Basic Nursing Skills + Chpt 13 vocab

Vital signs

Measuring body temp.

Counting PR

Counting RR

Measuring BP

Factors that can affect vital signs

Age, medical condition, medication, mental state, room temp., and noise lvl

Oral temp.

97.6-99.6 / 36.4-37.6

Rectum temp.

98.6-100.6 / 37.0-38.1

Axillary temp.

96.6-98.6 / 35.9-37.0

Tympanic temp.

96.6-99.7 / 35.9-37.6

Temporal temp.

97.2-100.1 / 36.2-37.8

Normal BP

120/80

Hypotension

Below 90/60

Elevated

120-129/ below 80

Stage 1 hypertension

130-139/ 80-89

Stage 2 hypertension

Over 140/90

Hypertensive crisis

Over 180/120

Body temp.

Balance between heat loss and heat created

Factors that affect body temp.

Age, illness, stress, environment, exercise, and circadian rhythm

Digital thermo.

Oral, rectal, or axillary placement; displays results in 2-60 secs. (Requires battery replacement and disposable sheath)

Electronic thermo.

Oral, rectal, axillary placement; displays in 2-60 secs. (Battery operated- needs recharging)

Tympanic thermo.

Ear placement; displays in secs.

Mercury-free thermo.

Oral (blue/green), rectal (red), axillary placement; wait 3 mins. for results

Cannot measure body temp.

If resident is unconscious, younger than 5, confused, heavily sedated, uses O2, facial paralysis, etc

Rectal temp. is used on

Residents w/ no teeth, or dentures, unconscious, or has a hard tim breathing through nose

Common pulse site

Brachial and radial artery

Pulse site

Temporal, carotid, apical, femoral, popliteal, and dorsals pedis

Children’s PR

100-120 bpm

Newborn PR

120-180 bpm

Factors that affect PR

exercise, fear, anger, anxiety, heat, infection, illness, medication, and pain

Apnea

Absence of breathing

Dyspnea

Difficulty breathing

Eupnea

normal respirations

Orthopnea

SOB when laying down

Cheyne-stokes

Changing respirations: slow irregular>rapid, shallow w/ short periods of apnea

Infants and childrens respirations

30-40 rpm

Systolic

Contracting and pushing the blood from the left ventricle; pressure on the walls of blood pumping through body

Diastolic

Heart relaxes; the pressure in the arteries when heart relaxes

Factors that affect BP

aging, exercise, stress, pain, medication, illness, obesity, alcohol intake, tobacco products, vol. of blood in circulation

Sphygomanometer

Measures BP

Electronic sphymomanometer

Digitally displayed, everything automatic; reads other vital signs

Aneroid sphymomanometer

Consist of cuff, bulb, and pressure gauge; manual requires stethoscope

Do not measure BP

If they have an IV, dialysis shunt, medical equipment, cast, recent trauma, paralysis, burns, or breast surgery

Pulse oximeter

Noninvasive device that uses light to determine O2 in blood

Pain

Subjective: personal experience

bi-

two

hemi-

half

hyper-

above normal

hypo-

below normal

olig-

scant

pan-

all

semi-

half

uni-

one

DBP

diastolic blood pressure

FUO

fever of unknown origin

SBP

systolic blood pressure

SpO2

peripheral oxygen saturation

T

temperature

TPR

temperature, pulse, respirations

WNL

within normal limits

Pain occurs

By illness/ disease, improper positioning, emotional distress, inactivity, and medications

NA can ask residents this

Where is the pain? On a scale of 0-10 how severe is it? When did it start? Can you describe the pain?

Things that delays residents pain reports are this

fear of addiction to pain medic., believing its normal for old age, worrying abt consitpation/fatigue from medic., etc

Observe and Report; Pain

increa. pulse, RR, BP, tightening jaw, squeezing eyes shut, clenching fist, grinding teeth, rocking, etc

Measures to reduce pain

report all complaints/ observations, give back rubs, gently position resident in proper alignment, provide a calm and quiet environment, be patient and caring

Heat applications

relieves pain and muscular tension, reduces swelling, elevates temp. in tissues, and increa. blood slow

Cold appilication

help stops bleeding, prevents swelling, reduce pain, and brings down fevers

Moisture

Strengthens the effect on both cold and heat applications; most likely to cause injury

Cant feel pain

Residents with paralysis, numbness, disorientation, confusion, dementia, and other conditions

Moist Applications

Compress (warm/cold), soaks (warm/cold), tub baths (warm), sponge bath (warm/cold), sitzs baths (warm), and ice packs (cold)

Dry Applications

Aquamatic K-Pad (warm/cold), electric heating pad (warm), disposable warm packs (warm), disposable cold packs (cold), ice bags (cold)

Observe & reporting; warm/ cold applications

Excessive redness, blisters, numbness, and pain

Sitz bath

Warm soak of the perineal area; reduc. infla. & cleans wounds, causes circulation to the perineal area so they might feel dizzy or faint after it

Sterile dressing

Covers new, open, or draining wounds; NA cant change it but could gather or store supplies, observe, and report

Equipment for sterile dressing

Special gauze, abdominal pads, cotton bandages, binders, and medical grade adhesive tape

Not sterile

If wrapper is torn, is opened, wet/ has been wet, shows expiration date, or your unable to tell

Elastic bandages

Non sterile dressing; covers dry, closed wounds- stretching bandages that holds dressings in place, secures splints, and supports & protects body parts

Must do for elastic bandages

Keep area dry & clean, wrap bandage evenly in 8 figure pattern, do not tie; use tape/clip, check for wrinkles or loose lvl, and apply snuggly to control bleeding & prevent movement of dressing

Intravenous Therapy

IV therapy; delivery of medication, nutrition, or fluids through arm- drips from a bad suspended on a pole / pumped by a portable pump through a tube

Port

An surgical opening allowing easy access for IV fuilds

Report IV

Tube/needle is removed or falls out, tubing disconnects, dressing is loose or not intact, blood around IV/site, site is swollen/discolored, or fluid is nearly gone

When resident has a IV

NA should not measure BP, pull or catch it on anything, lower bag below the IV site, leave the tubing kinked, touch the clamp, disconnect IV

Oxygen therapy

Administrating O2 to increa. the supply of O2 to the lungs

Tanks

Compressed & liquid O2 stored

Oxygen concentrator

Produces & distributes O2, doesn’t store; box like device that changes the room air w/ more O2 ( ran electronically )

Nasal cannula

Piece of plastic tubing that fits around the face; delivers by rhese prongs (1/2in)

Humidifiers

A device that puts warm and cold moisture in the air; great factor to grow pathogens so it must be cleaned

BRP

bathroom privileges

BR

bedrest

CCU

cardiac care unit

CICU

cardiac intensive care unit

ED

emergency department

IMC

intermediate care unit

IP

inpatient

MICU

medical intensive care unit

NICU

neonatal intensive care unit

PACU

post anesthesia care unit

SICU

surgical intensive care unit