Basic Nursing Skills ppt

Basic Nursing Skills ppt

1. 1
BASIC NURSING SKILLS
PRESENTED BY:
Prof. Vijayreddy Vandali
PhD Scholar, M.Sc (N), PGDHA, PGCDE,.
Dept of Medical-Surgical Nursing
INDIA

2. DHSR Approved Curriculum-Unit 10 2
Basic Nursing Skills
Introduction
This unit introduces the basic
nursing skills the nurse aide will need
to measure and record the resident’s
vital signs, height and weight, and
intake and output.
The vital signs provide information
about changes in normal body function
and the resident’s response to
treatment.

3. DHSR Approved Curriculum-Unit 10 3
Basic Nursing Skills
Introduction
(continued)
The resident’s weight, compared
with the height, gives information about
his/her nutritional status and changes
in the medical condition.
Intake and output records provide
information on fluid balance and kidney
function.

4. DHSR Approved Curriculum-Unit 10 4

5. DHSR Approved Curriculum-Unit 10 5
10.0Provide basic nursing skills.

6. DHSR Approved Curriculum-Unit 10 6
Vital Signs
•Reflect the function of three body
processes that are essential for life.
–Regulation of body temperature
–Heart function
–Breathing

7. DHSR Approved Curriculum-Unit 10 7
10.1Explain the meaning of vital signs
and the abbreviations used for
each vital sign.

8. DHSR Approved Curriculum-Unit 10 8
Vital Signs
(continued)
•Abbreviations:
–Temperature – T
–Pulse – P
–Respirations – R
–Blood Pressure – BP
–Vital signs - TPR and BP

9. DHSR Approved Curriculum-Unit 10 9
Vital Signs
(continued)
•Purpose
–Measured to detect
any changes in
normal body
function
–Used to determine
response to
treatment

10. DHSR Approved Curriculum-Unit 10 10
Vital Signs
(continued)
•Measurement (taken at rest)
–Temperature - measures body heat
–Pulse - measures heart rate
–Respiration - measures how often
resident inhales and exhales
–Blood Pressure - measures
pressure against walls of arteries

11. DHSR Approved Curriculum-Unit 10 11

12. DHSR Approved Curriculum-Unit 10 12
10.2Define body temperature and
discuss the way it is measured.

13. DHSR Approved Curriculum-Unit 10 13
Temperature –
Measurement Of Body Heat
•Heat production
–muscles
–glands
–oxidation of
food
•Heat loss
–respiration
–perspiration
–excretion

14. DHSR Approved Curriculum-Unit 10 14
Temperature –
Measurement Of Body Heat
(continued)
Balance between heat
production and heat loss is body
temperature

15. DHSR Approved Curriculum-Unit 10 15
10.2.1List the factors that affect
temperature.

16. DHSR Approved Curriculum-Unit 10 16
Factors Affecting Temperature
•Exercise
•Illness
•Age
•Time of day
•Medications
•Infection
•Emotions
•Hydration
•Clothing
•Environmental
temperature/air
movement

17. DHSR Approved Curriculum-Unit 10 17
Equipment - Thermometer
•Instrument used to measure body
temperature
•Types
–Non-mercury glass
•oral
•rectal

18. DHSR Approved Curriculum-Unit 10 18
Equipment - Thermometer
•Types (continued)
–chemically treated paper –
disposable
–plastic – disposable
–electronic - probe covered with
disposable shield
–tympanic - electronic probe used in
the ear

19. DHSR Approved Curriculum-Unit 10 19
10.2.2Identify the normal temperature
range, and the normal body
temperature.

20. DHSR Approved Curriculum-Unit 10 20
Normal Temperature Range For
Adults
•Oral - 97.6° - 99.6° F
(Fahrenheit) or 36.5°
-37.5° C (Celsius)
•Rectal - 98.6° - 100.6° F
or 37.0° - 38.1° C
•Axillary - 96.6° - 98.6° F
or 36.0° - 37.0° C

21. DHSR Approved Curriculum-Unit 10 21
10.2.3Read a non-mercury glass
thermometer.

22. DHSR Approved Curriculum-Unit 10 22
To Read A Non-mercury Glass
Thermometer
•Hold eye level
•Locate solid column of liquid in the
glass
•Observe lines on scale at upper
side of column of liquid in the glass

23. DHSR Approved Curriculum-Unit 10 23
To Read A Non-mercury Glass
Thermometer
(continued)
•Read at point where liquid ends
•If liquid falls between two lines, read it
to closest line
–long line represents degree
–short line represents 0.2 of a degree
Fahrenheit

24. DHSR Approved Curriculum-Unit 10 24
10.2.4List and discuss the sites used
to take a temperature.

25. DHSR Approved Curriculum-Unit 10 25
Sites To Take A Temperature
•Oral – most common
•Rectal – registers one degree
Fahrenheit higher than oral
•Axillary – least accurate; registers
one degree Fahrenheit lower than
oral
•Tympanic – probe inserted into the
ear canal

26. DHSR Approved Curriculum-Unit 10 26
Sites To Take A Temperature
(continued)
Condition of resident
determines which is the
best site for measuring
body temperature

27. DHSR Approved Curriculum-Unit 10 27
10.2.5Review safety precautions that
should be considered when
using a thermometer.

28. DHSR Approved Curriculum-Unit 10 28
Temperature: Safety Precautions
•Hold rectal and axillary thermometers
in place
•Stay with resident when taking
temperature
•Check glass thermometers for chips
•Prior to use, shake liquid in glass
down
•Shake thermometer away from
resident and hard objects

29. DHSR Approved Curriculum-Unit 10 29
Temperature: Safety Precautions
(continued)
•Wipe from end to tip of
thermometer prior to
reading
•Delay taking oral
temperature for 10 - 15
minutes if resident has
been smoking, eating or
drinking hot/cold liquids.

30. DHSR Approved Curriculum-Unit 10 30

31. DHSR Approved Curriculum-Unit 10 31
10.3Demonstrate the procedure for
measuring an oral temperature
using a non-mercury glass
thermometer.

32. DHSR Approved Curriculum-Unit 10 32
10.4Demonstrate the procedure for
measuring an axillary
temperature using a non-mercury
glass thermometer.

33. DHSR Approved Curriculum-Unit 10 33
10.5Demonstrate the procedure for
measuring a rectal temperature
using a non-mercury glass
thermometer.

34. DHSR Approved Curriculum-Unit 10 34
10.6Demonstrate measuring
temperature using an electronic
or tympanic thermometer.

35. DHSR Approved Curriculum-Unit 10 35

36. DHSR Approved Curriculum-Unit 10 36
10.7Define pulse and discuss the way
it is measured.

37. DHSR Approved Curriculum-Unit 10 37
Measurement of Pulse
•Pulse is pressure of
blood pushing against
wall of artery as heart
beats and rests
•Pulse easier to locate
in arteries close to
skin that can be
pressed against bone

38. DHSR Approved Curriculum-Unit 10 38
Sites For Taking Pulse
•Radial – base of thumb
•Temporal – side of
forehead
•Carotid – side of neck
•Brachial – inner aspect
of elbow
•Femoral – inner aspect
of upper thigh

39. DHSR Approved Curriculum-Unit 10 39
Sites For Taking Pulse
(continued)
•Popliteal - behind knee
•Dorsalis pedis – top of
foot
•Apical pulse – over apex
of heart
–taken with stethoscope
–left side of chest

40. DHSR Approved Curriculum-Unit 10 40
10.7.1List the factors that affect the
pulse.

41. DHSR Approved Curriculum-Unit 10 41
Factors Affecting Pulse
•Age
•Sex
•Position
•Drugs
•Illness
•Emotions
•Activity level
•Temperature
•Physical training

42. DHSR Approved Curriculum-Unit 10 42
10.7.2Identify the normal pulse range
and characteristics.

43. DHSR Approved Curriculum-Unit 10 43
Measurement of Pulse
•Normal pulse range/characteristics:
60 -100 beats per minute and regular
•Documenting pulse rate
–Noted as number of beats per
minute
–Rhythm - regular or irregular
–Volume - strong, weak, thready,
bounding

44. DHSR Approved Curriculum-Unit 10 44

45. DHSR Approved Curriculum-Unit 10 45
10.8Demonstrate counting the radial
pulse rate.

46. DHSR Approved Curriculum-Unit 10 46
10.9Demonstrate measuring the
apical pulse.

47. DHSR Approved Curriculum-Unit 10 47

48. DHSR Approved Curriculum-Unit 10 48
10.10Define respiration and discuss
how the respiratory rate is
measured.

49. DHSR Approved Curriculum-Unit 10 49
Measuring Respirations
•Respiration – process
of taking in oxygen
and expelling carbon
dioxide from lungs
and respiratory tract

50. DHSR Approved Curriculum-Unit 10 50
10.10.1List the factors that affect the
respiratory rate.

51. DHSR Approved Curriculum-Unit 10 51
Measuring Respirations
(continued)
•Age
•Activity
level
•Position
•Drugs
• Sex
• Illness
• Emotions
• Temperature
Factors Affecting Rate

52. DHSR Approved Curriculum-Unit 10 52
10.10.2Identify the qualities of normal
respirations.

53. DHSR Approved Curriculum-Unit 10 53
Measuring Respirations
(continued)
•Qualities of normal respirations
–12-20 respirations per minute
–Quiet
–Effortless
–Regular

54. DHSR Approved Curriculum-Unit 10 54
Measuring Respirations
(continued)
•Documenting respiratory rate
–Noted as number of inhalations
and exhalations per minute (one
inhalation and one exhalation
equals one respiration)
–Rhythm – regular or irregular
–Character: shallow, deep, labored

55. DHSR Approved Curriculum-Unit 10 55

56. DHSR Approved Curriculum-Unit 10 56
10.11Demonstrate counting
respirations.

57. DHSR Approved Curriculum-Unit 10 57

58. DHSR Approved Curriculum-Unit 10 58
10.12Define blood pressure and
discuss how it is measured.

59. DHSR Approved Curriculum-Unit 10 59
Measuring Blood Pressure
•Blood pressure is the force of blood
pushing against walls of arteries
–Systolic pressure: greatest force
exerted when heart contracting
–Diastolic pressure: least force
exerted as heart relaxes

60. DHSR Approved Curriculum-Unit 10 60
10.12.1List factors that influence
blood pressure.

61. DHSR Approved Curriculum-Unit 10 61
Factors Influencing Blood Pressure
•Weight
•Sleep
•Age
•Emotions
•Sex
•Heredity
•Viscosity of blood
•Illness/Disease

62. DHSR Approved Curriculum-Unit 10 62
Blood Pressure: Equipment
•Sphygmomanometer (manual)
–cuff - different sizes
–pressure control bulb
–pressure gauge – marked
with numbers
•aneroid
•mercury

63. DHSR Approved Curriculum-Unit 10 63
Blood Pressure: Equipment
(continued)
•Stethoscope
–magnifies sound
–has diaphragm

64. DHSR Approved Curriculum-Unit 10 64
10.12.2Identify the normal blood
pressure range.

65. DHSR Approved Curriculum-Unit 10 65
Measuring Blood Pressure
•Normal blood pressure range
–Systolic: 90-140 millimeters of
mercury
–Diastolic: 60-90 millimeters of
mercury

66. DHSR Approved Curriculum-Unit 10 66
Guidelines for Blood Pressure
Measurements
•Measure on upper
arm
•Have correct size
cuff
•Identify brachial
artery for correct
placement of
stethoscope

67. DHSR Approved Curriculum-Unit 10 67
Guidelines for Blood Pressure
Measurements
(continued)
•First sound heard –
systolic pressure
•Last sound heard or
change - diastolic
pressure

68. DHSR Approved Curriculum-Unit 10 68
Guidelines for Blood Pressure
Measurements
(continued)
•Record - systolic/diastolic
•Resident in relaxed
position, sitting or lying
down
•Blood pressure usually
taken in left arm

69. DHSR Approved Curriculum-Unit 10 69
Guidelines for Blood Pressure
Measurements
(continued)
•Do not measure blood
pressure in arm with IV,
A-V shunt (dialysis),
cast, wound, or sore

70. DHSR Approved Curriculum-Unit 10 70
Guidelines for Blood Pressure
Measurements
(continued)
•Apply cuff to bare
upper arm, not over
clothing
•Room quiet so blood
pressure can be heard
•Sphygmomanometer
must be clearly visible

71. DHSR Approved Curriculum-Unit 10 71
Blood Pressure: Reading Gauge
•Large lines are
at increments of
10 mmHg
•Shorter lines at
2 mm intervals
•Take reading at
closest line

72. DHSR Approved Curriculum-Unit 10 72
Blood Pressure: Reading Gauge
(continued)
•Gauge should be at
eye level
•Mercury column
gauge must not be
tilted
•Reading taken from
top of column of
mercury
300
280
260
240
220
200
180
160
140
120
100
80
60
40
20
290
270
250
230
210
190
170
150
130
110
90
70
50
30
10

73. DHSR Approved Curriculum-Unit 10 73

74. DHSR Approved Curriculum-Unit 10 74
10.13Demonstrate the procedure for
measuring blood pressure.

75. DHSR Approved Curriculum-Unit 10 75
10.14Demonstrate the procedure for
taking combined vital signs.

76. DHSR Approved Curriculum-Unit 10 76

77. DHSR Approved Curriculum-Unit 10 77
10.15Discuss height and weight and
how it is measured.

78. DHSR Approved Curriculum-Unit 10 78
Measuring Height And Weight
•Baseline measurement
obtained on admission
and must be accurate.
•Other measurements
obtained as ordered.

79. DHSR Approved Curriculum-Unit 10 79
Measuring Height And Weight
(continued)
•Height measurements
–Feet
–Inches
–Centimeters
•Weight measurements
–Pounds
–Ounces
–Kilograms

80. DHSR Approved Curriculum-Unit 10 80
Measuring Height and Weight
(continued)
•Reasons for obtaining height and
weight
–Indicator of nutritional status
–Indicator of change in medical
condition
–Used by doctor to order medications

81. DHSR Approved Curriculum-Unit 10 81
10.15.1List three guidelines for
weighing residents.

82. DHSR Approved Curriculum-Unit 10 82
Measuring Height and Weight
(continued)
–Use same scale
each time
–Have resident void,
remove shoes and
outer clothing
–Weigh at same time
each day
•Guidelines for weighing residents

83. DHSR Approved Curriculum-Unit 10 83
Measuring Height and Weight
(continued)
•Scales
–Remain more accurate if moved as
little as possible.
–Various types of scales
•bathroom scale
•standing scale
•scales attached to hydraulic lifts
•wheelchair scales
•bed scales

84. DHSR Approved Curriculum-Unit 10 84

85. DHSR Approved Curriculum-Unit 10 85
10.16Demonstrate the procedure for
measuring height and weight.

86. DHSR Approved Curriculum-Unit 10 86

87. DHSR Approved Curriculum-Unit 10 87
10.17Discuss measuring and
recording intake and output,
and conditions for which this
procedure would be ordered.

88. DHSR Approved Curriculum-Unit 10 88
Measuring Intake and Output
Fluid Balance
•Consume 2-1/2
to 3-1/2 quarts
daily
–eating
–drinking
•Eliminate 2-1/2
to 3-1/2 quarts
daily
–urine
–perspiration
–water vapor
through
respirations
–stool

89. DHSR Approved Curriculum-Unit 10 89
10.17.1Identify five symptoms of
edema.

90. DHSR Approved Curriculum-Unit 10 90
Edema
•Edema – fluid intake exceeds fluid
output
–Retention of fluids frequently
caused by kidney or heart failure or
excessive salt intake

91. DHSR Approved Curriculum-Unit 10 91
Edema
(continued)
•Symptoms
–weight gain
–swelling of feet, ankles,
hands, fingers, face
–decreased urine output
–shortness of breath
–collection of fluid in
abdomen (ascites)

92. DHSR Approved Curriculum-Unit 10 92
10.17.2List eight symptoms of
dehydration.

93. DHSR Approved Curriculum-Unit 10 93
Dehydration
•Dehydration: fluid
output exceeds fluid
intake
•Common problem of
long-term care
residents

94. DHSR Approved Curriculum-Unit 10 94
Dehydration
(continued)
•Symptoms
–thirst
–decreased urine output
–parched or cracked lips
–dry, cracked skin
–fever
–weight loss
–concentrated urine
–tongue coated and thick

95. DHSR Approved Curriculum-Unit 10 95
Dehydration
(continued)
•Causes of dehydration
–poor fluid intake
–diarrhea
–bleeding
–vomiting
–excessive perspiration

96. DHSR Approved Curriculum-Unit 10 96
Dehydration
(continued)
•Fluids measured in cubic
centimeters (cc)
–30 cc = 1 ounce
–cc - metric measure

97. DHSR Approved Curriculum-Unit 10 97

98. DHSR Approved Curriculum-Unit 10 98
10.18Identify the liquids that would
be measured and recorded as
fluid intake.

99. DHSR Approved Curriculum-Unit 10 99
Measuring and Recording
Intake/Output
•Physician orders intake and output
•Intake includes:
–All liquid taken by mouth
–Food items that turn to liquid at
room temperature
–Tube feedings into stomach through
nose or abdomen
–Fluids given by intravenous infusion

100. DHSR Approved Curriculum-Unit 10 100
10.18.1List the liquids that would be
measured and recorded as
fluid output.

101. DHSR Approved Curriculum-Unit 10 101
Measuring and Recording
Intake/Output
(continued)
•Output includes
–Urine
–Liquid stool
–Emesis
–Drainage
–Suctioned secretions
–Excessive perspiration

102. DHSR Approved Curriculum-Unit 10 102

103. DHSR Approved Curriculum-Unit 10 103
10.19Demonstrate measuring and
recording fluid intake and
output.

104. REFERENCES
1.DHSR Approved Curriculum
2.wikipedia
DHSR Approved Curriculum-Unit 10 104

105. THANK YOU
DHSR Approved Curriculum-Unit 10 105