1. DHSR Approved Curriculum-Unit 101 Unit 10 Basic Nursing Skills Nurse Aide I Course

2. DHSR Approved Curriculum-Unit 102 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.

3. DHSR Approved Curriculum-Unit 103 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.

4. DHSR Approved Curriculum-Unit 104

5. 5 10.0Provide basic nursing skills.

6. DHSR Approved Curriculum-Unit 106 Vital Signs Reflect the function of three body processes that are essential for life. –Regulation of body temperature –Heart function –Breathing

7. DHSR Approved Curriculum-Unit 107 10.1Explain the meaning of vital signs and the abbreviations used for each vital sign.

8. DHSR Approved Curriculum-Unit 108 Vital Signs (continued) Abbreviations: –Temperature – T –Pulse – P –Respirations – R –Blood Pressure – BP –Vital signs - TPR and BP

9. DHSR Approved Curriculum-Unit 109 Vital Signs (continued) Purpose –Measured to detect any changes in normal body function –Used to determine response to treatment

10. DHSR Approved Curriculum-Unit 1010 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

11. DHSR Approved Curriculum-Unit 1011

12. DHSR Approved Curriculum-Unit 1012 10.2Define body temperature and discuss the way it is measured.

13. DHSR Approved Curriculum-Unit 1013 Temperature – Measurement Of Body Heat Heat production –muscles –glands –oxidation of food Heat loss –respiration –perspiration –excretion

14. DHSR Approved Curriculum-Unit 1014 Temperature – Measurement Of Body Heat (continued) Balance between heat production and heat loss is body temperature

15. DHSR Approved Curriculum-Unit 1015 10.2.1List the factors that affect temperature.

16. DHSR Approved Curriculum-Unit 1016 Factors Affecting Temperature Exercise Illness Age Time of day Medications Infection Emotions Hydration Clothing Environmental temperature/air movement

17. DHSR Approved Curriculum-Unit 1017 Equipment - Thermometer Instrument used to measure body temperature Types –Non-mercury glass oral rectal

18. DHSR Approved Curriculum-Unit 1018 Equipment - Thermometer Types (continued) –chemically treated paper – disposable –plastic – disposable –electronic - probe covered with disposable shield –tympanic - electronic probe used in the ear

19. DHSR Approved Curriculum-Unit 1019 10.2.2Identify the normal temperature range, and the normal body temperature.

20. DHSR Approved Curriculum-Unit 1020 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

21. DHSR Approved Curriculum-Unit 1021 10.2.3Read a non-mercury glass thermometer.

22. DHSR Approved Curriculum-Unit 1022 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 1023 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

24. DHSR Approved Curriculum-Unit 1024 10.2.4List and discuss the sites used to take a temperature.

25. DHSR Approved Curriculum-Unit 1025 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

26. DHSR Approved Curriculum-Unit 1026 Sites To Take A Temperature (continued) Condition of resident determines which is the best site for measuring body temperature

27. DHSR Approved Curriculum-Unit 1027 10.2.5Review safety precautions that should be considered when using a thermometer.

28. DHSR Approved Curriculum-Unit 1028 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 1029 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.

30. DHSR Approved Curriculum-Unit 1030

31. DHSR Approved Curriculum-Unit 1031 10.3Demonstrate the procedure for measuring an oral temperature using a non-mercury glass thermometer.

32. DHSR Approved Curriculum-Unit 1032 10.4Demonstrate the procedure for measuring an axillary temperature using a non-mercury glass thermometer.

33. DHSR Approved Curriculum-Unit 1033 10.5Demonstrate the procedure for measuring a rectal temperature using a non-mercury glass thermometer.

34. DHSR Approved Curriculum-Unit 1034 10.6Demonstrate measuring temperature using an electronic or tympanic thermometer.

35. DHSR Approved Curriculum-Unit 1035

36. DHSR Approved Curriculum-Unit 1036 10.7Define pulse and discuss the way it is measured.

37. DHSR Approved Curriculum-Unit 1037 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 1038 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

39. DHSR Approved Curriculum-Unit 1039 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

40. DHSR Approved Curriculum-Unit 1040 10.7.1List the factors that affect the pulse.

41. DHSR Approved Curriculum-Unit 1041 Factors Affecting Pulse Age Sex Position Drugs Illness Emotions Activity level Temperature Physical training

42. DHSR Approved Curriculum-Unit 1042 10.7.2Identify the normal pulse range and characteristics.

43. DHSR Approved Curriculum-Unit 1043 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

44. DHSR Approved Curriculum-Unit 1044

45. DHSR Approved Curriculum-Unit 1045 10.8Demonstrate counting the radial pulse rate.

46. DHSR Approved Curriculum-Unit 1046 10.9Demonstrate measuring the apical pulse.

47. DHSR Approved Curriculum-Unit 1047

48. DHSR Approved Curriculum-Unit 1048 10.10Define respiration and discuss how the respiratory rate is measured.

49. DHSR Approved Curriculum-Unit 1049 Measuring Respirations Respiration – process of taking in oxygen and expelling carbon dioxide from lungs and respiratory tract

50. DHSR Approved Curriculum-Unit 1050 10.10.1List the factors that affect the respiratory rate.

51. DHSR Approved Curriculum-Unit 1051 Measuring Respirations (continued) Age Activity level Position Drugs Sex Illness Emotions Temperature Factors Affecting Rate

52. DHSR Approved Curriculum-Unit 1052 10.10.2Identify the qualities of normal respirations.

53. DHSR Approved Curriculum-Unit 1053 Measuring Respirations (continued) Qualities of normal respirations –12-20 respirations per minute –Quiet –Effortless –Regular

54. DHSR Approved Curriculum-Unit 1054 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

55. DHSR Approved Curriculum-Unit 1055

56. DHSR Approved Curriculum-Unit 1056 10.11Demonstrate counting respirations.

57. DHSR Approved Curriculum-Unit 1057

58. DHSR Approved Curriculum-Unit 1058 10.12Define blood pressure and discuss how it is measured.

59. DHSR Approved Curriculum-Unit 1059 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

60. DHSR Approved Curriculum-Unit 1060 10.12.1List factors that influence blood pressure.

61. DHSR Approved Curriculum-Unit 1061 Factors Influencing Blood Pressure Weight Sleep Age Emotions Sex Heredity Viscosity of blood Illness/Disease

62. DHSR Approved Curriculum-Unit 1062 Blood Pressure: Equipment Sphygmomanometer (manual) –cuff - different sizes –pressure control bulb –pressure gauge – marked with numbers aneroid mercury

63. DHSR Approved Curriculum-Unit 1063 Blood Pressure: Equipment (continued) Stethoscope –magnifies sound –has diaphragm

64. DHSR Approved Curriculum-Unit 1064 10.12.2Identify the normal blood pressure range.

65. DHSR Approved Curriculum-Unit 1065 Measuring Blood Pressure Normal blood pressure range –Systolic: 90-140 millimeters of mercury –Diastolic: 60-90 millimeters of mercury

66. DHSR Approved Curriculum-Unit 1066 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 1067 Guidelines for Blood Pressure Measurements (continued) First sound heard – systolic pressure Last sound heard or change - diastolic pressure

68. DHSR Approved Curriculum-Unit 1068 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 1069 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 1070 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 1071 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 1072 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

73. DHSR Approved Curriculum-Unit 1073

74. DHSR Approved Curriculum-Unit 1074 10.13Demonstrate the procedure for measuring blood pressure.

75. DHSR Approved Curriculum-Unit 1075 10.14Demonstrate the procedure for taking combined vital signs.

76. DHSR Approved Curriculum-Unit 1076

77. DHSR Approved Curriculum-Unit 1077 10.15Discuss height and weight and how it is measured.

78. DHSR Approved Curriculum-Unit 1078 Measuring Height And Weight Baseline measurement obtained on admission and must be accurate. Other measurements obtained as ordered.

79. DHSR Approved Curriculum-Unit 1079 Measuring Height And Weight (continued) Height measurements –Feet –Inches –Centimeters Weight measurements –Pounds –Ounces –Kilograms

80. DHSR Approved Curriculum-Unit 1080 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

81. DHSR Approved Curriculum-Unit 1081 10.15.1List three guidelines for weighing residents.

82. DHSR Approved Curriculum-Unit 1082 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

83. DHSR Approved Curriculum-Unit 1083 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

84. DHSR Approved Curriculum-Unit 1084

85. DHSR Approved Curriculum-Unit 1085 10.16Demonstrate the procedure for measuring height and weight.

86. DHSR Approved Curriculum-Unit 1086

87. DHSR Approved Curriculum-Unit 1087 10.17Discuss measuring and recording intake and output, and conditions for which this procedure would be ordered.

88. DHSR Approved Curriculum-Unit 1088 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

89. DHSR Approved Curriculum-Unit 1089 10.17.1Identify five symptoms of edema.

90. DHSR Approved Curriculum-Unit 1090 Edema Edema – fluid intake exceeds fluid output –Retention of fluids frequently caused by kidney or heart failure or excessive salt intake

91. DHSR Approved Curriculum-Unit 1091 Edema (continued) Symptoms –weight gain –swelling of feet, ankles, hands, fingers, face –decreased urine output –shortness of breath –collection of fluid in abdomen (ascites)

92. DHSR Approved Curriculum-Unit 1092 10.17.2List eight symptoms of dehydration.

93. DHSR Approved Curriculum-Unit 1093 Dehydration Dehydration: fluid output exceeds fluid intake Common problem of long-term care residents

94. DHSR Approved Curriculum-Unit 1094 Dehydration (continued) Symptoms –thirst –decreased urine output –parched or cracked lips –dry, cracked skin –fever –weight loss –concentrated urine –tongue coated and thick

95. DHSR Approved Curriculum-Unit 1095 Dehydration (continued) Causes of dehydration –poor fluid intake –diarrhea –bleeding –vomiting –excessive perspiration

96. DHSR Approved Curriculum-Unit 1096 Dehydration (continued) Fluids measured in cubic centimeters (cc) –30 cc = 1 ounce –cc - metric measure

97. DHSR Approved Curriculum-Unit 1097

98. DHSR Approved Curriculum-Unit 1098 10.18Identify the liquids that would be measured and recorded as fluid intake.

99. DHSR Approved Curriculum-Unit 1099 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

100. DHSR Approved Curriculum-Unit 10100 10.18.1List the liquids that would be measured and recorded as fluid output.

101. DHSR Approved Curriculum-Unit 10101 Measuring and Recording Intake/Output (continued) Output includes –Urine –Liquid stool –Emesis –Drainage –Suctioned secretions –Excessive perspiration

102. DHSR Approved Curriculum-Unit 10102

103. DHSR Approved Curriculum-Unit 10103 10.19Demonstrate measuring and recording fluid intake and output.

104. DHSR Approved Curriculum-Unit 10104