600 likes | 605 Views
Module 6 basic skills. BFI 2018 CNA Prep Course. Vital signs. measurements that show how well the vital organs of the body are working; consist of body temperature, pulse, respirations, oxygen saturation, blood pressure, and level of pain. Vital signs. Vital signs. Vital signs.
E N D
Module 6 basic skills BFI 2018 CNA Prep Course
Vital signs measurements that show how well the vital organs of the body are working; consist of body temperature, pulse, respirations, oxygen saturation, blood pressure, and level of pain.
Vital signs • Notify the nurse in any of these cases: • Resident has a fever • Respiratory or pulse rate is too rapid or slow • Blood pressure changes • Pain is worsening or unrelieved • Patient is cyanotic or pale
temperature • Remember these things about monitoring body temperature: • Age, illness, stress, environment, exercise, and the circadian rhythm all affect temperature. • There are four sites for measuring (mouth, rectum, armpit, ear). • Oral temperatures cannot be taken on someone who is unconscious, has recently had 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 sores, redness, swelling, or pain in the mouth, or has an injury to the face or neck
Vital signs-pulse • Pulse is the number of heartbeats per minute. • Pulse is commonly taken at the wrist where radial artery runs. • Normal rate 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.
Major pulse sites • Carotid – neck (used during emergency situations-CPR) • Apical – left chest below nipple (need stethoscope) • Brachial – inner aspect of elbow • Radial – thumb side of wrist (most frequently used site) • Femoral – groin • Popliteal – behind knee • Posterior tibialis – behind inner ankle • Dorsalis pedis – on top of foot
Qualities of pulse • Rate – number of beats/min • Rhythm – regularity of pulse • Strength – force • Weak or thready • Bounding • Strong
Vital signs-respirations • A breath includes both inspiration and expiration. • Normal adult rate is 12-20 breaths per minute. • Normal rate for infants is 30-40 breaths per minute. • Do the counting immediately after taking the pulse. • Do not let the resident know you are counting breaths • Normal breathing is quiet, effortless, & regular in rhythm
Abnormal respirations • Labored – struggles to breathe • Orthopnea- can breathe only when sitting or standing • Stertorous – snoring sounds when breathing (partial airway obstruction) • Abdominal – uses abdominal muscles • Shallow – uses only upper part of lungs • Dyspnea – painful or difficult breathing • Tachypnea – respiratory rate > 24 per min • Bradypnea – respiratory rate < 10 per min • Apnea – absence of breathing • Cheyne-Stokes – respiratory gradually increase in rate & depth & then become shallow & slow
Vital signs-blood pressure • Pressure exerted against walls of blood vessels • The two parts are systolic (top number) and diastolic (bottom number). • Hear thumping sounds as blood flows through arteries • Normal range is: Systolic=100 to 119, Diastolic=60 to 79. • Brachial artery at the elbow is used. • Equipment used is stethoscope and sphygmomanometer (blood pressure cuff) • An electronic sphymomanometer may be available. If so, you will be trained in its use. • The cuff must first be completely deflated before using it
Blood pressure • Normal adult reading 120/80 • Normal systolic = 100 – 140 • Normal diastolic = 60 – 90 • Abnormal readings • Hypertension – BP > 140/90 • Hypotension – BP < 90/60
Increased bp • Strong emotion • Exercise • Sitting or standing • Excitement • Pain • Decrease of vessel size • Digestion • Improperly placed or sized cuff
Low blood pressure • Rest/sleep • Lying down • Depression • Shock • Hemorrhage • Improperly sized cuff
Bp measurement procedure • Guidelines • Measure BP at brachial artery • Do not use injured arm, arm with IV, or casted • Resident should be at rest • Position arm level with heart • Apply cuff to bare arm NOT over clothing • Use appropriate size cuff • Position sphygmomanometer at eye level
Process of taking Vs • Take temperature first • Pulse second • Respirations, then blood pressure • When taking respirations, keep fingers on pulse so that resident does not know you are counting respirations • Blood Pressure and Oxygen saturation • Document all together
Vital signs-pain • Remember the following about pain management: • Pain is as important to monitor as vital signs. • Pain is an experience that is uncomfortable and different for each person. • Take complaints of pain seriously • Observe and report carefully since care plans are based on your reports. • Ask questions to get accurate information • Pain is not a normal part of aging
Vital signs- pain • Ask resident if they have pain • Observe facial expression, movement, respiration • Ask level of pain using facility method (Usually number 0 – 10) • Report c/o pain to licensed nurse
pain • Signs and symptoms of pain (cont’d.): • Increased restlessness • Agitation or tension • Change in behavior • Crying • Sighing • Groaning • Breathing heavily • Difficulty moving or walking
weight • Review the following points about weight: • Resident will be weighed repeatedly during his or her stay, and any change in weight should be reported immediately. • Some residents will be weighed on a wheelchair scale. The weight of the wheelchair may need to be subtracted from a resident’s weight. • Residents may need to be weighed on a bed scale. • Ambulatory residents may be weighed on a standing scale.
restraints Restraints are used for the following reasons: • If person is a danger to self or others • Keep person from pulling out tubing • Prevent falls Important: • Restraints can only be used with a doctor’s order. • It is against the law for staff to apply restraints for convenience or discipline REMEMBER: • There are also pads, belts, special chairs and alarms that can be used instead of restraints.
Specimen collecting • NAs must wear gloves for these procedures. • Tagging and storing specimens correctly is important. • Be sensitive to the fact that residents may find it embarrassing or uncomfortable to have others handling their body wastes. • If you feel the task is unpleasant, do not make it known. • Remain professional. • Label specimen with patient’s name, date of birth, date collected, time collected and your initials (per facility policy) • Remember, after discarding gloves after collecting specimens, WASH YOUR HANDS!
Catheter care • Keep drainage bag lower than the resident’s hips or bladder to prevent infection • Keep the drainage bag off the floor (hang on non-movable part of the side of bed) • Prevent kinks and twists in tubing (prevents the flow of urine) • Keep genital area clean (provide catheter care once per shift or as needed for soiling)
Catheter care • Observe and report when providing catheter care: • Bloody urine • Catheter bag does not fill after several hours • Catheter bag fills suddenly • Catheter is not in place • Urine leaks from catheter • Resident reports pain or pressure • Odor
Intravenous lines • In caring for residents with IVs, DO NOT • Take blood pressure on an arm with an IV • Get the site wet • Pull or catch the tubing in anything • Leave the tubing kinked • Lower the IV bag below the IV site • Touch the clamp • Disconnect IV from pump or turn off alarm
Indirect Care Skill • 1 Greet resident, address by name, and introduce self • 2 Provide explanations to resident about care before beginning and during care • 3 Ask resident about preferences during care • 4 Use Standard Precautions and infection control measures when providing care • 5 Ask resident about comfort or needs during care or before care completed • 6 Promote resident’s rights during care • 7 Promote resident’s safety during care
Skill #1handwashing • Handwashing is the single most important method of preventing the spread of infection • Always wash your hands: • Before entering a patient’s room, and upon leaving • Before handling a patient’s or resident’s meal tray • After using the bathroom • After sneezing, coughing or blowing your nose • After touching anything considered dirty • After removing disposable gloves # NOTE: It is not a good idea to wear rings or bracelets on the job or while testing as these can harbor microbes!
Skill #2ambulate patient with gait belt • Transfer belts give you a safe place to grasp and support the patient when assisting with standing, transferring or walking • Always use correct body mechanics • Use a transfer belt on the person according to your facility policy • Watch the person for fatigue or discomfort • Check the person’s clothing and shoes. Shoes should have good support and nonskid soles • Check ambulation devices to ensure that they are in good condition • Request help as necessary when you patient is weak or unsteady • Allow patient to dangle before standing
Skill #3assist with bedpan • Bedpan- Used for elimination when a person is unable to get out of bed at all • Use with extreme care so that patient’s skin is not bruised or easily torn • There are 3 types of bedpans: fracture pan and regular pan and bariatric • Fracture pans are used when patient is unable to use regular pan due to fracture, pain, or arthritis (smaller and less bulky) • Placement: Fracture Pan- thin edge goes towards the head of bed. Regular pan- buttocks are placed on wide part like a regular toilet seat • After placement, raise head of bed to allow for normal elimination • Provide privacy (close curtain, shut door) • Remember Safety- lower bed to lowest position, keep side rail up and place call light within reach
Skill #4Change linen with patient • Bed linen: top and bottom (fitted) sheets, draw sheet, lift sheet, bed protector (chux pad or incontinence pad), blanket, pillow and pillowcase, bed spread • Collect linen in order that you will use them and only collect linen that is needed • While handling linen always hold them away from your body and uniform • Always use gloves to remove linen from bed (soiling) • Always wash hands before collecting clean linen • Never place clean linen on the floor or other dirty surfaces • Place dirty linen in linen bag or linen hamper and take to designated area (soiled utility room)
Bedmaking continued • Linen must remain clean, dry and wrinkle free to protect your patient from skin breakdown • Bedmaking is best done while patient is out of bed (taking a shower or in a chair) • Know your facility policy as to how often the linen is to bed changed • Some linen needs to be changed more often such as with a patient with excessive perspiration or incontinence • Remember to use mitered corners for bedmaking • Types of bedmaking: closed bed, open bed, surgical bed, occupied bed • If bedmaking with person in bed, explain procedure, reassure, provide privacy and safety • Always finish bedmaking by making sure wheels are locked and bed is in the lowest position and patient has their call light within reach
Skill #5change patient to side-lying position • Remember your indirect skills: infection control, safety, communication, and resident preferences, needs, comfort and rights • Changing positions helps you to stay comfortable while preventing complications such as decubitus ulcers • Some patients are not able to change positions without your help • Proper body alignment is very important • Supportive devices may be used: pillows, sheets, blankets, wedge pillows
Positioning patient • Supine (Dorsal Recumbent) Position- lying on back, bed flat, head supported with pillow • Fowler’s Position- head of bed elevated between 45-60 degrees • Semi-Fowler’s Position- low fowler’s, HOB 35-40 degrees • High Fowler’s- HOB elevated 60-90 degrees • Side-lying Position (lateral)- laying on either the right or left side • Prone Position- lying on abdomen with head turned to either side • Sims Position- extreme side lying position • You can raise the patient’s knees with pillows or with bed to prevent sliding down in bed • Patient’s unable to reposition themselves are repositioned every 2 hours
Positioning patient • When positioning patient make sure to not cause injury to yourself or patient • Shearing- pulling a person across a surface that causes resistance • Friction- when 2 surfaces rub against each other (patient’s skin and the bed linen) • Always ask for assistance from a co-worker when needed
Skill 6dress resident with weak arm • In your career you may have residents that have weakness due to illnesses or diseases processes • Help residents to choose clothing that is easy to put on and take off • Dress the person starting with the affected extremity (weak arm) • Take off clothing starting with the unaffected extremity (strong arm)
Skill #7empty drainage bag/ I&O • For some residents you may have to record all intake and output • You may measure with cc’s (cubic centimeter) or ml’s (milliliters) • Fluids considered output include urine, vomit, blood, wound drainage and diarrhea • Collection devices for measurement: urinals, graduate, commode hat, emesis basin • Urinals have measurements marked on the side • Urine from catheter must be emptied into a graduate for measurement • Measurements are also located on emesis basin • Always wear gloves while measuring output
Skill #8feed resident in chair • Meals should be served as soon as they arrive from kitchen • Always check name card and food allergies prior to delivering tray to patient • Make sure diet on tray matches current Physician ordered diet • Always ask patient if is it ok to use clothing protector before placing it on before meal • Ask patient if it is ok for you to assist with meal. Tell patient what food is on the tray • Help set up meal tray (unwrap utensils, open cartons ect.) • Use a spoon for feeding and fill 1/3 full for each bite • Offer fluids in between each bite
Skill #9measure and record radial pulse • Every time the heart beats is sends a wave of blood through your arteries • All arteries have a pulse, you can only feel the pulse of an artery that runs close to the surface of the skin (radial artery-pulse) • Pulse is felt as a throbbing sensation over the artery • You feel it by placing your fingers gently over the artery • Most common pulse site is the radial pulse located on the thumb side of wrist • Pulse rate- number of pulsations felt in one minute • Pulse rhythm- the pattern of pulsations and the pauses between them (smooth and regular with even amount of time between pulsation) but can be (irregular) • Pulse character- not palpable, weak or thread, strong, bounding • Never measure pulse with your thumb (thumb has it own pulse) always use your middle 2 or 3 fingers for measurement • Normal pulse rate for adults is: 60-100 bpm
Skill #10measure and record respirations • Respiration= 1 inhalation and 1 exhalation • Inhalation= brings in oxygen and Exhalation= removes harmful carbon dioxide • Look for rate, rhythm and depth of each respiration • Normal adult respirations are 12-20 • Watch for rise and fall of chest for 30 secs. and multiply by 2 or for 1 full minute • Respirations are counted immediately after pulse with your fingers still on person’s wrist • Observe from side or behind person, or by placing your hand on collarbone • Always monitor for breathing abnormalities
Skill #11provide catheter care • Indwelling catheters are attached by tubing to a urinary drainage bag • Urine will drain continuously from bladder into the drainage bag • Some drainage bags are attached to patient’s bed or wheelchair, others attached to patient’s leg (leg bag) • Always keep drainage bag lower than person’s bladder • Never attach bag to side rail, always to bed frame! • Make sure that emptying spout is clamped when not in use-prevents urine from leaking • If you must change drainage bag, never let catheter tubing touch any other surface, always wipe exposed tubing with alcohol pad prior to attaching to new bag
Catheter care continued… • Catheter care involves cleaning of the perineal area and the catheter tubing in order to prevent infection • You must use soap and water and remember to always wear gloves • Make sure water temperature is comfortable for patient • You may need several washcloths to perform skills • Always wipe front to back and use different side of washcloth per stroke • Catheter care may need to be done per shift as many times an necessary especially if patient is incontinent of stool • Remember the indirect skills while performing care (make sure your non-working bed side rail is raised-safety, close curtains-privacy, ask if it’s ok to enter-respect for patient)