Unit 10 Basic Nursing Skills

Nurse Aide I Course

DFS Approved Curriculum-Unit 101

Basic Nursing Skills Introduction This unit introduces the basic nursin s!ills the nurse aide "ill need to measure and record the resident#s vital si ns$ hei ht and "ei ht$ and inta!e and output% The vital si ns provide in&ormation about chan es in normal bod' &unction and the resident#s response to treatment%
DFS Approved Curriculum-Unit 102

Basic Nursing Skills Introduction

)continued*

The resident#s "ei ht$ compared "ith the hei ht$ ives in&ormation about his+her nutritional status and chan es in the medical condition% Inta!e and output records provide in&ormation on &luid balance and !idne' &unction%
DFS Approved Curriculum-Unit 10(

DFS Approved Curriculum-Unit 10,

10%0 .rovide basic nursin s!ills%

DFS Approved Curriculum-Unit 10-

Vital Signs 0 1e&lect the &unction o& three bod' processes that are essential &or li&e% 2 1e ulation o& bod' temperature 2 3eart &unction 2 4reathin

DFS Approved Curriculum-Unit 10/

10%1 67plain the meanin o& vital si ns and the abbreviations used &or each vital si n%

DFS Approved Curriculum-Unit 105

Vital Signs
)continued*

0 Abbreviations9 2 Temperature 2 T 2 .ulse 2 . 2 1espirations 2 1 2 4lood .ressure 2 4. 2 :ital si ns - T.1 and 4.

DFS Approved Curriculum-Unit 108

Vital Signs
)continued*

0 .urpose 2 <easured to detect an' chan es in normal bod' &unction 2 Used to determine response to treatment
DFS Approved Curriculum-Unit 10;

Vital Signs
)continued*

0 <easurement )ta!en at rest* 2 Temperature - measures bod' heat 2 .ulse - measures heart rate 2 1espiration - measures ho" o&ten resident inhales and e7hales 2 4lood .ressure - measures pressure a ainst "alls o& arteries
DFS Approved Curriculum-Unit 1010

DFS Approved Curriculum-Unit 1011

10%2 De&ine bod' temperature and discuss the "a' it is measured%

DFS Approved Curriculum-Unit 1012

Temperature Measurement Of Body Heat 0 3eat production 2 muscles 2 lands 2 o7idation o& &ood 0 3eat loss 2 respiration 2 perspiration 2 e7cretion

DFS Approved Curriculum-Unit 101(

Temperature Measurement Of Body Heat

)continued*

4alance bet"een heat production and heat loss is bod' temperature

DFS Approved Curriculum-Unit 101,

10%2%1 =ist the &actors that a&&ect temperature%

DFS Approved Curriculum-Unit 101-

Factors Affecting Temperature 0 0 0 0 0 67ercise Illness A e Time o& da' <edications 0 0 0 0 0 In&ection 6motions 3'dration Clothin 6nvironmental temperature+air movement

DFS Approved Curriculum-Unit 101/

!uipment " T#ermometer 0 Instrument used to measure bod' temperature 0 T'pes 2 Non-mercur' lass 0 oral 0 rectal
DFS Approved Curriculum-Unit 1015

!uipment " T#ermometer 0 T'pes )continued* 2 chemicall' treated paper 2 disposable 2 plastic 2 disposable 2 electronic - probe covered "ith disposable shield 2 t'mpanic - electronic probe used in the ear
DFS Approved Curriculum-Unit 1018

10%2%2 Identi&' the normal temperature ran e$ and the normal bod' temperature%

DFS Approved Curriculum-Unit 101;

Normal Temperature $ange For Adults 0 >ral - ;5%/ - ;;%/ F )Fahrenheit* or (/%- -(5%- C )Celsius* 0 1ectal - ;8%/ - 100%/ F or (5%0 - (8%1 C 0 A7illar' - ;/%/ - ;8%/ F or (/%0 - (5%0 C
DFS Approved Curriculum-Unit 1020

10%2%( 1ead a non-mercur' lass thermometer%

DFS Approved Curriculum-Unit 1021

To $ead A Non"mercury %lass T#ermometer 0 3old e'e level 0 =ocate solid column o& li?uid in the lass 0 >bserve lines on scale at upper side o& column o& li?uid in the lass

DFS Approved Curriculum-Unit 1022

To $ead A Non"mercury %lass T#ermometer 0 1ead at point "here li?uid ends 0 I& li?uid &alls bet"een t"o lines$ read it to closest line 2 lon line represents de ree 2 short line represents 0%2 o& a de ree Fahrenheit
DFS Approved Curriculum-Unit 102(

)continued*

10%2%, =ist and discuss the sites used to ta!e a temperature%

DFS Approved Curriculum-Unit 102,

Sites To Take A Temperature 0 >ral 2 most common 0 1ectal 2 re isters one de ree Fahrenheit hi her than oral 0 A7illar' 2 least accurate@ re isters one de ree Fahrenheit lo"er than oral 0 T'mpanic 2 probe inserted into the ear canal
DFS Approved Curriculum-Unit 102-

Sites To Take A Temperature

)continued*

Condition o& resident determines "hich is the best site &or measurin bod' temperature

DFS Approved Curriculum-Unit 102/

10%2%- 1evie" sa&et' precautions that should be considered "hen usin a thermometer%

DFS Approved Curriculum-Unit 1025

Temperature& Safety 'recautions 0 3old rectal and a7illar' thermometers in place 0 Sta' "ith resident "hen ta!in temperature 0 Chec! lass thermometers &or chips 0 .rior to use$ sha!e li?uid in lass do"n 0 Sha!e thermometer a"a' &rom resident and hard obAects
DFS Approved Curriculum-Unit 1028

Temperature& Safety 'recautions

)continued*

0 Bipe &rom end to tip o& thermometer prior to readin 0 Dela' ta!in oral temperature &or 10 - 1minutes i& resident has been smo!in $ eatin or drin!in hot+cold li?uids%
DFS Approved Curriculum-Unit 102;

DFS Approved Curriculum-Unit 10(0

10%( Demonstrate the procedure &or measurin an oral temperature usin a non-mercur' lass thermometer%

DFS Approved Curriculum-Unit 10(1

10%, Demonstrate the procedure &or measurin an a7illar' temperature usin a non-mercur' lass thermometer%

DFS Approved Curriculum-Unit 10(2

10%- Demonstrate the procedure &or measurin a rectal temperature usin a non-mercur' lass thermometer%

DFS Approved Curriculum-Unit 10((

10%/ Demonstrate measurin temperature usin an electronic or t'mpanic thermometer%

DFS Approved Curriculum-Unit 10(,

DFS Approved Curriculum-Unit 10(-

10%5 De&ine pulse and discuss the "a' it is measured%

DFS Approved Curriculum-Unit 10(/

Measurement of 'ulse 0 .ulse is pressure o& blood pushin a ainst "all o& arter' as heart beats and rests 0 .ulse easier to locate in arteries close to s!in that can be pressed a ainst bone
DFS Approved Curriculum-Unit 10(5

Sites For Taking 'ulse 0 1adial 2 base o& thumb 0 Temporal 2 side o& &orehead 0 Carotid 2 side o& nec! 0 4rachial 2 inner aspect o& elbo" 0 Femoral 2 inner aspect o& upper thi h
DFS Approved Curriculum-Unit 10(8

Sites For Taking 'ulse

)continued*

0 .opliteal - behind !nee 0 Dorsalis pedis 2 top o& &oot 0 Apical pulse 2 over ape7 o& heart 2 ta!en "ith stethoscope 2 le&t side o& chest
DFS Approved Curriculum-Unit 10(;

10%5%1 =ist the &actors that a&&ect the pulse%

DFS Approved Curriculum-Unit 10,0

Factors Affecting 'ulse 0 0 0 0 0 0 0 0 0 A e Se7 .osition Dru s Illness 6motions Activit' level Temperature .h'sical trainin
DFS Approved Curriculum-Unit 10,1

10%5%2 Identi&' the normal pulse ran e and characteristics%

DFS Approved Curriculum-Unit 10,2

Measurement of 'ulse 0 Normal pulse ran e+characteristics9 /0 -100 beats per minute and re ular 0 Documentin pulse rate 2 Noted as number o& beats per minute 2 1h'thm - re ular or irre ular 2 :olume - stron $ "ea!$ thread'$ boundin
DFS Approved Curriculum-Unit 10,(

DFS Approved Curriculum-Unit 10,,

10%8 Demonstrate countin the radial pulse rate%

DFS Approved Curriculum-Unit 10,-

10%; Demonstrate measurin the apical pulse%

DFS Approved Curriculum-Unit 10,/

DFS Approved Curriculum-Unit 10,5

10%10

De&ine respiration and discuss ho" the respirator' rate is measured%

DFS Approved Curriculum-Unit 10,8

Measuring $espirations 0 1espiration 2 process o& ta!in in o7' en and e7pellin carbon dio7ide &rom lun s and respirator' tract

DFS Approved Curriculum-Unit 10,;

10%10%1 =ist the &actors that a&&ect the respirator' rate%

DFS Approved Curriculum-Unit 10-0

Measuring $espirations
)continued*

Factors A&&ectin 1ate 0A e 0 Activit' level 0 .osition 0 Dru s 0 Se7 0 Illness 0 6motions 0 Temperature

DFS Approved Curriculum-Unit 10-1

10%10%2 Identi&' the ?ualities o& normal respirations%

DFS Approved Curriculum-Unit 10-2

Measuring $espirations
)continued*

0 Cualities o& normal respirations 2 12-20 respirations per minute 2 Cuiet 2 6&&ortless 2 1e ular

DFS Approved Curriculum-Unit 10-(

Measuring $espirations
)continued*

0 Documentin respirator' rate 2 Noted as number o& inhalations and e7halations per minute )one inhalation and one e7halation e?uals one respiration* 2 1h'thm 2 re ular or irre ular 2 Character9 shallo"$ deep$ labored
DFS Approved Curriculum-Unit 10-,

DFS Approved Curriculum-Unit 10--

10%11 Demonstrate countin respirations%

DFS Approved Curriculum-Unit 10-/

DFS Approved Curriculum-Unit 10-5

10%12 De&ine blood pressure and discuss ho" it is measured%

DFS Approved Curriculum-Unit 10-8

Measuring Blood 'ressure 0 4lood pressure is the &orce o& blood pushin a ainst "alls o& arteries 2 S'stolic pressure9 reatest &orce e7erted "hen heart contractin 2 Diastolic pressure9 least &orce e7erted as heart rela7es

DFS Approved Curriculum-Unit 10-;

10%12%1 =ist &actors that in&luence blood pressure%

DFS Approved Curriculum-Unit 10/0

Factors Influencing Blood 'ressure 0 0 0 0 0 0 0 0 Bei ht Sleep A e 6motions Se7 3eredit' :iscosit' o& blood Illness+Disease
DFS Approved Curriculum-Unit 10/1

Blood 'ressure& !uipment 0 Sph' momanometer )manual* 2 cu&& - di&&erent siDes 2 pressure control bulb 2 pressure au e 2 mar!ed "ith numbers 0 aneroid 0 mercur'
DFS Approved Curriculum-Unit 10/2

Blood 'ressure& !uipment

)continued*

0 Stethoscope 2 ma ni&ies sound 2 has diaphra m

DFS Approved Curriculum-Unit 10/(

10%12%2 Identi&' the normal blood pressure ran e%

DFS Approved Curriculum-Unit 10/,

Measuring Blood 'ressure 0 Normal blood pressure ran e 2 S'stolic9 ;0-1,0 millimeters o& mercur' 2 Diastolic9 /0-;0 millimeters o& mercur'

DFS Approved Curriculum-Unit 10/-

%uidelines for Blood 'ressure Measurements 0 <easure on upper arm 0 3ave correct siDe cu&& 0 Identi&' brachial arter' &or correct placement o& stethoscope
DFS Approved Curriculum-Unit 10//

%uidelines for Blood 'ressure Measurements

)continued*

0 First sound heard 2 s'stolic pressure 0 =ast sound heard or chan e - diastolic pressure

DFS Approved Curriculum-Unit 10/5

%uidelines for Blood 'ressure Measurements

)continued*

0 1ecord - s'stolic+diastolic 0 1esident in rela7ed position$ sittin or l'in do"n 0 4lood pressure usuall' ta!en in le&t arm
DFS Approved Curriculum-Unit 10/8

%uidelines for Blood 'ressure Measurements

)continued*

0 Do not measure blood pressure in arm "ith I:$ A-: shunt )dial'sis*$ cast$ "ound$ or sore

DFS Approved Curriculum-Unit 10/;

%uidelines for Blood 'ressure Measurements

)continued*

0 Appl' cu&& to bare upper arm$ not over clothin 0 1oom ?uiet so blood pressure can be heard 0 Sph' momanometer must be clearl' visible
DFS Approved Curriculum-Unit 1050

Blood 'ressure& $eading %auge 0 =ar e lines are at increments o& 10 mm3 0 Shorter lines at 2 mm intervals 0 Ta!e readin at closest line
DFS Approved Curriculum-Unit 1051

Blood 'ressure& $eading %auge

)continued*

0 Eau e should be at e'e level 0 <ercur' column au e must not be tilted 0 1eadin ta!en &rom top o& column o& mercur'

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

DFS Approved Curriculum-Unit 1052

DFS Approved Curriculum-Unit 105(

10%1( Demonstrate the procedure &or measurin blood pressure%

DFS Approved Curriculum-Unit 105,

10%1, Demonstrate the procedure &or ta!in combined vital si ns%

DFS Approved Curriculum-Unit 105-

DFS Approved Curriculum-Unit 105/

10%1- Discuss hei ht and "ei ht and ho" it is measured%

DFS Approved Curriculum-Unit 1055

Measuring Heig#t And (eig#t 0 4aseline measurement obtained on admission and must be accurate% 0 >ther measurements obtained as ordered%

DFS Approved Curriculum-Unit 1058

Measuring Heig#t And (eig#t

)continued*

0 3ei ht measurements 2 Feet 2 Inches 2 Centimeters 0 Bei ht measurements 2 .ounds 2 >unces 2 Filo rams
DFS Approved Curriculum-Unit 105;

Measuring Heig#t and (eig#t

)continued*

0 1easons &or obtainin hei ht and "ei ht 2 Indicator o& nutritional status 2 Indicator o& chan e in medical condition 2 Used b' doctor to order medications
DFS Approved Curriculum-Unit 1080

10%1-%1 =ist three uidelines &or "ei hin residents%

DFS Approved Curriculum-Unit 1081

Measuring Heig#t and (eig#t

)continued*

0 Euidelines &or "ei hin residents 2 Use same scale each time 2 3ave resident void$ remove shoes and outer clothin 2 Bei h at same time each da'
DFS Approved Curriculum-Unit 1082

Measuring Heig#t and (eig#t 0 Scales 2 1emain more accurate i& moved as little as possible% 2 :arious t'pes o& scales 0 bathroom scale 0 standin scale 0 scales attached to h'draulic li&ts 0 "heelchair scales 0 bed scales
DFS Approved Curriculum-Unit 108(

)continued*

DFS Approved Curriculum-Unit 108,

10%1/ Demonstrate the procedure &or measurin hei ht and "ei ht%

DFS Approved Curriculum-Unit 108-

DFS Approved Curriculum-Unit 108/

10%15 Discuss measurin and recordin inta!e and output$ and conditions &or "hich this procedure "ould be ordered%

DFS Approved Curriculum-Unit 1085

Measuring Intake and Output Fluid Balance 0 6liminate 2-1+2 0 Consume 2-1+2 to (-1+2 ?uarts to (-1+2 ?uarts dail' dail' 2 urine 2 eatin 2 perspiration 2 drin!in 2 "ater vapor throu h respirations 2 stool
DFS Approved Curriculum-Unit 1088

10%15%1 Identi&' &ive s'mptoms o& edema%

DFS Approved Curriculum-Unit 108;

dema 0 6dema 2 &luid inta!e e7ceeds &luid output 2 1etention o& &luids &re?uentl' caused b' !idne' or heart &ailure or e7cessive salt inta!e

DFS Approved Curriculum-Unit 10;0

dema
)continued*

0 S'mptoms 2 "ei ht ain 2 s"ellin o& &eet$ an!les$ hands$ &in ers$ &ace 2 decreased urine output 2 shortness o& breath 2 collection o& &luid in abdomen )ascites*
DFS Approved Curriculum-Unit 10;1

10%15%2 =ist ei ht s'mptoms o& deh'dration%

DFS Approved Curriculum-Unit 10;2

)e#ydration 0 Deh'dration9 &luid output e7ceeds &luid inta!e 0 Common problem o& lon -term care residents

DFS Approved Curriculum-Unit 10;(

0 S'mptoms 2 thirst 2 decreased urine output 2 parched or crac!ed lips 2 dr'$ crac!ed s!in 2 &ever 2 "ei ht loss 2 concentrated urine 2 ton ue coated and thic!
DFS Approved Curriculum-Unit 10;,

)e#ydration )continued*

)e#ydration
)continued*

0 Causes o& deh'dration 2 poor &luid inta!e 2 diarrhea 2 bleedin 2 vomitin 2 e7cessive perspiration
DFS Approved Curriculum-Unit 10;-

)e#ydration
)continued*

0 Fluids measured in cubic centimeters )cc* 2 (0 cc G 1 ounce 2 cc - metric measure

DFS Approved Curriculum-Unit 10;/

DFS Approved Curriculum-Unit 10;5

10%18 Identi&' the li?uids that "ould be measured and recorded as &luid inta!e%

DFS Approved Curriculum-Unit 10;8

Measuring and $ecording Intake*Output 0 .h'sician orders inta!e and output 0 Inta!e includes9 2 All li?uid ta!en b' mouth 2 Food items that turn to li?uid at room temperature 2 Tube &eedin s into stomach throu h nose or abdomen 2 Fluids iven b' intravenous in&usion
DFS Approved Curriculum-Unit 10;;

10%18%1 =ist the li?uids that "ould be measured and recorded as &luid output%

DFS Approved Curriculum-Unit 10100

Measuring and $ecording Intake*Output

)continued*

0 >utput includes 2 Urine 2 =i?uid stool 2 6mesis 2 Draina e 2 Suctioned secretions 2 67cessive perspiration
DFS Approved Curriculum-Unit 10101

DFS Approved Curriculum-Unit 10102

10%1; Demonstrate measurin and recordin &luid inta!e and output%

DFS Approved Curriculum-Unit 1010(

DFS Approved Curriculum-Unit 1010,