This document discusses basic nursing skills related to taking vital signs including blood pressure, heart rate, temperature, respiratory rate, and pain level. It explains the importance of observing and reporting vital signs as they can alert nurses to changes in a patient's condition. Key points covered include normal ranges for blood pressure and temperature, common methods for taking temperature, how to take a pulse and count respirations, the process for taking a blood pressure, assessing pain, and ways nursing assistants can help patients with pain. The document also distinguishes between sterile and non-sterile dressings and notes the roles of nurses and nursing assistants regarding oxygen therapy.

1. Basic Nursing Skills
Chapter 14

2. Vital Signs
• 5 of them
– Blood pressure
– HR
– Temp
– RR
– Pain level – recently added to insure resident statu
Very important to observe and report it.

3. Importance of VS
• Will alert you and the nurse that something is
changing
• Normals:
BP – Systolic – 100 – 139
Diastolic – 60 – 89
Low – Systolic less than 100
Diastolic less than 60
High – Systolic greater than 139
Diastolic – greater than 89

4. Temperature
• Many ways to take:
– Oral – glass, disposable
– Tympanic
– Rectal
– Axillary
– Temporal artery (see pg 226 for picture)
• Rectal temperature the most accurate

5. Most common…what you will see
• Oral thermometer with disposable sheath
• Tympanic
• Maybe a temporal scan

6. Taking the pulse
• Most common site is the radial pulse
• See ppt on this…
• Brachial pulse…located on upper inner aspect of
arm
• You will feel for this when taking BP
• Always count for full minute (for test).
• In real setting, may count for 15 – 30 seconds,
then multiply by 4 or 2.

7. Apical pulse
• Use stethoscope to listen, using Diaphragm
(large part of listening device)
Will use when you cannot obtain radial pulse

8. Counting Respirations
• Will do this at same time as when taking
pulse…
• Do this without resident knowing…
• Count for a full minute

9. Taking a measuring blood pressure
• What you will need…
– BP Cuff
– Stethoscope
– Patient
– Notebook and pen to record
– We will practice this tonight…

10. Pain
• Subjective
• Whatever the resident says it is…it is!
• Ask about location, kind, when it happens
• What makes it better or worse
• Report to nurse
• Report when you see residents..
– Crying, grimacing, holding body part, sob

11. Ways you can help
• Warm and cold compresses
• K-Pad – you will need special instruction of
this from nurse
• Sitz bath
• Ice packs

12. Sterile vs Non-strerile bandages
• NAs will only apply “clean” bandages
• The nurse will do any “sterile” dressing
changes
• Sterile dressings cover open or draining
wounds.
• Report if dressings are loose or soiled and
need changing
• For IVs – NA role is to report any problems
noticed

13. Oxygen therapy
• Nasal cannula
• O2 saturation
• Oxygen concentrators
• CNAs do not adjust, turn on, or off, unless
trained to do so or nurse present