Chapter 7 Basic Nursing Skills Flashcards
Admission guidelines
Prepare the room. Restock supplies. Make the bed. Make sure there is an admission kit
Admission kits contain: bath basin
Emesis basin
Water pitcher / glass
Toothpaste / toothbrush
Comb
Lotion
Tissues
urine specimen cup
When a new client arrives at the facility no time and their condition. Are they using a wheelchair, on a stretcher, ambulatory? Who is with them? Observe the level of consciousness and possible signs of confusion. Note any tubes such as IVs or catheters.
Introduce yourself and state your position. Offered to take the client and their family on a tour. Review posted dining schedules. Introduce the client to other clients and staff members along the way. Place personal items where the resident would like them. Note valuables, medications, hearing aids, glasses or dentures.
Provide the client with a written copy of their legal rights and explain their rights to them in detail. This includes grievance procedures and advance directives.
It’s a family is present, ask them to step outside until the admission process is over.
Typical admission procedure includes:
Record Height and weight
Baseline vital signs
You’re in specimen if required
Inventory of all personal items.
Complete the paperwork
Help the client store personal items
Provide fresh water
Show the client the bathroom.
Explain that controls and the call light.
Familiarize the client with the telephone, lights and TV controls
For transfers, inform the client as soon as possible so they have time to adjust to the idea
Help pack personal items before transferring. Let them see the empty closet, drawer etc
Document intake/transfer procedures according to facility guidelines
Discharging guidelines
Assist the client with packing their belongings
Know if the resident will be using a wheelchair, stretcher or if they will be ambulatory
If the client seems apprehensive about their health suffering after leaving the facility remind them that their doctors believe that they are ready
Obra requires that residents receive advance notice before being transferred or discharged. Usually 30 days.
Measure the client’s vital signs
Compare the initial intake checklist to the items there. If they are all there ask the resident to sign.
Assist the client into the vehicle safely
Document the procedure using facility guidelines. These may include:
Vital signs
Time of discharge method of transport
who was with the client
Inventory checklist
Vital signs
Monitor how well the vital organs of the body are working. The consist of:
Measuring body temperature
Counting the pulse rate
Counting the rate of respirations
Measuring blood pressure
Observing and recording levels of pain
Always notify the nurse if:
The client has a fever
The client has a respiratory or pulse rate that is too rapid or too slow
The client’s blood pressure changes
The client’s pain is worse or is not relieved by pain management
Ranges for adult vital signs
Temperature:
Mouth (oral) 97.6 to 99.6
Rectal 98.6 to 100.6
Axcilla (armpit) 96.6 to 98.6
Tympanic (ear) 96.6 to 99.7
Temporal artery (forehead) 97.2 to 100.1
Normal pulse rate: 60 to 100 beats per minute
Normal respiratory rate: 12 to 20 respirations per minute
Blood pressure normal:
Systolic - less than 130
Diastolic - less than 80
Low BP: less than 90/60
High BP: above 130 / 80
Temperature
Body temperature is normally very close to 98.6 F
Each long line on a thermometer represents one degree. Each short line represents 2/10 of a degree
People’s body temperature is usually lower in the morning
Rectal temperature is considered the most accurate. Axillary temperature is considered to be the least accurate
DO NOT take an oral temperature on a person who is:
Unconscious
Heavily sedated
Prone to seizures
Confused or disoriented
Using oxygen
Has facial paralysis
Has a nasogastric tube
DO NOT take oral temperature if a client has:
Smoked, eaten or drink fluids, chewed gum or exercised in the last 10 to 20 minutes.
Wait 20 minutes if the client ate or drink cold food or beverage
Insert tympanic thermometers 1/4 to 1/2 in
Insert rectal thermometers 1/2 to 1 in
Wipe the axillary area with tissues before placing the thermometer
Pulse
The number of heartbeats per minute
The radial pulse is on the inside of the wrist
The brachial pulse is about 1 inch above the elbow and is at a medial point on the arm
The normal pulse rate for a healthy adult is 60 to 100 beats per minute
Respirations
The process of inhaling air into the lungs (inspiration) and exhaling air out of the lungs (expiration)
Each respiration consists of an inspiration and an expiration
The normal respiration rates for adults are 12 to 20 breaths per minute
Respirations are usually counted directly after counting the pulse rate while feigning to take the pulse. This is done because people may breathe more quickly if they know they are being observed. While counting respirations keep your fingers on the clients wrist. Do not make it obvious that you are counting their respirations.
Observe the pattern and character of the client’s breathing while counting respirations. Report to the nurse at breathing is irregular
Blood pressure
Is measured in millimeters of Hg (Mercury)
The systolic phase is the heart at work. Normal range is below 120
The diastolic phase is when the heart relaxes. Normal range is below 80
High blood pressure is considered above 130/80 and should be reported to the nurse
BP is measured with either a manual or digital sphygmomanometer
BP should not be measured on an arm with an IV, a dialysis shunt, any trauma or medical equipment.
It’s important to use a cough that is the correct size when measuring. The the various sizes are Small adult, adult, large adult and thigh.
Never measure blood pressure over clothing
When measuring, position the residents arm with his palm up. The arm should be level with the heart
Inflate the cuff to between 160 to 180 mm Hg. If a beat is heard immediately upon deflation, completely deflate the cuff. After 30 seconds Reinflate to 160 to 180.
When recording note which arm was used. RA for the right and LA for the left.
Pulse oximeter
Is a device that uses light to determine the amount of oxygen in the blood. It also measures a person’s pulse rate. It is most commonly used after a client has had surgery, they are on oxygen, are an intensive care or have cardiac or respiratory problems.
Pain management
Pain is subjective. The other vital signs are objective measurements.
Pain is not a normal part of aging
Questions to assess a client’s pain:
Where is the pain?
When did the pain start? How long does the pain last, and how often does it occur?
How severe is the pain? Ask them to rate the pain on a scale of 0 to 10.
Can you describe the pain?
What makes the pain better?
What makes the pain worse?
What were you doing when the pain started?
Observe body language or other messages that a client may be in pain
To help manage or alleviate pain:
*Give back rubs
offer warm baths or showers.
*Encourage slow deep breathing.
*Position the body in proper alignment using pillows for support
Observing and reporting pain:
Look for…
*Tightening the jaw
*Squeezing the eyes shut
*Holding a guarding a body part
*Frowning
*Grinding teeth
*Repetitive movements
Restraints
If a person cannot remove an enabler independently, it may be considered a restraint.
Enablers are things such as wheelchairs, geriatric chairs, and certain types of assistive devices etc.
Ray’s side rails on beds in geriatric chairs with tray tables attached maybe considered enablers or physical restraints.
If a restraint is needed, a doctor must order it. For an NA to use it the doctor must have ordered it in the care plan, charge nurse must have approved of it and the NA must have been trained in the restraints use.
A client who has been restrained must be checked on at least every 15 minutes.
At a minimum, the restraint must be released every two hours and the resident must be given proper care including:
*Measuring vital signs
*Offering fluids and food
*Checking the skin for signs of irritation
*Ambulation
Intake and output
(Fluid balance)
daily Fluid intake / input for a healthy person is 64 Oz
The amount needed depends on factors such as activity, heat, and overall health
The fluids taken in must be eliminated as output:
Urine
feces
vomitus
perspiration
moisture that a person exhales
wound drainage
Fluid balance: is maintaining equal input and output, or taking in and eliminating equal amounts of fluid
1 oz equals 30 ml
Specimens
The specimen is a sample that is used for analysis in order to try and make a diagnosis
Urine
stool
sputum
A routine urine specimen is collected anytime the client voids into a bedpan, urinal, commode or hat
Clean catch specimen: also known as midstream specimen, does not include the first and last urine in the sample it’s purpose is to determine the presence of bacteria in the urine
Early morning is the best time to collect sputum. These are collected to check for respiratory problems or illness. PPE is required..gloves/mask
Catheter care
Nas do not insert, remove or irrigate catheters. They may be asked to give daily catheter care, clean the area around the urethra opening and empty the drainage bag
Daily perineal care is necessary to help prevent bladder infections
Make sure that the drainage bag always hangs lower than the hips or the bladder.
Keep the drainage bag off the floor
Keep the tubing as straight as possible. It should not be kinked
After avoiding the catheter bag wipe the tube/spout clean with alcohol wipes
Report:
odor
Blood
Urine that looks unnatural
Catheter bag fills suddenly
Oxygen therapy
NA’s never stop, adjust or administer oxygen
A nurse or respiratory therapist fits/adjusts nasal cannulas
Never allow smoking near where oxygen is stored or used.
Do not use any petroleum-based products such as Vaseline or ChapStick in the proximity of oxygen
Keep fire hazards such as electric razors and hair dryers. flammable liquids such as alcohol and nail polish should be kept away as well
