168 terms

CNA study guide

Long Term Care Centers
Designed for persons who cannot care for themselves: Medical, nursing, dietary, recreational, rehabilitative, and social services are provided
Persons in long-term care centers; Center is their permanent or temporary home; Most residents are older and have chronic diseases, poor nurtrition, or poor health; Some residents are disabled from birth defects, accidents, or diseases;
Alert, oriented residents
Resident knows who & where they are, the year, and time of day. They have physical problems. Disability level affects the amount of care required. Some require complete care, others need help with daily activities
Confused & disoriented residents
Resident is mildly to severely confused & disoriented. Some simply have trouble remembering where the dining room is, the month, or year. Others are more confused & disoriented--they do not know who or where they are. Sometimes the problem is short term. For others it is permanent and becomes worse
Complete care residents
Residents who are disabled, confused, and disoriented. They cannot meet their own needs or tell you what they need. They need to be kept clean, safe, and comfortable
Short-term residents/Respite Care
Residents who need to recover from surgery, fractures, or illnesses and regain strength & mobility to return to their former living situations. Home care-giver is given a rest.
Life-long Residents
Residents with birth defects & childhood injuries & diseases can cause disabilities such as mental retardation & Down syndrome. Person has limited function in at least 3 ares: self-care, understanding, or expressing language, learning, mobility, self-direction, independent living, & financial support. Person needs lifelong assistance, support and special services.
Developmental Disability
A disability occurring before 22 years of age; May be a physical impairment, intellectual impairment, or both
Mentally ill residents
Residents with problems coping or adjusting to stress affecting behavioral and function.
Terminally ill residents
Residents who are going to die from terminal illness (cancer, AIDS, liver/heart/kidney/respiratory disease.
Nursing Team
RN's, LPN's (LVN's), & Nursing Assistant's
Nursing Process
1) Assessment - Collects information. 2) Nursing Diagnosis - Describes health problems. 3) Planning - Setting priorities and goals. 4) Implementation - Carries out the plan (goals). 5) Evaluation - Measures if the goals of the planning step were met.
A federal health insurance program for persons 65 yrs of age or older
A health care payment program sponsored by federal & state governments
OBRA-Residents Rights
Right to all his or her information records; Right to refuse treatment; Right to privacy & confidentiality; Right to personal choice; Right to voice concerns, questions, & complaints about care; Right to not have to work for care, care items, or other things or privileges; Right to form & take part in resident & family groups; Right to keep and use personal items; Right to be free from all abuse, mistreatment, & neglect; Right to be free of restraint; Right to a quality of life that promotes dignity & self esteem; Promotes physical, psychological, and mental well-being for quality of life
Quality of Life Activities
Nursing center provides activity programs that allow personal choice. They must promote physical, intellectual, social, spiritual, & emotional well being. Religious services promote spirtual health
Quality of Life Environment
Nursing centers environment must promote quality of life by being clean, safe & as home-like as possible.
OBRA Requirements for Dignity & Privacy
1. Courteous & Dignified Interactions (right tone of voice, good eye contact, stand or sit close, use proper name & title, gain attention before interacting with resident, use touch IF person approves, respect social status, listen with interest, DO NOT yell, scold, or embarrass resident) 2. Courteous & Dignified Care (grooming, dressing, clothing is personal choice, promote independence & dignity in dining, respect private space & property, assist with walking, transfers, bathing & hygiene preferences) 3. Privacy & Self-Determination (avoid exposure & embarrassment, keep person properly draped at all times, use curtains & screens during all care & procedures, knock before entering, close bathroom door when person uses it) 4. Maintain Personal Choice & Independence (Person smokes in allowed areas, takes part in activities according to interests, involved in scheduling activities & care, gives input to care plan about preferences & independence, involved in room or roommate change)
OBRA Requirements (all 50 states)
Nursing Assistant training and competency evaluation program must be completed to work in nursing centers and hospital long-term care units.
OBRA Training Program
Requires at least 75 hours of instruction (16 hrs are supervised practical training); includes knowledge & skills needed to give basic nursing care; takes place in a laboratory or clinical setting
OBRA Competency Evaluation
After training program you take a written test that has multiple-choice questions and a skills test that is performing certain skills learned in training program. OBRA allows at least 3 attempts to successfully complete the evaluation
OBRA Nursing Assistant Registry
An official record or listing of persons who have successfully completed a competency evaluation; Each state must have a nursing assistant registry; all information stays in registry for at least 5 years
OBRA other requirements & provisions
Retraining & new competency evaluation program are required for NA who have not worked for 2 consecutive years. It does not matter how long you worked, it is how long you did NOT work: Requires new competency evaluation OR Both retraining & new competency evaluation; Nursing agencies must provide 12 hrs of educational programs to NA's every year
RN's can delegate tasks to LPNs/LVNs, & NA's (Right Task, Right Circumstances, Right Person, Right Directions & Communication, Right Supervision)
Refusing a Task
Have the right to refuse when: Task is beyond legal limits of your role, Is not in your job description, You were not prepared to perform the task, Task could harm the person, Person's condition has changed, You do not know how to use the supplies or equipment, directions are unethical, illegal, or against agency policy, directions are unclear or incomplete, nurse is not available for supervision
Ethical Aspects
Knowing difference between right & wrong conduct; behaves and acts in the right way and does not harm anyone; not being prejudiced or biased
Good Work Ethics
Caring, Dependable, Considerate, Cheerful, Empathetic, Trustworthy, Respectful, Courteous, Conscientious, Honest, Cooperative, Enthusiastic, Self-aware
5 Steps of Nursing Process
Assessment, Nursing diagnosis, Planning, Implementation, & Evalualtion
Involves collecting information about the person; Nursing history is taken from family's health history, info from doctor, test results, & past medical records
Objective data that is seen, heard, felt, or smelled (you can feel a pulse, see urine)
Subjective data is things a person tells you about that you cannot observe through your senses (you cannot see pain, fear, or nausea)
Nursing Evaluation
Involves measuring if goals in planning step were met: progress is evaluated; changes in nursing diagnoses, goals & care plan may result; NA has keep role as NA's observations are used for this step
Safety & Security Needs
Feeling safe from harm, danger, & fear; People feel safe and more secure if they know told what is or going to happen (Tell them - Why it is needed, who will do it, how it will be done, what sensations or feelings to expect)
Dealing with Behavior Issues
Recognize frustrating & frightening situations; Treat person with dignity & respect; Answer questions clearly and thoroughly and have nurse answer questions you cannot answer; Keep person informed about what you are going to do and when; Do NOT keep person waiting, answer signal lights promptly; explain reason for long waits and ask if you can get or do something to increase person's comfort; Stay calm & professional if person is angry or hostile (usually angry at another person or situation); Listen & use silence as person may feel better if able to express feelings); Report person's behavior to the nurse and discuss how you should deal with the person
Family & Visitors
Family & friends help meet safety, security, love, belonging, self-esteem, support, & comfort needs. Presence or absence of family or friends can affect recovery & quality of life; Person has the right to visit with family & friends in private and without unnecessary interruptions; If visitor upsets person, report observations to the nurse
Accident Risk Factors
Age (decreased strength, move slowly & less steady); Awareness of surroundings (person in coma); Impaired vision (may not see toys, rugs, furniture or cords and may have problems reading labels on cleaners, drugs, and other containers); Impaired hearing (may not hear warning signals, fire alarms, approaching meals cards, drug carts, stretchers, or persons in wheelchair; Impaired smell & touch (senses may be dulled and they cannot detect smoke or gas odors, burns are a risk because of decreased pain sensation; Impaired mobility (cannot move quickly or safely away from danger; Drugs (side effects could include loss of balance, drowsiness, lack or coordination, reduced awareness, confusion, & disorientation)
Preventing Burns
Smoking in bed, spilling hot liquids, electrical devices and and very hot bath water are common causes of burns. Do following for prevention: Person smokes only in smoking areas; NO smoking in bed; NO smoking near oxygen equipment: Supervise persons smoking who cannot protect themselves; DO NOT use heating pads or electric blankets; Turn cold water on first, then hot - - turn hot water off first, then cold; Measure bath water temperature (110-115 degrees F) and check it before person gets in; Check for "hot spots" in water moving hand back and forth; Follow measures to prevent equipment accidents
Wheelchair Safety
Check wheel locks; Check for flat or loose tires; Check wheel spokes; Be sure casters point forward for balance and stability; Be sure person's feet are on footplates before pushing or repositioning (feet cannot touch or drag on floor); Push chair forward when transporting person, going backward ONLY through a doorway; Lock both wheels before you transfer person to or from the wheelchair; Follow care plan for keeping wheels locked when not mving wheelchair (locking would keep person from moving or getting out of chair is so desired); DO NOT let person stand on footplates; DO NOT let footplates fall back onto person's legs; Make sure person has needed safety belt, pouch, tray, lapboard or cushions; Remove armrests (if able) when transferring person to bed, toilet, commode, tub, or car; Swing front rigging out of way to transfer to & from wheelchair (some detach); Clean wheelchair according to agency policy; Ask nurse or PT to show you how to propel wheelchair up steps, ramps, and over curbs; Follow measure to prevent equipment accidents
Stretcher Safety
Ask 2 co-workers to help with transfer; Lock stretcher wheels before transfer; Fasten safety straps when person is properly positioned on stretcher; Ask co-worker to help with transport; Raise side rails and keep up during transport; Be sure person's arms, hands, legs, and feet stay on stretcher; Stand at head of stretcher and co-worker stands at foot; Move stretcher FEET FIRST; DO NOT leave person alone; Follow measure to prevent equipment accidents
Restorative Nursing/Rehabilitation
Involves promoting: Self-care, Elimination, Positioning, Mobility, Communication, Cognitive function; Focus's on the whole person
Whole Person
Has physical, social, psychological, and spiritual parts
Self-Help Devices
Often needed when the hands, wrists, & arms are affected. Equipment is changed, made, or bought to meet person's needs; Includes - Eating devices, Electric toothbrushes, Longer handles attached to combs, brushes, & sponges; Self-help devices for cooking, dressing, writing, phone calls
Rehab & Restorative Focus on PERSON
1. Provide Comfort - Practice good communication skills - just be there to listen, often you do not need to say anything 2. Ethical behavior: Personal choice is important but do not let person control you; Letting person control you is wrong and problems must be reported to nurse. 3. Remaining Independent: Focus on what the person CAN do: Independence to the greatest extent possible is goal of rehab & restorative care. 4. Speaking Up: Use the nurse or therapist words, guides and directions as this helps the person learn & remember what to do. 5. OBRA and other laws: Requires centers to provide services required by person's comprehensive care plan. 6. Nursing Teamwork: Rehab process can frustrate person, you, and other nursing team members. Help each other with care and emotional support
Restraint Use
Restraints are used ONLY as a LAST RESORT to protect persons from harming themselves or others: DO NOT use for discipline or convenience
Restraint Risks
Agitation, Anger, Cuts & Bruises, Constipation, Dehydration, Depression, Embarrassment & Humiliation, Fractures, Incontinence, Infections (pneumonia & urinary tract), Mistrust, Nerve Injuries, Pressure Ulcers, Strangulation
Restraint Safety
(Doctors order is required for restraint.) Use correct size as noted in care plan; Apply only after being instructed about its proper use (demonstrate to nurse); must have manufacturer instructions & warning labels (note front & back sides); Follow manufactures instructions and warnings (different restraints for different equipment); DO NOT use sheets, towels, tape, rope, straps, bandages, or other items; Use intact restraints (look for tears, cut or frays); DO NOT position person on toilet; Follow agency policies & procedures; Position in good alignment before application; Pad bony areas and skin; Secure restraint - should be snug but allow some movement); Check for snugness - - a.) Chest or waist restraint-Flat hand should slide between restraint & person's body b.) Wrist & Mitt restraints-Should be able to slide 1 or 2 fingers under restraint; Criss-Cross vest restraints in FRONT - Can cause strangulation; Tie restraints according to agency policy-quick release ties or buckles are used; Secure straps out of person's reach; Leave 1-2 in. of slack in straps to allow for some movement; Secure restraint to MOVABLE part of bed frame at waist level; NEVER secure restraints to bed rails; Make sure straps will not slide in any direction (could cause strangulation); Use bed rail covers or gap protectors according to nurse instructions as they prevent entrapment; Entrapment can occur between: a.) bars of bed rail b.) Space between half-length (split) bed rails c.) Bed rail & mattress d.) Headboard or footboard & mattress
Hand Washing Procedure
1.) Have soap, paper towels, orange stick or nail file, and a wastebasket. 2.) Push watch, and sleeves up arm 4-5 inches 3.) Stand away from sink so soap & faucet are easy to reach. DO NOT let clothes touch sink! 4.) Turn on and adjust water until warm 5.) Wet wrists & hands, keeping hands BELOW elbows 6.) Apply 1 teaspoon of soap 7.) Rub palms together and wash for 15-20 seconds 8.) Wash each hand & wrist thoroughly, cleaning well between fingers 9.) Clean under fingernails rubbing against palms 10.) Clean under nails with file or orange stick first washing of day or when hand are highly soiled 11.) Rinse wrists and hands well letting water flow DOWN from arms to hands 12.) Pat dry with paper towels starting from fingertips working up 13.) Discard paper towels 14.) Turn off faucets with clean paper towels 15.) Discard paper towels into wastebasket
Standard Precaution Rules
1.) HANDS-Follow rules for hand hygiene; DO NOT wear fake nails or extenders 2.) PERSONAL PROTECTIVE EQUIPMENT (PPE) - Wear when in contact with blood or body fluids is likely; DO NOT touch surfaces near the person when giving care; DO NOT contaminate your clothing or skin when removing PPE; Remove & discard PPE before leaving the person's room or bed area 3.) GLOVES-Wear gloves when in contact with blood, potentially infectious materials (body fluids, secretions, & excretions), mucous membranes: non-intact skin, skin that may be contaminated; Wear gloves that are appropriate for task - A. disposable gloves to provide direct care to person B. Disposable or utility gloves for cleaning equipment or care settings; Remove gloves after contact with person, person's care setting, or care equipment; DO NOT wear the same pair of gloves to care for more than one person and remove before going to next person; DO NOT wash gloves for reuse; Change gloves during care if hands move from a contaminated body site to a clean site 4.) MOUTH, NOSE, & EYE PROTECTION - Wear PPE masks, goggles, face shield for procedures & tasks likely to cause splashes and sprays of blood, body fluids, secretions, excretions and all appropriate procedures or tasks; For likely sprays of respiratory secretions wear Gloves, Gown, Faceshield or mask & goggles 6.) RESPIRATORY HYGIENE/COUGHING ETIQUETTE - Cover nose & mouth when coughing or sneezing; Use tissues to contain respiratory secretions; Dispose of tissues in the nearest waste container; Practice hand hygiene 7.) CARE EQUIPMENT - Wear appropriate PPE when handling care equipment that is visibly soiled or may have been in contact with blood, body fluids, secretions, or excretions 8.) CARE OF ENVIRONMENT - Follow agency policies & procedures for cleaning and maintaining surfaces 9.) TEXTILES & LAUNDRY - Handle used linens with minimum agitation to avoid contamination of the air, surfaces, and other persons 10.) WORKER SAFETY - Protect yourself & others from exposure to blood-borne pathogens (Bloodborne Pathogen Standards); Give rescue breathing with a mouthpiece, resuscitation bag or other ventilation device to prevent contact with person's mouth and oral secretions 11.) PATIENT or RESIDENT PLACEMENT - A private room is preferred if person is at risk for transmitting infection to others; Follow nurse's instruction if private room is not available
Rules for Isolation Precautions
1. Collect all needed items before entering room. 2. Prevent contamination of equipment and supplies. Floors and any object on floor is contaminated. 3. Use mops wetted with a disinfectant solution to clean floors. Floor dust is contaminated. 4. Prevent drafts as they carry pathogens in the air. 5. Use paper towels to handle contaminated items. 6. Remove items from room in leak-proof plastic bags. 7. Double bag items if the outer part of bag is or may be contaminated 8.) Follow agency policy for removing & transporting disposable & reusable items. 9.) Return reusable dishes, eating utensils, & trays to food service dept. Discard disposable dishes, utensils and trays in person's room. 10.) DO NOT touch your hair, nose, mouth, eyes, or other body parts 11.) DO NOT touch any clean area or object if your hands are contaminated. 12.) Wash hands if visibly dirty or contaminated with blood, body fluids, secretions, or excretions. 13.) Place clean items on paper towels. 14.) DO NOT shake linens. 15.) Use a paper towel to turn on/off faucets, 16.) Use paper towel to open door to person's room and discard at you leave. 17.) Tell nurse if you have any cuts, open skin areas, sore throat, vomiting, or diarrhea.
Person's Unit/Room
Residents rooms are as personal and home-like as possible. This space is like the person's home and is private and treated with respect.
Person's Room Temperature & Ventilation
OBRA requires the temperature range of 71 - 81 degrees F. Protect older and ill person from cool areas and drafts. Keep room temps war, Make sure they wear warm clothing, Provide enough blankets for warmth, Use bath blankets when giving personal care, Offer lap blankets to those in chairs or wheelchairs, Move them from drafty areas
Call System & Safety
Always keep signal light within the person's reach -- in the room, bathroom, shower or tub (even if person cannot use it, keep it within reach for use by visitor or staff who may need to signal for help); Place signal on strong side; Remind person to signal when help is needed; Answer signal lights promptly (means they needs help); Answer bathroom & shower/tub signal lights AT ONCE (these are red and have a loud ring)
Rules for Making Bed
Use good body mechanics at all times; Follow rules of medical asepsis; Follow Standard Precautions & Bloodborne Pathogen Standard; Practice hand hygience before handling clean linen; Practice hand hygiene after handling dirty linen; Bring enough linen to person's room (DO NOT bring extra); Extra linen in a person's room is considered contaminated and is NOT used for other people. Put it with the dirty laundry; Do not use torn linen; Hold linens AWAY from your uniform. Dirty & clean linen must NOT TOUCH your uniform; NEVER shake linens, it spreads microbes; NEVER put dirty linens on the floor or clean linens; Follow agency policy for dirty linen; Keep bottom linens tucked in and wrinkle-free; Cover a plastic drawsheet with a cotton drawsheet -- plastic drawsheet must not touch person's body; Straighten & tighten loose sheets, blankets, and bedspreads; Make as much of one side of bed as possible before going to the other side to save time & energy; Change wet, damp, & soiled linen right away
Denture Care
Dentures easily break or chip if dropped on hard surface. Hold firmly during cleaning over a basin of water lined with a towel. DO NOT use hot water - this causes dentures to (warp) lose their shape. Store dentures in a container with cool water or denture soaking solution; Remove at bedtime; Keep denture cup in top drawer of bedside stand
Perineal Care Guidelines - Female
(Warm Temp: 105 to 109 degrees F) Use standard precautions, medical asepsis, and the Bloodborne Pathogen Standard; Work from cleanest area to dirtiest (from front to back); Urethral area is cleanest, anal area is the dirtiest: Separate labia and clean downward (front to back) with one stroke; Repeat until are is clean using clean part of washcloth for each stroke when cleaning & rinsing, using more than one washcloth if necessary; Pat area dry from front to back
Perineal Care Guidelines - Male
(Warm Temp: 105 to 109 degrees F) Use standard precautions, medical asepsis, and the Bloodborne Pathogen Standard; Work from cleanest area to dirtiest. Retract foreskin (if uncircumcised), Clean tip using a circular motion; Start at meatus or urethra and work outward clean, using a clean part of washcloth for each time (do same when rinsing). Return foreskin to its natural position; Clean the shaft of the penis using firm downward strokes; Clean scrotum; Pat area dry from front to back
Dressing Person with Weak Side
Always undress the strong side first, weak side last (person can help assist with weak side), Always dress the weak side first, strong side last (person can assist with that side); Person always has two choices of clothing to pick from
Shaving Rules
Use electric shavers for persons taking anticoagulant drugs (NEVER use safety razors); Protect bed linens by placing a towel under the part being shaved or place towel across shoulders to protect clothing; Soften skin before shaving; Encourage the person to do as much as safely possible; Hold skin taut as needed; Shave in the direction of hair growth when shaving the face and under arms; Shave up from the ankles when shaving legs (this is against hair growth); DO NOT cut, nick, or irritate the skin; Rinse the body part thoroughly; Apply direct pressure to nicks or cuts.
Outer layer of the skin and has living & dead cells. Living cells of the epidermis contain pigment which gives skin its color. Epidermis has no blood vessels and few nerve endings.
Inner lay of the skin. It has blood vessels, nerves, sweat glands, oil glands, and hair roots. Oil glands, sweat glands, hair, and nails are skin appendages. Only palms of hands and soles of feet have no hair.
Skin Functions
Body's protective covering; Prevents bacteria & other substances from entering the body; Prevents excess amounts of water from leaving the body; Protects organs from injury; Nerve endings in the skin sense pleasant and unpleasant stimulation. Nerve endings are over the entire body and sense cold, pain, touch, & pressure to protect the body from injury; Skin helps regulate body temperature. Blood vessels dilate (widen) when temp outside body is high. More blood comes to the body surface for cooling during evaporation. When blood vessels constrict (narrow) the body retains heat because less blood reaches the skin
Strong, tough connective tissue that connects muscles to bones
The connective tissue at the end of long bones; Cushions the joint so that bone ends do not rub together
Strong bands of connective tissue that hold bones together at the joint
The point where two or more bones meet: Joints allow movement.
Joint Types
1. Ball -and-Socket joint: Allows movement in all directions (hip & shoulder joints) 2. Hinge Joint: Allows movement in one direction (elbow) 3. Pivot Joint: Allows turning from side to side (a pivot joint connects the skull to the spine)
Largest part of the brain; Center of thought and intelligence
Regulates and coordinate body movements: Controls balance and smooth movement of voluntary muscles
Connects the cerebrum to the spinal cord
A muscle that pumps blood through the blood vessels to the the tissue and cells
Outer layer of the heart; Thin sac covering the heart
Second layer of the heart; Thick muscular part of heart
Inner layer of the heart; Membrane that lines the inner surface of the heart
Right atrium
Receives blood from body tissues
Left atrium
Receives blood from the lungs
Right ventricle
Pumps blood to the lungs
Left ventricle
Pumps blood to all parts of the body
Resting phase; Heart chamber fills with blood
Working phase; Blood is pumped through the blood vessels when the heart contracts
The windpipe; Divides at its lower end into the right & left bronchus, then into smaller branches called bronchioles which then end up in tiny one-cell sacs alveoli
Food absorption
Takes place in the small intestine (jejunum and ileum)
Male sex glands or gonads that produce the male sex cells - sperm
Male hormone, testosterone, is produced in the testes
Sac (made of skin & muscle) that holds testes suspended between the thighs
Prostate Gland
Gland that secrete fluid into the semen
Outlet for urine and semen. The urethra is contained within the penis
Secrete female hormones estrogen and progesterone
Main part of uterus
Tissue lining the uterus
A hollow, muscular organ
Endometrium breaks up and is discharged from the body
Male sex cell (sperm) unites with female sex cell into one cell (46 chromosomes -- 23 from each).
Skin Changes for Older Person
Skin loses its elasticity; Fatty tissue layer is lost and makes person more sensitive to cold (protect from drafts); Oil & sweat glands decrease; Dry skin occurs and causes itching and is easily damaged; Skin is fragile and easily injured; Skin breakdown & pressure sores are risks; Skin has fewer nerve endings affecting senses of heat, cold and pain; Nails become thick & tough; Hair turns white or gray and thins
Digestive System for Older Person
Produce less saliva which can cause difficulty swallowing (dysphagia); Taste & smell dull; Appetite decreases; Secretion of digestive juices decreases; Loss of teeth & ill fitting dentures cause chewing problems; Peristalsis decreases, stomach & colon empty slower, flatulence & constipation can occur; Dry, fried, & fatty foods avoided to help with swallowing and digestion problems; Oral hygiene and denture care improve tase; High-fiber foods are hard to chew & can irritate intestines; Persons with chewing problems or constipation often need foods providing soft bulk (whole grain cereal, cooked fruits & veggies)
Closed Fracture
Bone is broken but the skin in intact
Open Fracture (compound fracture)
Broken bone has come through the skin
Closed Reduction
Moving the bone back into place - skin is not open
Open Reduction
Involves surgery. The bone is exposed and brought back into alignment with nails, rods, pins, screws, plates, or wires
Joint inflammation; Pain and decreased mobility occur in the affect joints
Degenerative joint disease that occurs with aging, joint injury and obesity. Hips, knees, spine, fingers, and thumbs are affected. Joint stiffness occurs with rest and lack of motion. Pain occurs with weight bearing and joint motion. Pain affects rest, sleep, and mobility. Cold weather & dampness seem to increase symptoms
Rheumatoid Arthritis
A chronic inflammatory diease that causes joint pain, swelling, and stiffness. Most common in women and can occur at any age. Some persons need joint replacement surgery
Care for Person with Stroke
Lateral position prevents aspiration; Coughing & Deep breathing are encouraged; Bed is kept in semi-Fowler's position; Turning & repositioning are done at least every 2 hrs; Food & fluid needs are met; Elastic stockings prevent thrombi in the legs (blood clots); ROM exercises prevent contractures; Catheter is inserted or bladder training program is started; Bowel trining program may be needed; Safety precautions are practiced (use bed rails according to care plan); Keep signal light within reach on the person's UNAFFECTED side (if unable to use signal light, check person often); Person does as much self-care as possible (assist as needed); Communication methods are established. Magic slates, pencil, paper, picture board, or other methods are used. Limit questions to yes or no answers. Speak slowly. Allow person time to respond; Good skin care prevents pressure ulcers; Speech, physical, and occupational therapies are ordered; Assistive & self-help devices are used as needed; Support, encouragement, & praise are given; Complete a safety check before leaving the room
Warning Signs of Stroke
Sudden numbness or weakness of the face, arm, or leg - especially on one side; Sudden confusion, trouble speaking, or understanding; Sudden trouble seeing in one or both eyes; Sudden trouble walking, dizziness, loss of balance or coordination; Sudden, sever headaches with no known cause
Communicating with Hearing Impaired Person
Gain attention and alert person to your presence (DO NOT startle person); Position at person's level; Face person when speaking; have person wearing hearing aid and make sure it's on; have person wearing needed eyeglasses to help for speech-reading; Speak clearly, distinctly and slowly; adjust the pitch of your voice as needed and ask person if he or she can hear better now (lower without hearing aid and raise pitch with a hearing aid); DO NOT cover your mouth, smoke, eat, or chew gum while talking; keep hands away from face; stand or sit on side of better ear; State topic of conversation first; Tell person when you are changing the subject; Use short sentences and simple words; Use gestures & facial expressions to give useful clues; Write out important names and words; Say things in another way if person looks confused; Keep conversations & discussions short; Repeat & rephrase statements as needed; Be alert to messages sent by your facial expressions, gestures, and body language; Reduce or elimante background noise (shut-off radios, stereos, TVs air conditioners, and fans)
Bacterial infection in the lungs that is spread by airborne droplets with coughing, sneezing, speaking & singing (respiratory system)
Heart Failure Diet
A sodium-controlled diet
Endocrine System
Made up of glands that secrete hormones that affect other organs and glands
Type 1 Diabetes
Occurs most often in children & young adults: Pancreas produces little or no insulin; Onset is rapid, increase in thirst & urination, constant hunger, weight loss, blurred vision, and extreme fatigue. Treated with daily insulin therapy, healthy eating, & exercise
Type 2 Diabetes
Occurs in adults - persons over 40 at risk; Obesity & hypertension are risk factors; Pancreas secretes insulin, however the body cannot use it well; Onset is slow; Person has fatigue, nausea, frequent urination, increased thirst, weight loss, blurred vision, infections frequently, wounds heal slowly. Treated with healthy eating , exercise, oral drugs, sometimes-insulin, weight loss for overweight persons
Gestational Diabetes
Develops during pregnancy and usually goes away after the baby is born; At rish for type 2 diabetes later in life
Low sugar in the blood
High sugar in blood
Small pouch in colon that is turned inside out
Condition of having diverticulum (small pouches turned inside out in the colon)
Infected or inflamed pouch (diverticulum) in the colon. Common in older persons; Low-fiber diet and constipation are risk factors.
Life threatening disease called Human Immunodeficiency Virus that causes AIDS - attacks the immune system. No vaccine or cure
Make up for, replace, or substitute. Person makes up for or substitutes a strength for a weakness (Example: Boy is not good in sports. He learns to play music)
To change. An emotion is shown or changed into a physical symptom (Example: Girl does not want to read out loud in school. She complains of a headache.
Refusing to accept or believe something that is true. Person refuses to face or accept unpleasant or threatening things (Example: Man has a heart attack. Continues to smoke after being told to quit.)
Move or take the place of. Individual moves behaviors or emotions from one person, place or thing to a safe person, place or thing (Example: You are angry with your boss. You yell at a friend.)
Blame another. Individual blames another person or object for unacceptable behaviors, emotions, ideas, or wishes (Example: Girl fails a test. She blames a friend for not helping her study.)
Sensible, reasonable, or logical. Acceptable reason or excuse is given for one's behavior or actions (Example: Man is often late for work. He did not get a raise. He says that the boss does not like him.)
Move back or to retreat. Person retreats or moves back to an earlier time or condition (Example: 3 year old boy want a baby bottle when a new baby comes into the family.)
Hold down or keep back. Person keeps unpleasant or painful thoughts or experiences from the conscious mind (Example: Child was sexually abused. Now 33 years old, she has no memory of the event.)
Anxiety Disorders
Vague, unesy feeling in response to stress. Person senses danger or harm (real or imagined) Person acts to relieve unpleasant feeling. Often occurs when needs are not met. SOME anxiety is normal
Panic Disorder
Panic is an intense and sudden feeling of fear, anxiety, terror, or dread. Onset is sudden with no obvious reason. Person cannot function. Signs & symptoms of anxiety are severe (Pain attacks can last for a few minutes or for hours)
Fear, panic or dread. Person has an intense fear of an object, situation, or actgivity.
Obsessive-Compulsive Disorder
Obsession - Recurrent, unwanted thought or idea. Compulsion - Repeating an act over and over again (a ritual). The act may not make sense, but the person has much anxiety if the act is not done.
Cardiac Arrest
The heart and breathing stop suddenly and without warning
CPR Pulse Site
Before starting chest compressions, check for pulse in the carotid artery on the side near/closest to you. Place 2 fingers on person's Trachea (windpipe) and then slide fingertips down to the groove of the neck
Internal Hemorrhage
Bleeding occurs inside the body into tissues and body cavities. Pain, shock, vomiting blood, coughing up blood, and loss of consciousness signal internal hmorrhage. Keep person warm, flat, and quiet until medical help arrives. DO NOT give fluids.
External Bleeding
Usually can be seen if not hidden by clothing. Bleeding from an artery occurs in spurts.
Normal Urination
Healthy adult produces about 1500 ml of urine a day.
Fracture Pan
Thin rim bedpan about 1/2'' deep at one end. Smaller end is placed under buttock. Used for: 1. Persons with casts or in traction 2. Persons with limited back motion 3. After spinal cord injury or surgery. 4. After hip fracture or hip replacement surgery.
Catheter Care
Follow Standard Precautions & Bloodborne Pathogen Standard. Allow urine to flow freely through catheter or tubing and DO NOT allow person to lie on it. Keep catheter connected to drainage tubing. Keep drainage bag below bladder. Attach bag to bed frame, back of chair, or lower part of IV pole (DO NOT ATTACH TO BED RAIL OR PUT ON FLOOR). Coil drainage tubing on the bed and secure to bottom linen (tubing must not loop below the drainage bag). Secure catheter to inner thigh or to a man's abdomen (prevents excess movement and friction at insertion site). Check for leaks; Provide catheter care daily or twice a day (follow care plan). Empty bag at end of shift or as nurse directs, measure and record amount of urine, report increases or decreases in amount or urine. Use separate measuring container for each person (prevents spread of microbes). Do not let drain on bag touch any surface. Encourage fluid intake as instructed by the nurse.
1 gram of fat
9 calories
1 gram of protein
4 calories
1 gram of carbohydrate
4 calories
Who's At Risk For Aspiration
Person's with feeding tubes are at risk for aspiration. The tubing can move out of place from coughing, sneezing, vomiting, suctioning, or poor positioning and move from the stomach into the esophagus & then into the airway. (RN CHECKS PLACEMENT - NEVER NA's RESPONSIBILITY)
Normal Fluid Balance
Amount of fluid taken in (intake) and the amount of fluid lost (output) must be equal. Adult needs 1500 ml of water daily to survive. 2000 - 2500 ml of fluid perday are needed for normal fluid balance
Rectal Body Temp
98.6 - 100. 6 degrees F - - Taken when the oral route cannot be used. Rectal temps are NOT taken if the person has diarrhea, rectal disorder or injury, heart disease, had rectal surgery, is confused or agitated.
Oral Body Temp Range
97.6 - 99. 6 degrees F - - Oral temperatures are NOT taken if person: Unconscious; Infant or child under 6; Has had surgery or injury to face, neck, nose, or mouth; Is receiving oxygen; Breathes through mouth; Has NG tube; Delirious, restless, confused, or disoriented; Paralyzed on one side of body; Has a sore mouth; Has a seizure/convulsion disorder
Tympanic Membrane Temp Range
98. 6 degrees F - - This site (the ear) has fewer microbes than the mouth or rectum, so risk of spreading infection is reduced. This site is NOT used if person has: Ear disorder; Ear drainage
Axillary Temp Range
96.6 - 98.6 degrees F This site (under arm) is less reliable than other sites. It is used when the other sites cannot be used.
Adult Pulse Rate
Between 60 - 100 beats per minute. (Report abnormal rates less 60 and more than 100 to nurse at once.)
Adult Blood Pressure
120/80 is normal. Report any hypertension - (systolic pressure above 120 mm Hg or diastolic pressure above 80 mm Hg) and report any hypotension - (Systolic pressure below 90 mm Hg and diastolic pressure below 60 mm Hg)
Temporal Pulse
Pulse on each side of temple: temporal artery
Carotid Pulse
Pulse felt on either side of neck; carotid artery
Apical Pulse
Pulse felt on the left side of chest slightly below the nipple. Taken with a stethoscope.
Brachial Pulse
Pulse felt in bend of either arm (inner side - follow arm up from pinkie finger) Brachial Artery
Radial Pulse
Used for routine vital signs. Pulse felt on either wrist (thumb side); Radial Artery
Femoral Pulse
Pulse felt on either side of the groin; Femoral artery
Popliteal Pulse
Pulse felt at the back of either knee; lower part of femoral artery
Posterior Tibial Pulse
Pulse felt on inside of either ankle
Pedal Pulse/Dorsalis Pedis Pulse
Pulse felt at top of bridge of either foot
Clear-Liquid Diet
Foods liquid at body temp and which leave small amounts of residue; non-irrating and non-gas forming; Liquids you can see through
Full-Liquid Diet
Foods liquid at room temp or melt at body temperature; Foods on clear liquid diet PLUS custard, eggnog, strained soups & fruit, vegetable juices; milk & milk shakes; strined cooked cereals; plain ice cream and sherbet; pudding; yogurt
Causes of Skin Breakdown
Pressure, friction, and shearing, breaks in the skin, poor circulation to an area, moisture, dry skin, irritation by urine & feces. Older & disabled people at greater risk because skin is easily injured.
Causes of Skin Tears
Caused by friction and shearing, pulling, or pressure on the skin
Preventing Skin Tears
Keep person's & your fingernails short and smoothly filed. Do NOT wear rings or bracelets. Follow the care plan & safety rules to move, position, transfer, bathe, & dress person. Prevent shearing & friction. Use an assist device to move & turn the person.
Elastic Bandages
Use correct size. Position the part in good alignment. Face the person during procedure. Start at lower (distal) part of extremity and work upward to the top (proximal) part. Expose fingers or toes if possible allowing for circulation checks. Apply bandage with firm, even pressure. Check color & temp of extremity every hour. Re-apply a loose or wrinkled badage. Replace a moist or soiled bandage.
Moist Cold Applications
Penetrates deeper than dry cold. Example: Cold Compress
Moist Heat Applications
Penetrates deeper than dry heat. Water is in contact with the skin. Water conducts heat and has greater and faster effects than dry heat. Example: Hot compresses, Hot soaks, Sitz baths, Hot packs
Coughing & Deep Breathing
Exercises help persons with repiratory problems. They are done after surgery & during bedrest and are painful at this time - Breaking an incision open while coughing is a fear. Usually done every 2 hours
NA's Role in Oxygen Therapy
NA's can ONLY check the oxygen flow rate and report to nurse at once if it is too high or too low. RN or respiratory therapist adjust the flow rate.
Psychological, Social , & Spiritual Needs for Dying Person
Dying people have psychological, social, and spiritual needs. They may want family or friends present, talk about their fears & worries especially at night when things are quiet. You need to listen and use touch, Some people want to see a spiritual leader or want to take part in religious practices. Provide privacy during prayer & spiritual moments. Person has right to have religious objects nearby (medals, pictures, statues, or religious writing) Handle these valuable with care and respect.
Care of Body After Death
Care begins after doctor pronounces the person dead. Postmortem care is given by a nurse and you may be asked to assist. Care is done to maintain good appearance to the body and prevent discoloration and skin damage. Right to privacy and to be treated with dignity & respect apply after death.
Assisting with Postmortem Care
The body is positioned in normal alignment before rigor mortis sets in. Body should appear in a comfortable and natural position for family viewing