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DFS Approved Curriculum-Unit 10 1
Unit 10Basic Nursing Skills
Nurse Aide I Course
DFS Approved Curriculum-Unit 10 2
Basic Nursing SkillsIntroduction
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 3
Basic Nursing SkillsIntroduction
(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 4
DFS Approved Curriculum-Unit 10 5
10.0 Provide basic nursing skills.
DFS Approved Curriculum-Unit 10 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 7
10.1 Explain the meaning of vital signs and the abbreviations used for each vital sign.
DFS Approved Curriculum-Unit 10 8
Vital Signs(continued)
• Abbreviations:–Temperature – T–Pulse – P–Respirations – R–Blood Pressure – BP–Vital signs - TPR and BP
DFS Approved Curriculum-Unit 10 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 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 11
DFS Approved Curriculum-Unit 10 12
10.2 Define body temperature and discuss the way it is measured.
DFS Approved Curriculum-Unit 10 13
Temperature –Measurement Of Body Heat
• Heat production–muscles–glands–oxidation of
food
• Heat loss–respiration–perspiration–excretion
DFS Approved Curriculum-Unit 10 14
Temperature –Measurement Of Body Heat
(continued)
Balance between heat production and heat loss is body
temperature
DFS Approved Curriculum-Unit 10 15
10.2.1 List the factors that affect temperature.
DFS Approved Curriculum-Unit 10 16
Factors Affecting Temperature
• Exercise• Illness• Age• Time of day• Medications
• Infection• Emotions• Hydration• Clothing• Environmental
temperature/air movement
DFS Approved Curriculum-Unit 10 17
Equipment - Thermometer
• Instrument used to measure body temperature
• Types–Non-mercury glass
• oral• rectal
DFS Approved Curriculum-Unit 10 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 19
10.2.2 Identify the normal temperature range, and the normal body temperature.
DFS 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
DFS Approved Curriculum-Unit 10 21
10.2.3 Read a non-mercury glass thermometer.
DFS 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
DFS 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–long line represents degree–short line represents 0.2 of a degree
Fahrenheit
DFS Approved Curriculum-Unit 10 24
10.2.4 List and discuss the sites used to take a temperature.
DFS Approved Curriculum-Unit 10 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 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 27
10.2.5 Review safety precautions that should be considered when using a thermometer.
DFS 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
DFS 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.
DFS Approved Curriculum-Unit 10 30
DFS Approved Curriculum-Unit 10 31
10.3 Demonstrate the procedure for measuring an oral temperature using a non-mercury glass thermometer.
DFS Approved Curriculum-Unit 10 32
10.4 Demonstrate the procedure for measuring an axillary temperature using a non-mercury glass thermometer.
DFS Approved Curriculum-Unit 10 33
10.5 Demonstrate the procedure for measuring a rectal temperature using a non-mercury glass thermometer.
DFS Approved Curriculum-Unit 10 34
10.6 Demonstrate measuring temperature using an electronic or tympanic thermometer.
DFS Approved Curriculum-Unit 10 35
DFS Approved Curriculum-Unit 10 36
10.7 Define pulse and discuss the way it is measured.
DFS 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
DFS Approved Curriculum-Unit 10 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 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 40
10.7.1 List the factors that affect the pulse.
DFS Approved Curriculum-Unit 10 41
Factors Affecting Pulse
• Age• Sex• Position• Drugs• Illness• Emotions• Activity level • Temperature• Physical training
DFS Approved Curriculum-Unit 10 42
10.7.2 Identify the normal pulse range and characteristics.
DFS Approved Curriculum-Unit 10 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 44
DFS Approved Curriculum-Unit 10 45
10.8 Demonstrate counting the radial pulse rate.
DFS Approved Curriculum-Unit 10 46
10.9 Demonstrate measuring the apical pulse.
DFS Approved Curriculum-Unit 10 47
DFS Approved Curriculum-Unit 10 48
10.10 Define respiration and discuss how the respiratory rate is measured.
DFS Approved Curriculum-Unit 10 49
Measuring Respirations
• Respiration – process of taking in oxygen and expelling carbon dioxide from lungs and respiratory tract
DFS Approved Curriculum-Unit 10 50
10.10.1 List the factors that affect the respiratory rate.
DFS Approved Curriculum-Unit 10 51
Measuring Respirations(continued)
• Age• Activity
level• Position• Drugs
• Sex• Illness• Emotions• Temperature
Factors Affecting Rate
DFS Approved Curriculum-Unit 10 52
10.10.2 Identify the qualities of normal respirations.
DFS Approved Curriculum-Unit 10 53
Measuring Respirations(continued)
• Qualities of normal respirations–12-20 respirations per minute–Quiet–Effortless–Regular
DFS Approved Curriculum-Unit 10 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 55
DFS Approved Curriculum-Unit 10 56
10.11 Demonstrate counting respirations.
DFS Approved Curriculum-Unit 10 57
DFS Approved Curriculum-Unit 10 58
10.12 Define blood pressure and discuss how it is measured.
DFS Approved Curriculum-Unit 10 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 60
10.12.1 List factors that influence blood pressure.
DFS Approved Curriculum-Unit 10 61
Factors Influencing Blood Pressure
• Weight• Sleep• Age• Emotions• Sex• Heredity• Viscosity of blood• Illness/Disease
DFS Approved Curriculum-Unit 10 62
Blood Pressure: Equipment
• Sphygmomanometer (manual)–cuff - different sizes–pressure control bulb–pressure gauge – marked
with numbers• aneroid• mercury
DFS Approved Curriculum-Unit 10 63
Blood Pressure: Equipment(continued)
• Stethoscope–magnifies sound–has diaphragm
DFS Approved Curriculum-Unit 10 64
10.12.2 Identify the normal blood pressure range.
DFS Approved Curriculum-Unit 10 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 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 67
Guidelines for Blood Pressure Measurements
(continued)
• First sound heard –systolic pressure
• Last sound heard or change - diastolic pressure
DFS 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
DFS 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
DFS 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
DFS 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
DFS 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
DFS Approved Curriculum-Unit 10 73
DFS Approved Curriculum-Unit 10 74
10.13 Demonstrate the procedure for measuring blood pressure.
DFS Approved Curriculum-Unit 10 75
10.14 Demonstrate the procedure for taking combined vital signs.
DFS Approved Curriculum-Unit 10 76
DFS Approved Curriculum-Unit 10 77
10.15 Discuss height and weight and how it is measured.
DFS Approved Curriculum-Unit 10 78
Measuring Height And Weight
• Baseline measurement obtained on admission and must be accurate.
• Other measurements obtained as ordered.
DFS Approved Curriculum-Unit 10 79
Measuring Height And Weight(continued)
• Height measurements–Feet–Inches –Centimeters
• Weight measurements–Pounds–Ounces–Kilograms
DFS Approved Curriculum-Unit 10 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 81
10.15.1 List three guidelines for weighing residents.
DFS Approved Curriculum-Unit 10 82
Measuring Height and Weight(continued)
–Use same scale each time
–Have resident void, remove shoes and outer clothing
–Weigh at same time each day
• Guidelines for weighing residents
DFS Approved Curriculum-Unit 10 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 84
DFS Approved Curriculum-Unit 10 85
10.16 Demonstrate the procedure for measuring height and weight.
DFS Approved Curriculum-Unit 10 86
DFS Approved Curriculum-Unit 10 87
10.17 Discuss measuring and recording intake and output, and conditions for which this procedure would be ordered.
DFS Approved Curriculum-Unit 10 88
Measuring Intake and OutputFluid 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
DFS Approved Curriculum-Unit 10 89
10.17.1 Identify five symptoms of edema.
DFS Approved Curriculum-Unit 10 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 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 92
10.17.2 List eight symptoms of dehydration.
DFS Approved Curriculum-Unit 10 93
Dehydration
• Dehydration: fluid output exceeds fluid intake
• Common problem of long-term care residents
DFS Approved Curriculum-Unit 10 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 95
Dehydration(continued)
• Causes of dehydration–poor fluid intake–diarrhea–bleeding –vomiting–excessive perspiration
DFS Approved Curriculum-Unit 10 96
Dehydration(continued)
• Fluids measured in cubic centimeters (cc)–30 cc = 1 ounce–cc - metric measure
DFS Approved Curriculum-Unit 10 97
DFS Approved Curriculum-Unit 10 98
10.18 Identify the liquids that would be measured and recorded as fluid intake.
DFS Approved Curriculum-Unit 10 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 10 100
10.18.1 List the liquids that would be measured and recorded as fluid output.
DFS Approved Curriculum-Unit 10 101
Measuring and Recording Intake/Output
(continued)
• Output includes–Urine–Liquid stool–Emesis–Drainage–Suctioned secretions–Excessive perspiration
DFS Approved Curriculum-Unit 10 102
DFS Approved Curriculum-Unit 10 103
10.19 Demonstrate measuring and recording fluid intake and output.
DFS Approved Curriculum-Unit 10 104