Basic Nursing Skills

  1. Admission, Transfer, and Discharge

    1. Admission

      1. prepare the room before the resident arrives

      2. know the condition of the patient

      3. know if they are bed bound or able to walk

      4. take the patient’s height, weight, and vital signs

    2. Transfers

      1. inform the patient of the transfer as soon as possible

      2. explain how, where, when and why the transfer will occur

        1. ask if they have any questions

      3. involve them with the packing process if possible

        1. patients often worry about losing their belongings

    3. Discharging

      1. TAPE THE PATIENT’S BOXES

      2. be positive and reassuring

  2. Vital Signs

    1. notify the nurse if:

      1. patient is running a fever

      2. patient has a respiratory or pulse rate that is too rapid

        1. tachycardia

      3. patient has a respiratory or pulse rate that is too slow

        1. bradycardia

      4. patient’s BP changes

    2. Temperature

      1. 4 sites

        1. oral

          1. most common site

          2. do not take oral temperatures on a person who:

            1. is unconscious

            2. is vomiting

            3. using oxygen

            4. is confused or disoriented

            5. is paralyzed from a stroke

            6. has facial trauma

            7. is likely to have a seizure

            8. has a nasogastric tube

              1. ng tube

            9. is younger than 6 years old

            10. has sores, redness, swelling, or pain in the mouth

            11. has injury to the face or neck

        2. rectal

          1. ½ to 1 inch in with lubricant

          2. most accurate reading

        3. axillary

        4. tympanic (the ear)

          1. insert ¼ to ½ inches into ear

    3. Pulse

      1. radial

        1. most common

      2. brachial

        1. to take BP with

      3. apical

        1. over heart with stethoscope

    4. Blood Pressure

      1. normal systolic is 100-119

      2. normal diastolic is 60-79

    5. Normal Vital Signs

      1. Temperature

        1. Oral: 97.6-99.6

        2. Rectal: 98.6-100.6

        3. Axillary: 96.6-98.6

        4. Tympanic: 96.6-99.7

        5. Temporal Artery (forehead): 97.2-100.1

      2. Normal pulse rate: 60-100 beats per minute

      3. Normal respiratory rate: 12-20 breaths per minute

      4. Blood pressure

        1. Normal

          1. Systolic: 90-119

          2. Diastolic: 60-79

        2. Low

          1. hypotension

          2. Systolic: below 90

          3. Diastolic: below 60

        3. Elevated

          1. Systolic: 120-129

          2. Diastolic: less than 80

        4. Stage 1 hypertension

          1. Systolic: 130-139

          2. Diastolic: 80-89

        5. Stage 2 hypertension

          1. Systolic: At or over 140

          2. Diastolic: At or over 90

        6. Hypertensive crisis

          1. Systolic: Over 180

          2. Diastolic: Over 120

  3. Pain Management

    1. called the 5th vital sign

    2. Subjective information:

      1. listen to what the patients are saying about the way they feel

      2. help them change positions

    3. sustained pain may lead to:

      1. withdrawal

      2. depression

      3. isolation

    4. Questions to ask

      1. where is the pain

      2. when did the pain start

      3. is the pain mild, moderate, or severe

        1. ask the patient to rate the pain on a scale of 1-10

        2. can also use the badge buddy if patient is unable to tell you

      4. describe the pain

      5. what they were doing before the pain started

      6. what makes it feel better or worse

    5. Observe and report:

      1. increased pulse, respirations, or BP

      2. sweating

      3. nausea

      4. vomiting

      5. tightening of the jaw

      6. squeezing the eyes shut

      7. holding the body part tightly

      8. change in behavior

      9. groaning

      10. breathing heavily

      11. difficulty in moving or walking

      12. increased restlessness

      13. agitation or tension

        1. frowning, crying, sighing

  4. Restraint free environment

    1. restraint

      1. physical or chemical way to restrict voluntary movement or behavior

        1. common physical restraints

          1. vest

          2. belt

          3. mitt

        2. physical restraints are also called postural supports or protective devices

      2. must have a doctor’s orders to place restraints on a patient

    2. restraint alternatives

      1. improve safety measures to prevent accidents and falls

      2. use postural devices to support and protect the patients bodies

      3. make sure the call light is within reach and answer them promptly

      4. ambulate with the resident when they are restless

      5. encourage repetitive and independent activities

      6. give frequent help with toileting

    3. Restrained person must be checked every 15 minutes

    4. Every 2 hours the following must be done:

      1. release the restraint for at least 15 minutes

      2. offer assistance with toileting

      3. offer fluids

      4. check skin for irritation

      5. reposition the patient

      6. ambulate the patient if possible

  5. Fluid Balance

    1. fluid is in liquids you drink and semi-liquid foods

      1. jello

      2. soup

      3. ice cream

      4. pudding

      5. yogurt

    2. fluid balance

      1. maintaining equal intake and output

    3. people to monitor I&O

      1. tube feedings

      2. IV therapy

      3. Foley catheters

  6. Collecting Specimens

    1. sputum specimen

      1. mucus coughed up from the lungs

        1. early morning is best time to collect

    2. urine specimen

      1. clean catch

      2. midstream

      3. straight catheter

    3. stool specimen

      1. collect in sterile cup after BM

  7. IVs

    1. Report and Observe

      1. tube falls out or is removed

      2. tubing disconnects

      3. dressing around IV is loose or not intact

      4. site is swollen or discolored

      5. patient reports pain

      6. blood is in the tubing or around the site of the IV

      7. pump beeps

      8. IV fluid is nearly gone

      9. IV fluid is not dripping

      10. bag is broken

      11. level of fluid does not seem to decrease

    2. Do not do the following when caring for a patient with an IV

      1. take a BP on the arm with the IV

      2. Get the IV wet

      3. pull or catch the tubing in anything such as clothing

      4. leave the tubing kinked

      5. lower the IV bag below the IV site

      6. touch the clamp

      7. disconnect the IV from the pump or turn off the alarm

  8. Catheter Care

    1. types of catheters

      1. catheter

        1. thin tube inserted into the body that is used to drain fluids or inject fluids

      2. urinary catheter

        1. used to drain urine from the bladder

      3. straight catheter

        1. used to drain urine from the bladder

        2. removed immediately after urine is drained

      4. indwelling catheter

        1. also called a Foley catheter

        2. remains inside the bladder for a period of time

        3. urine drains into a bad

      5. condom catheter

        1. also called a Texas catheter

        2. external catheter

        3. used for males

        4. changed daily or as needed

    2. see page 203 for guidelines regarding urinary catheters

    3. Observe and report

      1. blood in the urine or urine that looks unusual in any way

      2. catheter bag does not fill after several hours

      3. catheter bag fills suddenly

      4. catheter is not in place

      5. urine leaks from the catheter

      6. resident reports pain or pressure

      7. odor is present