unit 10 basic nursing skills4620

8/13/2019 Unit 10 Basic Nursing Skills4620

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DFS Approved Curriculum-Unit 102

Basic Nursing Skills

Introduction

This unit introduces the basicnursin s!ills the nurse aide "ill needto measure and record the resident#svital sins$ heiht and "eiht$ andinta!e and output%

The vital sins provide in&ormation

about chanes in normal bod' &unctionand the resident#s response totreatment%


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DFS Approved Curriculum-Unit 10(

Basic Nursing Skills

Introduction

)continued*

The resident#s "eiht$ compared"ith the heiht$ ives in&ormation about

his+her nutritional status and chanesin the medical condition%

Inta!e and output records provide

in&ormation on &luid balance and !idne'&unction%


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DFS Approved Curriculum-Unit 10,


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10%0 .rovide basic nursin s!ills%


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DFS Approved Curriculum-Unit 10/

Vital Signs

e&lect the &unction o& three bod'

processes that are essential &or li&e%

eulation o& bod' temperature3eart &unction

4reathin


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10%1 67plain the meanin o& vital sinsand the abbreviations used &or

each vital sin%


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Vital Signs)continued*

Abbreviations9

Temperature T

.ulse .espirations

4lood .ressure 4.

:ital sins - T. and 4.


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DFS Approved Curriculum-Unit 10;


.urpose


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10%2 De&ine bod' temperature anddiscuss the "a' it is measured%


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Temperature

Measurement Of Body Heat

3eat production

muscles

lands

o7idation o&

&ood

3eat loss

respiration

perspiration

e7cretion


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Temperature

Measurement Of Body Heat

)continued*

4alance bet"een heat

production and heat loss is bod'

temperature


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10%2%1 =ist the &actors that a&&ecttemperature%


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Factors Affecting Temperature

67ercise Illness

Ae

Time o& da'


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!uipment " T#ermometer

Instrument used to measure bod'temperature

T'pes

Non-mercur' lass

oral

rectal


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!uipment " T#ermometer

T'pes )continued*chemicall' treated paper

disposable

plastic disposable

electronic - probe covered "ith

disposable shieldt'mpanic - electronic probe used in

the ear


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10%2%2 Identi&' the normal temperaturerane$ and the normal bod'

temperature%


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Normal Temperature $ange For

Adults

>ral - ;5%/- ;;%/F)Fahrenheit* or (/%

-(5%C )Celsius*

ectal - ;8%/- 100%/For (5%0- (8%1C

A7illar' - ;/%/- ;8%/For (/%0- (5%0C


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10%2%( ead a non-mercur' lassthermometer%


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To $ead A Non"mercury %lass

T#ermometer

3old e'e level

=ocate solid column o& li?uid in the

lass >bserve lines on scale at upper

side o& column o& li?uid in the lass


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To $ead A Non"mercury %lass

T#ermometer

)continued* ead at point "here li?uid ends

I& li?uid &alls bet"een t"o lines$ read it

to closest linelon line represents deree

short line represents 0%2 o& a deree

Fahrenheit


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10%2%, =ist and discuss the sites usedto ta!e a temperature%


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10%2% evie" sa&et' precautions thatshould be considered "hen

usin a thermometer%


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Temperature& Safety 'recautions

3old rectal and a7illar' thermometersin place

Sta' "ith resident "hen ta!in

temperature Chec! lass thermometers &or chips

.rior to use$ sha!e li?uid in lass

do"n Sha!e thermometer a"a' &rom

resident and hard obects


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Temperature& Safety 'recautions)continued*

Bipe &rom end to tip o&thermometer prior toreadin

Dela' ta!in oraltemperature &or 10 - 1minutes i& resident hasbeen smo!in$ eatin ordrin!in hot+cold li?uids%


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DFS Approved Curriculum-Unit 10(0


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10%( Demonstrate the procedure &ormeasurin an oral temperature

usin a non-mercur' lass

thermometer%


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10%, Demonstrate the procedure &ormeasurin an a7illar'

temperature usin a non-mercur'

lass thermometer%


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DFS Approved Curriculum-Unit 10((

10% Demonstrate the procedure &ormeasurin a rectal temperature

usin a non-mercur' lass

thermometer%


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DFS Approved Curriculum-Unit 10(,

10%/ Demonstrate measurintemperature usin an electronic

or t'mpanic thermometer%


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DFS Approved Curriculum-Unit 10(/

10%5 De&ine pulse and discuss the "a'it is measured%


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Measurement of 'ulse

.ulse is pressure o&blood pushin aainst"all o& arter' as heart

beats and rests .ulse easier to locate

in arteries close to

s!in that can bepressed aainst bone


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Sites For Taking 'ulse

adial base o& thumb Temporal side o&

&orehead

Carotid side o& nec! 4rachial inner aspect

o& elbo"

Femoral inner aspecto& upper thih


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DFS Approved Curriculum-Unit 10(;

Sites For Taking 'ulse)continued*

.opliteal - behind !nee Dorsalis pedis top o&

&oot

Apical pulse over ape7o& heartta!en "ith stethoscope

le&t side o& chest


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DFS Approved Curriculum-Unit 10,0

10%5%1 =ist the &actors that a&&ect thepulse%


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Factors Affecting 'ulse

Ae Se7 .osition

Drus Illness 6motions

Activit' level Temperature .h'sical trainin


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10%5%2 Identi&' the normal pulse raneand characteristics%


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DFS Approved Curriculum-Unit 10,(

Measurement of 'ulse

Normal pulse rane+characteristics9/0 -100 beats per minute and reular

Documentin pulse rate

Noted as number o& beats perminute

h'thm - reular or irreular

:olume - stron$ "ea!$ thread'$boundin


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DFS Approved Curriculum-Unit 10,,


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10%8 Demonstrate countin the radialpulse rate%


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DFS Approved Curriculum-Unit 10,/

10%; Demonstrate measurin theapical pulse%


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10%10 De&ine respiration and discussho" the respirator' rate is

measured%


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DFS Approved Curriculum-Unit 10,;

Measuring $espirations

espiration processo& ta!in in o7'enand e7pellin carbondio7ide &rom lunsand respirator' tract


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10%10%1 =ist the &actors that a&&ect therespirator' rate%

M i $ i ti


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Measuring $espirations)continued*

Ae

Activit'level

.osition

Drus

Se7

Illness6motionsTemperature

Factors A&&ectin ate


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10%10%2 Identi&' the ?ualities o& normalrespirations%

M i $ i ti


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Measuring $espirations)continued*

ualities o& normal respirations12-20 respirations per minute

uiet

6&&ortless

eular


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10%11 Demonstrate countinrespirations%


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10%12 De&ine blood pressure anddiscuss ho" it is measured%


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Measuring Blood 'ressure

4lood pressure is the &orce o& bloodpushin aainst "alls o& arteries

S'stolic pressure9 reatest &orce

e7erted "hen heart contractinDiastolic pressure9 least &orce

e7erted as heart rela7es


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DFS Approved Curriculum-Unit 10/0

10%12%1 =ist &actors that in&luenceblood pressure%


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Factors Influencing Blood 'ressure

Beiht Sleep

Ae

6motions Se7

3eredit'

:iscosit' o& blood

Illness+Disease


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Blood 'ressure& !uipment

Sph'momanometer )manual*cu&& - di&&erent sies

pressure control bulb

pressure aue mar!ed

"ith numbers

aneroid mercur'

Blood 'ressure& !uipment


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DFS Approved Curriculum-Unit 10/(

Blood 'ressure& !uipment)continued*

Stethoscope

mani&ies sound

has diaphram


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DFS Approved Curriculum-Unit 10/,

10%12%2 Identi&' the normal bloodpressure rane%


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Measuring Blood 'ressure

Normal blood pressure rane

S'stolic9 ;0-1,0 millimeters o&

mercur'Diastolic9 /0-;0 millimeters o&

mercur'

%uidelines for Blood 'ressure


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DFS Approved Curriculum-Unit 10//


Measurements


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Measurements

)continued* First sound heard

s'stolic pressure

=ast sound heard or

chane - diastolic

pressure



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Measurements

)continued*

ecord - s'stolic+diastolic

esident in rela7edposition$ sittin or l'in

do"n

4lood pressure usuall'ta!en in le&t arm



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DFS Approved Curriculum-Unit 10/;


Measurements

)continued*

Do not measure blood

pressure in arm "ith I:$A-: shunt )dial'sis*$

cast$ "ound$ or sore



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Measurements

)continued* Appl' cu&& to bare

upper arm$ not over

clothin oom ?uiet so blood

pressure can be heard

Sph'momanometermust be clearl' visible


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Blood 'ressure& $eading %auge

=are lines areat increments o&10 mm3

Shorter lines at2 mm intervals

Ta!e readin atclosest line

Blood 'ressure& $eading %auge


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Blood 'ressure& $eading %auge)continued*

Eaue should be ate'e level


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10%1( Demonstrate the procedure &ormeasurin blood pressure%


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10%1, Demonstrate the procedure &or

ta!in combined vital sins%


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10%1 Discuss heiht and "eiht and

ho" it is measured%

M i H i #t A d ( i #t


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Measuring Heig#t And (eig#t

4aseline measurementobtained on admission

and must be accurate% >ther measurements

obtained as ordered%

Measuring Heig#t And (eig#t


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easu g e g t d e g t)continued*

3eiht measurementsFeet

Inches

Centimeters Beiht measurements

.ounds

>unces

ilorams

Measuring Heig#t and (eig#t


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Measuring Heig#t and (eig#t)continued*

easons &or obtainin heiht and

"eiht

Indicator o& nutritional statusIndicator o& chane in medical

condition

Used b' doctor to order medications


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Measuring Heig#t and (eig#t)continued*

Use same scaleeach time

3ave resident void$remove shoes andouter clothin

Beih at same timeeach da'

Euidelines &or "eihin residents



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g g g)continued*

Scalesemain more accurate i& moved as

little as possible%:arious t'pes o& scales

bathroom scale standin scale scales attached to h'draulic li&ts "heelchair scales bed scales


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10%1/ Demonstrate the procedure &or

measurin heiht and "eiht%


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10%15 Discuss measurin and

recordin inta!e and output$

and conditions &or "hich this

procedure "ould be ordered%

Measuring Intake and Output


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Measuring Intake and Output

Fluid Balance

Consume 2-1+2to (-1+2 ?uarts

dail'

eatin

drin!in

6liminate 2-1+2to (-1+2 ?uartsdail'

urineperspiration"ater vapor

throuhrespirationsstool


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10%15%1 Identi&' &ive s'mptoms o&

edema%

dema


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DFS Approved Curriculum-Unit 10;0

dema

6dema &luid inta!e e7ceeds &luidoutput

etention o& &luids &re?uentl'

caused b' !idne' or heart &ailure ore7cessive salt inta!e

dema


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)continued*

S'mptoms"eiht ain

s"ellin o& &eet$ an!les$

hands$ &iners$ &acedecreased urine output

shortness o& breath

collection o& &luid inabdomen )ascites*


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10%15%2 =ist eiht s'mptoms o&

deh'dration%

) # d ti


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DFS Approved Curriculum-Unit 10;(

)e#ydration

Deh'dration9 &luid

output e7ceeds &luid

inta!e

Common problem o&

lon-term care

residents

)e#ydration


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DFS Approved Curriculum-Unit 10;,

y

)continued*

S'mptomsthirstdecreased urine output

parched or crac!ed lipsdr'$ crac!ed s!in&ever"eiht lossconcentrated urinetonue coated and thic!


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)e#ydration


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DFS Approved Curriculum-Unit 10;/

y)continued*

Fluids measured in cubiccentimeters )cc*

(0 cc G 1 ouncecc - metric measure


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10%18 Identi&' the li?uids that "ould

be measured and recorded as

&luid inta!e%

Measuring and $ecording


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DFS Approved Curriculum-Unit 10;;

g g

Intake*Output

.h'sician orders inta!e and output Inta!e includes9

All li?uid ta!en b' mouth

Food items that turn to li?uid atroom temperature

Tube &eedins into stomach throuhnose or abdomen

Fluids iven b' intravenous in&usion


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10%18%1 =ist the li?uids that "ould be

measured and recorded as

&luid output%

Measuring and $ecording

I t k *O t t


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Intake*Output)continued*

>utput includesUrine

=i?uid stool6mesisDrainae

Suctioned secretions67cessive perspiration


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10%1; Demonstrate measurin and

recordin &luid inta!e and

output%


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unit 10 basic nursing skills4620

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