Nursing Skills

1. Nursing Skills

2. Position, Turn, and Transfer patients Make a bed Administer personal care and apply restraints Objectives

3. Must use correct body mechanics Alignment = Positioning body parts in relation to each other to maintain correct body posture Correct alignment helps pt. feel comfortable; prevents fatigue, Decubitus ulcers and contractures Positioning, Turning, Moving and Transferring Patients

4. Pressure sore or bed sore • Caused by pressure that interferes with circulation • Usually at bony prominences – coccyx, hips, knees, heels, and elbows • First sign is a pale or reddened area on the skin Decubitus Ulcer

5. Vesicle or blister may for at the site Cells die, skin breaks down and open sore (ulcer) develops EASIER TO PREVENT THAN TO TREAT Decubitus Ulcer Cont.

6. Good skin care Prompt cleaning of urine and feces from skin Massage in circular motion around reddened area Light dusting of powder to prevent friction Frequent turning and positioning…q 2h Linen dry and free from wrinkles Use of pressure-relieving surfaces Prevent Decubitus Ulcers by:

7. Carefully observe the skin during bathing for evidence of pressure sores

8. Tightening or shortening of muscle due to lack of movement or usage • Foot drop common contracture • Prevented by keeping foot at right angle to leg • ROM will help prevent contractures Contractures

9. Weakened body parts must be supported with pillows, bed cradles, footboards, rolled blankets or towels Pt must be turned frequently Contractures Cont.

10. Dangling • Sitting on side of bed prior to standing • Allows patient time to adjust • If the patient c/o vertigo, weakness or diaphoresis – return pt. Immediately to supine position • Mechanical Lifts • Used to transfer weak or paralyzed patients • Be sure you have been instructed on proper use • Reassure patient during transfer Turning, Moving, and Transferring

11. Transferring • Be sure to protect patient and health care worker • Be sure you know how to operate the wheelchair/stretcher • FIRST Lock the wheels Turning, Moving, andTransferring Cont.

12. Before moving patient, obtain proper authorization from immediate supervisor Watch the patient closely – pulse rate, respirations and color Observe for weakness, dizziness, increased perspiration or discomfort If you note abnormal changes, return the patient to a safe and comfortable position and notify your supervisor When turning and Transferring

13. Lower the head of the bed Place the pillow against the bed frame to protect the pts. Head If pt. has trouble breathing, raise the head of the bed Ask the pt. to flex the knees and brace the feet on bed / pushing heels into the bed to assist Moving the Pt. Up in Bed

14. Place one arm under the pts. Head and shoulders If the patient is unable to help, get someone to assist you Get a broad base of support and as close to the bed as possible Arrange a signal – “On the count of three, push with your feet” On the signal, shift your weight forward Two people can use a draw sheet or lift sheet

15. Lower the side rail nearest you – be sure the opposite side is up If the pt. is lying in the center of the bed, place hands under the pts head and shoulders and slide the pt toward you Place both hands under the hips and slide the hips toward you Turning the Pt.

16. Place both hands under the legs and slide the legs toward you Cross the pts. arms across his/her chest Move the leg closest to you over the other leg Get close to the pt. and roll the pt. away from you Explain what you are doing to the pt. Place your hands under the head and shoulders, then the hips, drawing the pt. to the center of the bed Turning the Pt. Cont.

17. Linen must be free of wrinkles as they could cause discomfort and lead to decubitus ulcers • Closed Bed • Made after the pt. is discharged and after terminal cleaning of unit • Purpose: keep bed clean until new pt. comes • Open Bed • Fanfold top sheets to welcome new pt. or for ambulatory pts. Bedmaking

18. Occupied Bed • Bed made while pt. is in it • Bed with Cradle • Cradle is placed under top sheets to prevent linen from touching parts of the pts. Body. Used for pts. With burns, skin ulcer, blood clots, fractures, and other similar conditions Bedmaking Cont.

19. Observe correct body mechanics Keep linen arranged in the order of use Make one side of the bed completely, then on the other side Roll dirty linens away from your body and place in hamper immediately Bedmaking Tips

20. Do not shake clean or dirty linen. Place open end of the pillowcase away form the door Wear gloves while handling dirty or contaminated linen

21. Benefits: • Provides comfort • Stimulates the appetite • Prevents disease and dental caries • Helps to prevent bad breath (halitosis) • Stimulates saliva production which contains digestive enzymes and promotes digestion Oral Hygiene

22. Involves tooth brushing and flossing Should be done at least three times a day Provide necessary equipment such as toothbrush, toothpaste, dental floss, mouthwash, emesis basin, cup, and water Assist the patient as needed Routine Oral Hygiene

23. Proved privacy for the pt. • Have pt. remove dentures if able • Place dentures in a denture cup to carry to sink • Use warm water to clean dentures…hold over emesis basin lined with paper towels to prevent them breaking if you drop them • Hold dentures securely. Let pt rinse mouth and brush gums • Store dentures in a denture cup labeled with the pts. Name Denture Care

24. Usually given to unconscious or semiconscious pts • Tell the pt. what you are doing • Turn pt to their side • Turn pts head toward you • Use a very small amt. of liquid • Clan all areas of mouth: • Teeth, Gums, Tongue, Roof of Mouth • Apply lubricant to tongue and lips Special Oral Hygiene

25. Types of Baths • Complete Bed Bath (CBB) • Pt. is usually confined to bed and the health care worker must bathe all parts of the pts. body • Partial Bed Bath • Pt. washes some of the parts of their body and the health care worker washes the parts of the body the pt. cannot reach Bathing

26. Tub Bath or Shower • Health care worker prepares the tub or shower area and assists pt. as needed • Cleans tub once bath is over and pt is back in their bed or chair Bathing Cont.

27. Use standard precautions • Provide privacy, comfort, and safety • Fill basin 2/3 full with warm water at a temp. of 105-110 F • Form a mitten around your hand with the cloth to keep from hitting pt during bath Complete Bed Bath

28. Wash body parts in this order: • Face, ears, and neck -> axilla, arms, and hands (apply deodorant) -> chest, breast, and abdomen -> thighs, legs, and feet (change water) -> back, buttock, and back of perineum (give back rub) -> perineum area • Change water when it becomes too cool, dirty or soapy CBB Cont.

29. Usually require a physician’s order Make sure tub or shower is clean Put rubber mat in tub or shower Full tubs half full with water at 105 F Help pt. into the tub or shower (Use the shower chair for pt. who cannot stand) Assist pt. as needed Tub Baths and Showers

30. Stay with pt. or make sure pt. can use the emergency call system After bath or shower, cover pt. with a towel or bath blanket Clean the tub or shower with a disinfectant after each use Tub Baths and Showers Cont.

31. Amount of fluid taken into the body should equal the amount of fluid lost from the body. • Excessive fluid retained by body = edema • What do you measure? IntakeOutput Oral Bowel IV Emesis Irrigation Urine Irrigation Measuring and Recording Intake and Output

32. Oral • Includes liquids taken by mouth • Also includes foods that are liquid at room temp. such as soup, jell-o, ice cream, pudding, and Popsicle’s • Tube feeding is usually recorded under oral intake • Fluids are measured in metric units – cc/ml Intake

33. 1 Cubic Centimeters (cc) = 1 Millimeter (ml) • Memorize these equivalents • 1 ml or cc =15gtts (drops) • 5ml or cc = 1 tsp (teaspoon) • 15 ml or cc = 1 tbsp (tablespoon) • 30 ml or cc = 1 (oz) ounce • 240 ml or cc = 1 cup (8 oz) • 500 ml or cc = 1 pint (16 oz) • 1000 ml or cc = 1 quart (32 oz) Intake Cont.

34. Fred is on I & O. When you go into his room after lunch, you examine his lunch tray and find he consumed the following: 1 hamburger, ½ bowl of chicken broth (1 soup bowl=200cc), 4 soda crackers, 1 cup of tea, ¾ carton of milk (1carton=8 oz), ½ bowl of jello (1 small bowl=120cc) What was Fred’s fluid intake? Measuring Intake 580

35. Output = all fluids eliminated by the pt. • BM • Liquids BMs are measured and recorded • Solid or formed BM is usually noted under feces or the remarks column • Emesis • Measure anything that is vomited • Also not color, type, and other facts in the remarks column Measuring Output

36. Urine • Measure all urine voided or drained via a catheter • Men can collect their urine in a urinal and women can collect their urine in a bedpan or a special urine collector that can be placed under the seat of the toilet • Irrigation • Measure any drainage from nasogastric tubes, hemo-vacs, chest tubes or other drainage tubes • These measurements are usually done by the nurse Measure Output Cont.

37. Jennifer is on I & O. A the end of an 8 hour shift, you note the following: 0800 she voided 400 cc of urine 1000 she vomited 200 cc of thick yellow emesis with food particles in it 1130 she had one formed green BM 1315 she voided 350 cc of urine What was Jennifer’s output for the 7-3 shift? Measuring Output 950

38. Prior to meal: • Provide privacy • Help pt. use the bedpan or urinal if needed • Provide oral hygiene if desired • Remove emesis basins or bedpans for sight • Position pt. in a sitting position if allowed • Wash pts. hands and face Feeding the Pt.

39. Put over bed table in position Check to make sure the pt. is not NPO Make sure the diet is correct for the pt. Place a towel or napkin under pts. chin Open packages and cartons; season and cut foods if necessary Feeding Cont.

40. Test temperature of hot foods by placing small amount on wrist Feed pt. slowly and allow them time to chew Use separate straw for each liquid Hold utensil at a 90 degree angle to the pt. mouth Give small bites Steps for feeding pt.

41. Alternate the foods and liquids Allow pt. to help as much as they are able to Offer choices to the pt. Wipe the pts. mouth as necessary Encourage pt. to each as much as possible Steps for Feeding Pts. Cont.

42. Allow pt. to wash their face and hands Provide oral hygiene Position pt. in correct body alignment Clean area Note how much food was eaten Calculate I & O if this is ordered for pt. After the Meal

43. Urinate, micturate, or void – terms for emptying of the bladder, which stores urine • Urinals are used by male pts. when they need to micturate • A bedpan is used by females when they need to micturate • Defecate – having a bowel movement • Both men and women must use a bedpan when they need to defecate Bed Pans and Urinals

44. Two main types of bedpans • Fracture or orthopedic bedpan • Standard bedpan • Many patients are sensitive about using the bedpan. Always provide privacy and make them as comfortable as possible. Bedpans and Urinals Cont.

45. Use standard precautions and wear gloves • Provide privacy for the pt • Warm bedpan by running warm water over it • There are two positions to place the pan under the pt. • Pt. flexes knees and puts weight on heels. They then lift their hips up • Pt. is turned to one side and the pan is placed against the buttock and the pt is rolled back on the pan Assisting with a Bedpan

46. The pts. buttocks should rest on the rounded portion of the pan Place call bell and tissue within the pts. reach Raise siderail before leaving the pt. Assisting with a Bedpan cont.

47. Answer call bell immediately • Use the same positions to get pt. off the pan, but hold pan firmly • Cover the bedpan and place on nearby chair or table • Make sure perineum is clean and dry • Assist pt. in washing hands • Clean bedpan and note any abnormalities of urine or BM All Done 

48. Use standard precautions and wear gloves Provide privacy for pt. Assist with placement of the urinal if needed Leave the call bell and toilet tissues near the patient Answer the pts. call bell immediately Assisting with Urinal

49. Avoid exposing the pt. Have pt. hand you the urinal if they are able Close the lid or cover the top of urinal Assist pt. with washing hands Assist pt. with washing perineum if needed Measure contents of pts. I & O Empty urinal and clean Report abnormalities related to urine All finished 

50. May be used only to protect pts. from harming themselves or others • Must have doctor’s order to use restraints • Conditions that may require restraints • Irrational or confused pts. • Skin conditions • Paralysis or limited muscular conditions Restraints