Unit 10-Basic Nursing Skills

Unit 10 Basic Nursing Skills
Nurse Aide I Course
DHSR Approved Curriculum-Unit 10
Basic Nursing Skills Introduction

This unit introduces the basic nursing skills the nurse aide will need to measure and record the residents vital signs, height and weight, and intake and output. The vital signs provide information about changes in normal body function and the residents response to treatment.
DHSR Approved Curriculum-Unit 10 2
Basic Nursing Skills Introduction

(continued)
The residents weight, compared with the height, gives information about his/her nutritional status and changes in the medical condition. Intake and output records provide information on fluid balance and kidney function.
10.0 Provide basic nursing skills.
Vital Signs
Reflect the function of three body processes that are essential for life. Regulation of body temperature Heart function Breathing
10.1 Explain the meaning of vital signs and the abbreviations used for each vital sign.
Vital Signs
(continued)
Abbreviations: Temperature T Pulse P Respirations R Blood Pressure BP Vital signs - TPR and BP
Vital Signs
(continued)
Purpose Measured to detect any changes in normal body function Used to determine response to treatment
Vital Signs
(continued)
Measurement (taken at rest) Temperature - measures body heat Pulse - measures heart rate Respiration - measures how often resident inhales and exhales Blood Pressure - measures pressure against walls of arteries
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10.2 Define body temperature and discuss the way it is measured.
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Temperature Measurement Of Body Heat

Heat production muscles glands oxidation of food Heat loss respiration perspiration excretion
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Temperature Measurement Of Body Heat

(continued)
Balance between heat production and heat loss is body temperature
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10.2.1 List the factors that affect temperature.
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Factors Affecting Temperature
Exercise Illness Age Time of day Medications
Infection Emotions Hydration Clothing Environmental temperature/air movement

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Equipment - Thermometer
Instrument used to measure body temperature Types Non-mercury glass oral rectal
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Equipment - Thermometer
Types (continued) chemically treated paper disposable plastic disposable electronic - probe covered with disposable shield tympanic - electronic probe used in the ear
10.2.2 Identify the normal temperature range, and the normal body temperature.
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Normal Temperature Range For Adults

Oral - 97.6 - 99.6 F (Fahrenheit) or 36.5 37.5 C (Celsius) Rectal - 98.6 - 100.6 F or 37.0 - 38.1 C Axillary - 96.6 - 98.6 F or 36.0 - 37.0 C
10.2.3 Read a non-mercury glass thermometer.
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To Read A Non-mercury Glass Thermometer Hold eye level Locate solid column of liquid in the glass Observe lines on scale at upper side of column of liquid in the glass
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To Read A Non-mercury Glass Thermometer
Read at point where liquid ends If liquid falls between two lines, read it to closest line long line represents degree short line represents 0.2 of a degree Fahrenheit
(continued)
10.2.4 List and discuss the sites used to take a temperature.
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Sites To Take A Temperature Oral most common Rectal registers one degree Fahrenheit higher than oral Axillary least accurate; registers one degree Fahrenheit lower than oral Tympanic probe inserted into the ear canal
Sites To Take A Temperature

(continued)
Condition of resident determines which is the best site for measuring body temperature
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10.2.5 Review safety precautions that should be considered when using a thermometer.
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Temperature: Safety Precautions

Hold rectal and axillary thermometers in place Stay with resident when taking temperature Check glass thermometers for chips Prior to use, shake liquid in glass down Shake thermometer away from resident and hard objects
Temperature: Safety Precautions

(continued)
Wipe from end to tip of thermometer prior to reading Delay taking oral temperature for 10 - 15 minutes if resident has been smoking, eating or drinking hot/cold liquids.
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10.3 Demonstrate the procedure for measuring an oral temperature using a non-mercury glass thermometer.
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10.4 Demonstrate the procedure for measuring an axillary temperature using a non-mercury glass thermometer.
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10.5 Demonstrate the procedure for measuring a rectal temperature using a non-mercury glass thermometer.
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10.6 Demonstrate measuring temperature using an electronic or tympanic thermometer.
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10.7 Define pulse and discuss the way it is measured.
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Measurement of Pulse Pulse is pressure of blood pushing against wall of artery as heart beats and rests Pulse easier to locate in arteries close to skin that can be pressed against bone
Sites For Taking Pulse Radial base of thumb Temporal side of forehead Carotid side of neck Brachial inner aspect of elbow Femoral inner aspect of upper thigh
Sites For Taking Pulse

(continued)
Popliteal - behind knee Dorsalis pedis top of foot Apical pulse over apex of heart taken with stethoscope left side of chest
10.7.1 List the factors that affect the pulse.
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Factors Affecting Pulse
Age Sex Position Drugs Illness Emotions Activity level Temperature Physical training
10.7.2 Identify the normal pulse range and characteristics.
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Measurement of Pulse
Normal pulse range/characteristics: 60 -100 beats per minute and regular Documenting pulse rate Noted as number of beats per minute Rhythm - regular or irregular Volume - strong, weak, thready, bounding
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10.8 Demonstrate counting the radial pulse rate.
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10.9 Demonstrate measuring the apical pulse.
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10.10
Define respiration and discuss how the respiratory rate is measured.
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Measuring Respirations Respiration process of taking in oxygen and expelling carbon dioxide from lungs and respiratory tract
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10.10.1 List the factors that affect the respiratory rate.
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Measuring Respirations
(continued)
Factors Affecting Rate
Age Activity level Position Drugs
Sex Illness Emotions Temperature
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10.10.2 Identify the qualities of normal respirations.
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(continued)
Qualities of normal respirations 12-20 respirations per minute Quiet Effortless Regular
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(continued)
Documenting respiratory rate Noted as number of inhalations and exhalations per minute (one inhalation and one exhalation equals one respiration) Rhythm regular or irregular Character: shallow, deep, labored
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10.11 Demonstrate counting respirations.
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10.12 Define blood pressure and discuss how it is measured.
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Measuring Blood Pressure
Blood pressure is the force of blood pushing against walls of arteries Systolic pressure: greatest force exerted when heart contracting Diastolic pressure: least force exerted as heart relaxes
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10.12.1 List factors that influence blood pressure.
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Factors Influencing Blood Pressure Weight Sleep Age Emotions Sex Heredity Viscosity of blood Illness/Disease
Blood Pressure: Equipment Sphygmomanometer (manual) cuff - different sizes pressure control bulb pressure gauge marked with numbers aneroid mercury
Blood Pressure: Equipment

(continued)
Stethoscope magnifies sound has diaphragm
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10.12.2 Identify the normal blood pressure range.
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Measuring Blood Pressure Normal blood pressure range Systolic: 90-140 millimeters of mercury Diastolic: 60-90 millimeters of mercury
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Guidelines for Blood Pressure Measurements Measure on upper arm Have correct size cuff Identify brachial artery for correct placement of stethoscope
Guidelines for Blood Pressure Measurements

(continued)
First sound heard systolic pressure Last sound heard or change - diastolic pressure
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(continued)
Record - systolic/diastolic Resident in relaxed position, sitting or lying down Blood pressure usually taken in left arm

(continued)
Do not measure blood pressure in arm with IV, A-V shunt (dialysis), cast, wound, or sore
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(continued)
Apply cuff to bare upper arm, not over clothing Room quiet so blood pressure can be heard Sphygmomanometer must be clearly visible
Blood Pressure: Reading Gauge Large lines are at increments of 10 mmHg Shorter lines at 2 mm intervals Take reading at closest line
Blood Pressure: Reading Gauge

(continued)
Gauge should be at eye level Mercury column gauge must not be tilted Reading taken from top of column of mercury
300 290 280 270 260 250 240 230 220 210 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 20 10
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10.13 Demonstrate the procedure for measuring blood pressure.
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10.14 Demonstrate the procedure for taking combined vital signs.
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10.15 Discuss height and weight and how it is measured.
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Measuring Height And Weight Baseline measurement obtained on admission and must be accurate. Other measurements obtained as ordered.
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Measuring Height And Weight

(continued)
Height measurements Feet Inches Centimeters Weight measurements Pounds Ounces Kilograms
Measuring Height and Weight

(continued)
Reasons for obtaining height and weight Indicator of nutritional status Indicator of change in medical condition Used by doctor to order medications
10.15.1 List three guidelines for weighing residents.
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Measuring Height and Weight

(continued)
Guidelines for weighing residents Use same scale each time Have resident void, remove shoes and outer clothing Weigh at same time each day
Measuring Height and Weight Scales Remain more accurate if moved as little as possible. Various types of scales bathroom scale standing scale scales attached to hydraulic lifts wheelchair scales bed scales
(continued)
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10.16 Demonstrate the procedure for measuring height and weight.
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10.17 Discuss measuring and recording intake and output, and conditions for which this procedure would be ordered.
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Measuring Intake and Output Fluid Balance Consume 2-1/2 to 3-1/2 quarts daily eating drinking
Eliminate 2-1/2 to 3-1/2 quarts daily urine perspiration water vapor through respirations stool
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10.17.1 Identify five symptoms of edema.
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Edema
Edema fluid intake exceeds fluid output Retention of fluids frequently caused by kidney or heart failure or excessive salt intake
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Edema
(continued)
Symptoms weight gain swelling of feet, ankles, hands, fingers, face decreased urine output shortness of breath collection of fluid in abdomen (ascites)
10.17.2 List eight symptoms of dehydration.
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Dehydration
Dehydration: fluid output exceeds fluid intake Common problem of long-term care residents
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Symptoms thirst decreased urine output parched or cracked lips dry, cracked skin fever weight loss concentrated urine tongue coated and thick
Dehydration (continued)
Dehydration
(continued)
Causes of dehydration poor fluid intake diarrhea bleeding vomiting excessive perspiration
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Dehydration
(continued)
Fluids measured in cubic centimeters (cc) 30 cc = 1 ounce cc - metric measure
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10.18 Identify the liquids that would be measured and recorded as fluid intake.
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Measuring and Recording Intake/Output

Physician orders intake and output Intake includes: All liquid taken by mouth Food items that turn to liquid at room temperature Tube feedings into stomach through nose or abdomen Fluids given by intravenous infusion
10.18.1 List the liquids that would be measured and recorded as fluid output.
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Measuring and Recording Intake/Output

(continued)
Output includes Urine Liquid stool Emesis Drainage Suctioned secretions Excessive perspiration
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10.19 Demonstrate measuring and recording fluid intake and output.
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Unit 10 Basic Nursing Skills

Nurse Aide I Course

DHSR Approved Curriculum-Unit 10

Basic Nursing Skills Introduction

Basic Nursing Skills Introduction

DHSR Approved Curriculum-Unit 10

10.0 Provide basic nursing skills.

DHSR Approved Curriculum-Unit 10

DHSR Approved Curriculum-Unit 10

DHSR Approved Curriculum-Unit 10

DHSR Approved Curriculum-Unit 10

10.2 Define body temperature and discuss the way it is measured.

DHSR Approved Curriculum-Unit 10

Temperature Measurement Of Body Heat

DHSR Approved Curriculum-Unit 10

Temperature Measurement Of Body Heat

Balance between heat production and heat loss is body temperature

DHSR Approved Curriculum-Unit 10

10.2.1 List the factors that affect temperature.

DHSR Approved Curriculum-Unit 10

Factors Affecting Temperature

Exercise Illness Age Time of day Medications

Infection Emotions Hydration Clothing Environmental temperature/air movement

DHSR Approved Curriculum-Unit 10

DHSR Approved Curriculum-Unit 10

DHSR Approved Curriculum-Unit 10

Normal Temperature Range For Adults

10.2.3 Read a non-mercury glass thermometer.

DHSR Approved Curriculum-Unit 10

DHSR Approved Curriculum-Unit 10

To Read A Non-mercury Glass Thermometer

10.2.4 List and discuss the sites used to take a temperature.

DHSR Approved Curriculum-Unit 10

Sites To Take A Temperature

DHSR Approved Curriculum-Unit 10

DHSR Approved Curriculum-Unit 10

Temperature: Safety Precautions

Temperature: Safety Precautions

DHSR Approved Curriculum-Unit 10

DHSR Approved Curriculum-Unit 10

DHSR Approved Curriculum-Unit 10

DHSR Approved Curriculum-Unit 10

10.6 Demonstrate measuring temperature using an electronic or tympanic thermometer.

DHSR Approved Curriculum-Unit 10

DHSR Approved Curriculum-Unit 10

10.7 Define pulse and discuss the way it is measured.

DHSR Approved Curriculum-Unit 10

Sites For Taking Pulse

10.7.1 List the factors that affect the pulse.

DHSR Approved Curriculum-Unit 10

Factors Affecting Pulse

10.7.2 Identify the normal pulse range and characteristics.

DHSR Approved Curriculum-Unit 10

DHSR Approved Curriculum-Unit 10

10.8 Demonstrate counting the radial pulse rate.

DHSR Approved Curriculum-Unit 10

10.9 Demonstrate measuring the apical pulse.

DHSR Approved Curriculum-Unit 10

DHSR Approved Curriculum-Unit 10

Define respiration and discuss how the respiratory rate is measured.