Chapter 7 - basic nursing skills

What is admission

The first time an NA meets a new resident

What does an admission kit contain

Bath basin, emesis basin, water pitcher, cup, toothepaste, soap, comb, lotion, and tissues.

When a new resident arrives to the facility what should you do

Not the time and their condition

In admission what does OBRA require that residents be told?

Their legal rights,, and be provided with a written copy of these rights. And rights related to advance directives.

During admission can you ask the family to step out until done?

Yes

Baseline signs

Intial values that can be compared to future measurements

During a transfer are NAs allowed to let residents be involved

Yes

During a transfer any questions a resident has a nurse must answer

Yes

What should you document when a patient is being dischharged

• vital signs at discharge

• Time of dischagre

• Method of transprot

• Who was with the resident

• What items the reisdent took woth her

Vital signs

Show how well the vital organs of the body, such as the heart and lungs are working.

What do vital signs consist of

• measuring body temp

• Counting the rate of respiration

• Measuring Bp

Changes in vital signs can indicate what?

Residents conditions is worsening

Normal pulse rate

60-100 beats per minute

Normal respiratory rate

12-20 respirations per minute

Normal blood pressure

Systolic (top number): 90-119 mm hg

Diastolic (bottom number): 60-79 mm hg

Low bp (hypertensive)

Systolic: below 90 mm hg

Diastolic: below 60 mm hg

Elevated bp (hypotensisve)

Systolic: 120-129 mm hg

Diastolic: less than 800 mm hg

Mouth

Oral

Rectum

Rectal

Armpit

Axillary

Ear

Tympanic

Forhead

Temperel artery

Normal oral temp for adults (fahrenheit)

97.6-99.6

Normal rectum temp for adults (fahrenheit)

98.6-100.6

Normal axillary temp for adults (fahrenheit)

96.6-98.6

Normal tympanic temp for adults (fahrenheit)

96.6-99.7

Normal temporal artery temp for adults (fahrenheit)

97.2-100.1

Body temperature

Balence between heat created by the body and the heat lost to the environment

What factors affect body temp

• age

• Ilness

• Stress

• Environment

• Excercise

• Cardiac rhythm

Cardiac rhythm

24-hours day night cycle

When do people tend to have lower temps

In the morning

Increase in body temp may indicate what

Infection or disease

Commo types of thermometers

• digital

• Electronic

• Tympanic

• Temporal artery

• Mercury-free

What does each long line on a thermometer represent

1 degree

What does each short line on a thermometer represent

Two-tenths of a degree

What temperture taken is considered to be the most accurate

Recta;

What temp is considered to be least accurate

Axillary temp

An Na should not measure an oral temp on a person who:

• is unconscious

• Has recently had facial or oral surgery

• Younger than 5 years old

• Is confused or disoriented

• Is heavilt sedated

• is likely to have a seizure

• Is coughing

• Is using oxygen

• Has facial paralysis

• Has a nasogastric tube (feeding tube that is inserted through the noes and goes into the stomach)

• Has sores, redness, swelling, or pain in the mouth

• Has an injury to the face or neck

Who should you not take an oral temp on

If a resident has smoked, eaten or drinken fluids, chewed gum, or excercised in the last 10 or 20 minutes

Steps for using digital themometr

• put on disposable sheath

• Turn on thermoter and wait for ready sign to pop up

  • Insert end of thermometer under the tounge on one side

  • Hold in place until the thermomter beeps or blinks

  • Remove thermoter read temp

  • Use a tissue to remove sheath

How to use ELECTRIC THERMOMETER

Hold in place until you hear a tone or see a flashing or steady light

How to us Mercury free thermometer

Hold in place for at keast three minutes

Removing electronic thermometer

Read temp on display screen, remebrr reading, remove the probe

What do the small arrows or high-lighted arrows show on a thermometer

The normal temp (98.6)

Should you stand away from funriture and walls while holding a mercury thermometer?

Yes

While a thermometer is in a resdients mouth should they keep their mouth closed?

Yes

What position should the resident be lying in when NA is checking rectal temp

Sims posisition

Checking rectal temp

• apply a small amount of lubricant to the tip of the bulb or probe cover

• Seperat buttocks and gently insert thermomter ½ to 1 inch. Stop if you meet resistence

How should you position the residents head when measuring tympanic temperature

Posistion redients head so that the ear is in front of you. Stragten the ear canal by gently pulling up and back on the outside edge of the ear.

Pulse

Radial pulse

Inside of wrist, runs beneath skin

Brachal pulse

Pulse inside the elbow 1- 1 ½ abouve the elbow

What is the normal pulse rate for adults

60-100 beats per minute

What is the pule rate of smaller children

100-120 beats per minute

Pulse rate of a newborm baby

120-180

Respiration

Process of inhaling air inro the lungs

Inspiration

Exhaling air out of the lungs

Each respiration consists of what

Inspiration and expiration

The chest rises during

Inspiration

The chest falls during

Expirations

Normal respirations for adults

12-20 breaths

Repiration rate for infants

30-40

Why is the respirations always counted after counting pulse

People may breathe more quickly if they know they are bing observed

Where do you put your hands when taking radial pusle

Place tips of index finger and middle finger on the thumb side of the residents wrist.

What does blood pressure show

How well the heart is working

Wha

How is blood pressure recorded

As a fraction ex: 110/70-

Systolic

Top number. It contracts and pushes blood from the left ventricle of the heart. The reading shows the pressure on the walls of the arteries as blood is pumped through the body.

What is the normal range for systolic blood pressure

Below 120 mm Hg

Diastolic

Bottom number- when the heart relaxes, its always lower than the systolic numbe. It shows the pressure in the arteries when the heart is at rest.

What is the normal diastolic number for adults

80 mm Hg

When measuring blood pressure manually what is the first sound heard

Systolic pressure

Should blood pressure be measure on an arm that has an IV, dialysis shunt, or any medical equipment

No

If a beat is hear immediatley upon cuff deflation what do you do

Deflayte the cuff and inflate the cuff to no more than 200 mm Hg.

What rnage should you inflate a manual cuff

160-180

How long should you wait befofre retaking BP

30 seconds

When taking BP the arm should be at level with the

Heart

Pulse oximeter

A device that uses a light to determine the amount of oxygen in the blood.

What does a pulse oximeter measure

Person’s pulse rate

When may a pulse oximeter be used

When residents had surgery, are on oxygen, are in intensive care, or have cardiac or respiratory problems.

Care plans are made based on what

NA’s reports

Can a erson’s culture affect how they respond to pain

Yes

What is weight mesured in

Pounds or kilograms

What is a pound

Unit of weight equal to 16 ounces.

What is a kilogram

Unit of mass equal to 1000 grams: one kilogram equals 2.2 punds

If the wheelchair weight isnt listed on the chair what should the NA do?

Weight the emoty chair first. The footrests should be attached if they will be attsached when the resident is in the chair. Then the wheelchair’s weight should be subtracted from the total.

How many inches are in a foot?

12

What do you measure height with

A standing scale

When resident is on a standing scale which way should they be facing

Away from the scale

When on a standing scale should you record weight before or after

After

If a resident is unable to get out of bed how do you measure height

By using a tape measure and making two pencil marking on the sheet that is underneath the resident

Types of physical restrainsts

Vest restraints, belt restraints, wrist/ankle restraints, and mitt restraints.

Chemical restraints

Medications used to control a persons mood or behavior

Enabler

Equipment or device that promotes a residents safety, comfort, indpendence, and mobility.

Examples of an enabler

Wheelchairs, geriatric chairs, cushions and pillows, and certain types of assistive devices such as special utensiles.

If a person cannot remove an enabler independelty what may it be considered as

A restriant

Long-term care facilities are prhobited from using restraints unless what?

They are medically nesccesary

Muscle atrosphophy

Weakenign or wasting away of the muscle