1. Unit 10 Basic Nursing Skills
Nurse Aide I Course
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 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

3. Basic Nursing Skills Introduction (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

4. Vital
Signs
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5. 10.0 Provide basic nursing skills.
Objective
10.0 Provide basic nursing skills.
DHSR Approved Curriculum-Unit 10

6. Regulation of body temperature Heart function Breathing
Vital Signs
Reflect the function of three body processes that are essential for life.
Regulation of body temperature
Heart function
Breathing
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7. Objective
10.1 Explain the meaning of vital signs and the abbreviations used for each vital sign.
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8. Vital Signs (continued)
Abbreviations:
Temperature – T
Pulse – P
Respirations – R
Blood Pressure – BP
Vital signs - TPR and BP
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9. Vital Signs (continued)
Purpose
Measured to detect any changes in normal body function used to determine response to treatment
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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
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11. Measurement Of
Body Temperature
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12. 10.2 Define body temperature and discuss the way it is measured.
Objective
10.2 Define body temperature and discuss the way it is measured.
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13. Temperature – Measurement Of Body Heat
Heat production
muscles
glands
oxidation of food
Heat loss
respiration
perspiration
excretion
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14. Temperature – Measurement Of Body Heat (continued)
Balance between heat production and heat loss is body temperature
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15. Factors Affecting Temperature
Exercise
Illness
Age
Time of day
Medications
Infection
Emotions
Hydration
Clothing
Environmental temperature/air movement
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16. Equipment - Thermometer
Instrument used to measure body temperature
Types
Non-mercury glass
oral
rectal
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17. Equipment - Thermometer
Types (continued)
chemically treated paper – disposable
plastic – disposable
electronic - probe covered with disposable shield
tympanic - electronic probe used in the ear
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18. Objective
Identify the normal temperature range, and the normal body temperature.
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19. Normal Temperature Range For Adults
Oral   F (Fahrenheit) or 36.5  C (Celsius)
Rectal   F or 37.0  C
Axillary   F or 36.0  C
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20. 10.2.3 Read a non-mercury glass thermometer.
Objective
Read a non-mercury glass thermometer.
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21. 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
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22. 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
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23. 10.2.4 List and discuss the sites used to take a temperature.
Objective
List and discuss the sites used to take a temperature.
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24. 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
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25. Sites To Take A Temperature (continued)
Condition of resident determines which is the best site for measuring body temperature
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26. Objective
Review safety precautions that should be considered when using a thermometer.
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27. Temperature: Safety Precautions (continued)
Wipe from end to tip of thermometer prior to reading 
Delay taking oral temperature for minutes if resident has been smoking, eating or drinking hot/cold liquids.
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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 
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29. Demonstration and Return Demonstration
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30. Objective
10.3 Demonstrate the procedure for measuring an oral temperature using a non-mercury glass thermometer.
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31. Objective
10.4 Demonstrate the procedure for measuring an axillary temperature using a non-mercury glass thermometer.
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32. Objective
10.5 Demonstrate the procedure for measuring a rectal temperature using a non-mercury glass thermometer.
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33. Objective
10.6 Demonstrate measuring temperature using an electronic or tympanic thermometer.
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34. Measurement Of
Pulse
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35. 10.7 Define pulse and discuss the way it is measured.
Objective
10.7 Define pulse and discuss the way it is measured.
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36. 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
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37. Temporal – side of forehead Carotid – side of neck
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
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38. 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
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39. 10.7.1 List the factors that affect the pulse.
Objective
List the factors that affect the pulse.
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40. Factors Affecting Pulse
Age
Sex
Position
Drugs
Illness
Emotions
Activity level
Temperature
Physical training
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41. 10.7.2 Identify the normal pulse range and characteristics.
Objective
Identify the normal pulse range and characteristics.
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42. Documenting pulse rate Noted as number of beats per minute
Measurement of Pulse
Normal pulse range/characteristics: beats per minute and regular
Documenting pulse rate
Noted as number of beats per minute
Rhythm - regular or irregular
Volume - strong, weak, thready, bounding
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43. Demonstration and Return Demonstration
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44. 10.8 Demonstrate counting the radial pulse rate.
Objective
10.8 Demonstrate counting the radial pulse rate.
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45. 10.9 Demonstrate measuring the apical pulse.
Objective
10.9 Demonstrate measuring the apical pulse.
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46. Measuring
Respirations
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47. Objective
10.10 Define respiration and discuss how the respiratory rate is measured.
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48. Measuring Respirations
Respiration – process of taking in oxygen and expelling carbon dioxide from lungs and respiratory tract
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49. 10.10.1 List the factors that affect the respiratory rate.
Objective
List the factors that affect the respiratory rate.
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50. Measuring Respirations (continued)
Factors Affecting Rate
Age
Activity level
Position
Drugs
Sex
Illness
Emotions
Temperature
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51. 10.10.2 Identify the qualities of normal respirations.
Objective
Identify the qualities of normal respirations.
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52. Measuring Respirations (continued)
Qualities of normal respirations
12-20 respirations per minute
Quiet
Effortless
Regular
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53. 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
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54. Demonstration and Return Demonstration
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55. 10.11 Demonstrate counting respirations.
Objective
10.11 Demonstrate counting respirations.
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56. Measuring
Blood
Pressure
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57. 10.12 Define blood pressure and discuss how it is measured.
Objective
10.12 Define blood pressure and discuss how it is measured.
DHSR Approved Curriculum-Unit 10

58. 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
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59. 10.12.1 List factors that influence blood pressure.
Objective
List factors that influence blood pressure.
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60. Factors Influencing Blood Pressure
Weight
Sleep
Age
Emotions
Sex
Heredity
Viscosity of blood
Illness/Disease
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61. Blood Pressure: Equipment
Sphygmomanometer (manual)
cuff - different sizes
pressure control bulb
pressure gauge – marked with numbers
aneroid
mercury
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62. Blood Pressure: Equipment (continued)
Stethoscope
magnifies sound
has diaphragm
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63. 10.12.2 Identify the normal blood pressure range.
Objective
Identify the normal blood pressure range.
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64. Measuring Blood Pressure
Normal blood pressure range
Systolic: millimeters of mercury
Diastolic: millimeters of mercury
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65. Guidelines for Blood Pressure Measurements
Measure on upper arm
Have correct size cuff
Identify brachial artery for correct placement of stethoscope
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66. Guidelines for Blood Pressure Measurements (continued)
First sound heard – systolic pressure
Last sound heard or change - diastolic pressure
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67. Guidelines for Blood Pressure Measurements (continued)
Record - systolic/diastolic
Resident in relaxed position, sitting or lying down
Blood pressure usually taken in left arm
118 76
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68. Guidelines for Blood Pressure Measurements (continued)
Do not measure blood pressure in arm with IV, A-V shunt (dialysis), cast, wound, or sore
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69. 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
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70. Blood Pressure: Reading Gauge
Large lines are at increments of 10 mmHg
Shorter lines at 2 mm intervals
Take reading at closest line
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71. 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
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72. Demonstration and Return Demonstration
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73. 10.13 Demonstrate the procedure for measuring blood pressure.
Objective
10.13 Demonstrate the procedure for measuring blood pressure.
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74. 10.14 Demonstrate the procedure for taking combined vital signs.
Objective
10.14 Demonstrate the procedure for taking combined vital signs.
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75. Measuring
Height
And
Weight
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76. 10.15 Discuss height and weight and how it is measured.
Objective
10.15 Discuss height and weight and how it is measured.
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77. Measuring Height And Weight
Baseline measurement obtained on admission and must be accurate.
Other measurements obtained as ordered.
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78. Measuring Height And Weight (continued)
Height measurements
Feet
Inches
Centimeters
Weight measurements
Pounds
Ounces
Kilograms
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79. 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
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80. 10.15.1 List three guidelines for weighing residents.
Objective
List three guidelines for weighing residents.
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81. Measuring Height and Weight (continued)
Guidelines for weighing residents
Use same scale each time
Have resident void, remove shoes and outer clothing
Weigh at same time each day
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82. 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
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83. Demonstration and Return Demonstration
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84. 10.16 Demonstrate the procedure for measuring height and weight.
Objective
10.16 Demonstrate the procedure for measuring height and weight.
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85. Measuring
Intake
And
Output
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86. Objective
10.17 Discuss measuring and recording intake and output, and conditions for which this procedure would be ordered.
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87. 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
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88. 10.17.1 Identify five symptoms of edema.
Objective
Identify five symptoms of edema.
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89. Edema – fluid intake exceeds fluid output
Retention of fluids frequently caused by kidney or heart failure or excessive salt intake
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90. swelling of feet, ankles, hands, fingers, face decreased urine output
Edema (continued)
Symptoms
weight gain
swelling of feet, ankles, hands, fingers, face
decreased urine output
shortness of breath
collection of fluid in abdomen (ascites)
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91. 10.17.2 List eight symptoms of dehydration.
Objective
List eight symptoms of dehydration.
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92. Dehydration: fluid output exceeds fluid intake
Common problem of long-term care residents
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93. Dehydration (continued)
Symptoms
thirst
decreased urine output
parched or cracked lips
dry, cracked skin
fever
weight loss
concentrated urine
tongue coated and thick
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94. Dehydration (continued)
Causes of dehydration
poor fluid intake
diarrhea
bleeding
vomiting
excessive perspiration
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95. Dehydration (continued)
Fluids measured in cubic centimeters (cc)
30 cc = 1 ounce
cc - metric measure 30 20 10
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96. Measuring and
Recording
Intake/Output
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97. Objective
10.18 Identify the liquids that would be measured and recorded as fluid intake.
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98. 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
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99. Objective
List the liquids that would be measured and recorded as fluid output.
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100. Measuring and Recording Intake/Output (continued)
Output includes
Urine
Liquid stool
Emesis
Drainage
Suctioned secretions
Excessive perspiration
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101. Demonstration and Return Demonstration
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102. 10.19 Demonstrate measuring and recording fluid intake and output.
Objective
10.19 Demonstrate measuring and recording fluid intake and output.
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103. The End
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