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7 Basic Nursing Skills

Vital signs measurements that show how well the vital organs of the body are working; consist of body temperature, pulse, respirations, blood pressure, and level of pain.

7 Basic Nursing Skills


Monitor, document, and report on the following vital signs: Temperature Pulse Rate of respirations Blood pressure Pain level Notify the nurse in any of these cases: Resident has a fever Respiratory or pulse rate is too rapid or slow Blood pressure changes Pain is worsening or unrelieved

7 Basic Nursing Skills

Transparency 7-1: Normal Ranges for Vital Signs Temperature Oral Rectal Axillary Fahrenheit 97.6-99.6 98.6-100.6 96.6-98.6 Celsius 36.5-37.5 37.0-38.1 36.0-37.0

Pulse: 60-100 beats per minute Respirations: 12-20 respirations per minute Blood Pressure: Normal: Systolic 100-119 Diastolic 60-79 Prehypertension: Systolic 120-139 Diastolic 80-89 High: 140/90 or above Low: Below 100/60

7 Basic Nursing Skills


Remember these things about monitoring body temperature: Age, illness, stress, environment, exercise, and the circadian rhythm all affect temperature. There are four sites for measuring (mouth, rectum, armpit, ear). Oral temperatures cannot be taken on someone who is unconscious, has recently had facial or oral surgery, is younger than 5 years old, is confused, is heavily sedated, is likely to have a seizure, is coughing, is using oxygen, has facial paralysis, has a nasogastric tube, has sores, redness, swelling, or pain in the mouth, or has an injury to the face or neck

7 Basic Nursing Skills


Remember when monitoring body temperature (contd.): Mercury-free thermometers are safer than mercury glass thermometers and are required in some states. Mercury-free thermometers and glass thermometers operate identically. Rectal temperatures are most accurate, but taking rectal temperature can be dangerous with some residents. Axillary temperatures are considered least accurate.

7 Basic Nursing Skills


Remember these points about taking rectal temperature: Explain what you will do before starting. Be reassuring. Hold onto thermometer at all times. Wear gloves. The privacy of the resident is important. Thermometer must be lubricated for this procedure. The privacy of the resident is important.

7 Basic Nursing Skills


Remember these things about taking typanic and axillary temperature: Tympanic thermometers are fast and accurate. The tympanic thermometer will only go into the ear 1/4 - 1/2 inch. Axillary temperatures are much less reliable. Axillary temperatures can be safer if residents are confused, disoriented, uncooperative, or have dementia.

7 Basic Nursing Skills


Define the following terms:

Radial pulse the pulse located on the inside of the wrist, where the radial artery runs just beneath the skin. Brachial pulse the pulse inside the elbow, about 1 to 1 1/2 inches above the elbow.

7 Basic Nursing Skills


Remember these things about monitoring pulse: Pulse is the number of heartbeats per minute. Pulse is commonly taken at the wrist where radial artery runs. Normal rate is 60-100 beats per minute for adults. Normal rate is 100-120 beats per minute for small children, as high as 120-140 for newborns. Pulse may be affected by exercise, fear, anger, anxiety, heat, medications and pain. Rapid pulse may result from fever, infection, or heart failure. Slow/weak pulse may indicate dehydration, infection, or shock.

7 Basic Nursing Skills


Remember these things about counting respirations: A breath includes both inspiration and expiration. Normal adult rate is 12-20 breaths per minute. Normal rate for infants is 30-40 breaths per minute. Do the counting immediately after taking the pulse. Do not let the resident know you are counting breaths.

7 Basic Nursing Skills


Systolic first measurement of blood pressure; phase when the heart is at work, contracting and pushing the blood from the left ventricle of the heart. Diastolic second measurement of blood pressure; phase when the heart relaxes or rests.

7 Basic Nursing Skills


Remember these facts about blood pressure: The two parts are systolic (top number) and diastolic (bottom number). Normal range is: S=100 to 119, D=60 to 79. Blood pressure measurements between 120/80 and 139/89 were once considered normal but are now considered prehypertension. Brachial artery at the elbow is used. Equipment used is stethoscope and sphygmomanometer. An electronic sphymomanometer may be available. If so, you will be trained in its use. The cuff must first be completely deflated.

7 Basic Nursing Skills


Facts about blood pressure (contd.): Never measure blood pressure on an arm that has an IV, a dialysis shunt, or any medical equipment. Avoid a side with a cast, recent trauma, paralysis from a stroke, burns, or mastectomy. One-step method does not include getting an estimated systolic before beginning. Two-step method does require getting an estimated systolic.

7 Basic Nursing Skills


Remember the following about pain management: Pain is as important to monitor as vital signs. Pain is an experience that is uncomfortable and different for each person. Take complaints of pain seriously. Observe and report carefully since care plans are based on your reports. Ask questions to get accurate information. Pain is not a normal part of aging.

7 Basic Nursing Skills


Observe and report these signs and symptoms of pain: Increased pulse, respirations, and blood pressure Sweating Nausea Vomiting Tightening the jaw Squeezing eyes shut Holding a body part tightly Frowning Grinding teeth

7 Basic Nursing Skills


Review the following points about weight: Resident will be weighed repeatedly during his or her stay, and any change in weight should be reported immediately. Some residents will be weighed on a wheelchair scale. The weight of the wheelchair may need to be subtracted from a residents weight. Residents may need to be weighed on a bed scale.

7 Basic Nursing Skills


Restraint a physical or chemical way to restrict voluntary movement or behavior. Restraint-free the state of being free of restraints and not using restraints for any reason. Restraint alternatives any intervention used in place of a restraint or that reduces the need for a restraint.

7 Basic Nursing Skills

Restraints were Keep person Keep person Keep person Prevent falls

used from from from

in the past for the following reasons: hurting self or others pulling out tubing wandering

7 Basic Nursing Skills

REMEMBER: Restraint usage is illegal in many states. Restraints can only be used with a doctors order. It is against the law for staff to apply restraints for convenience or discipline.

7 Basic Nursing Skills

Transparency 7-2: Problems from Restraint Use Reduced blood circulation Stress on the heart Incontinence Constipation Weakened muscle and bones Loss of bone mass Muscle atrophy Pressure sores Risk of suffocation Pneumonia Possible Injury or death

7 Basic Nursing Skills

Handout 7-3: Restraint Alternatives Improve safety measures. Keep call light within reach. Answer call lights promptly. Ambulate the person when he or she is restless. Provide activities for those who wander at night. Encourage activities and independence. Give frequent help with toileting. Offer food or drink. Offer reading materials.

7 Basic Nursing Skills


Intake the fluid a person consumes; also called input. Output all fluid that is eliminated from the body; includes fluid in urine, feces, vomitus, perspiration, and moisture in the air that is exhaled. Fluid balance taking in and eliminating equal amounts of fluid.

7 Basic Nursing Skills

Transparency 7-4: Conversion Table A milliliter (mL or ml) is a unit of measure equal to one cubic centimeter (cc). 1 oz. = 30 cc or 30 ml 2 oz. = 60 cc 3 oz. = 90 cc 4 oz. = 120 cc 5 oz. = 150 cc 6 oz. = 180 cc 7 oz. = 210 cc 8 oz. = 240 cc cup = 2 oz. = 60 cc cup = 4 oz. = 120 cc 1 cup = 8 oz. = 240 cc

7 Basic Nursing Skills


Specimen a sample. Hat in health care, a collection container that is sometimes inserted into a toilet to collect and measure urine or stool. Mid-stream specimen a type of urine specimen in which the first and last urine are not included in the sample.

7 Basic Nursing Skills


Remember these things about collecting specimens: NAs must wear gloves for these procedures. Tagging and storing specimens correctly is important. Be sensitive to the fact that residents may find it embarrassing or uncomfortable to have others handling their body wastes. If you feel the task is unpleasant, do not make it known. Remain professional. Remind students after they discard their gloves after collecting specimens, they must wash their hands.

7 Basic Nursing Skills


Remember these things about collecting a routine urine specimen: Do not include toilet paper with sample. Help with perineal care after urination if necessary. Fill container at least half full. Do not touch the inside of container. Complete label accurately. Wash your hands after completing the procedure.

7 Basic Nursing Skills


Catheter a thin tube inserted into the body used to drain or inject fluids. Straight catheter a catheter that does not remain inside the person; it is removed immediately after urine is drained. Indwelling catheter a catheter that remains inside the bladder for a period of time; the urine drains into a bag Condom catheter catheter that has an attachment on the end that fits onto the penis; also called an external or Texas catheter.

7 Basic Nursing Skills


REMEMBER: NAs never insert, irrigate, or remove catheters.

7 Basic Nursing Skills


Remember these guidelines for catheter care: Keep drainage bag lower than the residents hips or bladder to prevent infection. Keep the drainage bag off the floor. Prevent kinks and twists in tubing. Keep genital area clean.

7 Basic Nursing Skills


5. Define fluid balance and explain intake and output (I&O) Observe and report when providing catheter care: Bloody urine Catheter bag does not fill after several hours Catheter bag fills suddenly Catheter is not in place Urine leaks from catheter Resident reports pain or pressure Odor

7 Basic Nursing Skills


Combustion the process of burning. Flammable easily ignited and capable of burning quickly.

7 Basic Nursing Skills


Remember these guidelines for oxygen safety: Remove fire hazards. Post No Smoking and Oxygen in Use signs. Do not allow smoking around oxygen equipment. Do not allow flames around oxygen (this includes candles). Learn how to turn oxygen off in case of fire if facility allows this. Never adjust oxygen level. Report skin irritation.

7 Basic Nursing Skills


Equipment usually found in a residents unit includes the following: Electric or manual bed Bedside stand Urinal/bedpan and covers Wash basin Emesis basin Soap dish and soap Bath blanket

7 Basic Nursing Skills


Certain items may not be placed on an overbed table: Soiled items Bedpans Urinals

7 Basic Nursing Skills


Remember the following about call lights: They must always be placed within residents reach. They must be answered immediately, no matter how many times a resident has used the call light. NAs should respond kindly each time a resident uses his or her call light.

7 Basic Nursing Skills


REMEMBER: Privacy curtains promote residents right to privacy. They should be used every time care is performed. Privacy curtains do no block sound, so keep voices low during conversations and care.

7 Basic Nursing Skills


Remember these guidelines for caring for a residents unit: Clean the overbed table after each use. Keep equipment clean and in good condition. Report problems with equipment to nurse or according to facility guidelines. Keep call light within reach. Remove meal trays promptly, then remove crumbs and straighten linens. Change linens if they are wet, soiled, or wrinkled.

7 Basic Nursing Skills

Lack of sleep can cause the following problems: Decreased mental function Reduced reaction time Irritability Decreased immune system function

7 Basic Nursing Skills

Watch for these things when a resident is not sleeping well: Sleeping too much during the day Consuming too much caffeine Dressing in night clothes during the day Eating too late at night Refusing medication ordered for sleep Taking new medications TV, radio, or light on late at night Pain

7 Basic Nursing Skills


Occupied bed a bed made while a person is in the bed. Unoccupied bed a bed made while nobody is in the bed. Closed bed a bed completely made with the bedspread and blankets in place. Open bed a bed made with linen fanfolded down to the foot of the bed.

7 Basic Nursing Skills

Consider these reasons for careful bedmaking: Damp and wrinkled sheets keep the resident from sleeping well. Microorganisms thrive in moist, warm places and damp, unclean bedding may cause infection or disease. Sheets that are not flat increase risk for pressure sores.

7 Basic Nursing Skills

Remember these guidelines for bedmaking: Keep linens wrinkle-free and tidy. Wash hands before handling clean linen. Hold soiled linens away from your body. If dirty linen touches your uniform, your uniform becomes contaminated. Do not shake linen or clothes. Put on gloves before removing bed linens. Look for personal items before removing linens. When removing linens, fold or roll linen so the dirtiest area is inside.

7 Basic Nursing Skills

Guidelines for bedmaking (contd.): Bag soiled linen at point of origin and do not take it to other residents rooms. Sort soiled linen away from care areas. Place wet linen in leak-proof bags. Disposable bed protectors or pads are used for incontinent residents. Change them as soon as they are soiled or wet and dispose of them properly.

7 Basic Nursing Skills


REMEMBER: NAs do not change sterile dressings,which cover open or draining wounds. Non-sterile dressings are for wounds that have less chance of infection. NAs may assist with non-sterile dressing changes.

7 Basic Nursing Skills


Remember these points: Non-sterile bandages hold dressings in place, secure splints, and support and protect body parts. They may decrease swelling from an injury. NAs may assist with use of an elastic bandage. Some states allow NAs to apply and remove elastic bandages. Follow your facilitys policy.

7 Basic Nursing Skills


Remember these guidelines for elastic bandages: Keep area clean and dry. Apply snugly enough to control bleeding but make sure not to wrap too tightly, as this can decrease circulation. Wrap bandage evenly. Do not tie the bandage; use special clips. Remove bandage as often as indicated in care plan.

7 Basic Nursing Skills


Guidelines for elastic bandages (contd.): Check bandage often to be sure it doesnt become wrinkled or loose. 15 minutes after bandage is applied check for signs of poor circulation; loosen if any of these signs are present: Swelling Bluish (cyanotic) skin Shiny, tight skin Skin cold to touch Sores Numbness Tingling Pain or discomfort

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