UNIT-K

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NURSING SKILLS

• UNIT-K

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Objectives

• 2H11 Apply patient care skills in a clinical
  setting.
• 2H11.01 Position, turn and transfer patients.
• 2H11.02 Make a bed.
• 2H11.03 Administer personal care and apply
  restraints.

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Unit K Outline

• Position, turn, and transfer patients
• Normal body alignment
• Decubitus ulcer
• Contracture
• Supports
• Dangling
• Mechanical Lifts
• Moving the Patient up in bed
• Turning the patient
• Transferring to a chair or wheelchair
• Transferring to stretcher (conscious patient)
• Transferring to stretcher (unconscious patient)

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Terminology

• Alignment
• Bed Cradle
• Catheter
• Closed Bed
• Complete Bed Bath
• Contracture
• Dangling
• Decubitus ulcer
• Defecate
• Dehydration
• Edema
• Fanfolding
• Intake and output
• Mechanical lifts
• Micturate

• Midstream specimen
• Mitered corners
• Occult Blood
• Open Bed
• Oral hygiene
• Partial bed bath
• Personal hygiene
• Restraints
• Stool specimen
• Suppository
• 24-hour urine specimen
• Urinal
• Urinary-drainage unit
• Urinate
• Urine specimen
• Void

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Positioning, Turning, Moving and Transferring
Patients

• Must use correct body mechanics
• Alignment - Positioning body parts in relation to
  each other to maintain correct body posture
• Correct alignment helps patient feel comfortable
  prevents fatigue, decubitus ulcers and
  contractures

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Decubitus Ulcer

• 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

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Decubitus Ulcer cont.

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

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WARNING!!!

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

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Prevent Decubitus Ulcers by

• 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.
• Linen dry and free from wrinkles.
• Use of pressure-relieving surfaces.
• Turn patients every 2 hours.

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Contractures

• 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

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Contractures

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

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Turning, Moving Transferring

• 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

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Mechanical Lifts

• Used to transfer weak or paralyzed patients.
• Be sure you have been
• instructed on proper use.
• Reassure patient during
• Transfer.

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Turning, Moving, andTransferring Cont.

• Be sure to protect patient and health care worker
• Be sure you know how to operate the
  wheelchair/stretcher
• Lock the wheels

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When turning transferring

• 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.

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Moving the Patient up in Bed

1. Lower the head of the bed
2. Place the pillow against the bed frame to protect
   the patients head.
3. If patient has trouble breathing, raise the head
   of the bed.
4. Ask the patient to flex the knees brace the
   feet on bed.

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Moving the Pt. Up in Bed

• 5. Place one arm under the patients head
  shoulders.
• 6. If the patient is unable to help, get someone
  to assist you.
• 7. Get a broad base of support as close to the
  bed as possible.
• 8. Arrange a signal On the count of three,
  push with your feet.
• 9. On the signal, shift your weight forward.
• 10. Two people can use a draw sheet or lift sheet.

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Turning the Patient

• Lower the side rail nearest you be sure the
  opposite side is up.
• If the patient is lying in the center of the bed,
  place hands under the patients head shoulders
  slide the patient toward you.
• Place both hands under the hips side the hips
  toward you.

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Turning the Patient

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

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Bedmaking

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

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Mitered Corners

• Used to hold linens in place.

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Bedmaking

• Occupied Bed
• Bed made while patient is in it.
• Bed with Cradle
• Cradle is placed under top sheets to prevent
  linen from touching parts of the patients body.
  Used for patients with burns, skin ulcer, blood
  clots, fractures other similar conditions.

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Bedmaking Tips

• 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 place in
  hamper immediately.

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Bedmaking Tips Cont.

• 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.

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Oral Hygiene

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

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Routine Oral Hygiene

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

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Denture Care

• Proved privacy for the patient.
• Have patient remove dentures if able too.
• Place dentures in a denture cup to carry to sink.
• Use warm water to clean dentures.
• Hold dentures securely. Let pt rinse mouth and
  brush gums.
• Store dentures in a denture cup labeled with the
  patients name.

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Special Oral Hygiene

• Usually given to unconscious or semiconscious
  patients.
• Tell the patient what you are
• doing.
• Tell patient what you are doing.
• Turn patients head toward
• You.
• Use a very small amount of liquid.
• Clean all areas of mouth
• Teeth, Gums, Tongue
• roof of Mouth.
• Apply lubricant to tongue and lips.

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Types of Baths

• Complete Bed Bath (CBB)
• Pt. is usually confined to bed the health
• care worker must bathe all parts of the
• patients body. 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.

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Mitten Wash Cloth

• Use standard precautions
• Provide privacy, comfort, and safety
• Fill basin 2/3 full with warm water at a
  temperature of 105 - 110F
• Form a mitten around your hand with the cloth.

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Partial Bed Bath

• Patient washes some
• of the parts of their
• body the health
• care worker washes
• the part of the body
• the patient cannot
• Reach.

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Tub Bath or Shower

• Health care worker prepares the tub
• or shower area assists patients as
• needed. Usually require a physicians
• 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 patients into the tub or shower (Use the
  shower chair for patients who cannot stand).
• Assist patients as needed.
• Stay with patients or make sure patients can use
  the emergency call system.
• After bath or shower, cover patient with a towel
  or bath blanket.
• Clean the tub or shower with a disinfectant after
  each use.

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Measuring and Recording Intake and Output

• Amount of fluid taken into the body should equal
  the amount of fluid lost from the body.
• Excessive fluid retained by body edema
  (swelling)

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Measuring and Recording Intake and Output

• Excessive fluid lost by body Dehydration
• What do you measure?
• Intake/Output
• Oral intake
• Bowel output
• IVs
• Emesis (vomit)
• Irrigation
• Urine

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Intake

• 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)

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Measuring Intake

• 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 bowel of chicken broth (1 soup
  bowl200cc), 4 soda crackers, 1 cup of tea, ¾
  carton of milk (1carton8 oz), ½ bowel of jell-o
  (1 small bowl120cc)
• What was Freds fluid intake?

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Measuring Intake

• Freds Intake is.

460 cc
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Measuring Output

• Output all fluids eliminated by the pt.
• BM
• Liquids BMs are measured recorded.
• Solid or formed BM is usually noted under feces
  or the remarks column.
• Emesis
• Measure anything that is vomited.
• Also note color, type, and other facts in the
  remarks column.

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Measure Output

• 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.

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Measuring Output

• Irrigation
• Measure any drainage from nasogastric tubes,
  hemo-vacs, chest tubes or other drainage tubes.
• These measurements are usually done by the nurse.

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Measuring Output

• Jennifer is on I O. At the end of an 8 hour
  shift, you note the following
• - 0800 (800AM) she voided 400 cc of urine
• - 1000 (1000AM) she vomited 200 cc of thick
  yellow emesis with food particles in it.
• - 1130 (1130AM) she had one formed green BM
• - 1315 (115PM) she voided 350 cc of urine
• What was Jennifers output for the 0700-1500
  shift?

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Measuring Output

• Jennifers Output is.

750 cc
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Feeding the Patient

• 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 patient in a sitting position if
  allowed.
• Wash patients hands face.

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Feeding

• Put over bed table in position.
• Check to make sure the pt. is not NPO.
• Make sure the diet is correct.
• Place a towel or napkin under patients chin.
• Open packages cartoons season cut foods if
  necessary.

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Steps for feeding patient

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

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Steps for Feeding Patients

• Alternate the foods liquids.
• Allow the patient to help as much as possible.
• Offer choices.
• Wipe the their mouth as necessary.
• Encourage to eat as much as possible.

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After the Meal

• Allow patient to wash their face hands.
• Provide oral hygiene
• Position in correct body alignment.
• Clean area
• Note how much food was eaten.
• Calculate I O if this is ordered.

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Bed Pans Urinals
Standard bedpan

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

Fracture or orthopedic bedpan
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Assisting with a Bedpan

• Use standard precautions wear gloves.
• Provide privacy
• Warm bedpan by running warm water over it.
• There are two positions to place the pan under
  the patient.
• 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.

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Assisting with a Bedpan

• The buttock should rest on the rounded portion of
  the pan.
• Place call bell tissue within the patients
  reach.
• Raise side rail before leaving the patient.

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When Done

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

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Assisting with Urinal

• Use standard Precautions wear gloves.
• Provide privacy
• Assist with placement of the urinal if needed.
• Leave the call bell toilet tissues in reach.
• Answer the call bell immediately.

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When finished

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

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• NEVER EMPTY A BEDPAN OR AN URINAL UNTIL YOU
  CHECK TO SEE IF A SPECIMEN IS NEEDED!!!!!!

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Restraints

• May be used only to protect patients from harming
  themselves or others.
• Must have doctors order to use restraints.
• Conditions that may require restraints
• Irrational or confused
• Skin conditions
• Paralysis or limited muscular conditions

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Restraints

• Types of restraints
• Straps or safety belts
• Limb restraints
• Leather Cuffs or locks
• Restraint jackets
• Restraint applied
• unnecessarily false
• imprisonment

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When using restraints

• Use only when other alternatives fail.
• Allow pt. to move as much as possible.
• Always tell pt. why they are being restrained.
• Reassure pt. frequently.
• Check circulation below limb restraints every 15
  minutes.
• All restraints must be removed every 2 hours and
  skin color care given.

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Complications from Restraints

• Physical and mental frustration
• Impaired circulation
• Decubitus ulcers
• Loss of muscle tone
• Joint stiffness
• Respiratory or breathing problems

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Ankle Wraps

• Under wrap is used to protect the skin.
• When taping an ankle the anchor is the first
  piece of tape to go a around the ankle.
• To apply a bandage and adhesive tape, consult
  your doctor. The ankle shouldnt be wrapped so
  tightly that the blood flow is cut off.

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Under wrap
Ace bandage