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Unit 10 Basic Nursing Skills. Nurse Aide I Course. 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.

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unit 10 basic nursing skills

Unit 10Basic Nursing Skills

Nurse Aide I Course

DHSR Approved Curriculum-Unit 10

basic nursing skills introduction
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.

DHSR Approved Curriculum-Unit 10

basic nursing skills introduction continued
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.

DHSR Approved Curriculum-Unit 10

slide4

Vital

Signs

DHSR Approved Curriculum-Unit 10

slide5

Objective

10.0 Provide basic nursing skills.

DHSR Approved Curriculum-Unit 10

vital signs
Reflect the function of three body processes that are essential for life.

Regulation of body temperature

Heart function

Breathing

Vital Signs

DHSR Approved Curriculum-Unit 10

slide7

Objective

10.1 Explain the meaning of vital signs and the abbreviations used for each vital sign.

DHSR Approved Curriculum-Unit 10

vital signs continued
Abbreviations:

Temperature – T

Pulse – P

Respirations – R

Blood Pressure – BP

Vital signs - TPR and BP

Vital Signs(continued)

DHSR Approved Curriculum-Unit 10

vital signs continued1
Vital Signs(continued)
  • Purpose
    • Measured to detect any changes in normal body function
    • Used to determine response to treatment

DHSR Approved Curriculum-Unit 10

vital signs continued2
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

DHSR Approved Curriculum-Unit 10

slide11

Measurement

Of

Body Temperature

DHSR Approved Curriculum-Unit 10

slide12

Objective

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

DHSR Approved Curriculum-Unit 10

temperature measurement of body heat
Heat production

muscles

glands

oxidation of food

Heat loss

respiration

perspiration

excretion

Temperature – Measurement Of Body Heat

DHSR Approved Curriculum-Unit 10

temperature measurement of body heat continued
Temperature – Measurement Of Body Heat(continued)

Balance between heat production and heat loss is body temperature

DHSR Approved Curriculum-Unit 10

slide15

Objective

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

Factors Affecting Temperature

DHSR Approved Curriculum-Unit 10

equipment thermometer
Equipment - Thermometer
  • Instrument used to measure body temperature
  • Types
    • Non-mercury glass
      • oral
      • rectal

DHSR Approved Curriculum-Unit 10

equipment thermometer1
Equipment - Thermometer
  • Types (continued)
    • chemically treated paper – disposable
    • plastic – disposable
    • electronic - probe covered with disposable shield
    • tympanic - electronic probe used in the ear

DHSR Approved Curriculum-Unit 10

slide19

Objective

10.2.2 Identify the normal temperature range, and the normal body temperature.

DHSR Approved Curriculum-Unit 10

normal temperature range for adults
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

DHSR Approved Curriculum-Unit 10

slide21

Objective

10.2.3 Read a non-mercury glass thermometer.

DHSR Approved Curriculum-Unit 10

to read a non mercury glass thermometer
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

DHSR Approved Curriculum-Unit 10

to read a non mercury glass thermometer continued
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

DHSR Approved Curriculum-Unit 10

slide24

Objective

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

DHSR Approved Curriculum-Unit 10

sites to take a temperature
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

DHSR Approved Curriculum-Unit 10

sites to take a temperature continued
Sites To Take A Temperature(continued)

Condition of resident determines which is the best site for measuring body temperature

DHSR Approved Curriculum-Unit 10

slide27

Objective

10.2.5 Review safety precautions that should be considered when using a thermometer.

DHSR Approved Curriculum-Unit 10

temperature safety precautions
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 

DHSR Approved Curriculum-Unit 10

temperature safety precautions continued
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.

DHSR Approved Curriculum-Unit 10

slide30

Demonstration

and

Return Demonstration

DHSR Approved Curriculum-Unit 10

slide31

Objective

10.3 Demonstrate the procedure for measuring an oral temperature using a non-mercury glass thermometer.

DHSR Approved Curriculum-Unit 10

slide32

Objective

10.4 Demonstrate the procedure for measuring an axillary temperature using a non-mercury glass thermometer.

DHSR Approved Curriculum-Unit 10

slide33

Objective

10.5 Demonstrate the procedure for measuring a rectal temperature using a non-mercury glass thermometer.

DHSR Approved Curriculum-Unit 10

slide34

Objective

10.6 Demonstrate measuring temperature using an electronic or tympanic thermometer.

DHSR Approved Curriculum-Unit 10

slide35

Measurement

Of

Pulse

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slide36

Objective

10.7 Define pulse and discuss the way it is measured.

DHSR Approved Curriculum-Unit 10

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

Measurement of Pulse

DHSR Approved Curriculum-Unit 10

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

DHSR Approved Curriculum-Unit 10

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

Sites For Taking Pulse(continued)

DHSR Approved Curriculum-Unit 10

slide40

Objective

10.7.1 List the factors that affect the pulse.

DHSR Approved Curriculum-Unit 10

factors affecting pulse
Factors Affecting Pulse
  • Age
  • Sex
  • Position
  • Drugs
  • Illness
  • Emotions
  • Activity level
  • Temperature
  • Physical training

DHSR Approved Curriculum-Unit 10

slide42

Objective

10.7.2 Identify the normal pulse range and characteristics.

DHSR Approved Curriculum-Unit 10

measurement of pulse1
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

DHSR Approved Curriculum-Unit 10

slide44

Demonstration

and

Return Demonstration

DHSR Approved Curriculum-Unit 10

slide45

Objective

10.8 Demonstrate counting the radial pulse rate.

DHSR Approved Curriculum-Unit 10

slide46

Objective

10.9 Demonstrate measuring the apical pulse.

DHSR Approved Curriculum-Unit 10

slide47

Measuring

Respirations

DHSR Approved Curriculum-Unit 10

slide48

Objective

10.10 Define respiration and discuss how the respiratory rate is measured.

DHSR Approved Curriculum-Unit 10

measuring respirations
Respiration – process of taking in oxygen and expelling carbon dioxide from lungs and respiratory tract Measuring Respirations

DHSR Approved Curriculum-Unit 10

slide50

Objective

10.10.1 List the factors that affect the respiratory rate.

DHSR Approved Curriculum-Unit 10

measuring respirations continued
Age

Activity level

Position

Drugs

Measuring Respirations(continued)

Factors Affecting Rate

  • Sex
  • Illness
  • Emotions
  • Temperature

DHSR Approved Curriculum-Unit 10

slide52

Objective

10.10.2 Identify the qualities of normal respirations.

DHSR Approved Curriculum-Unit 10

measuring respirations continued1
Measuring Respirations(continued)
  • Qualities of normal respirations
    • 12-20 respirations per minute
    • Quiet
    • Effortless
    • Regular

DHSR Approved Curriculum-Unit 10

measuring respirations continued2
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

DHSR Approved Curriculum-Unit 10

slide55

Demonstration

and

Return Demonstration

DHSR Approved Curriculum-Unit 10

slide56

Objective

10.11 Demonstrate counting respirations.

DHSR Approved Curriculum-Unit 10

slide57

Measuring

Blood

Pressure

DHSR Approved Curriculum-Unit 10

slide58

Objective

10.12 Define blood pressure and discuss how it is measured.

DHSR Approved Curriculum-Unit 10

measuring blood pressure
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

DHSR Approved Curriculum-Unit 10

slide60

Objective

10.12.1 List factors that influence blood pressure.

DHSR Approved Curriculum-Unit 10

factors influencing blood pressure
Factors Influencing Blood Pressure
  • Weight
  • Sleep
  • Age
  • Emotions
  • Sex
  • Heredity
  • Viscosity of blood
  • Illness/Disease

DHSR Approved Curriculum-Unit 10

blood pressure equipment
Blood Pressure: Equipment
  • Sphygmomanometer (manual)
    • cuff - different sizes
    • pressure control bulb
    • pressure gauge – marked with numbers
      • aneroid
      • mercury

DHSR Approved Curriculum-Unit 10

blood pressure equipment continued
Blood Pressure: Equipment(continued)
  • Stethoscope
    • magnifies sound
    • has diaphragm

DHSR Approved Curriculum-Unit 10

slide64

Objective

10.12.2 Identify the normal blood pressure range.

DHSR Approved Curriculum-Unit 10

measuring blood pressure1
Measuring Blood Pressure
  • Normal blood pressure range
    • Systolic: 90-140 millimeters of mercury
    • Diastolic: 60-90 millimeters of mercury

DHSR Approved Curriculum-Unit 10

guidelines for blood pressure measurements
Guidelines for Blood Pressure Measurements
  • Measure on upper arm
  • Have correct size cuff
  • Identify brachial artery for correct placement of stethoscope

DHSR Approved Curriculum-Unit 10

guidelines for blood pressure measurements continued
Guidelines for Blood Pressure Measurements(continued)
  • First sound heard – systolic pressure
  • Last sound heard or change - diastolic pressure

DHSR Approved Curriculum-Unit 10

guidelines for blood pressure measurements continued1

118

76

Guidelines for Blood Pressure Measurements(continued)
  • Record - systolic/diastolic
  • Resident in relaxed position, sitting or lying down
  • Blood pressure usually taken in left arm

DHSR Approved Curriculum-Unit 10

guidelines for blood pressure measurements continued2
Guidelines for Blood Pressure Measurements(continued)
  • Do not measure blood pressure in arm with IV, A-V shunt (dialysis), cast, wound, or sore

DHSR Approved Curriculum-Unit 10

guidelines for blood pressure measurements continued3
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

DHSR Approved Curriculum-Unit 10

blood pressure reading gauge
Blood Pressure: Reading Gauge
  • Large lines are at increments of 10 mmHg
  • Shorter lines at 2 mm intervals
  • Take reading at closest line

DHSR Approved Curriculum-Unit 10

blood pressure reading gauge continued

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

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

DHSR Approved Curriculum-Unit 10

slide73

Demonstration

and

Return Demonstration

DHSR Approved Curriculum-Unit 10

slide74

Objective

10.13 Demonstrate the procedure for measuring blood pressure.

DHSR Approved Curriculum-Unit 10

slide75

Objective

10.14 Demonstrate the procedure for taking combined vital signs.

DHSR Approved Curriculum-Unit 10

slide76

Measuring

Height

And

Weight

DHSR Approved Curriculum-Unit 10

slide77

Objective

10.15 Discuss height and weight and how it is measured.

DHSR Approved Curriculum-Unit 10

measuring height and weight
Measuring Height And Weight
  • Baseline measurement obtained on admission and must be accurate.
  • Other measurements obtained as ordered.

DHSR Approved Curriculum-Unit 10

measuring height and weight continued
Measuring Height And Weight(continued)
  • Height measurements
    • Feet
    • Inches
    • Centimeters
  • Weight measurements
    • Pounds
    • Ounces
    • Kilograms

DHSR Approved Curriculum-Unit 10

measuring height and weight continued1
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

DHSR Approved Curriculum-Unit 10

slide81

Objective

10.15.1 List three guidelines for weighing residents.

DHSR Approved Curriculum-Unit 10

measuring height and weight continued2
Use same scale each time

Have resident void, remove shoes and outer clothing

Weigh at same time each day

Guidelines for weighing residents

Measuring Height and Weight(continued)

DHSR Approved Curriculum-Unit 10

measuring height and weight continued3
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

DHSR Approved Curriculum-Unit 10

slide84

Demonstration

and

Return Demonstration

DHSR Approved Curriculum-Unit 10

slide85

Objective

10.16 Demonstrate the procedure for measuring height and weight.

DHSR Approved Curriculum-Unit 10

slide86

Measuring

Intake

And

Output

DHSR Approved Curriculum-Unit 10

slide87

Objective

10.17 Discuss measuring and recording intake and output, and conditions for which this procedure would be ordered.

DHSR Approved Curriculum-Unit 10

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

Measuring Intake and OutputFluid Balance

DHSR Approved Curriculum-Unit 10

slide89

Objective

10.17.1 Identify five symptoms of edema.

DHSR Approved Curriculum-Unit 10

edema
Edema
  • Edema – fluid intake exceeds fluid output
    • Retention of fluids frequently caused by kidney or heart failure or excessive salt intake

DHSR Approved Curriculum-Unit 10

edema continued
Edema(continued)
  • Symptoms
    • weight gain
    • swelling of feet, ankles, hands, fingers, face
    • decreased urine output
    • shortness of breath
    • collection of fluid in abdomen (ascites)

DHSR Approved Curriculum-Unit 10

slide92

Objective

10.17.2 List eight symptoms of dehydration.

DHSR Approved Curriculum-Unit 10

dehydration
Dehydration
  • Dehydration: fluid output exceeds fluid intake
  • Common problem of long-term care residents

DHSR Approved Curriculum-Unit 10

dehydration continued
Dehydration(continued)
  • Symptoms
    • thirst
    • decreased urine output
    • parched or cracked lips
    • dry, cracked skin
    • fever
    • weight loss
    • concentrated urine
    • tongue coated and thick

DHSR Approved Curriculum-Unit 10

dehydration continued1
Dehydration(continued)
  • Causes of dehydration
    • poor fluid intake
    • diarrhea
    • bleeding
    • vomiting
    • excessive perspiration

DHSR Approved Curriculum-Unit 10

dehydration continued2

30

20

10

Dehydration(continued)
  • Fluids measured in cubic centimeters (cc)
    • 30 cc = 1 ounce
    • cc - metric measure

DHSR Approved Curriculum-Unit 10

slide97

Measuring and

Recording

Intake/Output

DHSR Approved Curriculum-Unit 10

slide98

Objective

10.18 Identify the liquids that would be measured and recorded as fluid intake.

DHSR Approved Curriculum-Unit 10

measuring and recording intake output
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

DHSR Approved Curriculum-Unit 10

slide100

Objective

10.18.1 List the liquids that would be measured and recorded as fluid output.

DHSR Approved Curriculum-Unit 10

measuring and recording intake output continued
Measuring and Recording Intake/Output(continued)
  • Output includes
    • Urine
    • Liquid stool
    • Emesis
    • Drainage
    • Suctioned secretions
    • Excessive perspiration

DHSR Approved Curriculum-Unit 10

slide102

Demonstration

and

Return Demonstration

DHSR Approved Curriculum-Unit 10

slide103

Objective

10.19 Demonstrate measuring and recording fluid intake and output.

DHSR Approved Curriculum-Unit 10

slide104

The End

DHSR Approved Curriculum-Unit 10