
  • 18.1. ADMINISTRATION OF PARENTERAL MEDICATIONS INTRODUCTION
  • 18.2. BASIC CONCEPTS
  • 18.3. EVIDENCE-BASED PRACTICES FOR INJECTIONS
  • 18.4. ADMINISTERING INTRADERMAL MEDICATIONS
  • 18.5. ADMINISTERING SUBCUTANEOUS MEDICATIONS
  • 18.6. ADMINISTERING INTRAMUSCULAR MEDICATIONS
  • 18.7. APPLYING THE NURSING PROCESS
  • 18.8. CHECKLISTS FOR PARENTERAL MEDICATION ADMINISTRATION
  • 18.9. SAMPLE DOCUMENTATION
  • 18.10. LEARNING ACTIVITIES
  • XVIII. GLOSSARY
  • 19.1. SPECIMEN COLLECTION INTRODUCTION
  • 19.2. BLOOD GLUCOSE MONITORING
  • 19.3. NASAL SPECIMEN COLLECTION
  • 19.4. OROPHARYNGEAL SPECIMEN COLLECTION
  • 19.5. SPUTUM SPECIMEN COLLECTION
  • 19.6. STOOL SPECIMEN COLLECTION
  • 19.7. SAMPLE DOCUMENTATION
  • 19.8. CHECKLIST FOR BLOOD GLUCOSE MONITORING
  • 19.9. CHECKLIST FOR OBTAINING A NASAL SWAB
  • 19.10. CHECKLIST FOR OROPHARYNGEAL TESTING
  • 19.11. LEARNING ACTIVITIES
  • XIX. GLOSSARY
  • 20.1. WOUND CARE INTRODUCTION
  • 20.2. BASIC CONCEPTS RELATED TO WOUNDS
  • 20.3. ASSESSING WOUNDS
  • 20.4. WOUND THERAPY
  • 20.5. WOUND DRESSINGS
  • 20.6. SAMPLE DOCUMENTATION
  • 20.7. CHECKLIST FOR WOUND ASSESSMENT
  • 20.8. CHECKLIST FOR SIMPLE DRESSING CHANGE
  • 20.9. CHECKLIST FOR WOUND CULTURE
  • 20.10. CHECKLIST FOR INTERMITTENT SUTURE REMOVAL
  • 20.11. CHECKLIST FOR STAPLE REMOVAL
  • 20.12. CHECKLIST FOR WOUND CLEANSING, IRRIGATION, AND PACKING
  • 20.13. CHECKLIST FOR DRAIN MANAGEMENT
  • 20.14. LEARNING ACTIVITIES
  • XX. GLOSSARY
  • 21.1. FACILITATION OF ELIMINATION INTRODUCTION
  • 21.2. BASIC CONCEPTS
  • 21.3. PREVENTING CAUTI
  • 21.4. INSERTING AND MANAGING INDWELLING URINARY CATHETERS
  • 21.5. OBTAINING URINE SPECIMEN FOR CULTURE
  • 21.6. REMOVING AN INDWELLING URINARY CATHETER
  • 21.7. MANAGING OSTOMIES
  • 21.8. APPLYING THE NURSING PROCESS TO CATHETERIZATION
  • 21.9. SAMPLE DOCUMENTATION
  • 21.10. CHECKLIST FOR FOLEY CATHETER INSERTION (MALE)
  • 21.11. CHECKLIST FOR FOLEY CATHETER INSERTION (FEMALE)
  • 21.12. CHECKLIST FOR OBTAINING A URINE SPECIMEN FROM A FOLEY CATHETER
  • 21.13. CHECKLIST FOR FOLEY REMOVAL
  • 21.14. CHECKLIST FOR STRAIGHT CATHETERIZATION – FEMALE/MALE (WITH URINE SPECIMEN COLLECTION)
  • 21.15. CHECKLIST FOR OSTOMY APPLIANCE CHANGE
  • 21.16. LEARNING ACTIVITIES
  • XXI. GLOSSARY
  • 22.1. TRACHEOSTOMY CARE & SUCTIONING INTRODUCTION
  • 22.2. BASIC CONCEPTS RELATED TO SUCTIONING
  • 22.3. ASSESSMENTS RELATED TO AIRWAY SUCTIONING
  • 22.4. OROPHARYNGEAL AND NASOPHARYNGEAL SUCTIONING CHECKLIST & SAMPLE DOCUMENTATION
  • 22.5. CHECKLIST FOR TRACHEOSTOMY SUCTIONING AND SAMPLE DOCUMENTATION
  • 22.6. CHECKLIST FOR TRACHEOSTOMY CARE AND SAMPLE DOCUMENTATION
  • 22.7. SUPPLEMENTARY VIDEOS
  • 22.8. LEARNING ACTIVITIES
  • XXII. GLOSSARY
  • 23.1. IV THERAPY MANAGEMENT INTRODUCTION
  • 23.2. IV THERAPY BASICS
  • 23.3. INTRAVENOUS THERAPY ASSESSMENT
  • 23.4. SAMPLE DOCUMENTATION
  • 23.5. CHECKLIST FOR PRIMARY IV SOLUTION ADMINISTRATION
  • 23.6. CHECKLIST FOR SECONDARY IV SOLUTION ADMINISTRATION
  • 23.7. SAMPLE DOCUMENTATION
  • 23.8. CHECKLIST FOR DISCONTINUING AN IV
  • 23.9. SUPPLEMENTARY VIDEOS RELATED TO IV THERAPY
  • 23.10. LEARNING ACTIVITIES
  • XXIII. GLOSSARY