Cover

Contents

Cover

Half Title page

Title page

List of contributors

Foreword to the eighth edition

Introduction and guidelines for use

Structure of chapters

References

Quick reference to the procedure guidelines

Acknowledgements

List of abbreviations

Part one: Managing the patient journey

Chapter 1: The context of nursing

Introduction

Political Factors

Economic Factors

Social Factors

Technical Factors

Conclusion

References

Chapter 2: Assessment, discharge and end of life care

Overview

Inpatient Assessment and the Process of Care

Preoperative Assessment

Discharge Planning

Care of the Dying Patient

Last Offices

References

Chapter 3: Infection Prevention and Control

Overview

Infection Prevention and Control

Aseptic Technique

Source Isolation

Protective Isolation

Prevention and Management of Inoculation Injury

Management of Waste in the Healthcare Environment

References

Chapter 4: Risk Management

Overview

Risk Management

The Assessment and Mitigation of Important Clinical Risks

Venous Thromboembolism

Pressure Ulcers

Prevention of Falls

Key Principles of Risk Management

References

Part two: Supporting the patient with human functioning

Chapter 5: Communication

Overview

Communication

Informing Patients

Managing Challenging Issues with Communication

Denial and Collusion

Anxiety

Panic Attacks (Acute Anxiety)

Depression

Suicidal Ideation

Anger, Aggression and Violence Management

Delirium

Acquired Communication Disorders

Communication for an Individual with a Laryngectomy

References

Chapter 6: Elimination

Overview

Normal Elimination

Assisting the Patient with Normal Elimination

Urinary Elimination

Penile Sheaths

Urinary Catheterization

Suprapubic Catheterization

Urinary Diversions

Bladder Irrigation

Faecal Elimination

Diarrhoea

Constipation

Enemas

Suppositories

Digital Rectal Examination

Manual Evacuation

Stoma Care and Intestinal (Bowel) Obstruction and Ileus

Stoma Care

Intestinal (Bowel) Obstruction and Ileus

References

Chapter 7: Moving and Positioning

Overview

Moving and Positioning

Positioning the Patient: Sitting in Bed

Positioning the Patient: Side-Lying

Positioning the Patient: in a Chair/Wheelchair

Moving the Patient from Sitting to Standing

Moving and Positioning the Unconscious Patient

Moving and Positioning the Patient with an Artificial Airway

Moving and Positioning the Patient with Respiratory Compromise

Positioning to Maximize Ventilation/Perfusion Matching

Positioning to Minimize the Work of Breathing

Positioning to Maximize the Drainage of Secretions

Moving and Positioning of the Patient with Actual or Suspected Spinal Cord Compression (SCC) or Spinal Cord Injury (SCI)

Moving and Positioning the Patient with an Amputation

References

Chapter 8: Nutrition, Fluid Balance and Blood Transfusion

Overview

Fluid balance

Nutritional Status

Provision of Nutritional Support: Oral

Nutritional Management of Patients with Dysphagia

Enteral Tube Feeding

Enteral Tube Insertion

Enteral Tube Care

Administration of Enteral Tube Feed

Enteral Feeding Tubes: Administration of Medication

Enteral Feeding Tubes: Unblocking

Parenteral Nutrition

Transfusion of Blood and Blood Components

References

Chapter 9: Patient comfort

Overview

Personal Hygiene

Eye Care

Ear Care

Mouth Care

Pain

Pain Management

Epidural and Intrathecal Analgesia

Entonox Administration

Abdominal Paracentesis

Compression Therapy in the Management of Lymphoedema

Assessment of the Patient with Lymphoedema and Calculation of Limb Volume

Compression Bandaging

Compression Garments

References

Chapter 10: Respiratory Care

Overview

Respiratory Therapy

Oxygen Therapy

Humidification

Continuous Positive Airway Pressure

Chest Drains

Tracheostomy and Laryngectomy Care

Tracheostomy: Dressing Change

Tracheostomy: Suctioning

Tracheostomy: Changing the Inner Cannula

Tracheostomy: Tube Change

Cardiopulmonary Resuscitation

References

Part three: Supporting the patient through the diagnostic process

Chapter 11: Interpreting diagnostic tests

Overview

Diagnostic Tests

Blood: Obtaining Samples from a Peripheral vein (Venepuncture)

Blood Sampling from a Central Venous Catheter

Arterial Sampling

Blood Tests

Blood Cultures

Antimicrobial Drug Assay

Cerebrospinal Fluid (CSF) Obtained by Lumbar Puncture

Semen Collection

Cervical Uterine Smear (Pap Smear)

Specimen Collection: Swab Sampling

Specimen Collection: Urine Sampling

Specimen Collection: Faecal Sampling

Specimen Collection: Respiratory Tract Secretion Sampling

Specimen Collection: Pleural Fluid

Endoscopic Investigations

Gastroscopy

Colonoscopy

Cystoscopy

Liver Biopsy

Radiological Investigations: X-ray

Magnetic Resonance Imaging (MRI)

Computed Tomography (CT)

References

Chapter 12: Haematological Procedures

Overview

Bone Marrow Procedures

Aspiration and Trephine Biopsy

Bone Marrow Harvest

Apheresis

References

Chapter 13: Observations

Overview

Observations

Pulse

Twelve-Lead Electrocardiogram (ECG)

Blood Pressure

Central Venous Pressure

Respiration and Pulse Oximetry

Peak Flow

Temperature

Urinalysis

Blood Glucose

Neurological Observations

References

Chapter 14: Radionuclide Investigations and Therapy

Overview

Radiation

Radiation Protection

Diagnostic Radioisotope Procedures (Nuclear Medicine)

Unsealed Source Therapy

Sealed Source Therapy

Sealed Source Iodine-125 Seeds used in Prostate Malignancies

Intraoral Sealed Sources

References

Part four: Supporting the patient through treatment

Chapter 15: Cytotoxic therapy

Overview

Cytotoxic Therapy

Cytotoxic Handling

Administration of Cytotoxic Medications by Nurses

Intravenous Administration of Cytotoxic Drugs

Extravasation of Vesicant Drugs

Oral Administration of Cytotoxic Drugs

Intramuscular and Subcutaneous Administration of Cytotoxic Drugs

Topical Application of Cytotoxic Drugs

Intrathecal Administration of Cytotoxic Drugs

Intrapleural Instillation of Cytotoxic Drugs

Intravesical Instillation of Cytotoxic Drugs

Intraperitoneal Instillation of Cytotoxic Drugs

Intra-Arterial Administration of Cytotoxic Drugs

Alopecia

References

Chapter 16: Medicines Management

Overview

Medicines Management

Self-Administration of Medicines

Controlled Drugs

Routes of Administration

Oral Administration

Topical Administration

Transdermal Administration

Rectal Administration

Vaginal Administration

Pulmonary Administration

Ophthalmic Administration

Nasal Administration

Otic Administration

Injections and Infusions

Intradermal Injection

Subcutaneous Injection

Subcutaneous Infusion

Intramuscular Injections

Intravenous Injections and Infusions

References

Chapter 17: Perioperative Care

Overview

Preoperative Care

Intraoperative Care

Intraoperative Care: Anaesthesia

Intraoperative Care: Theatre

Intraoperative Care: Recovery

Postoperative Care

References

Chapter 18: Vascular Access Devices: Insertion and Management

Overview

Vascular Access Devices

Peripheral Cannulas

Midline Catheters

Peripherally Inserted Central Catheters (PICC)

Removal of Peripherally Inserted Central Catheters

Short-Term Percutaneous Central Venous Catheters (Non-Tunnelled)

Removal of Short-Term Percutaneous Central Venous Catheters (Non-Tunnelled)

Skin-Tunnelled Catheters

Implanted Ports

Arterial Cannulas

Removal of Arterial Cannula

References

Chapter 19: Wound Management

Overview

Wounds

Fungating Wounds

Radiotherapy Skin Reactions

Pressure Ulcers

Surgical Wounds

Suturing

Removal of Sutures or Staples

Wound Drains

Plastic Surgery

Negative Pressure Wound Therapy

References

Appendix 1: The Code

Appendix 2: Contributors to previous editions

Index

The Royal Marsden Hospital Manual of Clinical Nursing Procedures

This edition first published 2011
© 1992, 1996, 2000, 2004, 2008, 2011 The Royal Marsden Hospital

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Library of Congress Cataloging-in-Publication Data

The Royal Marsden Hospital manual of clinical nursing procedures. — 8th ed. / edited by Lisa Dougherty and Sara Lister.
p. ; cm.
Manual of clinical nursing procedures
Includes bibliographical references and index.
ISBN 978-1-4443-3509-5 (pbk. : alk. paper)
1. Nursing—Handbooks, manuals, etc. I. Dougherty, Lisa. II. Lister, Sara E. III. Title: Manual of clinical nursing procedures.

[DNLM: 1. Nursing Care—methods. 2. Nursing Process. 3. Nursing Theory. 4. Patient Care Planning. WY 100.1]
RT42.R68 2011
610.73—dc22
2010044585

A catalogue record for this book is available from the British Library.

Every effort has been made in the writing of this book to present accurate and up-to-date information from the best and most reliable sources. However, the results of caring for individuals depends upon a variety of factors not under the control of the authors or the publishers of this book. Therefore, neither the authors nor the publishers assume responsibility for, nor make any warranty with respect to, the outcomes achieved from the procedures described herein.

List of Contributors

Lynn Ansell MPharm, PG Dip Clinical Pharmacy
Formerly Pharmacy Clinical Services Manager
(Chapter 16: Medicines management)

Amanda Baxter RN, RMN, ONC, BSc (Hons), PG Dip
Clinical Nurse Specialist, Pelvic Group
(Chapter 6: Elimination)

Hannah Brown RN, MN, Dip HE
Formerly Sister
(Chapter 6: Elimination)

Louise Causer RN, ONC, MBA
Clinical Nurse Specialist Nuclear Medicine
(Chapter 14: Radioactive investigations and therapy)

Suzanne Chapman RN, BSc, MSc
Clinical Nurse Specialist Pain Management
(Chapter 9: Patient comfort)

Rebecca Clarke RN, BSc (Hons), MSc
Ward Sister
(Chapter 17: Perioperative care)

Kirsty Cooke CSP, BSc (Hons)
Macmillan Specialist Lymphoedema Therapist
(Chapter 9: Patient comfort)

Jill Cooper Dip COT, MBE, PG Dip, MSc
Lead Occupational Therapist
(Chapter 7: Moving and positioning)

Maria Crisford RN, BSc (Hons), Dip HE
Specialist Sister Colorectal
(Chapter 6: Elimination)

Alison Diffley RN, Advanced Dip, Dip
Clinical Nurse Specialist Counsellor
(Chapter 5: Communication)

Andrew J. Dimech RN, BN, Dip HE, PG Dip, MSc
Intensive Care
Clinical Nurse Specialist Cancer, Critical Care, Resuscitation and Outreach
(Chapter 11: Interpreting diagnostic tests)

Shelley Dolan RN, BA (Hons), MSc, PhD
Chief Nurse
(Chapter 4: Risk management)

Pauline Doran-Williams RN, BSc, Dip HE
Specialist Sister Plastic Surgery
(Chapter 19: Wound management)

Lisa Dougherty OBE, RN, MSc, DClinP
Nurse Consultant Intravenous Therapy
(Chapter 11: Interpreting diagnostic tests; Chapter 15: Cytotoxic therapy; Chapter 16: Medicines management; Chapter 18: Vascular access devices: insertion and management)

Natalie Doyle RN, MSc
Nurse Consultant Rehabilitation
(Chapter 9: Patient comfort)

Steven Edmunds RN, BSc (Hons), Dip HE
Senior Staff Nurse
(Chapter 13: Observations)

Ann Farley RN, BA (Hons)
Specialist Sister Palliative Care
(Chapter 9: Patient comfort)

Andreia Fernandes RN, BSc, PG Dip
Clinical Nurse Specialist Gynaecology-Oncology
(Chapter 6: Elimination; Chapter 9: Patient comfort; Chapter 11: Interpreting diagnostic tests)

Catherine Forsythe RN, Dip HE, BSc (Hons)
Senior Staff Nurse
(Chapter 11: Interpreting diagnostic tests)

Charlotte Graham RN, BSc
Senior Staff Nurse
(Chapter 13: Observations)

Dimity Grant-Frost RN, BSc
Special Sister, Palliative Care
(Chapter 2: Assessment, discharge and end of life care)

Jagdesh K. Grewal RN, BA (Hons), PG Dip NE, DMS
Matron
(Chapter 17: Perioperative care)

Oonagh Griffin RD, BSc (Hons)
Dietetic Team Leader
(Chapter 8: Nutrition, fluid balance and blood transfusion)

Diz Hackman Dip Physiotherapy, MCSP, PG Dip, MSc
Clinical Specialist Physiotherapist
(Chapter 7: Moving and positioning)

Kate Hall RN, Dip HE, BSc
Matron
(Chapter 15: Cytotoxic therapy)

Sharlene Haywood RN, BSc (Hons)
Formerly Specialist Sister Rehabilitation Outreach Team
(Chapter 9: Patient comfort)

Beverley Henderson RN, PG Dip Counselling Psychotherapy, BSc (Hons)
Clinical Nurse Specialist Counsellor
(Chapter 5: Communication)

Geraldine Heneghan RN, BSc
Sister
(Chapter 11: Interpreting diagnostic tests)

Diana Higgins RN, Dip HE, BA (Hons), MA
PALS and Patient Information Officer
(Chapter 5: Communication)

Claire Hine MCSP, BSc (Hons)
Senior Physiotherapist
(Chapter 7: Moving and positioning)

Justine Hofland RN, BSc (Hons), Dip HE, MSc
Clinical Nurse Director
(Chapter 2: Assessment, discharge and end of life care)

Victoria Hollis RN, BN (Hons) MSc
Matron/Nurse Practitioner
(Chapter 13: Observations)

Sonja Hoy RN, PG Dip, PG Cert, BSc (Hons), Dip
Clinical Nurse Specialist for Thyroid, Head & Neck, and Radiation Protection
(Chapter 14: Radioactive investigations and therapy)

Lorraine Hyde RN, ONC, BSc (Hons)
Matron
(Chapter 15: Cytotoxic therapy)

Beth Jackson RN, Dip HE, BSc (Hons)
Senior Clinical Nurse Specialist Breast Care
(Chapter 19: Wound management)

Kate Jones MCSP, Dip Physiotherapy, MSc
Clinical Specialist Physiotherapist
(Chapter 7: Moving and positioning)

Joanna Lamb RN, BSc (Hons), BA
Ward Sister
(Chapter 13: Observations; Chapter 17: Perioperative care)

Carol Lane RD, BSc (Hons), PG Dip
Dietitian
(Chapter 8: Nutrition, fluid balance and blood transfusion)

Sara Lister RN, BSc (Hons), PGDAE, MSc
Assistant Chief Nurse/Head of School
(Chapter 1: The context of nursing; Chapter 2: Assessment, discharge and end of life care; Chapter 5: Communication)

Perrie Luke RN, RM, RMN
Sister
(Chapter 10: Respiratory care)

Kate Macfarlane MRCSLT, BSc (Hons), MSc
Speech and Language Therapist/Clinical Lead
(Chapter 5: Communication; Chapter 8: Nutrition, fluid balance and blood transfusion)

Jennifer Mackenzie RN, BA
Sister
(Chapter 11: Interpreting diagnostic tests)

Kath Malhotra MCSP, BSc (Hons), PGCE
Lecturer/Practitioner
(Chapter 7: Moving and positioning)

Rebecca Martirani RN, BN
Specialist Sister Infection Prevention
(Chapter 3: Infection prevention and control)

Stacey Magill RN, BN
Senior Staff Nurse
(Chapter 2: Assessment, discharge and end of life care)

Kelly McGovern RN, Dip HE, Dip Cancer
Senior Staff Nurse
(Chapter 2: Assessment, discharge and end of life care)

Hayley McHugh RN, CPPD, BSc (Hons)
Practice Educator
(Chapter 8: Nutrition, fluid balance and blood transfusion)

Chris McNamara RN, BSc (Hons), MSc
Lecturer Practitioner
(Chapter 6: Elimination)

Louise McNamara RN, BN, MSc
Matron
(Chapter 12: Haematological procedures)

Dee Mears DCR, DMS
Superintendent Radiographer
(Chapter 11: Interpreting diagnostic tests)

Helen Mills RN, BSc (Hons), MSc
Head of Quality Assurance
(Chapter 1: The context of nursing)

Carolyn Moore MCSP, SRP
Superintendent Physiotherapist
(Chapter 7: Moving and positioning)

Sarah Newton RD, BSc (Hons)
Dietitian
(Chapter 8: Nutrition, fluid balance and blood transfusion)

Gillian M. Parker RN, BSc, ONC
Specialist Sister Urology
(Chapter 6: Elimination)

Natalie Pattison BSc (Hons), MSc, PhD, Dip HE
Clinical Nursing Research Fellow
(Chapter 1: The context of nursing; Chapter 2: Assessment, discharge and end of life care)

Karon Payne RN
Transfusion Practitioner
(Chapter 8: Nutrition, fluid balance and blood transfusion)

Abby Peacock Smith RN, BN, CPPD
Sister
(Chapter 10: Respiratory care)

Hannah Perry RN, BSc (Hons)
Specialist Sister Gastrointestinal
(Chapter 6: Elimination)

Scott Pollock Dip SW, BA (Hons), SW, MSc
Complex Discharge Co-ordinator
(Chapter 1: The context of nursing; Chapter 2: Assessment, discharge and end of life care)

Stephen Pollock RN, BSc, Dip HE
Charge Nurse
(Chapter 10: Respiratory care)

Jorn Rixen-Osterbro RN, BSc (Hons), Dip HE
Charge Nurse
(Chapter 2: Assessment, discharge and end of life care)

Lara Roskelly RN, Dip N, Dip HE
Sister
(Chapter 10: Respiratory care; Chapter 11: Interpreting diagnostic tests)

Steve Scholtes RN, BSc, MSc
Matron
(Chapter 17: Perioperative care)

Richard Schorstein RN, BSc (Hons), PG Dip
Matron
(Chapter 15: Cytotoxic therapy)

Erica Scurr DCR(R), MSc
Lead MRI Superintendent Radiographer
(Chapter 11: Interpreting diagnostic tests)

Clare Shaw RD, BSc (Hons), PG Dip, PhD
Consultant Dietitian
(Chapter 8: Nutrition, fluid balance and blood transfusion)

Sian Shepherd RD, BSc (Hons), Advanced Dip
Dietitian
(Chapter 8: Nutrition, fluid balance and blood transfusion)

Victoria Sinnett DCR(R), MSc
Superintendent Radiographer
(Chapter 11: Interpreting diagnostic tests)

Jenny Smith RN
Senior PALS and Patient Information Officer
(Chapter 5: Communication)

Anna-Marie Stevens RN, RM, ONC, BSc (Hons), MSc
Macmillan Nurse Consultant Palliative Care
(Chapter 6: Elimination; Chapter 9: Patient comfort)

Nicola Tinne RN, BSc, Dip HE
Specialist Sister Head & Neck
(Chapter 19: Wound management)

Joanna Todd RN, BN (Hons), Dip HE
Senior Staff Nurse
(Chapter 13: Observations)

Richard Towers RN, Dip Onc, BSc (Hons), MSc
Lecturer Practitioner/Lead Nurse Counsellor
(Chapter 5: Communication)

Joanna Waller RN, Dip Onc, BN (Hons)
Ward Sister
(Chapter 17: Perioperative care)

Jen Watson RN, BSc, PG Dip
Matron
(Chapter 18: Vascular access devices: insertion and management)

Ashworth Paul Weaving RN, BSc, Cert, Advanced Dip
Lead Nurse Infection Prevention and Control
(Chapter 3: Infection prevention and control)

Jennifer Webster BSc (Hons), MSc
Senior Occupational Therapist
(Chapter 7: Moving and positioning)

Linda Wedlake RD, MSc, MMed Sci
Research Dietitian
(Chapter 8: Nutrition, fluid balance and blood transfusion)

Helen White MRCSLT, BSc (Hons)
Speech and Language Therapist/Team Leader
(Chapter 5: Communication; Chapter 8: Nutrition, fluid balance and blood transfusion)

Barbara Witt RN
Nurse Phlebotomist
(Chapter 11: Interpreting diagnostic tests)

Mary Woods RN, OncCert, BSc (Hons), MSc
Clinical Nurse Specialist/Head of Lymphoedema Services
(Chapter 9: Patient comfort)

Foreword to The Eighth Edition

As the Chief Nurse of the Royal Marsden Hospital NHS Foundation Trust and a contributor and clinical user for many years, it is a special pleasure and honour to be asked to introduce the eighth edition of The Royal Marsden Hospital Manual of Clinical Nursing Procedures. The manual is internationally renowned and used by nurses across the world to ensure their practice is evidence based and effective. As information becomes ever more available to the consumers of healthcare it is essential that the manual is updated frequently so that it reflects the most current evidence to inform our clinical practice.

More than ever in 2011, nurses need to be able to assure the public, patients and their families that care is based on the best available evidence. As nurses seeking to improve our care it is essential that we are able to critically analyse our judgements in the light of current knowledge. For all of us working with patients and their families there is an imperative to question and renew our practice using the many sources of knowledge available to us. In the busy world of clinical practice in a ward, unit or in the community it can be challenging to find time to search for the evidence and this is where The Royal Marsden Hospital Manual of Clinical Nursing Procedures is a real practical help.

As in the seventh edition, reviewing the evidence or sources of knowledge has been made more explicit with each level of evidence graded. This grading provides the reader with an understanding of whether the reference comes from a randomized controlled trial, national or international guidance or from expert opinion. At its best, clinical nursing care is an amalgam of a sensitive therapeutic relationship coupled with effective care based on the best evidence that exists. Some areas of practice have attracted international research such as cardiopulmonary resuscitation and infection prevention and control; other areas of practice have not attracted such robust research and therefore it is more of a challenge to ensure evidence-based care. Each time the next edition of the manual is prepared we reflect on the gaps in research and knowledge; this provides the impetus to start developing new concept analyses and develop further research studies. This year there are new areas covered including a chapter on risk management and a section on preparing the patient for diagnostic investigations such as endoscopy or CT scans.

As you look at the list of contributors to the manual you will see that this edition has continued to ask clinically active nurses to share their practice in their chapters. This has the double advantage of ensuring that this manual reflects the reality of practice but also ensures that nurses at the Royal Marsden Hospital NHS Foundation Trust are frequently reviewing the evidence and reflecting upon their care.

A textbook devoted to improving and enhancing clinical practice needs to be alive to the clinical practitioner. You will see that this edition has a new overall format designed to make the manual more effective in clinical care.

As I commend this eighth edition of The Royal Marsden Hospital Manual of Clinical Nursing Procedures to you I am aware that it will be used in many different countries and settings. Having had the privilege of visiting and meeting nurses across the world I know that there are more commonalities than differences between us. The common theme is, of course, the need to ensure that we as nurses provide care that is individually and sensitively planned and that it is based on the best available evidence. The Royal Marsden Hospital Manual of Clinical Nursing Procedures is a wonderful resource for such evidence and I hope it will be widely used in all clinical settings across the world.

Finally, I would like to pay a warm tribute to the amazing amount of work undertaken by the two editors, Lisa Dougherty and Sara Lister, and to all the nurses and allied health professionals at the Royal Marsden Hospital who have worked so hard on this eighth edition.

Shelley Dolan
Chief Nurse
The Royal Marsden Hospital NHS
Foundation Trust

Introduction and Guidelines for Use

The first edition of The Royal Marsden Hospital Manual of Clinical Nursing Procedures was produced in the early 1980s as a core procedure manual for safe practice within The Royal Marsden Hospital, the first cancer hospital in the world. Thirty years and eight editions later the staff of the hospital are still working together to keep it updated, ensuring that only current evidence-based practice is recommended.

The type of evidence that underpins procedures is made explicit by using a system to categorize the evidence, which is broader than that generally used. It has been developed from the types of evidence described by Rycroft-Malone et al. (2004) in an attempt to acknowledge that ‘in reality practitioners draw on multiple sources of knowledge in the course of their practice and interaction with patients’ (Rycroft-Malone et al. 2004, p. 88).

The sources of evidence, along with examples, are identified as follows:

1. Clinical experience (E):

Encompasses expert practical know-how, gained through working with others and reflecting on best practice.

If there is no written evidence to support clinical experience as a justification for undertaking a procedure the text will be referenced as an E but will not be preceded by an author’s name.

Example: (Dougherty 2008: E). This is drawn from the following article that gives expert clinical opinion: Dougherty, L. (2008) Obtaining peripheral vascular access. In: Intravenous Therapy in Nursing Practice (eds L. Dougherty & J. Lamb), 2nd edn. Blackwell Publishing, Oxford.

2. Patient (P):

Gained through expert patient feedback and extensive experience of working with patients.

Example: (Diamond 1999: P). This has been gained from a personal account of care written by a patient, Diamond, J. (1999) C: Because Cowards Get Cancer Too. Vermilion, London.

3. Context (C):

May include Audit and Performance data, Social and Professional Networks, Local and National Policy, guidelines from Professional Bodies (e.g. Royal College of Nursing; RCN) and manufacturer’s recommendations.

Example: (DH 2001: C). This document gives guidelines for good practice: DH (2001) Reference Guide to Consent for Examination or Treatment. Department of Health, London.

4. Research (R):

Evidence gained through research.

Example: (Fellowes et al. 2004: R1a). This has been drawn from the following evidence: Fellowes, D., Wilkinson, S. & Moore, P. (2004) Communication skills training for healthcare professionals working with cancer patients, their families and/or carers. Cochrane Database Syst Rev, 2, CD003751. DOI: 10.10002/14651858.CD003571.pub2.

The levels that have been chosen are adapted from Sackett, Strauss and Richardson (2000) as follows:

a. Systematic reviews of randomized controlled trials (RCTs).

b. Individual RCTs with narrow confidence limits.

a. Systematic reviews of cohort studies.

b. Individual cohort studies and low quality RCTs.

a. Systematic reviews of case-controlled studies.

b. Case-controlled studies.

4. Case series and poor quality cohort and case-controlled studies.

5. Expert opinion.

The rationale for the system and further explanation is discussed in more detail in Chapter 1.

The Manual is informed by the day-to-day practice in The Royal Marsden NHS Foundation Trust and conversely is the corporate policy and procedure document of the organization. It therefore does not cover all aspects of acute nursing practice or those relating to children’s or community nursing. However, it does contain the procedures and changes in practice that reflect modern acute nursing practice.

Core to nursing, wherever it takes place, is the commitment to care for individuals and to keep them safe. Increasing use is being made of the internet to record and access information essential in maintaining this safe environment. This edition of The Royal Marsden Hospital Manual of Clinical Nursing Procedures has been significantly revised to reflect the move in professional life to utilize electronic records and web-based information in the process of providing patient care.

A more detailed uniform structure has been introduced for all chapters so that there is a balance to the information included. The number of chapters has been reduced, grouping together similar procedures related to an aspect of human functioning. This is to avoid the need to duplicate material and to make it easier for the reader to find.

The chapters have been organized into four broad sections that represent as far as possible the needs of a patient along their care pathway. The first section, Managing the patient journey, presents the generic information that the nurse needs for every patient who enters the acute care environment. The second section, Supporting the patient with human functioning, relates to the support a patient may require with normal human functions such as elimination, nutrition, respiration. The third section, Supporting the patient through the diagnostic process, includes procedures that relate to any aspects of supporting a patient through the diagnostic process from the simple procedures such as taking a temperature, to preparing a patient for complex procedures such as a liver biopsy. The final section, Supporting the patient through treatment, includes the procedures related to specific types of treatment or therapies related to the disease or illness of the patient.

Structure of chapters

The structure of each chapter is consistent throughout the book:

Overview: As the chapters are larger and have considerably more content, each one begins with an overview to guide the reader, informing them of the scope and the sections included in the chapter.

Definition: Each section begins with a definition of the terms and explanation of the aspect of care, with any technical or difficult concepts explained.

Anatomy and physiology: Each section includes a discussion of the anatomy and physiology that relates to the aspect of nursing care in the chapter. If appropriate, this is illustrated with diagrams so the context of the procedure can be fully understood by the reader.

Related theory: If an understanding of theoretical principles is more appropriate background information to help carry out a procedure, this has been included.

Evidence-based approaches: This provides background and presents the research and expert opinion in this area. If appropriate the indications and contraindications are included as well as any principles of care.

Legal and professional issues: This outlines any professional guidance, law or other national policies that may need to be known about in respect to the procedures. If necessary this includes any professional competences or qualifications that are required in order to perform the procedures.

Preprocedural considerations: When carrying out any procedure there are certain actions that may need to be completed, equipment prepared or medication given beforehand. These are made explicit under this heading.

Procedure: Each chapter includes the current procedures that are used in the acute hospital setting. They have been drawn from the daily nursing practice at The Royal Marsden NHS Foundation Trust. Only procedures where the authors have the knowledge and expertise have been included.

Each procedure gives detailed step-by-step actions, supported by rationale, and, where available, the known evidence underpinning this rationale has been indicated. Within procedure guidelines, any action steps of the procedure that are a nursing responsibility are highlighted with colour shading, using the same colour as for the headings in that chapter. The manual also includes a few procedures where the primary role of the nurse is to assist another health care practitioner. Within those procedure guidelines, where action steps are carried out by either a doctor or other expert practitioner, rather than being a nursing responsibility, the action steps are highlighted with grey shading, for example, Procedure guideline 10.4: Chest drain: insertion.

Problem solving and resolution: If relevant, each procedure will be followed by a table of potential problems that may be encountered while carrying out the procedure and suggestions as to the cause, prevention and any action that may help resolve the problem.

Postprocedural considerations: Care for the patient doesn’t end with the procedure. This new section details any documentation the nurse may need to complete, education/ information that needs to be given to the patient, ongoing observations or referrals to other members of the multiprofessional team.

Complications: Any ongoing problems or potential complications are discussed in a final section and includes evidence-based suggestions for resolution.

Illustrations: The number of colour illustrations has been increased and where relevant they have been used to illustrate the steps of some procedures. This will enable the nurse carrying out the procedures to see in greater detail, for example, the correct position of hands or the angle of a needle.

Reference list: The chapter finishes with a reference list. Only recent texts from the last 10 years have been included unless they are seminal texts. For the first time a list of websites has also been included.

This book is intended as a reference and a resource, not as a replacement for practice-based education. None of the procedures in this book should be undertaken without prior instruction and subsequent supervision from an appropriately qualified and experienced professional. We hope that The Royal Marsden Hospital Manual of Clinical Nursing Procedures will continue to be a resource and a contribution to ‘continually improving the overall standard of clinical care’ (NHSE 1999, p. 3).

References

NHSE (1999) Clinical Governance: Quality in the New NHS. Department of Health, London.

NICE (2005) Violence. The Short-Term Management of Disturbed/Violent Behaviour in Psychiatric In-Patient Settings and Emergency Departments. National Institute for Health and Clinical Excellence, London.

NICE (2007) Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in in-patients undergoing surgery. National Collaborating Centre for Acute Care.

Pratt, R.J. et al. (2007) Epic 2: National evidence-based guidelines for preventing health-care associated infections in NHS hospitals in England. J Hosp Infect, 65(1)(Suppl), S1–S12.

Royal College of Surgeons for England, London. www.guidance-nice.org.uk/CG/published/CG46. Accessed 30/4/07.

Rycroft-Malone, J. et al. (2004) What counts as evidence in evidence based practice? J Adv Nurs, 47(1), 81–90.

Sackett, D.L., Strauss, S.E., Richardson, W.S. (2000) Evidence Based Medicine: How to Practice and Teach EBM, 2nd edn. Churchill Livingstone, Edinburgh.

Lisa Dougherty
Sara Lister

Quick Reference to the Procedure Guidelines

Abdominal paracentesis

Anaesthesia: caring for patient in anaesthetic room

Antiembolic stockings: assessment, fitting and wearing

Apheresis

Arterial blood gas sampling: arterial cannula

Arterial cannula insertion: preparation and setting up of monitoring set

Arterial cannula: removal

Arterial puncture: radial artery

Artificial eye care: insertion

Artificial eye care: removal

Aseptic technique, for example, changing a wound dressing

Bed bathing a patient

Blood component administration

Blood components: collection and delivery to the clinical area

Blood cultures: central venous access device

Blood cultures: peripheral (winged device collection method)

Blood glucose monitoring

Blood pressure measurement (manual)

Blood product request

Blood sampling antimicrobial drug assay

Blood sampling: pretransfusion

Bone marrow aspiration and trephine biopsy

Bone marrow harvest

Cardiopulmonary resuscitation

Care of the patient during bladder irrigation

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

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

Central venous access devices: unblocking an occlusion

Central venous catheter (skin-tunnelled): surgical removal

Central venous catheter: insertion site dressing change

Central venous pressure measurement

Cervical uterine smear using an endocervical brush

Cervical uterine smear using liquid-based cytology

Cervical uterine smear using a wooden spatula

Chest drain: changing the bottle

Chest drain: insertion

Chest drain: priming ambulatory chest drain bag

Chest drain: removal

Chest drainage: suction

Commencing bladder irrigation

Commode use: assisting a patient

Compression bandaging (standard multilayer): bandaging a leg and the toes

Compression bandaging (standard multilayer): bandaging an arm and the fingers

Compression therapy: limb volume calculation: lower limbs

Compression therapy: limb volume calculation: upper limbs

Contact lens removal: hard lenses

Contact lens removal: soft lenses

Continent urinary diversion stoma drainage tubes: flushing

Continent urinary diversion stoma: self-catheterization

Continuous positive airway pressure

Cytotoxic spillage management

Cytotoxic therapy: education for patients on oral cytotoxic drugs

Cytotoxic therapy: intramuscular administration of cytotoxic drugs (Z-track)

Cytotoxic therapy: intraperitoneal instillation of cytotoxic drugs

Cytotoxic therapy: intrapleural instillation of cytotoxic drugs

Cytotoxic therapy: intravenous administration of cytotoxic drugs

Cytotoxic therapy: intraventricular administration of cytotoxic drugs via an intraventricular access device (Ommaya reservoir)

Cytotoxic therapy: intravesical instillation of cytotoxic drugs

Cytotoxic therapy: topical application of cytotoxic drugs

Digital rectal examination

Discharge planning

Discharge planning for patients with epidural/intrathecal catheter in situ for chronic cancer pain

Donning a sterile gown and gloves: closed technique

Donning sterile gloves: open technique

Dressing a wound

Early mobilization of the patient in bed

Elastic compression garments: application to the arm

Elastic compression garments: application to the leg

Electrocardiogram

Enema administration

Enteral feeding tubes: unblocking

Enteral feeding tubes: administration of feed

Enteral feeding tubes: administration of medication

Entonox administration

Epidural/intrathecal analgesia top-up (bolus)

Epidural/intrathecal catheter insertion

Epidural/intrathecal catheter removal

Epidural/intrathecal exit site dressing change

Epidural/intrathecal infusion: setting up and utilizing an ambulatory pump

Epidural/intrathecal sensory blockade: assessment

Extravasation management: peripheral cannula

Extravasation: performing flush-out following an extravasation

Eye irrigation

Eye swabbing

Faecal sampling

Feeding an adult patient

Fluid input: measurement

Fluid output: measuring output from drains

Fluid output: monitoring output from bowels

Fluid output: monitoring output from gastric outlets, nasogastric tubes, gastrostomy

Fluid output: monitoring output from stoma sites

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

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

Hand decontamination using alcohol handrub

Handwashing

Humidification for respiratory therapy

Implanted ports: insertion and removal of non-coring needles

Intra-arterial administration of cytotoxic drugs

Jejunostomy feeding tube care

Last Offices

Log rolling for suspected/confirmed cervical spinal instability

Log rolling for suspected/confirmed thoracolumbar spinal instability

Lumbar puncture

Manual evacuation of faeces

Measuring the weight and height of the patient

Medication: administration by inhalation using a metered dose inhaler

Medication: administration by inhalation using a nebulizer

Medication: continuous infusion of intravenous drugs

Medication: controlled drug administration

Medication: ear drop administration

Medication: eye administration

Medication: injection (bolus or push) of intravenous drugs

Medication: injection administration

Medication: intermittent infusion of intravenous drugs

Medication: intradermal injection

Medication: intramuscular injection

Medication: multidose vial: powder preparation using a venting needle

Medication: multidose vial: powder preparation using equilibrium method

Medication: nasal drop administration

Medication: oral drug administration

Medication: self-administration

Medication: single-dose ampoule: powder preparation

Medication: single-dose ampoule: solution preparation

Medication: subcutaneous administration using a Graseby syringe driver

Medication: subcutaneous administration using a McKinley T34

Medication: subcutaneous infusion of fluids

Medication: subcutaneous injection

Medication: topical applications

Medication: transdermal applications

Medication: vaginal administration

Midline catheter insertion

Mouth care

Moving from sitting to standing: assisting the patient

Nasogastric intubation with tubes using an introducer

Nasogastric intubation with tubes without using an introducer, for example, a Ryle’s tube

Nasopharyngeal wash: syringe method

Nasopharyngeal wash: vacuum-assisted aspirate method

Negative pressure wound therapy

Neurological observations and assessment

Operating theatre procedure

Oxygen therapy

Pain assessment and education of patients prior to surgery

Pain assessment chart: chronic pain recording

Patients in PACU

Peak flow reading using a manual peak flow meter

Penile sheath application

Percutaneous endoscopically placed gastrostomy (PEG) tube care

Peripheral cannula insertion

PICC insertion using a standard introducer

PICC insertion using modified Seldinger technique (with or without ultrasound)

PICC removal

Positioning for suspected/confirmed cervical spinal instability: pelvic twist to right

Positioning the neurological patient with tonal problems

Positioning the patient to maximize V/Q matching for widespread pathology in a self-ventilating patient

Positioning the patient to maximize V/Q matching with unilateral lung disease in a self-ventilating patient

Positioning the patient: in a chair/wheelchair

Positioning the patient: lying down to sitting up

Positioning the patient: side-lying

Positioning the patient: sitting in bed

Positioning the patient: supine

Positioning the preoperative and postoperative amputee patient

Positioning the unconscious patient or patient with an airway in side-lying

Positioning the unconscious patient or patient with an airway in supine

Positioning to maximize the drainage of secretions

Preoperative care: theatre checklist

Protective isolation: entering the isolation room

Protective isolation: preparing the room

Pulse measurement

Putting on and removing a disposable apron

Putting on and removing a disposable mask or respirator

Putting on and removing non-sterile gloves

Putting on or removing goggles or a face shield

Radiation protection: cardiac arrest of patient who has received unsealed radioactive source therapy

Radiation protection: contamination of bare hands by radioactive body fluids

Radiation protection: death of patient who has received unsealed radioactive source therapy

Radiation protection: evacuation due to fire of patients who have received unsealed radioactive source therapy

Radiation protection: major spillage of radioactive body fluids through incontinence and/or vomiting

Radiologically inserted gastrostomy (RIG) tube care

Respiratory assessment and pulse oximetry

Safe disposal of foul, infected or infested linen

Scalp cooling

Sealed source therapy: caesium sources (manual or afterloading): patient care

Sealed source therapy: insertion of sealed radioactive sources into the oral cavity

Sealed source therapy: low dose-rate Selectron treatment

Sealed source therapy: Selectron applicator removal

Semen collection

Short-term central venous catheter (non-cuffed/tunnelled) insertion

Short-term central venous catheter (non-cuffed/tunnelled): removal

Slipper bedpan use: assisting a patient

Source isolation: entering the isolation room

Source isolation: leaving the isolation room

Source isolation: preparing an isolation room

Source isolation: transporting infected patients outside the source isolation area

Sputum sampling

Staple removal

Stoma bridge or rod removal

Stoma care

Suppository administration

Suture removal

Suturing a simple wound

Swab sampling: ear

Swab sampling: eye

Swab sampling: nose

Swab sampling: penis

Swab sampling: rectum

Swab sampling: skin

Swab sampling: throat

Swab sampling: vagina

Swab sampling: wound

Temperature measurement

Tracheostomy: dressing change

Tracheostomy: inner cannula change

Tracheostomy: suctioning a patient

Tracheostomy: tube change

Transfer to PACU

Unsealed radioactive sources for diagnostic investigations: patient care

Unsealed source therapy: entering and leaving the room of a patient who has received an unsealed radioactive source

Unsealed source therapy: iodine-131 (oral capsule/liquid): administration

Unsealed source therapy: iodine-131 mIBG treatment: patient care

Urinalysis: reagent strip procedure

Urinary catheter bag: emptying

Urinary catheter removal

Urinary catheterization: female

Urinary catheterization: intermittent self-catheterization: female

Urinary catheterization: intermittent self-catheterization: male

Urinary catheterization: male

Urine sampling: 24-hour urine collection

Urine sampling: catheter specimen of urine (CSU)

Urine sampling: midstream specimen of urine: female

Urine sampling: midstream specimen of urine: male

Urine sampling: sampling from an ileal conduit

Vascular access devices: maintaining patency

Venepuncture

Voice prosthesis: changing a Blom-Singer exdwelling duckbill voice prosthesis

Voice prosthesis: cleaning in situ

Wound drain removal (closed drainage system, for example, Redivac or concertina)

Wound drain shortening (open drainage systems, for example, Penrose, Yates or corrugated)

Wound drainage systems: changing the dressing around the drain site and observation/management

Wound drainage systems: changing the vacuum bottle of a closed drainage system