The Royal Marsden Hospital Manual of Clinical

Nursing Procedures

The Royal Marsden Hospital Manual of Clinical

Nursing ProceduresSixth Edition

Edited by

Lisa DoughertyRN, RM, Onc Cert, MScNurse Consultant Intravenous TherapyThe Royal Marsden Hospital

and

Sara E. ListerRN, PGDAE, BSc (Hons), MScAssistant Chief Nurse/Head of SchoolThe Royal Marsden Hospital School of Cancer Nursing & RehabilitationThe Royal Marsden Hospital

NHS Foundation Trust

© 1992, 1996, 2000, 2004, 2006 by The Royal Marsden Hospital

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First edition published by Harper and Row Ltd 1984Second edition published 1998Reprinted by HarperCollins 1990Third edition published by Blackwell Scientific Publications 1992Fourth edition published by Blackwell Science 1996Fifth edition published by Blackwell Science 2000Sixth edition published by Blackwell Publishing Ltd 2004Reprinted 2005 (twice)Pocket edition published, with corrections, 2006

ISBN-10: 1-4051-5846-8ISBN-13: 978-1-4051-5846-6

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

Contents

Quick reference to the guidelines xiiiContributors to sixth edition xviiForeword to sixth edition xxiAcknowledgements xxiiiIntroduction xxv

1 Context of care 1Introduction 1Evidence-based practice: doing the right thing 2Consent 5Conclusion 13References and further reading 14

2 Communication and assessment 16Introduction 16Communication 16Principles of assessment 25Conclusion 36References and further reading 36

3 Abdominal paracentesis 43Reference material 43Procedure guidelines: Abdominal paracentesis 46Procedure guidelines: Removal of an

intraperitoneal drain (short term) 47Problem solving 48References and further reading 48

4 Aseptic technique 50Reference material 51Procedure guidelines: Aseptic technique 57Procedure guidelines: Hand washing 58References and further reading 61

5 Barrier nursing: nursing the infectiousor immunosuppressed patient 64Barrier nursing 64Reference material 64Source isolation 66Reference material 67

Procedure guidelines: Source isolation 70Protective isolation 74Reference material 76Procedure guidelines: Nursing the

neutropenic patient 78Acquired immune deficiency syndrome (AIDS) 80Reference material 80Human immunodeficiency virus 2 (HIV 2) 85Reference material 85Procedure guidelines: Acquired immune deficiency

syndrome in a general ward 86Antimicrobial-resistant organisms 91Reference material 91Aspergillosis 96Reference material 96Clostridium difficile 98Reference material 98Cryptosporidiosis 99Reference material 99Hepatitis 101Hepatitis A 101Reference material 101Procedure guidelines: Hepatitis A 102Hepatitis B 103Reference material 103Procedure guidelines: Hepatitis B 106Non-A non-B hepatitis 109Reference material 109Procedure guidelines: Non-A non-B hepatitis 110Hepatitis C 110Reference material 110Hepatitis D 111Reference material 111Hepatitis E 111Reference material 111Hepatitis B genotype F 112Reference material 112Hepatitis G 112Reference material 112The herpes viruses 112Cytomegalovirus 112

Reference material 112Epstein–Barr virus 114Reference material 114Herpes simplex virus 115Reference material 115Varicella zoster virus 116Reference material 116Legionnaire’s disease 118Reference material 118Listeriosis 119Reference material 119Pneumocystosis 120Reference material 120Tuberculosis 121Reference material 122Transmissible spongiform encephalopathies 125Reference material 125References and further reading 127

6 Breast aspiration and seroma drainage 150Breast aspiration 150Reference material 150Procedure guidelines: Breast aspiration 153Seroma drainage 155Procedure guidelines: Seroma drainage 156References and further reading 157

7 Cardiopulmonary resuscitation 158Reference material 158Procedure guidelines: Cardiopulmonary

resuscitation 165References and further reading 169

8 Discharge planning 170Reference material 170Procedure guidelines: Discharge planning 179References and further reading 182

9 Drug administration: general principles 184Reference material 184Injections and infusions 193Procedure guidelines: Self-administration

of drugs 201Procedure guidelines: Oral drug administration 203Procedure guidelines: Administration of

injections 205Procedure guidelines: Administration of rectal

and vaginal preparations 210Procedure guidelines: Topical applications

of drugs 211Procedure guidelines: Administration of drugs

in other forms 211Procedure guidelines: Administration of

intravenous drugs by continuous infusion 213Procedure guidelines: Administration of drugs

by intermittent infusion 215Procedure guidelines: Administration of drugs

by direct injection, bolus or push 218Problem solving 220

References and further reading 224

10 Drug administration: cytotoxic drugs 228Reference material 228Procedure guidelines: Protection of the

environment 230Procedure guidelines: Protection of staff

during accidental exposure to cytotoxic drugs 233

Routes of administration 234Intravenous administration 234Reference material 235Procedure guidelines: Intravenous

administration of cytotoxic drugs 236Extravasation of vesicant drugs 238Reference material 238Procedure guidelines: Management of

extravasation when using a peripheral cannula 242

Oral administration 244Reference material 245Intramuscular and subcutaneous injection 245Reference material 245Topical application 245Reference material 246Intrathecal administration 246Reference material 246Intrapleural instillation 247Reference material 248Procedure guidelines: Administration of

intrapleural drugs 248Problem solving 249Intravesical instillation 249Reference material 249Procedure guidelines: Intravesical instillation

of cytotoxic drugs 250Problem solving 251Intraperitoneal administration 252Reference material 252Procedure guidelines: Intraperitoneal

instillation of cytotoxic drugs 253Problem solving 254Intra-arterial administration 254Reference material 254Problem solving 256References and further reading 256

11 Drug administration: delivery (infusion devices) 259

Reference material 260Infusion devices 265Gravity infusion devices 265Infusion pumps 266Summary 269Procedure guidelines: Subcutaneous

administration of drugs using a syringe driver (e.g. Sims (Graseby) Medical MS26) 270

Procedure guidelines: Preparation of the syringe for 24-hour drug administration using

CONTENTSvi

the Sims (Graseby) Medical MS26 syringe driver 270

Procedure guidelines: Priming the infusion set 271Procedure guidelines: Inserting the winged

infusion set or cannula 271Problem solving 272References and further reading 274

12 Elimination: bladder lavage and irrigation 275Reference material 275Procedure guidelines: Bladder lavage 278Procedure guidelines: Administering a catheter

maintenance solution 280Procedure guidelines: Continuous bladder

irrigation 281Bladder irrigation recording chart 282Problem solving 283References and further reading 283

13 Elimination: bowel care 285Reference material 285Enemas 292Reference material 292Procedure guidelines: Administration of enemas 293Problem solving 294Suppositories 295Reference material 295Procedure guidelines: Administration of

suppositories 295Digital rectal examination 296Procedure guidelines: Digital rectal examination 297Manual evacuation 298Rectal lavage 298Reference material 299Procedure guidelines: Administration of

rectal lavage 300Problem solving 301References and further reading 302

14 Elimination: continent urinary diversions 304

Reference material 304Teaching intermittent self-catheterization

of a continent urinary diversion stoma 310Reference material 310Procedure guidelines: Self-catheterization

of a continent urinary diversion stoma 311Procedure guidelines: Flushing of urinary

drainage tubes 312Problem solving 313Useful addresses 314References and further reading 314

15 Elimination: stoma care 316Reference material 316Procedure guidelines: Stoma care 324Procedure guidelines: Collection of a specimen

of urine from an ileal conduit or urostomy 325Procedure guidelines: Removal of stoma bridge

or rod 326

Problem solving 327Useful addresses 328References and further reading 328

16 Elimination: urinary catheterization 330Reference material 331Procedure guidelines: Urinary catheterization 335Procedure guidelines for patients: Intermittent

self-catheterization 339Procedure guidelines: Collection of a catheter

specimen of urine 341Procedure guidelines: Emptying a catheter bag 342Procedure guidelines: Removing a catheter 343Problem solving 343References and further reading 346

17 External compression and support in themanagement of lymphoedema 348Reference material 349Assessment of the patient with lymphoedema 349Measurement of limb volume 350Reference material 350Procedure guidelines: Calculation of limb

volume 351Phases of treatment 352Maintenance phase of treatment 352Intensive phase of treatment 353Procedure guidelines: The application of elastic

compression garments 355Procedure guidelines: Standard multilayer

compression bandaging 356References and further reading 360

18 Gene therapy for the management of cancer 362Reference material 362Procedure guidelines: Care of patients receiving

gene therapy 367Further advice 371References and further reading 371

19 Haematological procedures: specialist,diagnostic and therapeutic 372Reference material 373Procedure guidelines: Bone marrow aspiration

and trephine biopsy 376Problem solving 377Procedure guidelines: Bone marrow harvest 378References and further reading 379

20 Intrapleural drainage 380Reference material 380Procedure guidelines: Chest drain insertion 384Procedure guidelines: Removal of a chest drain 388Problem solving 389References and further reading 390

21 Last offices 391Reference material 391Procedure guidelines: Last offices 392Problem solving 394

CONTENTS vii

Procedure guidelines: Requirements for people of different religious faiths 396

References and further reading 399

22 Lumbar puncture 402Reference material 403Procedure guidelines: Lumbar puncture 405Problem solving 407References and further reading 408

23 Moving and handling of patients 409Reference material 409Summary 417Procedure guidelines: Moving and handling

of patients 418References and further reading 418

24 Nutritional support 420Reference material 421Procedure guidelines: Nasogastric intubation

with tubes using an introducer 430Procedure guidelines: Nasogastric intubation

with tubes without using an introducer,e.g. a Ryle’s tube 432

Procedure guidelines: Care of a percutaneous endoscopically placed gastrostomy (PEG) tube 434

Procedure guidelines: Care of a radiologically inserted gastrostomy (RIG) tube 435

Procedure guidelines: Care of a jejunostomy feeding tube 435

Procedure guidelines: Administration of drugs via enteral feeding tubes 436

Procedure guidelines: Unblocking an enteral feeding tube 437

Problem solving 438References and further reading 440

25 Observations 442Pulse 442Reference material 443Procedure guidelines: Pulse 44612 Lead electrocardiogram (ECG) 446Procedure guidelines: 12 Lead ECG 446Blood pressure 448Reference material 448Procedure guidelines: Manual blood pressure 454Respiration 455Reference material 455Procedure guidelines: Pulse oximetry 461Peak flow 462Reference material 462Procedure guidelines: Peak flow reading using

manual peak flow meter 463Temperature 464Reference material 465Procedure guidelines: Temperature 469Urinalysis 470Reference material 470Characteristics of urine 471

Procedure guidelines: Reagent sticks 473Blood glucose 473Reference material 474Procedure guidelines: Blood glucose

monitoring 477Central venous pressure 478Procedure guidelines: Reading central venous

pressure 480Problem solving 481References and further reading 481

26 Observations: neurological 485Reference material 485Procedure guidelines: Neurological observations

and assessment 492References and further reading 495

27 Pain management and assessment 496Reference material 496Procedure guidelines: Patient assessment and

preparation before surgery: optimizing pain control 509

Procedure guidelines: Using a chronic pain chart 509

References and further reading 510

28 Pain management: Entonox administration 513Reference material 514Procedure guidelines: Entonox administration 516Problem solving 517References and further reading 518

29 Pain management: epidural analgesia 519Reference material 520Epidural analgesia for patients with

intractable cancer pain 524Procedure guidelines: Insertion of an epidural

catheter 525Problem solving: Management of side-effects

associated with epidural infusions of local anaesthetic agents and opioids 526

Problem solving: Complications of epidural use and management 528

Procedure guidelines: Topping up epidural analgesia 528

Procedure guidelines: Removal of an epidural catheter 529

Procedure guidelines: Preinsertion management of an epidural for chronic pain 530

Procedure guidelines: Changing the dressing over the epidural exit site 530

Procedure guidelines: Postinsertion monitoring of respiratory and cardiac function in chronic pain management 531

Procedure guidelines: Setting up the epidural infusion (utilizing a syringe pump or driver) 532

Procedure guidelines: Setting up the epidural infusion (utilizing an ambulatory pump) 532

CONTENTSviii

Procedure guidelines: Discharge planning 533Problem solving 534References and further reading 535

30 Perioperative care 536Preoperative care 536Reference material 536Procedure guidelines: Preoperative care 538Intraoperative care 540Reference material 540Procedure guidelines: Intraoperative care 542Postanaesthetic recovery 544Reference material 544Procedure guidelines: Postanaesthetic recovery 545Problem solving 547Procedure guidelines: Postoperative recovery 549References and further reading 551

31 Personal hygiene: eye care 553Reference material 553Procedure guidelines: Eye swabbing 562Procedure guidelines: Eye swabbing for

comatose patients 563Procedure guidelines: Care of artificial eyes 564Procedure guidelines: Care of contact lenses 565Procedure guidelines: Instillation of eye drops 566Procedure guidelines: Instillation of eye ointment 567Procedure guidelines: Eye irrigation 568References and further reading 569

32 Personal hygiene: mouth care 570Reference material 570Procedure guidelines: Mouth care 575Problem solving 577References and further reading 577

33 Personal hygiene: skin care 580Reference material 580Procedure guidelines: Bed bathing a patient 584References and further reading 585

34 Radioactive source therapy: sealed sources 587Sealed radioactive source therapy 587Reference material 587Remote afterloading 593Reference material 594Procedure guidelines: Care of patients with

insertions of sealed radioactive sources 597Procedure guidelines: Care of patients with

intraoral sources 600Procedure guidelines: Care of patients with

manually and afterloaded iridium and caesium gynaecological sources 601

Procedure guidelines: Removal of gynaecological caesium and iridium wires 601

Problem solving 603Procedure guidelines: Care of patients

undergoing Selectron treatment 603Procedure guidelines: Removal of Selectron

applicators 604

Problem solving 605Procedure guidelines: Care of patients

with radioactive seeds (e.g. iodine-125) 605Procedure guidelines: Care of patients with

breast sources 606Procedure guidelines: Interstitial perineal

template (Hammersmith hedgehog) 606Useful websites 608References and further reading 608

35 Radioactive source therapy and diagnostic procedures: unsealed sources 610Reference material 611Procedure guidelines: Care of the patient before

administration of iodine-131 620Procedure guidelines: Care of the patient

receiving iodine-131 thyroid treatment 620Procedure guidelines: Care of the patient

receiving iodine-131 mIBG treatment 620Procedure guidelines: Care of the patient after

administration of unsealed source therapy 621Procedure guidelines: Care of the patient

receiving unsealed sources for diagnostic investigations 623

Procedure guidelines: Emergency procedures 624References and further reading 626

36 Renal replacement therapy: peritoneal dialysis and continuous venovenous haemodiafiltration 629Reference material 629Peritoneal dialysis (PD) 630Reference material 630Continuous renal replacement therapy (CRRT) 632Reference material 632Procedure guidelines: Peritoneal dialysis 633Problem solving 635Procedure guidelines: Preparation of equipment

for CVVHDF utilizing a CVVHDF device 637Procedure guidelines: Commencement of CVVHDF 638References and further reading 639

37 Respiratory therapy 641Reference material 641Continuous positive airway pressure (CPAP) 647Reference material 647Procedure guidelines: Pre-continuous positive

airway pressure (CPAP) 650Procedure guidelines: Setting up continuous

positive airway pressure (CPAP) 651Procedure guidelines: Humidification 652Problem solving: Oxygen therapy by nasal

cannulae or oxygen mask 652Problem solving: CPAP 653References and further reading 655

38 Scalp cooling 656Reference material 657Procedure guidelines: Scalp cooling 659Problem solving 660References and further reading 661

CONTENTS ix

39 Specimen collection for microbiological analysis 663Reference material 663Procedure guidelines: Specimen collection 668Procedure guidelines: Analysis of drug levels

in blood 674References and further reading 675

40 Spinal cord compression management 677Reference material 677Procedure guidelines: Care of patients with

spinal cord compression 680Problem solving 685References and further reading 686

41 Tracheostomy care and laryngectomy voice rehabilitation 688Tracheostomy care 688Reference material 689Laryngectomy voice rehabilitation 695Reference material 695Procedure guidelines: Changing a tracheostomy

dressing 698Procedure guidelines: Suctioning a patient with

a tracheostomy 698Humidification 700Procedure guidelines: Humidification 700Procedure guidelines: Changing a tracheostomy

tube 700Problem solving 702Procedure guidelines: Changing a Blom–Singer

type non-indewelling voice prosthesis 703References and further reading 703

42 Transfusion of blood, blood products andblood substitutes 705Reference material 705Problem solving 716References and further reading 717

43 The unconscious patient 719Reference material 720Procedure guidelines: Care of the unconscious

patient 721References and further reading 723

44 Vascular access devices: insertion and management 724Reference material 724Peripheral cannulae 729Reference material 729Midline catheters 733Reference material 733Central venous access devices 734Peripherally inserted central catheters 735Reference material 735Short-term percutaneous central venous

catheters (non-tunnelled) 737Reference material 737Skin-tunnelled catheters 739Reference material 740

Implantable ports 742Reference material 742Discharging patients home with a VAD in situ 743Quality of life issues: living with a VAD 744Procedure guidelines: Inserting a peripheral

cannula 745Procedure guidelines: Inserting a midline

catheter 746Procedure guidelines: Insertion and removal

of a peripherally inserted central catheter (PICC) 748

Procedure guidelines: Changing the dressing on a central venous catheter insertion site 750

Procedure guidelines: Maintaining patency ofa central venous access device 751

Procedure guidelines: Taking blood samples from a central venous access device 752

Procedure guidelines: Unblocking an occluded catheter 754

Procedure guidelines: Insertion and removal of non-coring needles in implantable ports 756

Procedure guidelines: Removal of a non-skin- tunnelled central venous catheter 758

Procedure guidelines: Surgical removal of a skin-tunnelled central venous catheter 758

Problem solving 761Arterial cannulae 763Reference material 763Procedure guidelines: Setting up the monitoring

set and preparation for insertion of an arterial cannula 765

Procedure guidelines: Taking a blood sample from an arterial cannula 766

Procedure guidelines: Removal of an arterial cannula 768

Problem solving 768References and further reading 769

45 Venepuncture 774Reference material 774Procedure guidelines: Venepuncture 779Problem solving 782References and further reading 784

46 Violence: prevention and management 786Reference material 787Procedure guidelines: Prevention and

management of violence 792References and further reading 794

47 Wound management 796Reference material 796Leg ulceration 810Reference material 810Pressure ulcers or decubitus ulcers 812Reference material 812Fungating wounds 818Reference material 818

CONTENTSx

Radiotherapy skin damage 822Reference material 823Plastic surgery wounds 825Reference material 825Scarring 826Reference material 826Procedure guidelines: Changing wound

dressings 827Procedure guidelines: Removal of sutures, clips

or staples 828Procedure guidelines: Drain dressing (Redivac –

closed drainage systems) 829Procedure guidelines: Change of vacuum

drainage system 829Procedure guidelines: Removal of drain

(Yeates vacuum drainage system) 830

Procedure guidelines: Shortening of drain (Penrose, etc., open drainage systems) 831

Procedure guidelines: Prevention of pressure ulcers 831

Procedure guidelines: Sharp debridement 832Procedure guidelines: VAC ATS dressing 833References and further reading 835

AppendicesAppendix 1: Contributors to previous

editions 843Appendix 2: Patient information

booklets 845

Index 847

CONTENTS xi

Quick reference to the guidelines

Abdominal paracentesis 46AIDS in a general ward 86Arterial cannula

removal 768setting up the monitoring set and

preparation for insertion 765taking a blood sample 766

Aseptic technique 57

Bed bathing a patient 584Bladder

continuous irrigation 281lavage 278

Blom–Singer type non-indwelling voice prosthesis: changing 702

Blood glucose monitoring 477Blood pressure 454Bone marrow

aspiration and trephine biopsy 376harvest 378

Breast aspiration 153

Cannula, peripheral, insertion 745Cardiopulmonary resuscitation 165Catheter

administering a maintenance solution 280insertion midline 746unblocking occluded 754

Central venous access deviceblood sampling 752maintaining patency of access device 751

Central venous catheterizationchanging a dressing on insertion site 750insertion and removal of non-coring

needles in implantable ports 756inserting a peripherally inserted

central catheter (PICC) 748non-skin tunnelled central venous catheter 758

Central venous pressure: reading 480Chest drain insertion 384Chest drain removal 388Chronic pain chart: using 509Compression bandaging: standard multilayer 356Continuous positive airway pressure (CPAP)

pre-CPAP 650setting up 651

Continuous venovenous haemodiafiltation (CVVHDF)

commencement 638Cytotoxic drugs

intraperitoneal instillation 253intravenous administration 236intravesical instillation 250management of extravasation 242protection of environment 230protection of staff 233

Digital rectal examination 297Discharge planning 179, 533Drain

change of vacuum drainage system 829dressing (Redivac – closed drainage systems) 829removal (Yeates vacuum drainage system) 830shortening (Penrose, etc., open drainage systems) 831

Drug administration continuous infusion 213direct injection, bolus or push 218enteral feeding tubes 436injections 205intermittent infusion 215intrapleural drugs 248oral 203other forms 211rectal and vaginal 210self-administration 201topical application 211

QUICK REFERENCE TO THE GUIDELINESxiv

Drug levels in blood: analysis 674

ECG, 12 Lead 446Elastic compression garments: application 355Enemas: administration 293Enteral feeding tube, unblocking 437Entonox administration 516Epidural analgesia

complications 527insertion of an epidural catheter 525postinsertion monitoring of respiratory

and cardiac function in chronic pain management 531

preinsertion management, for chronic pain 530removal of an epidural catheter 529side-effect management 526topping up 528

Epidural exit site dressing change 530Epidural infusions

discharge planning 533setting up (utilizing an ambulatory pump) 532setting up (utilizing a syringe pump or driver) 532side-effects 526

Eye careartificial eyes 563contact lenses 565drops: instillation 566irrigation 568ointment: instillation 567swabbing for comatose patients 563swabbing 562

Gene therapy: care of patient 367

Hand washing 58Hepatitis

A 102B 106non-A non-B 110

Humidification 652, 700

Infusion devisessubcutaneous administration of drugs

using a syringe driver 270preparation of the syringe for

24-hour drug administration 270priming the infusion set 271inserting the winged infusion set or cannula 271

Interstitial perineal template (Hammersmith hedgehog) 606

Intraoperative care 542Intraperitoneal drain: removal

(short term) 47

Iodine-131 care of patient before administration 620care of patient receiving mIBG treatment 620care of patient receiving thryoid treatment 620emergency procedures 624

Jejunostomy feeding tube care 435Last offices 392

requirements for people of different religious faiths 396Limb volume: calculation 351Lumbar puncture 405

Mouth care 575Moving and handling of patients 418

Nasogastric intubation with tubes using an introducer 430without using an introducer, e.g. a Ryle’s tube 432

Neurological observations and assessment 492Nursing the neutropenic patient 78

Patient assessment and preparation before surgery: optimizing pain control 509

Peak flow reading using manual peak flow meter 463Percutaneous endoscopically placed

gastrostomy (PEG) tube care 433Peritoneal dialysis 633Postanaesthetic recovery 544Postoperative recovery 549Preoperative care 538Preparation of

equipment for CVVHDF utilizing a CVVHDF device 637

the syringe for 24-hour drug administration using the Sims Graseby Medical MS26 syringe driver 270

Pressure ulcers: prevention 831Priming the infusion set 271Pulse oximetry 461Pulse 446

Radiologically inserted gastrostomy (RIG) tube care 435Reagent sticks 473Rectal lavage: administration 300

Scalp cooling 659Sealed radioactive source therapy

breast 606gynaecological 601gynaecological caesium and iridium wires, removal 601insertions 597intraoral sources 600radioactive seeds 605

Selectron applicator removal 604

QUICK REFERENCE TO THE GUIDELINES xv

Selectron treatment: care of patient 603Self-catheterization 311Seroma drainage 156Sharp debridement 832Source isolation 70Specimen collection 668Spinal cord compression 680Stoma bridge or rod: removal 326Stoma care 324Suppositories: administration 295Sutures, clips or staples: removal 828

Temperature 469Tracheostomy

dressing change 698suctioning 698tube change 700

Unconscious patient: care 721

Unsealed radioactive source therapycare of patient after administration 621care of patient receiving therapy for diagnostic investigations 623

Urinary catheterization 335bag emptying 342collecting a specimen of urine 341intermittent self-catheterization 339removal 343

Urinary drainage tubes: flushing of 312Urine

collection of a specimen of urine from an ileal conduit or urostomy 325

Vacuum assisted closure (VAC) dressing change 833

Venepuncture 779Violence: prevention and management 792Wound dressing change 827

Edited byLisa Dougherty, RN, RM, Onc Cert, MScNurse Consultant Intravenous Therapy,The Royal Marsden Hospital

Sara Lister, RN, PGDAE, BSc (Hons), MScAssistant Chief Nurse/Head of School, The Royal MarsdenHospital School of Cancer Nursing & Rehabilitation,The Royal Marsden Hospital

Contributors Karen Allen, RN, ENB 998, BSc (Hons) Cancer NursingSenior Staff Nurse – Smithers Ward (CHAPTER 33)

Emma Allum, RN, BN (Hons)Senior Staff Nurse – Wiltshaw Ward (CHAPTER 34)

Sarah Aylott, RN, BSc (Hons) Cancer NursingFormerly Practice Development Facilitator

(CHAPTER 24)

Amanda Baxter, RN, RMN, Onc Cert, BSc (Hons)Clinical Nurse Specialist – Pelvic Care

(CHAPTERS 12, 13, 14, 15, 16)

Rachel Bennett, RN, ENB 998, 934, A11,BSc (Hons) Cancer NursingFormerly Ward Sister – Wilson Ward (CHAPTER 25)

David Brighton, RN, BSc (Hons) Cancer NursingProfessional Development Facilitator (IT) (CHAPTER 25)

Susannah Button, RN, Cert Couns, Onc Cert, BSc (Hons)Cancer NursingFormerly Ward Sister – Ellis Ward (CHAPTER 6)

Neve Carter, RN Onc Cert,BSc (Hons) Nursing StudiesSenior Staff Nurse – Horder Ward and Practice Development Facilitator (CHAPTER 21)

Anne Chandler, RN, Onc Cert, BSc (Hons) Nursing Studies,MSc Pain ManagementClinical Nurse Specialist in Pain Management

(CHAPTERS 27, 28, 29)

Belinda Crawford, RN, BSc (Hons), PostgraduateNeurosciences Course (NZ) Matron – Neurointensive Care,Atkinson Morley Hospital (CHAPTERS 26, 40)

Shelley Dolan, RN, BA (Hons) English,MSc Cancer Care, ENB 100, Onc CertNurse Consultant Cancer – Critical Care

(CHAPTERS 25, 36)

Lisa Dougherty, RN, RM, Onc Cert, MScNurse Consultant Intravenous Therapy

(CHAPTERS 10, 11, 38, 44)

Ann Duncan, RN, Onc Cert,ENB 931, 901, 998Ward Sister – Smithers Ward (CHAPTER 33)

Stephen Evans, BSc, MSc, MIPEM, MSRPRadiation Protection Adviser,Physics Department (CHAPTERS 34, 35)

Emma Foulds, RN, ENB 264, 998, PGC (Management),PATHE, MALecturer Practitioner, The Royal Marsden Hospital Schoolof Cancer Nursing & Rehabilitation

(CHAPTER 30)

Tracey Gibson, RN, ENB 100, 998, 237,Diploma in Nursing Senior Staff Nurse – Critical Care Unit (CHAPTER 7)

Aileen Grant, RN, Onc CertStaff Nurse – Children’s Unit (CHAPTER 35)

Contributors to sixth edition

Jagdesh Grewal, RN, ENB A13, 188, City & Guilds 7307,BA (Hons) Health Studies, PG Dip Nurse EducationSenior Sister Theatres (CHAPTER 30)

Douglas Guerrero, RN, DN, ENB 930, 998, Onc Cert,Counselling Cert, BSc (Hons), MSc Clinical NeurosciencesClinical Nurse Specialist – Neuro-oncology

(CHAPTERS 26, 40)

Shujina Haq, BSc (Hons), MBBS, DRCOG, DCH, MRCGPSpecialist Registrar – Occupational Health (CHAPTER 10)

Sarah Hart, RN, FETC Oncology, HIV Infection ControlCert, MSc, BSc(Hons) Biological Science (Immunology),MSc Research and Development Clinical Nurse Specialist – Infection Control/RadiationProtection (CHAPTERS 4, 5, 18, 34, 35)

Patricia Hunt, RN, Palliative Care Cert, MSc AdvancedClinical Practice (Cancer Nursing)Clinical Nurse Specialist, Palliative Care/Lecturer Practitioner, The Royal Marsden Hospital Schoolof Cancer Nursing & Rehabilitation (CHAPTER 43)

Lorraine Hyde, RN, Onc Cert, ENB 998, 934, Diploma inProfessional Nursing Studies, BSc (Hons) NursingSenior Sister – Day Care Services (CHAPTER 10)

Betti Kirkman, RM, RN, BScFormerly Clinical Nurse Specialist – Breast Diagnostic Unit (CHAPTER 6)

Glynis Knowles, RCN, SCM, Onc CertSenior Staff, Breast Care – OPD Sutton

(CHAPTER 31)

Diane Laverty, RN, Onc Cert, BScClinical Nurse Specialist – Palliative Care

(CHAPTERS 11, 27, 47)

Maria Law, RN, Onc CertWard Sister – Kennaway Ward

(CHAPTER 3)

Susan J. Lee, RN, MBA, MScFormerly Occupational Health Manager

(CHAPTER 23)

Sally Legge, RN, Onc Cert, MScClinical Nurse Specialist – GI Cancer

(CHAPTER 3)

Sara Lister, RN, PGDAE, BSc (Hons), MScAssistant Chief Nurse/Head of SchoolThe Royal Marsden Hospital School of Cancer Nursing & Rehabilitation (CHAPTERS 1, 9)

Philippa A. Lloyd, RN, ENB 237, 998, BSc Nursing,BSc Cancer NursingSenior Staff Nurse – Wiltshaw Ward (CHAPTER 15)

Jane Machin, BA (Hons), DipCCS, Reg MCSLT, DALFSpecialist Speech and Language Therapist

(CHAPTER 41)

Hazel Mack, RN, ENB 931, BSc (Hons) Psychology, Post-grad Dip Onc, MSc Cancer CareFormerly Acting Ward Sister – Horder Ward

(CHAPTER 21)

Elizabeth MacKenzie, RN, ENB 100,ENB 237, 998 Teaching and Assessing, BSc (Hons) Human Physiology Sister – Critical Care Unit (CHAPTERS 20, 37)

Jean Maguire, RN, ENB 998, Diploma Palliative CareNursing, BSc Hons Respiratory NursingWard Sister/Specialist Sister for Lung Cancer (CHAPTERS 20, 33)

Chris McNamara, RN, ENB 237, 937, N23, 998,BSc (Hons) Cancer Nursing, MScTeaching Charge Nurse, The Royal Marsden Hospital School of Cancer Nursing & Rehabilitation (CHAPTER 25)

Lisa Mercer, RD BSc MNutriDiet Senior Dietitian (CHAPTER 24)

Wayne Naylor, RN, ENB 237, Dip Nurs,BSc (Hons) Cancer NursingClinical Nurse Specialist, Wellington Cancer Centre,Wellington, New ZealandFormerly Wound Management Research Nurse,The Royal Marsden Hospital (CHAPTER 47)

Liz O’Brien, RN, SEN, FETC, DPSN,BSc (Hons)Nursing, BSc (Hons)Specialist Practice District NursingClinical Team Leader, District Nursing,Croydon Primary Care Trust (CHAPTER 8)

Emma Osenton, RN, BSc (Hons) Cancer NursingWard Sister – Wiltshaw Ward (CHAPTER 16)

Evelyn Otunbade, RN, BSc (Hons) Occupational Health and SafetyBackcare Adviser (CHAPTER 23)

Buddy Joe Paris, RN, BSc (Hons)Staff Nurse – Critical Care Unit (CHAPTER 41)

Gillian Parker, RN, ENB 237, 980, 100, 998,Onc Health Studies Diploma, BSc Senior Staff Nurse – Burdett Coutts Ward (CHAPTER 16)

CONTRIBUTORS TO SIXTH EDITIONxviii

Rachelle Pearce, RN, ENB 980, 998,BSc Cancer NursingFormerly Sister – Medical Day Unit (CHAPTER 14)

Emma Pennery, RN, ENB A11, 931,Counselling Cert, MScFormerly Senior Clinical Nurse Specialist/HonoraryClinical Research Fellow (CHAPTER 6)

Joanne Preece, BSc (Hons), MIOSH, RSP, MBAFormerly Head of Risk Management (CHAPTER 18)

Ffion M. Read, RN, Onc CertSenior Staff Nurse – Medical Day Unit (CHAPTER 44)

Elizabeth Rees, RN, Onc Cert, BSc (Hons) Cancer NursingFormerly Research Nurse Palliative Care (CHAPTER 1)

Francis Regan, RN, BSc (Hons) Cancer NursingFormerly Senior Staff Nurse – Burdett Coutts Ward (CHAPTER 13)

Jean Maurice Robert, RN Dip HE Staff Nurse – Critical Care Unit (CHAPTER 29)

Corinne Rowbotham, RNSenior Staff Nurse – IV Services (CHAPTER 44)

Patricia Ryan, RN, BN (Bachelor of Nursing), Onc CertSenior Sister – Haemato-oncology Unit (CHAPTER 42)

Mave Salter RN, NDN (Cert), Onc Cert, Cert Ed., DipCouns, BSc (Hons) Nursing, MSc Research and EvaluationClinical Nurse Specialist – Community Liaison

(CHAPTER 8)

Neelam Sarpal, RN, ENB 237, 998, 934, N23,BSc Cancer NursingTeaching Sister, The Royal Marsden Hospital School ofCancer Nursing & Rehabilitation (CHAPTERS 9, 11)

Steve Scholtes, RN, ENB 998, 980, BSc Cancer NursingCharge Nurse – Burdett Coutts Ward (CHAPTERS 12, 14)

Kate Scott, RN, RMN, Onc Cert, Counselling Cert,ENB 870, 998, BSc (Hons) Nursing StudiesClinical Nurse Specialist – Psychological Care

(CHAPTER 46)

Clare Shaw, RD, BSc (Hons), Dip in Dietetics, PhDConsultant Dietitian (CHAPTER 24)

Caroline Soady, RN, BSc (Hons) Cancer NursingClinical Nurse Specialist – Head & Neck

(CHAPTERS 24, 31, 32, 41, 47)

Moira Stephens, RN, Onc Cert, ENB 934, C&G 7306,DPSN, BSc (Hons) Health Studies, MSc AdvancingProfessional Health Care PracticeClinical Nurse Specialist – Haemato-oncology

(CHAPTERS 19, 22)

Anna-Marie Stevens, RN, RM, BSc (Hons), Onc CertClinical Nurse Specialist – Palliative Care

(CHAPTER 43)

Rebecca Verity, RN, BSc (Hons) Nursing Studies, MScAdvanced Practice (Cancer Nursing)Formerly Senior Staff Nurse – Bud Flanagan Ward

(CHAPTER 39)

Chris Viner, RN, Onc Cert, FETC, MSc in Advanced Clinical PracticeClinical Nurse Specialist – Ambulatory Chemotherapy

(CHAPTER 44)

Jen Watson RN, ENB 100Sister – Critical Care Unit (CHAPTER 44)

Caro Watts, RGN, Dip Onc, Cert Mgt (OU), BSc (Hons),MScSenior Sister – Private Patients (CHAPTER 13)

Clare Webb, BN (Hons), RGN, District Nursing Cert,Postgraduate Diploma in Therapeutic Counselling(Integrative)Specialist Sister in Psychological Care (CHAPTER 2)

Barbara Witt, RNNurse Phlebotomist (CHAPTER 45)

Miriam Wood, RN, Onc Cert, BSc (Hons) Senior Practice Development Facilitator (CHAPTER 2)

Mary Woods, RN, Onc Cert, BSc (Hons), MSc AdvancedPractice NursingClinical Nurse Specialist/Head of Lymphoedema Services (CHAPTER 17)

CONTRIBUTORS TO SIXTH EDITION xix

Foreword to sixth edition

The Royal Marsden Hospital Manual of Clinical NursingProcedures has become a legend. When I look back atthe first edition, an internally produced proceduremanual just for use at The Royal Marsden, it is quiteamazing to think that ‘the manual’ has become such animportant source for nurses everywhere. The fifthedition, in particular, has enjoyed enormous success.This may be because of the nursing profession’sgrowing interest in evidence-based practice and clinicalgovernance, but regardless of the rationale we areconfident this work makes a significant contribution toimproving the quality of patient care.

There have been a number of major conceptualchanges in the development of this new edition. First,we undertook a major evaluation and market researchexercise before embarking on the development of thesixth edition. This involved practitioners from the UKand abroad, many of whom had views about thecontent and structure of the manual. As a result,numerous changes have been made and I would like totake this opportunity to thank everyone who hashelped us by contributing comments and suggestions.

Secondly, we believe that this book should not onlybe a way of The Royal Marsden sharing good practice,but that its publication should also present develop-mental opportunities for our staff. You will notice thatin this edition we have, for the first time, partneredexperienced nurse-authors with new authors, mostlystaff nurses, to write chapters. This not only providesstaff nurses with structured and developmental writingexperience, but also means that the content is groundedin the realities of current day-to-day nursing practicefrom the perspective of staff nurses.

Thirdly, we have had a number of requests fromnurse leaders and educators to present the informationcontained within the sixth edition in different ways,such as on a CD-ROM, in a ring-binder format and onprompt cards for use in skills laboratories. The editorshave worked tirelessly to ensure that these differentresources will now be available.

The benefits of ensuring that nursing care is, wherepossible, evidence based and consistent are well docu-mented and I believe that The Royal Marsden HospitalManual of Clinical Nursing Procedures helps us to dothis. However, of equal importance is ensuring that thenursing care we provide is individual, therapeutic,culturally sensitive and that it is centred on that specialrelationship between the nurse, the patient and theirloved ones and the partnership that develops betweenthem. It would be almost impossible to write aprocedure on creating an environment in which thissort of nursing practice could flourish. Creating a pro-fessional practice model, such as this, and an environ-ment in which nurses can think critically, is theresponsibility of all nurses.

The sixth edition is the product of an enormousamount of effort by nurses and other staff throughoutThe Royal Marsden Hospital, especially the editors Lisa Dougherty and Sara Lister. As always, it is withmany thanks and great pride, that I am able to supporttheir work.

Dr Dickon Weir-Hughes,Chief Nurse/Deputy Chief Executive

The Royal Marsden Hospital (London & Surrey)

Acknowledgements

In 1984 the first edition of The Royal Marsden HospitalManual was published, thanks to the vision andsupport of Robert Tiffany, the then Director of PatientServices and Phylip Pritchard, the first editor. Over thenext 20 years, the Manual has developed going fromstrength to strength. This process was aided by theinnovation and enthusiasm of former editors such as:Jennifer Hunt, Jill David, Valerie Anne Walker, ChrisBailey and Jane Mallett.

This edition introduces many new authors, some ofwhom are contributing for the first time. There havebeen changes in the structure of some of the chapters aswell as a new layout to increase the readability of thetext. Each chapter represents not only nursing in theory,but also nursing in practice. Staff at all levels wereencouraged to contribute, and to review and reflect onhow the procedures were used in their own areas withthe aim to make the practical aspects truly user friendly.

The chapters also rely on the authors’ appraisal of theliterature, national recommendations such as NationalInstitute for Clinical Excellence (NICE), local guide-lines, benchmarking and audit, as well as utilizing theauthors’ wealth of expertise and experience.

We extend our thanks to all those who wrote,reviewed and contributed to the text and the proced-ures. We would also like to thank all those who took the time to write to us and highlight sections that mayhave been unclear or incorrect – we have responded toall suggestions and made changes as appropriate.

Finally our thanks go to Griselda Campbell atBlackwell Publishing for advice and continual supportin all aspects of the publishing process.

Lisa DoughertySara Lister

Editors

There is an expectation from patients that the nursing carethey receive will be based on the best available evidence.Clinical procedures are a fundamental aspect of nursingcare so it is essential that they are evidence based. This sixthedition of The Royal Marsden Hospital Manual of ClinicalNursing Procedures includes the clinical procedures, andthe latest evidence underpinning the fundamental nursingcare of any sick adult, whatever their diagnosis.

The findings from a survey of readers, particularly stu-dent nurses, informed the writing of this edition. Therewere a number of requests for additional chapters relatingto a broad variety of aspects of nursing practice. We con-sidered all of these and have included those that relate tothe clinical expertise or practice of nurses within The RoyalMarsden NHS Trust, an international cancer hospital.

A different approach has been taken to the preparationof the sixth edition of this manual: led by clinical experts,nurses in clinical practice have been involved in review-ing the latest evidence and testing the revised procedures in practice. This has provided professional developmentopportunities for junior staff and practical experience ofidentifying and then implementing evidence in practice.We hope that it has also acknowledged and recognized thatimportant aspect of generating evidence in nursing: usingthe evidence that comes from practice (Kitson et al. 1998).

All chapters have been reviewed and some expanded toencompass new material including the legislative changesthat have impacted on nursing roles. Context of care(Chapter 1) explores the concept of clinical governance inrespect of clinical nursing practice, and includes anexpanded section about the consent to examination andtreatment in light of the NHS Reform and Health CareProfessions Act (2002). A new chapter, Communication andassessment (Chapter 2), looks in depth at the process ofpatient assessment, emphasizing its importance in relationto carrying out clinical nursing procedures. Aseptic tech-nique (Chapter 4) now includes a procedure for hand wash-ing. Breast care (Chapter 6) now incorporates a sectionabout seroma drainage. Drug administration (Chapter 9)includes an expanded section on nurse prescribing.Central venous pressure measurement has been moved to

Observations (Chapter 25); a section on peak flow meas-urement has also been added to this chapter.

In this edition the chapters have been reorganized,grouping together those addressing similar aspects of care:Drug administration; Elimination; Observations; Painmanagement and Personal hygiene, with the intention thatinformation can be found more easily.

This edition continues the work that began 20 years ago,providing a practical resource for nursing practice. Theformat follows that of the preceding editions with only afew changes.

Every chapter begins with definition: this conciselydefines the aspect of care addressed by the chapter.

This is followed by a reference material section consist-ing of a review of the literature and other relevant material.If available, the related research findings have been pre-sented. If there is no research evidence available the proced-ures have been based on experience and systematic reviews.

The procedure guidelines begin with a list of the equip-ment needed, followed by a detailed step-by-step accountof the procedure and the rationale for the proposed action.All relevant procedures begin with the action ‘Explain anddiscuss the procedure with the patient’, the rationale forthis being ‘to ensure the patient understands the procedureand gives his/her valid consent’. Gaining consent is anintegral part of the person-focused approach to care, a coreprinciple of nursing practice at The Royal MarsdenHospital. This is discussed further in Chapter 1.

Some chapters also include a problem-solving section.This lists the problems that may occur with a procedure,their possible causes and suggestions for their resolutionand prevention.

The references and further reading at the end of thechapter indicate the sources from which information hasbeen drawn to write the reference material and develop theprocedures. It is also available to assist the reader if theywant to study the subject in more depth. The further read-ing lists have been substantially revised for this edition;only publications from the past 10 years have beenincluded, unless they are seminal texts or the only materialavailable.

Introduction

This book is intended as a reference and resource, not areplacement for practice-based education. None of theprocedures in this book should be undertaken withoutprior instruction and subsequent supervision from anappropriately qualified and experienced professional.

We hope that The Royal Marsden Hospital Manual ofClinical Nursing Procedures will continue to be a resourceand be a contribution to ‘continually improving the overallstandard of clinical care, whilst reducing variations in out-comes … as well as ensuring that clinical decisions arebased on the most up to date evidence of what is known tobe effective’ (NHSE 1999, p. 3).

ReferencesKitson, A., Harvey, G. & McCormack, B. (1998) Enabling the

implementation of evidence based practice: a conceptual frame-work. Qual Health Care, 7(3), 149–158.

NHS (2002) NHS Reform and Health Care Professions Act. HMSO,London.

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

Lisa DoughertySara Lister

Editors

INTRODUCTIONxxvi