Chapter 7: Nursing Skills and Resident Care Guidelines

Fear

An emotional response to perceived threats or danger.

Uncertainty

A state of being unsure or having doubts.

Anger

A strong feeling of displeasure or hostility.

Loss

The state of no longer having something or someone important.

Independence

The state of being self-sufficient and not reliant on others.

Code status

A designation of a patient's wishes regarding resuscitation efforts (e.g., DNR, DNI, Full code).

Vital signs

Measurements that monitor the functioning of vital organs, including temperature, pulse, respirations, and blood pressure.

Temperature range (Mouth/Oral)

97.6 - 99.6 Fahrenheit (36.4 - 37.5 Celsius).

Temperature range (Rectum)

98.6 - 100.6 Fahrenheit (37.0 - 38.1 Celsius).

Temperature range (Armpit)

96.6 - 98.6 Fahrenheit (35.9 - 37.6 Celsius).

Temperature range (Ear)

96.6 - 99.7 Fahrenheit (35.9 - 37.8 Celsius).

Temperature range (Temporal artery)

97.7 - 100.1 Fahrenheit (36.5 - 37.8 Celsius).

Normal Blood Pressure

Systolic: 90-119 mmHg; Diastolic: 60-79 mmHg.

Low (hypotensive) Blood Pressure

Systolic: Below 90 mmHg; Diastolic: Below 60 mmHg.

Elevated Blood Pressure

Systolic: 120-129 mmHg; Diastolic: Less than 80 mmHg.

S1 Hypertension

Systolic: 130-139 mmHg; Diastolic: 80-89 mmHg.

S2 Hypertension

Systolic: At or over 140 mmHg; Diastolic: At or over 90 mmHg.

Hypertensive crisis

Systolic: Over 180 mmHg; Diastolic: Over 120 mmHg.

Mercury free thermometers

Thermometers that are color coded: Red for Rectal, Green or blue for Oral.

Digital thermometers

Commonly used for oral, rectal, and axillary temperatures.

Tympanic thermometers

Fast and accurate devices for measuring temperature in the ear.

Rectal temperatures

Considered the most accurate but may be dangerous for some residents.

Axillary temperature

Considered the least accurate method for measuring body temperature.

Conditions preventing oral temperature measurement

Includes unconsciousness, recent facial/oral surgery, being younger than 5, confusion, sedation, coughing, and facial paralysis.

Tympanic thermometer

A thermometer that is fast and accurate, inserted into the ear ¼ -½ inch.

Axillary temperature

A less reliable temperature measurement, safer for confused, disoriented, or uncooperative residents, or residents with dementia.

Radial Pulse

The pulse located on the inside of the wrist, where the radial artery runs just beneath the skin.

Brachial Artery

The pulse located inside the elbow, about 1 and a half inches above the elbow.

Respiration

Process of inhaling air into the lungs and exhaling air out of the lungs.

Inspiration

The process of inhaling air into the lungs.

Expiration

The process of exhaling air out of the lungs.

Pulse

The number of heartbeats per minute.

Normal pulse rate for adults

60-100 bpm.

Normal pulse rate for smaller children

100-120 bpm.

Normal pulse rate for newborns

120-180 bpm.

Factors affecting pulse

Exercise, fear, anger, anxiety, heat, medications, and pain.

Rapid pulse causes

Fever, dehydration, or heart failure.

Slow/Weak pulse indication

May indicate infection.

Breath

Includes both inspiration and expiration.

Normal respiration rate for adults

12 to 20 breaths per minute.

Normal respiration rate for infants

30 to 40 breaths per minute.

Systolic

First measurement of blood pressure; phase when the heart is at work, contracting and pushing blood out of the left ventricle.

Diastolic

Second measurement of blood pressure; phase when the heart relaxes or rests.

Normal systolic range

Below 120 mm Hg.

Normal diastolic range

Below 80 mm Hg.

Equipment for measuring blood pressure

Stethoscope and sphygmomanometer.

Weight measurement

A pound is equal to 16 ounces; a kilogram is equal to 1000 grams, and one kilogram equals 2.2 pounds.

Height measurement

There are 12 inches in one foot.

Signs of pain to observe

Increased pulse, respirations, and BP, sweating, nausea, vomiting, tightening of jaw, squeezing eyes shut, holding or guarding body part tightly, frowning, grinding teeth, increased restlessness, agitation or tension, change in behavior, crying, sighing, groaning, breathing heavily, rocking, pacing, repetitive movements, difficulty moving or walking.

Pain management techniques

Report complaints of pain immediately, gently position the body into proper alignment, help with changes of position, give back rubs, encourage slow deep breathing, provide a quiet environment, soft music may distract, help to bathroom or commode, offer bedpan or urinal, be patient, caring, gentle and responsive.

Restraint

A physical or chemical way to restrict voluntary movement or behavior

Restraint Free Care

An environment in which restraints are not kept or used for any reason

Restraint Alternatives

Measures used in place of a restraint or that reduce the need for restraint.

Wandering

A reason for using restraints in the past, related to individuals moving about without purpose.

Preventing falling

A reason for using restraints in the past, aimed at avoiding falls.

Keeping person from hurting themselves or other people

A reason for using restraints in the past to prevent harm.

Keeping person from pulling out tubing

A reason for using restraints in the past to prevent the removal of medical tubing.

Pressure Ulcers

A problem involved in using restraints, caused by prolonged pressure on the skin.

Pneumonia

A problem involved in using restraints, which can arise from immobility.

Risk of suffocation

A problem involved in using restraints, where breathing may be compromised.

Reduced blood circulation

A problem involved in using restraints, leading to poor blood flow.

Stress on the heart

A problem involved in using restraints, which can increase cardiovascular strain.

Incontinence

A problem involved in using restraints, potentially leading to loss of bladder control.

Constipation

A problem involved in using restraints, often due to lack of mobility.

Weakened muscles and bones

A problem involved in using restraints, resulting from inactivity.

Muscle atrophy

Weakening or wasting of muscle, a problem involved in using restraints.

Loss of bone mass

A problem involved in using restraints, leading to decreased bone density.

Poor appetite

A problem involved in using restraints, which can affect nutritional intake.

Malnutrition

A problem involved in using restraints, resulting from inadequate nutrition.

Depression or withdrawal

A psychological problem involved in using restraints, leading to emotional distress.

Sleep disorders

A problem involved in using restraints, which can disrupt normal sleep patterns.

Loss of dignity

A problem involved in using restraints, affecting the individual's sense of self-worth.

Loss of independence

A problem involved in using restraints, limiting personal freedom.

Loss of self-esteem

A problem involved in using restraints, impacting an individual's confidence.

Severe injury

A potential consequence of using restraints improperly.

Death

A potential consequence of using restraints in extreme cases.

Intake (input)

The fluid a person consumes, also called input.

Output

All fluid that is eliminated from the body; includes fluid in urine, feces, vomitus, perspiration, moisture that is exhaled in the air and wound drainage.

Fluid Balance

Taking in and eliminating equal amounts of fluid.

Specimen

A sample that is used for analysis in order to try to make a diagnosis.

Routine Urine Specimen

A urine specimen that can be collected any time a person voids.

Voids

Urinates.

Hat

In healthcare, a collection container that can be inserted into a toilet bowl to collect and measure urine or stool.

Clean catch specimen

A urine specimen that does not include the first or last urine voided; also called mid stream specimen.

Catheter

A thin tube inserted into the body to drain or inject fluids

Urinary Catheter

A type of catheter that is used to drain urine from the bladder

Straight Catheter

A type of urinary catheter that is removed immediately after urine is drained or collected

Indwelling Catheter

A type of urinary catheter that remains inside the bladder for a period of time; also called a foley catheter

Condom Catheter

A type of catheter that has an attachment on the end that fits onto the penis; also called a texas catheter

Oxygen therapy

The administration of oxygen to increase the supply of oxygen

Combustion

The process of burning

Flammable

Easily ignited and capable of burning quickly

Intravenous (IV) Therapy

The delivery of medication, nutrition, or fluids through one's vein

Effects of applying heat

Relieves pain and muscular tension. Reduces swelling. Elevates the temperature in tissues. Increases blood flow.

Effects of applying cold

Helps stop bleeding. Helps prevent swelling. Reduces pain. Helps bring down high fevers.

Moist Applications

Include compresses (warm or cold), soaks (warm or cold), tub baths (warm), sponge baths (warm or cold), sitz baths (warm or cold), ice packs (cold)

Dry Applications

Include Aquamatic K-pad® (warm or cold), electric heating pads (warm), disposable warm packs, ice bags (cold), disposable cold packs (cold)

Warm Compressions

Should be removed after 20 mins; check temp every 5 minutes; cover with plastic wrap; observe for redness

Warm Soaks

No higher than 105°; soak for 15-20 min

Guidelines for oxygen safety

Post no smoking and oxygen in use signs. Do not allow smoking around oxygen equipment. Remove fire hazards.