Chapter 17 Basic Nursing Skills 1 Explain the

Chapter 17 Basic Nursing Skills 1. Explain the importance of monitoring vital signs Define the following term: • Vital signs

Chapter 17 Basic Nursing Skills 1. Explain the importance of monitoring vital signs Vital signs consist of: • Taking temperature • Counting pulse • Counting rate of respirations • Taking blood pressure • Observing and reporting pain level

Chapter 17 Basic Nursing Skills 1. Explain the importance of monitoring vital signs When monitoring vital signs, it is important to tell the nurse the following: • Resident has a fever • Respiratory or pulse rate is too rapid or too slow • Changes in blood pressure • Pain is worsening or unrelieved

17 Basic Nursing Skills Transparency 17 -1 Normal Ranges for Vital Signs Temperature Oral Rectal Axillary Fahrenheit 97. 6° - 99. 6° 98. 6° - 100. 6° 96. 6° - 98. 6° Celsius 36. 5° - 37. 5° 37. 0° - 38. 1° 36. 0° - 37. 0° Pulse: 60 - 90 beats per minute Respirations: 12 - 20 respirations per minute Blood Pressure Normal: Systolic 100 – 119 mm Hg Diastolic 60 – 79 mm Hg Prehypertension: Systolic 120 – 139 mm Hg Diastolic 80 – 89 mm Hg High: 140/90 mm Hg or above

Chapter 17 Basic Nursing Skills 2. List guidelines for taking body temperature Define the following term: • Circadian rhythm

Chapter 17 Basic Nursing Skills 2. List guidelines for taking body temperature The following points about body temperature are important: • Normal ranges and variations are listed on p. 245 in textbook. • Age, illness, stress, environment, exercise, and the circadian rhythm all affect temperature. • There are four sites: oral, rectal, tympanic, and axillary.

Chapter 17 Basic Nursing Skills 2. List guidelines for taking body temperature The following points about body temperature are important (con’t. ): • Oral temperatures cannot be taken on someone who is unconscious; is using oxygen; is confused or disoriented; is paralyzed; has facial trauma; is likely to have a seizure; has a nasogastric tube; is younger than six years old; has sores, redness, swelling, or pain in her mouth; or has an injury to the face or neck.

Chapter 17 Basic Nursing Skills 2. List guidelines for taking body temperature The following points about body temperature are important (con’t. ): • Rectal temperatures are most accurate; axillary temperatures are the least accurate. • Mercury-free thermometers are safer than glass thermometers. They are becoming more common. • Mercury-free thermometers and glass thermometers operate identically. Glass thermometers must be shaken down.

Chapter 17 Basic Nursing Skills 2. List guidelines for taking body temperature The following points about body temperature are important (con’t. ): • Digital thermometers are commonly used for oral, rectal, and axillary temps. • Tympanic thermometers are fast and accurate. • All thermometers must be cleaned between residents, or protective covers must be used.

Taking and recording oral temperature Do not take an oral temperature on a resident who has smoked, eaten or drunk fluids, or exercised in the last 10– 20 minutes. Equipment: mercury-free, glass, digital, or electronic thermometer, disposable plastic sheath/cover for thermometer, tissues, pen and paper 1. Wash your hands. 2. Identify yourself by name. Identify the resident by name.

Taking and recording oral temperature 1. Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 2. Provide for the resident’s privacy with curtain, screen, or door. 3. If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels.

Taking and recording oral temperature Using a mercury-free or glass thermometer : 1. Hold thermometer by stem. 2. Before inserting thermometer in resident’s mouth, shake thermometer down to below the lowest number (at least below 96°F or 35°C). To shake thermometer down, hold it at the side opposite the bulb with the thumb and two fingers.

Taking and recording oral temperature 7. (con't. ) With a snapping motion of the wrist, shake thermometer (Fig. 17 -6). Stand away from furniture and walls while doing so. Fig. 17 -6.

Taking and recording oral temperature 1. Put a disposable sheath on thermometer, if applicable. Insert bulb end of thermometer into resident’s mouth. Place under tongue and to one side (Fig. 17 -7). Resident should breathe through his or her nose. 2. Tell resident to hold oral thermometer in mouth with lips closed. Help as necessary. Ask the resident not to bite down or to talk. Fig. 17 -7.

Taking and recording oral temperature 1. Leave thermometer in place for at least three minutes. 2. Remove thermometer. Wipe with tissue from stem to bulb or remove sheath. Dispose of tissue or sheath. 3. Hold thermometer at eye level. Rotate until line appears. Roll thermometer between your thumb and forefinger.

Taking and recording oral temperature 12. (con't. ) Read temperature. Record temperature, date, time, and method used (oral). 1. Rinse thermometer in lukewarm water. Dry. Return it to plastic case or container. If using a mercury/glass thermometer, store it away from a heat source.

Taking and recording oral temperature Using a digital thermometer : 1. Put a disposable sheath on thermometer. 2. Turn on thermometer. Wait until “ready” sign appears. 3. Insert end of digital thermometer into resident’s mouth. Place under tongue and to one side.

Taking and recording oral temperature 1. Leave in place until thermometer blinks or beeps. 2. Remove thermometer. 3. Read temperature on display screen. Record the temperature, date, time, and method used (oral). 4. Using a tissue, remove and dispose of sheath. 5. Replace thermometer in case.

Taking and recording oral temperature Using an electronic thermometer : 1. Remove probe from base unit. 2. Put probe cover on thermometer. 3. Insert end of electronic thermometer into resident’s mouth. Place under tongue and to one side.

Taking and recording oral temperature 1. Leave in place until you hear a tone or see a flashing or steady light. 2. Read the temperature on the display screen. 3. Remove the probe. Press the eject button to discard the cover (Fig. 17 -8). 4. Record temperature, date, time, and method used (oral). 5. Return the probe to the holder. Fig. 17 -8.

Taking and recording oral temperature Final steps: 14. Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs. 15. Return bed to appropriate position. Remove privacy measures. 16. Before leaving, place call light within resident’s reach.

Taking and recording oral temperature 17. Wash your hands. 18. Report any changes in the resident to the nurse. 19. Document procedure using facility guidelines.

Chapter 17 Basic Nursing Skills 2. List guidelines for taking body temperature The following points about taking a rectal temperature are important: • Mercury-free, digital, or glass thermometers can be used. • NA must explain what he or she will do before starting. • Be reassuring. • NA must hold on to thermometer at all times. • Gloves must be worn.

Chapter 17 Basic Nursing Skills 2. List guidelines for taking body temperature The following points about taking a rectal temperature are important (con’t. ): • Thermometer must be lubricated for this procedure. • The privacy of the resident is important.

Taking and recording rectal temperature Equipment: rectal mercuryfree, glass, or digital thermometer, lubricant, gloves, tissue, disposable sheath/cover, pen and paper 1. Wash your hands. 2. Identify yourself by name. Identify the resident by name.

Taking and recording rectal temperature 1. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 2. Provide for resident’s privacy with curtain, screen, or door. 3. If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels.

Taking and recording rectal temperature 1. Help the resident to the left-lying (Sims’ position) (Fig. 17 -9). 2. Fold back linens to expose only rectal area. 3. Put on gloves. Fig. 17 -9.

Taking and recording rectal temperature 1. Mercury-free or glass thermometer: Hold thermometer by stem. Digital thermometer : Apply probe cover. 1. Mercury-free or glass thermometer: Shake thermometer down to below the lowest number. 2. Apply small amount of lubricant to tip of bulb or probe cover (or apply pre-lubricated cover).

Taking and recording rectal temperature 1. Separate the buttocks. Gently insert thermometer one inch into rectum (Fig. 17 -10). Stop if you meet resistance. Do not force thermometer into rectum. 2. Replace sheet over buttocks. Hold on to thermometer at all times. Fig. 17 -10.

Taking and recording rectal temperature 1. Mercury-free or glass thermometer : Hold thermometer in place for at least three minutes. Digital thermometer : Hold thermometer in place until thermometer blinks or beeps.

Taking and recording rectal temperature 1. Gently remove thermometer. Wipe with tissue from stem to bulb or remove sheath. Dispose of tissue or sheath. 2. Read thermometer at eye level as you would for an oral temperature. Record temperature, date, time, and method used (rectal).

Taking and recording rectal temperature 1. Mercury-free or glass thermometer : Rinse thermometer in lukewarm water. Dry it. Return it to plastic case or container. If using a mercury/glass thermometer, store it away from a heat source. Digital thermometer : Throw away probe cover. Return thermometer to storage area.

Taking and recording rectal temperature 1. Remove and dispose of gloves. 2. Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs. 3. Return bed to appropriate position. Remove privacy measures. 4. Before leaving, place call light within resident’s reach. 5. Wash your hands.

Taking and recording rectal temperature 1. Report any changes in resident to the nurse. 2. Document procedure using facility guidelines.

Chapter 17 Basic Nursing Skills 2. List guidelines for taking body temperature The following points about tympanic and axillary temperatures are important: • Tympanic thermometers are fast and accurate. • The tympanic thermometer will only go into the ear 1/4 to 1/2 inch. • Axillary temperatures are much less reliable.

Taking and recording tympanic temperature Equipment: tympanic thermometer, disposable sheath/cover, pen and paper 1. Wash your hands. 2. Identify yourself by name. Identify the resident by name. 3. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.

Taking and recording tympanic temperature 1. Provide for resident’s privacy with curtain, screen, or door. 2. If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels. 3. Put a disposable sheath over earpiece of thermometer.

Taking and recording tympanic temperature 1. Position the resident’s head so that the ear is in front of you. Straighten the ear canal by pulling up and back on the outside edge of the ear (Fig. 17 -11). Insert the covered probe into the ear canal. Press the button. Fig. 17 -11.

Taking and recording tympanic temperature 1. Hold thermometer in place until thermometer blinks or beeps. 2. Read temperature. Record temperature, date, time, and method used (tympanic). 3. Dispose of sheath. Return thermometer to storage or to the battery charger if thermometer is rechargeable.

Taking and recording tympanic temperature 1. Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs. 2. Return bed to appropriate position. Remove privacy measures. 3. Before leaving, place call light within resident’s reach. 4. Wash your hands.

Taking and recording tympanic temperature 1. Report any changes in the resident to the nurse. 2. Document procedure using facility guidelines.

Taking and recording an axillary temperature Equipment: mercury-free, glass, digital, or electronic thermometer, tissues, disposable sheath/cover, pen and paper 1. Wash your hands. 2. Identify yourself by name. Identify the resident by name.

Taking and recording an axillary temperature 1. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 2. Provide for resident’s privacy with curtain, screen, or door. 3. If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels.

Taking and recording an axillary temperature 1. Remove resident’s arm from sleeve of gown. Wipe axillary area with tissues. Using a mercury-free or glass thermometer: 1. Hold thermometer at stem end. Shake down to below the lowest number. 2. Put disposable sheath on thermometer, if applicable.

Taking and recording an axillary temperature 1. Place bulb end of thermometer in center of armpit. Fold resident’s arm over chest. 2. Hold in place, with the arm close against the side, for 10 minutes (Fig. 17 -12). Fig. 17 -12.

Taking and recording an axillary temperature 1. Remove thermometer. Wipe with tissue from stem to bulb or remove sheath. Dispose of tissue or sheath. 2. Hold thermometer at eye level. Rotate until line appears. Read temperature. Record temperature, date, time, and method used (axillary). 3. Clean thermometer and/or return it to container for used thermometers.

Taking and recording an axillary temperature Using a digital thermometer : 1. Put on disposable sheath. Turn on thermometer. Wait until “ready” sign appears. 2. Position end of digital thermometer in center of armpit. Fold resident’s arm over chest. 3. Hold in place until thermometer blinks or beeps.

Taking and recording an axillary temperature 1. Remove thermometer. 2. Read temperature on display screen. Record the temperature, date, time, and method used (axillary). 3. Using a tissue, remove and dispose of sheath. 4. Replace thermometer in case.

Taking and recording an axillary temperature Using an electronic thermometer: 1. Remove prove from base unit. Put on probe cover. 2. Position end of electronic thermometer in center of armpit. Fold resident’s arm over chest. 3. Leave in place until you hear a tone or see a flashing or steady light. 4. Read the temperature on the display screen.

Taking and recording an axillary temperature 1. Remove the probe. Press the eject button to discard the cover. 2. Record temperature, date, time, and method used (axillary). 3. Return the probe to the holder.

Taking and recording an axillary temperature Final steps: 1. Put resident’s arm back into sleeve of gown. Make resident comfortable. Make sure sheets are free from wrinkles and the bed free from crumbs. 2. Return bed to appropriate position. Remove privacy measures. 3. Before you leave, place call light within resident’s reach.

Taking and recording an axillary temperature 1. Wash your hands. 2. Report any changes in resident to the nurse. 3. Document procedure using facility guidelines.

Chapter 17 Basic Nursing Skills 3. List guidelines for taking pulse and respirations Define the following terms: • Radial pulse • Brachial pulse • Apical pulse • Stethoscope

Chapter 17 Basic Nursing Skills 3. List guidelines for taking pulse and respirations The following points about the pulse are important: • Pulse is the number of heartbeats per minute. • Pulse is commonly taken at the wrist where radial artery runs. • Normal rate is 60 -90 beats per minute for adults. • Slow/weak pulse may indicate dehydration, infection, or shock.

Taking and recording apical pulse Equipment: stethoscope, watch with second hand, alcohol wipes, pen and paper 1. Wash hands. 2. Identify yourself by name. Identify the resident by name. 3. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.

Taking and recording apical pulse 1. Provide for resident’s privacy with curtain, screen, or door. 2. If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels.

Taking and recording apical pulse 1. Fit the earpieces of the stethoscope snugly in your ears. Place the flat metal diaphragm on the left side of the chest, just below the nipple (Fig. 17 -15). Listen for the heartbeat. Fig. 13 -19.

Taking and recording apical pulse 1. Use the second hand of your watch. Count beats for one full minute. Each “lubdub” that you hear is counted as one beat. A normal heartbeat is rhythmic. Leave the stethoscope in place to count respirations (see procedure later in chapter).

Taking and recording apical pulse 1. Record pulse rate, date, time, and method used (apical). Note any differences in the rhythm. 2. Clean earpieces and diaphragm of stethoscope with alcohol wipes. Store stethoscope.

Taking and recording apical pulse 1. Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs. 2. Return bed to appropriate position. Remove privacy measures. 3. Before leaving, place call light within resident’s reach. 4. Wash your hands.

Taking and recording apical pulse 1. Report any changes in the resident to the nurse. 2. Document procedure using facility guidelines.

Chapter 17 Basic Nursing Skills 3. List guidelines for taking pulse and respirations Define the following terms: • Respiration • Inspiration • Expiration

Chapter 17 Basic Nursing Skills 3. List guidelines for taking pulse and respirations The following points about respiration are important: • A breath includes both inspiration and expiration. • Normal rate is 12 -20 breaths per minute. • Do the counting immediately after taking the pulse. • Do not let the resident know you are counting breaths.

Taking and recording radial pulse and counting and recording respirations Equipment: watch with second hand, pen and paper 1. Wash your hands. 2. Identify yourself by name. Identify the resident by name. 3. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.

Taking and recording radial pulse and counting and recording respirations 1. Provide for resident’s privacy with curtain, screen, or door. 2. If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels. 3. Place fingertips on thumb side of resident’s wrist. Locate pulse Fig. 17 -16. (Fig. 17 -16). 4. Count beats for one full minute.

Taking and recording radial pulse and counting and recording respirations 1. Keep your fingertips on the resident’s wrist. Count respirations for one full minute. Observe for the pattern and character of the resident’s breathing. Normal breathing is smooth and quiet. If you see signs of troubled breathing, shallow breathing, or noisy breathing such as wheezing, report it.

Taking and recording radial pulse and counting and recording respirations 1. Record pulse rate, date, time, and method used (radial). Record the respiratory rate and the pattern or character of breathing. 2. Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs. 3. Return bed to appropriate position. Remove privacy measures.

Taking and recording radial pulse and counting and recording respirations 1. Before leaving, place call light within resident’s reach. 2. Wash your hands. 3. Report any changes in the resident to the nurse. 4. Document procedure using facility guidelines.

Chapter 17 Basic Nursing Skills 4. Explain guidelines for taking blood pressure Define the following terms: • Systolic • Diastolic • Hypertension • Hypotension • Sphygmomanometer

Chapter 17 Basic Nursing Skills 4. Explain guidelines for taking blood pressure The following points about blood pressure are important: • The two parts of the BP are systolic (top number) and diastolic (bottom number). • Normal range is: S=100 to 119; D=60 to 79 (according to newer prehypertension guidelines). • Brachial artery at the elbow is used. • Equipment used is stethoscope and sphygmomanometer. • The cuff must first be completely deflated.

Chapter 17 Basic Nursing Skills 4. Explain guidelines for taking blood pressure The following points about blood pressure are important (con’t. ): • The one-step method does not include getting an estimated systolic before beginning. The two-step method does require getting an estimated systolic.

Chapter 17 Basic Nursing Skills 4. Explain guidelines for taking blood pressure It is not always easy to perfect the skill of hearing the first and last sounds of the BP. You may have to do the procedure over and over again and have an instructor or another student check technique and results for correctness.

Taking and recording blood pressure (one-step method) Equipment: sphygmomanometer (blood pressure cuff), stethoscope, alcohol wipes, pen and paper to record your findings 1. Wash your hands. 2. Identify yourself by name. Identify the resident by name.

Taking and recording blood pressure (one-step method) 1. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 2. Provide for resident’s privacy with curtain, screen, or door. 3. If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels.

Taking and recording blood pressure (one-step method) 1. Position resident’s arm with palm up. The arm should be level with the heart. 2. With the valve open, squeeze the cuff. Make sure it is completely deflated.

Taking and recording blood pressure (one-step method) 1. Place blood pressure cuff snugly on resident’s upper arm. The center of the cuff is placed over the brachial artery (11½ inches above the elbow toward inside of elbow) (Fig. 17 -19). 2. Before using stethoscope, wipe diaphragm and earpieces with alcohol wipes. 3. Locate brachial pulse with fingertips. Fig. 17 -19.

Taking and recording blood pressure (one-step method) 1. Place diaphragm of stethoscope over brachial artery. 2. Place earpieces of stethoscope in ears. 3. Close the valve (clockwise) until it stops. Do not tighten it (Fig. 17 -20). 4. Inflate cuff to 30 mm Hg above the point at which the pulse is last heard or Fig. 17 -20. felt.

Taking and recording blood pressure (one-step method) 1. Open the valve slightly with thumb and index finger. Deflate cuff slowly. 2. Watch gauge. Listen for sound of pulse. 3. Remember the reading at which the first clear pulse sound is heard. This is the systolic pressure.

Taking and recording blood pressure (one-step method) 1. Continue listening for a change or muffling of pulse sound. The point of a change or the point the sound disappears is the diastolic pressure. Remember this reading. 2. Open the valve. Deflate cuff completely. Remove cuff.

Taking and recording blood pressure (one-step method) 1. Record both the systolic and diastolic pressures. 2. Wipe diaphragm and earpieces of stethoscope with alcohol. Store equipment. 3. Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs. 4. Return bed to appropriate position. Remove privacy measures.

Taking and recording blood pressure (one-step method) 1. Before leaving, place call light within resident’s reach. 2. Wash your hands. 3. Report any changes in the resident to the nurse. 4. Document procedure using facility guidelines.

Taking and recording blood pressure (two-step method) Equipment: sphygmomanometer (blood pressure cuff), stethoscope, alcohol wipes, pen and paper to record your findings 1. Wash your hands. 2. Identify yourself by name. Identify the resident by name.

Taking and recording blood pressure (two-step method) 1. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 2. Provide for resident’s privacy with curtain, screen, or door. 3. If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels.

Taking and recording blood pressure (two-step method) 1. Position resident’s arm with palm up. The arm should be level with the heart. 2. With the valve open, squeeze the cuff to make sure it is completely deflated.

Taking and recording blood pressure (two-step method) 1. Place blood pressure cuff snugly on resident’s upper arm. The center of the cuff is placed over the brachial artery (11½ inches above the elbow toward inside of elbow). 2. Locate the radial (wrist) pulse with fingertips. 3. Close the valve (clockwise) until it stops. Inflate cuff, watching gauge.

Taking and recording blood pressure (two-step method) 1. Stop inflating when you can no longer feel the pulse. Note the reading. The number is an estimate of the systolic pressure. 2. Open the valve. Deflate cuff completely. 3. Write down the systolic reading.

Taking and recording blood pressure (two-step method) 1. Before using stethoscope, wipe diaphragm and earpieces of stethoscope with alcohol wipes. 2. Locate brachial pulse with fingertips.

Taking and recording blood pressure (two-step method) 1. Place diaphragm of stethoscope over brachial artery. 2. Place earpieces of stethoscope in ears. 3. Close the valve (clockwise) until it stops. Do not tighten it (Fig. 17 -21). Fig. 17 -21.

Taking and recording blood pressure (two-step method) 1. Inflate cuff to 30 mm Hg above your estimated systolic pressure. 2. Open the valve slightly with thumb and index finger. Deflate cuff slowly. 3. Watch gauge. Listen for sound of pulse. 4. Remember the reading at which the first clear pulse sound is heard. This is the systolic pressure.

Taking and recording blood pressure (two-step method) 1. Continue listening for a change or muffling of pulse sound. The point of a change or the point the sound disappears is the diastolic pressure. Remember this reading. 2. Open the valve. Deflate cuff completely. Remove cuff.

Taking and recording blood pressure (two-step method) 1. Record both systolic and diastolic pressures. 2. Wipe diaphragm and earpieces of stethoscope with alcohol. Store equipment. 3. Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs. 4. Return bed to appropriate position. Remove privacy measures.

Taking and recording blood pressure (two-step method) 1. Before leaving, place call light within resident’s reach. 2. Wash your hands. 3. Report any changes in the resident to the nurse. 4. Document procedure using facility guidelines.

Chapter 17 Basic Nursing Skills 5. Describe guidelines for pain management The following points about pain are important: • It is as important to monitor as vital signs. • It is uncomfortable and an individual experience. • Take complaints of pain seriously. • Ask questions to get accurate information.

Chapter 17 Basic Nursing Skills 5. Describe guidelines for pain management The signs and symptoms of pain to observe and report are: • Increased pulse, respirations, and blood pressure • Sweating • Nausea and vomiting • Tightening the jaw • Squeezing eyes shut • Holding a body part tightly • Frowning • Grinding teeth

Chapter 17 Basic Nursing Skills 5. Describe guidelines for pain management The signs and symptoms of pain to observe and report are (con’t. ): • Increased restlessness • Agitation • Change in behavior • Crying • Sighing • Groaning • Breathing heavily

Chapter 17 Basic Nursing Skills 6. Explain the benefits of warm and cold applications The following points about pain management are important: • Heat relieves pain and muscular tension, decreases swelling, elevates temperature in the tissues, and increases blood flow, bringing more oxygen and nutrients to tissues. • Cold stops bleeding, prevents swelling, reduces pain, and helps bring down high fevers. • Moisture strengthens the effect of heat and cold. • Observe area for redness, pain, blisters, or numbness.

17 Basic Nursing Skills Transparency 17 -2 Warm and Cold Applications Application Temperature Timing Special Considerations Warm Compresses 105°-115°F Remove after 20 minutes. Cover with plastic wrap. Warm Soaks 105°-110°F Check temp every 5 minutes Observe for redness. Soak 15 -20 minutes. Aquamatic K-Pad Pre-set Remove after 20 minutes. Tubing should not hang below bed. Check water level and refill when necessary. Sitz bath 100°-104°F or 105°-110°F 20 minutes only Fill 2/3 full. Provide privacy. Check after 10 minutes. Remove after 20 minutes. Fill bag 2/3 full of ice. Cover bag; watch for blisters and white or pale skin. Ice packs

Applying warm compresses Equipment: washcloth or compress, plastic wrap, towel, basin, bath thermometer 1. Wash your hands. 2. Identify yourself by name. Identify the resident by name. 3. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.

Applying warm compresses 1. Provide for resident’s privacy with curtain, screen, or door. 2. If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels.

Applying warm compresses 1. Fill basin one-half to two -thirds full with warm water. Test water temperature with thermometer or your wrist. Ensure it is safe. Water temperature should be no more than 105° to 110°F. Have resident check water temperature. Adjust if necessary. 2. Soak the washcloth in the water. Wring it out. Immediately apply it to the area needing a warm compress. Note the time.

Applying warm compresses 1. (con't. ) Quickly cover the washcloth with plastic wrap and the towel to keep it warm (Fig. 17 -23). 2. Check the area every five minutes. Remove the compress if the area is red or numb or if the resident has pain or discomfort. Change the compress if cooling occurs. Remove the compress after 20 minutes. Fig. 17 -23.

Applying warm compresses 1. Commercial warm compresses are also available. If you are using these, follow the package directions and the nurse’s instructions. 2. Place soiled clothing and linens in appropriate containers. 3. Empty, rinse, and wipe basin. Return to proper storage. Discard plastic wrap.

Applying warm compresses 1. Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs. 2. Return bed to appropriate position. Remove privacy measures.

Applying warm compresses 1. Before leaving, place call light within resident’s reach. 2. Wash your hands. 3. Report any changes in the resident to the nurse. 4. Document procedure using facility guidelines.

Administering warm soaks Equipment: towel, basin, bath thermometer, bath blanket 1. Wash your hands. 2. Identify yourself by name. Identify the resident by name. 3. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.

Administering warm soaks 1. Provide for resident’s privacy with curtain, screen, or door. 2. If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels.

Administering warm soaks 1. Fill the basin half full of warm water. Test water temperature with thermometer or your wrist. Ensure it is safe. Water temperature should be 105° to 110°F. Have resident check water temperature. Adjust if necessary.

Administering warm soaks 1. Immerse the body part in the basin. Pad the edge of the basin with a towel if needed (Fig. 17 -24). Use a bath blanket to cover the resident if needed for extra warmth. 2. Check water temperature every five minutes. Add hot water as needed to maintain the temperature. Never add water warmer than 110°F. Fig. 17 -24.

Administering warm soaks 1. (con't. ) To prevent burns, tell the resident not to add warm water. Observe the area for redness. Discontinue the soak if the resident has pain or discomfort. 2. Soak for 15 -20 minutes, or as ordered. 3. Remove basin. Use the towel to dry the resident.

Administering warm soaks 11. Place soiled clothing and linens in appropriate containers. 12. Empty, rinse, and wipe basin. Return to proper storage. 13. Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs. 14. Return bed to appropriate position. Remove privacy measures.

Administering warm soaks 15. Before leaving, place call light within resident’s reach. 16. Wash your hands. 17. Report any changes in the resident to the nurse. 18. Document procedure using facility guidelines.

Applying an Aquamatic K-Pad® Equipment: K-Pad® and control unit (Fig. 17 -25), covering for pad, distilled water 1. Wash your hands. 2. Identify yourself by name. Identify the resident by name. 3. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. Fig. 17 -25.

Applying an Aquamatic K-Pad® 1. Provide for the resident’s privacy with a curtain, screen, or door. 2. If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels. 3. Place the control unit on the bedside table. Make sure cords are not frayed or damaged. Check that tubing between pad and unit is intact.

Applying an Aquamatic K-Pad® 1. Remove cover of control unit to check level of water. If it is low, fill it with distilled water to the fill line. 2. Put the cover of control unit back in place.

Applying an Aquamatic K-Pad® 1. Plug unit in. Turn pad on. Temperature should have been pre-set. If it was not, check with the nurse for proper temperature. 2. Place the pad in the cover. Do not pin the pad to the cover.

Applying an Aquamatic K-Pad® 1. Uncover area to be treated. Place the covered pad. Note the time. Make sure the tubing is not hanging below the bed. It should be coiled on the bed. 2. Return and check area every five minutes. Remove the pad if the area is red or numb or if the resident reports pain or discomfort.

Applying an Aquamatic K-Pad® 1. Check water level. Refill with distilled water to the fill line when necessary. 2. Remove pad after 20 minutes. 3. Clean and store supplies. 4. Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs. 5. Return bed to appropriate position. Remove privacy measures.

Applying an Aquamatic K-Pad® 1. Before leaving, place call light within resident’s reach. 2. Wash your hands. 3. Report any changes in the resident to the nurse. 4. Document procedure using facility guidelines.

Chapter 17 Basic Nursing Skills 6. Explain the benefits of warm and cold applications Define the following term: • Sitz bath

Assisting with a sitz bath Equipment: disposable sitz bath, bath thermometer, towels, gloves 1. Wash your hands. 2. Identify yourself by name. Identify the resident by name. 3. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.

Assisting with a sitz bath 1. Provide for resident’s privacy with curtain, screen, or door. 2. Put on gloves. 3. Fill the sitz bath twothirds full with warm water. Place the disposable sitz bath on the toilet seat. If the sitz bath is prescribed for cleaning the perineal area, the temperature should be 100°-104°F.

Assisting with a sitz bath 6. (con't. ) For pain and to stimulate circulation, the water temperature should be 105°-110°F. Check the water temperature using the bath thermometer. 1. Help the resident undress and get seated on the sitz bath. A valve on the tubing connected to the bag allows the resident or you to fill the sitz bath again with hot water.

Assisting with a sitz bath 1. You may be required to stay with the resident during the bath for safety reasons. If you leave the room, check on the resident every five minutes to make sure he or she is not dizzy or weak.

Assisting with a sitz bath 1. Help the resident out of the sitz bath in 20 minutes. Provide towels. Help with dressing if needed. 2. Clean and store supplies. 3. Remove gloves. 4. Make resident comfortable.

Assisting with a sitz bath 13. Before leaving, place call light within resident’s reach. 14. Wash your hands. 15. Report any changes in the resident to the nurse. 16. Document procedure using facility guidelines.

Applying ice packs Equipment: ice pack or sealable plastic bag and crushed ice, towel or cover for pack or bag 1. Wash your hands. 2. Identify yourself by name. Identify the resident by name. 3. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.

Applying ice packs 1. Provide for the resident’s privacy with curtain, screen, or door. 2. If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels. 3. Fill plastic bag or ice pack one-half to twothirds full with crushed ice. Seal bag. Remove excess air. Cover bag or ice pack with towel or cover (Fig. 17 -27). Fig. 17 -27.

Applying ice packs 1. Apply bag to the area as ordered. Note the time. Use another towel to cover bag if it is too cold. 2. Check the area after five minutes for blisters or pale, white, or gray skin. Stop treatment if resident reports numbness or pain. 3. Remove ice after 20 minutes or as ordered.

Applying ice packs 1. Store ice pack. 2. Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs. 3. Return bed to appropriate position. Remove privacy measures.

Applying ice packs 13. Before leaving, place call light within resident’s reach. 14. Wash your hands. 15. Report any changes in the resident to the nurse. 16. Document procedure using facility guidelines.

Chapter 17 Basic Nursing Skills 7. Explain how to apply non-sterile dressings The following points about non-sterile dressings are important: • Nursing assistants do not change sterile dressings. • Non-sterile dressings are for wounds that have less chance of infection.

Changing a dry dressing using non-sterile technique Equipment: package of square gauze dressings, adhesive tape, scissors, 2 pairs of gloves 1. Wash your hands. 2. Identify yourself by name. Identify the resident by name. 3. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.

Changing a dry dressing using non-sterile technique 1. Provide for the resident’s privacy with a curtain, screen, or door. 2. If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels. 3. Cut pieces of tape long enough to secure the dressing. Hang tape on the edge of a table within reach. Open fourinch gauze square package without touching gauze. Place the open package on a flat surface.

Changing a dry dressing using non-sterile technique 1. Put on gloves. 2. Remove soiled dressing by gently peeling tape toward the wound. Lift dressing off the wound. Do not drag it over wound. Observe dressing for any odor. Notice color and size of the wound. Dispose of used dressing in proper container. Remove and dispose of gloves.

Changing a dry dressing using non-sterile technique 1. Put on new gloves. Touching only outer edges of new four-inch gauze, remove it from package. Apply it to wound. Tape gauze in place. Secure it firmly (Fig. 17 -28). 2. Remove and dispose of gloves properly. 3. Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs. Fig. 17 -28.

Changing a dry dressing using non-sterile technique 1. Return bed to appropriate position. Remove privacy measures. 2. Before leaving, place call light within resident’s reach. 14. Wash your hands. 15. Report any changes in the resident to the nurse. 16. Document procedure using facility guidelines.

Chapter 17 Basic Nursing Skills 8. Discuss guidelines for non-sterile bandages The following points about non-sterile bandages are important: • Non-sterile bandages hold dressings in place, secure splints, and support and protect body parts. They may decrease swelling from an injury. • They should be applied snug enough to control bleeding and prevent movement of dressings. • Bandage should be checked 15 minutes after first being applied. • Signs of poor circulation are swelling, bluish skin, numbness, tingling, cold skin, pain, or discomfort.

Chapter 17 Basic Nursing Skills 9. List care guidelines for a resident who is on an IV Define the following term: • Intravenous

Chapter 17 Basic Nursing Skills 9. List care guidelines for a resident who is on an IV The nursing assistant’s role in caring for a resident with an IV include: • Nursing assistants never insert or remove IV lines. • Nursing assistants do not care for the IV site.

Chapter 17 Basic Nursing Skills 9. List care guidelines for a resident who is on an IV Nursing assistants only observe the site for changes or problems and report if: • 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 fluid level does not decrease • IV not dripping or nearly gone • Pump beeps

Chapter 17 Basic Nursing Skills 9. List care guidelines for a resident who is on an IV Nursing assistants cannot do any of the following: • Take a blood pressure on an arm with an IV • Get the site wet • Pull on or catch the tubing on anything • Leave the tubing kinked • Lower the IV bag below the site • Touch the clamp • Disconnect IV from pump or turn off alarm