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 Clinical Nursing Skills
Basic to Advanced Skills
Ninth Edition

Sandra F. Smith, MS, RN

President, National Nursing Review; Los Altos, California

Donna J. Duell, RN, MS, PhD ABD

Consultant to Deans and Directors of Nursing; California

Barbara C. Martin, RN, BSN

Professor of Nursing, The University of Tulsa; Tulsa, Oklahoma

Michelle L. Aebersold, PhD, RN, FAAN

Clinical Associate Professor, Director Clinical Learning Center, University of Michigan
School of Nursing; Ann Arbor, Michigan

Laura Gonzalez, PhD, ARNP, CNE

Assistant Professor of Nursing, University of Central Florida; Orlando, Florida

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Acknowledgments

T
he authors express their thanks to the many people
who assisted with the editorial and production phases
of this edition of Clinical Nursing Skills, with special
thanks to Lisa Rahn, Nursing Editor, and the team at Lumina
Datamatics, Inc. We especially wish to thank our Develop-
mental Editor, Rachel Bedard, for support, guidance, and edi-
torial advice. We thank our contributors to this edition, Brian
Busk and Janis Laiacona. We also thank our photographer for
this edition, Patrick Watson, and the many models involved
in our most recent photo shoot. A huge thanks to Sharon
Decker and her assistant Marissa Cisneros at Texas Tech Uni-
versity Health Sciences Center in Lubbock, Texas, for their as-
sistance and the use of their wonderful facility for our photo
shoot. We appreciated your generous assistance and support
throughout the process.
Thanks to our families and friends for their e­ ncour-
agement and support while we were preparing this new ­edition.

v
Thank You
A special thank you to all of the nurse educators and practicing nurses who have
spent their time reviewing and contributing to this new edition.

CONTRIBUTORS TO CURRENT AND PREVIOUS EDITIONS

Theresa Britt, rn, msn Deborah Denham, rn, ms, phd Janis Laiacona, msn, rn, pmhcns-bc
Director of Nursing, Lab and Clinical Critical Care Director of Accreditation and Clinical
Assessment Sequoia Hospital Support, John Muir Behavioral Health
University of Tennessee Health Science Redwood City, CA Center, Concord, CA
Center Nursing Programs Assistant Director,
Memphis, TN
Jacqueline Dowling, rn, ms College of the Siskiyous
Professor, University of Massachusetts
Weed, CA
Brian Busk, msn, rn Lowell, MA
Faculty and Assistant Director of Nursing, Patricia J. Rahnema, rn, msn, fnp
College of the Siskiyous
Lou Ann Emerson, rn, msn Nurse Practitioner, Southwest
Assistant Professor, University of
Yreka, CA Cardiovascular Associates
Cincinnati
Bullhead City, AZ
Shirley S. Chang, rn, ms, phd Cincinnati, OH
Professor, Evergreen Valley College Sally Talley, rn
San Jose, CA
Rachel Faiano, rn, ms ET Specialist in Enterostomal Therapy
Clinical Simulation Coordinator, Salinas
San Jose, CA
Janet W. Cook, rn, ms Valley Memorial Healthcare System
formerly Assistant Professor, University Salinas, CA Jean O. Trotter, rn, c, ms
of North Carolina Assistant Professor, University of
Greensboro, NC Maryland
Baltimore, MD

REVIEWERS
Patricia Ahearn, bs, msn Cynthia M. Bork, edd, rn Victor Ching, md, mba, facs
Saint Peter’s University Winona State University Loma Linda School of Medicine
Jersey City, NJ Winona, MN Loma Linda, CA
Traci Ashcraft, bsn, rn, bc Staci M. Boruff, phd, rn Ann-Marie Cote, msn, rn, cen
Ruby Memorial Hospital Walters State Community College Plymouth State University
Morgantown, WV Morristown, TN Plymouth, NH
Lawrette Axley, phd, rn, cne Katherine Brashears Melissa Culp, msn-ed, bsn, rn
University of Memphis University of Central Oklahoma University of South Florida
Memphis, TN Edmond, OK Tampa, FL
Katherine Balkema, mm, bsn, ba, Cody Bruce, msn, rn Mary Davis, rn, msn, mpa, crni
rrt, rn, cmsrn Texas A&M Hartnell College
Holland Hospital Bryan, TX Salinas, CA
Holland, MI
Michelle Bussard, msn, rn, Michelle DeLima
Mitzi Bass, msn, rn ancs-bc, cne Delgado Community College
Baltimore City Community College Firelands Regional Medical Center New Orleans, LA
Baltimore, MD Sandusky, OH
Erin Heleen Discenza, msn, rn
Michelle Beckford, bsn, msn, dmh Barbara Callahan, med, rn, ncc, Cuyahoga Community College—
Saint Peter’s University chse Metropolitan
Jersey City, NJ Lenoir Community College Cleveland, OH
Kinston, NC
Billie E Blake, EdD, msn, bsn, rn Denise R. Doliveira, rn, msn
St. John’s River Community College Barbara Celia, edd, rn, msn Community College of Allegheny
Orange Park, FL Drexel University County—Boyce
Philadelphia, PA Monroeville, PA

vi
Bernadette Dragich, phd, rn Vicky Keys, msn, dnp Nancy Renzoni, rn, ms
Bluefield State College Texas A&M University Trocaire College
Bluefield, WV Bryan, TX Buffalo, NY
Mary Farrell, msn-ed, rn Susan M. Koos, ms, rn, cne Mark Reynolds, msn, rn
Huron School of Nursing Heartland Community College University of Alabama
East Cleveland, OH Normal, IL Huntsville, AL
Cindy Fong, rn, msn Cheryl M. Lantz, phd, rn Kathy Rogers, msn, rn, cne
Loma Linda Hospital Dickinson State University Ursuline College
Loma Linda, CA Dickinson, ND Pepper Pike, OH
Mary A. Gers, msn, cns, rnc Lori Lioce, bsn, dnp Shielda Glover Rodgers, phd, rn
Northern Kentucky University University of Alabama The University of North Carolina
Highland Heights, KY Huntsville, AL Chapel Hill, NC
Theresa A. Glanville, rn, ms, cne Carol List, rn, bsn Deanna Schaffer, msn, rn, cne,
Springfield Technical Community College Hutchinson Community College acns-bc
Springfield, MA Hutchinson, KS Drexel University
Philadelphia, PA
Jeanine Goodin, msn, bsn Rosemary Macy, phd, rn, cne, chse
University of Cincinnati Boise State University Vicki Simpson rn, msn, ches, phd
Cincinnati, OH Boise, ID Purdue University
West Lafayette, IN
Susan Growe, dnp, rn, coi Kathleen McManus, rn, msn, cne
Nevada State College Central Maine Community College Kristen Smith, msn, rnc-nc
Henderson, NV Auburn, ME Northern Michigan University
Marquette, MI
Jennifer Hatley, rn, msn Joshua Meringa, mpa, mha, bsn,
Vernon College rn, onc Charlotte Stephenson, rn, dsn,
Vernon, TX Spectrum Health Hospitals clnc
Grand Rapids, MI Texas Woman’s University
Katherine Houle, rn, bsn, cns Houston, TX
Gillette Children’s Specialty Healthcare Juleann H. Miller, rn, phd
St. Paul, MN St. Ambrose College Patricia Taylor, rn, msn ed
Davenport, IA Kapiolani Community College
Kathleen Hudson, rn, msn Honolulu, HI
Illinois Eastern Community College Patricia Novak, rn, bsn, msn
Olney, IL Gateway Community College Jennifer M. Thayer, ms, arnp,
New Haven, CT pnp-bc
Paula Hutchings, msn, rn University of South Florida
Hill College Linda Olsen, bsn, msn Tampa, FL
Lamar Hillsboro, TX Mid-State Technical College
Wisconsin Rapids, WI Elaine Tobias, rn, bsn, ibclc
Denise Isibel, rn, msn The Women’s Place at Heart of Lancaster
Old Dominion University Rebecca Otten, edd, ms, ba Regional Medical Center
Norfolk, VA Mount Saint Mary’s University
Lititz, PA
Los Angeles, CA
Kathleen C. Jones, msn, rn, cns Cheryl Tveit, rn
Walters State Community College Amanda Pierce, dnp, rn Gillette Children’s Specialty Healthcare
Morristown, TN Texas Tech University
St. Paul, MN
El Paso, TX
Fran Kamp, rn, msn Donna Woshinsky, rn, msn, cne
Mercer University Janice Ramirez, msn, bs, adn, Springfield Technical Community College
Atlanta, GA ccrn, rn-bc, cne
Springfield, MA
North Idaho College
Patricia Ketcham, msn, rn Coeur d’Alene, ID
Oakland University
Rochester, MI

PHOTO CONSULTANTS
June Brown, rn, bsn Cathy Patton, rn, bsn, ma Constance Troolines, rn, bsn
Arnold Failano, rn, bsn Diana Soria, rn, bsn Virginia Williams, rn, ms
Wendy Ogden, rn, ms

vii
Preface
O Ninth Edition Highlights
ur primary goal in writing Clinical Nursing Skills is
to produce a relevant, useful, and comprehensive
text that is flexible for various education programs
and learning needs of students. Clinical Nursing Skills, a
highly acclaimed skills book since its first edition in 1982,
applies to all levels of nursing education. It is also used as
a procedure manual by many hospital systems. Current
with both the National Council Test Plan for RN and the
NCLEX®, this textbook offers faculty a format for teaching
nursing skills content that is both progressive and innova-
tive. Content flows from basic to more complex skills and
teaches the student how to assess the client, formulate nurs-
ing diagnoses, perform the procedure according to accepted
and safe protocols, evaluate the outcomes, and document
pertinent data.
The content continues to be organized around the
nursing process and offers both a theoretical overview and
step-by-step practical skills. Within the chapters, skills are
grouped together into units. Nursing process data is then
provided for each unit. Unlike other skill textbooks, Clinical
Nursing Skills conceptualizes the nursing process data for
each unit so that it does not have to be repeated with ev-
ery skill. Each numbered skill includes a list of necessary
equipment, associated preparation, and step-by-step nurs-
ing interventions. Critical steps include relevant rationales
for nursing actions. This streamlined approach continues
with Unit Documentation and Evaluation, giving students
a feel for categories of skills and the similarities when doc-
umenting them. Units conclude with sets of Unexpected
Outcomes and Alternative Actions. These charts not only
provide more information for students, but they also rein-
force how evaluation can lead to further action within the
nursing process.
Chapter Wrap-Ups provide information specific to
the older adult population. They also supply Manage-
ment Guidelines for assistance in delegating tasks and in
maintaining appropriate interprofessional communica-
tion to support quality care. They offer Case Study Ap-
plications, a set of clinical scenarios for students to use to
practice decision making and planning. They provide 10
NCLEX® questions per chapter for student review, plus a
new QSEN activity to promote awareness and adherence
to nursing standards.
The clear, newly numbered format of the ninth edi-
tion enables the student to easily access key material for
immediate reference in the clinical area. Extensive color
photographs and drawings within each unit illustrate the
concepts presented and enable students to visualize steps
that must be performed.
viii
• New! Updated design for fast access to content and
­features!
• New! QSEN Activities to give students practice aligning
nursing care with QSEN standards.
• Expanded! Evidence-Based Nursing Practice boxes
­presenting specific scientific studies that validate the
skills protocols. Research studies emphasize new infor-
mation related to improving client care.
• More than 550 new and updated skills with the most
up-to-date nursing techniques recommended by current
standards of practice.
• Documentation and Evaluation, with succinct teach-
ing about each unit of skills. To give students a broader
understanding of how to document, Documentation
sections list data to record for each category of skills. They
compare Expected Outcomes with Unexpected Out-
comes and then offer Alternative Actions the nurse might
take when client goals are not met.
• Critical Thinking and the Nursing Process chapter
­integrating critical thinking into the steps of the nursing
process.
• New skills Determining Gastric pH and NovaCath
­Integrated IV System.
• Legal Alerts that help nurses recognize legal pitfalls and
actions that constitute legal malpractice when perform-
ing procedures.
• New Trends feature presenting equipment and systems
that are being incorporated in 21st-century nursing care.
• Practice Guidelines boxes, with attention to maintaining
standards of care.
• Case Study Applications at the end of each chapter to
help students apply critical thinking principles to clinical
situations.
• NCLEX® questions with rationales for all distractors.
Hallmark Features
Clinical Nursing Skills’ all-inclusive, clear, and concise format
teaches the student to:
• Learn each skill from basic to advanced in a contextual
framework.
• Understand the theoretical concepts that serve as a
­foundation for skills.

• Apply this knowledge to a clinical situation with a “­client
need” focus.
• Use critical thinking to assess and evaluate the outcome
of the skill and consider unexpected outcomes.
• Appreciate cultural diversity principles as they apply to
client situations.
• Validate clinical skills by applying evidence-based nurs-
ing practice data and studies.
• Function in, and adapt to, the professional role by under-
standing management responsibilities.
Educator Resources
• Instructor’s Manual, which provides teaching and learn-
ing strategies for lecture and lab, writing assignments
and activity suggestions, and critical thinking exercises
Preface ix
• Skills Checklists featuring editable checklists of proce-
dures found in each chapter
• Image library that showcases photos and art from the
textbook to enhance “in-the-moment” teaching
• Test Item File offering over 700 questions that you can
use to create assignments
• NCLEX®-style questions with complete rationales for
both correct and incorrect answers.
We believe faculty will find this textbook a valuable
teaching tool and reference for clinical practice.
The Only Skill Resource You’ll Need . . .
Complete Coverage of over 550 Skills in a Clear, Time-Saving Format!

Chapter 10
Vital Signs
Learning Objectives
10.1 Identify the cardinal signs that reflect the 10.10 Identify the characteristics of peripheral
body’s physiologic status. pulses.
10.2 List three mechanisms that increase heat
production.
10.11 Explain why the blood pressure cuff should
be the appropriate size for the client. Each chapter opens with Learning Objectives and
10.3 Explain how disease alters the “set point” of
the temperature-regulating center.
10.12 Define Korotkoff sounds in terms of phases. a Chapter Outline for easy reference and review
10.13 Identify four of the seven factors that affect
10.4 Define hypothermia and list the symptoms blood pressure. of chapter contents.
of this condition.
10.14 Demonstrate the method of palpating
10.5 Differentiate between the oral, rectal, systolic arterial blood pressure.
axillary, and tympanic methods of taking
10.15 Discuss conditions when vital signs may
temperature.
be delegated and when they would not be
10.6 Describe two nursing actions that can be delegated.
performed when temperature is not within Chapter 10 Vital Signs 255
10.16 Demonstrate the proper techniques for
normal range.
obtaining peripheral pulses.
Unit 10.1 Documentation and Evaluation ................ 271 Procedures ............................................................................. 284
10.7 Describe at least three different types of
64 pulse
Chapter
characteristics.
Describe the most effective method of
10.17Relationship
4 Communication and Nurse–Client Skill procedures withinSkilleach
UNIT 10.2 Pulse Rate ......................................................... 272
chapter
10.4.1 Measuring a Bloodare Pressure ......................... 285
obtaining a respiratory rate.
10.8 Discuss the pulse, and indicate how it is an
10.18 Discuss conditions when respiratory rate
grouped together in Units and
Nursing Process Data........................................................... 272
Blood organized
Skill 10.4.2 Palpating Systolic Arterial
Pressure ................................................ 288
Example:
index of“. . . distrust
heart your diagnosis?”
rate and rhythm. Procedures ............................................................................. 272

Compare normalRepeating
Restatement
10.9 heart rate range
theforclient’s
adults
statement
would be elevated or decreased.
as encour-
Skill 10.2.1 Palpating around a Radial Pulse a................................
Nursing Process 273 Framework.
Skill 10.4.3 Measuring Lower-Extremity
Blood Pressure ................................................ 288
10.19 Compare normal respiratory rates for adults
Skill 10.2.2 Taking an Apical Pulse .................................. 274
and children. Skill 10.4.4 Measuring Blood Pressure by
agement for him or her to continue. and children.
Skill 10.2.3 Taking an Apical–Radial Pulse ..................... 275 Flush Method in Small Infant ....................... 289
Example: “You said that you can’t bear to look at your stoma.” Skill 10.2.4 Palpating a Peripheral Pulse ......................... 276 Skill 10.4.5 Using a Continuous Noninvasive
Skill 10.2.5 Monitoring Peripheral Pulses With a Monitoring Device ......................................... 290
Validation Verifying the accuracy of the sender’s message.
Doppler Ultrasound Stethoscope ................. 277 UNIT 10.4 Documentation and Evaluation............... 291
Chapter Outline
Example: “Yes, it is confusing when so many staff are in the Note: See also Skill 30.3.2, Using Pulse Oximetry, page 1187 Chapter Wrap-Up ................................................................293
room.”
Overview ................................................................................254
Unit 10.2 Documentation and Evaluation ..................277
Procedures ............................................................................. 264
Gerontologic Considerations ............................................. 293
Management Guidelines .................................................... 293
Vital Signs .............................................................................. 256 Skill 10.1.1 Using a Digital Thermometer ....................... 266 UNIT 10.3 Respirations ..................................................... 280
Delegation ........................................................................... 293
Temperature ........................................................................... 258 Skill 10.1.2 Using an Electronic Thermometer ............... 267 Nursing Process Data........................................................... 280
EVIDENCE-BASED PRACTICE
Pulse ........................................................................................ 259 Skill 10.1.3 Measuring an Infant or Child’s
Interprofessional Communication ....................................... 293
Procedures ............................................................................. 280
Healthcare Team Performance
Respiration ............................................................................. 260 Temperature .................................................... 268
Skill 10.3.1 Obtaining the Respiratory Rate .................... 281
Case Study Applications ..................................................... 294
There is evidence to suggest that outcomes in health care
Blood Pressure ....................................................................... 261 Skill 10.1.4 Obtaining a Tympanic Temperature ............ 268 Scenarios ............................................................................. 294
Unit 10.3 Documentation and Evaluation ..................282
Pain ......................................................................................... 262 Skill 10.1.5 Using a Temporal Thermometer NCLEX® Review Questions ................................................ 294
depend on effective healthcare team performance. As a(Infrared)
member ......................................................... 269
Cultural Awareness ............................................................... 263 UNIT 10.4 Blood Pressure ................................................. 284 QSEN Activity....................................................................... 295
of the healthcare team, you will be working alongside Skill 10.1.6physicians,
Using a Heat-Sensitive Wearable Nursing Process Data........................................................... 284 Bibliography.......................................................................... 295
UNIT 10.1 Temperature ..................................................... 264 Thermometer .................................................. 270
nurse practitioners, pharmacists, technicians, and other health
Nursing Process Data........................................................... 264
professionals. You will be a unique contributing member. Health
254
care is not a solitary event but an interprofessional exercise. Terminology
Working with others as a team, you can ensure greater client Antipyretic an agent that reduces febrile temperatures. Cardiac output the amount of blood ejected by the heart
safety and fewer errors. Teams who know their individual roles Apex the pointed end of a cone-shaped part or organ (e.g., or the stroke volume (SV) times the heart rate
lower heart, upper lung). (CO = SV × HR).
and responsibilities have fewer overall errors. As a student, you Cardiogenic originating in the heart itself.
Arteriosclerosis an arterial disease characterized by
Key Terminology
may have opportunities is provided
to interact with other healthcare disci- at ▶ inelasticity and thickening of the vessel walls with
lessened blood flow.
Chemoreceptor a sense organ or sensory nerve ending that
is stimulated by and reacts to chemical stimuli.
pline students. These interactions will assist you in being a con-
tributing m the beginning of the chapter for Atherosclerosis a form of arteriosclerosis in which there
are localized accumulations of lipid-containing material
Contractility having the ability to contract or shorten
muscle tissue or cells.
easy review. within the internal surfaces of blood vessels.
Atrial pertaining to the atrium, the upper cardiac chamber
Core temperature the body’s interior deep tissue
temperature (e.g., the abdominal cavity).
that receives blood from the lungs and systemic Diastole the period in which the heart dilates and fills with
circulation. blood; the period of relaxation.
Atrial fibrillation atrial arrhythmia characterized by rapid, Doppler a type of ultrasound stethoscope or probe that
random contractions of the atrial myocardium causing a uses an ultrasound beam to detect blood flow.
ember of the interprofessional team. rapid, irregular ventricular rate.
Febrile feverish, increased body temperature.
Among teams, there is a concept referred to as situational Autoregulation the intrinsic ability of an organ or tissue to
Fibrillation quivering, involuntary contraction of
awareness: being able to gather the right information, analyze maintain blood flow despite changes in arterial pressure.
individual muscle fibers.
Axilla armpit.
it in a timely manner, and make projections from it as it relates to Hypertension blood pressure that is considered to be
Bigeminal pulse a regularly irregular pulse where every higher than the normal range.
client care. This can occur only when the team is aware of t second beat has a decreased amplitude.
Hyperthermia unusually high body temperature.
Bounding pulse increased pulse pressure, felt as a slapping
Hypotension blood pressure that is lower than the normal
against the fingers because of the rapid upstroke and
range.
quick downstroke. It is seen in conditions of increased

Multicultural Health Care Cultural Awareness

cardiac output, such as exercise, anxiety, alcohol intake,
and pregnancy. It is also noted in pathology with fever,
anemia, hyperthyroidism, liver failure, complete heart
Hypothalamus the part of the brain that lies below the
◀ Cultural Awareness
thalamus; it maintains or regulates body temperature,
certain metabolic processes, and other autonomic
In the twenty-first century, demographic shifts are occurring It is important for nurses
block to understand
with bradycardia,
Bradycardia
the impact of var-
and hypertension. activities.
sections remind nurses
Hypothermia a body temperature below the average
that will change the direction of health care. As of the 2012 ious cultures on healthcare practices
a pulse rate below 60if beats
theyperare to become
minute

census, Asians are the fastest growing race or ethnic group

(beats/min).
culturally competent. As more and more people immigrate
normal range.
of issues surrounding
in the United States. This is due mostly to international to this country, nurses will be faced with challenges related
div­ersity and providing
migration. Hispanics remain the second largest race or eth- to cultural diversity when administering health care. Cul-
nic group, representing 17% of the nation. Five states have tural diversity implies the range of differences in values, ­culturally responsive client
a majority-minority, meaning that the prevailing minority beliefs, customs, folklore, traditions, language, and patterns
group is now more than half the population (Brown, 2014). of behavior for the various cultural groups. For example,
care.
Because of this change in the U.S. population demo- people from different cultures define personal space dif-
graphics, there are emerging barriers to health care for ferently. Some may prefer closer personal contact, while an
many groups of people. Perhaps the greatest barrier is individual moving into their personal space offends others.
language, and since communication is an essential compo- The nurse needs to be aware that personal space is related
nent of providing nursing care, it is important to consider to culture, gender, and group behavior. Because all of these
language under the topic of communication. Other barriers aspects potentially affect how an individual experiences,
may be living in urban, poor neighborhoods; poor preven- copes with, and responds to illness, nurses must be aware of
tion practices such as poor nutrition; and beliefs that affect these cultural differences (Box 4-2 ◾).
x how certain cultural groups understand illness and respond
to treatment. Perhaps the greatest barrier for many ethnic
groups is poverty. Those in the lower socioeconomic group
. . . for Accurate and Safe Skill Performance!

LEGAL ALERT ◀ Legal Alert boxes highlight

Nurses’ Negligence
The client had transthoracic vagotomy. The doctor ordered legal pitfalls and make nurses
vital signs q 15 minutes × 1 hour and q hour for 10 hours.
Vital signs were recorded four times for 1 day. The next day
aware of legal m ­ alpractice.
the client’s temperature was 102°F (38.9°C) and it remained
there until the day after, when it was 105°F (40.6°C). The
nurse administered aspirin when it rose to 106°F (41°C). The
nurse then contacted the doctor who found signs of serious
wound infection. The client suffered organic brain syndrome
as a direct result of the continued high temperature. The court
found that the nurses breached standard of care when they
failed to notify the doctor of the client’s high temperature.

New Trends boxes present new ▶ Box 10-8 NEW TrENDS: ElECTrONIC STETHOSCOPE

­equipment and systems that are A new electronic stethoscope is now available. It measures a
client’s blood pressure via Bluetooth-enabled Cardioscan and
being ­incorporated in 21st-century sends the results directly into the client’s computer record for
immediate evaluation.
nursing care.

10/18/15 4:29 PM

◀ Nursing Diagnoses for

Nursing Diagnoses each chapter give quick
The following nursing diagnoses may be appropriate to include in a client care plan when the components are related to es- and clear guidelines for
tablishing and maintaining a nurse–client relationship.
appropriate use of nursing
NURSING DIAGNOSIS RELATED TO . . .
diagnoses in client care
Impaired Communication: Psychologic barrier, inability to speak dominant language, impaired cognition, lack of privacy
Verbal plans.
Powerlessness Perceived lack of control resulting in dissatisfaction
Impaired Social Interaction Lack of motivation, anxiety, depression, lack of self-esteem, disorganized thinking, delusions,
hallucinations
Social Isolation Hospitalization, terminal illness

Source: Herdman, T. H. & Kamitsuru, S. (Eds.) Nursing Diagnoses – Definitions and Classification 2015-2017. Copyright © 2014, 1994–2014 by NANDA International.
Used by arrangement with John Wiley & Sons Limited. Companion website: www.wiley.com/go/nursingdiagnoses. In order to make safe and effective judgments
using NANDA-I nursing diagnosis it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work.
M10_SMIT7924_09_SE_C10.indd 292 9/16/15 11:13 PM

xi
 Unit 10.2
Pulse Rate

Nursing Process Data

ASSESSMENT Database IMPLEMENTATION Procedures

• Assess appropriate site to obtain pulse. • Skill 10.2.1Palpating a Radial Pulse .............................273
• Check pulse with health status changes, as ordered by • Skill 10.2.2Taking an Apical Pulse ................................274
healthcare provider, or before administering certain • Skill 10.2.3Taking an Apical–Radial Pulse ..................275
medications. • Skill 10.2.4Palpating a Peripheral Pulse ......................276
• Assess for rate, rhythm, volume, and quality. • Skill 10.2.5Monitoring Peripheral Pulses With a
• Assess an apical pulse on clients with irregular rhythms Doppler Ultrasound Stethoscope ..............277
Within each chapter, Units open with a complete
▶
or those on cardiac medications. Note: See also Skill 30.3.2, Using Pulse Oximetry, page 1187
• Obtain baseline peripheral pulses with initial assessment
or in any client undergoing cardiac or vascular surgery.
DOCUMENTATION AND EVALUATION
overview of the Nursing Process Data that applies to
Also obtain pulse for medical clients with diabetes,
arterial occlusive diseases, atherosclerosis, or aneurysm,
or any color or temperature changes in the periphery.
Expected Outcomes the Procedures.
• Pulse is palpated without difficulty.
• Obtain an apical–radial pulse when deficits occur
• Pulse rate is within normal range and rhythm is regular.
between apical and radial measurements.
• All peripheral pulses are equal in amplitude when com-
• Assess the need to monitor pulses with an ultrasound or
pared bilaterally and when compared with the next prox-
electronic device.
imal site.
• Apical pulse is easily detected and counted.
PLANNING Objectives
Unexpected Outcomes/Alternative Actions
• To determine whether the pulse rate is within normal
range and if the rhythm is regular
• To evaluate the quality (amount of blood pumped
through peripheral arteries) of arterial pulses
Pearson Nursing Student Resources Online Nursing Student Resources
Find additional review materials at
• To determine whether peripheral pulses are equal in
amplitude when compared with corresponding pulses nursing.pearsonhighered.com. for each unit contain competency
Prepare for success with NCLEX®-style practice
• To determine presence of peripheral pulses with
ultrasound device when palpation is ineffective questions and Skill Checklists. checklists for each procedure. (Visit
• To monitor and evaluate changes in the client’s health
status nursing.pearsonhighered.com.)
• To determine apical pulse rate before heart medications
are administered

Unit 10.2 Pulse Rate 277

11. Check to see that client is comfortable.

12. Perform hand hygiene and clean stethoscope.
13. Document apical pulse rate, rhythm, and intensity.

CLINICAL ALERT
The best practice for taking a pulse for infants or children is to
listen to the heart itself, rather than palpating the pulse. Too
much pressure may obliterate it, and inadequate pressure
may not detect it.

EVIDENCE-BASED PRACTICE
272 Step-by-Step Skills. More than ▶ ❹ Accurate apical pulse is found in fifth intercostal space, left of Effect of Music on Vital Signs
One hundred and fifteen clients who were scheduled to
1,100 full-color photographs,
sternum at midclavicular line or mitral area.
undergo ophthalmic procedures and who were exposed to
accurate readings are obtained over 1 minute, especially live classical piano music showed a statistically significant
line drawings, charts, and tables if pulse is irregular.
c. Determine if pattern is regular, regularly irregular, or
decrease (P < 0.0001) in blood pressure, heart rate, and
respiratory rate.

depict step-by-step nursing pro- chaotic. ➤ Rationale: This finding helps describe the
rhythm disturbance.
Source: Camara, Ruskowskis, & Worak, (2008)

cedures. Clear, concise skills with

helpful rationales enable nurses
Skill 10.2.3 | Taking an Apical–Radial Pulse
of all levels to visualize, perform,
and evaluate skills in any clinical Equipment
Watch with sweeping second hand
when two nurses are at the bedside, so a full explanation
helps allay fears.
Stethoscope 7. Assist client to a supine position and expose chest area.
setting. Another nurse to assist with procedure (optional) 8. Place watch where clearly visible to both nurses.
➤ Rationale: Both nurses count pulse rates within the
Procedure same time span, preferably using one watch.
1. Gather equipment. 9. Warm stethoscope in palm of your hand. ➤ Rationale:
2. Perform hand hygiene. This prevents startling the client with cold stethoscope.
3. Clean stethoscope bell and diaphragm with alcohol swab or 10. Locate radial pulse. The second nurse locates apical
equivalent. pulse at the fifth intercostal space left of sternum at
4. Check two forms of client ID. Introduce self. the midclavicular line and firmly places diaphragm of
5. Provide privacy. stethoscope on the site. ❶ ➤ Rationale: Firm application
6. Explain procedure to client, especially if two nurses are helps transmit high-pitched heart sounds.
taking the pulse. ➤ Rationale: Clients may be apprehensive

❶ A. Auscultate apical pulse and palpate radial pulse simultaneously. B. This can also be done by two nurses.
(continued)

xii
Ch10_vr.indd 277 10/18/15 8:24 PM
 insert covered and lubricated probe ¼–1½ in. (0.5–3.75
cm), depending on the client’s age, through anal
sphincter. ➤ Rationale: Taking in a deep breath relaxes xiii
the sphincter, and the lubrication prevents tissue trauma.
e. Position probe to side of rectum to ensure contact with
tissue wall. ➤ Rationale: This ensures probe is in contact
with large vessels of rectal wall.
f. Remove probe when audible signal occurs. Client’s
temperature is now registered on the screen.
❶ Electronic thermometer unit with digital probe. g. Discard probe cover into trash.
❸ Slide probe under front of tongue to sublingual pocket. h. Wipe anal area with tissues to remove lubricant and stool.
i. Discard tissue and gloves. ➤ Rationale: Proper disposal
der front of Clinical Alerts and Safety Alerts call
prevents transmission of microorganisms.
ublingual SAFETY ALERT ­attention
6. Assist client to safety
to comfortable issues, essential infor-
position.
ssels in the The temperature of an unconscious client is never taken by 7. Performmation, nursing judgment, and actions that
hand hygiene.
erature. mouth. The rectal, tympanic, or scanner method is preferred. 8. Record require critical decision making.
temperature.
d close at

Rectal Temperature CLINICAL ALERT

a. Perform hand hygiene. Only use client’s own dedicated electronic thermometer
b. Identify client with two forms of ID. (including rectal and oral) if diagnosis includes Clostridium
c. Don clean gloves. ➤ Rationale: This prevents exposure difficile-associated diarrhea because of the potential for
to feces. spreading the bacteria and increasing the risk of transmitting
d. Position client on side facing away from you, separate an HAI to other clients.
❷buttocks,
Cover probe instruct client to take
of thermometer in a deep
before takingbreath,
temperature.and
270 Chapterinsert covered
10 Vital Signs and lubricated probe ¼–1½ in. (0.5–3.75
cm), depending on the client’s age, through anal
Skill 10.1.5 | Using
sphincter. a Temporal Thermometer
➤ Rationale: Taking in a (Infrared)
deep breath relaxes
(continued)

the sphincter, and the lubrication prevents tissue trauma.

EVIDENCE-BASED PRACTICE ◀ Expanded! Evidence-Based
e. Position probe to side of rectum to ensure contact
Accuracy withArtery Thermometers
of Temporal
tissue wall. ➤ Rationale: This ensures Aprobe recent study by Emergency Nurses Association (ENA) on
is in contact ­Practice boxes present specific
temporal artery thermometer accuracy found that among the
with large vessels of rectal wall. pediatric participants (N = 52), temporal artery temperatures scientific studies that validate skill
f. Remove probe when audible signal occurs. were within the acceptable range set by the experts to use
Client’s
as a noninvasive substitute for core body temperatures
protocols.
temperature is now registered on the screen. (Reynolds et al., 2014).

obe. g. Discard probe cover into trash.

h. Wipe anal area with tissues to remove lubricant and stool.
i. Discard tissue and gloves. ➤ Rationale: Proper disposal Unit 10.4 Blood Pressure 291
prevents transmission of microorganisms.
❷ After releasing scan button, note the reading in the window.
6. Assist client to comfortable position.
10.4 Documentation and Evaluation
7. Perform hand hygiene.
8. Record temperature.
DOCUMENTATION for Blood Pressure
Skill 10.1.6 | Using a Heat-Sensitive Wearable Thermometer
• Two phases of Korotkoff sounds (e.g., 120/80) and site
• Three phases of Korotkoff sounds (e.g., 130/110/80) and site
CLINICAL ALERT
Equipment • Response to alternative nursing actions
LEGAL ALERT • Response to position changes
Only use
Wearable client’s
thermometer, own strip
chemical dedicated electronic
tape, or liquid crystal thermometer
Nurses’ Negligence • Document vital signs in chart, in addition to attaching digital readouts
thermometer
(including rectal and oral) if diagnosis includes The Clostridium
client had transthoracic vagotomy. The doctor ordered
EVALUATION/Critical Thinking
Each unit endsbecausewith Documentation and
vital signs q 15 minutes × 1 hour and q hour for 10 hours.
◀
difficile-associated
Procedure diarrhea of the potential
Vital signs for
were recorded four times for 1 day. The next day
1. Check orders for continuous-reading thermometer and Expected Outcomes
spreading Evaluation.
identify clientthe
with bacteria and
two forms of ID. increasing
Introduce self. the risk the
of client’s
transmitting
temperature was 102°F (38.9°C) and itpressure
• Blood remainedreadings provide information regarding
there until the day after, when it was 105°F (40.6°C). The status of the client.
the overall health
an HAI to other clients.
2. Dry forehead or axilla area, if necessary.
nurse administered aspirin when it rose to•106°F (41°C).from
Major changes Theprior assessments are documented.
ture.
The Documentation section
•  nursefocuses
3. Place strip on forehead ❶ or deep in client’s axilla ❷—may
then contacted the doctor who found • Accurate
signs ofreadings
serious are taken by using the correct cuff size
stay in place for 2 days. and procedure.
on important data to record wound
regard-
4. Read correct temperature by checking color changes or
infection. The client suffered organic brain syndrome
• Beginning and disappearance of Korotkoff sounds during
as a direct result of the continued high temperature. The court
a blood pressure reading are evaluated and documented.
dots that turn from green to black.
ing the skills, outcomes, andfound
5. Record temperature on appropriate form or record. client
that the nurses breached standard •ofThe carepresence
when they
failed to notify the doctor of the client’s highreadings
of factors that can alter blood pressure
is identified.
temperature.
responses. Unexpected Outcomes Alternative Actions
• Blood pressure reading is abnormally high without • Check if arm was unsupported.
apparent physiologic cause. • Check if cuff was not snug.
The Evaluation/Critical Thinking
•  • Check if cuff was deflated too slowly or reinflated during
deflation, causing venous engorgement and abnormally
section reviews Expected Outcomes high diastolic readings.
• Ask if client has pain, was anxious (white coat

and provides Alternative Actions to take syndrome), or had just exercised, eaten, or smoked.
Recheck pressure as indicated.

when Unexpected Outcomes occur.

• Check blood pressure on both arms. The normal difference
from arm to arm is usually no more than 5 mmHg.
• Check if insufficient rest before assessment.

• Blood pressure reading is very low and there are no • Assess if cuff is too wide.
significant clinical indicators. • Check if client’s arm was above heart level.
• Check if inflation was too slow. This reduces intensity of
Korotkoff sounds.
• Assess if Korotkoff sounds were barely audible. Raise
client’s arm, and then recheck. Sounds should be louder.
❶ Liquid crystal thermometer is placed against lower forehead for ❷ Place a continuous-reading, wearable thermometer deep in the • Identify if stethoscope was misplaced and was not on
15 seconds. client’s axilla. brachial artery.
• Take blood pressure 3 minutes after client rises from
supine to standing if postural hypotension is suspected.

• Blood pressure cannot be measured on upper extremity • Use lower extremity to obtain blood pressures.
due to casts or other causes of inaccessibility.
(continued)

xiii
xiv 

Chapter Wrap-Up Helps Tie Everything

Together!
Chapter 10 Vital Signs 293

Chapter Wrap-Up

GERONTOLOGIC Considerations
Cardiac Status—Changes
• Changes in cardiovascular status with aging are often
insidious and may become apparent when system is stressed
and there is increased demand for cardiac output (which
may occur with illness and hospitalization). Nursing care
assessment should focus on client’s cardiovascular status,
even when diagnosis does not include a cardiac condition.
• Blood pressure measurement should take age into
account. If client has severe joint stiffness, pseudohy-
pertension may be present. If this is suspected, raise the
cuff pressure above the systolic blood pressure and, if
the radial pulse remains palpable, the reading may show
10–15 mm Hg in error.
• Postural hypotension is common in the older adult (posi-
tional drop of less than 20 mm Hg); nurses should take
note when helping a client out of bed. Hypertension is
also common in this age group.
• A rise in blood pressure may be associated with reduced
cardiac output, vasoconstriction, increased blood volume,
or fluid overload.
• Pulse changes, particularly an irregular pulse, can be related
to hypoxia, airway obstruction, or electrolyte imbalance.
• The arteries in older adult clients may feel stiff and
knotty due to decreased elasticity. Excessive pressure to
site when taking pulse may obliterate it. The normal rate
is 60–90 beats/min.
• If pulses are not palpated, a Doppler may need to be used.
Respiratory Status—Changes
• Changes in the respiratory system may be subtle
and gradual with the older adult: Oxygen saturation
is decreased to 93%–94%; there is often poor cough
response and incomplete lung expansion—all of which
leads to increased risk of pulmonary infection when the
older adult client is hospitalized. Gerontologic Considerations help nurses con-
• Slightly irregular breathing patterns are not unusual in
the older adult. sider special adaptations for care of older adults.
Temperature—Changes
• With the older adult, temperature may be as low as 95°F
(35°C). Because they may be easily dehydrated with
Management Guidelines include two sections.
increased temperature, nursing assessment should include
baseline temperature at admission and continued moni-
A Delegation section teaches nurses to delegate
tasks within safe, legal, and appropriate parameters.
toring during hospitalization.
• Older adults with acute infections may have a subnormal
temperature.
• Increased temperatures can lead to increased metabo- An Interprofessional Communication section
lism, thus increasing the body’s demand for oxygen. This
causes the heart to work harder. helps nurses prioritize and communicate relevant
• Oral temperatures are the preferred method for obtaining
the older adult client’s temperature. client information to members of the healthcare
team, in order to ensure consistent quality of care.

MANAGEMENT Guidelines
Each state legislates a Nurse Practice Act for RNs and LPN/
LVNs. Healthcare facilities are responsible for establishing
and implementing policies and procedures that conform
to their state’s regulations. Verify the regulations and role
parameters for each healthcare worker in your facility.
Delegation
• Taking vital signs for clients may be assigned to any
healthcare worker provided they have been assessed for
competency in the procedure. This includes LPN/LVN,
unlicensed assistive personnel (UAP), and EMT.
• The registered nurse must identify parameters for which
the healthcare worker is to notify the nurse (i.e., blood
pressure above or below a certain reading, pulse rate, or
irregular pulse).
Case Study Applications
­provide case scenarios that help
nurses develop clinical reasoning
skills.
• The nurse must provide detailed explanations and/
or demonstrate alterations in the procedure or specific
methods of obtaining the vital signs to UAP, or EMTs.
294 Chapter 10 Vital Signs
• Obtaining peripheral pulses by use of the Doppler is
the responsibility of the RN or LPN/LVN. A UAP is not
responsible for using the Doppler. vital sign sheet at the nurses’ desk, or give the results to even though someone else performs the task of taking the
the nurse?
• The UAP may monitor blood pressure using the noninva- vital signs.
sive monitoring device; however, the UAP is not•respon-The registered nurse must evaluate all abnormal or • The registered nurse must ensure that the healthcare
changed vital signs identified by the healthcare workers.
sible for initiating the procedure or setting the alarms. workers know the parameters for reporting unusual vital
The nurse maintains total responsibility for client care signs. Periodic checks with the workers may be necessary.
Interprofessional Communication
• Directions must be given to healthcare workers on docu-
CASE STUDY Applications
mentation procedures. Do they complete the graphic
record, enter data into the EHR, write the findings on a
Scenario 1 hypertension and heart disease. The nurse will complete a
physical exam and a history.
Mr. Trager (age 92) has been admitted to your unit with a
temperature of 103°F (39.4°C), BP 140/90, P 114, and R 30
1. What information is missing in the family history that the
and labored. He reports a history of 3 days of diarrhea and
nurse will want to elicit from the client?
fever and asks you for something to drink.
2. Which questions regarding lifestyle would be appropri-
1. From your analysis of the admission data, determine the ate to ask?
following: 3. Which aspects of client teaching would the nurse want to
a. Appropriate nursing diagnosis in order of priority for cover before Mr. Sondheim is discharged?
this client.
Scenario 3
b. The metabolic effects of fever on pulse and respiration.
c. Age factors that contribute to the existing problem. You are caring for a client, and when checking his vital
signs, you are unable to palpate his radial pulse.
2. What are the other assessment findings indicative of the
diagnosis established from primary admitting data?
3. Develop a plan of care for this client.
1. What would be your follow-up intervention?
2. When you still cannot find a pulse clear enough to docu-
4. Describe the evaluative outcomes for problem resolution. ment, what would be your next intervention?
Scenario 2 3. What parameters of the pulse will you pay attention to
when assessing and recording a client’s pulse?
Mr. Sondheim is admitted to the hospital with unstable
hypertension for evaluation. He has a family history of

NCLEX® Review Questions

Unless otherwise specified, choose only one (1) answer.
1. During a shift assessment, the nurse notes that the
client’s peripheral pulses are absent. What would the
next intervention be?
A. Palpate the peripheral pulse.
B. Use a Doppler to assess peripheral pulse.
C. Notify the healthcare provider.
D. Administer O2 as ordered.
2. When a pulse deficit is detected in a client, what would
the nurse expect the client is experiencing?
A. Premature ventricular beats
B. Bradycardia
C. Tachycardia
D. Heart block
3. A client’s temperature remains elevated despite the
administration of antipyretic drugs. What would be the
first intervention after determining this condition?
A. Administer a cool bath.
B. Assess all remaining signs.
C. Request orders for a cooling blanket.
D. Obtain an order for a blood culture.
4. When taking a client’s blood pressure that has been
within normal limits, the nurse gets a reading that is
very low without any significant clinical indicators.
Which intervention would be appropriate?
A. Assess if the BP cuff is too narrow.
B. Assess if the BP cuff is too wide.
C. Assess if the client’s arm was positioned below heart
level.
D. Notify the healthcare provider.
5. When taking a client’s blood pressure, the nurse finds
the reading very different from previous readings re-
corded on the chart. What is the first intervention?
A. Recheck the blood pressure with different
equipment.
B. Notify the healthcare provider.
C. Validate the reading with another nurse.
D. Check the client’s circulatory status.

xiv
  xv

82 Chapter 4 Communication and Nurse–Client Relationship

NCLEX® Review Questions ◀ NCLEX® Review Questions. NCLEX®-style

Unless otherwise specified, choose only one (1) answer.
1. Which intervention is most useful when communicating
with an aphasic client?
A. Use correct medical terminology when teaching or
explaining.
B. Ask open-ended questions to obtain information.
C. Repeat the same word until the client understands.
D. Provide frequent praise and encouragement.
­ uestions have been included at the end of each
q
6. A client is admitted to CCU with a diagnosis of anterior
myocardial infarction. Shortly after admission, he states: chapter and reflect the Practice Analysis of newly
“I might as well have died because now I won’t be able
to do anything.” Which is the most appropriate response
by the nurse?
­Licensed Registered Nurses upon which the
A. “Don’t worry, everything will turn out all right.”
B. “What do you mean, not able to do anything?”
NCLEX® is based. Answers with complete rationales

2. A psychiatric client rapidly improves and is scheduled

to be discharged tomorrow. Which of the following re-
sponses demonstrates that the nurse has a good under-
standing of termination of a relationship?
A. “You have worked really hard the last three weeks.
Good-bye and good luck.”
B. “Stop by and let us know how things are going.”
C. “You’ve done some good work here. I hope you are
able to follow through with it.”
D. “Good-bye and good luck. Hopefully, we won’t be
seeing you here again.”
C. “Take one day at a time and it will all work out.”
D. “You shouldn’t be thinking like this, because you are
are in the Answers Appendix.
doing well now.”
7. A male client is becoming increasingly angry and
verbally abusive. Which of these is the appropriate
intervention?
A. Send the client back to his room.
B. Ask the healthcare provider for an order for
restraints.
C. Summon assistance from a male staff member.
D. Set firm limits on the abusive behavior.

3. One characteristic of a nurse–client relationship is that
it is a professional one. What does this imply about the
nurse?
A. The nurse should be primarily concerned with
implementing the policies of the hospital.
B. The nurse views the client’s needs as her or his
primary concern.
C. The nurse maintains a distance between self and
client.
D. The nurse establishes boundaries, formulate goals,
and maintain the boundaries of a professional
relationship.
4. One day a client with terminal cancer says to the nurse,
“Well, I’ve given up all hope. I know I’m going to die
soon.” Which is the most therapeutic response?
A. “Now, one should never give up hope. We are
finding new cures all the time.”
B. “We should talk about dying.”
C. “You’ve given up all hope?”
D. “Your doctor will be here soon. Why don’t you talk
to him about your feelings?”
5. Which of the following statements would be best to
stimulate conversation with a client about his or her so-
cial history?
A. “Are you married?”
B. “Do you have any children?”
C. “Tell me about your family.”
D. “Is your role in the family important?”
8. Which of the following components would you include
in a cultural assessment?
Select all that apply.
A. Cultural background
B. Nutritional practices
C. Beliefs and perceptions of health
D. Age of the client
E. Belief in God
F. Communication patterns
G. Health practices, including alternative
9. A client you are assigned to care for is hearing impaired.
Which is the most effective way to communicate with
this client?
A. Use a writing pad and gestures.
B. Speak clearly and slowly.
C. Use nonverbal communication.
D. Describe loudly and carefully what you are doing.
10. Which nursing intervention would be the highest prior-
ity when caring for a client who is depressed?
A. Form a good nurse–client relationship.
B. Encourage the client to talk about his feelings of
depression.
C. Suggest that the client do an activity.
D. Assess the client frequently for potential suicide.

Chapter 4 Communication and Nurse–Client Relationship 83

QSEN Activity These activities ▶ QSEN Activity

help train students to think about Domain: Communication • Student nurse and client
• Student nurse and family member
the knowledge, skills, and attitudes KSA: Attitude
Activity: • Student nurse and preceptor

that are integral to Quality and Have student(s) identify a particular clinical situation where
the communication was not very effective, and perhaps the
Safety Education for Nurses. student wished it had gone another way. The scenario can
be any dyad:
• Student nurse and provider
Have the group reflect on how it could have been more ef-
fective. Role-play effective communication within the class-
room using the techniques identified within the chapter.

Bibliography Opportunities for ▶ Bibliography

Agency for Healthcare Research and Quality (AHRQ). (n.d.).
further research are provided at TeamStepps: National implementation. Retrieved from http://
teamstepps.ahrq.gov/
the end of each chapter. Amato-Vealey, E. J., Barba, M. P., & Vealey, R. J. (2008, Nov.). Hand-off
communication: A requisite for perioperative patient safety. AORN
Journal, 88 (5), 763–770.
Baker, D. P., Gustafson, S., Beaubien, J. M., Salas, E., & Barch, P. (n.d.).
Medical team training programs in health care. Retrieved from
http://www.ahrq.gov/professionals/quality-patient-safety/
patient-safety-resources/resources/advances-in-patient-safety/
vol4/Baker.pdf
Blumenthal, J. A., Smith, P., & Benson, H. (2012, Jul.–Aug.). Opinion and
evidence: Is exercise a viable treatment for depression? ACSM’s Health
& Fitness, 16 (4), 14–21. doi: 10.1249/01.FIT.0000416000.09526.eb
Brown, A. (2014). U.S. Hispanic and Asian populations growing, but
for different reasons. Pew Research Center. Retrieved from http://
www.pewresearch.org/fact-tank/2014/06/26/u-s-hispanic-and-
asian-populations-growing-but-for-different-reasons/
Census. (2012). http://www.census.gov/newsroom/releases/
archives/population/cb13-112.html
Chen, K., Ku, Y., & Yang, H. (2012, Mar.). Violence in the nursing
workplace—A descriptive correlational study in a public
hospital. Journal of Clinical Nursing, 22(5–6), 798–805. doi:10.1111/
j.1365-2702.2012.04251
Downey, L., Zun, L., & Burke, T. (2012). What constitutes a good
hand off in the emergency department: A patient’s perspective.
International Journal of Healthcare Quality Assurance, 26 (8), 760–767.
Office of Minority Health. (2012). National Standards for Culturally
and Linguistically Appropriate Services (CLAS standards).
Retrieved from https://www.thinkculturalhealth.hhs.gov/CLAS/
Clas_Overview.asp
Schenker, Y., Karter, A. J., Schillinger, D. Warton, E. M., Adler, N. E.,
Moffet, H. H., & Fernandez, A. (2010, Nov.). The impact of limited
English proficiency and physician language concordance on
reports of clinical interactions among patients with diabetes: The
DISTANCE study. Patient Education and Counseling, 81(2), 222–228.
Spector, R. E. (2013). Cultural Diversity in Health and Illness (8th ed.).
Hoboken, NJ: Prentice Hall.

xv
Contents
Acknowledgments v Nursing Process24
Preface viii Assessment24
Nursing Diagnosis25
1 Professional Nursing1 Planning and Outcome Identification25
LEARNING OBJECTIVES 1 Implementation26
CHAPTER OUTLINE 1 Evaluation27
Overview Nursing Diagnosis: Uses, Types, and Components27
Professional Role2 Nursing Diagnosis Versus Medical Diagnosis27
Definition of Professional Nursing2 Types of Nursing Diagnoses28
Assuming the Nursing Role3 Diagnostic Statements28
The Client Role4 Components of a Nursing Diagnosis28

Standards and Statutes5 Evidence-Based Practice29

The Nurse Practice Act5 MANAGEMENT Guidelines31
Nurse Licensure5 CASE STUDY Applications32
Standards of Clinical Nursing Practice6 NCLEX® Review Questions32
Liability and Legal Issues6 QSEN Activity33
Drugs and the Nurse7
Bibliography33
Negligence/Malpractice7
HIPAA8
Medicare Prescription Act8
3 Managing Client Care: Documentation
Clients’ Rights and Responsibilities8
and Delegation34
LEARNING OBJECTIVES 34
Consent to Receive Health Services9
Confidentiality9 CHAPTER OUTLINE 34
Patient Self-Determination Act10 Overview
Advance Medical Directives10 Client Care Plans35
Do Not Resuscitate11 Components of a Care Plan36
Clinical Practice11 Updating Care Plans36
Legal Issues11 Paper Care Plans39
Guidelines for Safe Clinical Practice11 Evaluating Care Plans39
Use of Electronics in the Clinical Setting12 Critical Paths (Clinical Pathways)39
Providing Client Care12 Documentation (Charting)40
Essential Nurse Actions12 Documentation—A Method of Communication41
Client’s Forms13 Charting Format42
Client’s Chart14 Avoiding Legal Problems in Documentation42
Basic Nursing Assessment16 Forensic Charting43
Medical Asepsis Principles17 Informatics43
Hand Hygiene18 Electronic Charting43
Protocol for Procedures18 Alternative Documentation Systems45
Rules for Documenting Client Care45
MANAGEMENT Guidelines19
Assistive Devices46
CASE STUDY Applications19 Minimizing Legal Risks of Computer Charting47
NCLEX® Review Questions20 Legal Forms of Documentation47
QSEN Activity21 Unusual Occurrence, Variance, or Incident Report47
Bibliography21 Consent Forms48
Reporting/Handoff: A Component of Documentation50
2 Critical Thinking and the Nursing Process22 Intrashift Reports50
LEARNING OBJECTIVES 22 Intershift Reports50
CHAPTER OUTLINE 22 Healthcare Provider Notification50
Overview Nurse Manager Reports50
Client Care Conferences50
Critical Thinking23

xvi
 Contents xvii

Delegating Client Care50 Unit 4.2 Nurse–Client Relationship74

RN Delegation51 Nursing Process Data74
Parameters of Delegation52 Procedures74
Student Clinical Planning53 Skill 4.2.1 Initiating a Nurse–Client Relationship75
Preclinical Planning53
Skill 4.2.2 Facilitating a Nurse–Client Relationship75
Time Management53
Skill 4.2.3 Terminating a Nurse–Client Relationship76
MANAGEMENT Guidelines53
Unit 4.3 Communication in Special Situations:
CASE STUDY Applications54
Depression, Anxiety, Anger, and Denial78
NCLEX® Review Questions55
Nursing Process Data78
QSEN Activity56
Procedures78
Bibliography57
Skill 4.3.1 Communicating With a Depressed Client79

4 Communication and Nurse–Client Skill 4.3.2 Communicating With an Anxious Client79

Skill 4.3.3 Communicating With an Aggressive or
Relationship58
Angry Client79
LEARNING OBJECTIVES 58
Skill 4.3.4 Communicating With a Client in Denial80
CHAPTER OUTLINE 58
Overview GERONTOLOGIC Considerations81

Communication60 MANAGEMENT Guidelines81

Confidentiality (Client’s Right to Privacy)60 CASE STUDY Applications81
Health Insurance Portability and Accountability NCLEX® Review Questions82
Act (HIPAA)60 QSEN Activity83
Guidelines That Influence Effective
Bibliography83
Communication61
Guidelines for Communicating With Clients61
New Trends in Communication61
5 Admission, Transfer, and Discharge84
The Joint Commission Safety Goal 2: Improve LEARNING OBJECTIVES 84
Effectiveness of Caregiver Communication61 CHAPTER OUTLINE 84
“Handoff” Communication62 Overview

Therapeutic Communication Techniques62 Admission, Transfer, and Discharge85

Admission to the Hospital86
Barriers to Communication64
Admission to the Nursing Unit86
Multicultural Health Care64
Client Acuity Systems87
Cultural Awareness65
Transfer to Another Unit88
Cultural Competence65
Discharge From the Hospital88
Diversity in Health Care65
Discharge Against Medical Advice88
Spiritual Assessment65
Adaptation to Home Care89
Relationship Therapy65
Legal Issues in Home Care89
Relationship Principles67
Plan of Treatment89
Phases in Nurse–Client Relationship Therapy67
Documentation89
Unit 4.1 Therapeutic Communication 68 Cultural Awareness90
Nursing Process Data68
Unit 5.1 Admission and Transfer92
Procedures68
Nursing Process Data92
Skill 4.1.1 Introducing Yourself to a Client69
Procedures92
Skill 4.1.2 Beginning a Client Interaction69
Skill 5.1.1 Admitting a Client93
Skill 4.1.3 Teaching Clients to Communicate With Their
Skill 5.1.2 Transferring a Client94
Healthcare Providers70
Unit 5.2 Height and Weight92
Skill 4.1.4 Assessing Cultural Preferences71
Nursing Process Data97
Skill 4.1.5 Assessing Spiritual Issues71
Procedures97
Skill 4.1.6 Assisting a Client to Describe Personal
Experiences71 Skill 5.2.1 Measuring Height and Weight98

Skill 4.1.7 Encouraging a Client to Express Needs, Unit 5.3 Discharge101

Feelings, and Thoughts71 Nursing Process Data101
Skill 4.1.8 Using Communication to Increase a Client’s Procedures101
Sense of Self-Worth72 Skill 5.3.1 Discharging a Client101
xviii Contents

Skill 5.3.2 Discharging a Client Against Medical CASE STUDY Applications137

Advice (AMA)102 NCLEX® Review Questions138
Unit 5.4 Admission to Home Care104 QSEN Activity139
Nursing Process Data104 Bibliography139
Procedures104
Skill 5.4.1 Nurse’s Role in Home Care105 7 Safe Client Environment and Restraints140
Skill 5.4.2 Identifying Eligibility for Medicare LEARNING OBJECTIVES 140
Reimbursement105 CHAPTER OUTLINE 140
Skill 5.4.3 Completing Admission Documentation106 Overview
Skill 5.4.4 Maintaining Nurse’s Safety106 Orientation to the Client Environment142
Skill 5.4.5 Assessing for Elder Abuse107 Maintaining Homeostasis142

GERONTOLOGIC Considerations109
Characteristics That Influence Adaptation142
Age142
MANAGEMENT Guidelines109
Mental Status142
CASE STUDY Applications110 States of Illness143
NCLEX® Review Questions110 Physical and Biological Dimensions143
QSEN Activity111 Adequate Space143
Bibliography111 Natural and Artificial Light144
Humidity and Temperature144
6  lient Education and Discharge
C Ventilation144
Planning112 Comfortable Sound Levels144
Furniture: Bed Safety144
LEARNING OBJECTIVES 112
Additional Furniture145
CHAPTER OUTLINE 112
Food and Water146
Overview
Hazardous Products and Waste Management146
Client Education113
Sociocultural Dimensions147
Principles of Client Education115
Organization of Time147
Discharge Planning116 Privacy147
Adaptation to Home Care118 Individualized Care148
Home Care Definition118 Information and Teaching149
Referral to Home Care119 A Safe Environment149
Transition From Hospital to Home119
Sentinel Events150
Home Health Care Changes119
Client Teaching120 “Never Events”151
Adapting Care to the Home Setting120 Safety Precautions151
Client Falls152
Cultural Awareness120
Use of Restraints153
Unit 6.1 Client Education122 Adaptation to Home Care154
Nursing Process Data122
Unit 7.1 A Safe Environment156
Procedures122
Nursing Process Data156
Skill 6.1.1 Collecting Data and Establishing Rapport123
Procedures156
Skill 6.1.2 Determining Readiness to Learn124
Skill 7.1.1 Preventing Client Falls157
Skill 6.1.3 Assessing Learning Needs124
Skill 7.1.2 Preventing Thermal/Electrical Injuries159
Skill 6.1.4 Determining Appropriate Teaching Strategy126
Skill 7.1.3 Providing Safety for Clients During a Fire160
Skill 6.1.5 Selecting the Educational Setting127
Skill 7.1.4 Providing Safety for Clients Receiving
Skill 6.1.6 Implementing the Teaching Strategy128 Radioactive Materials161
Skill 6.1.7 Evaluating Teaching/Learning Outcomes129 Skill 7.1.5 Providing Safety for Clients with
Unit 6.2 Discharge Planning133 Seizure Activity162
Nursing Process Data133 Skill 7.1.6 Assessing Home for Safe Environment163
Procedures133 Unit 7.2 Restraints165
Skill 6.2.1 Preparing a Client for Discharge134 Nursing Process Data165
Skill 6.2.2 Completing a Discharge Summary134 Procedures165
GERONTOLOGIC Considerations136 Skill 7.2.1 Managing Clients in Restraints166
MANAGEMENT Guidelines137 Skill 7.2.2 Applying Torso/Belt Restraint167
 Contents xix

Skill 7.2.3 Using Wrist Restraints168 Skill 8.4.1 Providing Evening Care212
Skill 7.2.4 Using Mitt Restraints169 Skill 8.4.2 Providing Back Care212
Skill 7.2.5 Using Elbow/Pediatric Arm Restraints170 GERONTOLOGIC Considerations214
Skill 7.2.6 Applying a Vest Restraint170 MANAGEMENT Guidelines215
Skill 7.2.7 Applying Mummy Restraints173 CASE STUDY Applications215
GERONTOLOGIC Considerations176 NCLEX® Review Questions216
MANAGEMENT Guidelines176 QSEN Activity217
CASE STUDY Applications177 Bibliography217
NCLEX® Review Questions177
QSEN Activity178 9 Personal Hygiene218
Bibliography178 LEARNING OBJECTIVES 218
CHAPTER OUTLINE 218
8 Bathing, Bedmaking, and Maintaining Overview

Skin Integrity180 Hygiene Care220

Oral Hygiene220
LEARNING OBJECTIVES 180
Hair Care220
CHAPTER OUTLINE 180
Pediculosis220
Overview
Perineal and Genital Care220
Basic Health Care182 Eye Care220
Types of Beds182
Cultural Awareness221
Support Surfaces182
Specialty Beds182 Unit 9.1 Oral Hygiene222
Bathing183 Nursing Process Data222
Skin Conditions183 Procedures222
Cultural Awareness184 Skill 9.1.1 Providing Oral Hygiene223
Unit 8.1 Bedmaking185 Skill 9.1.2 Providing Denture Care225
Nursing Process Data185 Skill 9.1.3 Providing Oral Care for Unconscious
Procedures185 Clients226
Skill 8.1.1 Folding a Mitered Corner186 Unit 9.2 Hair Care229
Skill 8.1.2 Changing a Pillowcase186 Nursing Process Data229
Skill 8.1.3 Making an Unoccupied/Surgical Bed186 Procedures229
Skill 8.1.4 Changing an Occupied Bed189 Skill 9.2.1 Providing Hair Care230
Unit 8.2 Bath Care193 Skill 9.2.2 Shampooing Hair230
Nursing Process Data193 Skill 9.2.3 Shaving a Client231
Procedures193 Unit 9.3 Pediculosis233
Skill 8.2.1 Providing Morning Care194 Nursing Process Data233
Skill 8.2.2 Bathing an Adult Client194 Procedures233
Skill 8.2.3 Providing Foot Care197 Skill 9.3.1 Identifying the Presence of Lice and Nits
Skill 8.2.4 Bathing a Client in Tub or Shower198 (Lice Eggs)234
Skill 8.2.5 Bathing Using Disposable System198 Skill 9.3.2 Removing Lice and Nits234
Skill 8.2.6 Bathing an Infant200 Unit 9.4 Bedpan, Urinal, and Commode237
Skill 8.2.7 Bathing in a Hydraulic Bathtub Chair201 Nursing Process Data237

Unit 8.3 Skin Integrity203 Procedures237

Nursing Process Data203 Skill 9.4.1 Using a Bedpan and Urinal238
Procedures203 Skill 9.4.2 Assisting Client to Commode239
Skill 8.3.1 Monitoring Skin Condition204 Unit 9.5 Perineal and Genital Care241
Skill 8.3.2 Preventing Skin Breakdown205 Nursing Process Data241
Skill 8.3.3 Preventing Skin Tears208 Procedures241
Skill 8.3.4 Managing Skin Tears209 Skill 9.5.1 Draping a Female Client241
Unit 8.4 Evening Care211 Skill 9.5.2 Providing Female Perineal Care242
Nursing Process Data211 Skill 9.5.3 Providing Male Perineal Care243
Procedures211 Skill 9.5.4 Providing Incontinence Care244
xx Contents

Unit 9.6 Eye and Ear Care246 Unit 10.3 Respirations280

Nursing Process Data246 Nursing Process Data280
Procedures246 Procedures280
Skill 9.6.1 Providing Routine Eye Care246 Skill 10.3.1 Obtaining the Respiratory Rate281
Skill 9.6.2 Providing Eye Care for Comatose Client247 Unit 10.4 Blood Pressure284
Skill 9.6.3 Removing and Cleaning Contact Lenses247 Nursing Process Data284
Skill 9.6.4 Cleaning and Checking a Hearing Aid248 Procedures284
GERONTOLOGIC Considerations250 Skill 10.4.1 Measuring a Blood Pressure285
MANAGEMENT Guidelines250 Skill 10.4.2 Palpating Systolic Arterial Blood Pressure288
CASE STUDY Applications251 Skill 10.4.3 Measuring Lower-Extremity Blood Pressure288
NCLEX® Review Questions251 Skill 10.4.4 Measuring Blood Pressure by Flush Method
QSEN Activity252 in a Small Infant289
Bibliography253 Skill 10.4.5 Using a Continuous Noninvasive
Monitoring Device290
10 Vital Signs254 GERONTOLOGIC Considerations293
LEARNING OBJECTIVES 254 MANAGEMENT Guidelines293
CHAPTER OUTLINE 254 CASE STUDY Applications294
Overview NCLEX® Review Questions294
Vital Signs256 QSEN Activity295
Factors Influencing Vital Signs257
Bibliography295
Temperature258
Regulatory Mechanisms258
Measuring Body Temperature258
11 Physical Assessment296
LEARNING OBJECTIVES 296
Pulse259
CHAPTER OUTLINE 296
Circulatory System Control259
Overview
Heart Rate and Rhythm259
Assessment297
Evaluating Pulse Quality259
Equipment297
Respiration260
Health History297
Evaluating Respirations261
Nurse’s Role297
Blood Pressure261
Measuring Blood Pressure261 Examination Techniques297
Inspection297
Pain262
Auscultation297
Cultural Awareness263
Palpation298
Unit 10.1 Temperature264 Percussion298
Nursing Process Data264 Assessment of the Nervous System300
Procedures264 Assessment of the Head and Neck309
Skill 10.1.1 Using a Digital Thermometer266 Assessment of the Skin and Nails313
Skill 10.1.2 Using an Electronic Thermometer267 Assessment of the Chest, Lungs, and Heart315
Skill 10.1.3 Measuring an Infant or Child’s Temperature268 Assessment of the Abdomen, Spleen, Kidney, Liver,
Skill 10.1.4 Obtaining a Tympanic Temperature268 and Genitourinary Tract321
Skill 10.1.5 Using a Temporal Thermometer (Infrared)269 Mental Health Assessment327
Skill 10.1.6 Using a Heat-Sensitive Wearable Thermometer270 Obstetrical Assessment330
Unit 10.2 Pulse Rate272 Newborn Assessment336
Nursing Process Data272 Pediatric Assessment340
Procedures272 GERONTOLOGIC Considerations345
Skill 10.2.1 Palpating a Radial Pulse273 MANAGEMENT Guidelines348
Skill 10.2.2 Taking an Apical Pulse274 CASE STUDY Applications348
Skill 10.2.3 Taking an Apical–Radial Pulse275 NCLEX® Review Questions348
Skill 10.2.4 Palpating a Peripheral Pulse276 QSEN Activity349
Skill 10.2.5 Monitoring Peripheral Pulses With a Bibliography349
Doppler Ultrasound Stethoscope277
 Contents xxi

12 Body Mechanics and Positioning350 13 Exercise and Ambulation388

LEARNING OBJECTIVES 350 LEARNING OBJECTIVES 388
CHAPTER OUTLINE 350 CHAPTER OUTLINE 388
Overview Overview
Musculoskeletal System352 Rehabilitation Concepts390
Skeletal Muscles352 Musculoskeletal System390
Joints352 Muscle Function391
Bones352 Joints391
System Alterations352 Exercise391
Nursing Measures352
Ambulation392
Safe Patient Handling and Mobility353
Assistive Devices392
ANA Promotes Safe Patient Handling and Mobility354 Crutches392
Home Care354 Walkers393
Cultural Awareness355 Canes393
Unit 12.1 Proper Body Mechanics356 Adaptation to Home Care393
Nursing Process Data356 Unit 13.1 Range of Motion394
Procedures356 Nursing Process Data394
Skill 12.1.1 Performing Back Exercises357 Procedures394
Skill 12.1.2 Applying Body Mechanics358 Skill 13.1.1 Performing Passive Range of Motion395
Skill 12.1.3 Maintaining Proper Body Alignment359 Skill 13.1.2 Teaching Active Range of Motion398
Skill 12.1.4 Using Coordinated Movements360 Unit 13.2 Ambulation400
Skill 12.1.5 Using Basic Principles361 Nursing Process Data400
Unit 12.2 Moving and Turning Clients364 Procedures400
Nursing Process Data364 Skill 13.2.1 Minimizing Orthostatic Hypotension401
Procedures365 Skill 13.2.2 Ambulating With Two Assistants401
Skill 12.2.1 Assessing Clients for Safe Moving Skill 13.2.3 Ambulating With One Assistant402
and Handling366 Skill 13.2.4 Ambulating With a Walker404
Skill 12.2.2 Placing a Trochanter Roll367 Skill 13.2.5 Ambulating With a Cane405
Skill 12.2.3 Turning to Lateral Position368 Unit 13.3 Crutch Walking408
Skill 12.2.4 Turning to a Prone Position368 Nursing Process Data408
Skill 12.2.5 Moving Client Up in Bed369 Procedures408
Skill 12.2.6 Moving Client With Assistance370 Skill 13.3.1 Teaching Muscle-Strengthening Exercises409
Skill 12.2.7 Logrolling the Client370 Skill 13.3.2 Measuring Client for Crutches409
Skill 12.2.8 Transferring Client From Bed to Gurney372 Skill 13.3.3 Teaching Crutch Walking: Four-Point Gait410
Skill 12.2.9 Dangling at the Bedside373 Skill 13.3.4 Teaching Crutch Walking: Three-Point Gait410
Skill 12.2.10 Moving From Bed to Chair374 Skill 13.3.5 Teaching Crutch Walking: Two-Point Gait411
Skill 12.2.11 Using a Floor-Based (Sling) Lift375 Skill 13.3.6 Teaching Swing-To Gait and Swing-
Skill 12.2.12 Using a Hydraulic Lift377 Through Gait411
Skill 12.2.13 Using a Footboard379 Skill 13.3.7 Teaching Upstairs and Downstairs Ambulation
Unit 12.3 Adaptations for Home Care381 With Crutches412
Nursing Process Data381 Skill 13.3.8 Teaching Moving in and out of Chair
Procedures381 With Crutches412

Skill 12.3.1 Evaluating Client’s Safety382 Unit 13.4 Adaptation for Home Care414
Skill 12.3.2 Assessing Caregiver’s Safety382 Nursing Process Data414

GERONTOLOGIC Considerations384 Procedures414

MANAGEMENT Guidelines384 Skill 13.4.1 Positioning Nonhospital Bed for
Client Care415
CASE STUDY Applications385
Skill 13.4.2 Moving a Helpless Client up in Bed Without
NCLEX® Review Questions385
Assistance415
QSEN Activity386
Skill 13.4.3 Using Assistive Devices in Home415
Bibliography387
Skill 13.4.4 Instructing Caregiver on Safety Issue416
xxii Contents

GERONTOLOGIC Considerations417 Skill 14.2.2 Removing Personal Protective Equipment447

MANAGEMENT Guidelines418 Unit 14.3 Transmission-Based Precautions (Tier 2,
CASE STUDY Applications418 Isolation)450
NCLEX® Review Questions419 Nursing Process Data450
QSEN Activity420 Procedures450
Bibliography420 Skill 14.3.1 Preparing for Isolation451
Skill 14.3.2 Using a Mask452
14 Infection Control421 Skill 14.3.3 Guidelines When Assessing Vital Signs of
LEARNING OBJECTIVES 421 Client in Isolation452
CHAPTER OUTLINE 421 Skill 14.3.4 Removing Items From Isolation Room453
Overview Skill 14.3.5 Removing a Specimen From Isolation Room454
Chain of Infection423 Skill 14.3.6 Transporting Isolation Client Outside
Barriers to Infection424 the Room454
The Body’s Natural Defenses425 Skill 14.3.7 Removing Soiled Large Equipment From
Healthcare-Associated Infections425 Isolation Room454
Clostridium difficile425 Unit 14.4 Home Care Adaptation456
MRSA426
Nursing Process Data456
VRE426
CRKP426 Procedures456
Surgical Site Infections426 Skill 14.4.1 Preparing for Client Care in the Home457
Respiratory Tract Infections426 Skill 14.4.2 Disposing of Waste Material in the Home
Urinary Tract Infections427 Setting457
Primary Bloodstream Infections427 Skill 14.4.3 Cleansing Equipment in the Home Setting458
Standard Precautions427 Skill 14.4.4 Teaching Preventive Measures in the Home
Transmission-Based precautions428 Setting458
Needlestick Safety and Prevention Act430 GERONTOLOGIC Considerations460
AIDS431 MANAGEMENT Guidelines460
Epidemiology and Modes of Transmission431 CASE STUDY Applications461
Definitions431 NCLEX® Review Questions461
Healthcare Workers’ Exposure to HIV432
QSEN Activity462
Other Infectious Diseases432
Bibliography462
Tuberculosis432
Viral Hepatitis433
Seasonal Flu433 15 Disaster Preparedness463
LEARNING OBJECTIVES 463
Emerging Viruses (Possible Pandemic Threats)433
Ebola Virus Disease434 CHAPTER OUTLINE 463
Severe Acute Respiratory Syndrome434 Overview
Middle East Respiratory Syndrome434 Natural Disasters466
Avian Influenza434 Disaster Defined467
Home Care Adaptations434 Public Policy467
Cultural Awareness435 Mass Casualty Characteristics467
Bioterrorism Response Act468
Unit 14.1 Basic Medical Asepsis436
Disaster Impact on the Infrastructure468
Nursing Process Data436
Disaster Mitigation468
Procedures436 Community Response Plan469
Skill 14.1.1 Hand Hygiene (Medical Asepsis)437 Strategic Plan for Responding to Biological or
Skill 14.1.2 Cleaning Washable Articles439 Chemical Terrorism469
Skill 14.1.3 Donning and Removing Clean Gloves439 The Joint Commission Standards470
Hospitals Must Be Disaster Ready470
Skill 14.1.4 Managing Latex Allergies442
Disaster Management471
Unit 14.2 Standard Precautions (Tier 1)444
Hospital Evacuation Plans472
Nursing Process Data444 Internal (or In-Hospital) Communication472
Procedures444 Triage Systems472
Skill 14.2.1 Donning Personal Protective Equipment445 Field Triage473
 Contents xxiii

Catastrophic Triage474 Nursing Process Data504

Triage Victim Flow474 Procedures504
Decontamination474 Skill 15.4.1 Establishing Triage Treatment Areas505
Triage and Decontamination474
Skill 15.4.2 Establishing Public Health Parameters505
Posttriage Organization474
Skill 15.4.3 Developing a Communication Network506
Weapons of Mass Destruction475
Skill 15.4.4 Establishing Viable Communication506
Biological Agents475
Chemical Agents475 Skill 15.4.5 Carrying Out Steps of Triage507
Radiation475 Skill 15.4.6 Treating Life-Threatening Conditions507
Ethical Considerations478 Skill 15.4.7 Assessing Victims Posttriage508
Diversity Considerations478 Skill 15.4.8 Caring for Those Who Died509
Summary478 Skill 15.4.9 Caring for Clients and Staff With
Unit 15.1 Natural Disasters480 Psychological Reactions509

Nursing Process Data480 Skill 15.4.10 Identifying Posttraumatic Stress Disorder510

Procedures480 GERONTOLOGIC Considerations511

Skill 15.1.1 Creating a Safety Plan for Disasters481 MANAGEMENT Guidelines511

Skill 15.1.2 Teaching Clients Earthquake Safety481 CASE STUDY Applications512

Skill 15.1.3 Preventing Diarrhea-Related Diseases NCLEX® Review Questions513

After a Natural Disaster482 QSEN Activity514

Unit 15.2 Bioterrorism Agents, Antidotes, Bibliography514

and Vaccinations484
Nursing Process Data484 16 Pain Management516
Procedures484 LEARNING OBJECTIVES 516
CHAPTER OUTLINE 516
Skill 15.2.1 Identifying Agents of Biological Terrorism485
Overview
Skill 15.2.2 Identifying Chemical Agent Exposure488
Coping With Pain517
Skill 15.2.3 Triaging for Chemical Agent Exposure489
Theories of Pain519
Skill 15.2.4 Managing Care After Chemical Agent Pain Pathways519
Exposure490 The Pain Experience520
Skill 15.2.5 Identifying Acute Radiation Syndrome490 The Joint Commission Standards for Pain Management521
Skill 15.2.6 Dealing With a Nuclear Disaster491 Noninvasive Pain Relief522
Unit 15.3 Personal Protective Equipment The Nurse’s Role522
and Decontamination493 Techniques for Pain Control524
Nursing Process Data493 IV Patient-Controlled Analgesia524
Procedures493 Epidural Pain Control524
Breakthrough Pain Control524
Skill 15.3.1 Implementing Hospital Infection Control
Transdermal Patches525
Protocol494
Cultural Awareness525
Skill 15.3.2 Decontaminating via Triage496
Unit 16.1 Pain Assessment526
Skill 15.3.3 Choosing Protective Equipment for Biological
Exposure497 Nursing Process Data526

Skill 15.3.4 Choosing Protective Equipment for Chemical Procedures526

Exposure498
Skill 15.3.5 Choosing Protective Equipment for
Radiological Attack499
Skill 15.3.6 Decontaminating Victims After a Biological
Terrorist Event499
Skill 15.3.7 Decontaminating Victims After a Chemical
Terrorist Event500
Skill 15.3.8 Decontaminating Victims After Radiation
Exposure501
Skill 15.3.9 Controlling Radiation Contamination502
Unit 15.4 Triage, Treatment, and a Communication
Matrix504
Skill 16.1.1 Assessing Pain527
Skill 16.1.2 Assessing Pain in a Cognitively Impaired or
Nonverbal Client528
Skill 16.1.3 Assessing Pain in Young Children528
Unit 16.2 Pharmacologic Pain Management530
Nursing Process Data530
Procedures530
Skill 16.2.1 Administering Pain Medications531
Skill 16.2.2 Improving Client Satisfaction With Pain Control531
Skill 16.2.3 Managing Pain With Patient-Controlled
Analgesia (PCA)532
Skill 16.2.4 Ongoing Assessment of the Client With PCA533
xxiv Contents

Skill 16.2.5 Teaching PCA to a Client533

18 Medication Administration568
Skill 16.2.6 Monitoring a Client Receiving An Epidural
LEARNING OBJECTIVES 568
Infusion534
CHAPTER OUTLINE 568
Unit 16.3 Nonpharmacologic Pain Relief538 Overview
Nursing Process Data538 Pharmacologic Agents570
Procedures538 Biological Effects of Drugs570
Skill 16.3.1 Alleviating Pain Through Touch (Massage)538 Administering Medications Safely571
Skill 16.3.2 Using Relaxation Techniques539 Safety Precautions572
GERONTOLOGIC Considerations540 The Six Rights572
MANAGEMENT Guidelines541 Cultural Awareness572
CASE STUDY Applications541 Unit 18.1 Medication Preparation574
NCLEX® Review Questions542 Nursing Process Data574
QSEN Activity543 Procedures574
Bibliography543 Skill 18.1.1 Preparing for Medication
Administration575
17 
Alternative Therapies and Stress Skill 18.1.2 Converting Dosage Systems576
Management544 Skill 18.1.3 Calculating Dosages576
LEARNING OBJECTIVES 544 Skill 18.1.4 Using the Controlled Substance System577
CHAPTER OUTLINE 544 Skill 18.1.5 Administering Medication Protocol578
Overview
Unit 18.2 Oral Medication Administration582
Stress545
Nursing Process Data582
The Effect of Stress546
Procedures582
Individual Responses to Stress547
Stress and Disease547 Skill 18.2.1 Preparing Oral Medications583
Guidelines for Implementing Stress Objectives in Skill 18.2.2 Administering Oral Medications to Adults585
Nursing549 Skill 18.2.3 Administering Medications per
A New Paradigm for Health550 Enteral (NG or NI) Feeding Tube585
A Holistic Approach to Health550 Unit 18.3 Topical Medication Administration588
Complementary and Alternative Medicine551 Nursing Process Data588
Complementary Health Approaches551 Procedures588
Herb–Drug Interactions555 Skill 18.3.1 Applying Topical Medications589
Cultural Awareness555 Skill 18.3.2 Applying Creams to Lesions589
Unit 17.1 Stress and Adaptation559 Skill 18.3.3 Applying Transdermal Medications590
Nursing Process Data559 Skill 18.3.4 Instilling Ophthalmic Drops591
Procedures559 Skill 18.3.5 Administering Ophthalmic Ointment592
Skill 17.1.1 Determining the Effect of Stress560 Skill 18.3.6 Irrigating the Eye593
Skill 17.1.2 Determining Response Patterns560 Skill 18.3.7 Administering Otic Medications593
Skill 17.1.3 Managing Stress561 Skill 18.3.8 Irrigating the Ear Canal594
Skill 17.1.4 Manipulating the Environment to Unit 18.4 Mucous Membrane Medication
Reduce Stress561 Administration596
Skill 17.1.5 Teaching Coping Strategies561 Nursing Process Data596
Skill 17.1.6 Managing Stress Using a Holistic Model562 Procedures596
Skill 17.1.7 Teaching Controlled Breathing563 Skill 18.4.1 Administering Sublingual Medications597
Skill 17.1.8 Teaching Body Relaxation563 Skill 18.4.2 Instilling Nose Drops598
Skill 17.1.9 Using Meditation as an Alternative Therapy564 Skill 18.4.3 Administering Metered-Dose Inhaled (MDI)
GERONTOLOGIC Considerations565 Medications598
MANAGEMENT Guidelines565 Skill 18.4.4 Using MDI with Spacer600
CASE STUDY Applications566 Skill 18.4.5 Administering Dry Powder Inhaled (DPI)
NCLEX® Review Questions566 Medications600
QSEN Activity567 Skill 18.4.6 Administering Medication by Nonpressurized
Bibliography567 (Nebulized) Aerosol (NPA)601
 Contents xxv

Skill 18.4.7 Administering Rectal Suppositories602 Unit 19.1 Modified Therapeutic Diets642
Skill 18.4.8 Administering Vaginal Suppositories602 Nursing Process Data642
Unit 18.5 Parenteral Medication Procedures642
Administration605 Skill 19.1.1 Restricting Dietary Protein643
Nursing Process Data605 Skill 19.1.2 Restricting Dietary Fat643
Procedures605 Skill 19.1.3 Restricting Mineral Nutrients (Sodium,
Skill 18.5.1 Preparing Injections606 Potassium)643
Skill 18.5.2 Administering Intradermal Injections610 Skill 19.1.4 Providing Consistent Carbohydrate Diets644
Skill 18.5.3 Administering Subcutaneous Injections611 Skill 19.1.5 Providing Nutrient-Enhanced Diets644
Skill 18.5.4 Preparing Insulin Injections612 Skill 19.1.6 Providing Progressive Diets645
Skill 18.5.5 Using an Insulin Pen615 Skill 19.1.7 Providing Altered Food Consistency Diets646
Skill 18.5.6 Administering Subcutaneous Anticoagulants Unit 19.2 Nutrition Maintenance648
(Heparin, Low-Molecular-Weight Heparin [LMWH])617 Nursing Process Data648
Skill 18.5.7 Administering Intramuscular (IM) Injections619 Procedures648
Skill 18.5.8 Using Z-Track Method622 Skill 19.2.1 Serving a Food Tray649
GERONTOLOGIC Considerations624 Skill 19.2.2 Assisting the Visually Impaired Client to Eat649
MANAGEMENT Guidelines625 Skill 19.2.3 Assisting the Dysphagic Client to Eat650
DRUG Supplement625 Unit 19.3 Nasogastric Tube Therapies652
CASE STUDY Applications627 Nursing Process Data652
NCLEX® Review Questions628 Procedures652
QSEN Activity629 Skill 19.3.1 Inserting a Large-Bore Nasogastric (NG) Tube653
Bibliography629 Skill 19.3.2 Flushing and Maintaining Nasogastric
(NG) Tube657
19 
Nutritional Management and Enteral Skill 19.3.3 Performing Gastric Lavage659
Intubation631 Skill 19.3.4 Administering Poison Control Agents659
LEARNING OBJECTIVES 631 Skill 19.3.5 Removing an NG or Nasointestinal (NI) Tube660
CHAPTER OUTLINE 631
Unit 19.4 Enteral Feeding663
Overview
Nursing Process Data663
Nutritional Management633
Dietary Reference Intakes and Recommended Procedures663
Dietary Allowances633 Skill 19.4.1 Administering an Intermittent Feeding via
Macronutrients634 Large-Bore Nasogastric Tube664
Carbohydrates634 Skill 19.4.2 Determining Gastric pH666
Fats634 Skill 19.4.3 Dressing the Gastrostomy Tube Site667
Proteins635 Skill 19.4.4 Inserting a Small-Bore Feeding Tube668
Water635 Skill 19.4.5 Providing Continuous Feeding via Small-Bore
Micronutrients635 Nasointestinal or Jejunostomy Tube670
Vitamins635 GERONTOLOGIC Considerations674
Minerals635
MANAGEMENT Guidelines675
Nutritional Assessment636
CASE STUDY Applications676
Assimilation of Nutrients638
NCLEX® Review Questions676
Gastrointestinal System638
The Accessory Organs638 QSEN Activity677

Gastrointestinal Dysfunctions639 Bibliography677

Dysphagia639
GI Hemorrhage639 20 Specimen Collection678
Intestinal Obstruction639 LEARNING OBJECTIVES 678
Normal and Therapeutic Nutrition639 CHAPTER OUTLINE 678
Nutrition Problems in the Hospital640 Overview
Enteral Feeding for Nutritional Support640 Laboratory Tests680
Parenteral Nutrition (PN)641 Point-of-Care Testing680
Cultural Awareness641 Nursing Responsibility680
General Recommendations641 Urine Tests681
xxvi Contents

Blood Tests681 21 Diagnostic Procedures715

Cultures682 LEARNING OBJECTIVES 715
Unit 20.1 Urine Specimens684 CHAPTER OUTLINE 715
Nursing Process Data684 Overview
Procedures684 Client Preparation717
X-Ray Studies718
Skill 20.1.1 Collecting Midstream Urine685
Ultrasound Studies718
Skill 20.1.2 Collecting 24-Hour Urine Specimen685
Nuclear Imaging719
Skill 20.1.3 Collecting a Specimen From an Infant686 Microscopic Studies719
Skill 20.1.4 Teaching Clients to Test for Urine Ketone Bodies687 Endoscopic Studies719
Unit 20.2 Stool Specimens689 Fluid Analysis Studies719
Nursing Process Data689 Magnetic Resonance Imaging719
Interventional Radiology720
Procedures689
Assisting the Physician During Tests720
Skill 20.2.1 Collecting Adult Stool Specimen690 Genetic Testing720
Skill 20.2.2 Collecting Stool for Ova and Parasites690 Cultural Awareness720
Skill 20.2.3 Collecting Child or Infant Stool Specimen691
Unit 21.1 Contrast Media and X-Ray Studies722
Skill 20.2.4 Testing for Occult Blood691
Nursing Process Data722
Skill 20.2.5 Collecting Stool for Bacterial Culture692
Procedures722
Skill 20.2.6 Teaching Parents to Test for Pinworms692
Skill 21.1.1 Preparing for Diagnostic Imaging
Unit 20.3 Blood Specimens694 Studies723
Nursing Process Data694 Unit 21.2 Nuclear Imaging732
Procedures694 Nursing Process Data732
Skill 20.3.1 Withdrawing Venous Blood (Phlebotomy)— Procedures732
Needle & Syringe Method695
Skill 21.2.1 Preparing for Nuclear Scans733
Skill 20.3.2 Using Vacutainer System696
Skill 21.2.2 Teaching for Nuclear Scans735
Skill 20.3.3 Withdrawing Arterial Blood698
Unit 21.3 Barium Studies737
Skill 20.3.4 Collecting a Blood Specimen for Culture699
Nursing Process Data737
Skill 20.3.5 Calibrating a Blood Glucose Meter
Procedures737
(One Touch Ultra)700
Skill 21.3.1 Preparing for Barium Studies738
Skill 20.3.6 Obtaining Blood Specimen for Glucose
Testing (Capillary Puncture)700 Unit 21.4 Endoscopic Studies 738
Procedures738
Unit 20.4 Sputum Collection703
Nursing Process Data 741
Nursing Process Data703
Skill 21.4.1 Preparing For Endoscopic Studies742
Procedures703
Unit 21.5 Fluid Analysis and Microscopic
Skill 20.4.1 Obtaining Sputum Specimen704
Studies747
Skill 20.4.2 Using Suction Trap705
Nursing Process Data747
Unit 20.5 Swab Specimens 705
Procedures747
Nursing Process Data 705
Skill 21.5.1 Assisting With Lumbar Puncture748
Procedures705
Skill 21.5.2 Assisting With Liver Biopsy749
Skill 20.5.1 Obtaining a Throat Specimen708
Skill 21.5.3 Assisting With Thoracentesis750
Skill 20.5.2 Obtaining a Gum Swab for HIV Antibodies708
Skill 21.5.4 Assisting With Paracentesis751
Skill 20.5.3 Obtaining Wound Specimen for Aerobic
Culture709 Skill 21.5.5 Assisting With Bone Marrow Aspiration752
Skill 20.5.4 Obtaining Wound Specimen for Anaerobic Skill 21.5.6 Assisting With Vaginal Examination and
Culture709 Papanicolaou (PAP) Smear752
Skill 20.5.5 Collecting an Ear Specimen710 Skill 21.5.7 Assisting With Amniocentesis753
GERONTOLOGIC Considerations711 GERONTOLOGIC Considerations754

MANAGEMENT Guidelines712 MANAGEMENT Guidelines755

CASE STUDY Applications712 CASE STUDY Applications755

NCLEX® Review Questions713 NCLEX® Review Questions756

QSEN Activity714 QSEN Activity757

Bibliography714 Bibliography757
 Contents xxvii

22 Urinary Elimination758 Skill 22.6.1 Collecting Specimen From a Closed System797

LEARNING OBJECTIVES 758 Unit 22.7 Urinary Diversion799
CHAPTER OUTLINE 758 Nursing Process Data799
Overview
Procedures799
Urinary System760
Skill 22.7.1 Applying a Urinary Diversion Pouch800
Urine Production761
Skill 22.7.2 Obtaining Urine Specimen From an Ileal
Micturition761
Conduit801
Alterations in Urinary Elimination761
Skill 22.7.3 Catheterizing Continent Urinary Reservoir802
Alterations Related to Fluids761
Alterations Related to Obstructions762 Unit 22.8 Hemodialysis (Renal Replacement
Alterations Related to Aldosterone and Antidiuretic Therapy)804
Hormone762 Nursing Process Data804
Alterations Related to Changes in Blood Volume762 Procedures804
Alterations in Disease States762 The Hemodialysis Process805
Alterations Related to Chronic Renal Failure763
Skill 22.8.1 Providing Ongoing Care of Hemodialysis
Nursing Interventions763 Client805
Indwelling Catheters763
Unit 22.9 Adaptation to Home Care808
Adaptations for Home Care764
Nursing Process Data808
Cultural Awareness764
Procedures808
Unit 22.1 Intake and Output766
Skill 22.9.1 Teaching Clean Technique for Intermittent
Nursing Process Data766 Self-Catheterization809
Procedures766 Skill 22.9.2 Providing Suprapubic Catheter Care in
Skill 22.1.1 Measuring Intake and Output767 Home Care809
Unit 22.2 External Urine Collection System770 Skill 22.9.3 Administering Continuous Ambulatory
Nursing Process Data770 Peritoneal Dialysis (CAPD)810
Procedures770 Skill 22.9.4 Changing Dressing for CAPD Client811
Skill 22.2.1 Applying a Condom Catheter for Urine GERONTOLOGIC Considerations813
Collection771 MANAGEMENT Guidelines813
Skill 22.2.2 Attaching Urine Collection Condom Catheter CASE STUDY Applications814
to Leg Bag771 NCLEX® Review Questions814
Unit 22.3 Catheterization774 QSEN Activity815
Nursing Process Data774 Bibliography815
Procedures774
Skill 22.3.1 Using a Bladder Scanner775 23 Bowel Elimination816
Skill 22.3.2 Inserting a Straight Catheter (Female)775 LEARNING OBJECTIVES 816
Skill 22.3.3 Inserting a Straight Catheter (Male)778 CHAPTER OUTLINE 816
Overview
Skill 22.3.4 Inserting an Indwelling Catheter (Female)779
Skill 22.3.5 Inserting an Indwelling Catheter (Male)782 Anatomy and Physiology818

Skill 22.3.6 Providing Catheter Care786 Defecation819

Constipation819
Skill 22.3.7 Removing an Indwelling Catheter786
Bowel (Fecal) Incontinence819
Unit 22.4 Bladder Irrigation790 Alterations in Elimination820
Nursing Process Data790 Changes in Motility820
Procedures790 Obstruction of the Lumen of the Bowel820
Skill 22.4.1 Maintaining Continuous Bladder Irrigation791 Circulatory Deficiencies821
Unit 22.5 Suprapubic Catheter Care793 Surgically Induced Alterations in Bowel Elimination821

Nursing Process Data793

Adaptation for Home Care824

Procedures793 Cultural Awareness824

Skill 22.5.1 Providing Suprapubic Catheter Care794 Unit 23.1 Bowel Management826
Nursing Process Data826
Unit 22.6 Specimens from Closed Systems796
Nursing Process Data796
Procedures826

Procedures796 Skill 23.1.1 Providing Assistive Digital Evacuation827

xxviii Contents

Skill 23.1.2 Providing Digital Stimulation828 Unit 24.2 Local Cold Therapies (Cryotherapy)866
Skill 23.1.3 Developing a Regular Bowel Routine828 Nursing Process Data866
Skill 23.1.4 Administering a Suppository829 Procedures866
Skill 23.1.5 Inserting a Rectal Tube830 Skill 24.2.1 Applying an Ice Pack or Commercial Cold
Skill 23.1.6 Instructing Client in Colostomy Irrigation831 Gel Pack867
Skill 23.1.7 Instructing Home Care Client in Skill 24.2.2 Applying a Disposable Instant (Chemical)
Colostomy Care832 Cold Pack868
Unit 23.2 Enema Administration835 Skill 24.2.3 Applying a Circulating Cold Therapy Pad868
Nursing Process Data835 Unit 24.3 Temperature Management Therapies871
Procedures835 Nursing Process Data871
Skill 23.2.1 Administering a Large-Volume Enema836 Procedures871
Skill 23.2.2 Administering an Enema to a Child838 Skill 24.3.1 Using a Warm Air Blanket872
Skill 23.2.3 Administering a Small-Volume Enema839 Skill 24.3.2 Providing Tepid Sponging872
Skill 23.2.4 Administering a Retention Enema839 Skill 24.3.3 Using a Cooling Blanket873
Skill 23.2.5 Administering a Return Flow Enema840 Skill 24.3.4 Using a Hypothermia Garment
(Body Wraps)875
Unit 23.3 Fecal Ostomy Pouch Application843
GERONTOLOGIC Considerations878
Nursing Process Data843
MANAGEMENT Guidelines879
Procedures843
CASE STUDY Applications879
Skill 23.3.1 Applying a Fecal Ostomy Pouch843
NCLEX® Review Questions880
GERONTOLOGIC Considerations850
QSEN Activity880
MANAGEMENT Guidelines850
Bibliography881
CASE STUDY Applications850
NCLEX® Review Questions851
QSEN Activity852
25 Wound Care and Dressings882
LEARNING OBJECTIVES 882
Bibliography852
CHAPTER OUTLINE 882
Overview
24 Heat and Cold Therapies854 Wound Healing885
LEARNING OBJECTIVES 854 Inflammatory Phase (Reaction)885
CHAPTER OUTLINE 854 Proliferative, or Granulation, Phase (Regeneration)885
Overview Maturation, or Wound-Remodeling, Phase885
Temperature Regulation855 Wound Classification885
Processes of Heat Transfer856
Types of Wound Healing885
Conditions Affecting Temperature Regulation856 Primary Intention885
Fever856 Secondary Intention885
Hyperthermia (Body Temperature Tertiary Intention886
Exceeding 41.1°C [106°F])857
Major Factors Affecting Wound Healing886
Hypothermia (Body Temperature
Nutrition886
Below 36°C [96.8°F])857
General Physical Health886
The Inflammatory Response857 Medications886
Local Heat Therapies (Thermotherapy)857 Goals of Wound Care886
Local Cold Therapies (Cryotherapy)859 Complications Associated With Wound Healing887
Induced Hypothermia859 Wound Infections887
Cultural Awareness860 Wound Specimens for Culture888
Unit 24.1 Local Heat Therapies (Thermotherapy)861 Surgical Site Infections888
Wounds Caused by Vascular Insufficiency888
Nursing Process Data861
Venous Ulcers889
Procedures861 Arterial Ulcers889
Skill 24.1.1 Applying a Commercial Heat Pack861 Pressure Ulcers889
Skill 24.1.2 Applying an Aquathermic Pad862 Adjunctive Wound Care Therapy890
Skill 24.1.3 Applying a Hot Moist Pack863 Home Care890
Skill 24.1.4 Assisting With a Sitz Bath864 Unit 25.1 Measures to Prevent Infection892
Nursing Process Data892
Another random document with
no related content on Scribd:
 Puhemies Näppisen kysyttyä, oliko vielä muita asioita, huusi Kaisa
Kompura kahvilan puolelta, että entäs se vallankumouksen
toimeenpaneminen, jokos siitä on päätetty?

Puhemies Näppinen esitteli käsiteltäväksi kysymyksen

vallankumouksen valmistamisesta ensi syksyksi.

Poliisi Pekka Suova ilmoitti, että nimismies on antanut käskyn

hajoittaa kokouksen, jos siinä ruvetaan puhumaan
vallankumouksesta.

Kokouksen jäsenten ilmaistessa huudoilla inhomieltä kysyi

puhemies
Näppinen, että aiotkos sitten hajoittaa?

Pekka Suova vastasi, että niinkuin käsky on.

Puhemies Näppisen kysyttyä, mitä Pekka Suova aikoi tehdä, jos ei

internaali tottele hajoittamiskäskyä, vastasi Suova, että sittenpähän
sen näette.

Puhemies Näppinen sanoi, ettei poliisi voi mitään näin isolle

kansanjoukolle, mihin Pekka Suova vastasi, että älä turise Näppinen
joutavia selvässä asiassa.

Tov. Jerobeam Näppisen tiedusteltua, luuliko nimismies olevansa

niin iso herra, että voi uhmata vallankumouksellisen kansan
joukkotahtoa Pöllölässä, vastasi Pekka Suova ivamielisesti, että
näkyypä tuossa olevan teille herraa tarpeeksi.

Keittiön puolella aloitti Kaisa Kompura kimakalla äänellä

nimismiestä vastaan tähdätyn virren, johon useat tuvassa olevat
kommunistisolut virkavallan kiusaksi yhtyivät:
 »Juur turhaan kiukuissaan
Nyt maailman päämies vaan
Pauhaapi…»

Huomattiin että myöskin poliisi Suova veteli virttä, minkä johdosta

nähtiin eräiden puolinoskien kummallisesti hymyilevän.

Virren päätyttyä kysyi poliisi Suova, eikö Näppinen vielä pitäisi

pientä rukousta, mikä noskemaisuutta kuvaava lauselma
puhemiehen puolelta jätettiin omaan alhaiseen arvoonsa.

Puhemies Näppinen teki julkisen ilmoituksen, että hän alistuu

porvarillisen väkivallan edessä, lausuen surkuttelunsa, että poliisi,
köyhän leskivaimon poikana, sortaa sitä luokkaa, josta on itsekin
lähtöisin.

Pekka Suova sanoi, että jos tässä sortaminen olisi kyseessä, niin
olisi hän ensin mennyt tuonne kahvilan puolelle pyytämään
maistellakseen sitä Reeta Sinkkosen limonaatia, jolla on niin muikea
haju, että tuntuu pihalle asti.

Puhemies Näppinen selitti, ettei hän suinkaan ole tahtonut millään

tavoin loukata Pekka Suovaa, joka tunnetaan maltilliseksi
virkamieheksi.

Israel Huttunen ehdotti, että kokous lausuisi Pekka Suovalle

kansan luottamuksen, mikä yksimielisesti hyväksyttiin.

Poliisi Pekka Suova lausui kansalle: kiitoksia!

8 §.
 Kokouksen jatkuessa sääntöperäisessä järjestyksessä ilmoitti
puhemies Näppinen kysymystä olleen kommuunin keskuudessa
yksityisesti, olisiko kommunistien ryhdyttävä keskustelemaan
noskelaisten kanssa yhteistoiminnan aikaansaamisesta
eduskuntavaaleissa köyhälistön rintaman lujittamiseksi porvarillista
taantumusta vastaan.

Tov. Kusti Pirhonen selvitteli yhteiskunnallisia katsantokantoja

luokkataistelun valossa, tullen siihen johtoperään, että noskelaisille
olisi tarjottava tilaisuus yhteistoimintaan luokkatietoisen köyhälistön
kanssa.

Tämä puhe synnytti kiivasta mielenliikutusta laajoissa

vallankumouksellisissa riveissä, jotka huusivat, että Pirhosen Kusti
on tainnut saada urakakseen täyttää ohrananoskelaisten
syöttiläspomojen mahalaukut työtätekevän luokan tuloksilla.

Esittäen halpamaisia hulikaani- y.m. parjauksia maalasi Kusti

Pirhonen noskelaista sosialibatrioottista aatetta mitä
voimakkaimmilla pääväreillä, ollen tilaisuudessa esittämään
profveettamaisen itserakkautensa, ja vastaväittäjiä kohtaan kohdisti
ala-arvoisia sanasutkauksia.

Kun Simo Turtiainen antoi ymmärtää, että demokraatit tahtovat

rukoilemalla saavuttaa pikkuparannuksia, huusi puolinoske Heikki
Putkonen, että koska se on Turtiaisesta tullut asiantuntija, kun ei ole
tähän asti ymmärtänyt kuin ne kaksi asiaa, jotka äskensyntynyt
lapsikin osaa.

Muutamien nauraa räkättäessä kutsui puhemies Näppinen Heikki

Putkosen päiväjärjestykseen.
 Mari Kukkonen toi päivänvaloon vainotun punikkikansan
kiusaukset valkoisen tasavallan verivaakunan alla, saattaen esille
räikeitä ja kyynillisiä epäkohtia.

Puhemiehen huomautettua Mari Kukkoselle, että nyt on kysymys

noskelaisista eikä porvareista, kiljasi Mari Kukkonen, että mikä sinä
luulet olevasi määrääjä, mistä minä puhun.

Muutkin akat rupesivat huutamaan, että naisella on äänioikeus,

antaa
Mari Kukkosen puhua.

Melkoisen naurunrähäkän vallitessa sanoi puhemies Näppinen,

että voi hyvä isä, jos kuka saisi nuo akat riivatut pitämään turpansa
kiinni.

Justus Tiilikainen ehdotti, että ajetaan ne kahvilan puolelle, mikä

hyväksyttiin.

Merkittiin pöytäkirjaan, että muut akat lähtivät vastustelematta,

paitsi Kaisa Kompura, joka oli heitettävä, ja joka sitten vielä kävi
pirtin ovella pyllistämässä internaalille ja sen puhemiehelle.

Levollisuuden palattua jatkettiin asian käsittelyä

yhteistoimintamahdollisuuksista noskelaisten kanssa.

Justus Tiilikainen esiintoi perustellussa lausunnossa, että

kapitalismin raastamat työläiset kääntäisivät Kotolaisten
reformistiselle petturisakille selkänsä, ennenkuin joutuvat
kapitalismin jättiläiskäärmeen nieluelimistä alashotkaistuksi, mikä
muutamilta hyväksyttiin.
 Paavo Pellikka vänkäsi laajemmassa esitelmässä
noskelaisuuteen, sanoen Tiilikaisen sotkevan veden voidakseen
kalastaa sameudessa yksilöllisten tarkoitusperien hyväksi.

Tov. Tiilikaisen selvitettyä Pellikan roistomaista vääristelyä käytti

Heikki Putkonen pitemmän puheenvuoron, tarkoitusperänä kohottaa
työläisväestö luokkana laumakantaa korkeammalle.

Simo Turtiainen paljasti kuvaannollisia esimerkkejä porvarillisesta

oikeuspuntarista, joka noteeraa kommunistisille sanomalehdille
kuritushuonetta vallankumouksellisen totuuden puhumisesta.

Paavo Pellikka veti esiin näytöksiä sos. dem. lehdistä, että nämä
tuomitsevat ankarasti porvarillisen oikeuspuntarin, jos se tahtoo
takseerata tuomiota vallankumouksen valmistamisesta, mihin
sihteeri Mikko Tarjus liitti välihuudahduksen, että ne ovat vain
salataantumuksen grogotiilin mustia murhekyyneliä
vallankumouksellisen käsityksen hämäämiseksi.

Suuressa loppupuheessa teki puhemies Jerobeam Näppinen

yhteenvedon noskelaisten rötöksistä työväen pettämiseksi sekä
salaisesta suostuvaisuudesta vallankumouksen esitaistelijain
ohranoimiseen, todistaen kommunistisella tietoisuudella sos.-dem.
johtoherralurjusten inhoittavien taistelukeinojen ainoana tuloksena
olevan vain sen, että työväki jättää omiin hoteisiinsa nämä kurjat
ohranan kätyrit, jotka valta-asemansa pelastamiseksi eivät näe
muuta keinoa kuin usuttaa valkoisen taantumuksen mustat ohranat
työväenliikkeen kimppuun.

Puhemies Näppinen kysyi lopuksi, onko se kansan tahto, johon

kansa vastasi että on.
 Heikki Putkosen ja Paavo Pellikan lausuttua päivittelynsä kielsi
puhemies heitä puhumasta kansan tahtoa vastaan Pöllölässä.

Puhemiehen tiedusteltua, olisiko valittava pöytäkirjan tarkastaja,

vastasi kokous yksimielisesti, että tarkastakoon Mikko Tarjus, koska
on itse sen laatinutkin.

Poliisi Pekka Suova kysyi, eikö kokous jo pian lopu, mihin

puhemies vastasi, ettei tässä enää tule esille mitään
vallankumouksellista, niin että senpuolesta joudat kyllä lähteä, jos on
mihin kiire.

Poliisi Suova tiedusteli vielä, oliko kokouksen jälkeen pidettävissä

iltamissa erikoista ohjelmaa, minkä johdosta sihteeri Mikko Tarjus
ilmoitti, että liekö tuossa muuta kuin kintun vingutusta ja lattian
silitystä.

Poliisi Suova sanoi, että siispä jääkää terveeksi, Pöllölän

kommunistit, johon kokous vastasi, että hyvästi vain ja kiitoksia
seurasta.

Poliisin mentyä arveli Simo Turtiainen, että lieneekö sille nokkaan

käynyt haju noista Pussisen pojan limonaatipulloista, kun se siihen
suuntaan oppaili, mihin kansankerrokset vastasivat, että on tässä
tuvassa niin monensorttista hajua, ettei siitä poliisikoirakaan selvää
ottaisi.

Virallisen kokouksen päätyttyä otettiin esille kysymys parista

puolikuppisesta köyhälistön tiktatuurin kunniaksi.

Solutar Reeta Sinkkonen ilmoitti, että kahvia kyllä olisi, mutta

Pussisen pojan tuomiset ovat lopussa.
 Sihteeri Mikko Tarjuksen lausuttua läsnäolijain puolesta
kummastuksen tunteet Pussisen aikamiespojalle, ilmoitti mainittu
poika, että demokraateilla sitä kyllä olisi, kun ne varustivat sitä yli
oman tarpeen sinne Törkysen saunaan.

Sihteeri Mikko Tarjus ilmaisi otaksuman, etteivät nosket ole

halukkaat jakamaan kommunistien kanssa.

Puhemies Näppinen esitti valittavaksi kolmimiehisen komitean

laatimaan mietintöä siitä, mihin toimenpiteisiin olisi ryhdyttävä asian
valaisemiseksi.

Hyväksyen ehdotuksen valitsi kokous huutoäänestyksellä

komitean jäseniksi Jerobeam Näppisen puheenjohtajana, Mikko
Tarjuksen varapuheenjohtajana ja sihteerinä sekä Israel Huttusen
jäsenenä. Komitealle lausuttiin toivomus, että se valmistaisi
mietinnön nopeasti, hautaamatta sitä vihertävän veran alle.

Komitean puolesta vastasi Mikko Tarjus, että yhtä jano se on

meillä kuin teilläkin.

Komitea kokoontui heti porstuassa.

Viiden minuutin kuluttua esitti komitea internaateille ehdotuksen,

että valiokunta kommunistisia soluja saisi tehtäväkseen lähestyä
noskelaisia Törkysen saunassa yhteistoiminnan aikaansaamisen
nimessä valtiollisissa vaaleissa. Kokous ilmaisi myötätuntoista
kannatustaan yleisellä hölinällä.

Justus Tiilikainen ilmoitti vastustavansa kaikkia valtiollista

yhteistoimintaa koskevia neuvotteluja, viitaten yleispöllöläläisen
internaalin äsken tekemään päätökseen.
 Israel Huttunen huomautti sattuvasti, että kansalla, jolla on valta
sitoa, on myöskin valta päästää, joten läsnä olijat voivat vaikeuksitta
purkaa äskeisen päätöksen.

Sihteeri Mikko Tarjus selitti asiantuntemuksella, ettei sitä tarvitse

purkaakaan, vaan voi hän pöytäkirjaa tarkistaessaan jysteerata
päätöstä siihen suuntaan kuin vallankumouksellisen köyhälistön
tarpeet vaativat.

Kunniasolu Jerobeam Näppinen valaisi asiaa

vallankumouksellisen taktillisuuden merkeissä, koska ei Pöllölän
kommuunin tosiperäinen tarkoitus ole valtiollisen
yhteistoimintapohjan luominen aatteen pettäjien välille, vaan
ainoastaan tarpeellisen pirtun hankkiminen vallankumouksen
hyväksi, mille valtiolliselle kaukonäköisyydelle nähtiin
luokkatietoisten toverien ymmärtäväisesti virnuilevan.

Jerobeam Näppisen kysymykseen, olisiko se kansan tahto,

vastattiin yksimielisesti myöntäen.

Valtuutettiin ilman keskustelua äskeinen komitea ryhtymään

neuvotteluihin noskelaisten kanssa Törkysen saunassa.

Justus Tiilikaisen toivomukseen, ettei komitea antaisi

jesuiittamaisten noskelaisten pettää itseään, vakuutti komitea
tulevansa toimimaan vallankumouksellisen järjen selvässä valossa.

Pannen komitea tämän jälkeen hatut päähänsä ja lähtien matkalle

Törkysen saunaan.
 10 §.

Komitean lähdettyä esitti Justus Tiilikainen ulkopuolella

pöytäkirjan, eikö toveri Kuusinen olisi kutsuttava aitasta, koska poliisi
on mennyt matkaansa.

Kansa hyväksyi tämän yksimielisesti, ja valtuutettiin toveri

Tiilikainen noutamaan toveri Kuusisen aitasta.

Toveritar Reeta Sinkkonen esitti, että internaali tervehtisi toveri

Kuusista seisoalleen nousten, mikä hyväksyttiin.

Toveri Kuusisen tultua tupaan kunnioitti internaali häntä

seisoalleen nousten, mistä arvonannosta toveri Kuusinen lausui
Pöllölän vallankumoukselliselle internaalille liikutetun kommunistisen
kiitollisuutensa.

Toveri Tiilikainen pyysi kunniavierasta käymään pöydän päähän,

minkä johdosta toveri Kuusinen kysyi, oliko varmaa, että kaikki
läsnäolijat olivat luotettavia, ja eikö ollut mahdollista, että poliisi
Pekka Suova tai muut ohranat voivat odottamatta saapua paikalle.

Useat läsnäolijat lausuivat mielipiteenään, ettei se ole luultavaa ja

että kyllä tässä aina keinot keksitään, jos sattuisikin ohranoita
tulemaan.

Toveri Kuusinen, kun oli ensin keskusteltu arkipäiväisistä asioista

ja ohranan loukuista, ryhtyi kyselemään Pöllölän kommuunin
valtiollisesta valistustyöstä, ja kysyi tämän ohella sitäkin, onko
Pöllölän internaaleilla jo kommunistin katkesmusta.
 Tähän vastasivat läsnäolevat kieltävästi, minkä johdosta toveri
Kuusinen lausui surkuttelunsa, ilmaisten kommunistisen
katkesmuksen tärkeyden järkiperäisessä vallankumoustaistelussa
käsitteiden tosiperäiseksi selvittämiseksi vähemmän luokkatietoisille
kansanaineksille.

Tov. Simo Turtiainen myönsi, että olisihan se hyvä olla katkesmus,

mutta kun ei ole.

Toveri Kuusinen ilmoitti, ettei hänellä ole painettua katkesmusta

mukanaan, mutta että hän osaa sen ulkoa, joten se voidaan kirjoittaa
vaikka tänä iltana, jos tuonne aittaan nostetaan tuolta kahvilan
puolelta se pienempi pöytä ja läkkilamppu.

Toveritar Reeta Sinkkonen kiiruhti niiaten vakuuttamaan, että se

pöytä kyllä joutaa.

Tov. Kuusinen ilmoitti, että häneltä on käsi kipeänä, kun on

loukannut sen ohranan kynsistä paetessaan, mutta jos tämä Hilta
Kukkasjärvi, joka oli tuonut hänelle aittaan virvokkeita, tulisi hänelle
kirjuriksi, niin hän sanelisi sille.

Muutamat läsnäolevat todistivat Hilta Kukkasjärven hyvin

kirjoitustaitoiseksi, ja Justus Tiilikainen ilmoitti:

— Tämä Hilta kun on meidän kommuunin pikasihteeri Mikko

Tarjuksen morsian, niin tämähän se aina Mikollekin kirjoittaa
pöytäkirjat puhtaiksi.

Kaikkien läsnäolijain hyväksyttyä kommunistisella mielihyvällä

Hilta Kukkasjärven toveri Kuusisen sihteeriksi kommunistin
katkesmuksen toimitustyössä, nostettiin Reeta Sinkkosen pienempi
pöytä aittaan, minkä jälkeen toveri Kuusinen ja Hilta Kukkasjärvi
sulkeutuivat aittaan ja ottivat avaimen ovelta, ettei kukaan
iltamavieraista tulisi kurkistelemaan ja häiritsemään katkesmuksen
kirjoittamista, iltaman kun piti alkaa tunnin päästä.

Toveritar Kaisa Kompura sanoi takaisin tupaan tultua, että mitähän

se Mikko Tarjus meinaa, kun kuulee morsiamensa olevan lukon
takana kahden kesken tuntemattoman miehen kanssa. Tälle
aiheettomalle huomautukselle kuultiin useiden miesten päästävän
ala-arvoisen naurunhörinän.

Tov. Justus Tiilikainen nuhteli Kaisa Kompuraa kiivaasti

epäkommunistisesta puhetavasta ja toveri Kuusisen kunnian
loukkaamisesta halpa-arvoisella epäluulolla, jolloin toveritar Kaisa
Kompura alkoi räkättää vastaan ja haukkua tov. Tiilikaista
kerrassaan epäparlamenttaarisella tavalla.

Justus Tiilikaisen haukkuessa vastaan ja yleisen tunnelman

uhatessa täten joutua häiriöön käskivät useat karjuen kumpaakin
pitämään turpansa kiinni.

Toveritar Reeta Sinkkonen sanoi vallankumouksellisen köyhälistön

sankarien olevan kaikkien epäluulojen yläpuolella akallisissa
asioissa, koska he elävät aatteellisuuden ilmakehässä.

Justus Tiilikaisen sanottua rumasti Kaisa Kompurasta ja lausuttua,

että Kaisa itse olisi halunnut sinne aittaan, jos olisi huolittu, vaikka
silloin kyllä olisivat kirjoitusneuvot olleet tarpeettomat, sylki toveritar
Kaisa Kompura toveri Justus Tiilikaista vasten kuonoa ja yritti repiä
silmät hänen päästään, mikä vastavallankumouksellinen toiminta
saatiin toisten toverien väliintulolla ehkäistyksi.
 Tov. Aatami Lötjönen, joka oli lähtenyt Törkysen saunan taakse
kuuntelemaan, palasi ilmoittaen, että neuvottelut yhteisestä
rintamasta sujuvat täysin lojaalisti, koska komitean jäsenet
Näppinen, Huttunen ja Tarjus jo ryyppäävät samasta pullosta
noskelaisten kanssa.

Muutamat luokkatietoisista tovereista lausuivat epäilyksen, että

komitea saattaa kukaties jäädä sinne yhteiselle rintamalle koko
illaksi, minkä johdosta yksimielisesti päätettiin lähettää Pussisen
poika hakemaan komiteaa kotiin, ellei sitä pian alkaisi kuulua.

Toveritar Reeta Sinkkosen sytyttäessä tuvan katossa olevaa

lamppua, koska jo alkoi hämärtää, palasi komitea Törkysen saunalta
omasta alotteestaan ja vapaasta tahdostaan.

Kansan syvien rivien kysymykseen, kuinka lähetystö oli onnistunut

tehtävässään, vastasi puhemies Jerobeam Näppinen jossain määrin
sammaltaen, että lähetyskunta oli onnistunut kiitettävästi kaikin
puolin ja että sovinnollinen yhteistoiminta vallankumouksellisen
proletaarin molempien siipien välillä on saanut tosiperäisen
perustuksen.

Justus Tiilikaisen kysymykseen, olivatko nosket asettaneet joitakin

ehtoja puolestaan yhteistyötä varten, ilmoitti Israel Huttunen parin
nikotuskohtauksen keskeyttämänä noskelaisten päävaatimuksen
olevan, että kommunistit lakkaavat vaalitaistelun ajaksi kiihotuksesta
noskelaiskoplaa vastaan.

Tov. Tiilikaisen seuraavaan tiedusteluun, oliko komitea mennyt

antamaan siinä suhteessa mitään lupauksia, vastasi kunniasolu
Näppinen ensin kieltäen, mutta sitten, asiaa tarkemmin muisteltuaan,
kolmasti myöntäen.
 Justus Tiilikainen ilmoitti tämän johdosta vastalauseensa,
esiintuoden vallankumouksellisen taktillisuuden valossa, ettei
komitealla ollut sellaiseen lupaukseen mitään ehdotonta oikeutta.

Israel Huttusen kiellettyä tov. Tiilikaista puhumasta

vallankumouksen nimessä esitti Justus Tiilikainen, että kokous
huutaisi alas komitean, mihin suuri enemmistö karjuen yhtyi,
leimaten komitean menettelyn kansan pettämiseksi.

Sihteeri Mikko Tarjus otti taskuistaan kolme noskelaisilta saatua

täysinäistä putelia, ilmoittaen niistä pääsevän osallisiksi vain niiden,
jotka yhtyvät kannattamaan komitean menettelytapaa, koska
noskelaiset ovat myöntäneet nämä putelit nimenomaan mielialan
muokkaamista varten kommunistien keskuudessa.

Tämän ilmoituksen johdosta syntyneen pitkän ja synkän

vallankumouksellisen äänettömyyden aikana asettui komitea pöydän
ääreen, asettaen pullot eteensä, minkä jälkeen puhemies Näppinen,
siveltyään muutamia kertoja kämmenellä kasvojaan ja pyyhittyään
suupieliään, esitti Pöllölän vallankumouksellisen köyhälistön
vastattavaksi, nauttiiko neuvotteleva komitea luottamusta, ja onko
saapuvilla ketään, joka sihteeri Tarjuksen ilmoituksen kuultuaan
edelleenkin tahtoo leimata komitean menettelyn kansan
pettämiseksi?

Mikko Tarjuksen ottaessa korkkiruuvin taskustaan ja alkaessa

hitaasti vetää korkkia auki yhdestä putelista pyysi toveri Kusti
Pirhonen puheenvuoroa ja lausui mielipiteenään, että kokouksen
taholta on tapahtunut väärinkäsitys ja että Pöllölän
vallankumouksellinen internaali, ottaen huomioon
vallankumouksellisen joukkotahdon ahdistetun aseman
lahtariyhteiskunnassa ja komitean jäsenten yleisesti tunnustetut
suuret ansiot internaalissa, mielenylevyydellä hyväksyy komitean
toimenpiteet yhteisen rintaman luomiseksi porvarillista
ohranamaisuutta vastaan sekä luopuu kaikesta kiihoituksesta
noskelaisia vastaan.

Puhemiehen kysymykseen, onko tämä kansan tahto, vastasi

kokous jyrisevällä huutoäänestyksellä myöntävästi.

Puhemiehen kysymykseen, katsooko Pöllölän internaali, että

toveri Justus Tiilikainen on kenkku ja että hän on yrittänyt antaa
iskun vallankumouksen selkään, vastattiin niinikään myöntävästi
kaikilla äänillä tov. Tiilikaisen ääntä vastaan.

Toveritar Reeta Sinkkonen ilmoitti, että koska iltamavieraita alkaa

jo keräytyä pihalle, olisi internaalin siirryttävä pulloineen kahvilan
puolelle, mikä hyväksyttiin.

11 §.

Pöllölän kommunistisen internaalin sijoituttua kahvilan puolelle

nauttimaan noskelaisilta saatuja virvokkeita kysyi sihteeri Tarjus
ulkopuolella päiväjärjestyksen, minne kahvilan pienempi pöytä on
viety, sekä missä hänen morsiamensa Hilta Kukkasjärvi on?

Tähän välikyselyyn vastasi internaalin puolesta toveri Kusti

Pirhonen, tehden lyhyesti ja selväpiirteisesti selkoa toveri Kuusisen
kirjallisesta toiminnasta ja kommunistin katkesmuksesta.

Mikko Tarjuksen kysymykseen, mitä tekemistä Hiltalla siellä

aitassa on, vastattiin seikkaperäisellä selvityksellä toveri Kuusisen
kipeästä kädestä.

Koska Tov. Mikko Tarjus tällöin puhkesi kommunistisiin sadatuksiin

ja uhkasi lähteä vaatimaan Hiltaa pois aitasta, ryhtyivät useat
läsnäolijat rauhoittamaan Mikko Tarjusta, leimaten selvässä valossa
hänen aikomuksensa sopimattomaksi yleisen luokkataistelun
kannalta.

Puhemies Näppinen todisti vastustamattomasti, että koska toveri

Kuusinen kerran tarvitsee sihteeriä, niin täytyy Pöllölän internaalien
kustantaa hänelle sihteeri kommunistin katkesmuksen toimittamista
varten.

Mikko Tarjus, iskien nyrkillä pöytään, sanoi ei ymmärtävänsä,

miksi juuri Hiltan täytyy sihteerinä olla, ja lupasi itse ryhtyä Kuusisen
kirjuriksi.

Eräät Pöllölän luokkatietoiset internaalit vastasivat tähän ikeniänsä

irvistellen tov. Tarjuksen jo olevan siinä kypsyyden tilassa, ettei
hänellä pysy kynä näpissä, minkä johdosta nähtiin Mikko Tarjuksen
vihaisesti vääntelevän silmiään.

Muutamien nauraessa sanoi Kaisa Kompura ilkeästi

mielipiteekseen toveri
Kuusisen varmasti pitävän mieluummin sihteerinään Hiltaa kuin
Mikko
Tarjusta.

Toveri Mikko Tarjus yritti tämän johdosta nousta ylös, mutta

painoivat Israel Huttunen ja Kusti Pirhonen hänet jälleen istumaan ja
käskivät hänen olla siivolla.
 Puhemies Näppinen selvitti rauhoittavasti kommunismin
hengessä, että jos vallankumouksen johtomiehet tahtovat meiltä
esimerkiksi morsiamet tai vaikka akatkin, niin on ne heille
luovutettava aatteen mukaisesti tarkoitusperiä varten, niinkuin
Venäjälläkin, koska kommunistin aatteena on omaisuuden yhteys, ja
nuhteli tov. Tarjusta hänen pikkumaisuutensa johdosta yhteisessä
asiassa, missä yksilön onni on vähäpätöinen.

Toveri Tarjus, ryhtyen metelöimään, ilmoitti antavansa kirkkaan

pirun sellaiselle vallankumoukselle.

Kun ilmeni, ettei toveri Tarjus tahtonut kuulla vallankumouksellisen

järjen ääntä, ehdotti puhemies Näppinen hänelle annettavaksi
kommunistisen varoituksen, mikä hyväksyttiin.

Tov. Tarjus sanoi, ettei hän ota semmoisen seurapiirin varoituksia

huomioonsa, minkä johdosta läsnäolijat lausuivat tov. Tarjukselle
kummastuksensa, jota ei voitu merkitä pöytäkirjaan, ollen se tov.
Tarjuksen taskussa.

Kaisa Kompura sanoi Mikko Tarjukselle toivovansa, ettei Hilta

Kukkasjärvi siitä paljon pahene, vaikkapa onkin yhden illan vieraan
miehen kanssa lukon takana aitassa katkesmuksen teossa, minkä
johdosta jotkut internaalit äänekkäästi karjuen käskivät Kaisa
Kompuran pitää suunsa kiinni ja laputtaa pellolle.

Useiden toverien vannottaessa Mikko Tarjusta uhraamaan

tilapäisesti rakkautensa vallankumouksen alttarille, vaikkapa toveri
Kuusisella olisikin joitakin sivutarkoituksia Hiltaan nähden, puhkesi
tov. Tarjus kyyneleihin ja ilmoitti olevansa luokkataistelun uhri.
 Koska tov. Tarjus hetken kuluttua putosi pöydän alle, annettiin
hänen nukkua siellä, kun ei muuallakaan ollut tilaa.

Tämän jälkeen ryhdyttiin vilkastuvan mielialan vallitessa

keskustelemaan kommunistin katkesmuksen käytäntöön
ottamisesta, ja ehdotti puhemies Näppinen, että toverit esittäisivät
mielipiteensä.

Tov. Lötjönen murahti, että kommunistin katkesmus on aivan

lojaali asia jokaiselle luokkatietoiselle kommunistille, jonka tähden
sitä olisi kannatettava.

Tov. Israel Huttunen, tehden laajaperäisesti selkoa kirkon

pimitystyöstä ja kinkerien käyttämisestä kansan orjuuttamiseen sekä
selväpiirteisen valistuksen hämäämiseen, esitti että kommunistin
katkesmus hyväksyttäisiin käytäntöön ensi kuun alusta, mihin
kokous vastasi myöntävästi.

Reeta Sinkkosen kysymykseen, olisko opeteltava koko katkesmus

ulkoa, vastattiin laajan puheenvaihdon jälkeen, mikä välistä muuttui
yleislaatuiseksi hölinäksi, ettei tarvitse lukea muuta kuin kymmenet
käskyt ja uskontunnustukset ulkoa, mutta muuten kunhan tietää
kertoa pääkohdat.

Valtuutettiin tov. Israel Huttunen kommunisterin arvolla pitämään

syksyllä kommunistiset kinkerit, joissa kuulustelee luokkatietoiselta
proletaarilta katkesmuksen taitoa.

Tov. Lötjösen ilmoitettua, ettei hän osaa oikein lojaalisti lukea,

päätettiin äänten enemmistöllä, ettei hänen tarvitse opetella muuta
kuin uskontunnustus, minkä Reeta Sinkkonen hänelle takokoon
päähän.
 Tov. Lötjönen lausui toivomuksenaan, että uskontunnustus ei olisi
lojaalia pitempi, mihin Kaisa Kompura muutamien nauraa
räkättäessä huusi, että jos ne siellä aitassa koko ajan
uskontunnustusta tekevät, niin riittää siinä sinulle opettelemista sivu
ensi pääsiäisenkin.

12 §.

Kommunistisen yleispöllöläläisen internaalin iltamat pidettiin

samana iltana samassa paikassa vaihtelevalla ohjelmalla.

Tilaisuuteen oli saapunut runsaasti luokkatietoista internaalia kuin

myöskin noskelaisia, sekä sellaistakin väkeä, joka ei vielä ole
herännyt täyteen vallankumoukselliseen tietoisuuteen, vaan liikkuu
vielä porvärillisen valhevaipan nukuttavien sumusireeniäänien
lumoissa.

Kun suuri osa yleisöä oli asettunut paikoilleen tuvassa, katselivat

kaikki ympärilleen, nähdäkseen toveri Kuusisen, jonka saapumisesta
salainen sana oli levinnyt laajoihin uskottuihin kerroksiin, ja
tähystelivät useat kunnioittavasti etenkin uunille, kunnes saatiin
kuulla kuiskaus toveri Kuusisen olevan aitassa kirjallisissa
toimenpiteissä.

Puhemies Näppisen tuntiessa itsensä väsyneeksi piti

tervehdyspuheen tov. Justus Tiilikainen, kosketellen järjestötoimintaa
vallankumouksellisessa hengessä, ja havaittiin avauspuheen pitäjän
kasvonpiirteissä mitä vakavimpia ilmeitä, hänen sanoessaan että
hän olisi tahtonut puhua kaiken mitä ajatteli, katsellessaan sitä
suurilukuista nuorisoparvea, mikä harhailee ulkopuolella järjestöjen.
Siirtyen sitten puhumaan noskelaisista ilmoitti puhuja, että
noskelaisten ohjelmassa ilmenevät perusjuonet ovat ilmianto,
provokatsiooni, oman mädännäisyytensä peittäminen ja
tietämättömien joukkojen tunnoton pimittäminen ja uskotteleminen,
jotka ovat tämän kuolemaantuomitun liikkeen viimeisiä,
kouristuksentapaisesti nytkähteleviä elonmerkkejä.

Puhujan ennätettyä näin pitkälle keskeyttivät ylvästelevät nosket

esityksen mitä raakamaisimmalla jalkojen töminällä ja pehmeäksi
keitetyllä nauriilla, joka lätkähti keskelle puhujan otsaa, leviten
ympäri naamaa, ja matkaansaattoi ilkeän naurun-ulvonnan ei
ainoastaan noskelaisissa, vaan eräissä vähemmän valistuneissa
kommunisteissakin.

Kun toveri Tiilikainen, pyyhkien naurismuhennosta otsaltaan,

poskiltaan ja leuastaan, oli astunut pois puhujan paikalta ja tämän
häpeällisen attentaatin nostama meteli oli vähän asettunut, lausui
Reeta Sinkkonen tunnelmallisella taidolla runon »Työn orjat», mitä
tervehdittiin vilkkailla kättentaputuksilla.

Tämän jälkeen seurasi ohjelmassa yleinen tanssi hanurin

säestyksellä, minkä aikana muutamat korven kyynelistä liikutetut
pikkunosket tekivät paheksittavaa ilkivaltaa ulkona pihalla, nostaen
rappuset pois oven edestä ja jyskyttäen haloilla seiniä.

Myöskin oli joku heistä iltamapirtin ovella seisten kysellyt,

kumpaako kansa tahtoo, pimeyttä vaiko valkeutta, katsellen
sääliväisesti katossa palavaa lamppua ja poistuen sitten ulos
myrtyneen näköisenä, lamppuun koskematta.
 Reeta Sinkkosen kysymykseen, missä järjestysmiehet ovat, kun
eivät ole hoitamassa virkaansa, ilmoitti Kaisa Kompura asiaan
perehdyttyään järjestysmiesten nukkuvan saunan lauteilla ja ettei ole
mahdollista saada heitä hereille.

Koska kahvilanpuolella oli vesiämpäri kaatunut permannolle, niin

että sihteeri Mikko Tarjus oli kastunut selkäpuoleltaan märäksi näin
syntyneessä lätäkössä, oli toveri Tarjus herännyt pöydän alla,
noussut ylös ja ryhtynyt kuivailemaan selkäänsä hellan edessä.

Tällöin tuli Kaisa Kompura, joka oli vähäväliä liikkunut ulkona

huomioita tekemässä, sisään ja sanoi kovalla äänellä, että niillä
katkesmuksen kirjoittajilla mahtaa olla kissan silmät, kun näkevät
pimeässäkin kirjoittaa ja ovat sammuttaneet lampun.

Tämän johdosta päästi toveri Mikko Tarjus niin kovan kirouksen,

että se kuului yli tanssin jytkytyksen, ja läksi syöksymään ulos.

Koska näytti olevan pelättävissä väkivaltaisuutta tov. Kuusista

kohtaan tov. Tarjuksen taholta, ryhtyivät Simo Turtiainen ja Jerobeam
Näppinen estämään Mikko Tarjusta, jolloin kaikki kolme iltamayleisön
huutaessa vyöryivät ulos ovesta ja putosivat päistikkaa alas
kynnykseltä edellämainitun, portaille tehdyn ilkivaltaisuuden
johdosta.

Tässä putouksessa onnistui Mikko Tarjuksen päästä irti Jerobeam

Näppisen ja Simo Turtiaisen käsistä, ja juosten aitan ovelle alkoi
Mikko Tarjus, monisanaisesti kiroillen, perkaa ovea nyrkeillään,
vaatien, niinkuin sanat kuuluivat, päästä varajäseneksi
katkesmuskomiteaan.