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Basic Nursing Skills ppt
1. 1
BASIC NURSING SKILLS
PRESENTED BY:
Prof. Vijayreddy Vandali
PhD Scholar, M.Sc (N), PGDHA, PGCDE,.
Dept of Medical-Surgical Nursing
INDIA
2. DHSR Approved Curriculum-Unit 10 2
Basic Nursing Skills
Introduction
This unit introduces the basic
nursing skills the nurse aide will need
to measure and record the residentâs
vital signs, height and weight, and
intake and output.
The vital signs provide information
about changes in normal body function
and the residentâs response to
treatment.
3. DHSR Approved Curriculum-Unit 10 3
Basic Nursing Skills
Introduction
(continued)
The residentâs 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.
6. DHSR Approved Curriculum-Unit 10 6
Vital Signs
⢠Reflect the function of three body
processes that are essential for life.
âRegulation of body temperature
âHeart function
âBreathing
7. DHSR Approved Curriculum-Unit 10 7
10.1 Explain the meaning of vital signs
and the abbreviations used for
each vital sign.
8. DHSR Approved Curriculum-Unit 10 8
Vital Signs
(continued)
⢠Abbreviations:
âTemperature â T
âPulse â P
âRespirations â R
âBlood Pressure â BP
âVital signs - TPR and BP
9. DHSR Approved Curriculum-Unit 10 9
Vital Signs
(continued)
⢠Purpose
âMeasured to detect
any changes in
normal body
function
âUsed to determine
response to
treatment
10. DHSR Approved Curriculum-Unit 10 10
Vital Signs
(continued)
⢠Measurement (taken at rest)
âTemperature - measures body heat
âPulse - measures heart rate
âRespiration - measures how often
resident inhales and exhales
âBlood Pressure - measures
pressure against walls of arteries
13. DHSR Approved Curriculum-Unit 10 13
Temperature â
Measurement Of Body Heat
⢠Heat production
âmuscles
âglands
âoxidation of
food
⢠Heat loss
ârespiration
âperspiration
âexcretion
14. DHSR Approved Curriculum-Unit 10 14
Temperature â
Measurement Of Body Heat
(continued)
Balance between heat
production and heat loss is body
temperature
20. DHSR Approved Curriculum-Unit 10 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
22. DHSR Approved Curriculum-Unit 10 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
23. DHSR Approved Curriculum-Unit 10 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
âlong line represents degree
âshort line represents 0.2 of a degree
Fahrenheit
25. DHSR Approved Curriculum-Unit 10 25
Sites To Take A Temperature
⢠Oral â most common
⢠Rectal â registers one degree
Fahrenheit higher than oral
⢠Axillary â least accurate; registers
one degree Fahrenheit lower than
oral
⢠Tympanic â probe inserted into the
ear canal
26. DHSR Approved Curriculum-Unit 10 26
Sites To Take A Temperature
(continued)
Condition of resident
determines which is the
best site for measuring
body temperature
27. DHSR Approved Curriculum-Unit 10 27
10.2.5 Review safety precautions that
should be considered when
using a thermometer.
28. DHSR Approved Curriculum-Unit 10 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
29. DHSR Approved Curriculum-Unit 10 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.
37. DHSR Approved Curriculum-Unit 10 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
38. DHSR Approved Curriculum-Unit 10 38
Sites For Taking Pulse
⢠Radial â base of thumb
⢠Temporal â side of
forehead
⢠Carotid â side of neck
⢠Brachial â inner aspect
of elbow
⢠Femoral â inner aspect
of upper thigh
39. DHSR Approved Curriculum-Unit 10 39
Sites For Taking Pulse
(continued)
⢠Popliteal - behind knee
⢠Dorsalis pedis â top of
foot
⢠Apical pulse â over apex
of heart
âtaken with stethoscope
âleft side of chest
43. DHSR Approved Curriculum-Unit 10 43
Measurement of Pulse
⢠Normal pulse range/characteristics:
60 -100 beats per minute and regular
⢠Documenting pulse rate
âNoted as number of beats per
minute
âRhythm - regular or irregular
âVolume - strong, weak, thready,
bounding
49. DHSR Approved Curriculum-Unit 10 49
Measuring Respirations
⢠Respiration â process
of taking in oxygen
and expelling carbon
dioxide from lungs
and respiratory tract
53. DHSR Approved Curriculum-Unit 10 53
Measuring Respirations
(continued)
⢠Qualities of normal respirations
â12-20 respirations per minute
âQuiet
âEffortless
âRegular
54. DHSR Approved Curriculum-Unit 10 54
Measuring Respirations
(continued)
⢠Documenting respiratory rate
âNoted as number of inhalations
and exhalations per minute (one
inhalation and one exhalation
equals one respiration)
âRhythm â regular or irregular
âCharacter: shallow, deep, labored
59. DHSR Approved Curriculum-Unit 10 59
Measuring Blood Pressure
⢠Blood pressure is the force of blood
pushing against walls of arteries
âSystolic pressure: greatest force
exerted when heart contracting
âDiastolic pressure: least force
exerted as heart relaxes
65. DHSR Approved Curriculum-Unit 10 65
Measuring Blood Pressure
⢠Normal blood pressure range
âSystolic: 90-140 millimeters of
mercury
âDiastolic: 60-90 millimeters of
mercury
66. DHSR Approved Curriculum-Unit 10 66
Guidelines for Blood Pressure
Measurements
⢠Measure on upper
arm
⢠Have correct size
cuff
⢠Identify brachial
artery for correct
placement of
stethoscope
67. DHSR Approved Curriculum-Unit 10 67
Guidelines for Blood Pressure
Measurements
(continued)
⢠First sound heard â
systolic pressure
⢠Last sound heard or
change - diastolic
pressure
68. DHSR Approved Curriculum-Unit 10 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
69. DHSR Approved Curriculum-Unit 10 69
Guidelines for Blood Pressure
Measurements
(continued)
⢠Do not measure blood
pressure in arm with IV,
A-V shunt (dialysis),
cast, wound, or sore
70. DHSR Approved Curriculum-Unit 10 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
71. DHSR Approved Curriculum-Unit 10 71
Blood Pressure: Reading Gauge
⢠Large lines are
at increments of
10 mmHg
⢠Shorter lines at
2 mm intervals
⢠Take reading at
closest line
72. DHSR Approved Curriculum-Unit 10 72
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
280
260
240
220
200
180
160
140
120
100
80
60
40
20
290
270
250
230
210
190
170
150
130
110
90
70
50
30
10
78. DHSR Approved Curriculum-Unit 10 78
Measuring Height And Weight
⢠Baseline measurement
obtained on admission
and must be accurate.
⢠Other measurements
obtained as ordered.
80. DHSR Approved Curriculum-Unit 10 80
Measuring Height and Weight
(continued)
⢠Reasons for obtaining height and
weight
âIndicator of nutritional status
âIndicator of change in medical
condition
âUsed by doctor to order medications
82. DHSR Approved Curriculum-Unit 10 82
Measuring Height and Weight
(continued)
âUse same scale
each time
âHave resident void,
remove shoes and
outer clothing
âWeigh at same time
each day
⢠Guidelines for weighing residents
83. DHSR Approved Curriculum-Unit 10 83
Measuring Height and Weight
(continued)
⢠Scales
âRemain more accurate if moved as
little as possible.
âVarious types of scales
â˘bathroom scale
â˘standing scale
â˘scales attached to hydraulic lifts
â˘wheelchair scales
â˘bed scales
87. DHSR Approved Curriculum-Unit 10 87
10.17 Discuss measuring and
recording intake and output,
and conditions for which this
procedure would be ordered.
88. DHSR Approved Curriculum-Unit 10 88
Measuring Intake and Output
Fluid Balance
⢠Consume 2-1/2
to 3-1/2 quarts
daily
âeating
âdrinking
⢠Eliminate 2-1/2
to 3-1/2 quarts
daily
âurine
âperspiration
âwater vapor
through
respirations
âstool
99. DHSR Approved Curriculum-Unit 10 99
Measuring and Recording
Intake/Output
⢠Physician orders intake and output
⢠Intake includes:
âAll liquid taken by mouth
âFood items that turn to liquid at
room temperature
âTube feedings into stomach through
nose or abdomen
âFluids given by intravenous infusion