Basic Nursing Care and Patient Hygiene
This domain tests the routine bedside skills that keep a patient clean, safe, comfortable and free of complications: vital signs, positioning, hygiene and skin care.
Vital signs
Temperature (oral 3 minutes, axillary 5 minutes), pulse, respiration, blood pressure and SpO2. For blood pressure the cuff bladder should encircle about 40% of the arm circumference and cover two-thirds of the upper-arm length, placed 2 cm above the cubital fossa with the arm at heart level. Record on the TPR chart with date and time.
Positions and their uses
Supine (routine), prone (pressure relief, respiratory drainage), lateral, Sims' (enema, unconscious patient), Fowler's at 45–60° (breathlessness, feeding), semi-Fowler's, Trendelenburg (shock), lithotomy (gynaecological examination).
Hygiene care
Bed bath, oral care, hair and nail care, back care and perineal care. For an unconscious patient, oral care uses swabs or suction - never pour water into the mouth. Perineal care is always from front to back. Change linen when soiled and keep the skin dry.
Pressure ulcers
Stage I is non-blanchable erythema of intact skin; Stage II is partial-thickness loss or a blister; Stage III extends to subcutaneous tissue; Stage IV reaches muscle, tendon or bone. Prevention: two-hourly repositioning, air or water mattress, dryness, adequate protein and calories, and inspection at every turn.
Worked example
A bedridden patient has a red patch on the heel that does not turn pale when pressed. Reasoning: intact skin with non-blanchable erythema is Stage I, not an open wound. Action: relieve pressure, use a pillow or offloading device, keep the area clean and dry, document, and never massage the reddened area.
Traps that cost marks
Massaging reddened skin; calling Stage I an ulcer with skin loss; recording temperature without the site; using too small a BP cuff, which falsely raises the reading.