1. 1. Explain the importance of monitoring vital signs
Define the following term:
Vital signs

2. 1. Explain the importance of monitoring vital signs
Vital signs consist of:
Taking temperature
Counting pulse
Counting rate of respirations
Taking blood pressure
Observing and reporting pain level

3. 1. Explain the importance of monitoring vital signs
When monitoring vital signs, it is important to tell the nurse the following:
Resident has a fever
Respiratory or pulse rate is too rapid or too slow
Changes in blood pressure
Pain is worsening or unrelieved

4. Transparency 17-1 Normal Ranges for Vital Signs
Temperature Fahrenheit Celsius
Oral ° ° 36.5° °
Rectal ° ° 37.0° °
Axillary 96.6° ° 36.0° °
Pulse: beats per minute
Respirations: respirations per minute
Blood Pressure
Normal:
Systolic 100 – 119 mm Hg Diastolic 60 – 79 mm Hg
Prehypertension:
Systolic 120 – 139 mm Hg Diastolic 80 – 89 mm Hg
High:
140/90 mm Hg or above

5. 2. List guidelines for taking body temperature
Define the following term:
Circadian rhythm

6. 2. List guidelines for taking body temperature
The following points about body temperature are important:
Normal ranges and variations are listed on p. 245 in textbook.
Age, illness, stress, environment, exercise, and the circadian rhythm all affect temperature.
There are four sites: oral, rectal, tympanic, and axillary.

7. 2. List guidelines for taking body temperature
The following points about body temperature are important (con’t.):
Oral temperatures cannot be taken on someone who is unconscious; is using oxygen; is confused or disoriented; is paralyzed; has facial trauma; is likely to have a seizure; has a nasogastric tube; is younger than six years old; has sores, redness, swelling, or pain in her mouth; or has an injury to the face or neck.

8. 2. List guidelines for taking body temperature
The following points about body temperature are important (con’t.):
Rectal temperatures are most accurate; axillary temperatures are the least accurate.
Mercury-free thermometers are safer than glass thermometers. They are becoming more common.
Mercury-free thermometers and glass thermometers operate identically. Glass thermometers must be shaken down.

9. 2. List guidelines for taking body temperature
The following points about body temperature are important (con’t.):
Digital thermometers are commonly used for oral, rectal, and axillary temps.
Tympanic thermometers are fast and accurate.
All thermometers must be cleaned between residents, or protective covers must be used.

10. Taking and recording oral temperature
Do not take an oral temperature on a resident who has smoked, eaten or drunk fluids, or exercised in the last 10–20 minutes.
Equipment: mercury-free, glass, digital, or electronic thermometer, disposable plastic sheath/cover for thermometer, tissues, pen and paper
Wash your hands.
Identify yourself by name. Identify the resident by name. 10

11. Taking and recording oral temperature
Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.
Provide for the resident’s privacy with curtain, screen, or door.
If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels. 11

12. Taking and recording oral temperature
Using a mercury-free or glass thermometer:
Hold the thermometer by stem.
Before inserting thermometer in resident’s mouth, shake thermometer down to below the lowest number (at least below 96°F or 35°C). To shake thermometer down, hold it at the side opposite the bulb with the thumb and two fingers. 12

13. Taking and recording oral temperature
7. (con't.) With a snapping motion of the wrist, shake the thermometer (Fig. 17-6). Stand away from furniture and walls while doing so.
Fig 13

14. Taking and recording oral temperature
Put a disposable sheath on thermometer, if applicable. Insert bulb end of thermometer into resident’s mouth. Place under tongue and to one side (Fig. 17-7). Resident should breathe through his or her nose.
Tell resident to hold oral thermometer in mouth with lips closed. Help as necessary. Ask the resident not to bite down or to talk.
Fig 14

15. Taking and recording oral temperature
Leave thermometer in place for at least three minutes.
Remove the thermometer. Wipe with tissue from stem to bulb or remove sheath. Dispose of tissue or sheath.
Hold thermometer at eye level. Rotate until line appears. Roll the thermometer between your thumb and forefinger. 15

16. Taking and recording oral temperature
12. (con't.) Read temperature. Record temperature, date, time, and method used (oral).
Rinse the thermometer in lukewarm water. Dry. Return it to plastic case or container. If using a mercury/glass thermometer, store it away from a heat source. 16

17. Taking and recording oral temperature
Using a digital thermometer:
Put a disposable sheath on thermometer.
Turn on thermometer. Wait until “ready” sign appears.
Insert end of digital thermometer into resident’s mouth. Place under tongue and to one side. 17

18. Taking and recording oral temperature
Leave in place until thermometer blinks or beeps.
Remove the thermometer.
Read temperature on display screen. Record the temperature, date, time, and method used (oral).
Using a tissue, remove and dispose of sheath.
Replace thermometer in case. 18

19. Taking and recording oral temperature
Using an electronic thermometer:
Remove probe from base unit.
Put probe cover on thermometer.
Insert end of electronic thermometer into resident’s mouth. Place under tongue and to one side. 19

20. Taking and recording oral temperature
Leave in place until you hear a tone or see a flashing or steady light.
Read the temperature on the display screen.
Remove the probe. Press the eject button to discard the cover (Fig. 17-8).
Record temperature, date, time, and method used (oral).
Return the probe to the holder.
Fig 20

21. Taking and recording oral temperature
Final steps:
14. Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs.
15. Return bed to appropriate position. Remove privacy measures.
16. Before leaving, place call light within resident’s reach. 21

22. Taking and recording oral temperature
17. Wash your hands.
18. Report any changes in the resident to the nurse.
19. Document procedure using facility guidelines. 22

23. 2. List guidelines for taking body temperature
The following points about taking a rectal temperature are important:
Mercury-free, digital, or glass thermometers can be used.
NA must explain what he or she will do before starting.
Be reassuring.
NA must hold on to the thermometer at all times.
Gloves must be worn.

24. 2. List guidelines for taking body temperature
The following points about taking a rectal temperature are important (con’t.):
Thermometer must be lubricated for this procedure.
The privacy of the resident is important.

25. Taking and recording rectal temperature
Equipment: rectal mercury- free, glass, or digital thermometer, lubricant, gloves, tissue, disposable sheath/cover, pen and paper
Wash your hands.
Identify yourself by name. Identify the resident by name. 25

26. Taking and recording rectal temperature
Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.
Provide for resident’s privacy with curtain, screen, or door.
If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels. 26

27. Taking and recording rectal temperature
Help the resident to the left-lying (Sims’ position) (Fig. 17-9).
Fold back linens to expose only rectal area.
Put on gloves.
Fig 27

28. Taking and recording rectal temperature
Mercury-free or glass thermometer: Hold thermometer by stem.
Digital thermometer: Apply probe cover.
Mercury-free or glass thermometer: Shake the thermometer down to below the lowest number.
Apply small amount of lubricant to tip of bulb or probe cover (or apply pre-lubricated cover). 28

29. Taking and recording rectal temperature
Separate the buttocks. Gently insert thermometer one inch into rectum (Fig ). Stop if you meet resistance. Do not force the thermometer into rectum.
Replace sheet over buttocks. Hold on to the thermometer at all times.
Fig 29

30. Taking and recording rectal temperature
Mercury-free or glass thermometer: Hold thermometer in place for at least three minutes.
Digital thermometer: Hold thermometer in place until thermometer blinks or beeps. 30

31. Taking and recording rectal temperature
Gently remove the thermometer. Wipe with tissue from stem to bulb or remove sheath. Dispose of tissue or sheath.
Read the thermometer at eye level as you would for an oral temperature. Record temperature, date, time, and method used (rectal). 31

32. Taking and recording rectal temperature
Mercury-free or glass thermometer: Rinse the thermometer in lukewarm water. Dry it. Return it to plastic case or container. If using a mercury/glass thermometer, store it away from a heat source.
Digital thermometer: Throw away probe cover. Return thermometer to storage area. 32

33. Taking and recording rectal temperature
Remove and dispose of gloves.
Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs.
Return bed to appropriate position. Remove privacy measures.
Before leaving, place call light within resident’s reach.
Wash your hands. 33

34. Taking and recording rectal temperature
Report any changes in resident to the nurse.
Document procedure using facility guidelines. 34

35. 2. List guidelines for taking body temperature
The following points about tympanic and axillary temperatures are important:
Tympanic thermometers are fast and accurate.
The tympanic thermometer will only go into the ear 1/4 to 1/2 inch.
Axillary temperatures are much less reliable.

36. Taking and recording tympanic temperature
Equipment: tympanic thermometer, disposable sheath/cover, pen and paper
Wash your hands.
Identify yourself by name. Identify the resident by name.
Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 36

37. Taking and recording tympanic temperature
Provide for resident’s privacy with curtain, screen, or door.
If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels.
Put a disposable sheath over earpiece of the thermometer. 37

38. Taking and recording tympanic temperature
Position the resident’s head so that the ear is in front of you. Straighten the ear canal by pulling up and back on the outside edge of the ear (Fig ). Insert the covered probe into the ear canal. Press the button.
Fig 38

39. Taking and recording tympanic temperature
Hold thermometer in place until thermometer blinks or beeps.
Read temperature. Record temperature, date, time, and method used (tympanic).
Dispose of sheath. Return the thermometer to storage or to the battery charger if thermometer is rechargeable. 39

40. Taking and recording tympanic temperature
Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs.
Return bed to appropriate position. Remove privacy measures.
Before leaving, place call light within resident’s reach.
Wash your hands. 40

41. Taking and recording tympanic temperature
Report any changes in the resident to the nurse.
Document procedure using facility guidelines. 41

42. Taking and recording an axillary temperature
Equipment: mercury-free, glass, digital, or electronic thermometer, tissues, disposable sheath/cover, pen and paper
Wash your hands.
Identify yourself by name. Identify the resident by name. 42

43. Taking and recording an axillary temperature
Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.
Provide for resident’s privacy with curtain, screen, or door.
If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels. 43

44. Taking and recording an axillary temperature
Remove resident’s arm from sleeve of gown. Wipe axillary area with tissues.
Using a mercury-free or glass thermometer:
Hold thermometer at stem end. Shake down to below the lowest number.
Put disposable sheath on thermometer, if applicable. 44

45. Taking and recording an axillary temperature
Place bulb end of thermometer in center of armpit. Fold resident’s arm over chest.
Hold in place, with the arm close against the side, for 10 minutes (Fig ).
Fig 45

46. Taking and recording an axillary temperature
Remove the thermometer. Wipe with tissue from stem to bulb or remove sheath. Dispose of tissue or sheath.
Hold thermometer at eye level. Rotate until line appears. Read temperature. Record temperature, date, time, and method used (axillary).
Clean thermometer and/or return it to container for used thermometers. 46

47. Taking and recording an axillary temperature
Using a digital thermometer:
Put on disposable sheath. Turn on thermometer. Wait until “ready” sign appears.
Position end of digital thermometer in center of armpit. Fold resident’s arm over chest.
Hold in place until thermometer blinks or beeps. 47

48. Taking and recording an axillary temperature
Remove the thermometer.
Read temperature on display screen. Record the temperature, date, time, and method used (axillary).
Using a tissue, remove and dispose of sheath.
Replace thermometer in case. 48

49. Taking and recording an axillary temperature
Using an electronic thermometer:
Remove prove from base unit. Put on probe cover.
Position end of electronic thermometer in center of armpit. Fold resident’s arm over chest.
Leave in place until you hear a tone or see a flashing or steady light.
Read the temperature on the display screen. 49

50. Taking and recording an axillary temperature
Remove the probe. Press the eject button to discard the cover.
Record temperature, date, time, and method used (axillary).
Return the probe to the holder. 50

51. Taking and recording an axillary temperature
Final steps:
Put resident’s arm back into sleeve of gown. Make resident comfortable. Make sure sheets are free from wrinkles and the bed free from crumbs.
Return bed to appropriate position. Remove privacy measures.
Before you leave, place call light within resident’s reach. 51

52. Taking and recording an axillary temperature
Wash your hands.
Report any changes in resident to the nurse.
Document procedure using facility guidelines. 52

53. 3. List guidelines for taking pulse and respirations
Define the following terms:
Radial pulse
Brachial pulse
Apical pulse
Stethoscope

54. 3. List guidelines for taking pulse and respirations
The following points about the pulse are important:
Pulse is the number of heartbeats per minute.
Pulse is commonly taken at the wrist where radial artery runs.
Normal rate is beats per minute for adults.
Slow/weak pulse may indicate dehydration, infection, or shock.

55. Taking and recording apical pulse
Equipment: stethoscope, watch with second hand, alcohol wipes, pen and paper
Wash hands.
Identify yourself by name. Identify the resident by name.
Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 55

56. Taking and recording apical pulse
Provide for resident’s privacy with curtain, screen, or door.
If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels. 56

57. Taking and recording apical pulse
Fit the earpieces of the stethoscope snugly in your ears. Place the flat metal diaphragm on the left side of the chest, just below the nipple (Fig ). Listen for the heartbeat.
Fig 57

58. Taking and recording apical pulse
Use the second hand of your watch. Count beats for one full minute. Each “lubdub” that you hear is counted as one beat. A normal heartbeat is rhythmic. Leave the stethoscope in place to count respirations (see procedure later in chapter). 58

59. Taking and recording apical pulse
Record pulse rate, date, time, and method used (apical). Note any differences in the rhythm.
Clean earpieces and diaphragm of stethoscope with alcohol wipes. Store stethoscope. 59

60. Taking and recording apical pulse
Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs.
Return bed to appropriate position. Remove privacy measures.
Before leaving, place call light within resident’s reach.
Wash your hands. 60

61. Taking and recording apical pulse
Report any changes in the resident to the nurse.
Document procedure using facility guidelines. 61

62. 3. List guidelines for taking pulse and respirations
Define the following terms:
Respiration
Inspiration
Expiration

63. 3. List guidelines for taking pulse and respirations
The following points about respiration are important:
A breath includes both inspiration and expiration.
Normal rate is breaths per minute.
Do the counting immediately after taking the pulse.
Do not let the resident know you are counting breaths.

64. Equipment: watch with second hand, pen and paper Wash your hands.
Taking and recording radial pulse and counting and recording respirations
Equipment: watch with second hand, pen and paper
Wash your hands.
Identify yourself by name. Identify the resident by name.
Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 64

65. Provide for resident’s privacy with curtain, screen, or door.
Taking and recording radial pulse and counting and recording respirations
Provide for resident’s privacy with curtain, screen, or door.
If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels.
Place fingertips on thumb side of resident’s wrist. Locate pulse (Fig ).
Count beats for one full minute.
Fig 65

66. Taking and recording radial pulse and counting and recording respirations
Keep your fingertips on the resident’s wrist. Count respirations for one full minute. Observe for the pattern and character of the resident’s breathing. Normal breathing is smooth and quiet. If you see signs of troubled breathing, shallow breathing, or noisy breathing such as wheezing, report it. 66

67. Return bed to appropriate position. Remove privacy measures.
Taking and recording radial pulse and counting and recording respirations
Record pulse rate, date, time, and method used (radial). Record the respiratory rate and the pattern or character of breathing.
Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs.
Return bed to appropriate position. Remove privacy measures. 67

68. Before leaving, place call light within resident’s reach.
Taking and recording radial pulse and counting and recording respirations
Before leaving, place call light within resident’s reach.
Wash your hands.
Report any changes in the resident to the nurse.
Document procedure using facility guidelines. 68

69. 4. Explain guidelines for taking blood pressure
Define the following terms:
Systolic
Diastolic
Hypertension
Hypotension
Sphygmomanometer

70. 4. Explain guidelines for taking blood pressure
The following points about blood pressure are important:
The two parts of the BP are systolic (top number) and diastolic (bottom number).
Normal range is: S=100 to 119; D=60 to 79 (according to newer prehypertension guidelines).
Brachial artery at the elbow is used.
Equipment used is stethoscope and sphygmomanometer.
The cuff must first be completely deflated.

71. 4. Explain guidelines for taking blood pressure
The following points about blood pressure are important (con’t.):
The one-step method does not include getting an estimated systolic before beginning. The two-step method does require getting an estimated systolic.

72. 4. Explain guidelines for taking blood pressure
It is not always easy to perfect the skill of hearing the first and last sounds of the BP. You may have to do the procedure over and over again and have an instructor or another student check technique and results for correctness.

73. Taking and recording blood pressure (one-step method)
Equipment: sphygmomanometer (blood pressure cuff), stethoscope, alcohol wipes, pen and paper to record your findings
Wash your hands.
Identify yourself by name. Identify the resident by name. 73

74. Taking and recording blood pressure (one-step method)
Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.
Provide for resident’s privacy with curtain, screen, or door.
If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels. 74

75. Taking and recording blood pressure (one-step method)
Position resident’s arm with palm up. The arm should be level with the heart.
With the valve open, squeeze the cuff. Make sure it is completely deflated. 75

76. Taking and recording blood pressure (one-step method)
Place blood pressure cuff snugly on resident’s upper arm. The center of the cuff is placed over the brachial artery (1- 1½ inches above the elbow toward inside of elbow) (Fig ).
Before using stethoscope, wipe diaphragm and earpieces with alcohol wipes.
Locate brachial pulse with fingertips.
Fig 76

77. Taking and recording blood pressure (one-step method)
Place diaphragm of stethoscope over brachial artery.
Place earpieces of stethoscope in ears.
Close the valve (clockwise) until it stops. Do not tighten it (Fig ).
Inflate cuff to 30 mm Hg above the point at which the pulse is last heard or felt.
Fig 77

78. Taking and recording blood pressure (one-step method)
Open the valve slightly with thumb and index finger. Deflate cuff slowly.
Watch gauge. Listen for sound of pulse.
Remember the reading at which the first clear pulse sound is heard. This is the systolic pressure. 78

79. Taking and recording blood pressure (one-step method)
Continue listening for a change or muffling of pulse sound. The point of a change or the point the sound disappears is the diastolic pressure. Remember this reading.
Open the valve. Deflate cuff completely. Remove cuff. 79

80. Taking and recording blood pressure (one-step method)
Record both the systolic and diastolic pressures.
Wipe diaphragm and earpieces of stethoscope with alcohol. Store equipment.
Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs.
Return bed to appropriate position. Remove privacy measures. 80

81. Taking and recording blood pressure (one-step method)
Before leaving, place call light within resident’s reach.
Wash your hands.
Report any changes in the resident to the nurse.
Document procedure using facility guidelines. 81

82. Taking and recording blood pressure (two-step method)
Equipment: sphygmomanometer (blood pressure cuff), stethoscope, alcohol wipes, pen and paper to record your findings
Wash your hands.
Identify yourself by name. Identify the resident by name. 82

83. Taking and recording blood pressure (two-step method)
Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.
Provide for resident’s privacy with curtain, screen, or door.
If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels. 83

84. Taking and recording blood pressure (two-step method)
Position resident’s arm with palm up. The arm should be level with the heart.
With the valve open, squeeze the cuff to make sure it is completely deflated. 84

85. Taking and recording blood pressure (two-step method)
Place blood pressure cuff snugly on resident’s upper arm. The center of the cuff is placed over the brachial artery (1- 1½ inches above the elbow toward inside of elbow).
Locate the radial (wrist) pulse with fingertips.
Close the valve (clockwise) until it stops. Inflate cuff, watching gauge. 85

86. Taking and recording blood pressure (two-step method)
Stop inflating when you can no longer feel the pulse. Note the reading. The number is an estimate of the systolic pressure.
Open the valve. Deflate cuff completely.
Write down the systolic reading. 86

87. Taking and recording blood pressure (two-step method)
Before using stethoscope, wipe diaphragm and earpieces of stethoscope with alcohol wipes.
Locate brachial pulse with fingertips. 87

88. Taking and recording blood pressure (two-step method)
Place diaphragm of stethoscope over brachial artery.
Place earpieces of stethoscope in ears.
Close the valve (clockwise) until it stops. Do not tighten it (Fig ).
Fig 88

89. Taking and recording blood pressure (two-step method)
Inflate cuff to 30 mm Hg above your estimated systolic pressure.
Open the valve slightly with thumb and index finger. Deflate cuff slowly.
Watch gauge. Listen for sound of pulse.
Remember the reading at which the first clear pulse sound is heard. This is the systolic pressure. 89

90. Taking and recording blood pressure (two-step method)
Continue listening for a change or muffling of pulse sound. The point of a change or the point the sound disappears is the diastolic pressure. Remember this reading.
Open the valve. Deflate cuff completely. Remove cuff. 90

91. Taking and recording blood pressure (two-step method)
Record both systolic and diastolic pressures.
Wipe diaphragm and earpieces of stethoscope with alcohol. Store equipment.
Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs.
Return bed to appropriate position. Remove privacy measures. 91

92. Taking and recording blood pressure (two-step method)
Before leaving, place call light within resident’s reach.
Wash your hands.
Report any changes in the resident to the nurse.
Document procedure using facility guidelines. 92

93. 5. Describe guidelines for pain management
The following points about pain are important:
It is as important to monitor as vital signs.
It is uncomfortable and an individual experience.
Take complaints of pain seriously.
Ask questions to get accurate information.

94. 5. Describe guidelines for pain management
The signs and symptoms of pain to observe and report are:
Increased pulse, respirations, and blood pressure
Sweating
Nausea and vomiting
Tightening the jaw
Squeezing eyes shut
Holding a body part tightly
Frowning
Grinding teeth

95. 5. Describe guidelines for pain management
The signs and symptoms of pain to observe and report are (con’t.):
Increased restlessness
Agitation
Change in behavior
Crying
Sighing
Groaning
Breathing heavily

96. 6. Explain the benefits of warm and cold applications
The following points about pain management are important:
Heat relieves pain and muscular tension, decreases swelling, elevates temperature in the tissues, and increases blood flow, bringing more oxygen and nutrients to tissues.
Cold stops bleeding, prevents swelling, reduces pain, and helps bring down high fevers.
Moisture strengthens the effect of heat and cold.
Observe area for redness, pain, blisters, or numbness.

97. Transparency 17-2 Warm and Cold Applications
Temperature
Timing
Special Considerations
Warm Compresses
105°-115°F
Remove after 20 minutes.
Cover with plastic wrap.
Warm Soaks
105°-110°F
Check temp every 5 minutes
Observe for redness. Soak minutes.
Aquamatic K-Pad
Pre-set
Tubing should not hang below bed. Check water level and refill when necessary.
Sitz bath
100°-104°F or 105°-110°F
20 minutes only
Fill 2/3 full. Provide privacy.
Ice packs
Check after 10 minutes. Remove after 20 minutes.
Fill bag 2/3 full of ice. Cover bag; watch for blisters and white or pale skin.

98. Applying warm compresses
Equipment: washcloth or compress, plastic wrap, towel, basin, bath thermometer
Wash your hands.
Identify yourself by name. Identify the resident by name.
Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 98

99. Applying warm compresses
Provide for resident’s privacy with curtain, screen, or door.
If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels. 99

100. Applying warm compresses
Fill basin one-half to two-thirds full with warm water. Test water temperature with thermometer or your wrist. Ensure it is safe. Water temperature should be no more than 105° to 110°F. Have resident check water temperature. Adjust if necessary.
Soak the washcloth in the water. Wring it out. Immediately apply it to the area needing a warm compress. Note the time.
100

101. Applying warm compresses
(con't.) Quickly cover the washcloth with plastic wrap and the towel to keep it warm (Fig ).
Check the area every five minutes. Remove the compress if the area is red or numb or if the resident has pain or discomfort. Change the compress if cooling occurs. Remove the compress after 20 minutes.
Fig
101

102. Applying warm compresses
Commercial warm compresses are also available. If you are using these, follow the package directions and the nurse’s instructions.
Place soiled clothing and linens in appropriate containers.
Empty, rinse, and wipe basin. Return to proper storage. Discard plastic wrap.
102

103. Applying warm compresses
Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs.
Return bed to appropriate position. Remove privacy measures.
103

104. Applying warm compresses
Before leaving, place call light within resident’s reach.
Wash your hands.
Report any changes in the resident to the nurse.
Document procedure using facility guidelines.
104

105. Administering warm soaks
Equipment: towel, basin, bath thermometer, bath blanket
Wash your hands.
Identify yourself by name. Identify the resident by name.
Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.
105

106. Administering warm soaks
Provide for resident’s privacy with curtain, screen, or door.
If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels.
106

107. Administering warm soaks
Fill the basin half full of warm water. Test water temperature with thermometer or your wrist. Ensure it is safe. Water temperature should be 105° to 110°F. Have resident check water temperature. Adjust if necessary.
107

108. Administering warm soaks
Immerse the body part in the basin. Pad the edge of the basin with a towel if needed (Fig ). Use a bath blanket to cover the resident if needed for extra warmth.
Check water temperature every five minutes. Add hot water as needed to maintain the temperature. Never add water warmer than 110°F.
Fig
108

109. Administering warm soaks
(con't.) To prevent burns, tell the resident not to add warm water. Observe the area for redness. Discontinue the soak if the resident has pain or discomfort.
Soak for minutes, or as ordered.
Remove basin. Use the towel to dry the resident.
109

110. Administering warm soaks
Place soiled clothing and linens in appropriate containers.
Empty, rinse, and wipe basin. Return to proper storage.
Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs.
Return bed to appropriate position. Remove privacy measures.
110

111. Administering warm soaks
Before leaving, place call light within resident’s reach.
Wash your hands.
Report any changes in the resident to the nurse.
Document procedure using facility guidelines.
111

112. Applying an Aquamatic K-Pad®
Equipment: K-Pad® and control unit (Fig ), covering for pad, distilled water
Wash your hands.
Identify yourself by name. Identify the resident by name.
Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.
Fig
112

113. Applying an Aquamatic K-Pad®
Provide for the resident’s privacy with a curtain, screen, or door.
If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels.
Place the control unit on the bedside table. Make sure cords are not frayed or damaged. Check that tubing between pad and unit is intact.
113

114. Applying an Aquamatic K-Pad®
Remove cover of control unit to check level of water. If it is low, fill it with distilled water to the fill line.
Put the cover of control unit back in place.
114

115. Applying an Aquamatic K-Pad®
Plug unit in. Turn pad on. Temperature should have been pre-set. If it was not, check with the nurse for proper temperature.
Place the pad in the cover. Do not pin the pad to the cover.
115

116. Applying an Aquamatic K-Pad®
Uncover area to be treated. Place the covered pad. Note the time. Make sure the tubing is not hanging below the bed. It should be coiled on the bed.
Return and check area every five minutes. Remove the pad if the area is red or numb or if the resident reports pain or discomfort.
116

117. Applying an Aquamatic K-Pad®
Check water level. Refill with distilled water to the fill line when necessary.
Remove pad after 20 minutes.
Clean and store supplies.
Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs.
Return bed to appropriate position. Remove privacy measures.
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118. Applying an Aquamatic K-Pad®
Before leaving, place call light within resident’s reach.
Wash your hands.
Report any changes in the resident to the nurse.
Document procedure using facility guidelines.
118

119. 6. Explain the benefits of warm and cold applications
Define the following term:
Sitz bath

120. Assisting with a sitz bath
Equipment: disposable sitz bath, bath thermometer, towels, gloves
Wash your hands.
Identify yourself by name. Identify the resident by name.
Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.
120

121. Assisting with a sitz bath
Provide for resident’s privacy with curtain, screen, or door.
Put on gloves.
Fill the sitz bath two- thirds full with warm water. Place the disposable sitz bath on the toilet seat. If the sitz bath is prescribed for cleaning the perineal area, the temperature should be 100°-104°F.
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122. Assisting with a sitz bath
6. (con't.) For pain and to stimulate circulation, the water temperature should be 105°-110°F. Check the water temperature using the bath thermometer.
Help the resident undress and get seated on the sitz bath. A valve on the tubing connected to the bag allows the resident or you to fill the sitz bath again with hot water.
122

123. Assisting with a sitz bath
You may be required to stay with the resident during the bath for safety reasons. If you leave the room, check on the resident every five minutes to make sure he or she is not dizzy or weak.
123

124. Assisting with a sitz bath
Help the resident out of the sitz bath in 20 minutes. Provide towels. Help with dressing if needed.
Clean and store supplies.
Remove gloves.
Make resident comfortable.
124

125. Assisting with a sitz bath
Before leaving, place call light within resident’s reach.
Wash your hands.
Report any changes in the resident to the nurse.
Document procedure using facility guidelines.
125

126. Identify yourself by name. Identify the resident by name.
Applying ice packs
Equipment: ice pack or sealable plastic bag and crushed ice, towel or cover for pack or bag
Wash your hands.
Identify yourself by name. Identify the resident by name.
Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.
126

127. Provide for the resident’s privacy with curtain, screen, or door.
Applying ice packs
Provide for the resident’s privacy with curtain, screen, or door.
If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels.
Fill plastic bag or ice pack one-half to two- thirds full with crushed ice. Seal bag. Remove excess air. Cover bag or ice pack with towel or cover (Fig ).
Fig
127

128. Remove ice after 20 minutes or as ordered.
Applying ice packs
Apply bag to the area as ordered. Note the time. Use another towel to cover bag if it is too cold.
Check the area after five minutes for blisters or pale, white, or gray skin. Stop treatment if resident reports numbness or pain.
Remove ice after 20 minutes or as ordered.
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129. Return bed to appropriate position. Remove privacy measures.
Applying ice packs
Store ice pack.
Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs.
Return bed to appropriate position. Remove privacy measures.
129

130. 13. Before leaving, place call light within resident’s reach.
Applying ice packs
13. Before leaving, place call light within resident’s reach.
14. Wash your hands.
15. Report any changes in the resident to the nurse.
16. Document procedure using facility guidelines.
130

131. 7. Explain how to apply non-sterile dressings
The following points about non-sterile dressings are important:
Nursing assistants do not change sterile dressings.
Non-sterile dressings are for wounds that have less chance of infection.

132. Changing a dry dressing using non-sterile technique
Equipment: package of square gauze dressings, adhesive tape, scissors, 2 pairs of gloves
Wash your hands.
Identify yourself by name. Identify the resident by name.
Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.
132

133. Changing a dry dressing using non-sterile technique
Provide for the resident’s privacy with a curtain, screen, or door.
If the bed is adjustable, adjust to a safe level, usually waist high. If the bed is movable, lock bed wheels.
Cut pieces of tape long enough to secure the dressing. Hang tape on the edge of a table within reach. Open four- inch gauze square package without touching gauze. Place the open package on a flat surface.
133

134. Changing a dry dressing using non-sterile technique
Put on gloves.
Remove soiled dressing by gently peeling tape toward the wound. Lift dressing off the wound. Do not drag it over wound. Observe dressing for any odor. Notice color and size of the wound. Dispose of used dressing in proper container. Remove and dispose of gloves.
134

135. Changing a dry dressing using non-sterile technique
Put on new gloves. Touching only outer edges of new four-inch gauze, remove it from package. Apply it to wound. Tape gauze in place. Secure it firmly (Fig ).
Remove and dispose of gloves properly.
Make resident comfortable. Make sure sheets are free from wrinkles and the bed is free from crumbs.
Fig
135

136. Changing a dry dressing using non-sterile technique
Return bed to appropriate position. Remove privacy measures.
Before leaving, place call light within resident’s reach.
14. Wash your hands.
15. Report any changes in the resident to the nurse.
16. Document procedure using facility guidelines.
136

137. 8. Discuss guidelines for non-sterile bandages
The following points about non-sterile bandages are important:
Non-sterile bandages hold dressings in place, secure splints, and support and protect body parts. They may decrease swelling from an injury.
They should be applied snug enough to control bleeding and prevent movement of dressings.
Bandage should be checked 15 minutes after first being applied.
Signs of poor circulation are swelling, bluish skin, numbness, tingling, cold skin, pain, or discomfort.

138. 9. List care guidelines for a resident who is on an IV
Define the following term:
Intravenous

139. 9. List care guidelines for a resident who is on an IV
The nursing assistant’s role in caring for a resident with an IV include:
Nursing assistants never insert or remove IV lines.
Nursing assistants do not care for the IV site.

140. 9. List care guidelines for a resident who is on an IV
Nursing assistants only observe the site for changes or problems and report if:
Needle falls out
Tubing disconnects
Dressing is loose
Blood is in tubing
Site is swollen or discolored
Resident complains of pain
IV bag breaks or fluid level does not decrease
IV not dripping or nearly gone
Pump beeps

141. 9. List care guidelines for a resident who is on an IV
Nursing assistants cannot do any of the following:
Take a blood pressure on an arm with an IV
Get the site wet
Pull on or catch the tubing on anything
Leave the tubing kinked
Lower the IV bag below the site
Touch the clamp
Disconnect IV from pump or turn off alarm