Chapter 14: Basic Nursing Skills

list 5 vital signs that must be monitored

1. taking body temps

2. counting the pulse

3. counting the rate of respirations

4. taking blood pressure

5. observing and reporting level of pain

what are the main sites for taking the bodys temp?

• oral (mouth)

• rectum (rectal)

• armpit (axillary)

• ear (tympanic)

which temp. site is considered to be the most accurate?

through the rectum

what is the most common site for monitoring the pulse? where is it located?

• inside of the wrist (radial pulse)

• where the radial artery runs, just beneath the skin

why should respirations be counted immediately after measuring the pulse rate?

normal pulse rate for adults: 60-00 bpm

list 2 parts of measuring bp and briefly define both phases

1. systolic phase: heart is at work. it contracts and pushes blood from left ventricle of the heart. reading shows the pressure on the walls of arteries as blood is pumped through the body. normal range for systolic bp is 100-119 mmHg.

2. diastolic phase: heart is at rest. measurement is always lower than the systolic measurement. it shows the pressure in arteries when heart is at rest. the normal range for adults is 60-79 mmHg

list 2 pieces of equipment normally used to monitor bp

1. sphygmomanometer

2. electronic sphygmomanometer

how are bp numbers written and recored?

in fraction form

list 15 signs that may show that a res. is in pain

1. nausea

2. vomiting

3. sweating

4. increased pulse, respirations, bp

5. tightening in jaw

6. squeezing eyes shut

7. holding/guarding a body part

8. frowning

9. grinding teeth

10. increased restlessness

11. agitation/tension

12. change in behavior

13. crying

14. sighing

15. groaning

list 7 measures that can reduce pain

1. report complaints of pain immediately

2. gently position the body in good alignment

3. use pillows for support

4. assist in frequent changes of position if the res. desires

5. give back rubs

6. see if res. would like to take a warm bath/shower

7. assist the res. to the bathroom/commode/offer the bedpan/urinal

what are the benefits of warm applications? what are the benefits of cold applications?

• warm applications: relieves pain and muscular tension, reduces swelling, elevates the temp in the tissues and increases blood flow

• cold applications: helps stop bleeding, prevents swelling, reduces pain, brings down high fevers

what signs should an NA watch for at the site of a warm/cold application?

excessive redness, pain, blisters, numbness

what is the purpose of the sitz bath?

it cleans perineal wounds and reduce inflammation and pain

when are non-sterile dressings usually used?

applied to dry

what duties may a NA have regarding sterile dressings?

• gather and store equipment and supplies

• observe and report about the dressing site

• may be allowed to clean the equipment

list 6 signs of poor circulation that an NA should observe for when an elastic bandage is applied

1. swelling

2. bluish/cyanotic skin

3. shiny, tight skin

4. skin that is cold to the touch

5. sores

6. numbness

what is a NAs responsibility regarding care of an IV?

report and document any observations of changes or problems with the IV

what is an oxygen concentrator?

a box like device that changes air in the room into air with more oxygen.

what is a nasal cannula?

a piece of plastic tubing that fits around the face and is secured by a strap that goes over the ears and around the head.

why is oxygen a dangerous fire hazard?

it makes other things burn