Transcript Chapter 7 NA Basic Nursing Skills

Chapter 7 NA
Basic Nursing Skills
Admission
• First impressions, you will be the first one they meet. Change is difficult,
so explain what to expect. Ask questions to find out a resident’s personal
preferences and routine.
• Prepare the room before the resident arrives
• Note the time of arrival and the resident’s conditon
• Introduce yourself, giving your position
• Address the resident by his formal name.
• Don’t rush the process
• Make sure he feels welcome.
• Explain daily operations. Offer a tour
• Introduce resident to everyone
• Handle personal items with care, honor resident preferences when setting
up the room
• Observe the resident for problems that are missed
• Tell them about their rights, make sure they got a copy.
Transfers to another room or facility
• Must be informed, it is their legal right
• Explain the details and pack the personal
items carefully
• Must always be informed of any room or
roommate change as well, dining seating
changes too.
Discharging a resident
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Help collect belongings and pack them
Ask the resident which personal care items to include
Know the resident’s condition, vital signs at the time of discharge.
Find out if using wheelchair or stretcher.
Help say his good byes
Help get belongings into car, help him into car
Document : time of discharge method of transport, who was with
the resident, vital signs at discharge, items took with
• Be positive.
• If has specific questions about care, refer to the nurse.
– Nurse will discuss future appointments, home care, medications,
ambulation instructions, restrictions, medical equipment, exercises,
nutrition, community resources
Vital signs
• Include temperature, pulse, rate of respirations, blood
pressure, pain level
• Show how well the vital organs of the body are working
• Notify the nurse if:
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Has a fever
Respiratory or pulse rate is too rapid or too slow
Changes in blood pressure
Pain is worsening or unrelieved.
• Protect privacy when taking vital signs
• Don’t discuss in earshot of others
Normal ranges
• Temperature
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Oral 97.6-99.6 (mouth)
Rectal 98.6-100.6
(rectum) most accurate
Axillary 96.6-98.6
(armpit)
Tympanic
(ear)
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Pulse: 60-100 beats per minute
Respirations: 12-20 respirations per minute
b/p systolic; 100-139
b/p diastolic: 60-89
• High: 140/90 or above
• Low: below 100/60
Body temperature
• Age, illness, stress, environment, exercise and the
circadian rhythm (24 hour day-night cycle) all
affect temperature
• Oral temperature cannot be taken on someone
who is unconscious, has had recent facial or oral
surgery, is younger than 5 years old, is confused,
is heavily sedated, is likely to have a seizure, is
coughing, is using oxygen, has facial paralysis, has
a nasogastric tube, has mouth problems or
face/neck injuries.
• Mercury-free thermometers are safer than
mercury glass thermometers and are required in
some states
• Rectal temperatures are most accurate, but
taking temp rectally can be dangerous with some
residents
• Rectal temperatures
– NA must hold onto the thermometer at all times ,
– Gloves must be worn
– Thermometer must be lubricated
• Axillary temperatures are considered least
accurate
• Axillary temperatures can be safer if resients
are confused, disorientated, uncooperative or
have dementia
• Tympanic thermometers are fast and accurate
• Tympanic thermometers will only go into the
ear ¼- ½ inch
Pulse
• Pulse is the number of heartbeats per minute.
• Pulse is commonly taken at the wrist where radial artery
runs
• Normal rage is 60-100 beats per minute for adults
• Normal rate is 100-120 beats per minute for small children,
as high as 120-140 for newborns
• Pulse may be affected by exercise, fear, anger, anxiety, heat,
medications and pain
• Rapid pulse may result from fever, infection or heart failure
• Slow/weak pulse may indicate dehydration, infection, or
shock
Pulse sites
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Temporal- side of head/temple
Carotid- side of neck
Apical- heart
Brachial-inside of upper arm
Radial- wrist
Femoral- groin
Popliteal- behind knee
Pedal (dorsalis pedis)- top of foot
Respiration
• A breath includes both inspiration and
expiration
• Normal rate for adults is 12-20 breaths per
minute
• Normal rate for infants is 30-40 breaths per
minute
• Do the counting immediately after taking the
pulse, while still holding the wrist, do no let
the person know you are counting breaths.
Blood pressure
• The two parts of the BP are systolic (top number) and diastolic (bottom
number)
• Normal range is s= 100-119 and d= 60-79
• Blood pressure measurements between 120/80 and 139/89 were once
considered normal but are now considered prehypertension
• Brachial artery at the elbow is used.
• Equipment used is stethoscope and sphygmomanometer
• The cuff must first be completely deflated
• Never measure BP on an arm that has an IV, a dialysis shunt, or any
medical equipment. Avoid a side with a cast, recent trauma, paralysis
from a stroke, burns or mastectomy
• Two step method includes getting an estimated systolic first. One step
does not.
• It is not always easy to perfect the skill of hearing the first and last sounds
of the BP. Students may have to do the procedure over and over to
master.
Pain
• Pain is as important to monitor as vital signs are.
• often called the fifth vital sign
• Pain is uncomfortable and is an individual
experience
• Take complaints of pain seriously
• Observe and report carefully since care plans are
based on your report
• Ask questions to get accurate information.
• Pain is not a normal part of aging.
s/s of pain to report and observe
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Increased pulse, respirations, and blood pressure
Sweating
Nausea and/or vomiting
Tightening the jaw
Squeezing eyes shut
Holding a body part tightly
frowning
Grinding teeth
Increased restlessness
Agitation or tension
Change in behavior
Crying
Sighing
Groaning
Breathing heavily
Difficulty moving or walking
• Ask questions and report your observations
– Where is the pain
– When did it start
– Is it mild, moderate or severe? Rate on a scale of
1-10 with ten being the worst or use faces to point
to.
– What makes it better or worse
Measures that may reduce pain
• Report complaints of pain or unrelieved pain
• Gently position body in good alignment, use
pillows for support, help in changes of position
• Give back rubs
• Offer a warm bath or shower
• Encourage slow, deep breathing
• Provide a calm and quiet environment, soft music
• be patient, caring, gentle, kind and responsive
Weight and height
• Resident will be weighted repeatedly during his
or her stay, any change in weight should be
reported immediately
• If weighed in a wheelchair, subtract the weight of
the wheelchair from the total weight
• Residents may need to be weighed on a bed scale
• To determine the height on a standing scale,
gently lower the measuring rod until it rests flat
on the resident’s head.
restraints
• Restraints were used in the past to:
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Keep person from hurting self or others
Keep person from pulling out tubing
Keep person from wandering
Prevent falls
– Restraint usage is illegal in many states
– Restraints can only be used with a doctor’s order
– It is against the law for staff to apply restraints for the
convenience or for discipline
Problems related to restraint use
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Reduced blood circulation
Stress on the heart
Incontinence
Constipation
Weakened muscle and bones
Loss of bone mass
Muscle atrophy
Pressure sores
Risk of suffocation
Pneumonia
Less activity dealing to poor appetite
Sleep disorders
Loss of dignity
Loss of independence
Increased agitation or depression
Poor self-esteem
Possible injury or death
• Restraints in LTC facilities has declined due to
these problems. Many LTC facilities have
declared themselves “restraint-free” in an
effort to increase the safety and quality of
their resident’s lives
Alternatives to restraints
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Focus should be individualized for each resident
Improve safety measures
Answer call lights promptly, keep in reach
Ambulate the person when he or she is restless
Provide activities for those who wander at night
Encourage activities and independence
Give frequent help with toileting
Offer food or drink. Offer reading materials
Distract or redirect interest
Decrease the noise level, use relaxation techniques
Reduce pain levels through medication
Offer one-to-one time with a care giver. Provide familiar caregivers
Use a team approach
There are pads, belts, special chairs and alarms that can be used instead of
restraints.
When a resident is restrained
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Monitoring is vital
Call light must be placed where the resident can access it
The resident must be checked at least every 15 minutes.
At least every two hours the following just be done:
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Release the restraint or discontinue it
Offer assistance with toileting
Offer fluids
Check skin for irritation
Check for swelling
Reposition the resident
Ambulate resident if able
Fluid balance I & O
• Health person needs to take in from 64 to 96
ounces of fluid each day.
• Intake or input is what is consumed
• Output is what is eliminated… includes urine,
feces, vomit, perspiration and moisture in the
air we exhale.
• Fluid balance is maintaining equal input and
output, or taking in and eliminating equal
amount of fluids.
Conversions
• 1 oz= 30 mL or 30 cc
• A milliliter (mL or ml) is a unit of measure
equal to one cubic centimeter (cc)
• When measuring a fluid, put on a flat surface
and look at eye level
Collecting specimens
• Routine urine specimen- may be collected in any clean
container any time the resident voids. A “hat” is a
plastic collection container sometimes put into a toilet
to collect and measure urine or stool. Should be
labeled and cleaned after each use.
• Clean catch specimen, “mid-stream”, because the first
and last urine are not included in the sample. Must be
a sterile container, do not touch the inside. Clean the
perineal area. Have resident urinate a little and then
stop, place the container under the urine stream, have
start urinating again, fill container at least half full.
Have the resident finish urinating after. Wipe off the
outside of the container. Place in plastic bag.
• Stool specimen- after it is collected in a hat,
use two tongue blades and take about two
tablespoons of stool and put it in a specimen
container and cover. Wrap tongue blades in
toilet paper and put in another plastic bag and
discard properly.
Caring for catheters
• NAs do not insert, irrigate, or remove
catheters
• Keep drainage bag lower than the resident’s
hips or bladder to prevent infection
• Keep drainage bag off floor
• Prevent kinks and twists in tubing
• Keep genital area clean.
Observe and report
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Bloody urine
Bag not filling after several hours
Bag filling suddenly
Catheter not in place
Urine leaking from catheter
Resident reporting pain or pressure
odor
Providing catheter care
• Hold catheter near meatus. Avoid tuggin the
catheter.
• Clean at least four inches of catheter nearest
meatus. Move in only one direction, away
from meatus. Use a clean area of the cloth for
each stroke. Rinse the same way, dry the
same way.
Guidelines for oxygen safety
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Remove fire hazards.
Post “no smoking” or “oxygen in use” signs
Do not allow flames, candles, smoking
Never adjust oxygen level
Report skin irritation, check behind ears
Role in caring for IVs
• NAs never insert or remove IV lines
• NAs do not care for the IV site
• NAs only observe the site for changes or problems and
report if:
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Needle falls out
Tubing disconnects
Dressing is loose
Blood is in tubing
Site is swollen or discolored
Resident complains of pain
IV bag breaks or the fluid level does not decrease or stops
dripping or is nearly gone
– Pump beeps or is dropped
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Do not take a b/p on an arm with an IV
Do not get the site wet
Do not pull on or catch the tubing on anything
Do not leave the tubing kinked
Do not lower the IV bag below the site
Do not touch the clamp
Do not disconnect the IV from the pump or
turn off the alarm
Resident’s room
• The resident’s room is their home. The living spaces
and their personal possessions should be respected.
• Overbed table- never place soiled items, bedpans or
urinals on top of them.
• Use privacy curtains, keep call bells in reach
• Clean the overbed table after each use.
• Clean equipment, bedpans, basins after each use.
• Remove meal trays promptly
• Straighten linens, re-stock personal supplies, keep
water pitchers filled, empty trash, tidy area.
Sleep
• Lack of sleep can cause:
– Decreased mental function
– Reduced reaction time
– Irritability
– Decreased immune system function
– Fear, stress, noise, medication, illness, diet and
sharing a room can affect sleep
What to observe if a resident is not
sleeping well
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Sleeping during the day
Consuming too much caffeine
Dressing in night clothes during the day
Eating too late at night
Refusing medication ordered
Taking new medications
TV, radio, light on late at tnight
pain
Bedmaking guidelines
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Keep linens wrinkle-free
Wash hands before handling clean linen
Hold soiled linens away from your uniform
Don’t shake linen or clothes
Put on gloves before removing bed linens
Look for personal items before removing linens
Fold or roll linen so the dirtiest area is inside
Bag soiled linen at the point of origin
Wet linen should be bagged in leak-proof bags
Closed bed- made completely- for day time, when discharged
Open bed- made by folding the linen down to the foot of the bed.
Is ready to receive a resident who is being admitted or ready to get
into bed.
Dressings and bandages
• NAs do not change sterile dressings, which cover open or draining
wounds
• Non-sterile dressings are for wounds that have less chance of
infection, NAs may help with non-sterile dressing changes.
• Non-sterile bandages hold dressings in place, secure splints, and
support and protect body parts. They may decrease swelling.
• NAs may assist with use of an elastic bandage.
• Keep area clean and dry
• Wrap bandage evenly, and not too snugly, check circulation, make
sure isn’t wrinkled or loose
• 15 minutes after applying check for signs of poor circulation:
– Swelling
bluish (cyanotic) skin
– Skin cold to touch sores
– Tingling
pain or discomfort
shiny, tight skin
numbness