The Royal Marsden Manual of Clinical Nursing Procedures

Sara Lister, Head of Pastoral Care, Psychological Support, and PALS, The Royal Marsden Hospital NHS Foundation Trust, UK.

Justine Hofland, Divisional Clinical Nurse Director - Cancer Services, The Royal Marsden NHS Foundation Trust, UK.

Hayley Grafton, Chief Nursing Information Officer, The Royal Marsden NHS Foundation Trust, UK.

Brief table of contents v


Foreword to the tenth edition xv


Preface xvii


Acknowledgements xix


List of contributors xxi


Quick reference to the procedure guidelines xxv


How to use your manual xxix


1 The context of nursing 1


Overview 2


Background 2


Context of nursing 2


Evidence-based practice 7


Structure of the manual 8


Structure of the chapters 9


Finally 9


References 10


Part One Managing the patient journey 13


2 Admissions and assessment 14


Overview 16


Inpatient assessment and the process of care 16


Observation 24


Physical assessment 24


3 Discharge care and planning 45


Overview 46


Discharge care and planning 46


Discharging patients from hospital: internal procedures 47


Interface between primary and secondary care: external processes 53


Informal carers 58


The role of voluntary services 62


References 62


4 Infection prevention and control 64


Overview 66


Infection prevention and control 66


Hand hygiene 75


Personal protective equipment (PPE) 87


Specific patient-related procedures 101


Isolation procedures 105


Environmental hygiene and the management of waste in the healthcare environment 111


Prevention and management of inoculation injury 118


Websites 119


References 119


4.1 Hand washing 79


4.2 Hand decontamination using an alcohol-based handrub 80


4.3 Surgical scrub technique using soap and water 82


4.4 Surgical scrub technique using an alcohol-based handrub 84


4.5 Putting on and removing non-sterile gloves 88


4.6 Applying and removing a disposable apron 89


4.7 Putting on and removing a disposable mask or respirator 91


4.8 Putting on or removing goggles or a face-shield 93


4.9 Donning a sterile gown and gloves: closed technique 94


4.10 Donning sterile gloves: open technique 98


4.11 Aseptic technique example: changing a wound dressing 102


4.12 Source isolation: preparing an isolation room 106


4.13 Source isolation: entering an isolation room 107


4.14 Source isolation: leaving an isolation room 108


4.15 Source isolation: transporting infected patients outside a source isolation area 108


4.16 Protective isolation: preparing an isolation room 109


4.17 Protective isolation: entering an isolation room 110


4.18 Cleaning a hard surface without recontamination 112


4.19 Safe disposal of foul, infected or infested linen 117


Part Two Supporting patients with human functioning 123


5 Communication, psychological wellbeing and safeguarding 124


Overview 126


Communication 126


Providing information and making shared decisions 138


Communicating with specific populations 141


Psychological wellbeing 147


Safeguarding, mental capacity and the Mental Health Act 169


Websites 187


References 187


6 Elimination 194


Overview 196


Normal elimination 196


Altered urinary elimination 200


Altered faecal elimination 237


Stoma care 257


Websites 272


References 272


6.1 Slipper bedpan use: assisting a patient 198


6.2 Commode use: assisting a patient 199


6.3 Penile sheath application 202


6.4 Urinary catheterization: male 208


6.5 Urinary catheterization: female 210


6.6 Changing a suprapubic catheter 214


6.7 Urinary catheterization: intermittent self-catheterization patient guidance: male 216


6.8 Urinary catheterization: intermittent self-catheterization patient guidance: female 217


6.9 Urinary catheter bag: emptying 219


6.10 Urinary catheter removal 219


6.11 Commencing bladder irrigation 223


6.12 Nephrostomy tube: weekly dressing and bag change and sample collection 227


6.13 Nephrostomy tube: flushing technique 229


6.14 Nephrostomy tube: removal of locking pigtail drainage system 230


6.15 Flushing externalized ureteric stents 232


6.16 Removal of externalized ureteric stents 233


6.17 Continent urinary diversion stoma: self-catheterization 236


6.18 Insertion of a faecal management system 240


6.19 Insertion of a nasogastric drainage tube 247


6.20 Removal of a nasogastric drainage tube 249


6.21 Enema administration 250


6.22 Suppository administration 252


6.23 Digital rectal examination 254


6.24 Digital removal of faeces 256


6.25 Stoma siting 263


6.26 Stoma bag change 264


6.27 Obtaining a clean-catch urine sample from an ileal conduit 265


6.28 Stoma bridge or rod removal 266


7 Moving and positioning 278


Overview 280


Moving and positioning: general principles 280


Moving and positioning an unconscious patient 293


Moving and positioning a patient with an artificial airway 294


Moving and positioning a patient with respiratory compromise 298


Moving and positioning a patient with neurological impairment 301


Moving and positioning a patient with actual or suspected spinal cord compression or spinal cord injury 313


Moving and positioning a patient with raised intracranial pressure 325


Moving and positioning a patient with an amputation 326


Websites 329


References 329


7.1 Positioning a patient: supine 284


7.2 Positioning a patient: sitting up in bed 285


7.3 Positioning a patient: side-lying 286


7.4 Positioning a patient: lying down to sitting up 288


7.5 Moving a patient from sitting to standing: assisting the patient 289


7.6 Positioning a patient: in a chair or wheelchair 291


7.7 Assisting a patient to walk 292


7.8 Positioning an unconscious patient or a patient with an artificial airway in supine 295


7.9 Positioning an unconscious patient or a patient with an artificial airway in side-lying 296


7.10 Positioning a neurological patient with tonal problems in bed 309


7.11 Positioning a neurological patient with tonal problems in a chair 312


7.12 Application of a two-piece cervical collar 318


7.13 Log rolling a patient with suspected or confirmed cervical spinal instability (above T6) 319


7.14 Log rolling a patient with suspected or confirmed thoracolumbar spinal instability (T7 and below) 321


7.15 Early mobilization of a patient with spinal considerations 323


7.16 Positioning a patient with an amputation 327


8 Nutrition and fluid balance 334


Overview 336


Fluid balance 336


Nutritional status 351


Provision of nutritional support: Oral 359


Nutritional management of patients with dysphagia 364


Enteral tube feeding 365


Parenteral nutrition 385


Websites 389


References 389


8.1 Fluid input: measurement 345


8.2 Fluid output: monitoring/measuring output if the patient is catheterized 346


8.3 Fluid output: monitoring/measuring output if the patient is not catheterized 347


8.4 Fluid output: monitoring/measuring output from drains 347


8.5 Fluid output: monitoring/measuring output from gastric outlets, nasogastric tubes or gastrostomy 348


8.6 Fluid output: monitoring/measuring output from bowels 349


8.7 Fluid output: monitoring/measuring output from stoma sites 349


8.8 Measuring the weight and height of a patient 356


8.9 Feeding an adult patient 362


8.10 Nasogastric intubation with tubes using an internal guidewire or stylet 369


8.11 Removal of a nasogastric tube 374


8.12 Percutaneous endoscopically placed gastrostomy (PEG) tube care 375


8.13 Radiologically inserted gastrostomy (RIG) tube care 376


8.14 Removal of T-fasteners 377


8.15 Changing the balloon water and checking the volume of a balloon gastrostomy 378


8.16 Jejunostomy feeding tube care including dressing change 379


8.17 Insertion of a silicone gastrostomy stoma plug 380


8.18 Enteral feeding tubes: administration of feed using an enteral feeding pump 381


8.19 Enteral feeding tubes: administration of medication 384


8.20 Enteral feeding tubes: unblocking 386


9 Patient comfort and supporting personal hygiene 394


Overview 396


Personal hygiene 396


Sleep promotion in a hospitalized patient 407


Patient environment 409


Eye care 413


Ear care 423


Mouth care 427


Websites 439


References 439


9.1 Bedbathing a patient 401


9.2 Washing a patient's hair in bed 403


9.3 Shaving the face: wet shave 405


9.4 Shaving the face: dry electric shaver 406


9.5 Making an unoccupied bed 410


9.6 Making an occupied bed 412


9.7 Eye swabbing 417


9.8 Eye irrigation 418


9.9 Artificial eye care: insertion 420


9.10 Artificial eye care: removal 420


9.11 Contact lens removal: hard lenses 421


9.12 Contact lens removal: soft lenses 422


9.13 Irrigation of the external auditory canal using an electronic irrigator 425


9.14 Mouth care 436


9.15 Mouth care for a patient with dentures 437


10 Pain assessment and management 446


Overview 448


Pain 448


Pain management 456


Regional analgesia: local anaesthetic nerve blocks and infusions 462


Epidural analgesia 469


Entonox administration 481


Non-pharmacological methods of managing pain 485


References 491


10.1 Pain assessment 455


10.2 Peripheral nerve catheter removal 464


10.3 Epidural sensory blockade: assessment 475


10.4 Epidural exit site dressing change 475


10.5 Epidural catheter removal 479


10.6 Entonox administration 484


10.7 Preparation for acupuncture and actions post-treatment 490


11 Symptom control and care towards the end of life 496


Overview 498


End-of-life care 498


Symptom control 515


Verification and certification of death 526


Care after death (last offices) 528


Websites 534


References 534


11.1 Management of dyspnoea (breathlessness) 516


11.2 Care of a patient who is vomiting 519


11.3 Abdominal paracentesis 523


11.4 Terminal sedation 526


11.5 Verification of death 527


11.6 Care after death 529


12 Respiratory care, CPR and blood transfusion 538


Overview 540


Respiratory therapy 540


Oxygen therapy 542


High-flow oxygen via a nasal cannula 551


Humidification 553


Non-invasive ventilation 555


Chest drain management 562


Tracheostomy and laryngectomy care 578


Basic life support 607


Transfusion of blood and blood components 620


Websites 645


References 645


12.1 Oxygen therapy 546


12.2 High-flow oxygen therapy 552


12.3 Continuous positive airway pressure (CPAP) 559


12.4 Chest drain: assisting insertion 567


12.5 Chest drainage: suction 572


12.6 Chest drain: changing the bottle 573


12.7 Chest drain: removal 576


12.8 Tracheostomy: dressing and tube tape/tie change 587


12.9 Tracheostomy: suctioning a patient (single-use suction catheter) 590


12.10 Tracheostomy: changing an inner cannula 592


12.11 Tracheostomy: changing a tube 594


12.12 Tracheostomy: insertion and removal of a speaking valve 597


12.13 Tracheostomy: decannulation 599


12.14 Tracheostomy: emergency management 601


12.15 Laryngectomy care 605


12.16 Insertion of an oropharyngeal airway 616


12.17 Basic life support 617


12.18 Blood product request 634


12.19 Blood sampling: pre-transfusion 635


12.20 Blood components: collection and delivery to the clinical area 636


12.21 Blood component administration 638


Part Three Supporting patients through the diagnostic process 653


13 Diagnostic tests 654


Overview 656


Diagnostic tests 656


Blood sampling 660


Venepuncture: obtaining blood samples from a peripheral vein 662


CVAD sampling: sampling from a central venous access device 671


Arterial blood sampling 675


Blood cultures 683


Antimicrobial drug assay 687


Cerebrospinal fluid obtained by lumbar puncture 689


Semen collection and analysis 694


Cervical screening 697


Specimen collection: swab sampling 701


Specimen collection: urine sampling 710


Specimen collection: faecal sampling 715


Specimen collection: respiratory tract secretion sampling 717


Specimen collection: pleural fluid 722


Endoscopic investigations 723


Liver biopsy 728


Radiological investigations: X-ray 730


Magnetic resonance imaging (MRI) 730


Computed tomography (CT) 732


Websites 733


References 733


13.1 Venepuncture 666


13.2 Central venous access devices: taking a blood sample for vacuum sampling 672


13.3 Central venous access devices: taking a blood sample for syringe sampling 673


13.4 Arterial puncture: radial artery 678


13.5 Arterial blood gas sampling: arterial cannula 680


13.6 Blood cultures: peripheral (winged device collection method) 684


13.7 Blood cultures: central venous access device 686


13.8 Blood sampling: antimicrobial drug assay 688


13.9 Lumbar puncture 692


13.10 Semen collection 696


13.11 Cervical uterine smear using liquid-based cytology 699


13.12 Swab sampling: ear 702


13.13 Swab sampling: eye 703


13.14 Swab sampling: nose 704


13.15 Swab sampling: penis 705


13.16 Swab sampling: rectum 705


13.17 Swab sampling: skin 706


13.18 Swab sampling: throat 707


13.19 Swab sampling: vagina 708


13.20 Swab sampling: wound 709


13.21 Urine sampling: midstream specimen of urine: male 711


13.22 Urine sampling: midstream specimen of urine: female 712


13.23 Urine sampling: catheter specimen of urine 713


13.24 Urine sampling: sampling from an ileal conduit 713


13.25 Urine sampling: 24-hour urine collection 714


13.26 Faecal sampling 716


13.27 Sputum sampling 719


13.28 Nasopharyngeal wash: syringe method 719


13.29 Nasopharyngeal wash: vacuum-assisted aspirate method 721


14 Observations 740


Overview 742


Observations 742


Pulse (heart rate) 744


Electrocardiogram (ECG) 751


Blood pressure 758


Respiration and pulse oximetry 766


Peak flow 777


Temperature 781


Urinalysis 788


Blood glucose 793


Neurological observations 800


References 814


14.1 Pulse measurement 749


14.2 Electrocardiogram (ECG) 755


14.3 Blood pressure measurement (manual) 763


14.4 Respiratory assessment and pulse oximetry 775


14.5 Peak flow reading using a manual peak flow meter 780


14.6 Tympanic temperature measurement 786


14.7 Urinalysis: reagent strip 792


14.8 Blood glucose monitoring 797


14.9 Neurological observations and assessment 811


Part Four Supporting patients through treatment 819


15 Medicines optimization: ensuring quality and safety 820


Overview 822


Medicines management 822


Self-administration of medicines 833


Controlled drugs 835


Routes of administration 843


Parenteral administration (injections and infusions) 869


Infiltration and extravasation 918


Websites 932


References 932


15.1 Medication: controlled drug administration 841


15.2 Medication: oral drug administration 849


15.3 Medication: topical applications 851


15.4 Medication: transdermal applications 853


15.5 Medication: vaginal administration 855


15.6 Medication: administration by inhalation using a metered dose or dry powder inhaler 858


15.7 Medication: administration by inhalation using a nebulizer 860


15.8 Medication: eye administration 864


15.9 Medication: nasal drop administration 866


15.10 Medication: ear drop administration 868


15.11 Medication: single-dose ampoule: solution preparation 872


15.12 Medication: single-dose ampoule: powder preparation 873


15.13 Medication: multidose vial: powder preparation using a venting needle 874


15.14 Medication: multidose vial: powder preparation using the equilibrium method 876


15.15 Medication: injection administration 877


15.16 Medication: intradermal injection 879


15.17 Medication: subcutaneous injection 882


15.18 Medication: subcutaneous infusion of fluids 885


15.19 Medication: subcutaneous administration using a CME Medical T34 syringe pump (previously McKinley) 886


15.20 Medication: intramuscular injection 891


15.21 Inserting an intraosseous needle 894


15.22 Removing an intraosseous needle 897


15.23 Medication: continuous infusion of intravenous drugs 909


15.24 Medication: intermittent infusion of intravenous drugs 911


15.25 Medication: injection (bolus or push) of intravenous drugs 914


15.26 Extravasation management: peripheral cannula 925


15.27 Extravasation: performing flush-out following an extravasation 928


16 Perioperative care 940


Overview 942


Pre-operative care 942


Intraoperative care 977


Post-operative care 1001


16.1 Measuring and applying antiembolic stockings 963


16.2 Pre-operative care: checking that the patient is fully prepared for surgery 975


16.3 Caring for the patient in the anaesthetic room 979


16.4 Operating theatre procedure: maintaining the safety of a patient during surgery 992


16.5 Handover in the post-anaesthetic care unit (PACU): scrub nurse or operating department practitioner to recovery practitioner 996


16.6 Safe management of patients in the post-operative care unit (PACU) 997


16.7 Drainage systems: changing the dressing around the drain site for both open and closed drains 1006


16.8 Closed drainage systems: changing a vacuum bottle 1007


16.9 Wound drain removal: closed drainage system 1008


16.10 Wound drain shortening for open drainage systems 1010


16.11 Wound drain shortening for closed drainage systems 1012


17 Vascular access devices: insertion and management 1028


Overview 1030


Vascular access devices 1030


Peripheral cannulas 1046


Midline catheters 1068


Peripherally inserted central catheters 1073


Short-term percutaneous central venous catheters (non-tunnelled) 1090


Skin-tunnelled catheters 1097


Implanted ports 1102


Arterial cannulas 1110


References 1117


17.1 Central venous catheter: insertion site dressing change 1042


17.2 Vascular access devices: maintaining patency 1043


17.3 Central venous access devices: unblocking an occlusion 1043


17.4 Peripheral cannula insertion 1053


17.5 Ultrasound-guided peripheral cannula insertion 1059


17.6 Midline catheter insertion 1069


17.7 PICC insertion using modified Seldinger technique (MST) with ultrasound 1082


17.8 PICC removal 1089


17.9 Short-term central venous catheter (non-cuffed and non-tunnelled) insertion into the internal jugular vein 1092


17.10 Short-term central venous catheter (non-cuffed and non-tunnelled): removal 1096


17.11 Central venous catheter (skin tunnelled): surgical removal 1099


17.12 Implanted arm PORT insertion using modified Seldinger technique (MST) with ultrasound guidance and ECG technology 1104


17.13 Implanted ports: insertion and removal of non-coring needles 1107


17.14 Arterial cannula insertion: preparation and setting up of monitoring set 1112


17.15 Arterial cannula: removal 1114


18 Wound management 1128


Overview 1130


Wounds 1130


Pressure ulcers 1143


Surgical wounds 1152


Negative pressure wound therapy 1154


Websites 1157


References 1157


18.1 Dressing a wound 1142


18.2 Suture removal 1153


18.3 Clip removal 1153


18.4 Negative pressure wound therapy 1155


Part Five Looking after ourselves so we can support patients 1161


19 Self-care and wellbeing 1162


Overview 1164


Self-care and wellbeing 1164


Mindfulness 1172


Eating and drinking 1173


Physical wellbeing and musculoskeletal health 1175


Websites 1181


References 1181


19.1 Working at low or floor level 1178


19.2 Working with a patient lying in a bed or on another raised supportive surface 1179


19.3 Carrying out clinical procedures in a seated posture (e.g. cannulation) 1180


19.4 Working in a seated position: office work 1180


Appendix: Standards of Proficiency for Registered Nurses 1183


List of abbreviations 1185


Index 1189