Unit 10 Basic Nursing Skills

Slide 1: Unit 10 Basic Nursing Skills Nurse Aide I Course DFS Approved Curriculum-Unit 10 1

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

Slide 3: Basic Nursing Skills Introduction (continued) The resident’s 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. DFS Approved Curriculum-Unit 10 3

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Slide 5: 10.0 Provide basic nursing skills. DFS Approved Curriculum-Unit 10 5

Slide 6: Vital Signs • Reflect the function of three body processes that are essential for life. – Regulation of body temperature – Heart function – Breathing DFS Approved Curriculum-Unit 10 6

Slide 7: 10.1 Explain the meaning of vital signs and the abbreviations used for each vital sign. DFS Approved Curriculum-Unit 10 7

Slide 8: Vital Signs (continued) • Abbreviations: – Temperature – T – Pulse – P – Respirations – R – Blood Pressure – BP – Vital signs - TPR and BP DFS Approved Curriculum-Unit 10 8

Slide 9: Vital Signs (continued) • Purpose – Measured to detect any changes in normal body function – Used to determine response to treatment DFS Approved Curriculum-Unit 10 9

Slide 10: 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 DFS Approved Curriculum-Unit 10 10

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Slide 12: 10.2 Define body temperature and discuss the way it is measured. DFS Approved Curriculum-Unit 10 12

Slide 13: Temperature – Measurement Of Body Heat • Heat production • Heat loss – muscles – respiration – glands – perspiration – oxidation of – excretion food DFS Approved Curriculum-Unit 10 13

Slide 14: Temperature – Measurement Of Body Heat (continued) Balance between heat production and heat loss is body temperature DFS Approved Curriculum-Unit 10 14

Slide 15: 10.2.1 List the factors that affect temperature. DFS Approved Curriculum-Unit 10 15

Slide 16: Factors Affecting Temperature • Exercise • Infection • Illness • Emotions • Age • Hydration • Time of day • Clothing • Medications • Environmental temperature/air movement DFS Approved Curriculum-Unit 10 16

Slide 17: Equipment - Thermometer • Instrument used to measure body temperature • Types – Non-mercury glass • oral • rectal DFS Approved Curriculum-Unit 10 17

Slide 18: Equipment - Thermometer • Types (continued) – chemically treated paper – disposable – plastic – disposable – electronic - probe covered with disposable shield – tympanic - electronic probe used in the ear DFS Approved Curriculum-Unit 10 18

Slide 19: 10.2.2 Identify the normal temperature range, and the normal body temperature. DFS Approved Curriculum-Unit 10 19

Slide 20: 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 DFS Approved Curriculum-Unit 10 20

Slide 21: 10.2.3 Read a non-mercury glass thermometer. DFS Approved Curriculum-Unit 10 21

Slide 22: 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 DFS Approved Curriculum-Unit 10 22

Slide 23: To Read A Non-mercury Glass Thermometer (continued) • 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 DFS Approved Curriculum-Unit 10 23

Slide 24: 10.2.4 List and discuss the sites used to take a temperature. DFS Approved Curriculum-Unit 10 24

Slide 25: 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 DFS Approved Curriculum-Unit 10 25

Slide 26: Sites To Take A Temperature (continued) Condition of resident determines which is the best site for measuring body temperature DFS Approved Curriculum-Unit 10 26

Slide 27: 10.2.5 Review safety precautions that should be considered when using a thermometer. DFS Approved Curriculum-Unit 10 27

Slide 28: 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 DFS Approved Curriculum-Unit 10 28

Slide 29: 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. DFS Approved Curriculum-Unit 10 29

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Slide 31: 10.3 Demonstrate the procedure for measuring an oral temperature using a non-mercury glass thermometer. DFS Approved Curriculum-Unit 10 31

Slide 32: 10.4 Demonstrate the procedure for measuring an axillary temperature using a non-mercury glass thermometer. DFS Approved Curriculum-Unit 10 32

Slide 33: 10.5 Demonstrate the procedure for measuring a rectal temperature using a non-mercury glass thermometer. DFS Approved Curriculum-Unit 10 33

Slide 34: 10.6 Demonstrate measuring temperature using an electronic or tympanic thermometer. DFS Approved Curriculum-Unit 10 34

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Slide 36: 10.7 Define pulse and discuss the way it is measured. DFS Approved Curriculum-Unit 10 36

Slide 37: 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 DFS Approved Curriculum-Unit 10 37

Slide 38: 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 DFS Approved Curriculum-Unit 10 38

Slide 39: 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 DFS Approved Curriculum-Unit 10 39

Slide 40: 10.7.1 List the factors that affect the pulse. DFS Approved Curriculum-Unit 10 40

Slide 41: Factors Affecting Pulse • Age • Sex • Position • Drugs • Illness • Emotions • Activity level • Temperature • Physical training DFS Approved Curriculum-Unit 10 41

Slide 42: 10.7.2 Identify the normal pulse range and characteristics. DFS Approved Curriculum-Unit 10 42

Slide 43: 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 DFS Approved Curriculum-Unit 10 43

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Slide 45: 10.8 Demonstrate counting the radial pulse rate. DFS Approved Curriculum-Unit 10 45

Slide 46: 10.9 Demonstrate measuring the apical pulse. DFS Approved Curriculum-Unit 10 46

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Slide 48: 10.10 Define respiration and discuss how the respiratory rate is measured. DFS Approved Curriculum-Unit 10 48

Slide 49: Measuring Respirations • Respiration – process of taking in oxygen and expelling carbon dioxide from lungs and respiratory tract DFS Approved Curriculum-Unit 10 49

Slide 50: 10.10.1 List the factors that affect the respiratory rate. DFS Approved Curriculum-Unit 10 50

Slide 51: Measuring Respirations (continued) Factors Affecting Rate • Age • Sex • Activity • Illness level • Emotions • Position • Temperature • Drugs DFS Approved Curriculum-Unit 10 51

Slide 52: 10.10.2 Identify the qualities of normal respirations. DFS Approved Curriculum-Unit 10 52

Slide 53: Measuring Respirations (continued) • Qualities of normal respirations – 12-20 respirations per minute – Quiet – Effortless – Regular DFS Approved Curriculum-Unit 10 53

Slide 54: Measuring Respirations (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 DFS Approved Curriculum-Unit 10 54

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Slide 56: 10.11 Demonstrate counting respirations. DFS Approved Curriculum-Unit 10 56

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Slide 58: 10.12 Define blood pressure and discuss how it is measured. DFS Approved Curriculum-Unit 10 58

Slide 59: 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 DFS Approved Curriculum-Unit 10 59

Slide 60: 10.12.1 List factors that influence blood pressure. DFS Approved Curriculum-Unit 10 60

Slide 61: Factors Influencing Blood Pressure • Weight • Sleep • Age • Emotions • Sex • Heredity • Viscosity of blood • Illness/Disease DFS Approved Curriculum-Unit 10 61

Slide 62: Blood Pressure: Equipment • Sphygmomanometer (manual) – cuff - different sizes – pressure control bulb – pressure gauge – marked with numbers • aneroid • mercury DFS Approved Curriculum-Unit 10 62

Slide 63: Blood Pressure: Equipment (continued) • Stethoscope – magnifies sound – has diaphragm DFS Approved Curriculum-Unit 10 63

Slide 64: 10.12.2 Identify the normal blood pressure range. DFS Approved Curriculum-Unit 10 64

Slide 65: Measuring Blood Pressure • Normal blood pressure range – Systolic: 90-140 millimeters of mercury – Diastolic: 60-90 millimeters of mercury DFS Approved Curriculum-Unit 10 65

Slide 66: Guidelines for Blood Pressure Measurements • Measure on upper arm • Have correct size cuff • Identify brachial artery for correct placement of stethoscope DFS Approved Curriculum-Unit 10 66

Slide 67: Guidelines for Blood Pressure Measurements (continued) • First sound heard – systolic pressure • Last sound heard or change - diastolic pressure DFS Approved Curriculum-Unit 10 67

Slide 68: Guidelines for Blood Pressure Measurements (continued) • Record - systolic/diastolic • Resident in relaxed position, sitting or lying down • Blood pressure usually taken in left arm DFS Approved Curriculum-Unit 10 68

Slide 69: Guidelines for Blood Pressure Measurements (continued) • Do not measure blood pressure in arm with IV, A-V shunt (dialysis), cast, wound, or sore DFS Approved Curriculum-Unit 10 69

Slide 70: Guidelines for Blood Pressure Measurements (continued) • Apply cuff to bare upper arm, not over clothing • Room quiet so blood pressure can be heard • Sphygmomanometer must be clearly visible DFS Approved Curriculum-Unit 10 70

Slide 71: Blood Pressure: Reading Gauge • Large lines are at increments of 10 mmHg • Shorter lines at 2 mm intervals • Take reading at closest line DFS Approved Curriculum-Unit 10 71

Slide 72: Blood Pressure: Reading Gauge (continued) • Gauge should be at 300 eye level 290 280 270 260 250 240 230 220 210 • Mercury column 200 190 180 170 160 150 140 130 gauge must not be 120 110 100 90 80 70 60 50 tilted 40 30 20 10 • Reading taken from top of column of mercury DFS Approved Curriculum-Unit 10 72

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Slide 74: 10.13 Demonstrate the procedure for measuring blood pressure. DFS Approved Curriculum-Unit 10 74

Slide 75: 10.14 Demonstrate the procedure for taking combined vital signs. DFS Approved Curriculum-Unit 10 75

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Slide 77: 10.15 Discuss height and weight and how it is measured. DFS Approved Curriculum-Unit 10 77

Slide 78: Measuring Height And Weight • Baseline measurement obtained on admission and must be accurate. • Other measurements obtained as ordered. DFS Approved Curriculum-Unit 10 78

Slide 79: Measuring Height And Weight (continued) • Height measurements – Feet – Inches – Centimeters • Weight measurements – Pounds – Ounces – Kilograms DFS Approved Curriculum-Unit 10 79

Slide 80: 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 DFS Approved Curriculum-Unit 10 80

Slide 81: 10.15.1 List three guidelines for weighing residents. DFS Approved Curriculum-Unit 10 81

Slide 82: 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 DFS Approved Curriculum-Unit 10 82

Slide 83: Measuring Height and Weight (continued) • 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 DFS Approved Curriculum-Unit 10 83

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Slide 85: 10.16 Demonstrate the procedure for measuring height and weight. DFS Approved Curriculum-Unit 10 85

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Slide 87: 10.17 Discuss measuring and recording intake and output, and conditions for which this procedure would be ordered. DFS Approved Curriculum-Unit 10 87

Slide 88: Measuring Intake and Output Fluid Balance • Eliminate 2-1/2 to • Consume 2-1/2 3-1/2 quarts daily to 3-1/2 quarts – urine daily – perspiration – eating – water vapor – drinking through respirations – stool DFS Approved Curriculum-Unit 10 88

Slide 89: 10.17.1 Identify five symptoms of edema. DFS Approved Curriculum-Unit 10 89

Slide 90: Edema • Edema – fluid intake exceeds fluid output – Retention of fluids frequently caused by kidney or heart failure or excessive salt intake DFS Approved Curriculum-Unit 10 90

Slide 91: Edema (continued) • Symptoms – weight gain – swelling of feet, ankles, hands, fingers, face – decreased urine output – shortness of breath – collection of fluid in abdomen (ascites) DFS Approved Curriculum-Unit 10 91

Slide 92: 10.17.2 List eight symptoms of dehydration. DFS Approved Curriculum-Unit 10 92

Slide 93: Dehydration • Dehydration: fluid output exceeds fluid intake • Common problem of long-term care residents DFS Approved Curriculum-Unit 10 93

Slide 94: Dehydration (continued) • Symptoms – thirst – decreased urine output – parched or cracked lips – dry, cracked skin – fever – weight loss – concentrated urine – tongue coated and thick DFS Approved Curriculum-Unit 10 94

Slide 95: Dehydration (continued) • Causes of dehydration – poor fluid intake – diarrhea – bleeding – vomiting – excessive perspiration DFS Approved Curriculum-Unit 10 95

Slide 96: Dehydration (continued) • Fluids measured in cubic centimeters (cc) – 30 cc = 1 ounce – cc - metric measure DFS Approved Curriculum-Unit 10 96

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Slide 98: 10.18 Identify the liquids that would be measured and recorded as fluid intake. DFS Approved Curriculum-Unit 10 98

Slide 99: 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 DFS Approved Curriculum-Unit 10 99

Slide 100: 10.18.1 List the liquids that would be measured and recorded as fluid output. DFS Approved Curriculum-Unit 10 100

Slide 101: Measuring and Recording Intake/Output (continued) • Output includes – Urine – Liquid stool – Emesis – Drainage – Suctioned secretions – Excessive perspiration DFS Approved Curriculum-Unit 10 101

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Slide 103: 10.19 Demonstrate measuring and recording fluid intake and output. DFS Approved Curriculum-Unit 10 103

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