The things your hands have to be able to do
Everything else in this library is knowledge. This is the subject where a pair of hands has to do something to a person who is frightened, in a room that is too busy, with equipment that may not be the equipment you practised on. Skills are what nursing is judged on in practical examinations and what patients experience directly — a cannula placed once instead of four times, a catheter passed without injury, a dressing that does not hurt, a wash that leaves somebody feeling human. This manual cannot teach a skill, and it says so repeatedly. What it can do is explain why each step exists, which is the part most often skipped and the part that determines whether the skill survives contact with a situation that is not the textbook one.
Every clinical skill has a manual part, a knowledge part and a relational part, and the manual part is the easiest of the three. Knowing why a step exists lets you adapt when the equipment differs; knowing how to talk to the person determines whether they let you near them and whether they will come back next time. Students concentrate almost entirely on the hands, and it is the part examiners weight least.
Being competent at a procedure on a mannequin, on a well patient, in daylight, with a mentor beside you is not the same as being competent alone at three in the morning on a frightened, dehydrated, confused patient with difficult veins. Competence is specific to conditions, and recognising which conditions you have not yet worked in is part of being safe rather than a lack of confidence.
Almost every step in a procedure exists because somebody was harmed when it was omitted. Cleaning a port before accessing it, checking a tube's position before using it, counting swabs, confirming identity — each has a history. Learning the reason rather than the sequence is what makes somebody able to improvise safely and unwilling to take the shortcut that looks harmless.
It cannot make you competent, and reading it may make you feel that it has. That combination — confidence without capability — is genuinely dangerous, and the correct use of this manual is as preparation for supervised practice and as explanation afterwards, never as a substitute for either.
Ask the person to state their own name and a second identifier rather than asking whether they are the named patient, because somebody unwell, hard of hearing or eager to co-operate will agree. Check against the band and the documentation. Bed numbers are not identifiers, and patients move.
Say what you are going to do, why, what it will feel like, and how long it takes, then ask. Consent is required for washing, moving, injecting and examining, not only for operations, and being in hospital does not supply it. Say explicitly that they can ask you to stop, and mean it, because that sentence is what makes the consent real.
Gathering equipment before starting is not tidiness; it is what prevents leaving a patient exposed, or a sterile field unattended, or a hand contaminated, while you go to find something. The time to discover a missing item is before the packet is open and before the person is undressed.
Most procedures that go badly were attempted at the wrong height, in poor light, with the patient in an awkward position because moving them felt like a delay. Adjusting the bed, closing the curtain, turning on a light and taking a moment to position the limb properly costs under a minute and changes the success rate substantially.
Hand hygiene before touching the patient, before the clean part of the procedure, and after — each of these protects a different person, and knowing which one you are performing makes the sequence far harder to forget. Gloves protect you and become contaminated themselves; they are not a substitute for cleaning hands before and after.
Pulse, breathing, blood pressure, temperature, oxygen saturation and conscious level are the standard set, and they are recorded together because they move together. A nurse who records them as boxes to fill has collected data; a nurse who reads them as a picture has assessed a patient, and the difference is visible in whether deterioration is noticed.
Breathing rate is the most sensitive early sign of deterioration and the observation most often estimated rather than counted. Count it for a full period, without announcing that you are doing it, because people who know their breathing is being watched change it. This is the highest-value minute in routine observation.
A cuff too small reads high, a cuff too large reads low, an unsupported arm reads high, an arm above heart level reads low, and a patient who has just walked in or is in pain reads high. Most of the abnormal readings that trigger repeat measurement are produced by one of these rather than by the patient.
A saturation probe on a cold finger, a temperature taken immediately after a hot drink, an automated pressure in a patient who is shivering — each produces a value that describes the measurement rather than the person. A result that does not fit the patient in front of you is a reason to look at the patient, not to record the number and move on.
Weight determines drug doses, fluid decisions and nutritional assessment, and it is routinely estimated, copied from a previous admission, or reported by a patient who last weighed themselves years ago. An estimated weight used for a dose calculation is a guess with a decimal point on it. Weighing on the same scales, at the same time of day, in similar clothing, is what makes a series of weights comparable — and a rapid change between two of them is water rather than tissue, which is one of the most useful pieces of information a ward can generate.
Aseptic technique keeps organisms away from a site that must not be contaminated — a wound, an insertion point, the inside of a device. Identifying which parts of the equipment are critical, not touching them, and keeping a clean field is the whole of it, and it is a discipline of sequence and attention rather than of expensive equipment.
Cleaning removes soil and must come first, because dirt shields organisms from anything applied afterwards. Disinfection reduces organisms to a safe level without reliably killing spores. Sterilisation destroys everything. What is required depends on what the item will touch — intact skin, a mucous membrane, or sterile tissue — and these three levels answer most questions about what to use.
A sterile field is contaminated by anything that touches it, by reaching across it, by turning your back on it, by liquid soaking through it, and by an edge that has drooped below the level of the surface. None of these are visible afterwards, which is exactly why the rules are rigid rather than a matter of judgement at the time.
Asepsis erodes under time pressure, in a cramped space, when something has been forgotten, and when somebody senior is waiting. These are predictable, which means the defence is preparation rather than willpower: everything gathered first, the space cleared, and a willingness to start again rather than continue with a field you are not sure about.
Into the skin, under it, into muscle, or into a vein — each reaches the bloodstream at a different speed and each requires a different depth, angle and volume. Giving an intramuscular injection into fat because the needle was too short delays absorption unpredictably, and giving a subcutaneous one into muscle can be painful and absorbed too fast.
Intramuscular sites are located by bony landmarks rather than by the appearance of a limb, because soft tissue varies enormously between patients while the skeleton's relative arrangement does not. The site on the side of the hip is preferred in many settings because large vessels and nerves lie further away; the thigh is used in infants because the muscle develops there early.
Every site is chosen as much for what is not under it as for what is. The nerve running around the upper arm is the reason the deltoid site sits well below the shoulder's bony point, and the sciatic nerve is why injections into the buttock are placed where they are. Knowing what is beneath is what makes the landmark meaningful rather than arbitrary.
Never recap, never pass a sharp hand to hand, bring the container to the point of use rather than carrying the sharp to the container, and never overfill it. Most sharps injuries happen during and after use, in those four situations, and they account for most of the achievable reduction.
Warning the person, positioning so the muscle is relaxed, using the right needle length, inserting briskly rather than slowly, injecting steadily, and not rubbing afterwards all reduce pain measurably. A person who has had a painful injection avoids the next one, which makes this a matter of future adherence and not only of kindness.
A vein that can be felt is better than one that can only be seen, straight is better than at a junction, forearm is better than the back of the hand for a cannula intended to last, and anything over a joint will be uncomfortable and will fail sooner. Spending two minutes choosing saves three attempts.
Warmth, gravity, a tourniquet that is not left on too long, hydration, and letting the arm hang all help. A cold, frightened, dehydrated patient has veins that are genuinely harder to access, and addressing that before attempting is more effective than technique. A tourniquet left on for minutes distorts the blood and the vein alike.
Two attempts is a common limit before asking somebody else, and it exists to protect the patient rather than to judge the nurse. Repeated attempts damage veins that may be needed for months, and each failure makes the next harder because the patient is more distressed. Asking for help early is a skill, not an admission.
Secure it so it cannot move, label it with the date, inspect the site rather than assuming it is fine under an old dressing, and ask daily whether it is still needed. A cannula nobody has looked at for three days is a cannula nobody is caring for, and it is one of the most direct routes into a patient's bloodstream.
The female urethra is short and straight; the male urethra is long, curved and passes through the prostate. This single difference explains why the technique differs, why resistance is met in men at a predictable point, and why force is never the answer — urethras are injured by people who push against resistance rather than pausing and reassessing.
A catheter balloon inflated while still in the urethra causes severe injury, which is why urine must be seen before inflating and why the catheter is advanced further than the point urine appears in men. This is one of the clearest examples in nursing of a step whose reason is a specific and serious harm.
Organisms travel into the bladder both through the tube and along its outside, and every disconnection is an opportunity. Keeping the system closed, the bag below bladder level and off the floor, and the tubing free of loops that trap urine, are the practices that reduce infection between insertion and removal.
Risk of infection rises with every day a catheter remains, so the single most effective intervention is removing it. Asking daily whether it is still needed prevents more harm than any refinement of insertion technique, and it costs nothing but the asking.
This procedure involves exposing and touching the most private part of somebody's body, frequently while they are frightened and in a room separated from others by a curtain. Explaining each step before it happens, covering what is not being worked on, and having a chaperone where appropriate are not optional refinements; they are what distinguishes a clinical procedure from an assault.
Size, depth, what the base looks like, the edges, the surrounding skin, exudate, odour and pain together describe a wound and its direction of travel. A dressing applied without that assessment records nothing, and a wound photographed or measured consistently over weeks tells you far more than any single impression.
Healing proceeds better in a moist environment than under a scab, which reverses the folk wisdom most patients arrive with. Dressings are chosen to manage moisture — adding it to a dry wound, absorbing it from a wet one — which is the main principle behind an otherwise bewildering array of products.
A wound is most vulnerable when it is open, and it is cooled and disrupted by every change. Dressings are changed when there is a reason rather than by routine, and where a dressing is left for several days that is usually a decision rather than neglect. Understanding this prevents it being undone by somebody being helpful.
Whether a wound closes depends on blood supply, nutrition, glucose control, smoking, pressure, infection and whether the person can manage it at home. Wound care that addresses only the wound has a poor record, which is why the nutrition and circulation chapters of other manuals in this library belong in this conversation.
What can the person do themselves, what equipment is needed, how many people are required, and what could go wrong. Most injuries to staff and patients happen during unplanned moves — catching somebody who is falling, an unexpected slide, a transfer attempted alone because help was not available. The assessment is the intervention.
Keep the load close, keep your back in line and bend at hips and knees, avoid twisting, plan the move and tell everybody including the patient what will happen, and move on an agreed count. These hold whether you have a hoist and a slide sheet or nothing at all, which is why they are principles rather than instructions.
A patient who knows what is happening and is asked to help with what they can manage is safer to move and retains capability. Moving somebody as an object is faster once and produces a person who can do less next week, which is how independence is lost during an admission that was meant to restore it.
Attempting a move that needs two people alone is how backs are injured and patients are dropped, and it happens because the alternative is leaving somebody uncomfortable. The honest position is that this is a staffing failure rather than a personal choice, that it should be recorded when it occurs, and that a nurse who is injured helps nobody.
A person left in one position develops pressure damage, stiff joints that shorten permanently, a chest that does not clear, and swelling in whatever is lowest. Changing position regularly addresses all four at once, and the interval is set by the individual's risk and by local policy rather than by a universal number. Every position has its own pressure points to protect and its own consequences — lying flat risks aspiration and makes breathing harder, sitting slumped shears the skin over the sacrum, and a limb left unsupported pulls at the shoulder it hangs from.
Washing somebody is the point at which skin is inspected, pressure areas are seen, pain is noticed, wasting becomes obvious, mood is observed and conversation happens. It is simultaneously the most delegated task and one of the richest assessments available, and a great deal of what is later discovered by investigation was visible during a wash.
Explain, uncover only the part being washed, keep the person warm, offer choices about order and water temperature, let them do whatever they can manage, and do not talk over them to a colleague. The details are small and the difference between being cared for and being processed is made of exactly these.
A dry, dirty mouth is uncomfortable, makes eating and speaking difficult, and supplies the organisms that cause pneumonia when aspirated. Mouth care is therefore an infection prevention measure rather than a comfort task, and it matters most in exactly the patients least able to ask for it — those who are nil by mouth, sedated, oxygen-dependent or dying.
A dry mouth causes far more distress in the last days of life than hunger or thirst do, and frequent meticulous mouth care relieves it in a way that fluids given into a vein do not. It can be taught to a family in a few minutes and gives them something real to do, which is itself part of the care.
Oxygen is prescribed, has a target range, and can cause harm at both extremes — too little, and tissue suffers; too much, and in particular patients it can reduce the drive to breathe and cause carbon dioxide to accumulate. Treating it as a comfort measure to be turned up when somebody looks breathless is a recognised source of harm.
Different masks and cannulae deliver very different concentrations, and some require a minimum flow to work at all or to prevent rebreathing. Using a device below its intended flow produces a patient receiving less than intended while everybody believes otherwise, which is a quiet and common failure.
Sitting a breathless patient upright, letting them lean forward on a table, and clearing an obstructed airway by position alone are interventions available immediately, without equipment, and before anything else arrives. In a patient with reduced consciousness, position is what protects the airway when the protective reflexes have gone.
Suction removes what a patient cannot clear and also causes hypoxia, trauma, and distress if applied for too long or too deep. It is done briefly, with pre-oxygenation where indicated, and on the way out rather than continuously, and it is a procedure where more is reliably worse.
A very large proportion of patients using inhalers do so incorrectly, which means a treatment recorded as given has not been delivered, and the usual response is to escalate the dose rather than to watch the person use it. Asking a patient to demonstrate their own technique takes a minute, routinely finds the problem, and is one of the highest-yield checks available in respiratory care. The same applies to nebulisers, where an inadequate gas flow, a poorly fitting mask or a device held away from the face quietly reduces the dose to a fraction of what was prescribed.
A feeding tube that has entered the airway rather than the stomach, and is then used, delivers liquid directly into a lung. The defence is a verification method that does not depend on how the patient looked, on whether they coughed during insertion, or on listening for a sound. Local policy specifies the method; following it without shortcut is the whole of the safeguard.
Position is confirmed before every use and after any episode of vomiting, coughing or displacement, not only at insertion. Tubes migrate, and a tube that was correct this morning may not be correct now, which is why confirmation is a repeated act rather than a single one.
Sitting the patient upright during and after feeding, keeping the equipment clean, flushing as directed, monitoring tolerance, and continuing mouth care for somebody who is no longer eating are the routine responsibilities. The mouth care is the one most often dropped, precisely because nothing is going into the mouth.
Feeding through a tube is distressing to families and frequently misunderstood in both directions — as a cure, or as giving up. Explaining what it is for, how long it may be needed, and what will be reviewed, is part of the procedure and is usually the part that determines how the family experiences the whole admission.
What was done, when, by whom, with what, how the patient tolerated it, and what the findings were. A record written for the next person to act on looks different from one written to discharge an obligation, and the difference is whether it contains what they would need.
The date a cannula, catheter or tube was inserted determines when it should be reviewed or changed, and an undated device is one nobody can make a decision about. This is a small administrative act that directly drives the infection prevention described in several chapters here.
Unsuccessful attempts, difficulty encountered, a patient who declined, and anything unexpected all belong in the record. A patient who has had four failed cannulation attempts is different from one who has had none, and the next person cannot know unless somebody wrote it.
What is due, what is overdue, what was difficult, and what the patient found distressing. Handing over only the tasks and not the experience means the next nurse repeats an approach that has already failed, which patients notice and resent considerably more than the original difficulty.
Right patient, right medicine, right dose, right route, right time — and, added later because they were repeatedly the missing step, right documentation and the patient's right to refuse. Each item on that list is on it because a patient was harmed when it was omitted, and reciting it without understanding which harm each prevents is how it becomes a ritual instead of a check.
Interruption during a medicine round is strongly associated with error, and nurses are interrupted continuously. Protecting the task — a designated area, a visible signal, or simply an agreement on the ward that the person doing the round is not approached — reduces errors because it changes the conditions rather than asking anyone to concentrate harder.
Most drug calculations a nurse performs are simple, and the errors are almost never arithmetic. They are decimal points, unit confusion, reading a concentration as a total, and working from a dose rather than from what is in the ampoule in front of you. Writing the calculation down and having somebody arrive at it independently catches these; agreeing with somebody else's working does not.
Administration is not the end of the task. Whether the medicine had the intended effect, whether it caused something unintended, and whether the patient can actually swallow or tolerate it are observations that belong to whoever gave it. A medicine recorded as given and never followed up has been documented rather than administered.
An adult with capacity may decline any medicine, and the response is to find out why — a side effect, a belief, a taste, a misunderstanding, a previous bad experience — then record the refusal and the reason and inform whoever needs to know. Concealing medicine in food without a documented decision process is a serious matter and not an individual nurse's judgement to make.
A laboratory reports on what arrives. A specimen taken from the wrong place, at the wrong time, into the wrong container, or left warm for hours produces an answer that treatment will then be based on. This is one of the clearest places where nursing technique directly determines a clinical decision, and it is frequently treated as an errand.
Specimens for culture are taken before antimicrobial treatment begins wherever possible, because even one dose can prevent the organism growing while leaving the patient infected. A negative result obtained after treatment started is not a true negative, and recording the timing is what allows anybody to interpret it honestly.
Sputum means what comes from the chest, not saliva. A wound swab is taken from the wound tissue after cleaning away surface debris, not from the crust. A urine sample intended to identify infection is collected so it is not contaminated on the way out. Each of these determines whether the laboratory examines the patient's problem or something irrelevant.
Samples are discarded every year because they are unlabelled, mislabelled or arrive too late, and each one means a patient sampled again or treated blindly. Labelling at the bedside from the patient's own identification, immediately after collection, is the final part of taking the specimen rather than paperwork that follows it.
Airway, breathing, circulation, disability, exposure — the order exists because it treats what kills fastest first, and because it prevents a frightened person fixing on the dramatic injury and missing the obstructed airway. Following it aloud also tells everybody else present what has and has not been assessed.
Recognise arrest, call for help and for the defibrillator, start compressions immediately, and interrupt them as little as possible. Compressions are the intervention with the clearest effect on survival and the one most degraded by hesitation, so beginning quickly and pushing hard and fast matters more than any refinement of technique.
An automated device analyses the rhythm and instructs, which means it can be used safely by somebody with minimal training, and hesitancy about using one costs lives. Knowing where the nearest one is, and that it is checked and charged, is a responsibility that belongs to whoever works in that area.
Most in-hospital arrests are preceded by hours of abnormal observations that were recorded and not acted on. The most valuable emergency skill is therefore not resuscitation but noticing the deterioration that precedes it, which is a skill exercised on ordinary shifts rather than in emergencies.
Sterility of anything entering a sterile space, the single use of needles and syringes, and the confirmation of identity and tube position cannot be compromised, because the harm they prevent is immediate and severe. Being clear about which rules are absolute is what allows sensible improvisation everywhere else.
Positioning, warmth, hydration, mouth care, pressure relief, wound cleansing with clean water, and almost all observation require little or no equipment. A great deal of effective nursing is available in a setting with nothing, and teaching it as though it depended on supplies leaves staff feeling helpless when the store is empty.
Where single-use items are reused out of necessity, the decision carries real risk and should be made openly as policy, with the risk recorded, rather than left to whoever is holding the item at the time. An individual nurse carrying that decision alone is a failure of the organisation rather than of the nurse.
Recording that a procedure was performed without a particular item, or that a device was unavailable, protects the patient and the nurse and is the only way the shortage ever becomes visible to anybody who can address it. A review concluding that staff needed more training when the ward had no gloves has recorded a falsehood.
Watch it done properly, have it explained step by step with reasons, practise it where a mistake costs nothing, perform it supervised, then perform it alone with somebody available. Skipping the middle stages produces people who have seen a great deal and can do very little, which is the commonest failure of busy placements.
Learners become competent by doing, and a mentor who takes over whenever it gets slow is protecting the schedule rather than the patient. The judgement is where the risk actually lies: allowing somebody to be slow is usually safe; allowing them to be unsupervised frequently is not.
Asking a colleague to watch you do something you are unsure about is a professional act, and the reluctance to ask is almost always about how it will look rather than about the patient. Nurses who ask early are safer and, in practice, are trusted more rather than less.
Being asked to perform a procedure you have not been trained and assessed for should be declined, and instruction from a senior person is not a defence in any jurisdiction. Regulators everywhere hold the individual accountable for practising within their competence, which makes this one of the few absolutes in this manual.
Assisting somebody to use a toilet, a commode or a bedpan, cleaning them afterwards, and managing incontinence is a large part of what nursing actually consists of and is almost absent from textbooks. It is also where dignity is most easily lost, where skin damage begins, and where patients form their lasting impression of whether they were treated as a person.
Patients delay asking for the toilet because they do not want to be a nuisance, then attempt it alone and fall, or wait too long and are incontinent and humiliated. Offering proactively and at regular intervals prevents both, and it is the single most effective fall-prevention measure available on most wards.
Skin exposed to urine or faeces breaks down quickly, and the damage is frequently recorded as pressure damage when it is a separate mechanism requiring a different response. Cleansing promptly and gently, drying properly, and protecting the skin matter more here than any dressing applied afterwards.
Immobility, dehydration, poor intake, unfamiliar surroundings, lack of privacy and several medicines all cause it, and it produces pain, confusion in older patients, retention of urine, and occasionally obstruction. Asking about bowels is not intrusive routine; in an unwell older patient it frequently explains the whole presentation.
Patients are embarrassed and will minimise or avoid the subject, so questions are asked plainly and without euphemism, in private, using words the person understands. A nurse who is uncomfortable with the vocabulary transmits it immediately, and the patient then withholds exactly the information that was needed.
Giving the wrong blood to the wrong patient can kill within minutes, and the error is almost always identification rather than laboratory science. Every step in the chain — sampling, labelling, collection, checking, administration — exists to test the assumption that the person in front of you is who you believe, and each one is a separate opportunity to catch it.
A large share of serious incidents begins when a tube is labelled away from the patient or from a form rather than from the person. Labelling at the bedside, from the patient's own stated identity and their band, immediately after taking the sample, is the defence, and it fails whenever tubes are carried elsewhere to be labelled.
Immediately before administration, identity is confirmed against the unit and the documentation at the bedside, with the patient stating their own name where able. A check performed at the desk, or from the notes rather than from the person, has verified the paperwork against itself and confirmed nothing about who is receiving the blood.
Serious reactions usually appear within the first minutes, which is why observation is closest at the start and the patient is not left alone then. Fever, chills, pain, breathlessness, a falling blood pressure, or a patient simply saying something feels wrong all mean stopping while it is assessed. Stopping and being wrong costs very little.
In practical stations a large share of the marks is for introducing yourself, explaining, gaining consent, hand hygiene, checking identity, maintaining dignity, safe sharps disposal and documenting — not for manual dexterity. Candidates who perform the task perfectly in silence lose marks they never knew existed.
Examiners cannot award marks for what they cannot observe, so narrating briefly — I am going to check your identity, I am cleaning my hands, I will now explain what this will feel like — both scores and is good practice. It also slows the candidate down, which improves the procedure itself.
Breaking asepsis, dropping something, or realising a step was missed is not automatically a failure. Stopping, saying so, and starting that part again scores better than continuing and hoping, because the behaviour being assessed is whether you would do the safe thing when nobody was watching.
Prepare everything first. Position the patient properly before starting. Ask them to state their name. Say what you are about to do before you touch them. Ask daily whether each device is still needed. These five cost almost nothing and account for most of the difference between a procedure that goes well and one that does not.