chapters 7-9, ed 6 [Autosaved] (1) (1)

1. Shaving(from chapter 6, but added here) • Never trim beards, mustaches or side burns • Wear gloves • Place towel across chest, wet face, apply liberal amount of shaving cream • Hold skin taut, shave in direction of hair growth with short strokes, rinsing blade often • If nick occurs- apply pressure, tell CN • If resident is on an anticoagulant (blood thinner)- must shave with electric razor • Dispose of razor in sharps container

2. Basic Nursing Skills

3. Admitting, Discharge and Transfer

4. Admission • Feelings at this time may be: Fear, depression, anxiety, happiness, anger • Paperwork will be completed by admissions, resident rights reviewed and explanation of PSDA reviewed, polaroid photo taken

5. Prep before arrival • Obtain admissions kit (p. 175) • Open bed • Need scale, vital signs equipment, gown, extra blanket and pillow, urine specimen cup • Ask about oxygen therapy, IV, etc. • Need belongings or inventory checklist form

6. Upon Admission • Greet and call by name the person prefers- for testing purposes it is Mr or Mrs….., • Take to room and assist into gown • Obtain weight and ht, VS if requested by RN • Complete inventory checklist, count and secure money, document valuables • Orient to room/unit- call bell, BR, DR, nurse’s station, activity room • Introduce to others, including roommate

7. Admission • Feelings at this time may be: Fear, depression, anxiety, happiness, anger • Paperwork will be completed by admissions, resident rights reviewed and explanation of PSDA reviewed, polaroid photo taken

8. Vital Signs • Vital signs are a reflection of health. They should be relatively stable unless illness occurs • May be taken at time of admission & then monthly or more often as needed • Vital signs include temperature (T), pulse (P), respirations (R) and blood pressure (BP).

9. Temperature • The amount of heat in the body • Affected by outside temp, emotions, exercise, illness, age, pregnancy and menstrual cycle • Lowest in morning, before rising • A fever is also known as pyrexia

11. Measuring T Route Time Range Guidelines for use Axillary (ax) 7-11 min 96.6-98.6 least accurate, arm across chest to keep thermometer in place Oral (o) 3-5 min 97.6-99.6 Place under tongue, to one side don’t take if comatose, confused under 4 yrs, mouth breather, recent seizure activity wait 15-20 min after hot/cold liquids, heavy exercise or cig Rectal (r ) 1-3 min 98.6-100.6 Hold in place, wear gloves, lubricate a rectal thermometer covered, sims position Don’t take if severe constipation/diarrhea hemorrhoids, rectal disease or colostomy MOST ACCURATE WAY TO MEASURE TEMP IS RECTAL ½ to 1 inch in rectum

12. Other routes for measuring temp • Tympanic Membrane (aural) thermometers measure temp in the ear (pull ear back and up, gently) insert ¼-1/2 inch into ear • Temporal artery- on the forehead • Temperature sensitive tape • Tempa-dots • Oral thermometers color coded blue or green • Rectal thermometers color coded red

14. Pulsehttps://www.youtube.com/watch?v=K8ryHOgfTtY • Pulse is the number of times the heart beats • Should also note quality (strong, weak, thready) and the rhythm (regular or irregular) • Radial pulse is used- thumb side of wrist • Use 2-3 fingertips, never your thumb, pressing lightly (too hard blocks the pulse) • Count for 1 full minute, 30 seconds (multiply by 2) or 15 seconds (multiply by 4). • Keep arm at heart level

15. Other body pulses

16. Word Alert • Tachycardia is a HR >100 • Bradycardia is a HR <60 • Normal heart rate is between 60-100 • HR may increase with emotions, illness, certain drugs, exercise, caffeine and nicotine • HR may decrease with extreme grief, meds • Note rhythm & force (weak, bounding, thread) • Infants pulse 120 to 180 • Children’s pulse 100 t0 120

17. Pulse cont. • An apical pulse requires the use of a stethoscope- placed over apex of heart to auscultate (listen to) heart beat • An apical-radial deficit is the difference between the apical and radial pulses- take at same time by nurse and nurse aide

18. Respirations • Each breath in of oxygen is followed by a breath out of carbon dioxide • One inspiration (inhalation) + one expiration (exhalation) = 1 Respiration • Normal respiratory rate is 12-20 breaths/minute • Normal respirations are quiet, effortless, symmetrical (same on both sides) • RR increases with illness, emotions, body positions • Don’t tell a person you are measuring their RR, he will change the breathing pattern, count immediately after Pulse

19. Respiratory Patterns • Kussmaul’s- in diabetics, very deep and rapid RR • Cheyne-Stokes- periods of apnea with shallow RR • Tachypnea >20 • Bradypnea <12 • Apnea- no breathing • Dyspnea- difficulty breathing • Orthopnea- can’t breathe if lying down • Infants respirations 30 to 40*

21. Blood Pressure • BP measures the force of blood within the walls of an artery • Arteries that are narrowed, blood that is very viscous (thick) and stress make the resistance greater and raise BP • BP is measured as an inverted fraction (top number > than lower number) • Normal BP is less than 140/90 (new numbers are 130/80) • Hypotension less than 90/60

22. Parts of a stethoscope

23. Blood Pressure cont. • Systolic pressure is created when blood is being pumped as the heart contracts (top number) • Diastolic pressure is created when the heart is at rest (bottom number)

24. Number Game… • A systolic of >140 = hypertension • A systolic of <90=hypotension • A diastolic of >90= hypertension • A diastolic of < 60= hypotension

25. The new guidelines are based on a rigorous review of nearly 1,000 studies on the subject, which took the authors three years to complete. • The new guidelines now classify people's blood pressure measurements into the following categories: • Normal: Less than 120 mm Hg for systolic and 80 mm Hg for diastolic. • Elevated: Between 120-129 for systolic, and less than 80 for diastolic. • Stage 1 hypertension: Between 130-139 for systolic or between 80-89 for diastolic. • Stage 2 hypertension: At least 140 for systolic or at least 90 mm Hg for diastolic.

26. Guidelines for measuring BP • Roll up long sleeves • Rest arm at heart level • Place BP cuff 2-3 inches above brachial artery • Inflate cuff to 180 mmHg • Slowly deflate cuff listening for first sound=systolic reading • Continue to listen until last sound heard=diastolic reading • Must use proper size cuff

27. Orthostatic BP • Take when resident lying down and record • Then have resident sit up, wait 2 minutes and then take BP again • Have resident stand up, wait 2 minutes and then take BP again • All 3 measurements given to RN

28. Pain management • Pain is a subjective finding (a symptom) and therefore must be described by the resident • Not a normal part of aging • Ask where, when, duration, scale of 0-10, describe character of pain, what makes it worse or better, what may have contributed to it??? • Observe for change in vital signs, sweating, squeezing eyes shut, clenching fist, agitation, rocking, pacing, frowning

29. BP Guidelines continued • Clean stethoscope ear pieces and bell between uses • Don’t overinflate cuff • Don’t take BP in one arm > 3 times • Left arm best • No BP in arm which has dialysis access or on side of a mastectomy

30. Factors affecting BP • Gender- men higher • Race-esp in AAs • Blood volume- decrease with hemorrhage, increase with fluid retention of IVs • Stress- raises • Pain-raise • Exercise-raises • Weight-raises • Diet- esp high in NA • Position- higher when lying down • Smoking-raises • Alcohol-raises

31. Pain management • Rated on scale of 0 to 10 • Inform nurse- where, when, precipitated by, chronic, acute, phantom? • Visual signs such as crying, grimacing? • Reposition • Warm liquids • Massage • Distraction • Breathing exercises • Walking…….

32. Restraints • Anything that restricts freedom of movement • Active- applied directly to the body- mittens, waist belt, vest, wrist restraints • Passive- not attached to body- side rails, geriatric chair with tray attached • Must be ordered by MD. Least restrictive type used as a last resort. • Must be released every 2 hours and checked every 15-30 minutes. • Must be tied to nonmovable part. Must be able to slip fingers inside • Check for irritation, change in temp/color of extremities • Never used to punish or control behavior

33. Complications of restraints • Fractures • Bedsores • Depression • Atrophy • Suffocation • Constipation/incontinence • Pneumonia • death

34. Restraints- anything that restricts freedom of movement Guidelines for use: • Must be ordered by the MD • Only used to protect resident from self or others • Only used as last resort • Least restrictive type used • removed every 2 hours for toileting, nutrition, exercise • Check restraint every 30 minutes • Never tie straps to bed rails • Tie in a quick release bow • Never used for staff convenience or to punish • Tie in slipknot • Straps to bed frame or non-movable part, never the side rails

35. More guidelines for restraint use • Keep call bell within reach • Document time on and off • Check skin for irritation, discoloration • Check fit by slipping 2-3 fingers inside restraint • Vest restraint criss-crossed in front • Don’t make a restraint (such as tying a sheet around a resident’s waist)

36. https://www.youtube.com/watch?v=h7J28x6fRaQraints • Vest or chest- criss cross in front • Wrists • Mittens • Waist or belt • Side rails • Geriatric chair with tray attached • Passive restraints aren’t attached to the body • Active restraints are attached to the body

37. Pics of restraints

38. Alternative to restraints • Lap buddy or tray • Bed and chair alarms • Low bed • Hip protectors • Wedge cushions • Bed bolsters

39. Alternatives to restraints

40. reading aread

42. Hydration • Water is needed to live • Fluid intake must be in balance with output • Edema (swelling) occurs when too much fluid is taken in and output is not equal (fluid retention) • Dehydration occurs when not enough fluid is taken in or too much out

43. S/SX of Edema & Dehydration • Edema: • Swollen ankles, feet, hands, wrists • Weight gain • SOB • Dehydration • Dry skin • Dry mucous membranes (tongue, gums) • Dark, scant amt of urine • Sunken periorbital (around the eyes) spaces

44. How much fluid is needed? • 1 ounce of fluid = 30 milliliters (ml) • 1 ml is equal to 1 cubic centimeter (cc) • 1 liter is = to 1000cc/ml • Humans need at least 1500 ml to survive (or 1.5 liters/day) • For fluid balance 2000-2500ml are needed

45. Measuring Intake and Output • If ordered, you may need to record all fluids taken in: juice, water, soup, hot cereals, yogurt, ice cream, etc AND all fluids put out: urine, diarrhea, wound drainage, emesis • Fluids out must be measured in a GRADUATE container • Total I & O at the end of the shift

46. Special Fluid Needs • Force fluids- if a person is at risk of or suffering from dehydration: • Offer a small amt (6 oz) of different types of fluids Q2h while awake

47. Restrict fluids- if • if a person is retaining fluids: • Remove water pitcher and cup • Resident can only drink fluids that are served • A set amount is allowed per shift

48. NPO • Remove water pitcher and cup • Post sign over bed reminding staff/visitors • No gum, no ice chips, nothing allowed by mouth • Give special mouthcare Q2h to keep mouth moistened

49. How much fluid in?? • Calculate John’s fluid intake… 4 ounces juice 8 ounces coffee 4 ounces of skim milk 10 ounces oat meal