Basic Nursing Skills

RNSG 1205 NURSING SKILLS UNIT 1 LECTURE 1. Describe “caring “and the various descriptions, actions and outcomes associated with caring. Caring is central to all helping professions, and enables persons to create meaning in their lives. Caring means that people, relationships, and things matter. Caring is a process that develops overtime, resulting in deepening and transformation of the relationship. Different definitions of caring(Morse, Solberg, Neander, Battorff, and Johnson: five viewpoints: 1. caring as a moral imperative 2. caring as an affect 3. caring as a human trait 4. caring as an interpersonal relationship 5. caring as a therapeutic intervention The Six Cs of caring in Nursing 1. Compassion- Awareness of one’s relationship to others, sharing their joys, sorrows, pain and accomplishment. Participation in the experience of another. 2. Competence- Having the knowledge, judgment, skills energy, experienced and motivation to respond adequately to others within the demands of professional responsibilities. 3. Confidence- The quality that fosters trusting relationships. Comfort with self, client, and family. 4. Conscience- Morals, ethics, and an informed sense of right and wrong. Awareness. Of personal responsibility. 5. Commitment- Convergence between one’s desires and obligations and the deliberate choice to act in accordance with them. 6. Comportment- Appropriate bearing, demeanor, dress, and language, that are in harmony with a caring presence. Presenting oneself as some one who respects other and demands respect What attributes identify a caring nurse from a non caring nurse: Process and definition Knowing Striving to understand and event as if has meaning in the life of the other Being with Being emotionally present to the other

Doing for Doing for the other as he/she would do for the self if it were at all possible Enabling Facilitating the other’s passage through life transitions and unfamiliar events. Maintaining Belief Sustaining faith in the other’s capacity to get through an event or transition and face a future with meaning Subdimensions 1. Avoiding assumptions 2. Centering on the one cared 3. Assessing thoroughly 4. seeing cues 5. Engaging the self of both 6. Being there 7. Conveying ability 8. Sharing feelings 9. Not burdening 10. Informing/explaining 11. Supporting/allowing 12. Focusing 13. Comforting 14. Anticipation 15. Performing competently/skillfully 16. Protecting 17. Preserving dignity 18. Generating alternatives/thinking it through 19. Validating/giving feedback 20. Believing in/holding in esteem 21. Maintaining a hope-filled attitude 22. Offering realistic optimism 23. “Going the distance”

2.

Differentiate between the oral, rectal and axillary methods of taking a temperature. Vital signs- are body temperature, pulse, respirations, and blood pressure.

Temperature- reflects the balance between the heat produced and the heat lost form the body, and is measured in heat units called degrees. 2 types Temperature: 1. Core temperature is the temperature of the deep tissues of the body, such as the abdominal cavity and pelvic cavity. It remains relatively constant. 2. Surface temperature – is the temperature of the skin, the subcutaneous tissue, and fat, It by contrast, rises and falls in response to the environment.

SITE Oral- Body temperature

ADVANTAGES Accessible and convenient

DISADVANTAGE Thermometers can break if bitten. Inaccurate if client has just ingested hot or cold food or fluid or smoked. Could injure the mouth following oral surgery

Rectal-

Reliable measurement

Axillary- newborns, infants, toddlers, and children

Safe and noninvasive

Tympanic membrane- nearby tissue in the ear canal

Readily accessible; reflects the core temperature. Very fast

Inconvenient and more unpleasant for client; difficult for client who cannot turn to the side. Could injure the rectum following rectal surgery. Presence of stool may interfere with thermometer placement. If the stool is soft, the thermometer may be embedded in stool rather than against the wall of the rectum. The thermometer must be left in place a long time to obtain an accurate measurement. Can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far. Repeated measurements may vary. Right and left measurements can differ. Presence of cerumen can affect the reading

Temporal artery -forehead measurements are most usef for infants and children

Safe and noninvasive, very fast

Requires electronic equipment that may be expensive or unavailable; variation in technique needed if the client has perspiration on the forehead.

3. Describe the different anatomical sites where a pulse can obtained 1. Apical (PMI)- at the apex of the heart 2. Brachial- at the inner aspect of the biceps muscle o the arm or medially in the antecubital space

3. Carotid-at the side of the neck where the carotid artery runs between the trachea and the sternocleidomastoid muscle.

4. Dorsalis Pedis- (Pedal) dorsalis pedis artery passes over the bones of the foot, on an 5. 6. 7. 8.

imaginary line drawn from the middle of the ankle to the space between the big and second toes. Femoral- where the femoral artery passes alongside the inguinal ligament Popliteal- where the popliteal artery passes behind the knee Posterior tibial- on the medial surface of the ankle where the posterior tibial artery passes behind the medial malleolus. Radial-where the radial artery runs along the radial bone, on the thumb side of the inner aspect of the wrist.

9. Temporal- where the temporal artery passes over the temporal bone of the head. The site is superior ( above) and lateral to (away for the midline of ) the eye.

4. Compare the normal range of heart rates of various clients throughout the life span Age Newborn 1 year 5-8 years 10 year Teen Adult Older adult

Pulse Average (and ranges) 130 (80-180) 120 (80-140) 100 (75-120) 70 (50-90) 75 (50-90) 80 (60-100) 70 (60-100)

Life span considerations Pulse: Infants • Use the apical pulse for the heart rate of newborns, infants, and children 2 to 3 years old to establish baseline data for subsequent evaluation, to determine whether the cardiac rate is within normal rage, and to determine if the rhythm is regular. • Place a baby in a supine position, and offer a pacifier if the baby is crying or restless. Crying and physical activity will increase the pulse rate. For this reason, take the apical pulse rate of infants and small children before assessing body temperatures. • Locate the apical pulse in the fourth intercostals space, lateral to the midclavicular line during infancy. • Brachial, popliteal, and femoral pulses may be palpated. Due to a normally low blood pressure and rapid heart rate, infants; other distal pulses my be hard to feel. • Newborn infants may have heart murmurs that are not pathological, but reflect functional incomplete closure of fetal heart structures(ductus arteriosus or foramen ovale). Children • • •

To take a peripheral pulse, position the child comfortably in the adult’s arms, or have the adult remain close by. This may decrease anxiety and yield more accurate results. To assess the apical pulse, assist a young child to a comfortable supine or sitting position. Demonstrate the procedure to the child using a stuffed animal or doll, and allow the child to handle the stethoscope before beginning the procedure. This will decrease anxiety and promote cooperation.

• • • Elders

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The apex of the hear is normally located in the fourth intercostals space in young children; fifth intercostals space in children 7 years of age and over Locate the apical impulse along the fourth intercostals space, between the MCL and the anterior axillary line Count the pulse prior to other uncomfortable procedures so that the rate is not artificially elevated by the discomfort. If the client has severe hand or arm tremors, the radial pulse may be difficult to count. Cardiac changes in elders, such as decrease in cardiac output, sclerotic changes to heart valves, and dysrhytmias often indicate that obtaining an apical pulse will be more accurate. Elders often have decreased peripheral circulation, so pedal pulses should also be checked for regularity, volume, and symmetry. The pulse returns to baseline after exercise more slowly than with other age groups.

5. Compare the normal rage of respiratory rates of various clients throughout the life span. Age

Respirations average(and ranges) Newborn 35 (30-80) 1 year 30 (20-40) 5-8 years 20 (15-25) 10 year 19 (`15-25) Teen 18 (15-20) Adult 16 (12-20) Older adult 16 (15-20) Lifespan Considerations Respirations: Infants

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An infant or child who is crying will have an abnormal respiratory rate and rhythm and needs to be quieted before respirations can be accurately assessed. Infants and young children use their diaphragms for inhalation and exhalation, If necessary, place your hand gently on the infants abdomen to feel the rapid rise and fall during respirations. Most newborns are complete nose breathers, and nasal obstruction can be life threatening Some newborns display” periodic breathing” in which they pause for a few seconds between respirations. This condition can be normal, but

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Children

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Elders

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parents should be alert to prolonged or frequent pauses (apnea) that require medical attention. Compared to adults, infants have fewer alveoli and their airways have a smaller diameter. As a result, infants respiratory rate and effort of breathing will increase with respiratory infections Because you children are diaphragmatic breathers, observe the rise and fall of the abdomen. If necessary, place your hand gently on the abdomen to feel the rapid rise and fall during respirations. Count respirations prior to other uncomfortable procedures so that the respiratory rate is not artificially elevated by the discomfort. Ask the client to remain quiet or count respirations after taking the pulse. Elders experience anatomic and physiologic changes that cause the respiratory system to less efficient. Any changes in rate or type of breathing should be reported immediately.

6. Identify the tools and steps in taking a blood pressure Euipment: • STETHOSCOPE OR DUS • BOLOD PRESSURE CUFF OF THE APPROPRIATE SIZE • SPHYGMOMANOMETER Implementation 1. Ensure that the equipment is intact and functioning properly. 2. Make sure that the client has not smoked or ingested caffeine within 30 minutes prior to measurement Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. provide for client privacy 4. Position the client appropriately • Adult client should be sitting unless otherwise specified Both feet should be flat on the floor. • Elbow should be slightly flexed with the palm of the hand facing up and the forearm supported the hear level • Expose the upper arm. 5. Wrap the deflated cuff evenly around the upper arm. Locate the brachial artery • For an adult, place the lower border of the cuff approximately 2.5cm (1 in) above the antecubital space.

6. The clients; initial examination, perform a preliminary palpatory determination of systolic pressure • Palpate the brachial artery with the fingertips • Close the valve on the bulb • Pump up the cuff until you no longer feel the brachial pulse. • Release the pressure completely in the cuff, and wait 1 to 2 minutes before making further measurements. 7. Position the stethoscope appropriately. • Cleanse the earpieces with antiseptic wipe • Insert the ear attachment of the stethoscope in your ears so that they tilt slightly forward. • Ensure the stethoscope hangs freely from the ears to the diaphragm. • Place the bell side of the amplifier of the stethoscope ove the brachial pulse site • Place the stethoscope directly on the skin, not on clothein over the site. • Hold the diaphragm with the thumb and index finger 8. Auscultate the client’s blood pressure. • Pump u the cuff until the sphygmomanometer reads 30 mm Hg above the point where the brachial pulse disappeared. • Release the valve on the cuff carefully so that the pressure decreases at the rate of 2 to 3 mm hg per second • As the pressure fall, identify the manometer reading at Kortkoff phases I,IV, and V • Deflate the cuff rapidly and completely • Wait 1 to 2 minutes before making further determination • Repeat the above steps to confirm the accuracy of reading especially if it falls outside the normal range • If this is the clients; initial examination repeat the procedure on the client’s other arm. There should be a difference of no more than 10mm Hg between the arms. 7. Identify the steps in performing aseptic hand washing and clean gloving 1. If you are washing your hands where the client can observe you, introduce yourself and explain the client what you are going to do and why it is necessary. 2. Turn on the water and adjust the flow • Adjust the flow so that the water is warm

3. Wet the hands thoroughly by holding them under the running water and apply soap to the hands. • Hold the hands lower than the elbows so that the water flows from the arms to the fingertips • If the soap is liquid apply 2 to 4 ml (1 tsp) if it is bar soap, granules, or sheets, rub them firmly between the hands. 4. Thoroughly wash and rinse the hands. • Use firm, rubbing and circular movements to wash the palm, back and wrist of each hand. Be sure to include the heel of the hand. Interlace the finger and thumbs, and move the hands back and forth • Rub the fingertips against the palm of the opposite hand. • Rinse the hands. 5. Thoroughly pat dry the hands and arms. • Dry hands and arms thoroughly with paper towel without scrubbing • Discard the paper towel in the appropriate container 6. Turn off the water. • Use a new paper towel to grasp a hand –operated control Donning and removing sterile gloves (Open Method) 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol 2. observe other appropriate infection control procedure 3. Provide for client privacy 4. Open the package of sterile gloves • Place the package of gloves on a clean, dry surface • Some gloves are packed in an inner as well as an outer package. Open the outer package without contaminating the gloves or the inner package • Remove the inner package from the outer package • Open the inner package as in according to the manufacture direction. If no tabs are provided pluck the flap so that the fingers do not touch the inner surface. 5. Put the fist glove on the dominant hand • Gloves are packaged so that they lie side by side, grasp the glove for the dominant hand by it s folded cuff edge with the thumb and first finger of the nondominant hand . Touch only the inside of the cuff. • Insert the dominant hand into the glove and pull the glove on. keep the thumb of the inserted hand against the palm of the during insertion.

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Leave the cuff in place once the unsterile hand releases the glove.

6. Put the second glove on the nondominat hand. • Pick up the other glove with the sterile gloved hand, inserting the gloved fingers under the cuff and holding the gloved thumb close to the gloved palm • Pull on the second glove carefully. Hold the thumb of the gloved first hand as far as possible from the palm • Adjust each glove so that it fits smoothly, and carefully pull the cuffs up by sliding the fingers under the cuffs 7. Remove and dispose of used gloves. • There is no technique for removing sterile gloves that is different from removing unsterile gloves. If they are soiled with secretions, remove them by turning them inside out 8. Differentiate between medical asepsis and surgical asepsis. Asepsis is the freedom from disease-causing microorganism. To decrease the possibility of transferring microorganisms from one place to another. 2 Type of Asepsis: • Medical Asepsis- includes all practices intended to confine a specific microorganism to a specific area, limiting the number, growth, and transmission of microorganism. In medical asepsis, objects are referred to as clean, which means the absence of almost all microorganisms, or dirty (soiled, contaminated), which means likely to have microorganisms, some of which may be capable of causing infection. • Surgical asepsis, or sterile technique,- refers to those practices that keep an area or object free of all microorganisms: it includes practices that destroy all microorganisms and spores(microscopic dormant structures formed by some pathogens that are very hardy and often survive common cleaning techniques) 9. Describe the chain of infection barriers to infection, the body’s natural defenses and conditions that predispose a client to infection Chain of infection Six : a. Etiologic agent- microorganism is capable of producing and infection process depends on the number of microorganisms present. b. Reservoir- or sources of microorganisms. Common sources are other humans, the client’s own microorganisms, plants, animals, or the general environment. People are the most common source of infection for other and for themselves.

c. Portal of exit from Reservoir- before an infection can establish itself in a host; the microorganisms must leave the reservoir. Common human reservoirs : nose or mouth through sneezing, coughing, breathing, or talking. (Respiratory tract). Mouth; saliva, vomitus;anus;feces; ostomies (gastrointestinal tract) Anus, feces, colostomies,Urethral meatus and urinary diversion(Urinary tract). Vagina; vaginal discharge; urinary meatus semen urine(Reproductive tract) Open wound needle puncture site, any disruption of intact skin or mucous membrane surfaces. (blood) Drainage from cut or wound(tissue) d. Method of transmission- After a microorganism leaves its source or reservoir. Three meachanisms: 1. direct transmission-involves immediate and direct transfer of microorganisms from person to person through touching, biting, kissing, or sexual intercourse. 2. Indirect transmission- may be either vehicle-borne or vectorborne. • Vehicle-borne-is any substance that serves as an intermediate means to transport and introduce an infection agent into a susceptible host through suitable portal of entry. Fomites (inanimate material or objects, such as handkerchiefs, toys , soiled, clothes, cooking or eating utensils, and surgical instruments or dressings, can act as vehicles. • Vector-borne transmission-vector is an animal or flying or crawling insect that serves as an intermediate means of transporting the infectious agent. Airborne transmission- may involve droplets or dust. e. Portal of Entry to the susceptible Host- Before a person can become infected, microorganisms must enter the body. The skin is a barrier to infectious agents; however, any break in the skin can readily serve as a portal of entry. f. Susceptible Host- is any person who is at risk for infection a compromised host is a person at increased risk, an individual who for one or more reasons is more likely than others to acquire an infection (age) 10. Compare and contrast standard precautions, precautions for compromised clients and transmission-based precautions. Standard Precautions- are used in the care of all hospitalized persons regardless of their diagnosis or possible infection status. They apply to blood, all body fluids, secretions, and excretions except sweat(whether or not blood is present or visible) nonintact skin and mucous membranes. Combine the major features of Universal precautions and body substance isolation.

Transmission- based Precaution-This is used in addition to standard precautions for clients with known or suspected infections that are spread in one of the three ways; Airborne or droplet transmission or by contact. Compromised Clients- those highly susceptible to infection are often infected by their own microorganisms, by microorganisms on the inadequately cleansed hands of halth care personnel, and by nonsterile items.(food, water, air, and client care equipment. (leukemia, major burns, ) 11. Describe the nursing considerations related to standard precautions Initiation of practices to prevent the transmission of microorganisms is generally a nursing responsibility and is based on a comprehensive assessment of the client. This assessment takes into account the status of the client’s normal defense mechanisms, the client ability to implement necessary precautions, and the source and mode of transmission of the infection precaution, and the source and mode transmission of the infection agent. The nurse then decides whether to wear gloves, gowns, masks, and protective eyewear. In all client situations, nurses must cleanse their hands before and after giving care. 12. Discuss the principles and practice of surgical asepsis that pertain to donning a sterile gown and gloves. 13. Identify the components that are part of providing a safe environment Safe environment: • Age and evelopment • Lifestyle • Mobility and health status • Sensory-perceptual alterations • Cognitive awareness, psychosocial state • Ability to communicate, • Safety awareness • Environmental safety 14. Identify various environmental safety concerns for clients. Home-well maintained flooring and carpets and nonskid bathtub or shower surface, functioning smoke alarms. Outdoor- swimming pools safely secured and maintained. Adequate lighting, both inside and out will minimize the potential for accidents.

Workplace- machinery, industrial belts and pulleys, and chemical may create danger. Worker fatigue, noise and air pollution, or working at great heights or in subterranean areas may also create occupational hazards. Community- Adequate street lighting, safe water and sewage treatment, and regulation of sanitation in food buying and handling all contribute to healthy, hazard-free community. Health care setting - Medication errors, wrong site surgery, and restraint related injuries or death falls burns pressure ulcers and mistaken identity . 15. Describe the steps in making an occupied, unoccupied and surgical bed. Ref to page 788-793 16. Compare and contrast the various types of baths that con be administered to meet the hygienic needs of a variety of clients. Cleaning baths: 1. Complete bed bath- washes the entire body of the client in bed 2. Self-help bed bath- Clients confined to bed are able to bathe themselves with help from the nurse for washing the back and perhaps the feet 3. Partial bath- only the parts of the clients; body that might cause discomfort or odor, if neglected are washed; the face, hands, axillae, perineal areas, and back. Omitted are the arms chest abdomen, legs and feet. 4. Bag bath- commercially prepared product that contains 10-12 presoaked disposable washcloths that contain no rinse cleanser solution. The package is warmed in a microwave. Is about 1 minute. 5. Tub bath-are often preferred to bed baths because it is easier to wash and rinse in a tub. Tubs are also used for therapeutic baths. 6. Shower-Many ambulatory clients are able to use shower facilities and require only minimal assistance for the nurse. Therapeutic bath- given for physical effects, such as to soothe irritated skin or a treat an area. Medications may be placed in the water. 17. Identify the steps of the nursing process used in relation to providing bath care, especially assessment of skin integrity 18. Differentiate between morning care and evening care.

Morning care – is often provided after clients have breakfast, although it may be provided before bath or shower, perineal care, back massages, or oral, nail, and hair care. Making the client’s bed is part of morning care. Evening care – is provided to clients before they retire for the night. It usually involves providing the elimination needs, washing face and hands, giving oral care, and giving a back massage. 19. Identify the components that need to document with bathing and bed making. 1. 2. 3. 4. 5.

Bed lowest position side rails up or down Patients tolerance during bath Noted any skin abrasions, pressure ulcers call bell within reach