Module three, b
- 1. Chapter 13: Personal care skills
- 2. Why do it??? • Promotes comfort • Prevents infection • Improves self esteem • Prevents body odor
- 3. EARLY AM CARE • WAKE UP • ASSIST WITH TOILETING • WASH HANDS AND FACE • RINSE MOUTH/DENTURES • LEAVE IN UPRIGHT POSITION • NEEDS TO BE COMPLETED BEFORE BREAKFAST ARRIVES
- 4. PM Care • Undress • Toilet • Brush teeth or dentures • Wash hands and face • Give back rub • Change into night clothes
- 5. ASSISTING WITH PERSONAL CARE • ENCOURAGE INDEPENDENCE • BE AWARE OF PREFERENCES AND ROUTINES • EXPLAIN WHAT YOU ARE DOING • PRIVACY • OBSERVE AND REPORT FINDINGS • LEAVE ROOM CLEAN AND TIDY • LEAVE CALL BELL WITHIN REACH
- 6. Bathing Guidelines • Water temp between 110-115 degrees when you start because it will cool • No soap on the face • Change water if too soapy, cold or dirty • Bath from clean to dirty areas • Rinse soap well • Pat skin dry • Allow resident to do as much as possible for self • Privacy, only expose area being bathed, reduce drafts in room • Clean the eyes from inner to outer canthus using separate part of washcloth for each eye
- 7. Perineal Care • For female- clean from front to back using a separate part of washcloth for each side of labia, rinse well • For male, push back foreskin if uncircumcised; clean in circular motion from urinary meatus (opening) towards scrotum, using a separate part of washcloth for each stroke • Done during AM/PM care and incontinent care
- 8. Word Alert • Incontinent is the medical term for loss of bowel or bladder control • Never considered a normal part of aging • We are always expected to assist residents in regaining control (B & B training) • Never shame a resident for incontinence
- 9. Bony Prominences • Bony prominences are areas where the bone is close to the surface and are more prone to breakdown • Elbows, heels, ankles, hips, shoulders, wrists, etc, should all have lotion applied to them
- 10. Complete bedbath vs. Partial •Complete, the entire body is bathed •Partial includes eyes, face, axilla (under arms), hands, perineal area and back
- 11. A word about Showers…. •Never leave a resident unaccompanied in the shower area
- 12. Mouthcare • Oral hygiene prevents infection, improves appetite, improves self- esteem and reduces halitosis (bad breath) • Done at least BID- after breakfast and HS • Wear gloves! • Equipment: brush, paste, emesis basin, swabs • Report bleeding, odor, sores
- 13. Routine Mouthcare • Resident placed in Fowler’s position • Resident must be able to expectorate (spit) • Note and report any problems with oral cavity or teeth
- 14. Special Mouthcare • Done for people who cannot expectorate such as someone in a coma, very weak, very confused, or NPO (nothing by mouth) • Head is turned to the side! • Use mouth swabs or toothettes • Never put your hand/fingers inside a resident’s mouth- keep mouth open with tongue depressor • Performed Q2h • Goal is prevent aspiration: breathing fluid, food vomitus into lungs- keep head turned to side!
- 16. Denture Care • Dentures are expensive. Care must be taken to prevent damage to plate or teeth. • Store dentures in a labeled, covered container filled with cool water (never in a paper towel, or glass) • Rinse and brush dentures using cool water to prevent plate from warping (melting) • Line sink with a towel to prevent teeth from accidentally cracking
- 17. Back Rub • Performed to increase circulation and for relaxation • Should be offered with PM care or done when back is washed • Use warmed lotion and move in circular motion from buttocks to shoulder • 3 to 5 minutes with resident in lateral position • Never massage or rub over a RED area
- 18. Hand and foot care • Hands or feet should be soaked for 5-15 minutes • Check with facility before trimming fingernails, never clip toenails • Use an orangewood stick to clean under fingernails • Never apply lotion to palms of hands or in between toes
- 19. Hair Care • Performed as part of daily ADLs • If hair is tangled, comb from ends toward scalp in sections • Never cut the hair • Long hair should be pinned up or pulled back • Note/Report any problems to nurse • Style appropriately and use hair care products as provided • Shampoo on shower days • Pediculosis- lice, wingless insects that attach their nits (eggs) to hair and cause itching • Hirsutism- excessive body hair growth • Alopecia- baldness
- 20. Shaving • Never trim beards, mustaches or side burns • Wear gloves • Place towel across chest, wet face, apply liberal amount of shaving cream • Hold skin taut, shave in direction of hair growth with short strokes, rinsing blade often • If nick occurs- apply pressure, tell CN • If resident is on an anticoagulant (blood thinner)- must shave with electric razor • Dispose of razor in sharps container •
- 21. Dressing • If a person has a weak or affected (cast, IV, bandaged, contracted) arm or leg when removing clothes: UNdress Unaffected side 1st • Dress the affected side first • Bob has a cast on his left leg. Which leg is Undressed first? When putting clean pants on Bob which leg is Dressed first????? • If client has an IV, can only change if NOT attached to a pump. If running by gravity, pass IV bag through sleeve (p. 330)
- 22. Comfort and Sleep • Pain is a subjective finding. It is perceived differently for each of us. It is unpleasant • Types of: 1. Acute- comes on suddenly “stabbing” 2. Chronic- comes and goes “ache” 3. Radiating- moves from site of tissue damage to nearby areas 4. Phantom pain- experienced in an amputated limb • Pain is rated on a scale of 0-10
- 24. Vital Signs • Vital signs are a reflection of health. They should be relatively stable unless illness occurs • May be taken at time of admission & then monthly or more often as needed • Vital signs include temperature (T), pulse (P), respirations (R) and blood pressure (BP).
- 25. Temperature • The amount of heat in the body • Affected by outside temp, emotions, exercise, illness, age, pregnancy and menstrual cycle • Lowest in morning, before rising • A fever is also known as pyrexia
- 27. Measuring T Route Time Range Guidelines for use Axillary (ax) 7-11 min 96.6-98.6 least accurate, arm across chest to keep thermometer in place Oral (o) 3-5 min 97.6-99.6 Place under tongue, to one side don’t take if comatose, confused under 4 yrs, mouth breather, recent seizure activity wait 15-20 min after hot/cold liquids, heavy exercise or cig Rectal (r ) 1-3 min 98.6-100.6 Hold in place, wear gloves, lubricate a rectal thermometer covered, sims position Don’t take if severe constipation/diarrhea hemorrhoids, rectal disease or colostomy MOST ACCURATE WAY TO MEASURE TEMP IS RECTAL
- 28. Other routes for measuring temp • Tympanic Membrane (aural) thermometers measure temp in the ear (pull ear back and up, gently) • Temporal artery- on the forehead • Temperature sensitive tape • Tempa-dots
- 30. Pulse https://www.youtube.com/watch?v=K8ryHOgfTtY • Pulse is the number of times the heart beats • Should also note quality (strong, weak, thready) and the rhythm (regular or irregular) • Radial pulse is used- thumb side of wrist • Use 2-3 fingertips, never your thumb, pressing lightly (too hard blocks the pulse) • Count for 1 full minute, 30 seconds (multiply by 2) or 15 seconds (multiply by 4). • Keep arm at heart level
- 32. Word Alert • Tachycardia is a HR >100 • Bradycardia is a HR <60 • Normal heart rate is between 60-100 • HR may increase with emotions, illness, certain drugs, exercise, caffeine and nicotine • HR may decrease with extreme grief, meds • Note rhythm & force (weak, bounding, thread) • Infants pulse 120 to 180 • Children’s pulse 100 t0 120
- 33. Pulse cont. • An apical pulse requires the use of a stethoscope- placed over apex of heart to auscultate (listen to) heart beat • An apical-radial deficit is the difference between the apical and radial pulses- take at same time by nurse and nurse aide
- 34. Respirations • Each breath in of oxygen is followed by a breath out of carbon dioxide • One inspiration (inhalation) + one expiration (exhalation) = 1 Respiration • Normal respiratory rate is 12-20 breaths/minute • Normal respirations are quiet, effortless, symmetrical (same on both sides) • RR increases with illness, emotions, body positions • Don’t tell a person you are measuring their RR, he will change the breathing pattern, count immediately after Pulse
- 35. Respiratory Patterns • Kussmaul’s- in diabetics, very deep and rapid RR • Cheyne-Stokes- periods of apnea with shallow RR • Tachypnea >20 • Bradypnea <12 • Apnea- no breathing • Dyspnea- difficulty breathing • Orthopnea- can’t breathe if lying down • Infants respirations 30 to 40*
- 36. Promoting respirations • Positioning- orthopneic used with COPD • Cough and deep breathing exercises • IS (incentive spirometer)
- 38. Oxygen Therapy • If a resident is ordered supplemental O2 therapy do the following: 1. Post “No smoking” sign outside door 2. Remove smoking materials, small electrical appliances (hair dryer), flammables (aftershave, nail polish) and wool items 3. Prepare O2 setup- can be nasal cannula or mask
- 39. O2 Responsibilities of nurse aide • Keep O2 tubing unkinked • Clean mask or nasal cannula tubing PRN • Inform CN if humidifier bottle is empty or not bubbling • Note rate of O2 ordered, if changed, inform CN • Order: NC O2 @ 2L/min • Shut off O2 in case of fire as directed by CN
- 41. Blood Pressure • BP measures the force of blood within the walls of an artery • Arteries that are narrowed, blood that is very viscous (thick) and stress make the resistance greater and raise BP • BP is measured as an inverted fraction (top number > than lower number) • Normal BP is less than 140/90
- 42. Parts of a stethoscope
- 43. Blood Pressure cont. • Systolic pressure is created when blood is being pumped as the heart contracts (top number) • Diastolic pressure is created when the heart is at rest (bottom number)
- 44. Number Game… • A systolic of >140 = hypertension • A systolic of <90=hypotension • A diastolic of >90= hypertension • A diastolic of < 60= hypotension
- 45. • The new guidelines are based on a rigorous review of nearly 1,000 studies on the subject, which took the authors three years to complete. • The new guidelines now classify people's blood pressure measurements into the following categories: • Normal: Less than 120 mm Hg for systolic and 80 mm Hg for diastolic. • Elevated: Between 120-129 for systolic, and less than 80 for diastolic. • Stage 1 hypertension: Between 130-139 for systolic or between 80-89 for diastolic. • Stage 2 hypertension: At least 140 for systolic or at least 90 mm Hg for diastolic.
- 46. Guidelines for measuring BP • Roll up long sleeves • Rest arm at heart level • Place BP cuff 2-3 inches above brachial artery • Inflate cuff to 180 mmHg • Slowly deflate cuff listening for first sound=systolic reading • Continue to listen until last sound heard=diastolic reading
- 47. BP Guidelines continued • Clean stethoscope ear pieces and bell between uses • Don’t overinflate cuff • Don’t take BP in one arm > 3 times • Left arm best • No BP in arm which has dialysis access or on side of a mastectomy
- 48. Factors affecting BP • Gender- men higher • Race-esp in AAs • Blood volume- decrease with hemorrhage, increase with fluid retention of IVs • Stress- raises • Pain-raise • Exercise-raises • Weight-raises • Diet- esp high in NA • Position- higher when lying down • Smoking-raises • Alcohol-raises
- 49. Pain management • Rated on scale of 0 to 10 • Inform nurse- where, when, precipitated by, chronic, acute, phantom? • Visual signs such as crying, grimacing? • Reposition • Warm liquids • Massage • Distraction • Breathing exercises • Walking…….
- 50. Hot and cold applications • Heat dilates (opens)-relieves pain, reduces swelling, increases blood flow to injured area • Cold closes (constricts)- stops bleeding, reduces pain and swelling, lowers fever • If resident receiving an application check every 5 minutes, never in place over 20 minutes • Dry ice, ice bags, sponge baths, cool the body • Warm compresses, warm soaks, K pads, heat the body
- 51. Heat applications • Dry: heating pad, K pad, dry heat pack • Moist: sitz bath, warm soak, compress • COLD APPLICATIONS • Dry: dry ice pack, ice pack • Moist: sponge bath I
- 52. Guidelines for hot/cold apps • Temperature never above 105 on heating apps • Check every 5 minutes • Never place app directly on skin • Soaks for no more than 15-20 minutes
- 53. Aquathermia pads and sitz baths • Aka K pads- set to 105 degrees • Sitz baths used to bathe the perianal area for pain of hemorrhoids, • or after childbirth
- 54. Changing a dry dressing (non-sterile) • After confirming order, ID self and resident, explain procedure • Wash hands, give privacy • Prepare equipment (tape, new dressing while avoiding touching) • Put on gloves to remove old dressing • Remove gloves, wash hands • Reglove • Touch only outer edges of new gauze- apply to wound and tape in place • Remove gloves and wash hands • document
- 55. Wound vac • Foam placed in wound, connected to a negative pressure device to pump out dead tissue and debris
- 56. Applying an ace wrap • Should be snug, but not tight • Use figure eight pattern • Check area Q15 minutes after first applied to observe for signs of poor circulation
- 57. Intravenous therapy • Provides fluid when they cannot be taken by mouth or additional fluids • Replace minerals (such as sodium and potassium) and vitamins • Provide sugar for energy (dextrose)
- 58. COMPLICATIONS OF IV THERAPY • Bleeding • Pale or reddened skin • Complaints of pain at or above IV site • Hot or cold skin near site • Puffiness, swelling or leaking fluid
- 59. Chapter 15: Nutrition and Hydration
- 60. You are what you eat!!! • Food is necessary for life. Essential nutrients give the body the fuel needed to perform at optimum level • Many factors affect nutrition: food preferences, lack of teeth, difficulty swallowing, illness, appetite, religion, culture, finances and age
- 61. Essential Nutrients • Carbohydrates (CHO)- needed for energy Sources: whole grains, fruits, fiber rich fruits • Protein-needed for healing and growth Sources: a. complete-meats, fish, fowl, milk b. incomplete-tofu, nuts, seeds • Fat-needed for storage of vitamins & energy Sources: oils, fish, nuts
- 62. Essential nutrients cont. • Vitamins, two categories 1. Water soluble-lost from body thru urine, sweat, feces- need to be replaced daily- B complex and C 2. Fat soluble-stored in body fat-A,D,E,K (HANDOUT)
- 63. Minerals • Calcium • Sodium • Potassium • Iron • Selenium
- 64. Diets • Regular or house- no restrictions • Low sodium- for HBP, heart & renal disease • Clear liquid- pre-testing, postop, if vomiting • Full liquid- milkshakes, custards • Low fat- for heart and liver disease • Diabetic-1500 cal ADA or exchange diet • Pureed- mechanically altered or blended, for edentulous resident or with dysphagia • Mechanical soft- scrambled eggs
- 65. vitamins
- 66. minerals
- 67. SAMPLE EXCHANGES FOR DM • STARCH: 1 SLICE BREAD, ½ BAGEL, ½ C PASTA, 1 BAKED POTATO, 3 CUPS OF POPCORN • MILK: 1 C OF MIL, ¾ YOGURT • FRUIT: ½ C UNSWEETETENED APPLESAUCE, 1 SM BANANA, ½ C OJ, 2 T RAISINS • VEG: ½ C COOKED VEG, 1 C RAW VEG • MEAT: 1 OZ MEAT, 1 EGG, ½ C DRIED BEANS
- 68. Thickened liquids • Ordered for residents with dysphagia to prevent aspiration (inhalation of food/liquids into lungs, can cause pneumonia) • Medium thick- like V-8 • Honey thick • Yogurt thick- need a spoon • pureed
- 69. Thickened liquids…always check fluid orders!
- 70. Managing Dysphagia • Monitor and report pocketing or squirreling food, coughing, drooling, spitting out food, eating slowly, especially solids • Position in high fowler’s, body in good alignment, feed slowly alternating food with liquids, leave sitting up for 1 hour pc (after meal)
- 71. Meal time • Toilet, allow to wash hands, rinse mouth out • Serve trays in order assigned by health team • If food not correct temperature- get another tray • Always check menu cards • Sit to feed • Allow for choices • Use eating utensils for designed for special needs • Set food up like face of clock for blind person
- 72. Nourishments and Supplements • Nourishments are ‘snacks’ offered between meals such as ½ sandwich, ice cream, cookies and juice, piece of fruit • Supplements are ordered by the dietician for people who are not eating enough to satisfy caloric needs or losing weight such as Boost, HealthShakes, or Glucerna
- 73. Supplements- are expensive! Pour into cup and assist with intake. If resident doesn’t take, report to RN
- 74. Guidelines for feeding • Sit! • Describe meal, ask what the resident would like first • Alternate food and liquids • Encourage “swallowing” • Use spoon only- 1/3 full • Cut food up in to small pieces
- 75. Parenteral Nutrition • If a person is unable to eat by mouth or is not taking enough enough nutrients, may require nutritional support via IV, Parenteral nutrition or a Feeding Tube
- 76. Intravenous therapy • Provides fluid when they cannot be taken by mouth or additional fluids • Replace minerals (such as sodium and potassium) and vitamins • Provide sugar for energy (dextrose)
- 77. Parenteral Nutrition • Giving nutrients through a catheter inserted into a vein; Para-beyond and Enteral-relates to bowel • Nutrient solution contains water, proteins, CHOs, vitamins, minerals, and fat • Indications: disease of GI tract, severe trauma, NPO > 5-7 days, prolonged coma, prolonged anorexia • Inserted into subclavian vein in neck=TPN (total) • Inserted into arm=PPN (peripheral)
- 79. Feeding Tubes- Enteral Nutrition • Types of feeding tubes: 1. Nasogastric tube (NGT) 2. Gastrosotomy tube (GT) 3. Jejunostomy tube- inserted into a part of sm. Intestine 4. Percutaneous endoscopic gastrostomy (PEG)
- 81. Guidelines for caring for a resident with a feeding tube • HOB elevated during feeds • People with NGT are always NPO- special mouthcare • Some people with GTs are allowed “comfort” foods, some are NPO • Clean nostrils and apply tape, if NGT • Keep tubing kink free • Never stop feeding or place on “hold” • Report N&V, diarrhea, regurgitation, swollen or hard abdomen, redness, swelling at ostomy site
- 82. Hydration • Water is needed to live • Fluid intake must be in balance with output • Edema (swelling) occurs when too much fluid is taken in and output is not equal (fluid retention) • Dehydration occurs when not enough fluid is taken in or too much out
- 83. S/SX of Edema & Dehydration • Edema: 1. Swollen ankles, feet, hands, wrists 2. Weight gain 3. SOB • Dehydration 1. Dry skin 2. Dry mucous membranes (tongue, gums) 3. Dark, scant amt of urine 4. Sunken periorbital (around the eyes) spaces
- 84. How much fluid is needed? • 1 ounce of fluid = 30 milliliters (ml) • 1 ml is equal to 1 cubic centimeter (cc) • 1 liter is = to 1000cc/ml • Humans need at least 1500 ml to survive (or 1.5 liters/day) • For fluid balance 2000-2500ml are needed
- 85. Measuring Intake and Output • If ordered, you may need to record all fluids taken in: juice, water, soup, hot cereals, yogurt, ice cream, etc AND all fluids put out: urine, diarrhea, wound drainage, emesis • Fluids out must be measured in a GRADUATE container • Total I & O at the end of the shift
- 86. Special Fluid Needs • Force fluids- if a person is at risk of or suffering from dehydration: 1. Offer a small amt (6 oz) of different types of fluids Q2h while awake
- 87. Restrict fluids- if • if a person is retaining fluids: 1. Remove water pitcher and cup 2. Resident can only drink fluids that are served 3. A set amount is allowed per shift
- 88. NPO • Remove water pitcher and cup • Post sign over bed reminding staff/visitors • No gum, no ice chips, nothing allowed by mouth • Give special mouthcare Q2h to keep mouth moistened
- 89. How much fluid in?? • Calculate John’s fluid intake… 4 ounces juice 8 ounces coffee 4 ounces of skim milk 10 ounces oat meal
- 92. Chapter 20: Mental Health/Mental Illness • Mental health- able to cope and adapt to everyday life stresses in a socially acceptable manner • Mental illness- maladjustment to life stressors • Factors affecting: chemical imbalance, genetics, psychological factors, physical factors, SA and ETOHism, social and cultural factors
- 93. Anxiety • A vague feeling that something is wrong with a known or unknown cause • Can be a good thing- leads to increase productivity, willingness to make changes • Manifests itself as sweating, chest pain, SOB, tachycardia, insomnia, lump in stomach, nausea, diarrhea • Relieved with coping mechanisms and defense mechanisms (p. 684) • Types of anxiety disorders include panic do, phobias, OCD, PTSD
- 95. Schizophrenia • A split mind, a physical, chronic, disabling brain disorder • Characterized by delusions, hallucinations, paranoia, delusions of grandeur/persecution, poor self care, neologisms, echolalia, perseveration, waxy flexibility, catatonia • Treated with psychotropics that have challenging side effects such as lip smacking, grimacing, writhing (tardive dyskinesia), Parkinsonism and dystonia • Begins in young (12-20) • Stigmatized
- 96. Mood Disorders • Bipolar disorder (manic-depression)- chemical imbalance of NE, serotonin and Da • Person has excessive highs (mania) and lows (depression) • May cycle • Treated with Neurontin, Lithium, Depakote • Major Depression
- 97. Suicide and elderly • Greatest risk presented by elderly white male • Risk factors include depression, previous attempt, family hx of, stressful life event, easy access to lethal methods, incarceration, firearms in home, hx of SA or ETOHism • “I just don’t want to live anymore” • “I wish I was dead” • “Everyone would be better off without me” • Report! Stay with person!
- 98. Personality disorder vs mental disorder • Personality are the characteristics and qualities that make each person unique; fully formed by 16 and sadly, can’t be changed • 4 types: Driver, Expressive, Amiable, and Analytical. • Personality dos don’t require professional treatment, just a lot of patience! • Sociopath (bully, user, disregard for societal norms) • Psychopath (“devil told me to do it” literally)
- 100. Restorative and Rehab nursing
- 101. Restorative Nursing • Care that helps persons regain health, strength, and independence • Restorative nursing programs help: 1. Prevents unnecessary decline 2. Promotes self care 3. Assists with elimination 4. Assists with mobility 5. Assists with communication 6. Assists with cognitive functions
- 102. Protective Devices • Bed cradle • Heel and elbow protectors • Heel and foot elevators • Eggcrate mattress • Sheepskin • Special beds
- 105. CNA Guidelines in Restorative Care • Allow resident to do as much as possible for self • Offer realistic reassurances, praise for efforts • Emphasize what resident can do instead of what cannot be done • Be patient, use empathy • Remember not all disabilities are permanent • Disabilities affect the WHOLE person: spiritually, emotionally, socially, physically
- 106. Restorative Devices • Long handled combs/brushes • Button hook • Shoe horn • Doorknob turner • Splints • Transfer boards • Grabbers
- 107. Range of motion exercises • Only do if ordered • Care Plan: PROM left elbow, TID, 5 reps • Stop, report any pain • Support above, below joint • Exercise to point of resistance • Only expose area being exercised • Ask nurse to medicate before workout
- 108. Movements • flexion- bending • Extension-straightening • Rotation- moving around • Pronation- facing down • Suppination- facing up • Abduction-moving away • Adduction- moving toward • Dorsiflexion- bending up • Plantar flexion- bending down
- 109. Special Care Skills • Subacute units may serve those who were recently discharged from the hospital and are still to sick to go home • May be recovering from an illness, surgery or require specialized care • Surgery may be indicated to relieve symptoms, to repair or remove, to improve appearance or correct function of damaged tissue, to diagnose and to cure • Preoperative stage may include testing, bloodwork to determine blood type, education, shaving and cleansing of operative site • Postoperative stage requires close monitoring of vital signs, the operative site and prevention of infection
- 110. Pulse oximeter • Measure the amount of saturated oxygen in the blood • Should be placed on a warm finger, without nail polish • Normal is 95 to 100%
- 111. Telemetry • All patients on this unit require close monitoring of their cardiovascular state- are on ECG machine. • Technicians may be watching monitors constantly • Pads and electrodes should be kept dry and attached to the body
- 112. Artificial Airways • Tube is inserted into the respiratory tract to maintain or promote breathing • Referred to as ventilator, respirator • May have tube down mouth, nose or into the trachea • Report if tube comes out, report if resident trying to pull out, give frequent mouthcare, may be anxious, find an effective way to communicate, report SOB, report increase drainage from area
- 114. Chest tubes • Inserted to remove air or fluid (pus or blood) from the pleural cavity (chest) • May be placed after chest trauma, chest surgery • Report if tube become dislodged stat • Report respiratory distress stat
- 115. Binders • Protect the wound from opening when changing positions or coughing • Help to keep dressing in place
- 116. Drains- Jackson Pratt, hemovac, penrose