Chapter 7Basic Nursing Skills

Guidelines for Admission

◦ Prepare the roomAdmit kit

◦ Introduce self

◦ Explain mealtimes, schedules of activities

◦ Help put items away, ask resident where…

Make introductions, fill out paperwork (belongings checklist)

Handle possessions with care, it’s a resident right.

Admission, Discharge, Transfer

Vital signs Height and weight Mood Any abnormal breathing, skin color c/o pain…where, what kind Pressure ulcers…very important to

document upon admit.

Baseline status - Admission

Pack belongings Resident may want to help Bring to new area Help put some things away, if needed Give call light to resident Inform new CNA that resident is in room

Transfer

Pack belongings Make sure resident is leaving with

everything they came with. Reassure resident that doctor feels he/she is

ready to go home. Accompany resident to car, make sure

safely in. Report to nurse time of discharge.

Discharge

BP Temp – different thermometers

◦ Oral, tympanic, rectal, axillary, temporal

Respirations – inspiration/expiration = 1 breath

Pulse/Heart rate Pain level – rating scale

Vital Signs

Definition – physical or chemical way to restrict movement or behavior

Bed rails considered restraint in NH Restraints used as last resort, need an MD

order. Restraint alternatives used instead:

◦ 1 to 1 CNAs◦ Alarms – chair, bed

If restrained, needs frequent checking

Restraints

Needs to be measured◦ Intake – food/fluids during meals◦ Output – urine, emesis, wound drainage, may not

be required for measurement Conversions – 30 ml = 1 ounce

◦ 240 ml – 8 oz, usual glass of fluid, cup of coffee

Fluid balance

Urine – clean catch, midstream Voiding – urinating Process for specimen collection – pg

187/188 Stool specimen – pg 189/190

◦ Reasons for collecting

Specimen collection

Urinary Retention catheters Condom Catheter Indwelling Straight Catheter Care – one of our skills Emptying drainage bag

Catheters

Used to treat breathing problems◦ Cannula◦ Concentrator◦ Tank◦ In hospital, on wall◦ CNAs may adjust cannula, BUT, not within scope

of practice to stop or adjust dose.◦ Very flammable…should know how to turn off!

Oxygen

Report redness, swelling, c/o pain Report alarms Report problems with IV tubing, kinks, bag

almost empty. Do not take blood pressure on arm with IV.

IV (intravenous) sites

Similar to school set-up◦ Electric or manual bed◦ Overbed table◦ Bedside table◦ Privacy curtain

Closed bed – Blankets in place, neat Open bed – Blankets down

Resident’s unit

Sterile vs non-sterile

Nurses change dressings on wounds that are draining.

CNAs can change dressings if wound is closed, dry

Dressings