Lesson7:Basic Nursing Skills Objectives 1.Student will be able to correctly demonstrate how to perform Initial & Final Steps when care for a resident. 2.Student will be able to correctly demonstrate how to take and record a resident’s vital signs. 3.Student will be able to correctly demonstrate how to measure and record a resident’s height and weight.

Initial & Final Steps Important to consider with any procedure or contact you will have with a resident or patient. Done before and after care provided Initial-ask nurse of resident needs, abilities and limitations, follow infection control guidelines, providing privacy, safety, and respect to the resident Final- ensure resident is comfortable and safe, remove or clean up supplies/equipment, report unexpected findings and document care

Vital Signs  Temperature  Pulse  Respirations  Blood Pressure Common to take Oxygen Saturation (02 sat)- measures amount of oxygen in the blood (100% normal) Height & Weight also important (Discussed later) Helps healthcare workers know how the body is functioning, responding to care, or changing

Temperature Measures heat in the body. Can be affected by time of day, age, exercise, emotional state, environmental temp, medications, pregnancy, illness, menstruation 1.Oral (by mouth) º F 2.Axillary (armpit) º F=safest, least accurate 3.Aural (ear, tympanic) º F Rectal temps also can be done ONLY by nurse=most accurate, but most invasive

Temperature Continued Types of thermometers 1.Glass (not used as much anymore) 2.Electronic-probe covered by plastic disposable sheath, result displayed on screen 3.Paper or plastic tape-placed on forehead or abdomen (colors indicate temp) 4.Aural (tympanic)-covered probe is placed in ear to measure temp at eardrum (considered as accurate as rectal temp) into ear ¼-½ in Often Color Coded: ****Oral=green or blue Rectal=red tip

Pulse Rate Measures number of heart beats per minute. Can be affected by age, sex, emotions, body position, medication, illness, fever, physical activity, and fitness level A.Pulse points: 1. Carotid-sides of neck=CPR 2. Apical-left side of chest=stethoscope 3. Radial-thumb side of wrist=standard pulse 4. Brachial-bend of the elbow=BP B. Important to note 3 things: 1. Rate: per minute is normal range 2. Rhythm (Regular or Irregular) 3. Force (Strong or Weak)

Respirations Measures number of times a person inhales per minute. Can be affected by age, sex, emotional stress, medication, lung disease, heat and cold, heart disease, and physical activity A.Note 3 things: 1. Rate:12-20 per minute is normal range 2. Rhythm: Regular or Irregular 3. Character/Sound: ie. labored, wheezing, shallow, deep, normal B. Special Considerations: 1. Count respirations after finishing pulse without moving fingers from wrist. WHY? People breathe faster if they know they are being observed. 2. If resident agitated-place hand on resident’s chest and feel chest rise and fall

Blood Pressure Measures force the blood exerts against walls of the arteries. Can be affected by heredity, diet, condition of vessels and volume of blood in the system and all other factors affecting other vitals. A.2 measurements taken 1. Systolic-first beat heard, contraction of vessels, upper number 2. Diastolic-second beat heard, relaxation of vessels, lower number B. To ensure accurate readings: 1. take BP only if resident is lying or sitting unless otherwise instructed 2. Correctly apply proper sized cuff and keep arm at below the level of the heart 3. Place Diaphragm of stethoscope over brachial artery and read the sphygmomanometer gauge accurately

Blood Pressure Ranges (Nursing) Adults (18yrs of age and older) SystolicDiastolic Normal<120<80 Pre-hypertension Hypertension Stage I Stage II160 or >100 or > Hypotension <90<60 (Can also depend on persons norm)

CNA BP Ranges to Remember Systolic: (hearts contraction) Diastolic: (hearts relaxation) S= __________________________ D= Hypotension-Lower than the ranges Hypertension-Higher than the ranges Orthostatic Hypotension-BP drops with position changes Anything outside of these ranges need to be verbally reported to the nurse. * If resident has had a mastectomy or has a dialysis access, do not take BP on that arm

Height-measure at time of admission or at significant change Procedure depends on abilities/limitations of the resident: 1) Standard standing scale 2) In bed marking blanket at head and heel 3) In bed following curvatures of body (when contracted) Height

Weight Weight-measure at time of admission and at least monthly according to resident’s care plan. ~Types of scales: standard, chair, bed scales, wheel chair scale

Weight Continued 1.Checked every month to: A.Assist physician to determine medication dosage B.Assess fluid balance, kidney & heart function C.Determine changes in nutritional status 2. To Weigh resident: A.Have resident wear same type of clothing each time B.Have resident empty bladder before weight C.Schedule daily weights at the same time each day D.Follow manufacturer’s guidelines for use of the scale. E.Take into consideration prosthetics and be consistent whether or not they are in place at time of weight F.Balance scale to zero before weighing a patient

End of Lesson 7: Review Questions 1.What is the normal range for heart rate in adults? beats per minute. 2.What is the normal range for BP in adults? 100/60-140/80 3.How can the respiratory rate be counted when a resident is sleeping or agitated? Place hand on chest or watch the rise and fall of the chest. 4.Where is the radial pulse? Thumb side of the wrist 5. What is the name of the pulse site over which the stethoscope is placed when taking a BP? Brachial

End of Lesson 7:Review questions 6.How long does it take to measure pulse and respirations? 60seconds 7.What three positions, in order, are used to take an orthostatic blood pressure? Lying, sitting, standing. 8.What is it called when the blood pressure decreases while taking orthostatic blood pressure? orthostatic hypotension. 6.Do you take an oral temperature on someone who is confused or disoriented? No 7.Which artery most commonly used for measuring pulse rate? Radial