Hartman’s Nursing Assistant Care

Long-Term Care and Home Health

Susan Alvare
Jetta Fuzy, RN, MS
and Suzanne Rymer, MSTE, RN, C, LSW
ii

Credits Notice to Readers

Managing Editor Though the guidelines and procedures contained in this
Susan Alvare text are based on consultations with healthcare profession-
als, they should not be considered absolute recommenda-
Designer
tions. The instructor and readers should follow employer,
Kirsten Browne
local, state, and federal guidelines concerning healthcare
Illustrator practices. These guidelines change, and it is the reader’s re-
Thaddeus Castillo sponsibility to be aware of these changes and of the policies
and procedures of her or his healthcare facility.
Cover Illustrator
Jo Tronc The publisher, author, editors, and reviewers cannot accept
any responsibility for errors or omissions or for any conse-
Page Layout
quences from application of the information in this book
Thaddeus Castillo
and make no warranty, expressed or implied, with respect
Dara Elerath
to the contents of the book. The Publisher does not war-
Photography rant or guarantee any of the products described herein or
Art Clifton/Dick Ruddy perform any analysis in connection with any of the product
information contained herein.
Proofreaders
Kristin Calderon/Angela Storey/Michele Wiedemer
Sales/Marketing Gender Usage
Debbie Rinker/Caroyl Scott This textbook utilizes the pronouns “he,” “his,” “she,” and
Kendra Robertson/Erika Walker “hers” interchangeably to denote healthcare team members
Customer Service and residents and clients.
Fran Desmond/Tom Noble
Angela Storey/Cheryl Garcia
Warehouse Coordinator
Stacy White

Copyright Information
© 2009 by Hartman Publishing, Inc.
8529 Indian School Road, NE
Albuquerque, New Mexico 87112
(505) 291-1274
web: hartmanonline.com
e-mail: [email protected]
All rights reserved. No part of this book may be repro-
duced, in any form or by any means, without permission in
writing from the publisher.
ISBN 978-1-60425-010-7
ISBN 978-1-60425-013-8 (Hardcover)
PRINTED IN CANADA
 iii

Special Thanks
A special thank you goes to Beverly Cobb, RN, in Anthem,
AZ for her invaluable assistance with our special care skills
chapter.
Another warm thank you goes to Charles Illian, RN, BSN,
CIC, our infection control expert in Orlando, FL for help-
ing us with the infection prevention chapter. Charles, we
couldn’t have done it without you!
Thank you to Jill Holmes Long, MA, BSN, BS, RN, our go-to
reviewer and author in Hayesville, NC for her important
contributions to our mothers and newborns chapter and
conflict resolution section.
A heartfelt thank you also goes to our insightful and won-
derful reviewers, listed in alphabetical order:
Larry Bailey, RN, BA, BSN, HSTE
Mansfield, TX
Tracie L. Carter, LPN
Brunswick, GA
Regina G. Cottrell, MN-Ed, BS, RN
Tucson, AZ
Margaret J. Denault, M.Ed., RN-BC, SDS
Becket, MA
Mandy Farmer, LPN, HCC Instructor
Fort Cobb, OK
Pamela Hatchett, LPN
Brunswick, GA
Elizabeth A. Huss, RN, BSN
Austin, TX
Janice M. Joyce, RN, BSN
Springfield, IL
Vivian Luzar, RNC
Niles, OH
Aretha D. Meggett, LPN/SNRN
Pittsburgh, PA
Gloria Stafford, RN
Austin, TX
Beverly Vespico, MHA, RN, C
Harveys Lake, PA
Nancy Whatley, RN
William J. Whatley, Administrator
Colorado Springs, CO
Betty Wolfe, RN
Tulsa, OK
iv

Contents Page Learning Objective Page

1 Understanding 5. List examples of behavior supporting

and promoting residents’ rights 27
Healthcare Settings
6. Describe what happens when a complaint
1. Discuss the structure of the healthcare of abuse is made against a nursing assistant 28
system and describe ways it is changing 1
7. Explain how disputes may be resolved
2. Describe a typical long-term care facility 4 and identify the ombudsman’s role 29
3. Describe residents who live in long-term care 8. Explain HIPAA and list ways to protect
facilities 4 residents’ privacy 29
4. Explain policies and procedures 5 9. Explain The Patient Self-Determination
5. Describe the long-term care survey process 6 Act (PSDA) and discuss advance directives 31

6. Explain Medicare and Medicaid 6

7. Discuss the term “culture change” and describe
4 Communication and
Pioneer Network and The Eden Alternative 7 Cultural Diversity
1. Define the term “communication” 33
2 The Nursing Assistant and 2. Explain verbal and nonverbal communication 34
The Care Team 3. Describe ways different cultures communicate 34
1. Identify the members of the care team and 4. Identify barriers to communication 35
describe how the care team works together
to provide care 9 5. List ways to make communication accurate and
explain how to develop effective interpersonal
2. Explain the nursing assistant’s role 11 relationships 37
3. Explain professionalism and list examples of 6. Explain the difference between facts and opinions 39
professional behavior 12
7. Explain objective and subjective information and
4. Describe proper personal grooming habits 14 describe how to observe and report accurately 39
5. Explain the chain of command and 8. Explain how to communicate to other
scope of practice 14 team members 40
6. Define “care plan” and explain its purpose 16 9. Describe basic medical terminology and
7. Describe the nursing process 16 abbreviations 40

8. Describe “The Five Rights of Delegation” 17 10. Explain how to give and receive an
accurate report of a resident’s status 42
9. Demonstrate how to manage time
and assignments 18 11. Explain documentation and describe
related terms and forms 42

3 Legal and Ethical Issues 12. Describe incident reporting and recording 45

1. Define the terms “law” and “ethics” and list 13. Demonstrate effective communication on
examples of legal and ethical behavior 20 the telephone 45

2. Explain the Omnibus Budget 14. Understand guidelines for basic office
Reconciliation Act (OBRA) 21 machines and computers 47

3. Explain residents’ rights and discuss 15. Explain the resident call system 48
why they are important 23 16. List guidelines for communicating with
4. Discuss abuse and neglect and explain residents with special needs 48
how to report abuse and neglect 24
 v

Learning Objective Page Learning Objective Page

5 Preventing Infection 8. Explain the principles of body mechanics 86

1. Define “infection control” and related terms 56 9. Apply principles of body mechanics to
daily activities 87
2. Describe the chain of infection 57
10. Identify major causes of fire and list fire
3. Explain why the elderly are at a higher risk for safety guidelines 88
infection and identify symptoms of an infection 58
4. Describe the Centers for Disease Control and 7 Emergency Care and
Prevention (CDC) and explain standard precautions 59
Disaster Preparation
5. Explain the term “hand hygiene” and identify
when to wash hands 60 1. Demonstrate how to recognize and respond to
medical emergencies 91
6. Discuss the use of personal protective
equipment (PPE) in facilities 62 2. Demonstrate knowledge of CPR and
first aid procedures 92
7. List guidelines for handling equipment
and linen 65 3. Describe disaster guidelines 104

8. Explain how to handle spills 66

9. Explain transmission-based precautions 67
8 Human Needs and
Human Development
10. Define “bloodborne pathogens” and describe
two major bloodborne diseases 70 1. Identify basic human needs 108

11. Explain OSHA’s Bloodborne 2. Define “holistic care” and explain its
Pathogen Standard 71 importance in health care 109

12. Define “tuberculosis” and list infection 3. Explain why independence and self-care
control guidelines 72 are important 109

13. Define the terms “MRSA,” “VRE,” 4. Explain ways to accommodate sexual needs 111
and “C. Difficile” 74 5. Identify ways to help residents meet their
14. List employer and employee responsibilities spiritual needs 112
for infection control 75 6. Identify ways to accommodate cultural
and religious differences 113
6 Safety and Body Mechanics 7. Describe the need for activity 115
1. Identify the persons at greatest risk for accidents 8. Discuss family roles and their significance in
and describe accident prevention guidelines 77 health care 116
2. List safety guidelines for oxygen use 80 9. List ways to respond to emotional needs
3. Explain the Material Safety Data Sheet (MSDS) 81 of residents and their families 117

4. Define the term “restraint” and give reasons 10. Describe the stages of human growth and
why restraints were used 83 development and identify common disorders
for each group 118
5. List physical and psychological problems
associated with restraints 83 11. Distinguish between what is true and
what is not true about the aging process 122
6. Define the terms “restraint-free” and
“restraint alternatives” and list examples of 12. Explain developmental disabilities and
restraint alternatives 84 list care guidelines 123

7. Describe guidelines for what must be done if a 13. Identify community resources available to help the
restraint is ordered 85 elderly 126
vi

Learning Objective Page Learning Objective Page

9 The Healthy Human Body 12 The Resident’s Unit

1. Describe body systems and define key 1. Explain why a comfortable environment
anatomical terms 127 is important for the resident’s well-being 183
2. Describe the integumentary system 128 2. Describe a standard resident unit 184
3. Describe the musculoskeletal system 129 3. Discuss how to care for and clean
unit equipment 186
4. Describe the nervous system 131
4. Explain the importance of sleep and
5. Describe the cardiovascular system 134
factors affecting sleep 186
6. Describe the respiratory system 136
5. Describe bedmaking guidelines and
7. Describe the urinary system 137 perform proper bedmaking 187
8. Describe the gastrointestinal system 138
9. Describe the endocrine system 140 13 Personal Care Skills
10. Describe the reproductive system 141 1. Explain personal care of residents 193

11. Describe the immune and lymphatic systems 143 2. Identify guidelines for providing good skin care
and preventing pressure sores 195
3. Explain guidelines for assisting with bathing 199
10 Positioning, Lifting, and Moving
4. Explain guidelines for assisting with grooming 208
1. Review the principles of body mechanics 146
5. List guidelines for assisting with dressing 214
2. Explain beginning and ending steps in
care procedures 147 6. Identify guidelines for good oral care 216
3. Explain positioning and describe how to safely 7. Define “dentures” and explain how to
position residents 148 care for dentures 220
4. Describe how to safely transfer residents 157
5. Discuss how to safely ambulate residents 166 14 Basic Nursing Skills
1. Explain the importance of monitoring
vital signs 223
11 Admitting, Transferring, and
2. List guidelines for taking body temperature 223
Discharging
3. List guidelines for taking pulse
1. Describe how residents may feel when
and respirations 230
entering a facility 171
4. Explain guidelines for taking blood pressure 233
2. Explain the nursing assistant’s role in
the admission process 172 5. Describe guidelines for pain management 236
3. Explain the nursing assistant’s role during an 6. Explain the benefits of warm and
in-house transfer of a resident 177 cold applications 237
4. Explain the nursing assistant’s role in 7. Explain how to apply non-sterile dressings and
the discharge of a resident 178 discuss sterile dressings 243
5. Describe the nursing assistant’s role 8. Discuss guidelines for non-sterile bandages 245
in physical exams 179
9. List care guidelines for a resident who is
on an IV 245
10. Discuss oxygen therapy and explain
related care guidelines 247
 vii

Learning Objective Page Learning Objective Page

15 Nutrition and Hydration 2. List factors affecting bowel elimination 296

1. Describe the importance of good nutrition 250 3. Describe common diseases and disorders
of the gastrointestinal system 298
2. List the six basic nutrients and explain
the USDA’s MyPyramid 250 4. Discuss how enemas are given 300

3. Identify nutritional problems of the elderly or ill 254 5. Demonstrate how to collect a stool specimen 304

4. Describe factors that influence food preferences 256 6. Explain occult blood testing 305

5. Explain the role of the dietary department 257 7. Define the term “ostomy” and list
care guidelines 306
6. Explain special diets 257
8. Explain guidelines for assisting with
7. Explain thickened liquids and identify bowel retraining 308
three basic thickened consistencies 261
8. Describe how to make dining enjoyable 18 Common Chronic and
for residents 261
Acute Conditions
9. Explain how to serve meal trays and
assist with eating 262 1. Describe common diseases and
disorders of the integumentary system 310
10. Describe how to assist residents with
special needs 266 2. Describe common diseases and
disorders of the musculoskeletal system 312
11. Define “dysphagia” and identify signs
and symptoms of swallowing problems 268 3. Describe common diseases and
disorders of the nervous system 318
12. Explain intake and output (I&O) 269
4. Describe common diseases and
13. Identify ways to assist residents in disorders of the cardiovascular system 324
maintaining fluid balance 271
5. Describe common diseases and
disorders of the respiratory system 328
16 Urinary Elimination
6. Describe common diseases and
1. List qualities of urine and identify signs and disorders of the endocrine system 331
symptoms about urine to report 275
7. Describe common diseases and
2. List factors affecting urination and disorders of the reproductive system 335
demonstrate how to assist with elimination 275
8. Describe common diseases and
3. Describe common diseases and disorders of the immune and lymphatic systems 337
disorders of the urinary system 281
9. Identify community resources for
4. Describe guidelines for urinary catheter care 285 residents who are ill 343
5. Identify types of urine specimens
that are collected 289 19 Confusion, Dementia, and
6. Explain types of tests performed on urine 292 Alzheimer’s Disease
7. Explain guidelines for assisting with 1. Describe normal changes of aging in the brain 346
bladder retraining 294
2. Discuss confusion and delirium 346
3. Describe dementia and define related terms 347
17 Bowel Elimination
4. Describe Alzheimer’s disease and
1. List qualities of stools and identify signs
identify its stages 348
and symptoms to report about stool 296
viii

Learning Objective Page Learning Objective Page

5. Identify personal attitudes helpful in caring for 21 Rehabilitation and

residents with Alzheimer’s disease 350
Restorative Care
6. List strategies for better communication with
residents with Alzheimer’s disease 351 1. Discuss rehabilitation and restorative care 375

7. Explain general principles that will help assist 2. Describe the importance of promoting
residents with personal care 353 independence and list ways exercise
improves health 377
8. List and describe interventions for problems
with common activities of daily living (ADLs) 353 3. Describe assistive devices and equipment 378

9. List and describe interventions for common 4. Explain guidelines for maintaining proper
difficult behaviors related to Alzheimer’s disease 356 body alignment 379

10. Describe creative therapies for residents 5. Explain care guidelines for prosthetic devices 379
with Alzheimer’s disease 361 6. Describe how to assist with range of
11. Discuss how Alzheimer’s disease may motion exercises 381
affect the family 363 7. Describe the benefits of deep
12. Identify community resources available to breathing exercises 385
people with Alzheimer’s disease and their families 364
22 Special Care Skills
20 Mental Health and 1. Understand the types of residents who are
Mental Illness in a subacute setting 386

1. Identify seven characteristics of mental health 366 2. Discuss reasons for and types of surgery 386

2. Identify four causes of mental illness 366 3. Discuss preoperative care 387

3. Distinguish between fact and fallacy 4. Describe postoperative care 388

concerning mental illness 367 5. List care guidelines for pulse oximetry 389
4. Explain the connection between mental 6. Describe telemetry and list care guidelines 390
and physical wellness 367
7. Explain artificial airways and list care guidelines 390
5. List guidelines for communicating with
mentally ill residents 367 8. Discuss care for a resident with a tracheostomy 391

6. Identify and define common 9. List care guidelines for residents

defense mechanisms 368 requiring mechanical ventilation 392

7. Describe the symptoms of anxiety, 10. Describe suctioning and list signs
depression, and schizophrenia 368 of respiratory distress 393

8. Explain how mental illness is treated 371 11. Describe chest tubes and explain related care 393

9. Explain your role in caring for residents

who are mentally ill 371 23 Death and Dying
10. Identify important observations that 1. Discuss the stages of grief 396
should be made and reported 372 2. Describe the grief process 397
11. List the signs of substance abuse 372 3. Discuss how feelings and attitudes
about death differ 397
4. Discuss how to care for a dying resident 398
 ix

Learning Objective Page Learning Objective Page

5. Describe ways to treat dying residents and 7. Identify guidelines for using your car on the job 426
their families with dignity and honor their rights 399
8. Identify guidelines for working in
6. Define the goals of a hospice program 401 high-crime areas 427
7. Explain common signs of approaching death 403
8. List changes that may occur in the 26 Medications in Home Care
human body after death 403 1. List four guidelines for safe and proper
9. Describe postmortem care 403 use of medications 429
2. Identify the five “rights” of medications 430
24 Introduction to Home Care 3. Explain how to assist a client with
self-administered medications 430
1. Explain the purpose of and need for
home health care 406 4. Identify observations about medications
that should be reported right away 433
2. Describe a typical home health agency 407
5. Describe what to do in an emergency
3. Explain how working for a home health agency
involving medications 433
is different from working in other types of facilities 408
6. Identify methods of medication storage 433
4. Discuss the client care plan and explain
how team members contribute to the care plan 409 7. Identify signs of drug misuse and abuse
and know how to report these 434
5. Describe the role of the home health
aide and explain typical tasks performed 410
6. Explain common policies and procedures 27 New Mothers, Infants,
for home health aides 412 and Children
7. Demonstrate how to organize care assignments 413 1. Explain the growth of home care for new
mothers and infants 436
8. Identify an employer’s responsibilities 413
2. Identify common neonatal disorders 436
9. Identify the client’s rights in home health care 414
3. Explain how to provide postpartum care 436

25 Infection Prevention and 4. List important observations to report

and document 438
Safety in the Home
5. Explain guidelines for safely handling a baby 438
1. Discuss disinfection in the home 418
6. Describe guidelines for assisting with
2. Describe guidelines for assisting a client
feeding a baby 439
when isolation precautions have been ordered 419
7. Explain guidelines for bathing and
3. List ways to adapt the home to principles
changing a baby 443
of good body mechanics 420
8. Identify how to measure weight and
4. Identify common types of accidents in
length of a baby 447
the home and describe prevention guidelines 421
9. Explain guidelines for special care 448
5. List home fire hazards and describe fire
safety guidelines 425 10. Identify special needs of children and
describe how children respond to stress 450
6. Identify ways to reduce the risk of
automobile accidents 426 11. List symptoms of common childhood
illnesses and the required care 451
x

Learning Objective Page Learning Objective Page

12. Identify guidelines for working with children 451 30 Managing Time, Energy, and
13. List the signs of child abuse and Money in the Home
neglect and know how to report them 452
1. Explain three ways to work more efficiently 479
2. Describe how to follow an established work
28 Meal Planning, Shopping, plan with the client and family 480
Preparation, and Storage
3. Discuss ways to handle inappropriate requests 480
1. Explain how to prepare a basic food plan and list
food shopping guidelines 455 4. List five money-saving homemaking tips 480

2. List and define common health claims 5. List guidelines for handling a client’s money 481
on food labels 457
3. Explain the information on the FDA-required 31 Caring for Your Career
Nutrition Facts label 459 and Yourself
4. List guidelines for safe food preparation 460 1. Discuss different types of careers in the
5. Identify methods of food preparation 461 healthcare field 483

6. Identify four methods of low-fat 2. Explain how to find a job and how to
food preparation 463 write a résumé 484

7. List four guidelines for safe food storage 464 3. Identify information that may be required
when filling out a job application 485
4. Discuss proper job interview techniques 487
29 The Clean, Safe, and Healthy
Home Environment 5. Describe a standard job description 488

1. Describe how housekeeping affects 6. Discuss how to manage and resolve conflict 488
physical and psychological well-being 466 7. Describe employee evaluations and discuss
2. List qualities needed to manage a home and appropriate responses to criticism 489
describe general housekeeping guidelines 466 8. Explain how to make job changes 490
3. Describe cleaning products and equipment 468 9. Identify guidelines for maintaining
4. Describe proper cleaning methods for living certification and explain the state’s registry 490
areas, kitchens, bathrooms, and storage areas 468 10. Describe continuing education 491
5. Describe how to prepare a cleaning schedule 473 11. Define “stress” and “stressors” 491
6. List special housekeeping procedures to 12. Explain ways to manage stress 492
use when infection is present 473
13. Describe a relaxation technique 494
7. Explain how to do laundry and care for clothes 474
14. List ways to remind yourself of the
8. List special laundry precautions to importance of the work you have chosen to do 494
use when infection is present 476
Abbreviations 496
9. List guidelines for teaching housekeeping
skills to clients’ family members 476 Appendix 499
10. Identify hazardous household materials 477 Glossary 501
Index 519
 xi

Procedure Page Procedure Page

Procedures Measuring and recording weight of an

ambulatory resident 175
Measuring and recording height of a resident 176
Washing hands 61
Transferring a resident 177
Putting on gloves 63
Discharging a resident 179
Taking off gloves 63
Making an occupied bed 188
Putting on a gown 64
Making an unoccupied bed 190
Putting on mask and goggles 65
Making a surgical bed 191
Performing abdominal thrusts for the
conscious person 95 Giving a complete bed bath 200

Clearing an obstructed airway in a Giving a back rub 203

conscious infant 96
Shampooing hair 205
Responding to shock 97
Giving a shower or tub bath 207
Responding to a heart attack 98
Providing fingernail care 209
Controlling bleeding 98
Providing foot care 210
Responding to poisoning 99
Shaving a resident 211
Treating burns 100
Combing or brushing hair 213
Responding to fainting 101
Dressing a resident with an affected (weak)
Responding to a nosebleed 101 right arm 215

Responding to seizures 103 Providing oral care 216

Responding to vomiting 104 Providing oral care for the

unconscious resident 217
Helping a resident sit up using the arm lock 149
Flossing teeth 218
Moving a resident up in bed 150
Cleaning and storing dentures 220
Moving a resident to the side of the bed 152
Taking and recording an oral temperature 226
Turning a resident 153
Taking and recording a rectal temperature 228
Logrolling a resident with one assistant 154
Taking and recording a tympanic temperature 229
Assisting a resident to sit up on
side of bed: dangling 155 Taking and recording an axillary temperature 229

Applying a transfer belt 157 Taking and recording apical pulse 231

Transferring a resident from bed to wheelchair 159 Taking and recording radial pulse and counting
and recording respirations 232
Transferring a resident from bed to stretcher 161
Taking and recording blood pressure
Transferring a resident using a mechanical lift 163
(one-step method) 234
Transferring a resident onto and off of a toilet 164
Taking and recording blood pressure
Transferring a resident into a car 165 (two-step method) 235
Assisting a resident to ambulate 166 Applying warm compresses 238
Assisting with ambulation for a resident using a Administering warm soaks 239
cane, walker, or crutches 168
Applying an Aquamatic K-Pad ® 240
Admitting a resident 174
xii

Procedure Page Procedure Page

Assisting with a sitz bath 241 Sterilizing bottles 442

Applying ice packs 242 Assisting with bottle feeding 442
Applying cold compresses 242 Burping a baby 442
Changing a dry dressing using non-sterile Giving an infant sponge bath 444
technique 243
Giving an infant tub bath 445
Assisting in changing clothes for a resident who
Changing cloth or disposable diapers 446
has an IV 246
Measuring a baby’s weight 447
Feeding a resident who cannot feed self 265
Measuring a baby’s length 448
Measuring and recording intake and output 270
Taking an infant’s axillary or tympanic
Serving fresh water 272
temperature 449
Assisting a resident with the use of a bedpan 278
Cleaning a bathroom 472
Assisting a male resident with a urinal 280
Doing the laundry 475
Assisting a resident to use a portable
commode or toilet 280
Providing perineal care for an
incontinent resident 282
Providing catheter care 286
Emptying the catheter drainage bag 287
Applying a condom catheter 288
Collecting a routine urine specimen 289
Collecting a clean catch (mid-stream)
urine specimen 290
Collecting a 24-hour urine specimen 291
Testing urine with reagent strips 293
Giving a cleansing enema 301
Giving a commercial enema 303
Collecting a stool specimen 304
Testing a stool specimen for occult blood 305
Caring for an ostomy 307
Putting elastic stockings on a resident 327
Collecting a sputum specimen 331
Providing foot care for the diabetic resident 334
Assisting with passive range of motion exercises 381
Disinfecting using wet heat 419
Disinfecting using dry heat 419
Picking up and holding a baby 438
xiii
18 xiv

Using a
Hartman
Using a Hartman Textbook

Textbook

Understanding how your book

is organized and what its special
features are will help you make
the most of this resource!
 xv 18

We have assigned each chapter its own colored tab.

Each colored tab contains the chapter number and
title, and you’ll see them on the side of every page.

Using a Hartman Textbook

1. List examples of legal and Everything in this book, the student workbook, and
ethical behavior your instructor’s teaching material is organized
around learning objectives. A learning objective is a
very specific piece of knowledge or a very specific skill.
After reading the text, if you can do what the learning
objective says, you know you have mastered the
material.

bloodborne pathogens You’ll find bold key terms throughout the text followed
by their definition. They are also listed in the glossary
at the back of this book.

All care procedures are highlighted by the same black

Giving a back rub
bar for easy recognition.

Care Guidelines and Observing and Reporting are

Guidelines:
colored green for easy reference.
Handwashing

Residents’ Rights These boxes teach important information on how to

support and promote Resident’s Rights, as well as
Cuts, Scrapes and Rashes
providing other types of important information.
When you have any kind of opening, such as a cut,
scrape, or rash, on the skin of your hands, you
should report this to your supervisor. If your health
Chapter
service or Review
doctor has cleared you to be at work, you
Chapter-ending questions test your knowledge of the
may want to double-glove (put two complete sets of information found in the chapter. If you have trouble
gloves on) while working, until the openings in your answering a question, you can return to the text and
skin have healed. reread the material.
 1 1

Understanding Healthcare Settings

Understanding
Healthcare Settings
1. Discuss the structure of the healthcare hospitals or other healthcare settings. Their
system and describe ways it is changing length of stay (the number of days a person
stays in a healthcare facility) may be short, such
Welcome to the world of health care. Health care as a few days or a few months, or longer than six
is a growing field. The healthcare system refers months. Some of these people will have a termi-
to all the different kinds of providers, facili- nal illness, which means that the person is ex-
ties, and payers involved in delivering medical pected to die from the illness. Other people may
care. Providers are people or organizations that recover and return to their homes or to other liv-
provide health care, including doctors, nurses, ing facilities or situations.
clinics, and agencies. Facilities are places where
care is delivered or administered, including Most conditions seen in LTC are chronic. This
hospitals, long-term care facilities or nursing means they last a long period of time, even a
homes, and treatment centers. Payers are people lifetime. Chronic conditions include physical
or organizations paying for healthcare services. disabilities, heart disease, stroke, and dementia.
These include insurance companies, govern- (You will learn more about these disorders and
ment programs like Medicare and Medicaid, and diseases in Chapter 18.)
the individual person needing care. Together, all People who live in long-term care facilities are
these people, places, and organizations make up usually called “residents” because it is where
our healthcare system. they reside or live. These places are their homes
This textbook will focus on two types of care: for the duration of their stay (Fig. 1-1).
long-term care and home health care. Long-
term care (LTC) is given in long-term care
facilities (LTCF) for people who need 24-hour,
supervised nursing care. This type of care is
given to people who need a high level of care for
ongoing conditions. The term “nursing homes”
was once widely used to refer to these facilities;
Now, however, they are often called long-term
care facilities, skilled nursing facilities, residen-
tial facilities, rehabilitation centers, or extended
care facilities. Fig. 1-1. Long-term care is given to people who need a
high level of care for ongoing conditions. People who live
People who live in long-term care facilities may in long-term care facilities are called “residents” because
be disabled and/or elderly. They may arrive from they reside in the facility and it is their home.
 1 2

Home health care takes place in a person’s Other healthcare settings include the following:
home (Fig. 1-2). This type of care is also gen-
• Assisted living facilities provide some help
erally given to people who are older and are
with daily care, such as showers, meals, and
chronically ill but who are able to and wish to
Understanding Healthcare Settings

dressing. Help with medications may also

remain at home. Home care may also be needed
be given. People who live in these facilities
when a person is weak after a recent hospital
do not need skilled, 24-hour care, and they
stay. Skilled assistance or monitoring may be
are relatively independent. Assisted living
required. People who receive home care are usu-
facilities allow more independent living in a
ally referred to as “clients.”
home-like environment. A resident can live
in a single room or an apartment; however,
some residents have roommates. An assisted
living facility may be attached to a long-term
care facility, or it may stand alone. “Boarding
home” is another term that may be used to
refer to assisted living facilities.
• Adult daycare is care given at a facility dur-
Fig. 1-2. Home care is performed in a person’s home. ing daytime working hours. Generally, adult
People receiving home care are generally referred to as daycare is for people who need some help
“clients.”
but are not seriously ill or disabled. Adult
In some ways, working as a home health aide daycare centers give different levels of care.
is similar to working as a nursing assistant. Al- Adult daycare can also provide a break for
most all care described in this textbook for nurs- spouses, family members, and friends.
ing assistants applies to home health aides. Most • Acute care is given in hospitals and ambu-
of the personal care and basic nursing proce- latory surgical centers. It is for people who
dures are the same. Home health aides may also have an immediate illness. People are admit-
clean, shop for groceries, do laundry, and cook. ted for short stays for surgery or diseases.
There is information on home care throughout Acute care is 24-hour skilled care for tempo-
the textbook, but Chapters 24 through 30 deal rary, but serious, illnesses or injuries (Fig.
solely with home care. 1-3). Skilled care is medically necessary care
Home health aides may have more contact with given by a skilled nurse or therapist. This
the client’s family. They also will work more care is available 24 hours a day. It is ordered
independently, although a supervisor monitors by a doctor, and involves a treatment plan.
their work. The advantage of home health care is
that clients do not have to leave home. They may
have lived there for many years, and staying at
home can be comforting.
People who need long-term care or home care
will have different diagnoses, or medical con-
ditions determined by a doctor. The stages of
illnesses or diseases affect how sick people are
and how much care they will need. The job of
nursing assistants and home health aides will
also vary. This is due to each person’s different Fig. 1-3. Acute care is performed in hospitals for illnesses
symptoms, abilities, and needs. or injuries that require immediate care.
 3 1

• Subacute care can be given in a hospital or As a reaction to the increased costs of traditional
in a long-term care facility. Subacute care is insurance plans, many employers and employees
given to people who have had an acute injury belong to health maintenance organizations
or illness or problem resulting from a dis- (HMOs). HMOs require that you use a particu-

Understanding Healthcare Settings

ease. These patients need treatment that re- lar doctor or group of doctors except in case of
quires more care and observation than some emergency. The doctors working for HMOs are
long-term care facilities can give and less paid to provide care while keeping costs down.
care than acute illnesses require. Treatment Thus they may see more patients, order fewer
usually ends when the condition has stabi- tests, or cut costs in other ways.
lized and/or after the predetermined time
Preferred provider organizations (PPOs) are
period for treatment has been completed.
another healthcare option used to reduce costs.
The cost is usually less than a hospital but
A PPO is a network of providers that contract
more than long-term care. You will learn
to provide health services to a group of people.
more about subacute care in Chapter 22.
Employees are given incentives to use network
• Outpatient care is usually given for less providers. Employers are given reduced, fee-for-
than 24 hours. It is for people who have had service rates for getting employees to participate
treatments or surgery and need short-term in the network. A person in a PPO may still get
skilled care. health care outside the network of providers, but
must pay a higher portion of the cost.
• Rehabilitation is care given in facilities or
homes by a specialist. Physical, occupational, If you become seriously ill, you may be admit-
and speech therapists restore or improve ted to a hospital. The costs of hospital care have
function after an illness or injury. You will risen greatly. To make up for it, healthcare pay-
learn more about rehabilitation and related ers are controlling who can be admitted to a
care in Chapter 21. hospital and for how long. After release from
the hospital, many people need continuing care.
• Hospice care is given in facilities or homes
This is particularly true as people are released
for people who have six months or less to
after shorter hospital stays. Continuing care may
live. Hospice workers give physical and
be provided in a long-term care facility, a reha-
emotional care and comfort, while also sup-
bilitation hospital, or by a home health agency.
porting families. You will learn more about
The type of care depends on the medical condi-
hospice care in Chapter 23.
tion and needs of the patient or client.
Who will pay for medical care may determine
Our healthcare system is constantly changing.
what kind of care a person receives and where he
As we develop new and better ways of caring
receives it. Often payers control the amount and
for people, care becomes more expensive. Better
types of healthcare services people receive. Tradi-
health care helps people live longer, which leads
tional insurance companies offer plans that pay
to a larger elderly population that may need ad-
for the health care of plan members. Most peo-
ditional health care. New discoveries and expen-
ple covered by traditional insurance are part of
sive equipment have also driven healthcare costs
a plan at their place of work. The costs are paid
higher (Fig. 1-4).
for by the employer, the employee, or shared by
both. The costs have risen greatly, however, and HMOs and PPOs continue to replace traditional
many employers and employees can no longer insurance plans. This affects the amount and
afford to pay for traditional insurance plans. quality of health care provided. These cost con-
 1 4

trol strategies are often called managed care. In nary disease (COPD), cancer, and congestive
the past, the goal of health care was to make sick heart failure (CHF)
people well. Today it is to get sick people well in
When specialized care is offered at long-term
the most efficient (least expensive) way possible.
Understanding Healthcare Settings

care facilities, the employees must have special

training. Residents with similar needs may be
placed in units together. Non-profit companies
or for-profit companies can own long-term care
facilities.

3. Describe residents who live in

long-term care facilities
There are some general statements that can be
made about residents in nursing homes. How-
Fig. 1-4. Technology makes it possible to offer better ever, more important than understanding the
health care, but equipment can be expensive. entire population is understanding the individu-
als for whom you will care. Make sure you know
2. Describe a typical long-term care how to care for residents based on their needs,
facility illnesses, and preferences.
According to the National Center for Health
Long-term care facilities (LTCF) are businesses
Statistics, almost 91 percent of long-term care
that provide skilled nursing care 24 hours a day.
residents in the U.S. are over age 65. Only nine
These facilities may offer assisted living hous-
percent are younger than 65. Almost 72 percent
ing, dementia care, or subacute care. Some facili-
of residents are female (Fig. 1-5). More than 85
ties offer specialized care, while others care for
percent are Caucasian. This is a much larger
all types of residents. The typical long-term care
percentage than the U.S. population as a whole.
facility offers personal care for all residents and
About one-third of residents come from a private
focused care for residents with special needs.
residence; over 50 percent come from a hospital
Personal care includes bathing, skin, nail and
or other facility.
hair care, and assistance with walking, eating,
dressing, transferring, and toileting. All of these
daily personal care tasks are called “activities of
daily living,” or ADLs.
Other common services offered at LTCFs in-
clude the following:
• Physical, occupational, and speech therapy
• Wound care
• Care of different types of tubes and cath-
eters (a thin tube inserted into the body that
is used to drain fluids or inject fluids)
• Nutrition therapy
• Management of chronic diseases, such as Fig. 1-5. Caucasian women make up a high percentage
AIDS, diabetes, chronic obstructive pulmo- of residents in long-term care facilities.
 5 1

The length of stay of almost one-half of residents 4. Explain policies and procedures
is six months or more. These residents need
enough help with their activities of daily living You will be told where to locate a list of policies
that 24-hour care is needed. Often, they did not and procedures that all staff members are ex-

Understanding Healthcare Settings

have caregivers available to give enough care for pected to follow. A policy is a course of action
them to live in the community. The groups with that should be taken every time a certain situ-
the longest average stay are the developmentally ation occurs. For example, a very basic policy
disabled. They are often younger than 65. You is that healthcare information must remain
will learn more about these groups in Chapter 8. confidential. A procedure is a method, or way,
of doing something. For example, your facility
The other half of residents stay for less than six will have a procedure for reporting information
months. This group generally falls into two cat- about residents. The procedure explains what
egories. The first category is residents admitted form to complete, when and how often to fill it
for terminal care. They will die in the facility. out, and to whom it is given. You will be told
The second category is residents admitted for where to find a list of policies and procedures
rehabilitation or temporary illness. They will that all staff are expected to follow.
recover and return to the community. As you
can imagine, care of these residents may be very Common policies at long-term care facilities in-
different. clude the following:

Dementia is defined as the loss of mental abili­ • All resident information must remain con-
ties, such as thinking, remembering, reason­ fidential. This is not only a facility rule, it
ing, and communicating. Various studies place is also the law. See Chapter 3 for more in-
the number of nursing home residents with formation on confidentiality, including the
dementia between 50 and 90 percent. Dementia Health Insurance Portability and Account-
and other mental disorders are major causes of ability Act (HIPAA).
nursing home admissions. Many residents are • The plan of care must always be followed.
admitted with other disorders as well. However, Nursing assistants should perform tasks as-
the disorders themselves are often not the main signed by the care plan. They should not do
reason for admission. It is most often the lack of any tasks that are not included or approved
ability to care for oneself and the lack of a sup­ by the nurse.
port system that leads people into a facility.
• Nursing assistants should not do tasks not
A support system is vital in allowing the elderly included in the job description.
to live outside a facility. For every elderly person
• Nursing assistants must report important
living in a long-term care facility, at least two
events or changes in residents to a nurse.
with similar disorders and disabilities live in the
community. • Personal problems must not be discussed
with the resident or the resident’s family.
You may notice the lack of outside support given
to your residents. It is one reason you will care • Nursing assistants should not take money or
for the “whole person” instead of only the illness gifts from residents or their families
or disease. Residents have many needs besides (Fig. 1-6).
bathing, eating, drinking, and toileting. These
• Nursing assistants must be on time for
needs will go unmet if staff do not work to meet
work. They must be dependable.
them.
 1 6

When surveyors are in your facility, try not to be

nervous. Give the same great care you do every
day. Answer any questions to the best of your
ability. If you do not know the answer, be hon-
Understanding Healthcare Settings

est. Never guess. Tell the surveyor that you do

not know the answer but will find out as quickly
as possible, then do just that. Do not offer any
information unless asked.
The Joint Commission, formerly the Joint
Fig. 1-6. Nursing assistants should not accept money or
gifts because it is unprofessional and may lead to conflict. Commission on Accreditation of Healthcare Or-
ganizations (JCAHO), is an independent, not-for-
Your employer will have policies and procedures profit organization that evaluates and accredits
for every resident care situation. Written proce- healthcare organizations. Its goal is to improve
dures may seem long and complicated, but each the safety and quality of care given to patients,
step is important. Become familiar with your clients, and residents. For an organization to re-
facility’s policies and procedures. ceive accreditation from the Joint Commission,
it must undergo a comprehensive survey process
at least every three years. The survey process
5. Describe the long-term care survey
includes carefully checking performance in spe-
process
cific areas, such as patient rights, treatment, and
Inspections are done to make sure long-term infection prevention.
care facilities (and home health agencies) follow The surveys that the Joint Commission performs
state and federal regulations. Inspections are are not affiliated with state inspections. Health-
done every 9 to 15 months by the state agency care organizations are not required to participate
that licenses facilities. These inspections are in the Joint Commission’s survey process; this
called surveys. They may be done more often if is done on a volunteer basis. Organizations that
a facility has been cited. To cite means to find a are accredited by the Joint Commission include
problem through a survey. Inspections may be hospitals, long-term care facilities, rehabilitation
done less often if the facility has a good record. centers, hospice services, home care agencies,
Inspection teams include a variety of trained laboratories, and other organizations.
healthcare professionals.
Surveyors study how well staff care for residents.
6. Explain Medicare and Medicaid
They focus on how residents’ nutritional, physi-
cal, social, emotional, and spiritual needs are The Centers for Medicare & Medicaid Ser-
being met. They interview residents and family vices (CMS), formerly known as the Health
and observe staff’s interactions with residents Care Finance Administration (HCFA), is a
and the care given. They review resident charts federal agency within the U.S. Department of
and observe meals. Surveys are one reason the Health and Human Services (Fig. 1-7). CMS
“paperwork” part of a nursing assistant’s job is runs two national healthcare programs—Medi-
so important. care and Medicaid. They both help pay for health
care and health insurance for millions of Ameri-
If a facility is cited for not following a federal
cans. CMS has many other responsibilities as
regulation, surveyors use federal tags (F-tags) to
well.
note these problems.
 7 1

pay the full cost of most covered home healthcare

services. However, Medicare will not pay for round-
the-clock home health care. Home health care plays
an important role when skilled care is needed on a

Understanding Healthcare Settings

part-time basis.

7. Discuss the term “culture change” and

describe Pioneer Network and The Eden
Alternative
Culture change is a term given to the process of
transforming services for elders so that they are
Fig. 1-7. The CMS website’s address is cms.hhs.gov.
based on the values and practices of the person
receiving care. Culture change involves respect-
Medicare is a health insurance program that
ing both elders and those working with them.
was established in 1965 for people aged 65 or
Core values are choice, dignity, respect, self-
older. It also covers people of any age with per-
determination, and purposeful living. To honor
manent kidney failure or certain disabilities.
culture change, healthcare settings may need to
Medicare currently covers more than 40 million
change organization practices, physical environ-
people. Medicare has two parts: Hospital Insur-
ments, and relationships at all levels.
ance (Part A), and Medical Insurance (Part B).
Part A helps pay for care in a hospital or skilled Pioneer Network was formed in 1997 by a small
nursing facility or for care from a home health group of professionals in long-term care to advo-
agency or hospice. Part B helps pay for physician cate for person-directed care. This group called
services and various other medical services and for a change in how elders are treated wherever
equipment. Medicare will only pay for care it de- they live—whether in care facilities or at home.
termines to be medically necessary. Pioneer Network promotes a movement away
from institutions and promotes caring environ-
Medicaid is a medical assistance program for
ments in which a person’s individual voice is
low-income people. It is funded by both the fed-
heard and his or her choices are respected. For
eral government and each state. Eligibility is de-
more information about this organization, visit
termined by income and special circumstances.
pioneernetwork.net.
People must qualify for this program.
The Eden Alternative is a not-for-profit organiza-
Medicare and Medicaid pay long-term care facili-
tion founded in the mid 1990s by Dr. William
ties a fixed amount for services. This is based on
Thomas. Its ongoing focus is to improve the
the resident’s need upon admission.
lives of elders and their caregivers by creating
environments that support growth and devel-
Home Care Focus
opment, while trying to eliminate problems of
For home care, Medicare pays for intermittent, not loneliness, helplessness, and boredom that many
continuous, services provided by a certified home elderly people suffer.
health agency. The agency must meet specific guide-
lines established by Medicare. To qualify for home The Eden Alternative offers education, resources
health care, Medicare recipients must usually be and consulting services to help make environ-
unable to leave home, and their doctors must deter-
mine that they need home health care. Medicare will
ments for the elderly meaningful. Places that
have adopted the Eden Alternative’s philosophy
 1 8

are typically filled with plants and animals, and 8. List two ways that surveyors study how well
are regularly visited by children. The Eden Alter- staff care for residents in a facility.
native strives to improve the quality of life and
9. Briefly describe what the Medicare and Med-
quality of care for the elderly (Fig. 1-8). For more
Understanding Healthcare Settings

icaid programs do.

information about this organization, visit their
website at edenalt.org. 10. List three problems that elderly people
may face that The Eden Alternative tries to
eliminate.

Fig. 1-8. The Eden Alternative focuses on eliminating

boredom, loneliness, and helplessness by promoting
meaningful elder care. (photo courtesy of the eden alternative)

Chapter Review
1. What is long-term care?
2. What is home health care?
3. List one fact about each of the following
healthcare settings: assisted living facilities,
adult daycare, acute care, subacute care, out-
patient care, rehabilitation, and hospice care.
4. List five services commonly offered at long-
term care facilities.
5. Who makes up the majority of nursing
home residents—men or women?
6. What are two general categories of residents
who stay in a care facility for less than six
months?
7. List five common policies at long-term care
facilities.
 9 2

The Nursing Assistant and the Care Team

The Nursing Assistant and
the Care Team
1. Identify the members of the care team This includes administering special treatments
and describe how the care team works and giving medication as prescribed by a physi-
together to provide care cian. A registered nurse also assigns tasks and
supervises daily care of residents by nursing
Residents will have different needs and prob- assistants.
lems. Healthcare professionals with different
kinds of education and experience will help
care for them. This group is known as the “care
team.” Members of the care team include the
following:
Nursing Assistant (NA) or Certified Nursing
Assistant (CNA). The nursing assistant (NA)
performs delegated tasks, such as taking vital
signs, and provides routine personal care, such
as bathing residents and helping with toileting.
Nursing assistants must have at least 75 hours Fig. 2-1. Observing carefully and reporting accurately are
of training, and in many states, training exceeds some of the most important duties you will have.
100 hours. Nursing assistants spend more time
with residents than other members of the care Licensed Practical Nurse (LPN) or Licensed Vo-
team. That is why they act as the “eyes and ears” cational Nurse (LVN). A licensed practical nurse
of the team. Observing and reporting changes or licensed vocational nurse is a licensed profes-
in the resident’s condition or abilities is a very sional who has completed one to two years of
important role of the NA (Fig. 2-1). education. A LPN/LVN administers medications
and gives treatments. LPNs may also supervise
Registered Nurse (RN). A registered nurse is a
nursing assistants’ daily care of residents.
licensed professional who has completed two
to four years of education. RNs have diplomas Physician or Doctor (MD or DO). A doctor’s job
or college degrees and have passed a licensing is to diagnose disease or disability and prescribe
exam administered by the state board of nurs- treatment. Doctors have graduated from four-
ing. Registered nurses may have additional aca- year medical schools, which they attended after
demic degrees or education in specialty areas. In receiving bachelor’s degrees. Many doctors also
long-term care, a registered nurse coordinates, take specialized training programs after medical
manages, and provides skilled nursing care. school (Fig. 2-2).
 2 10

undergraduate degree before being admitted to

either a doctoral or master’s program, but some
students are admitted without a bachelor’s de-
gree. OTs have to pass a national certification
The Nursing Assistant and the Care Team

examination and most must be licensed within

their state.

Fig. 2-2. Doctors diagnose disease and prescribe

treatment.

Physical Therapist (PT). A physical therapist

evaluates a person and develops a treatment
plan to increase movement, improve circulation,
promote healing, reduce pain, prevent disability,
and help the resident regain or maintain mobil-
ity (Fig. 2-3). A PT administers therapy in the
form of heat, cold, massage, ultrasound, electric-
ity, and exercise to muscles, bones, and joints.
For example, a PT helps a person to safely use
Fig. 2-3. A physical therapist will help restore specific
a walker, cane, or wheelchair. Physical therapist abilities.
education programs are offered at two degree
levels: doctoral and master’s. Entrance into these
programs usually requires an undergraduate de-
gree. Master’s degree programs usually last two
years, and doctoral degree programs last three
years. PTs have to pass national and state licen-
sure exams before they can practice.
Occupational Therapist (OT). An occupational
therapist helps residents learn to compensate
for disabilities. An OT helps residents perform Fig. 2-4. An occupational therapist will help residents
learn to use adaptive devices, such as this one for eating.
activities of daily living (ADLs). ADLs are (photo courtesy of north coast medical, inc. 800-821-9319)

personal daily care tasks. They include bathing,

dressing, caring for teeth and hair, toileting, and Speech-Language Pathologist (SLP). A speech-
eating and drinking. This often involves equip- language pathologist helps with speech and
ment called assistive or adaptive devices (Fig. swallowing problems. An SLP identifies com-
2-4). (See Chapter 21 for more information.) munication disorders, addresses factors involved
For example, an OT can teach a person to use in recovery, and develops a plan of care to meet
a special fork to feed himself. The OT observes short- and long-term recovery goals. An SLP
a resident’s needs and plans a treatment pro- teaches exercises to help the resident improve or
gram. Occupational therapists generally have an overcome speech problems. For example, after
 11 2

a stroke, a person may not be able to speak or team revolves around the resident and his or her
speak clearly. An SLP may use a picture board to condition, treatment, and progress. Without the
help the person communicate thirst or pain. An resident, there is no care team.
SLP also evaluates a person’s ability to swallow

The Nursing Assistant and the Care Team

Information on home health aides as members
food and drink. Speech-language pathologists
of the care team is found in Chapter 24.
(SLPs) are generally required to have a master’s
degree in speech-language pathology. Most
states require that SLPs be licensed or certified 2. Explain the nursing assistant’s role
to work.
Nursing assistants can have many different
Registered Dietitian (RD). A registered dietitian titles. “Nurse aide,” “certified nurse aide,” “unli-
creates diets for residents with special needs. censed assistive personnel,” and “certified nurs-
Special diets can improve health and help man- ing assistant” are some examples. This textbook
age illness. RDs may supervise the prepara- will use the term “nursing assistant.”
tion and service of food and educate others on
Nursing assistants (NAs) perform delegated or
healthy nutritional habits. Registered dietitians
assigned nursing tasks, such as taking a resi-
have completed a bachelor’s degree and may also
dent’s temperature and blood pressure. Delega-
have a master’s degree or have completed post-
tion means transferring authority to a person
graduate work. Most states require that RDs be
for a specific task. Nursing assistants also pro-
licensed or certified.
vide personal care, such as bathing residents,
Medical Social Worker (MSW). A medical social helping them eat and drink, and helping with
worker determines residents’ needs and helps hair care (Fig. 2-5). Promoting independence
get them support services, such as counseling. and self-care are other very important tasks that
He or she may help residents obtain clothing nursing assistants do. Other nursing assistant
and personal items if the family is not involved duties include the following:
or does not visit often. A medical social worker
may book appointments and transportation.
Generally, MSWs hold a master’s degree in so-
cial work.
Activities Director. The activities director plans
activities for residents to help them socialize
and stay physically and mentally active. These
activities are meant to improve and maintain
residents’ well-being and to prevent further com-
plications from illness or disability. An activities
director may have a bachelor’s degree, associate
Fig. 2-5. Encouraging residents to drink often will be an
degree, or qualifying work experience. An activi-
important part of your job.
ties director may be called a “recreational thera-
pist” depending upon education and experience. • Feeding residents
Resident and Resident’s Family. The resident is • Helping residents with toileting needs
an important member of the care team. The resi-
dent has the right to make decisions and choices • Assisting residents to move around safely
about his or her own care. The resident’s family • Keeping residents’ living areas neat and
may also be involved in these decisions. The care clean
 2 12

• Encouraging residents to eat and drink sionalism is how you behave when you are on
the job. It includes how you dress, the words you
• Caring for supplies and equipment
use, and the things you talk about. It also in-
• Helping dress residents cludes being on time, completing tasks, and re-
The Nursing Assistant and the Care Team

• Making beds porting to the nurse. For an NA, professionalism

means following the care plan, making careful
• Giving backrubs
observations, and reporting accurately. Follow-
• Helping residents with mouth care ing policies and procedures is an important part
Nursing assistants are generally not allowed to of professionalism. Residents, coworkers, and
give medications; nurses are responsible for giv- supervisors respect employees who behave in a
ing medications. Some states allow nursing as- professional way. Professionalism will help you
sistants to work with medications after receiving keep your job and may help you earn promotions
special training. Examples of other tasks that and raises.
nursing assistants are generally not allowed to A professional relationship with residents in-
do are inserting/removing tubes, changing ster- cludes the following:
ile dressings, and giving tube feedings.
• Keeping a positive attitude
Nursing assistants spend more time with resi-
• Doing only the assigned tasks you are
dents than other care team members do. They
trained to do and that are listed in the care
act as the “eyes and ears” of the care team. Ob-
plan
serving changes in a resident’s condition and re-
porting them is a very important role of the NA. • Keeping all residents’ information
Another is writing down important information confidential
about the resident; this is called charting. • Being polite and cheerful, even if you are not
Nursing assistants are part of a team of health in a good mood (Fig. 2-6)
professionals. Everyone, including the resident,
works closely together to meet goals. Goals in-
clude helping residents to recover from illnesses
or to do as much as possible for themselves.

Residents’ Rights
Responsibility for Residents
All residents are the responsibility of each nursing
assistant. You will receive assignments to do tasks,
care, and paperwork for specific residents. If you see
a resident who needs help, even if he or she is not
on your assignment sheet, provide the needed care.
Fig. 2-6. Being polite and cheerful is something that will
be expected of you.
3. Explain professionalism and list
• Not discussing your personal problems
examples of professional behavior
• Not using profanity, even if a resident does
Professional means having to do with work or
a job. The opposite of professional is personal, • Listening to the resident
which refers to your life outside your job, such • Calling a resident “Mr.,” “Mrs.,” “Ms.,”, or
as your family, friends, and home life. Profes- “Miss,” or by the name he or she prefers
 13 2

• Never giving or accepting gifts team depends on your honesty in planning care.
• Always explaining the care you will provide Employers count on truthful records of your care
before providing it and observations.

The Nursing Assistant and the Care Team

• Following practices, such as handwashing, to Tactful: Tact is the ability to understand what is
protect yourself and residents proper and appropriate when dealing with oth-
ers. It is the ability to speak and act without of-
A professional relationship with an employer in- fending others.
cludes the following:
Conscientious: People who are conscientious
• Completing tasks efficiently always try to do their best. They are guided by
• Always following all policies and procedures a sense of right and wrong and have principles.
They are always alert, observant, accurate, and
• Always documenting and reporting carefully
responsible. Conscientious care means making
and correctly
accurate observations and reports, following as-
• Communicating problems with residents or signments and the care plan, and taking respon-
tasks sibility for actions (Fig. 2-7). For example, taking
• Reporting anything that keeps you from accurate measurements of vital signs, such
completing duties as temperature or pulse, is important. Other
members of the care team will make treatment
• Asking questions when you do not know or
decisions based on your measurements. Without
understand something
conscientious care, a resident’s health and well-
• Taking directions or criticism without get- being are in danger.
ting upset
• Being clean and neatly dressed and groomed
• Always being on time
• Telling your employer if you cannot report
for work
• Following the chain of command
• Participating in education programs
• Being a positive role model for your facility
Nursing assistants must be
Fig. 2-7. Nursing assistants must be conscientious about
Compassionate: Being compassionate is being documenting observations and procedures.
caring, concerned, considerate, empathetic, and
understanding. Demonstrating empathy means Dependable: Nursing assistants must make and
entering into the feelings of others. Compassion- keep commitments. You must report to work
ate people understand others’ problems. They on time. You must skillfully do assigned tasks,
care about them. Compassionate people are also avoid too many absences, and help your peers
sympathetic. Showing sympathy means sharing when they need it.
in the feelings and difficulties of others. Respectful: Being respectful means valuing
Honest: A person who is honest tells the truth other people’s individuality. This includes their
and can be trusted. Residents need to feel that age, religion, culture, feelings, and beliefs. Peo-
they can trust those who care for them. The care ple who are respectful treat others politely and
 2 14

kindly. You should care about people’s self-es- • Brushing teeth frequently and using mouth-
teem. Do not do or say anything that will harm wash when necessary
it. You must not disrespect others by gossiping • Keeping hair clean and neatly brushed or
about them. Respect the various cultures and
The Nursing Assistant and the Care Team

combed, tying long hair back in a bun or

practices of your residents and others. ponytail
Unprejudiced: You will work with many different • Keeping facial hair short, clean, and neat
people from different backgrounds. You must (men)
give each resident the same quality care regard-
less of age, gender, sexual orientation, religion, • Dressing neatly in a uniform that is washed
race, ethnicity, or condition. and ironed
• Not wearing clothes that are too tight or too
Tolerant: You may not like or agree with things
baggy, torn or stained, or too revealing (short
that your residents or their families do or have
skirts, low-cut blouses, see-through fabrics)
done. However, your job is to care for each resi-
dent as assigned, not to judge him or her. Put • Not wearing large jewelry (the main excep-
aside your opinions, and see each resident as an tion to this rule is to wear a simple, water-
individual who needs your care. proof watch that is used to take vital signs
and record events)

4. Describe proper personal • Not having visible tattoos and body pierc-
grooming habits ings, except for the ear lobes
• Wearing comfortable, clean, and high quality
Regular grooming makes you feel good about
shoes.
yourself, and it makes others feel good about you
(Fig. 2-8). Grooming affects how confident resi- • Keeping fingernails short, smooth, and clean
dents feel about the care you give. Good nursing • Not wearing artificial nails, extenders, over-
assistants have the following personal grooming lays, etc. because they harbor bacteria
habits:
• Wearing little or no makeup
Your facility will have rules about your appear-
ance. Know these rules and always follow them.

5. Explain the chain of command and

scope of practice
As a nursing assistant, you will be carrying out
instructions given to you by a nurse. The nurse
is acting on the instructions of a physician or
Fig. 2-8. Good grooming includes being clean and neatly other member of the care team. This is called
dressed. Keep long hair tied back, and apply makeup the chain of command. It describes the line of
lightly. Wear clean clothes and comfortable, clean shoes.
authority and helps to make sure that your resi-
dents get proper health care. The chain of com-
• Bathing or showering daily and using de-
mand also protects you and your employer from
odorant or anti-perspirant (do not use per-
liability. Liability is a legal term that means
fume or cologne, as some residents may be
someone can be held responsible for harming
intolerant of some odors)
someone else. For example, imagine that some-
 15 2

thing you do for a resident harms him. However, things you are allowed to do and how to do them
what you did was in the care plan and was done correctly.
according to policy and procedure. Then you
Laws and regulations on what NAs can and can-
may not be liable, or responsible, for hurting the

The Nursing Assistant and the Care Team

not do vary from state to state. However, some
resident. However, if you do something not in
procedures are not performed by nursing as-
the care plan that harms a resident, you could
sistants under any circumstances. Tasks that are
be held responsible. That is why it is important
said to be outside the scope of practice of a nurs-
to follow instructions in the care plan and know
ing assistant include the following:
the chain of command (Fig. 2-9).
• NAs do not administer medications unless
trained and assigned to do so.
• NAs do not honor a request to do something
outside the scope of practice, not listed in
the care plan, or not on the assignment
sheet. In this situation an NA should explain
that he or she cannot do the task requested.
The request should then be reported to a
nurse. This is true even if a nurse or doctor
asks the NA to perform the task. The NA
should refuse to perform the task and ex-
plain why. Refusing to do something that the
NA cannot legally do is the NA’s right and
responsibility.
Fig. 2-9. The chain of command describes the line of au-
thority and helps ensure that the resident receives proper • NAs do not usually perform procedures
care. that require sterile technique. For example,
changing a sterile dressing on a deep, open
Nursing assistants must understand what they
wound requires sterile technique.
can and cannot do. This is important so that
you do not harm a resident or involve yourself • NAs do not diagnose or prescribe treatments
or your employer in a lawsuit. Some states cer- or medications.
tify that a nursing assistant is qualified to work. • NAs do not tell the resident or the family
However, nursing assistants are not licensed the diagnosis or the medical treatment plan.
healthcare providers. Everything in your job is This is the responsibility of the doctor or
assigned to you by a licensed healthcare profes- nurse.
sional. You work under the authority of another
Your instructor or employer may provide a list
person’s license. That is why these professionals
of other tasks outside your scope of practice. In
will show great interest in what you do and how
some cases, you may be trained to do a particu-
you do it.
lar task that your employer does not want nurs-
Every state grants the right to practice various ing assistants to perform. Know which tasks
jobs in health care through licensure. Examples these are and do not perform them. Many of
include a license to practice nursing, medicine, these specialized tasks require more training.
or physical therapy. All members of the care It is important to learn how to refuse a task for
team work under each professional’s “scope which you have not been trained, or which is
of practice.” A scope of practice defines the outside your scope of practice.
 2 16

6. Define “care plan” and explain its Many factors are considered when formulating a
purpose care plan. These include the following:

A care plan is created for each resident by the • The resident’s health and physical condition
The Nursing Assistant and the Care Team

nurse or doctor. It is individualized for each resi- • The resident’s diagnosis and treatment
dent to help achieve the goals of care. The resi-
• The resident’s goals or expectations
dent assists with developing the care plan. The
care plan lists the steps and tasks the care team, Multiple care plans may be necessary for some
including nursing assistants, must perform (Fig. residents. In these situations, the nurse will co-
2-10). It states how often these tasks should be ordinate the resident’s overall care. There may
performed and specifies how they should be car- be one care plan for the nursing assistant to fol-
ried out. low. There may be separate care plans for other
providers, such as the physical therapist.
Throughout this text you will read how impor-
tant it is to make observations and report them
to the nurse. Sometimes even simple observa-
tions are very important. The information you
collect, such as vital signs, and the changes you
observe are both important in determining how
care plans may need to change. Because you
spend so much of your time with residents, you
may have a lot of valuable information about
them that will help in care planning. You may
be asked to attend care planning meetings. If
you attend these meetings, do not be afraid to
speak up. Share your observations of your resi-
dents. If you are not sure what is important to
say, speak to a nurse before the meeting to find
Fig. 2-10. Sample resident care plans. (reprinted with permis-
out.
sion of briggs corporation, des moines, Iowa, 800-247-2343,
www.briggscorp.com)

7. Describe the nursing process

The care plan is a guide to help the resident
reach and maintain the best level of health pos- Care plans must be updated as the resident’s
sible. Activities not listed on the care plan should condition changes. Reporting changes and prob-
not be performed. The care plan must be fol- lems to the nurse is a very important role of the
lowed very carefully. nursing assistant. That is how the care team re-
vises care plans to meet the resident’s changing
Care planning should involve input from the
needs.
resident and/or the family, as well as healthcare
professionals. Healthcare professionals will as- To communicate with other care team members,
sess the resident’s physical, financial, social, and nurses use the nursing process (Fig. 2-11). The
psychological needs. After the doctor prescribes process has five steps:
treatment, the supervisor, nurses, and other care
• Assessment: getting information about the
team members formulate the care plan.
resident’s status from different sources,
 17 2

including medical history, physical assess- 8. Describe “The Five Rights of

ment, and environment, and reviewing this Delegation”
information
While care planning, nurses decide which tasks

The Nursing Assistant and the Care Team

• Diagnosis: identifying the health problems to delegate to other team members, such as
after looking at all the resident’s needs nursing assistants. Everything you do in your
• Planning: setting goals and creating a care job is delegated to you by a licensed healthcare
plan to meet the resident’s needs professional, and licensed nurses are accountable
for care. This includes all delegated tasks. The
• Implementation: putting the care plan into
National Council of State Boards of Nursing has
action; giving care
identified “The Five Rights of Delegation.” This
• Evaluation: a careful examination to see if can be used as a mental checklist to help nurses
the goals are being met in the decision-making process.
“The Five Rights of Delegation” are the “Right
Assessment:
What is the Task,” “Right Circumstance,” “Right Person,”
resident’s status, “Right Direction/Communication,” and “Right
including health and Supervision/Evaluation.” Before delegating tasks,
environment? nurses may consider these questions:
Evaluation: • Is there a match between the resident’s
What signs should we
Diagnosis: needs and the NA’s skills, abilities, and
look for to check that
we are on the right The problem(s) have experience?
path? Are we meeting been identified after
• What is the level of resident stability?
our goals? Evaluation, looking at all of the
observations, docu- resident’s needs. • Is the NA the right person to do the job?
mentation of care,
changes in resident • Can the nurse give appropriate direction and
status, unexpected Planning: communication?
outcomes. What are the • Is the nurse available to give the supervision,
Implementation: goals (expected
support, and help that the NA needs?
How will we achieve outcomes) of
these goals? (Steps in providing care? There are questions you may want to ask your-
the care plan) self before accepting a task. Consider these
questions:
Fig. 2-11. The nursing and care planning process.
• Do I have all the information I need to do
this job? Are there questions I should ask?
The goal of the nursing process is to meet the
resident’s nursing needs. Good communication • Do I believe that I can do this task? Do I
between all care team members and the resident have the necessary skills?
is vital. It helps ensure the success of the nurs- • Do I have the needed supplies, equipment,
ing process. This process constantly changes as and other support?
new information is collected and reported. Nurs-
ing assistants are an important part of this pro- • Do I know who my supervisor is, and how to
cess; their observations and reports may trigger reach him/her?
changes in the process. • Do we both understand who is doing what?
 2 18

Do not be afraid to ask for help. If you need any Make a schedule. Write out the hours of the day
more information or are unsure about some- and fill in when you will do what. This will help
thing, communicate this to the nurse. If you feel you be realistic.
The Nursing Assistant and the Care Team

that you do not have the skills for a task, or the Combine activities. Can you visit with residents
task is not within your scope of practice, discuss while providing care? Work more efficiently
this with the nurse. when you can.
Get help. It is not reasonable for you to do every-
9. Demonstrate how to manage time and thing. Sometimes you will need help to ensure a
assignments resident’s safety. Do not be afraid to ask for help.
When you take care of residents, it is important
to manage your time well every day. You will Chapter Review
have a variety of tasks to do during your shift.
Managing time properly will help you to com- 1. Briefly describe what each of the following
plete these tasks. Many of the ideas for manag- members of the care team does: nursing
ing time on the job can be used to manage your assistant; registered nurse; physician; physi-
personal time as well. The following ideas are cal therapist; occupational therapist; speech
basic ways to manage time: language pathologist; registered dietitian;
medical social worker; activities director; and
Plan ahead. Planning is the single best way to resident and resident’s family.
help you manage your time better. Sometimes
you may feel you do not even have the time to 2. List six examples of duties that nursing as-
plan. Take the time to sit down and list every- sistants perform.
thing you have to do. Take time to check to see if 3. List two duties that nursing assistants do not
you have all the supplies needed for a procedure. usually perform.
Often just making the list and taking the time
4. Describe professionalism. List five examples
to recheck will help you feel better. This will get
of professional behavior with residents.
you focused.
5. List seven examples of professional behavior
The nurse will make your work assignments. He
with an employer.
or she bases this on needs of residents and avail-
ability of staff. The assignments will allow staff 6. List eight personal qualities that are impor-
to work as team. Your responsibilities in com- tant for nursing assistants to have.
pleting assignments include the following:
7. Why do you think it is important for nursing
• Helping others when needed assistants to keep their hair tied back if they
have long hair?
• Never ignoring a resident who needs help
• Answering all call lights even if you are not 8. Why would wearing comfortable shoes be
assigned to a particular resident important to nursing assistants?

• Notifying the nurse if you cannot complete 9. Give one reason why the chain of command
an assignment is important.

Prioritize. Identify the most important things to 10. List three tasks that are said to be outside the
get done. Do these first. scope of practice of a nursing assistant.
 19 2

11. Why are observing and reporting even sim-

ple observations about a resident important?
12. What are three factors considered when

The Nursing Assistant and the Care Team

forming a care plan?
13. List five steps in the nursing process.
14. List the “Five Rights of Delegation.”
15. What should a nursing assistant do if he
feels he does not have the skills necessary to
perform a task?
16. List five steps in managing time and
assignments.
 3 20

3
Legal and Ethical Issues

Legal and Ethical Issues

1. Define the terms “law” and “ethics”

and list examples of legal and ethical
behavior
Ethics and laws guide our behavior. Ethics are
the knowledge of right and wrong. An ethical
person has a sense of duty and responsibility
toward others. He or she always tries to do what
is right. If ethics tell us what we should do, laws
tell us what we must do. Laws are usually based
on ethics. Governments establish laws to help
people live peacefully together and to ensure
order and safety. When someone breaks the law,
he or she may be punished by having to pay a
fine or spend time in prison.
Ethics and laws are extremely important in
health care (Fig. 3-1). They protect people receiv-
ing care and guide people giving care. Nursing
assistants, home health aides, and other health- Fig. 3-1. Behaving ethically and following the law applies
to all healthcare providers.
care providers should be guided by a code of eth-
ics. They must know the laws that apply to their G Protect residents’ privacy. Do not discuss
jobs. their cases except with other members of the
care team. Keeping resident information con-
Guidelines: fidential is one of the residents’ rights, which
Legal and Ethical Behavior are covered later in this chapter. All team
members must keep resident information
G Be honest at all times. Stealing from a resi- confidential.
dent and lying about care you provided are G Keep staff information confidential. You
examples of dishonesty. Communicate hon- should not share information about your
estly with all team members. coworkers at home or anywhere else.
 21 3

G Report abuse or suspected abuse of resi- 2. Explain the Omnibus Budget

dents, and assist residents in reporting abuse Reconciliation Act (OBRA)
if they wish to make a complaint of abuse.
You will learn more about this later in this Due to reports of poor care and abuse in long-

Legal and Ethical Issues

chapter. term care facilities, the U.S. government passed
the Omnibus Budget Reconciliation Act
G Follow the care plan and your assignments.
(OBRA) in 1987. It has been updated several
If you make a mistake, report it promptly.
times since. OBRA set minimum standards for
This helps prevent any further problems.
nursing assistant training. Nursing assistants
Reporting mistakes promotes the safety and
must complete at least 75 hours of training and
well-being of all residents.
must pass a competency evaluation (testing pro-
G Do not perform any task outside your scope gram) before they can be employed. They must
of practice. attend regular in-service education to keep their
G Report all resident observations and inci- skills updated.
dents to the nurse. OBRA requires that states keep a current list of
G Document accurately and promptly. nursing assistants in a state registry.

G Follow rules on safety and infection control. OBRA sets guidelines for minimum staff re-
You will learn more about these rules in quirements. It specifies the minimum services
Chapters 5 and 6. that long-term care facilities must provide. An-
other important part of OBRA is the resident
G Do not accept gifts or tips.
assessment requirements. OBRA requires com-
G Do not get personally or sexually involved plete assessments on every resident. The assess-
with residents or their family members or ment forms are the same for every facility.
friends.
A resident assessment system was developed in
Many associations, organizations, and compa- 1990 and is revised periodically. It is called the
nies have created their own “Code of Ethics” for Minimum Data Set (MDS) (Fig. 3-2). The MDS
their members or employees to follow. These is a detailed form with guidelines for assessing
vary, but generally they focus on promoting residents. It also lists what to do if resident prob-
proper conduct and high standards of practice. lems are identified. Facilities must complete the
If your facility has its own “Code of Ethics,” you MDS for each resident within 14 days of admis-
will be given a copy and expected to follow it. sion and again each year. In addition, the MDS
for each resident must be reviewed every three
Tip
months. A new MDS must be done when there
Crimes in Healthcare Settings
is any major change in the resident’s condition.
Most of the crimes that occur in the community can
also occur in healthcare settings. Theft is frequently OBRA made major changes in the survey pro-
reported. Physical abuse, including hitting, punch- cess. You first learned about the survey process
ing, shoving, and rough handling, and many other
types of abuse can occur. Violations of residents’ in Chapter 1. The results from surveys are avail-
rights are reported and can be prosecuted as a able to the public and posted in the facility.
crime. As you read through this chapter, pay close
attention to the many legal issues. Know what to OBRA also identifies important rights for resi-
observe and how to report any illegal activity. Your dents in long-term care facilities. You will learn
vigilance can help prevent crimes and promote legal more about them in the next learning objective.
and ethical behavior in the workplace.
 3
Legal and Ethical Issues
22

Fig. 3-2. A sample MDS form. (reprinted with permission of the briggs corporation, 800-247-2343, www.briggscorp.com)
 23 3

3. Explain residents’ rights and discuss the help of a doctor, makes informed decisions
why they are important about his or her health care.

Residents’ rights relate to how residents must The right to make independent choices: Resi-

Legal and Ethical Issues

be treated while living in a facility. They provide dents can make choices about their doctors, care,
an ethical code of conduct for healthcare work- and treatments. They can make personal deci-
ers. Facilities give residents a list of these rights sions, such as what to wear and how to spend
and review each right with them. You need to their time. They can join in community activi-
be familiar with residents’ rights, which are very ties, both inside and outside the care facility.
detailed. They include the following: The right to privacy and confidentiality: Resi-
Quality of life: Residents have the right to the dents can expect privacy when care is given.
best care available. Dignity, choice, and indepen- Their medical and personal information cannot
dence are important parts of quality of life. be shared with anyone but the healthcare team.
Residents have the right to private, unrestricted
Services and activities to maintain a high level communication with anyone they choose
of wellness: Residents must receive the correct (Fig. 3-3).
care. Their care should keep them as healthy as
possible every day. Health should not decline as
a direct result of the facility’s care.
The right to be fully informed about rights and
services: Residents must be told what care and
services are available. They must be told the fees
for each service. They must be made aware of all
their legal rights. Legal rights must be explained
in a language they can understand. This in-
cludes being given a written copy of their rights.
They have the right to be notified in advance of
any change of room or roommate. They have the
right to communicate with someone who speaks
Fig. 3-3. Residents have the right to private communica-
their language. They have the right to assistance
tion with anyone; mail cannot be opened or read by staff,
for any sensory impairment. Blindness is one unless someone is directed to do so by the resident.
type of sensory impairment.
The right to participate in their own care: Resi- The right to dignity, respect, and freedom:
dents have the right to participate in planning Residents must be respected and treated with
their treatment, care, and discharge. Residents dignity by caregivers. They cannot be abused,
have the right to refuse medication, treatment, mistreated, or neglected in any way. You will
care, and restraints. They have the right to be learn more about abuse and neglect in the next
told of changes in their condition. They have the learning objective.
right to review their medical record. Informed The right to security of possessions: Residents’
consent is a concept that is part of participating personal possessions must be safe at all times.
in one’s own care. A person has the legal and They cannot be taken or used by anyone with-
ethical right to direct what happens to his or her out a resident’s permission. Residents have the
body. Doctors also have an ethical duty to involve right to manage their own finances or choose
the person in his or her health care. Informed someone to do it for them. Residents can ask the
consent is the process by which a person, with care facility to handle their money and in this
 3 24

case, the resident must sign a written statement.

Persons with disabilities need to be able to get into
If the care facility handles residents’ financial and around in buildings and use the bathrooms,
affairs, residents must have access to their ac- drinking fountains, and other areas. The law re-
counts and financial records, and they must re- quires new buildings to be accessible and for older
Legal and Ethical Issues

buildings to be updated when they are renovated.

ceive quarterly statements, among other things.
Americans with disabilities have the right to educa-
Rights during transfers and discharges: Location tion, employment, and all the services offered to the
changes must be made safely and with the resi- public. Schools, colleges, and many employers are
dent’s knowledge and consent. Residents have not allowed to discriminate and must make reason-
the right to stay in a facility unless a transfer or able accommodations, or changes, to make their
services available. Examples of accommodations
discharge is needed. are providing a large screen for a computer, or al-
The right to complain: Residents have the right lowing a service dog. Providers of health care, social
services, transportation, restaurants, hotels, and rec-
to make complaints and voice grievances without reation are also not allowed to discriminate against
fear of punishment. Facilities must work quickly persons with disabilities. They must provide equal
try to resolve complaints. opportunities, which may include making some
changes to their services.
The right to visits: Residents have the right to
visits from family, friends, doctors, clergy mem-
bers, groups, and others (Fig. 3-4). 4. Discuss abuse and neglect and explain
how to report abuse and neglect
The healthcare community has become aware
of the growing problem of elder abuse and ne-
glect. In their “National Elder Abuse Incidence
Study” published in 1998, The National Center
on Elder Abuse estimated that more than a mil-
lion elders suffered abuse or neglect in a single
year, many of them in nursing homes. This
study also found that for every reported incident
of elder abuse or neglect, approximately five go
Fig. 3-4. Residents have the right to visitors. unreported.

Rights with social services: The care facility The National Citizens’ Coalition for Nursing
must provide residents with access to social ser- Home Reform (NCCNHR) is a national non-
vices, including counseling, assistance in solving profit organization founded in 1975 to protect
problems with others, and help contacting legal the rights, safety, and dignity of long-term
and financial professionals. care residents. In a fact sheet compiled by the
NCCNHR (nccnhr.org), they list this statistic: “in
The Americans with Disabilities Act (ADA) 2000, states reported 472,813 reported incidents
of abuse.” They also mention that “The National
The Americans with Disabilities Act (ADA) became
a law in 1990. It was passed to help people with
Academies estimate between 1 and 2 million
disabilities gain skills, do jobs they want to do, and Americans age 65 or older have been injured, ex-
take part in desired activities. The ADA prohibits dis- ploited, or otherwise mistreated by someone on
crimination because of a disability. The law requires whom they depended for care.”
that employers, schools, and businesses offer equal
opportunities to individuals with disabilities to use As the elderly population grows, this problem
the services in our society and improve their quality may become worse. Elderly people may be
of life.
abused intentionally or unintentionally, through
 25 3

ignorance, inexperience, or inability to care for • Psychological abuse is emotionally harm-

them. People who abuse elders may mistreat ing a person by threatening, scaring, humili-
them physically, psychologically, sexually, ver- ating, intimidating, isolating, insulting, or
bally, financially, and/or materially. They may treating him or her as a child.

Legal and Ethical Issues

deprive them of their rights or they may neglect
• Verbal abuse involves the use of lan-
them by failing to provide food, clothing, shelter,
guage—spoken or written—that threatens,
or medical care. Some older adults may also be-
embarrasses, or insults a person.
come self-abusive or neglect their own needs. In
order to help prevent abuse and neglect, it helps • Assault is threatening to touch a person
if you understand more about the different types without his or her permission. The person
of each. feels fearful that he or she will be harmed.
Telling a resident that she will be slapped if
Neglect means harming a person physically,
she does not stop yelling is an example of
mentally, or emotionally by failing to provide
assault.
needed care. Neglect can be divided into two
categories: active neglect and passive neglect. • Battery means a person is actually touched
Active neglect is purposely harming a person without his or her permission. An example
by failing to provide needed care. Examples of is an NA hitting or pushing a resident,
active neglect are leaving a bedridden resident which is also physical abuse. Forcing a resi-
alone for lengthy periods or willfully deny- dent to eat a meal is another example of
ing the resident food, dentures, or eyeglasses. battery.
Passive neglect is unintentionally harming a • Sexual abuse is forcing a person to perform
person physically, mentally, or emotionally by or participate in sexual acts against his or
failing to provide needed care. The caregiver her will. This includes unwanted touching
may not know how to properly care for the and exposing oneself to a person. It also in-
resident, or may not understand the resident’s cludes sharing pornographic material.
needs.
• Financial abuse is stealing, taking advan-
Negligence means actions, or the failure to act tage of, or improperly using the money,
or provide the proper care for a resident, that property, or other assets of another.
result in unintended injury. An example of neg-
ligence is an NA forgetting to lock a resident’s • Domestic violence is abuse by spouses,
wheelchair before transferring her. The resident intimate partners, or family members. It can
falls and is injured. Malpractice occurs when a be physical, sexual, or emotional. The vic-
person is injured due to professional misconduct tim can be a man or woman of any age or a
through negligence, carelessness, or lack of skill. child.

Abuse means purposely causing physical, men- • Workplace violence is abuse of staff by
tal, or emotional pain or injury to someone. residents or other staff members. It can be
There are many forms of abuse, including the verbal, physical, or sexual. This includes im-
following: proper touching and discussion about sexual
subjects.
• Physical abuse refers to any treatment,
intentional or not, that causes harm to a • Involuntary seclusion is separating a per-
person’s body. This includes slapping, bruis- son from others against the person’s will.
ing, cutting, burning, physically restraining, For example, an NA confines a resident to
pushing, shoving, or even rough handling. his room without his consent.
 3 26

• Sexual harassment is any unwelcome Burns of unusual shape and in unusual loca-
sexual advance or behavior that creates an tions; cigarette burns
intimidating, hostile, or offensive working
Scalding burns
environment. Requests for sexual favors, un-
Legal and Ethical Issues

wanted touching, and other acts of a sexual Scratches and puncture wounds
nature are examples of sexual harassment. Scalp tenderness and patches of missing hair
• Substance abuse is the use of legal or ille- Swelling in the face, broken teeth, nasal dis-
gal drugs, cigarettes, or alcohol in a way that charge
harms oneself or others. You will learn more
Bruises, bleeding, or discharge from the vagi-
about this in Chapter 20.
nal area
Nursing assistants must never abuse residents
Signs that could indicate abuse include the
in any way. They must also try to protect resi-
following:
dents from others who abuse them. If you ever
see or suspect that another caregiver, family Yelling obscenities
member, or resident is abusing a resident, report Fear, apprehension, fear of being alone
this immediately to the nurse in charge. Report-
ing abuse is not an option—it is the law. Poor self-control

If action is not taken, keep reporting up the Constant pain

chain of command, and do this until action is Threatening to hurt others
taken. If no appropriate action is taken at the fa-
Withdrawal or apathy (Fig. 3-5)
cility level, call the state abuse hotline, which is
an anonymous call.
Nursing assistants must follow the chain of
command when reporting abuse. They do not re-
port directly to the authorities. If a life-or-death
situation is witnessed, remove the resident to a
safe place, if possible. Get help immediately or
have someone go for help. Do not leave the resi-
dent alone.

Observing and Reporting:

Abuse and Neglect

These are “suspicious” injuries. They should be

reported:
Poisoning or traumatic injury Fig. 3-5. Withdrawing from others is an important
change to report.
Teeth marks
Belt buckle or strap marks Alcohol or drug abuse
Old and new bruises, contusions and welts Agitation or anxiety, signs of stress
Scars Low self-esteem
Fractures, dislocation Mood changes, confusion, disorientation
 27 3

Private conversations are not allowed, or the Never retaliate against (punish) residents com-
family member/caregiver is present during all plaining of abuse. If you see someone being
conversations cruel or abusive to a resident who made a com-
plaint, you must report it. All care team mem-

Legal and Ethical Issues

Resident or family reports of questionable
care bers are responsible for residents’ safety. Take
this responsibility seriously. Help end the dis-
Signs that could indicate neglect include the turbing trend of elder abuse and neglect.
following:
Pressure sores Residents’ Rights
Body not clean Vulnerable Adults
Some states have Vulnerable Adults Acts or Adult
Body lice Protective Service (APS) laws. These laws are written
Unanswered call lights by each state, and are not the same throughout the
country. There are states that do not have any such
Soiled bedding or incontinence briefs not laws.
being changed In general, these Vulnerable Adults Acts or Adult
Protective Service laws protect individuals who be-
Poorly-fitting clothing
cause of a physical or mental impairment need help
Refusal of care from other people for their care. The residents of
long-term care facilities, assisted living and other in-
Unmet needs relating to hearing aids, stitutions fit into this category.
eyeglasses, etc. It is important to know the laws in your state. How-
ever, even if your state does not have a specific law
Weight loss, poor appetite
like the ones above, residents of long-term care fa-
Uneaten food cilities are covered by the federal laws relating to res-
idents’ rights, which also forbid abuse and neglect
Dehydration and require reporting if these acts do occur.
Fresh water or beverages not being passed
each shift
5. List examples of behavior supporting
You will be in an excellent position to observe
and report abuse or neglect. As mentioned ear-
and promoting residents’ rights
lier NAs have an ethical and legal responsibility You can help protect your residents’ rights in the
to observe for signs of abuse and report sus- following ways:
pected cases to the charge nurse. In some states,
• Never abuse a resident physically, emotion-
nursing assistants are considered “mandated
ally, verbally, or sexually.
reporters” and can be convicted of a crime for
not reporting knowledge of abuse or neglect of a • Watch for and report any signs of abuse or
resident. Mandated reporters are people who neglect immediately.
are legally required to report suspected or ob-
• Call the resident by the name he or she
served abuse or neglect because they have regu-
prefers.
lar contact with vulnerable populations, such as
the elderly in facilities. • Involve residents in your planning. Allow
the residents to make as many choices as
If abuse is suspected or observed, give the nurse
possible about when, where, and how care
as much information as possible. If residents
performed.
want to make a complaint of abuse, you must
assist them in every way. This includes telling • Always explain a procedure to a resident be-
them of the process and their rights. fore performing it.
 3 28

• Do not unnecessarily expose a resident while Residents’ Rights

giving care.
Voting
• Respect a resident’s refusal of care. Resi- People retain their legal right to vote even if they are
Legal and Ethical Issues

dents have a legal right to refuse treatment living in a care facility. They may request and receive
and care. However, report the refusal to the absentee ballots. Sometimes they will be driven to
the polling places to cast their vote by family, friends,
nurse immediately. or an employee of the facility. If you are asked to as-
• Inform the nurse if a resident voices con- sist a resident with voting, ask the resident how he
or she wants you to help. For example, a resident
cerns, complaints, or has questions about may want you to read the ballot aloud and/or mark
treatment or the goals of care. the ballot as he instructs you. Make sure you under-
stand how to complete the ballot if you are asked
• Be truthful when documenting care. to assist. Ask the nurse for help if you need it. Do
• Do not talk or gossip about residents. Keep not discuss your opinions with the resident, even
if asked. Do not try to influence the resident in any
all resident information confidential. way. Do not discuss how the resident voted with
• Knock and ask for permission before enter- anyone.
ing a resident’s room. (Fig. 3-6).
6. Describe what happens when a
complaint of abuse is made against a
nursing assistant
The Nurse Aide Training Competency Evalua-
tion Program (NATCEP) makes the rules about
training and testing nursing assistants. The
state programs make sure that federal rules are
followed in nursing facilities that receive pay-
ment from Medicare or Medicaid. Setting up
and running the nursing assistant registry is
also a part of this program. This registry keeps
track of each nursing assistant working in that
state.
Fig. 3-6. Always respect your residents’ privacy. Knock be-
fore entering their rooms, even if the door is open. If a nursing assistant is accused of abusing a
resident, the facility will investigate according
• Do not accept gifts or money. to its policies and procedures. If they determine
• Do not open a resident’s mail or look abuse has occurred, a report must be made to
through his belongings. the Nurse Aide Training Competency Evaluation
Program (NATCEP).
• Respect residents’ personal possessions.
Handle them gently and carefully. Keep per- The nursing assistant will be notified of any
sonal items labeled and stored, according to complaint made about him or her to NATCEP.
facility policy. The nursing assistant can request a hearing.
NATCEP will investigate and decide whether
• Report observations about a resident’s condi-
or not to mark in the nursing assistant’s record
tion or care.
that he or she was abusive. Some states have an
• Help resolve disputes by reporting them to abuse registry and will place the nursing assis-
the nurse. tant’s name this list. Other states do not have a
 29 3

separate list but will add the information on the responsibility of the state’s department of health.
required registry of nursing assistants. Complaints may be made directly to the state
agency. Each one has policies and procedures
If NATCEP places the nursing assistant on the
that are used to follow up on complaints.

Legal and Ethical Issues

abuse registry and marks the record that he or
she was abusive, the nursing assistant will not
be allowed to work in a certified nursing facility.
All nursing facilities must check the registry be-
fore hiring a nursing assistant. They will be told
of the abuse when they inquire.

7. Explain how disputes may be resolved

and identify the ombudsman’s role
An ombudsman is assigned by law as the legal
advocate for residents. The Older Americans Act
(OAA) is a federal law that requires all states Fig. 3-7. An ombudsman is a legal advocate for resi-
dents. He or she may work with other agencies to resolve
have an ombudsman program. The ombudsman
complaints.
visits facilities and listens to residents. He or she
decides what action to take if there are problems.
Ombudsmen can help resolve conflicts and set- Residents’ Rights
tle disputes concerning residents’ health, safety, Residents’ Council
welfare, and rights. The ombudsman will gather A Residents’ Council is a group of residents who
meet regularly to discuss issues related to the long-
information and try to resolve the problem on
term care facility. This Council gives residents a
the resident’s behalf, and may suggest ways to voice in facility operations. Topics of discussion may
solve the problem. Ombudsmen provide an on- include facility policies, decisions regarding activi-
going presence in long-term care facilities. They ties, concerns, and problems. The Residents’ Council
offers residents a chance to provide suggestions on
monitor care and conditions.
improving the quality of care. Council executives are
An ombudsman typically does the following elected by residents. Family members are invited
to attend meetings with or on behalf of residents.
tasks:
Staff may participate in this process when invited by
• Advocates for residents’ rights and quality Council members.
care
• Educates consumers and care providers 8. Explain HIPAA and list ways to protect
• Investigates and resolves complaints residents’ privacy
• Appears in court and/or in legal hearings To respect confidentiality means to keep pri-
• Works with investigators from the police, vate things private. You will learn confidential
adult protective services, and health depart- (private) information about your residents. You
ments to resolve complaints (Fig. 3-7) may learn about a resident’s state of health, fi-
nances, and relationships. Ethically and legally,
• Gives information to the public you must protect the confidentiality of this
Each state has a department that performs sur- information. You should not tell anyone except
veys and is responsible for enforcing long-term members of the care team anything about your
care facility laws and rules. Generally, this is the residents.
 3 30

Congress passed the Health Insurance Portabil- ample, if a neighbor asks you how a resident is
ity and Accountability Act (HIPAA) in 1996. It doing, you should reply, “I’m sorry, but I cannot
was further defined and revised in 2001 and share that information. It’s confidential.” That
2002. One of the reasons this law was passed is the correct response to anyone who does not
Legal and Ethical Issues

is to help keep health information private and have a legal reason to know about the resident.
secure. All healthcare organizations must take Other ways to protect residents’ privacy include
special steps to protect health information. the following guidelines:
They and their employees can be fined and/or
imprisoned if they break rules to protect patient
Guidelines:
privacy. This applies to all healthcare providers,
Protecting Privacy
including doctors, nurses, nursing assistants,
and all care team members. G Make sure you are in a private area when you
Under this law, a person’s health information are listening to or reading your messages.
must be kept private. It is called protected G Know with whom you are speaking on the
health information (PHI). Examples of PHI phone. If you are not sure, get a name and
include the patient’s name, address, telephone number, and call back after you get approval.
number, social security number, e-mail ad-
dress, and medical record number. Only people G When talking to a care team member on the
who must have information to provide care or phone, use regular phones, not cell phones.
to process records should know this informa- Cell phones can be scanned.
tion (Fig. 3-8). They must make sure they pro- G Do not talk about residents in public places
tect the information so that it does not become (Fig. 3-9). Public areas include elevators, gro-
known or used by anyone else. It must be kept cery stores, lounges, waiting rooms, parking
confidential. garages, schools, restaurants, etc.

Fig. 3-9. Do not discuss any information about residents

in any public place, such as grocery stores or restaurants.
Fig. 3-8. Special care must be taken to keep medical re- Only discuss residents’ information with the care team.
cords confidential. Only people who give care or process
records should have access to this information.
G Use confidential rooms for reports to other
NAs cannot give out any information about a care team members.
resident to anyone not directly involved in the G If you see a resident’s family member or a
resident’s care, unless the resident gives official former resident in public, be careful in greet-
consent or unless the law requires it. For ex- ing him or her. He or she may not want oth-
 31 3

ers to know about the family member or that PSDA requires all healthcare agencies receiving
he or she has been a resident. Medicare and Medicaid money to give adults,
during admission or enrollment, information
G Do not bring family or friends to the facility
about their rights relating to advance directives.

Legal and Ethical Issues

to meet residents.
Advance directives are legal documents that
G Make sure nobody can see health or personal allow people to choose what medical care they
information on your computer screen while wish to have if they cannot make those decisions
you are working. themselves. Advance directives can also name
G Log off when not using your computer. someone to make decisions for a person if that
person becomes ill or disabled. Living wills and
G Do not give confidential information in
durable power of attorney for health care are ex-
e-mails because you do not know who has
amples of advance directives.
access to your messages.
A living will states the medical care a person
G Make sure fax numbers are correct before fax- wants, or does not want, in case he or she be-
ing any healthcare information. Use a cover comes unable to make those decisions him- or
sheet with a confidentiality statement. herself. It is called a “living will” because it takes
G Do not leave papers or documents where effect while the person is still living. It may also
others may see them. be called a “directive to physicians,” “health care
declaration,” or “medical directive.” A living will
G Store, file, or shred documents according to
is not the same thing as a will. A will is a legal
your facility’s policy.
declaration of how a person wishes his or her
G If you find documents with a resident’s infor- possessions to be disposed of after death.
mation, give them to the nurse.
A durable power of attorney for health care
All healthcare workers must follow HIPAA regu- is a signed, dated, and witnessed paper that
lations no matter where they are or what they are appoints someone else to make the medical
doing. There are serious penalties for violating decisions for a person in the event he or she be-
these regulations. Penalties differ depending comes unable to do so. This can include instruc-
upon the violation and can include: tions about medical treatment the person wants
• Fines ranging from $100 to $250,000 to avoid.

• Prison sentences of up to ten years A do-not-resuscitate (DNR) order is another

tool that helps medical providers honor wishes
Maintaining confidentiality is a legal and ethical about care. A DNR order tells medical profes-
obligation. It is part of respecting your residents sionals not to perform CPR. CPR (cardiopulmo-
and their rights. Discussing a resident’s care or nary resuscitation) refers to medical procedures
personal affairs with anyone other than mem- to restart the heart and breathing. You will learn
bers of the care team violates the law. more about CPR in Chapter 7. A DNR order
means that medical personnel will not attempt
9. Explain the Patient Self-Determination emergency CPR if breathing or the heartbeat
stops. In general, DNR orders are appropriate for
Act (PSDA) and discuss advance
those in the final stages of a terminal illness or
directives
who suffer from a serious condition.
The Patient Self-Determination Act (PSDA) was According to the Patient Self-Determination Act,
passed in 1990 as an amendment to OBRA. The rights relating to advance directives that must be
 3 32

given upon admission include the following: 4. How soon must a Minimum Data Set
(MDS) be completed on new residents after
• The right to participate in and direct health-
admission?
care decisions
Legal and Ethical Issues

5. What is the purpose of residents’ rights?

• The right to accept or refuse treatment
6. Pick five residents’ rights in Learning Objec-
• The right to prepare an advance directive
tive 3 that are most important to you and ex-
• Information on the facility’s policies that plain why you chose those particular rights.
govern these rights
7. If a nursing assistant sees abuse or suspects
The act prohibits discriminating against a pa- that a resident is being abused, what is her
tient who does not have an advance directive. responsibility?
The PSDA requires documentation of patient
8. List five possible signs of abuse that should
information and ongoing community education
be reported by the nursing assistant. List five
on advance directives.
possible signs of neglect that should be re-
Advance Directives ported by the nursing assistant.

Laws related to advance directives vary from state

9. If residents want to make a complaint
to state. Here are a few resources that may help you of abuse, what is the role of the nursing
locate the proper forms for your state: assistant?
• The National Hospice and Palliative Care Organi- 10. Pick three of the examples of behavior pro-
zation (NHPCO) is a nonprofit organization that
moting residents’ rights in Learning Objec-
represents hospice and palliative care programs
in the United States. NHPCO is involved with tive 5. Describe how it supports or promotes
improving care for people who are dying and residents’ rights.
their loved ones. For more information visit their
website at caringinfo.org, or call 800-658-8898. 11. What happens if a nursing assistant is ac-
cused of abusing a resident?
• The U.S. Living Will Registry is a privately held
organization that electronically stores advance 12. What does an ombudsman do?
directives, organ donor information and emer-
gency contact information, and makes them 13. What is a Residents’ Council?
available to healthcare providers across the
14. What is one important reason that HIPAA
country 24 hours a day. For more information
about the U.S. Living Will Registry, call 800-LIV- was passed?
WILL (800-548-9455) or visit their website at
15. List five examples of a person’s protected
uslivingwillregistry.com.
health information (PHI).
16. To whom is a nursing assistant allowed to
Chapter Review give information about a resident?
1. What is the difference between ethics and 17. To what members of the healthcare team
laws? does HIPAA apply?
2. List eight examples of legal and ethical be- 18. Define “advance directives” and briefly de-
havior for a nursing assistant. scribe two examples.
3. What is the minimum number of hours of 19. List three rights relating to advance direc-
training that nursing assistants must com- tives that the PSDA requires be given to a
plete as required by OBRA? resident at the time of admission.
 33 4

Communication and Cultural Diversity

Communication and Cultural
Diversity
1. Define the term “communication” sage was received and understood. Feedback is
especially important when working with the el-
Communication is the process of exchanging derly. Nursing assistants must take time to make
information with others. It is a process of send- sure residents understand messages.
ing and receiving messages. People communi-
cate by using signs and symbols, such as words, All three steps must occur before the commu-
drawings, and pictures. They also communicate nication process is complete. During a conversa-
by their behavior. tion, this three-step process is repeated over and
over.
The simplest form of communication takes place
between two people (Fig. 4-1). The person who Effective communication is a vital part of your
communicates first is the “sender” who sends a job. Nursing assistants must communicate with
message. The person who receives the message supervisors, the care team, residents, and family
is called the “receiver.” Receiver and sender con- members. A resident’s health depends on how
stantly switch roles as they communicate. well you communicate your observations and
concerns to the nurse. You must also be able to
The third step is providing feedback. The re- communicate clearly and respectfully in stress-
ceiver repeats the message or responds to it in ful or confusing situations.
some way. This lets the sender know the mes-

Fig. 4-1. The communication process consists of sending a message, receiving a message, and providing feedback.
 4 34

2. Explain verbal and nonverbal Other examples of positive nonverbal communi-

communication cation include smiling, nodding your head, and
looking at the person who is speaking.
Communication is either verbal or nonverbal.
Communication and Cultural Diversity

Verbal communication involves the use of Sometimes people send one message verbally
words or sounds, spoken or written. Oral re- and a very different message nonverbally.
ports are an example of verbal communication. Nonverbal communication often tells us how
It is important to use words that have the same someone is feeling. This message may be quite
meaning to both the sender and the receiver. different from what he or she is saying. For ex-
Misunderstandings may occur if each person in- ample, a resident who tells you “I’m feeling fine
terprets the same words differently. For example, today,” but does not want to get out of bed and
if you ask a resident to “turn on the light” when winces in pain, is sending two very different
she needs help, she may not understand that you messages. Paying attention to nonverbal com-
actually meant for her to push the call button. munication helps you give better care. Com-
municate to the nurse your observation that
Nonverbal communication is the way we the resident is staying in bed and appears to be
communicate without using words. Examples wincing in pain despite what he says.
include shaking your head or shrugging your
shoulders. Nonverbal communication includes You must also be aware of your own verbal and
how a person says something. For example, you nonverbal messages. If you say “It’s nice to see
might say, “I’ll be right there, Mrs. Gonzales.” you today, Mr. Lee” but you do not smile or look
This communicates that you are ready and will- him in the eye, he may feel that you are not re-
ing to help. But saying the same phrase in a ally all that happy to see him.
different tone can communicate frustration and When communication is confusing, try to clarify
annoyance: “I’ll be right there, Mrs. Gonzales!” it. Ask for an explanation of the message. Say
Body language is another form of nonverbal something like, “Mrs. Jones, you’ve just told me
communication. Movements, facial expressions, something that I don’t understand. Would you
and posture can express different attitudes or explain it to me?” Or state what you have ob-
emotions. Just as with speaking, you send mes- served and ask if the observation is correct. For
sages with your body language. Other people example, “Mrs. Jones, I see that you’re smiling,
receive and interpret them. For example, slouch- but I hear by the sound of your voice that you
ing in a chair and sitting erect send two differ- may be sad. Are you sad?” Take the time to clar-
ent messages (Fig. 4-2). Slouching says that you ify communication. It can help you know your
are bored, tired, or hostile. Sitting up straight residents better and avoid misunderstandings.
sends the message that you are interested and
respectful. 3. Describe ways different cultures
communicate
Cultural diversity has to do with the different
groups of people with varied backgrounds and
experiences living together in the world. Posi-
tive responses to cultural diversity include ac-
ceptance and knowledge, not bias, or prejudice.
Fig. 4-2. Body language often speaks as plainly as words. A culture is a system of learned behaviors by a
Which of these people seems more interested in the con- group of people that are considered to be the tra-
versation they are having? dition of that people and are passed on from one
 35 4

generation to the next. Each culture may have Learning each resident’s behavior can be a
different knowledge, behaviors, beliefs, values, challenge. However, it is an important part of
attitudes, religions, and customs. communication. It is especially vital in a multi-
cultural society (a society made up of many cul-

Communication and Cultural Diversity

Nonverbal communication may depend on per-
tures), such as the United States. Be aware of all
sonality or cultural background. Some people
the messages you send and receive. As you listen
are more animated when they speak. They use
and observe carefully, you will learn to better
lots of gestures and facial expressions. Other
understand your residents’ needs and feelings.
people speak quietly or calmly, regardless of
their moods. Depending on their cultural back-
Residents’ Rights
ground, people may make motions with their
Ask, acknowledge, and accept.
hands when they talk. They may stand close to
Focus on compassionate, respectful, and culturally-
the person to whom they are talking, or touch sensitive care. Treat your residents as they wish to be
the other person. treated, not how you want to treat them. Your culture
and experiences have shaped your thinking. Others
People from some cultural groups stand fur- may come from different cultures and have had dif-
ther apart when talking than people from other ferent experiences, which have shaped the way they
groups. When one person moves closer, the think. Something you may want or need from others
other person may view it as a threat. Be sensitive may be different from what your resident wants or
needs. Ask questions to find out what is appropriate.
to your residents’ needs. Let them decide how Never try to make residents change their beliefs in
close they want to be when talking to you. any way.
The use of touch and eye contact also varies with
cultural background and personality (Fig. 4-3).
For some people, touching is welcome. It ex- 4. Identify barriers to communication
presses caring and warmth. For others, it seems Communication can be blocked or disrupted in
threatening or harassing. In the United States, many ways (Fig. 4-4). Following are some barri-
we often talk about “looking someone straight ers and ways to avoid them:
in the eye” or speaking “eye to eye.” We see eye
contact as a sign of honesty. However, in some Resident does not hear you, does not hear cor-
cultures, looking someone in the eye may seem rectly, or does not understand. Face the resident.
overly bold or disrespectful. Speak more slowly than you do with family and
friends. Speak clearly. Use a low, pleasant voice.
Do not whisper or mumble. If the resident says
he cannot hear you, speak more loudly. However,
use a pleasant, professional tone. If the resident
wears a hearing aid, check that it is on and is
working properly.
Resident is difficult to understand. Be patient
and take time to listen. Ask the resident to re-
peat or explain. State the message in your own
words to make sure you have understood.
Message uses words receiver does not under-
stand. Do not use medical terms with residents.
Fig. 4-3. How a person perceives your touch may depend Speak in simple, everyday words. Ask what a
on his cultural background. word means if you are not sure.
 4
Communication and Cultural Diversity
36

Fig. 4-4. Barriers to communication.

Using slang confuses the message. Avoid using not within the scope of your practice. It could be
slang words that are unprofessional or may not dangerous.
be understood. Do not curse or use profanity,
Yes/no answers end a conversation. Ask open-
even if the resident does.
ended questions that need more than a “yes” or
Avoid using clichés. Clichés are phrases that are “no” answer. Yes and no answers bring conversa-
used over and over again and do not really mean tion to an end. For example, if you want to know
anything. For example, “Everything will be fine” what your resident likes to eat, do not ask “Do
is a cliché. Instead of using a cliché, listen to you like vegetables?” Instead, try, “Which veg-
what your resident is really saying. Respond with etables do you like best?”
a meaningful message. For example, if a resi-
Resident speaks a different language. If a resi-
dent is afraid of having a bath, say “I understand
dent speaks a different language than you do,
that it seems scary to you. What can I do to
speak slowly and clearly. Keep your messages
make you more comfortable?” Do not say, “Oh,
short and simple. Be alert for words the resident
it’ll be over before you know it.”
understands. Also be alert for signs the resident
Asking “why” makes the resident defensive. is only pretending to understand you. You may
Avoid asking “why” when a resident makes a need to use pictures or gestures to communi-
statement. “Why” questions make people feel cate. Ask the resident’s family, friends, or other
defensive. For example, a resident may say she staff members who speak the resident’s lan-
does not want to go for a walk today. If you ask guage for help. Be patient and calm
“why not?” you may receive an angry response.
Nonverbal communication changes the message.
Instead, ask, “Are you too tired to take a walk? Is
Be aware of your body language and gestures
there something else you want to do?” Your resi-
when you are speaking. Look for nonverbal mes-
dent may then be willing to discuss the issue.
sages from residents and clarify them. For ex-
Giving advice is inappropriate. Do not offer your ample, “Mr. Feldman, you say you’re feeling fine
opinion or give advice. Giving medical advice is but you seem to be in pain. Can I help?”
 37 4

5. List ways to make communication than what you thought. The important thing
accurate and explain how to develop is to understand words and expressions when
effective interpersonal relationships others use them. Do not be judgmental; accept
people who are different from you.

Communication and Cultural Diversity

In addition to avoiding the barriers to commu-
Accept a resident’s religion or lack of religion.
nication listed above, the following techniques
Religious differences also affect communication.
will help ensure that you send and receive clear,
Religion can be very important in people’s lives,
complete messages.
particularly when they are ill or dying. Respect
Be a good listener. Allow the other person to residents’ religious beliefs, practices, or lack
express her ideas completely. Concentrate on of beliefs, especially if they are different from
what she is saying, and do not interrupt. Do not yours. Never question your residents’ beliefs. Do
finish her sentences even if you know what she not discuss your beliefs with them.
is going to say. When she is finished, restate the
Understand the importance of touch. Softly pat-
message in your own words to make sure you
ting residents’ hands or shoulders or holding
have understood.
their hands may communicate caring. Some
Provide feedback as you listen. Active listening people’s backgrounds may make them less com-
means focusing on the person sending the mes- fortable being touched. Ask permission before
sage and giving feedback. Feedback might be touching residents. Be sensitive to their feelings.
an acknowledgment, a question, or repeating You must touch residents in order to do your
the sender’s message. Offer general but leading job. However, recognize that some residents feel
responses, such as “Oh?” or “Go on,” or “Hmm.” more comfortable when there is little physical
By doing this you are actively listening, provid- contact. Learn about your residents and adjust
ing feedback, and encouraging the sender to care to their needs.
expand the message.
Ask for more. When residents report symptoms,
Bring up topics of concern. If you know of a topic events, or feelings, have them repeat what they
that might concern a resident, raise the issue in have said. Ask them for more information.
a general, non-threatening way. This lets the res-
Make sure communication aids are clean and
ident decide whether or not to discuss it. For ex-
in good working order (Fig. 4-5). These include
ample, if you see that your resident is unusually
hearing aids, glasses, dentures, and wrist or
quiet, you could say, “Mrs. Jones, you seem so
hand braces. Tell the nurse if they do not work
quiet today.” Or you may notice a certain emo-
properly or are dirty or damaged.
tion. You might say, “Mrs. Jones, you seemed
upset earlier. Would you like to talk about it?”
Let some pauses happen. Use silence for a few
moments at a time. This encourages the resi-
dent to gather his or her thoughts and compose
messages.
Tune in to other cultures. Learn the words and
phrases of your resident’s culture. This shows
that you respect the culture and are interested
in what the resident has to say. It will help you
understand your resident’s messages more fully. Fig. 4-5. Glasses must fit well, be clean, and be in good
Be careful about using new words and terms, condition. Tell the nurse if you think communication aids
though. Some may have a different meaning are not clean or not working properly.
 4 38

Do not ignore a resident’s request. Ignoring a

Proper Communication
request is considered negligent behavior. Honor
When communicating with your residents, remem- the request if you can. Otherwise, explain why
ber the following steps: the request cannot be fulfilled. Always report
Communication and Cultural Diversity

• Always greet the resident by his or her preferred such requests to the nurse.
name.
• Identify yourself. Do not talk down to an elderly or disabled per-
son or a child. Talk to your residents and their
• Focus on the proper topic to be discussed.
families as you would talk to any person. Make
• Face the resident while speaking. Avoid talking
into space. adjustments if someone is visually- or hearing-
impaired. Guidelines for visually and hearing-
• Talk with the resident while giving care.
impaired residents are found later in the chapter.
• Listen and respond when the resident speaks.
Praise the resident and smile often. Sit near the person who has started the conversa-
• Encourage the resident to interact with you and tion. This shows you find what he or she is say-
others. ing important and worth your time.
• Be courteous.
Lean forward in your chair when someone is
• Tell the resident when you are leaving the room.
speaking to you. Leaning forward communicates
interest. Pay attention to your nonverbal commu-
Residents’ Rights nication. If you fold your arms in front of you,
Names you send the negative message that you wish to
Call residents by the names that they prefer you to distance yourself from the speaker.
use. Do not refer to them by their first names unless
they have told you that it is OK to do so. Do not use
Talk directly to the person whom you are as-
disrespectful terms such as “sweetie,” “honey,” or sisting. Do not talk to other staff while helping
“dearie.” residents (Fig. 4-6). Avoid gossip. Do not criticize
other staff members.
Having good relationships with residents, their
family members, and the care team will help you
provide excellent care. You should not try to be-
come friends with your residents. However, you
should try to develop warm professional relation-
ships with them based on trust. Good communi-
cation will help you get to know your residents.
It will also help them learn to trust you. In addi-
tion to the strategies already discussed, the fol-
lowing tips can help you communicate well and
Fig. 4-6. When helping residents, do not talk to other
develop good relationships: staff. Do not talk over residents’ heads. Look and speak
Avoid changing the subject when your resident directly to the person you are helping.
is discussing something. This is true even if the
Approach the person who is talking. Even if you
subject makes you feel uncomfortable or help-
are in another area of the room, approach the
less. For example, a resident might say, “I’m hav-
person. This tells the person you are interested
ing so much pain today.” Do not try to avoid the
in what he or she has to say.
topic by asking the resident if he wants to watch
television. This makes the resident feel that you Put yourself in other people’s shoes. Try to un-
are not interested in him or what he is talking derstand what they are going through. This is
about. called empathy. Ask yourself how you would feel
 39 4

if you were confined to bed or needed help to go 7. Explain objective and subjective
to the bathroom. Do not tell residents you know information and describe how to observe
how they feel because you do not know exactly and report accurately
how they feel. Do say things like, “I can imagine

Communication and Cultural Diversity

this must be difficult for you.” When making any report, you must collect the
right information before documenting it. Facts,
Show residents’ families and friends that you not opinions, are most useful to the nurse and
have time for them, too. Communicate with the care team. Two kinds of factual information
them. Do not discuss a resident’s care with are needed in your reporting. Objective infor-
friends or family members, but listen if they mation is based on what you see, hear, touch,
want to talk. Be respectful and nice, and give or smell. Objective information is collected by
privacy for visits. Do not interfere with private using the senses. Subjective information is
family business. Families are great sources of something you cannot or did not observe, but is
information for residents’ personal preferences, based on something the resident reported to you
history, diet, habits, and routines. Ask them that may or may not be true. An example of ob-
questions. If you see any abusive behavior to- jective information is, “Mr. McClain is holding
wards a resident during a visit, report it immedi- his head and rubbing his temples.” A subjective
ately to the nurse. report of the same situation might be, “Mr. Mc-
Clain says he has a headache.” The nurse needs
6. Explain the difference between facts factual information in order to make decisions
and opinions about care and treatment. Both objective and
subjective reports are valuable.
A fact is something that is definitely true. For
In any report, make sure what you observe
example, “Mr. Ford has lost four pounds this
(signs) and what the resident reports to you
month.” You can back up this fact with evidence:
(symptoms) are clearly noted. For example, “Ms.
weighing Mr. Ford and comparing his current
Scott reports pain in left shoulder.” You are not
weight to his weight last month. An opinion
expected to make diagnoses based on signs
is something someone believes to be true, but
and symptoms you observe. Your observations,
is not definitely true. “I think Mr. Ford looks
however, can alert staff to possible problems. In
thinner,” is an opinion. It might be true, but
order to report accurately, observe your residents
you cannot back it up with evidence. Separat-
accurately. To observe accurately, use as many
ing facts from opinions will make you a better
senses as possible to gather information (Fig.
communicator.
4-7). Some examples follow.
Using facts instead of your opinion lets you
Sight. Look for changes in resident’s appearance.
communicate in a more professional way. When
These include rashes, redness, paleness, swell-
communicating with members of the healthcare
ing, discharge, weakness, sunken eyes, and pos-
team, separate facts and opinions. For example,
ture or gait (walking) changes.
“Mr. Morgan is acting like he had a stroke,” is an
opinion and could very well be wrong. Instead, Hearing. Listen to what the resident tells you
report the facts: “Mr. Morgan has lost strength about his condition, family, or needs. Is he
on his right side and his speech is slurred.” speaking clearly and making sense? Does he
When you need to report your opinion, begin show emotions, such as anger, frustration, or
it with “I think….” Then it is clear that you are sadness? Is breathing normal? Does the resident
giving your opinion and not a fact you have wheeze, gasp, or cough? Is the area calm and
observed. quiet enough for him to rest as needed?
 4 40

Touch. Does your resident’s skin feel hot or cool, Always respect your resident’s privacy. When
moist or dry? Is the pulse rate regular? giving information to other members of the care
team, be sure that other residents or staff can-
Smell. Do you notice odor from the resident’s
not overhear. Be cautious when communicating
Communication and Cultural Diversity

body? Odors could suggest poor bathing, infec-

with residents and their families and friends.
tions, or incontinence. Incontinence is the in-
Do not tell them any new information about the
ability to control the bladder or bowels. Breath
resident’s condition or any new diagnoses. That
odor could suggest use of alcohol or tobacco,
is the nurse’s or doctor’s responsibility. When in
indigestion, or poor oral care.
doubt, ask the nurse what you can say. The resi-
Using all your senses will help you make the dent may not want information shared with fam-
most complete report of a resident’s situation. ily members and that is his legal right.

Sight: Use the chain of command to voice any com-

Smell:
resident’s body or changes in plaints you may have. Go to your charge nurse
breath odor resident’s first. Refer to the facility’s policies or procedures
appearnce if your complaint is not resolved. If you feel that
your charge nurse has abused a resident, com-
Hearing: municate this to her supervisor.
resident’s words,
tone and breathing
9. Describe basic medical terminology
and abbreviations
Throughout your training, you will learn medi-
cal terms for specific conditions. For example,
Touch:
resident’s skin
the medical term for a runny nose is nasal dis-
and pulse charge; a resident whose skin is pale or blue is
called cyanotic. Medical terms are made up of
Fig. 4-7. Reporting what you observe means using more
than one sense. roots, prefixes, and suffixes. A root is a part of a
word that contains its basic meaning or defini-
tion. The prefix is the word part that precedes
8. Explain how to communicate to other the root to help form a new word. The suffix
team members is the word part added to the end of a root that
helps form a new word. Prefixes and suffixes are
Nursing assistants will communicate regularly called “affixes” because they are attached to a
with care team members, residents and their root. Here are some examples:
families and friends. NAs should communicate
• The root “derm” or “derma” means skin. The
freely with the charge nurse regarding residents.
suffix “itis” means inflammation. Dermatitis
Keep the nurse informed of all important issues
is an inflammation of the skin.
during your shift. Share information with other
staff members as needed for quality of care. You • The prefix “brady” means slow. The root
may need to share a resident’s personal infor- “cardia” means heart. “Bradycardia” is slow
mation with another nursing assistant to help heartbeat or pulse.
her give care to a resident. However, the activi- • The suffix “pathy” means disease. The root
ties staff may have no need to know that same “neuro” means of the nerve or nervous sys-
information. Refer any doctor’s questions to the tem. Neuropathy is a nerve disease or dis-
nurse. ease of the nervous system.
 41 4

When speaking with residents and their fami-

F Fahrenheit degree
lies, use simple, non-medical terms. Do not use
medical terms, because they may not under- FBS fasting blood sugar
stand these terms. But when you speak with the

Communication and Cultural Diversity

ft foot
care team, using medical terminology will help
you give more complete information. FWB full weight-bearing

Abbreviations are a way to communicate more GI gastrointestinal

efficiently with other caregivers. For example,
H2O water
the abbreviation “p.r.n.” means “as necessary.”
“BP” means “blood pressure.” It is important to hr. hour
learn the standard medical abbreviations your
hs hours sleep
facility uses. Use them to report information
briefly and accurately. You may need to know I&O intake and output
these abbreviations to read assignments or care NKDA no known drug allergies
plans. Here is a brief list of abbreviations, and
more are located at the end of this textbook. NPO nothing by mouth
Check with your facility to see if there are terms NWB no weight-bearing (absolutely no
you must know. weight on leg)

Common Abbreviations O2 oxygen

a before OOB out of bed

abd abdomen P pulse

ac, AC before meals p after

ad lib as desired p.c., pc after meals

am morning po by mouth

amb ambulate PRN as necessary

AP apical pulse PWB partial weight-bearing

b.i.d., bid twice daily Q every

BM, B.M. bowel movement R respirations

BP blood pressure ROM range of motion

c with s without

C Celsius degree SOB shortness of breath

c/o complains of stat at once

CHF congestive heart failure t.i.d., tid three times a day

CPR cardiopulmonary resuscitation TPR temperature, pulse, respiration

DNR do not resuscitate v.s., VS vital signs

dx or DX diagnosis w/c, W/C wheelchair

 4 42

10. Explain how to give and receive an report any important details; do not rely on your
accurate report of a resident’s status memory alone. Following an oral report, docu-
ment when, why, about what, and to whom an
Nursing assistants must make brief and accurate oral report was given.
Communication and Cultural Diversity

oral and written reports to residents and staff.

Good communication skills are needed to col- Sometimes the nurse or another member of the
lect information about residents. These skills care team will give you a brief oral report on one
will help you get information from residents and of your residents. Listen carefully and take notes
their families to report to the care team. This (Fig. 4-8). Ask about anything you do not under-
information may be written or given in oral stand. At the end of the report, restate what you
reports from shift to shift. Remember that all have been told to make sure you understand.
resident information is confidential; only share
information with members of the care team.
Your careful observations are very important to
the health and well-being of all residents. Signs
and symptoms that should be reported will be
discussed throughout this textbook. Some of
your observations will need to be reported im-
mediately to the nurse. Deciding what to report
Fig. 4-8. Take notes so you can remember facts and
immediately involves critical thinking. Anything report accurately.
that endangers residents should be reported at
once, including the following:
11. Explain documentation and describe
• Falls related terms and forms
• Chest pain
Nursing assistants spend more time with resi-
• Severe headache dents than other members of the care team. You
• Trouble breathing may observe things about your residents that
nurses or doctors have not noticed. You will not
• Abnormal pulse, respiration, or blood
make diagnoses or decide on treatment. How-
pressure
ever, you will have valuable information about
• Change in mental status residents that will help in care planning. Docu-
• Sudden weakness or loss of mobility menting accurately is the key to care planning. A
thorough written record shows your observations
• High fever
to others. It helps you remember details about
• Loss of consciousness each resident.
• Change in level of consciousness Because you will see many residents during the
• Bleeding day, you cannot remember everything that each
resident did or said, or every observation you
• Change in resident’s condition
make. Documentation gives you an up-to-date
• Bruises, abrasions, or other signs of possible record of each resident’s care. You must learn
abuse (Chapter 3) to document accurately. Always take the time to
Use oral reports to discuss your experiences observe and record carefully. Follow your facil-
with residents and your observations of resi- ity’s policies and procedures for documentation.
dents’ conditions. Use facts, not opinions. For an Because documentation is so important, do not
oral report, write notes so you do not forget to put it off until later.
 43 4

A medical chart is a legal document. What is • Medical history (illnesses, immunizations,

written in the chart is considered in court to be medications, previous surgeries, family and
what actually happened. If you gave a resident a social histories)
bath and took his temperature, but never docu-

Communication and Cultural Diversity

• Doctor’s orders (instructions given to other
mented it, you could not necessarily prove that members of the care team)
you actually performed the care. In general, if
something does not appear in a resident’s chart, • Progress notes (updates from all care team
it did not legally happen. Failing to document members detailing changes or new informa-
your care could cause very serious legal prob- tion in the person’s condition)
lems for you and your employer. It could also • Test results (blood tests, lab results, other
cause harm to your resident. Remember: if you tests)
did not document it, you did not do it.
• Graphic sheet (vital signs, intake and output,
Information found in medical chart includes the bladder and bowel elimination)
following: • Nurse’s notes (the person’s reported symp-
• Admission sheet (protected health informa- toms and actions taken to address them)
tion about the person, such as name, ad- • Flow sheets (check-off sheets for document-
dress, social security number, and date of ing care; may also be called an ADL (activi-
birth, among other items) ties of daily living) sheet (Fig. 4-9)

Fig. 4-9. Some facilities use an ADL flow sheet for documenting care. (reprinted with permission of briggs corporation, 800-247-2343,
www.briggscorp.com)
 4 44

If your facility’s policies allow you to chart in a Nursing assistants may need to document using
medical record, remember: there are legal as- the 24-hour clock, or military time (Fig. 4-11).
pects to your documentation. Careful charting is Regular time uses the numbers 1 to 12 to show
important for these reasons: each of the 24 hours in a day. In military time,
Communication and Cultural Diversity

the hours are numbered from 00 to 23: midnight

• It is the only way to guarantee clear and
is expressed as 00 (although it can also be writ-
complete communication among all the
ten as 24), 1 a.m. is 01, 1 p.m. is 13, and so on.
members of the care team.
• It is a legal record of every resident’s treat- 1200
ment. Medical charts are used in court as
PM
2300 1300
evidence. 12
11 1
0000
• Documentation protects you and your em- 2200 1100 or 0100 1400
2400
ployer from liability by proving what you did. 10 2
1000 0200
• Documentation gives an up-to-date record of AM
the status and care of each resident. 2100 9 0900 0300 3 1500

Guidelines: 0800 0400

Careful Documentation 8 4
2000 0700 0500 1600
0600
G Write your notes immediately after the care is 7 5
6
given. This helps you to remember important 1900 1700
details. Always wait to document until after 1800
you have completed care. Do not record any
care before it has been done. Fig. 4-11. Divisions in the 24-hour clock.

G Think about what you want to say before writ-

Both regular and military time list minutes and
ing. Be as brief and as clear as possible.
seconds the same way. The minutes and seconds
G Write facts, not opinions. do not change when converting from regular to
G Write as neatly as you can. Use black ink. military time. The abbreviations a.m. and p.m.
are used in regular time to show what time of
G If you make a mistake, draw one line through
day it is. However, these are not used in military
it, and write the correct word or words. Put
time, since specific numbers show each hour of
your initials and the date. Never erase what
the day.
you have written. Do not use correction fluid
(Fig. 4-10). To change the regular hours between 1:00 p.m.
to 11:59 p.m. to military time, add 12 to the reg-
ular time. For example, to change 3:00 p.m. to
military time, add 3 + 12. The time is expressed
as 1500 (fifteen-hundred) hours. To change 4:22
p.m. to military time, add 4 + 12. The minutes
do not change. The time is expressed as 1622
Fig. 4-10. Corrected notes.
hours.
G Sign your full name and title, and write the Midnight is the only time that differs. Midnight
correct date. can be written as 0000, and it can also be writ-
G Document as specified in the care plan. ten as 2400. This follows the rule of adding 12
 45 4

to the regular time. Follow your facility’s policy Reporting and documenting incidents is done to
on whether to use 0000 or 2400 to express protect everyone involved. This includes the resi-
midnight. dent, your employer, and you. When document-
ing incidents, complete the report as soon as

Communication and Cultural Diversity

You first learned about the Minimum Data Set
possible and give it to the charge nurse. This is
(MDS) manual in Chapter 3. It is an assess-
important so that you do not forget any details.
ment tool to give facilities a structured, stan-
dardized approach to care. The MDS manual State and federal guidelines require incidents to
offers a detailed guide to help nurses complete be recorded in an incident report (Fig. 4-12). The
assessments accurately. The reporting you do information in an incident report is confidential.
on changes in your residents may “trigger” a
If a resident falls, and you did not see it, do not
needed assessment. Always report changes you
write “Mr. G fell.” Instead write “found Mr. G on
notice to the nurse. They may be a sign of an ill-
the floor,” or “Mr. G states that he fell.” For your
ness or problem. By reporting them promptly, a
protection, write a brief and accurate description
new MDS assessment can be done if needed.
of the events as they happened. Never place any
blame or liability within the incident report.
12. Describe incident reporting and Incident reports help demonstrate areas where
recording changes can be made to avoid repeating the
same incident. When completing an incident re-
An incident is an accident or unexpected event
port, follow these guidelines:
during the course of care. It is not part of the
normal routine in a facility. An error in care,
such as feeding a resident from the wrong meal Guidelines:
tray, is an incident. A fall or injury to a resident, Incident Reporting
employee, or visitor is another type of incident.
An accusation from a resident or family member G Tell what happened. State the time, and the
against staff is another example of an incident. mental and physical condition of the person.
Employee injuries also require reporting. In G Tell how the person tolerated the incident
general, file a report when any of the following (his reaction).
incidents occur:
G State the facts; do not give opinions.
• A resident falls
G Do not write anything in the incident report
• You or a resident break or damage on the medical record (incident reports are
something confidential).
• You make a mistake in care G Describe the action taken to give care.
• A resident or a family member makes a re- G Include suggestions for change.
quest that is out of your scope of practice
• A resident or a family member makes sexual
13. Demonstrate effective communication
advances or remarks
on the telephone
• Anything happens that makes you feel un-
comfortable, threatened, or unsafe You may be asked to make a call or answer the
telephone at your facility. A home health aide
• You get injured on the job working in the home may need to answer the
• You are exposed to blood or body fluids phone for clients or call a supervisor.
 4
Communication and Cultural Diversity
46

Fig. 4-12. A sample incident report. (reprinted with permission of briggs corporation, 800-247-2343, www.briggscorp.com)
 47 4

When making a call, follow these steps: 14. Understand guidelines for basic office
• Always identify yourself before asking to machines and computers
speak to someone. Never ask, “Who is this?” There are many types of machines you will

Communication and Cultural Diversity

when someone answers your call. encounter in various healthcare settings, and
• After you have identified yourself, ask for the you may already be familiar with most of them.
person with whom you need to speak. Following is some brief information on office
machines and computers. These machines or
• If the person you are calling is available,
devices can make communication easier, faster,
identify yourself again. State why you are
and more accurate.
calling. Planning your call before you pick
up the phone will help you be as efficient as
possible. Photocopier

• If the person is not available, ask if you can A photocopier, commonly called a “copier,” is a
leave a message. Always leave a brief mes- machine that makes paper copies of documents
sage, even if it is only to say you called. The and other images quickly. To operate a copier,
message shows that you were trying to reach open the lid. Place the document to be copied
someone. face-down on the glass. There may be marks on
the sides of the glass to show where to place dif-
• Leave a brief and clear message. Do not give ferent-sized documents. Select the options you
more information than necessary. A basic want, such as how many copies you want. Other
message includes your name, your facility’s options may include enlarging or decreasing the
name, the phone number you are calling image, making it lighter or darker, and collating
from, and a brief description of the reason the copies. Collate means to assemble or arrange
for your call. in the proper order. Once you have selected the
• Thank the person who takes the message for options you want, press the start button.
you. Always be polite over the telephone, as
you would be in person. Fax Machine
When answering calls, follow these steps: A fax machine transfers copies of documents
over a telephone network. Fax machines also
• Always identify your facility’s name and your
function as photocopiers. To send a fax, place
name. Be friendly and professional.
the piece of paper to be faxed in the document
• If you need to find the person the caller feeder. The machine should have instructions
wishes to speak with, place the caller on hold on whether the document must be placed face-
after asking if it is OK to do so. down or face-up. Enter the phone number that
• If the caller has to leave a message, write it you want to send the fax to, and press the send
down and repeat it to make sure you have button. You may need to dial a special number
the correct message. Ask for proper spellings to reach an outside line. After the fax has been
of names. Do not ask for more information transmitted, you may receive a printed confirma-
than the person needs to return the call: a tion from the paper tray below.
name, short message, and phone number
is enough. Do not give out any information Calculator
about staff or residents. A calculator performs mathematical calcula-
• Thank the person for calling and say tions. Calculators have standard symbols for per-
goodbye. forming these calculations. They include a plus
 4 48

sign ( + ) for addition problems, a minus sign 15. Explain the resident call system
( - ) for subtraction, a multiplication symbol
( x or * ), a division sign ( ÷ ), and an equal Long-term care facilities are required to have
sign ( = ). call systems—often called “call lights,”—so that
Communication and Cultural Diversity

residents can call for help whenever they need

You must be able to understand basic math in it. They are in resident rooms and bathrooms.
order to use a calculator to perform these pro- Some have strings for residents to pull and
cesses. Most calculators have numbers in the others have buttons to be pushed. The signal
middle or bottom of the device. They begin with is usually both a light outside the room and a
zero and work upwards in rows of three until sound and can be heard in the nurses’ station.
you reach the number 9. This is the primary way a resident can call for
help. Always assume there is an emergency
Computer when you see the light or hear the sound and
Computers are electronic devices that process respond immediately. Check before you leave a
and store information. They may be used in vari- room that the resident can reach the signal and
ous ways in your facility. Some facilities and hos- knows how to use it.
pitals use computers to document information;
this is faster and more accurate than writing
16. List guidelines for communicating
information by hand. Doctors and nurses may
with residents with special needs
carry computers from room to room to review
medical records, document symptoms, tests, Due to illness or impairments, some residents
and treatments, manage medications, and per- will need special techniques to aid communica-
form other functions. Computers may be used tion. An impairment is a loss of function or
to transmit records or other patient information ability; it can be a partial or complete loss. Spe-
to other facilities and healthcare professionals. cial techniques for different conditions are listed
They may be used for research. Employees may below. Information on communicating with resi-
use computers to clock in and out when they dents who have dementia, such as Alzheimer’s
work, so that their total hours worked are calcu- disease, is in Chapter 19. Guidelines for commu-
lated for a specific time period for payment. nicating with residents who are mentally ill are
Computers are used to send and receive e-mail in Chapter 20.
and access the Internet. E-mail, short for “elec-
tronic mail,” is a system for sending and receiv- Hearing Impairment or Deafness
ing messages electronically over a computer
Persons who have impaired hearing or are deaf
system or network. The Internet is a worldwide
may have lost their hearing gradually, or they
communications system that links a network of
may have been born deaf. If they have a gradual
computers.
hearing loss, they may not be conscious of it.
If your facility uses computers for documenta- Signs of hearing loss include the following:
tion, research, tracking employee hours, or any
• Speaking loudly
other reason, you will be trained how to use
them. HIPAA privacy guidelines apply to com- • Leaning forward when someone is speaking
puter use. Make sure nobody can see private and
protected health or personal information on your • Cupping the ear to hear better
computer screen. Do not share confidential in-
• Responding inappropriately
formation with anyone except the care team.
 49 4

• Asking the speaker to repeat what has been G Reduce or remove noise, such as TVs, radios,
said and loud speech. Close doors if needed.
• Speaking in a monotone G Get residents’ attention before speaking. Do

Communication and Cultural Diversity

• Avoiding social gatherings or acting irritable not startle them by approaching from behind.
in the presence of people who are having a Walk in front or touch them lightly on the
conversation arm to show you are near.

• Suspecting others of talking about them or G Speak clearly and slowly. Directly face the per-
of deliberately speaking softly son (Fig. 4-14). Make sure there is enough
light in the room. The light should be on your
People who have hearing impairment may use
face, rather than on the resident’s. Ask if he
a hearing aid, they may read lips, or use sign
or she can hear what you are saying.
language. People with impaired hearing also
closely observe the facial expressions and body
language of others to add to their knowledge of
what is being said. Hearing loss may affect how
well residents can express their needs.

Guidelines:
Hearing Impairment

G If the person has a hearing aid, make sure

he or she is wearing it and that it is working
properly (Fig. 4-13). There are many types of Fig. 4-14. Speak face-to-face in good light.
hearing aids. Follow manufacturer’s direc-
tions for cleaning. In general, the hearing aid G Do not shout at the resident or mouth the
needs to be cleaned daily. Wipe it with alco- words in an exaggerated way.
hol using a tissue or soft cloth. Do not put G Keep the pitch of your voice low.
it in water. Handle the hearing aid carefully.
G Residents may read lips, so keep hands away
Do not drop it. Always store it inside its case
from your face while talking.
when it is not worn. Turn it off when it is not
in use. Remove it before showers or when G Know which ear hears better. Try to speak to
bathing resident and during the night. When and stand on that side.
storing it for an extended period of time, G Use short sentences and simple words. Avoid
remove the battery. sudden topic changes.
G Repeat what you have said using different
words, when needed. Some hearing-impaired
people want you to repeat exactly what you
said. This is because they miss only a few
words.
G Use picture cards or a notepad as needed.
G Hearing impaired residents may hear less
Fig. 4-13. This is one type of hearing aid. Make sure when they are tired or ill. This is true of every-
hearing aids are turned on. one. Be patient and empathetic.
 4 50

G Hearing decline can be a normal aspect of G Make sure there is proper lighting in the
aging. Be matter-of-fact about this. Be under- room. Face the resident when speaking.
standing and supportive. G When you enter a new room with the resi-
Communication and Cultural Diversity

dent, orient him or her to the area. Describe

Vision Impairment the things you see around you. Do not use
Like hearing impairment, vision impairment words such as “see,” “look,” and “watch.”
can affect people of all ages. It can exist at birth G Tell the resident where the call light is.
or develop gradually. It can occur in one eye or
G Use the face of an imaginary clock as a guide
in both. It can also be the result of injury, ill-
to explain the position of objects that are
ness, or aging. Some vision impairment causes
in front of resident. For example,”There is a
people to wear corrective lenses. These can be
sofa at 7 o’clock” (Fig. 4-15).
contact lenses or eyeglasses. Farsightedness is
the ability to see objects in the distance better
than objects nearby. It develops in most people
as they age. Nearsightedness is the ability
to see things near but not far. It may occur in
younger persons. Some people need to wear
eyeglasses all the time. Others only need them
to read or for activities, such as driving, that re-
quire seeing distant objects. There is more infor-
mation on vision impairment in Chapter 18.

Guidelines:
Vision Impairment

G If the person has glasses, make sure they are

clean and that he or she wears them. Clean Fig. 4-15. The face of a clock can explain the position
glass lenses with water and soft tissue. Clean of objects.
plastic lenses with cleaning fluid and a lens
cloth. Also, make sure that glasses are in G Do not move personal items or furniture
good condition and fit well. If they do not, without the resident’s knowledge and
inform the nurse. permission.
G Knock on the door and identify yourself when G Put everything back where it was found.
you enter the room. Do this before touching G Leave the door completely open or complete-
the resident. Explain why you are there and ly closed.
what you would like to do. Let the resident
G Encourage the use of the other senses, such
know when you are leaving the room.
as hearing, touch, and smell.
G Always tell the resident what you are doing
G Encourage the resident to feel and touch
while caring for him. Give specific directions,
things, such as clothing, furniture, or items
such as, “On your right” or, “In front of you.”
in the room.
Talk directly to the resident whom you are
assisting. Do not talk to other residents or G Offer large-print newspapers, magazines, and
staff members. books.
 51 4

G Use large clocks, clocks that chime, and radi- • Loss of bowel or bladder control
os to help keep track of time.
• Confusion
G Get books on tape and other aids from the
• Poor judgment

Communication and Cultural Diversity

local library or support organizations.
• Memory loss
G If the resident has a guide dog, do not play
with or distract it or feed it. • Loss of cognitive abilities
• Tendency to ignore one side of the body,
CVA or Stroke
called one-sided neglect
The medical term for a stroke is a cerebrovas-
• Laughing or crying without any reason, or
cular accident (CVA). CVA, or stroke, is caused
when it is inappropriate, called emotional
when the blood supply to the brain is cut off
lability
suddenly by a clot or a ruptured blood vessel
(Fig. 4-16). Without blood, part of the brain gets • Difficulty swallowing, called dysphagia
no oxygen. This causes brain cells to die. Brain Depending on the severity of the stroke and
tissue is further damaged by leaking blood, speech loss or confusion, these guidelines may
clots, and swelling. These cause pressure on sur- help:
rounding areas of healthy tissue. Strokes can be
mild or severe. Afterward, a resident may experi-
ence any of the following: Guidelines:
Communication and Stroke

G Keep questions and directions simple. Give

directions one step at a time.
G Phrase questions so they can be answered
with a “yes” or “no.” For example, when help-
ing a resident with eating, ask, “Would you
like to start with a drink of milk?”
G Agree on signals, such as shaking or nodding
Fig. 4-16. A stroke is caused when the blood supply to the head or raising a hand or finger for “yes”
the brain is cut off suddenly by a clot or ruptured blood or “no.”
vessel.
G Give residents time to respond. Listen atten-
• Paralysis on one side of the body, called tively.
hemiplegia G Use a pencil and paper if the resident can
• Weakness on one side of the body, called write. A thick handle or tape around it may
hemiparesis help the resident hold it more easily.
• Inability to speak or speak clearly, called ex- G Never call the weaker side the “bad side,” or
pressive aphasia talk about the “bad” leg or arm. Use the term
“weaker” or “involved” to refer to the side
• Inability to understand spoken or written
with paralysis or weakness.
words, called receptive aphasia
G Keep the call signal within reach of residents.
• Loss of sensations such as temperature or
They can let you know when you are needed.
touch
 4 52

G Use pictures, gestures, or pointing. Use com- Residents’ Rights

munication boards or special cards to aid
Residents Who Cannot Speak
communication (Fig. 4-17).
Never talk about residents as if they were not there.
Communication and Cultural Diversity

Just because they cannot speak does not mean they

cannot hear. Treat all residents with respect.

Combative Behavior
Residents may display combative, meaning vio-
lent or hostile, behavior. Such behavior includes
hitting, pushing, kicking, or verbal attacks. It
may be the result of disease affecting the brain.
It may also be due to frustration. Or it may just
be part of someone’s personality. In general,
combative behavior is not a reaction to you. Try
not to take it personally.
Always report and document combative behav-
ior. Even if you do not find the behavior upset-
ting, the care team needs to be aware of it. Use
these guidelines when dealing with combative
behavior:

Guidelines:
Combative Behavior

G Block physical blows or step out of the way,

but never hit back (Fig. 4-18). No matter how
much a resident hurts you, or how angry or
afraid you are, never hit or threaten a
resident.

Fig. 4-17. A sample communication board. Fig. 4-18. Step out of the way, but never hit back.

You will learn more about caring for someone G Remain calm. Lower the tone of your voice.
who has had a CVA in Chapter 18. G Be flexible and patient.
 53 4

G Stay neutral. G Treat the resident with dignity and respect.

Explain what you are going to do and when
G Try not respond to verbal attacks. Do not
you will do it.
argue. Do not accuse the resident of wrong-

Communication and Cultural Diversity

doing. G Answer call lights promptly.
G Do not use gestures that could frighten or G Stay at a safe distance if the resident
startle the resident. becomes combative.
G Be reassuring and supportive.
Assertive vs. Aggressive Behavior
G Consider what provoked the resident.
A person is behaving assertively when he expresses
Sometimes something as simple as a change thoughts, feelings, and beliefs in a direct and honest
in caregiver or routine can be very upsetting way. Being assertive involves respect for a person’s
to a resident. Leave the resident alone if you own needs and feelings and for those of other peo-
can safely do so. Get help to take the resident ple. It is not the same as being aggressive, combat-
ive, or angry.
to a quieter place.
A person is behaving aggressively when he ex-
presses thoughts, feelings, and beliefs in ways that
Anger humiliate, disgrace, or overpower the other person.
Little or no respect is shown for the needs or feel-
Anger is a natural emotion that has many
ings of others. Report aggressive behavior when you
causes, such as disease, fear, pain, and loneli- witness it.
ness. A loss of independence due to illness can
cause anger. Anger may also just be a part of
Inappropriate Behavior
someone’s personality. Some people get angry
more easily than others. Some residents will demonstrate inappropriate
behavior. Inappropriate behavior from a resident
People express anger in different ways. Some
includes trying to establish a personal, rather
may shout, yell, threaten, throw things, or pace.
than a professional, relationship. Examples in-
Others express their anger by withdrawing,
clude asking personal questions, requesting vis-
being silent, or sulking.
its on personal time, asking for or doing favors,
Always report angry behavior to the nurse. giving tips or gifts, and loaning or borrowing
Use these guidelines when dealing with angry money.
residents:
Inappropriate behavior includes making sexual
advances and comments. Sexual advances in-
Guidelines: clude any sexual words, comments, or behavior
Angry Behavior that makes you feel uncomfortable. Report this
behavior to the nurse immediately.
G Stay calm. Inappropriate behavior also includes residents
G Try not respond to verbal attacks. Do not removing their clothes or touching themselves
argue. in public. Illness, dementia, confusion, and
medication may cause this behavior. If you en-
G Empathize with the resident. Try to under-
counter any embarrassing situation, be matter-
stand what he or she is feeling.
of-fact. Do not over-react, as it may actually
G Try to find out what caused the resident’s reinforce the behavior. Try to distract the person.
anger. Using silence may help the resident If that does not work, gently direct the resident
explain. to a private area, and notify the nurse.
 4 54

Confused residents may have problems that 10. Why should a nursing assistant sit near a
mimic inappropriate sexual behavior. They may resident who has started a conversation?
have an uncomfortable rash, clothes that are too 11. For each statement, decide whether it is a
tight, too hot, or too scratchy, or they may need
Communication and Cultural Diversity

fact or an opinion. Write “F” for fact and “O”

to go to the bathroom. Consider and watch for for opinion.
these problems.
___ Mr. Moore looked terrible today.
When residents behave inappropriately, report
the behavior, even if you think it was harmless. ___ Mr. Gaston had a fever of 100.7° F.
___ Ms. Martino needs to make some
Residents’ Rights friends.
Never hit a resident. ___ Mr. Klein has not had a visitor since last
Unfortunately, it is not uncommon to read or hear Tuesday.
about physical abuse of the elderly by caregivers.
These caregivers may be family, friends, or care team ___ The doctor says Mrs. Storey has to walk
members. Often, physical abuse is due to stressful once a day.
situations causing the caregiver to lash out quickly.
You can never hit a resident, no matter how a resi- 12. What is objective information? What is sub-
dent may have provoked you. Hitting a resident is jective information?
considered abuse and is grounds for termination
and legal action. If you feel that you need help han- 13. Why should nursing assistants use simple,
dling stressful situations, talk with the charge nurse. non-medical terms when speaking with resi-
dents and their families?
14. What does the abbreviation “ROM” stand
Chapter Review
for?
1. Briefly describe three steps in the communi-
15. What does the abbreviation “NPO” stand
cation process.
for?
2. Define nonverbal communication and
16. What does the abbreviation “DNR” stand
give one example that is not listed in the
for?
textbook.
17. List ten signs and symptoms that should be
3. What does the word “culture” mean?
reported immediately to the nurse.
4. What is one positive response to cultural
18. Describe four reasons why careful documen-
diversity?
tation is important.
5. Why should “why” questions be avoided
19. When should care be documented—before
when talking with residents?
or after it is done?
6. If a resident speaks a different language
20. Convert 10:00 p.m. to military time.
than the nursing assistant does, what can
the nursing assistant do? 21. Convert 1400 hours to regular time.

7. What is one way to provide feedback while 22. What is an incident at a facility?
listening? 23. List four guidelines for incident reporting.
8. What can silence or pauses help a resident 24. Give an example of a proper greeting when
do? answering the phone.
9. What is one reason that a nursing assistant 25. What are computers? Give two reasons why
should not ignore a resident’s request? they may be used in a facility.
 55 4

26. What is the purpose of the resident call light

or call system?
27. When a resident has a hearing impairment,

Communication and Cultural Diversity

on whose face should the light be shining
while communicating—the resident’s or the
nursing assistant’s?
28. How can a nursing assistant explain the
position of objects in front of a visually im-
paired resident?
29. How should questions be phrased to a resi-
dent who has had a stroke?
30. How should a nursing assistant refer to the
weaker side of a resident who has had a
stroke?
31. What should a nursing assistant always do
after a resident behaves inappropriately?
 5 56

5
Preventing Infection

Preventing Infection

1. Define “infection control” and related Generally, there are two types of infections:
terms systemic and localized. A systemic infection
is in the bloodstream and is spread throughout
Infection control is the term for measures the body. It causes general symptoms, such as
practiced in healthcare facilities to prevent and fever, chills, or mental confusion. A localized
control the spread of disease. Working to prevent infection is confined to a specific location in
the spread of disease is the responsibility of all the body and has local symptoms. Its symptoms
care team members. Know your facility’s infec- are near the site of infection. For example, if a
tion control policies; they are there to help pro- wound becomes infected, the area around it may
tect you, residents, and others from disease. become red, hot, and painful.
A microorganism is a living thing or organism Another type of infection is a healthcare-
that is so small that it can be seen only through associated infection, or nosocomial infection.
a microscope. A microbe is another name for Healthcare-associated infections (HAIs) are
a microorganism. Microorganisms are always infections that patients acquire within health-
present in the environment (Fig. 5-1). Infections care settings that result from treatment for other
occur when harmful microorganisms, called conditions.
pathogens, invade the body and multiply.
Medical asepsis is the process of removing
pathogens, or the state of being free of patho-
gens. It refers to the clean conditions you want
to create in your facility and is used in all health-
care settings. In healthcare settings, the term
“clean” means objects are not contaminated
with pathogens. The term “dirty” means that
objects have been contaminated with pathogens.
Surgical asepsis is the state of being free of all
microorganisms, not just pathogens. Surgical
asepsis, also called “sterile technique,” is used
for many types of procedures, such as dressing
wounds and changing catheters.
Preventing the spread of infection is very impor-
Fig. 5-1. Microorganisms are always present in the envi- tant. To understand how to prevent disease you
ronment. They are on almost everything we touch. must first understand how it is spread.
 57 5

Tip
Infection Prevention
Many facilities now use the term “infection preven-

Preventing Infection
tion,” rather than “infection control.” The reason for
this is that infections should not be allowed to de-
velop and then need to be controlled. Instead, they
should be prevented.

2. Describe the chain of infection

The chain of infection is a way of describing
how disease is transmitted from one living being Fig. 5-3. Portals of exit.
to another (Fig. 5-2). Definitions and examples
of each of the six links in the chain of infection Link 4: The mode of transmission describes
follow. how the pathogen travels from one person to the
next person. Transmission can happen through
the air or through direct or indirect contact. Di-
rect contact happens by touching the infected
person or his secretions. Indirect contact re-
sults from touching something contaminated by
the infected person, such as a tissue or clothes.
Link 5: The portal of entry is any body open-
ing on an uninfected person that allows patho-
gens to enter. This can occur through the nose,
mouth, eyes, other mucous membranes, a cut in
Fig. 5-2. The chain of infection. the skin, or dry/cracked skin (Fig. 5-4). Mucous
membranes are the membranes that line body
Link 1: The causative agent is a pathogen or cavities, such as the mouth, nose, eyes, rectum,
microorganism that causes disease. Normal and genitals.
flora are the microorganisms that live in and
on the body and do not cause harm. When they
enter a different part of the body, they may cause
an infection. Causative agents include bacteria,
viruses, fungi, and protozoa.
Link 2: A reservoir is a place where the patho-
gen lives and grows. It can be a person, animal,
plant, soil, or substance. Microorganisms grow
best in warm, dark, and moist places where food
is present. Some microorganisms need oxygen
to survive; others do not. Examples of reservoirs
include the lungs, blood, and the large intestine.
Link 3: The portal of exit is any body opening Fig. 5-4. Portals of entry.
on an infected person that allows pathogens to
leave, such as the nose, mouth, eyes, or a cut in Link 6: A susceptible host is an uninfected
the skin (Fig. 5-3). person who could get sick. Examples include
 5 58

all healthcare workers and anyone in their care The elderly are hospitalized more often than
who is not already infected with that particular younger people. This makes them more likely to
disease. get healthcare-associated infections. Difficulty
swallowing and incontinence increase the risk of
Preventing Infection

If one of the links in the chain of infection is

respiratory and urinary tract infections. Feeding
broken, then the spread of infection is stopped.
tubes, oxygen tubes, and other types of tubing,
By using infection prevention practices, you can
such as catheters (see Chapter 16), increase the
help stop pathogens from traveling (Link 4) and
risk of infection.
getting on your hands, nose, eyes, mouth, skin,
etc. (Link 5). You can also reduce your chances Infection is more dangerous for the elderly
of getting sick by having immunizations (Link because even a simple cold can turn into a life-
6) for diseases such as hepatitis B and influenza. threatening illness such as pneumonia. It also
may take longer for older people to recover from
Transmission (passage or transfer) of most
an infection or illness. This is why preventing
infectious, or contagious, diseases can be
infection is so important. Nursing assistants
prevented by always taking a few precautions.
play an important role in preventing infection.
Washing your hands is the most important way
to stop the spread of infection. All caregivers You will need to recognize signs and symptoms
should wash their hands often. of infections so that you can report them to the
nurse.

3. Explain why the elderly are at a higher

Observing and reporting:
risk for infection and identify symptoms
Localized and Systemic Infections
of an infection
The elderly are at a higher risk for infection. Signs and symptoms of a localized infection are:
This is due, in part, to weakened immune sys- Pain
tems as a result of aging. Weakened immune
Redness
systems can also result from chronic illnesses.
Other physical changes of aging, such as de- Pus
creased circulation and slow wound healing, Swelling
may also contribute to infections in the elderly.
Drainage (fluid from a wound or cavity)
Older adults are at risk for malnutrition and
Heat to the site
dehydration. A person who is malnourished is
not getting the proper nutrition. Dehydration Signs and symptoms of a systemic infection are:
is a condition that results from inadequate fluid Fever
in the body. These conditions can result from
Body aches
difficulty chewing and/or swallowing, lack of
appetite and thirst, illnesses, weakness, and Chills
medication. Both malnutrition and dehydration Nausea
are serious conditions (see Chapter 15). When
the body is not getting the nutrients and fluid Vomiting
it needs, the risk of infection greatly increases. Weakness
Also, the elderly may have limited mobility,
Headache
which is another risk factor for serious prob-
lems, such as pressure sores, skin infections, Mental confusion
and pneumonia. Drop in person’s normal blood pressure
 59 5

4. Describe the Centers for Disease • Always practice standard precautions with
Control and Prevention (CDC) and explain every single person in your care.
standard precautions • Transmission-based precautions vary based

Preventing Infection
on how an infection is transmitted. When
The Centers for Disease Control and Preven-
indicated, they are used in addition to the
tion (CDC) is a government agency under the
standard precautions. You will learn more
Department of Health and Human Services
about these precautions later in the chapter.
(HHS) that issues information to protect the
health of individuals and communities. It pro-
motes public health and disease, injury, and dis- Guidelines:
ability prevention and control through education. Standard Precautions
In 1996, the CDC recommended a new infection
control system to reduce the risk of contracting G Wash your hands before putting on gloves.
infectious diseases in healthcare settings. In Wash your hands immediately after remov-
2007 some additions and changes were made to ing your gloves. Be careful not to touch clean
this system. objects with your used gloves.
There are two tiers of precautions within the in- G Wear gloves if you may come into contact
fection control system: standard precautions and with: blood; body fluids or secretions; broken
transmission-based, or isolation, precautions. To skin, such as abrasions, acne, cuts, stitches,
isolate means to keep something separate, or by or staples; or mucous membranes. Such situ-
itself. ations include mouth care, toilet assistance,
Following standard precautions means treat- perineal care, helping with a bedpan or uri-
ing all blood, body fluids, non-intact skin (like nal, cleaning up spills, cleaning basins, uri-
abrasions, pimples, or open sores), and mucous nals, bedpans, and other containers that have
membranes (lining of mouth, nose, eyes, rec- held body fluids, and disposing of wastes.
tum, or genitals) as if they were infected with an G Remove gloves immediately when finished
infectious disease. Following standard precau- with a procedure.
tions is the only safe way of doing your job. You
G Immediately wash all skin surfaces that have
cannot tell by looking at your residents or their
been contaminated with blood and body
medical charts if they have a contagious disease
fluids.
such as HIV, hepatitis, or influenza.
G Wear a disposable gown that is resistant to
Under standard precautions, “body fluids” in-
body fluids if you may come into contact with
clude saliva, sputum (mucus coughed up), urine,
blood or body fluids.
feces, semen, vaginal secretions, and pus or other
wound drainage. They do not include sweat. G Wear a mask and protective goggles if you
may come into contact with splashing or
Standard precautions and transmission-based
spraying blood or body fluids (for example,
precautions are a way to stop the spread of infec-
emptying a bedpan).
tion. They interrupt the mode of transmission.
In other words, these guidelines do not stop an G Wear gloves and use caution when handling
infected person from releasing pathogens. How- razor blades, needles, and other sharps.
ever, by following these guidelines you help pre- Sharps are needles or other sharp objects.
vent those pathogens from infecting you or those Discard these objects carefully in a puncture-
in your care: resistant biohazard container.
 5 60

G Never attempt to put a cap on a needle or disease. If you practice standard precautions, you
syringe. Dispose of them in a biohazardous greatly reduce the risk of transmitting infection
waste container. (Fig. 5-5). to yourself and others. You will learn more about
following standard precautions in the next sev-
Preventing Infection

eral learning objectives.

5. Explain the term “hand hygiene” and

identify when to wash hands
In your work you will use your hands constantly.
Microorganisms are on everything you touch.
Washing your hands is the single most impor-
tant thing you can do to prevent the spread of
disease (Fig. 5-6).

Fig. 5-5. One type of biohazardous waste container.

G Avoid nicks and cuts when shaving residents.

G Carefully bag all contaminated supplies.
Dispose of them according to your facility’s
policy.
G Clearly label body fluids that are saved for a
specimen with the resident’s name and a bio-
hazard label. Keep them in a container with a
lid. Put in a biohazardous specimen bag for
transportation, if required.
G Dispose of contaminated wastes according to
Fig. 5-6. All people working in health care must wash
your facility’s policy. Waste containing blood
their hands often. Washing your hands is the most impor-
or body fluids is considered biohazardous tant thing you can do to prevent the spread of disease.
waste. Liquid waste can usually be disposed
through the regular sewer system as long as The CDC has defined hand hygiene as hand-
there is no splashing, spraying, or aerosol- washing with either plain or antiseptic soap
izing of the waste as it is being disposed. and water and using alcohol-based hand rubs.
Appropriate PPE needs to be worn, followed Alcohol-based hand rubs include gels, rinses,
by proper removal and handwashing. Follow and foams. They do not require the use of water.
instructions at your facility. Hand antisepsis refers to washing hands with
Again, standard precautions should ALWAYS water and soap or other detergents that contain
be practiced on those in your care regardless of an antiseptic agent.
their infection status. You cannot tell by how Alcohol-based hand rubs—often just called
someone looks or acts, or even by reading his “hand rubs”—have proven effective in reducing
or her chart, if he or she carries a bloodborne bacteria on the skin. However, they are not a
 61 5

substitute for proper handwashing. Always use • After touching areas on your body, such as
plain or antimicrobial soap and water for visibly your mouth, face, eyes, hair, ears, or nose
soiled hands. An antimicrobial agent destroys
• Before and after applying makeup
or resists pathogens. Once hands are clean, hand

Preventing Infection
rubs can be used in addition to handwashing • After any contact with pets and after contact
any time your hands are not visibly soiled. When with pet care items
using a hand rub, the hands must be rubbed • Before leaving the facility
together until the product has completely dried.
Use hand lotion to prevent dry, cracked skin. Washing hands
If you wear rings, consider removing them while
Equipment: soap, paper towels
working. Rings may increase the risk of contam-
ination. Keep your fingernails short, smooth, 1. Turn on water at sink. Keep your clothes dry,
and clean. Do not wear artificial nails or extend- because moisture breeds bacteria.
ers because they har­bor bacteria and increase 2. Angle your arms down, holding your hands
the risk of contamination. lower than your elbows. This prevents water
You should wash your hands: from running up your arm. Wet hands and
wrists thoroughly (Fig. 5-7).
• When you arrive at work
• Whenever they are visibly soiled
• Before, between, and after all contact with
residents
• Before putting on gloves and after removing
gloves
• After contact with any body fluids, mucous
membranes, non-intact skin, or dressings
Fig. 5-7.
• After handling contaminated items
• After contact with objects in the resident’s 3. Apply skin cleanser or soap to your hands.
room (care environment)
4. Rub hands together and fingers between
• Before and after touching meal trays and/or each other to create a lather. Lather all sur-
handling food faces of your fingers and hands, including
• Before and after feeding residents your wrists (Fig. 5-8). Use friction for at least
• Before getting clean linen 20 seconds. Friction helps clean.

• After touching garbage or trash

• After picking up anything from the floor
• After using the toilet
• After blowing your nose or coughing or
sneezing into your hand
• Before and after you eat
• After smoking Fig. 5-8.
 5 62

5. Clean your nails by rubbing them in palm of 6. Discuss the use of personal protective
other hand. equipment (PPE) in facilities
6. Being careful not to touch the sink, rinse Personal protective equipment (PPE) is
Preventing Infection

thoroughly under running water. Rinse all equipment that helps protect employees from
surfaces of your hands and wrists. Run water serious workplace injuries or illnesses resulting
down from wrists to fingertips. Do not run from contact with workplace hazards. In long-
water over unwashed arms down to clean term care facilities, PPE helps protect you from
hands (Fig. 5-9). contact with potentially infectious material. Your
employer is responsible for giving you the appro-
priate PPE to wear.
Personal protective equipment includes gloves,
gowns, masks, goggles, and face shields. Gloves
protect the hands. Gowns protect the skin
and/or clothing. Masks protect the mouth and
nose. Goggles protect the eyes. Face shields pro-
tect the entire face—the mouth, nose, and eyes.

Gloves
Fig. 5-9.
You must wear gloves when there is a chance
you may come into contact with body fluids,
7. Use a clean, dry paper towel to dry all sur-
open wounds, or mucous membranes. Your fa-
faces of your hands, wrists, and fingers. Do
cility will have specific policies and procedures
not wipe towel on unwashed forearms and
on when to wear, or don, gloves. Learn and fol-
then wipe clean hands. Dispose of towel
low these rules. Always wear gloves for the fol-
without touching wastebasket. If your hands
lowing tasks:
touch the sink or wastebasket, start over.
• Any time you might touch blood or any body
8. Use a clean, dry paper towel to turn off the
fluid, including vomitus, urine, feces, or
faucet (Fig. 5-10). Do not contaminate your
saliva
hands by touching the surface of the sink or
faucet. • Performing or helping with mouth care or
care of any mucous membrane
• Performing or helping with perineal care
(care of the genitals and anal area)
• Performing personal care on non-intact
skin—skin that is broken by abrasions, cuts,
rashes, acne, pimples, or boils
• Assisting with personal care when you have
open sores or cuts on your hands
Fig. 5-10.
• Shaving a resident
9. Dispose of used paper towel(s) in wastebas-
• Disposing of soiled bed linens, gowns, dress-
ket immediately after shutting off faucet.
ings, and pads
 63 5

Clean, non-sterile gloves are generally adequate. becoming contaminated. After giving care, your
They may be vinyl, latex, or nitrile; however, gloves are contaminated. If you open a door with
some people are allergic to latex. If you are, let the gloved hand, the doorknob becomes con-
the nurse know. Alternative gloves will be pro- taminated. Later, when you open the door with

Preventing Infection
vided. Tell the nurse if you have dry, cracked, an ungloved hand, you will be infected even
or broken skin. Gloves should fit your hands though you wore gloves during the procedure. It
comfortably. They should not be too loose or too is a common mistake to contaminate the room
tight. around you. Do not do this. Before touching
surfaces, remove your gloves. Wash your hands.
If you have cuts or sores on your hands, first
Afterward, put on new gloves if needed.
cover these areas with bandages or gauze, and
then put on gloves. Disposable gloves are to be
worn only once. They may not be washed or dis- Taking off gloves
infected for reuse. Change gloves right before
1. Touch only the outside of one glove. Pull the
contact with mucous membranes or broken skin,
first glove off by pulling down from the cuff
or if gloves are soiled, torn, or damaged. Wash
(Fig. 5-12).
your hands before putting on fresh gloves.

Putting on gloves

1. Wash your hands.

2. If you are right-handed, slide one glove on
your left hand (reverse if left-handed).
3. With gloved hand, slide the other hand into
the second glove.
4. Interlace fingers. Smooth out folds and cre-
Fig. 5-12.
ate a comfortable fit.
5. Carefully look for tears, holes, or discolored 2. As the glove comes off your hand, it should
spots. Replace the glove if needed. be turned inside out.
6. If wearing a gown, pull the cuff of the gloves 3. With the fingertips of your gloved hand,
over the sleeve of gown (Fig. 5-11). hold the glove you just removed. With your
ungloved hand, reach two fingers inside the
remaining glove. Be careful not to touch any
part of the outside of glove (Fig. 5-13).

Fig. 5-11.

Remove, or doff, gloves promptly after use and Fig. 5-13.

wash your hands. Remove your gloves before
touching non-contaminated items or surfaces. 4. Pull down, turning this glove inside out and
You are wearing gloves to protect your skin from over the first glove as you remove it.
 5 64

5. You should now be holding one glove from 3. Tie the neck ties into a bow so they can be
its clean inner side. The other glove should easily untied later.
be inside it.
4. Reach behind you. Pull the gown until it com-
Preventing Infection

6. Drop both gloves into the proper container. pletely covers your clothing. Tie the back ties
7. Wash your hands. (Fig. 5-15).

The guidelines for wearing other PPE are the

same as for gloves. You should wear PPE if
there is a chance you could come into contact
with body fluids, mucous membranes, or open
wounds. Gowns, masks, goggles, and face
shields are worn when splashing or spraying of
body fluids or blood could occur.

Gowns
Clean, non-sterile gowns protect your exposed
skin. They also prevent soiling of your cloth- Fig. 5-15.
ing. Gowns should fully cover your torso. They
should fit comfortably over your body, and have
5. Use a gown only once and then remove and
long sleeves that fit snugly at the wrist. When
discard it. When removing a gown, roll the
finished with a procedure, remove the gown as
dirty side in and away from the body. If your
soon as possible and wash your hands.
gown ever becomes wet or soiled, remove
it. Check clothing and put on a new gown.
Putting on a gown The Occupational Safety and Health Admin-
istration (OSHA) requires non-permeable
1. Wash your hands.
gowns—gowns that liquids cannot pen-
2. Open the gown. Hold out in front of you and etrate—when working in a bloody situation.
allow gown to open. Do not shake it. Slip
your arms into the sleeves and pull gown on 6. Put on your gloves after putting on gown.
(Fig. 5-14).

Masks and Goggles

Masks should also be worn when caring for

residents with respiratory illnesses. Sometimes
special masks are required for certain diseases,
such as tuberculosis (TB). You will learn more
about TB later in the chapter. Masks should
fully cover your nose and mouth and prevent
fluid penetration. Masks should fit snugly over
the nose and mouth. Always change your mask
between residents; do not wear the same mask
Fig. 5-14. from one resident to another.
 65 5

Goggles provide protection for your eyes. Eye-

glasses alone do not provide proper eye protec-
tion. Goggles should fit snugly over and around
your eyes or eyeglasses.

Preventing Infection
Putting on mask and goggles

1. Wash your hands.

2. Pick up the mask by top strings or elastic

strap. Be careful not to touch the mask where
it touches your face.

3. Adjust the mask over your nose and mouth. Fig. 5-17. Using PPE is an important way to reduce the
Tie top strings first, then bottom strings. spread of infection.
Masks must always be dry or they must be
replaced. Never wear a mask hanging from When applying PPE, remember this order:
only the bottom ties (Fig. 5-16). 1. Apply gown.
2. Apply mask.
3. Apply goggles or face shield.
4. Apply gloves last.
When removing PPE, remember this order:
1. Remove gloves.
2. Remove goggles or face shield.
3. Remove gown.
Fig. 5-16.
4. Remove mask.

4. Put on the goggles. Performing hand hygiene is always the final

step after re­moving and disposing of PPE.
5. Put on your gloves after putting on mask and
goggles. Tip
Wearing PPE
OSHA states that it is the employer’s responsibility
Face Shields to instruct the staff on how to properly wear (don)
the PPE, how to wear the PPE effectively, and how to
When additional skin protection is needed, a
safely remove (doff) the PPE. This instruction needs
face shield can be used as a substitute for wear- to be given before the employee is in a situation
ing a mask or goggles. Follow your facility’s poli- where PPE is indicated, and as an annual review.
cies. The face shield should cover your forehead
and go below the chin. It wraps around the sides
of your face. 7. List guidelines for handling equipment
and linen
Your employer will give you PPE as needed. It is
your responsibility to know where it is kept and Equipment, linen, and supplies are kept in spe-
how to use it (Fig. 5-17). cial supply or utility rooms. There are separate
 5 66

rooms for supplies that are considered “clean” G Dispose of all “single-use,” or disposable,
and for supplies that are considered “dirty” or equipment properly. Disposable means it is
contaminated. You will be told where these discarded after one use. Disposable razors
Preventing Infection

rooms are located and what types of equipment are an example of disposable equipment.
and supplies are found in each room. Perform
G Clean and disinfect
hand hygiene before entering clean utility rooms
and before leaving dirty utility rooms. This helps • All environmental surfaces
prevent the spread of pathogens. • Beds, bedrails, all bedside equipment
Cleaning usually involves the use of water with • All frequently touched surfaces (such as
or without detergents. General cleaning removes doorknobs, call lights, handles on dress-
microorganisms but does not kill them. This ers and tables)
type of cleaning is often adequate for equipment G Handle, transport, and process soiled linens
that does not touch residents or touches only and clothing in a way that prevents
skin that is intact (for example, crutches and
• Skin and mucous membrane exposure
blood pressure cuffs). Sterilization is a mea-
sure that destroys all microorganisms, includ- • Contamination of clothing (hold linen
ing pathogens. It uses steam under pressure, and clothing away from uniform) (Fig.
liquid or gas chemicals, or dry heat to sterilize. 5-18)
Items that need to be sterilized are ones that • Transfer of disease to other residents and
go directly into the bloodstream or into other areas (do not shake linen or clothes; fold
normally sterile areas of the body (for example, or roll linen so that the dirtiest area is
surgical instruments). Disinfection is a process inside)
that kills pathogens, but not all microorganisms;
it reduces the organism count to a level that is
generally not considered infectious. It is defined
as a measure that falls between general clean-
ing and sterilization. Disinfection is carried out
with pasteurization or chemical germicides.
Examples of items that are usually disinfected
are re-usable oxygen tanks, wall mounted blood
pressure cuffs, and any re-usable resident care
equipment. Fig. 5-18. Hold and carry dirty linen away from your
uniform.
Guidelines:
G Bag soiled linen at point of origin.
Handling Equipment, Linen, and Clothing
G Sort soiled linen away from resident care
G Handle all equipment in a way that prevents areas.

• Skin/mucous membrane contact G Place wet linen in leak-proof bags.

• Contamination of your clothing You will learn more about cleaning equipment
and supplies in Chapter 12.
• Transfer of disease to other residents or
areas
8. Explain how to handle spills
G Do not use “re-usable” equipment again
Spills, especially those involving blood, body flu-
until it has been properly cleaned and repro-
ids, or glass, can pose a serious risk of infection.
cessed.
 67 5

Long-term care facilities will have cleaning solu- tions are used when caring for persons who are
tions for spills. Clean spills using proper equip- infected or suspected of being infected with a
ment and procedure. disease. These precautions are called transmis-
sion-based, or isolation, precautions. When

Preventing Infection
Guidelines: ordered, these precautions are used in addition
Cleaning Spills Involving Blood, Body Fluids, to standard precautions. These precautions will
or Glass always be listed in the care plan and on your
assignment sheet. It is for your safety and the
G Apply gloves before starting. In some cases, safety of others that these precautions must be
industrial-strength gloves are best. followed.
G First, absorb the spill with whatever product There are three categories of transmission-based
is used by the facility. It may be an absorbing precautions:
powder.
• Airborne precautions
G Scoop up the absorbed spill, and dispose of
in a designated container. • Droplet precautions

G Apply the proper disinfectant to the spill area • Contact precautions

and allow it stand wet for a minimum of 10 The category used depends on the disease and
minutes. how it spreads to other people. They may also
G Clean up spills immediately with the proper be used in combination for diseases that have
cleaning solution. multiple routes of transmission. Diseases that
require isolation precautions in addition to stan-
G Do not pick up any pieces of broken glass,
dard precautions include the following:
no matter how large, with your hands. Use a
dustpan and broom or other tools. • Multidrug-resistant organisms (MDROs)
G Waste containing broken glass, blood, or (microorganisms, mostly bacteria, that
body fluids should be properly bagged. Waste are resis­tant to one or more antimicro-
containing blood or body fluids may need to bial agents), such as methicillin-resistant
be placed in a special biohazard container. Staphylo­coccus aureus (MRSA) and vancomy-
Follow facility policy. cin-resistant enterococcus (VRE) *
• Clostridium difficile (C- diff or C. difficile) *
Tip
• Scabies (a skin disease that causes itching)
Cleaning Spills
Many facilities use special clean-up kits for spills. • Lice
Follow directions when using these kits.
• Influenza (during an outbreak)
Sometimes staff members assume that the disin-
fectant should be placed directly on the spilled fluid * You will learn more about these infections
before absorbing and removing the fluid. This is in-
later in the chapter.
correct. The spilled fluid may neutralize the disinfec-
tant upon contact. Absorb and remove the spill first.
Airborne Precautions
Airborne precautions are used for diseases that
9. Explain transmission-based
are transmitted through the air after being ex-
precautions
pelled (Fig. 5-19). The pathogens are so small
The CDC set forth a second level of precautions that they can attach to moisture in the air and
beyond standard precautions. These precau- remain floating for some time. For certain care
 5 68

you may be required to wear a special mask,

Respiratory Hygiene/Cough Etiquette in
such as N-95 or HEPA masks, to avoid being
Healthcare Settings
infected. Airborne diseases include tuberculosis,
measles, and chickenpox. More information on The CDC has set forth special infection prevention
Preventing Infection

measures for all respiratory infections in healthcare

tuberculosis is found later in this chapter.
settings. They include the following:
1. Post visual alerts at the entrances of care facilities
instructing that all patients and visitors inform staff
of symptoms of respiratory infections and to practice
respiratory hygiene/cough etiquette.
2. All individuals with signs and symptoms of a re-
spiratory infection must:
• Cover their nose/mouth when coughing and
Fig. 5-19. Airborne diseases stay suspended in the air. sneezing.
• Use tissues for respiratory secretions and dispose
Droplet Precautions of them in the nearest waste container.
• Perform hand hygiene after contact with respira-
Droplet precautions are used when the disease-
tory secretions and contaminated objects.
causing microorganism does not stay suspended
in the air and usually only travels short distances Healthcare facilities must make these items available
to staff, patients, and visitors:
after being expelled. Droplets normally do not
travel more than three feet. Droplets can be • Tissues and no-touch receptacles for tissue
created by coughing, sneezing, talking, laugh- disposal
ing, or suctioning (Fig. 5-20). Droplet precau- • Conveniently located hand rub dispensers and
tions include wearing a face mask during care handwashing supplies in areas where sinks are
located
and restricting visits from uninfected people.
Residents should wear masks, if they are able to 3. During times of increased respiratory infections,
do so, when being moved from room to room. offer masks to anyone who is coughing and encour-
age coughing people to sit at least three feet away
Cover your nose and mouth with a tissue when from others in waiting areas.
you sneeze or cough, and ask residents, family,
and others to do the same. Dispose of the tissue
in the nearest waste container. If you sneeze on Contact Precautions
your hands, wash them promptly. An example of
Contact precautions are used when there is a
a droplet disease is the mumps.
risk of transmitting or contracting a microorgan-
ism from touching an infected object or person
(Fig. 5-21). Lice, scabies, and bacterial conjunc-
tivitis (pink eye) are examples of situations that
require contact precautions. Transmission can
occur with skin-to-skin contact during transfers
or bathing.

Contact precautions include wearing PPE and

resident isolation. They require washing hands
Fig. 5-20. Droplet precautions are followed when the
with antimicrobial soap and not touching in-
disease-causing microorganism does not stay suspended fected surfaces with ungloved hands or unin-
in the air. fected surfaces with contaminated gloves.
 69 5

within the resident’s room, there may be an

alcohol-based hand rub dispenser mounted
on the wall inside the room as you exit the
door.

Preventing Infection
G Do not share equipment between residents.
Use disposable supplies that can be discard-
Fig. 5-21. Contact precautions are followed when the per- ed after use whenever possible. Use dedi-
son is at risk of transmitting or getting a microorganism
cated (only for use by one resident) equip-
from touching an infected object or person.
ment when disposable is not an option. For
Staff often refer to residents who need transmis- example, a resident in isolation has her own
sion-based precautions as being in “isolation.” A (dedicated) blood pressure cuff and stetho-
sign should be on the door indicating “isolation” scope. Disposable thermometers are used to
or “contact precautions” and alerting people to take her temperature. When using disposable
see the nurse before entering the room. Other supplies, discard them in the resident’s room
guidelines to follow for isolation (contact) pre- before leaving. Be careful not to contaminate
cautions include the following: reusable equipment by setting it on furniture
or counters in the resident’s room. When the
Guidelines: resident is discharged or no longer needs the
Isolation additional precautions, properly dispose of
dedicated equipment, if required. If the dedi-
G When they are indicated, transmission-based cated equipment is to be used for other resi-
precautions are always used in addition to dents, it should be cleaned and disinfected
standard precautions. after use.
G Nurses will set up the isolation unit. Some G Some facilities will require that disposable
facilities have a special room where isolation dishes, glasses, cups, and eating utensils
supplies are kept. Some facilities keep sup- be used for residents in isolation. Wear the
plies within the room itself, while other facili- proper PPE, if indicated, when serving food
ties set up an isolation cart outside the room. and drink. Do not leave uneaten food uncov-
Isolation supplies consist of gloves, masks, ered in the resident’s room. When the meal
gowns, or aprons and, if indicated, goggles, is completed, remove the meal tray and
face shields, respirator masks, or other forms take it to the designated area, or put it back
of specialized personal protective equipment on the food cart. When the food carts are
(PPE). returned to the kitchen, all soiled trays will be
handled with gloves by the dietary staff and
G You will be told the proper PPE to wear for
the tray and dinnerware will be cleaned and
care of each resident in isolation. Make sure
sanitized.
to put on the PPE properly and remove it
safely. Remove PPE and place it in the appro- G Follow standard precautions when dealing
priate container before exiting a resident’s with body waste removal. Wear gloves when
room. PPE cannot be worn outside the resi- touching or handling the resident’s waste.
dent’s room. Perform hand hygiene following Wear gowns and goggles when indicated. The
removal of PPE and exiting the resident’s waste must be disposed of in such a manner
room. In addition to handwashing areas as to minimize splashing and spraying.
 5 70

G If required to take a specimen from a can become infected with a bloodborne disease
resident in isolation, wear the proper PPE. by having sexual contact with someone with that
Collect the specimen following proper proce- disease. It is not necessary to have sexual inter-
dure, and place it in the appropriate contain- course to transmit disease. Other kinds of sexual
Preventing Infection

er without the outside of the container com- activity can just as easily cause infection. Using
ing into contact with the specimen. Properly a needle to inject drugs and sharing needles
remove your PPE and dispose of it in the can also transmit bloodborne diseases. In addi-
room. Perform hand hygiene before leaving tion, infected mothers may transmit bloodborne
the room, and take the container holding the diseases to their babies in the womb or during
specimen to the nurse. birth.
G Residents need to feel that their circum- In health care, contact with infected blood or
stances and feelings are appreciated and certain other body fluids is the most common
understood by members of the care team way to be infected with a bloodborne disease.
without criticism or judgment. Listen to what This chapter explains work practices, such as
your resident is telling you and allow time to standard precautions, hand hygiene, isolation,
talk with your resident about his concerns. and using PPE to help prevent transmission of
Reassure residents that it is the disease, not bloodborne diseases. Employers are required
the person, that is being isolated. Explain by law to help prevent exposure to bloodborne
why these steps are being taken. Relay any pathogens. You will learn more about that law in
requests outside your scope of practice to the the next learning objective. Understand and fol-
nurse. low standard precautions and other procedures
to protect yourself from bloodborne diseases.
Residents’ Rights
You can safely touch, hug, and spend time talk-
Isolation
ing with residents who have a bloodborne dis-
Residents’ basic needs remain the same while in
isolation. Human basic needs do not change, even ease (Fig. 5-22). They need the same thoughtful,
though physical conditions may change. Do not personal attention you give to all your residents.
avoid a resident in isolation. Do not rush through Follow standard precautions but never isolate
care tasks or make the resident feel that he or she
a resident emotionally because he or she has a
should be avoided. Being professional, caring and
competent may help lessen a resident’s worries or bloodborne disease.
concerns and feelings of being isolated. If you have
questions about the care you are giving, talk to the
charge nurse.

10. Define “bloodborne pathogens” and

describe two major bloodborne diseases
Bloodborne pathogens are microorganisms
found in human blood that can cause infec-
tion and disease in humans. They may also
be in body fluids, draining wounds, and mu-
cous membranes. Bloodborne diseases can be
transmitted by infected blood entering your
bloodstream, or if infected semen or vaginal se- Fig. 5-22. Hugs and touches cannot spread a bloodborne
disease.
cretions contact your mucous membranes. You
 71 5

The major bloodborne diseases in the United • Liver cancer

States are acquired immune deficiency syn- • Death
drome (AIDS) and hepatitis. HIV stands for
human immunodeficiency virus, and it is the Hepatitis C is also transmitted through blood

Preventing Infection
virus that can cause AIDS. HIV weakens the and possibly sexual intercourse. Hepatitis B and
immune system so that people cannot effec- C can lead to cirrhosis and liver cancer; they
tively fight infections. Some of these people will can even cause death. Many more people have
develop AIDS as a result of their HIV infection. hepatitis B (HBV) than HIV. The risk of acquir-
People with AIDS lose all ability to fight infec- ing hepatitis is greater than the risk of acquiring
tion. They can die from illnesses that a healthy HIV. HBV poses a serious threat to healthcare
body could handle. You will learn more about workers.
HIV and AIDS in Chapter 18. Hepatitis D is caused by the hepatitis D virus
Hepatitis is inflammation of the liver caused (HDV) and is only found in people who carry
by infection. It begins with symptoms that re- the hepatitis B virus. It is uncommon in the
semble the flu (fever, fatigue, nausea, vomiting), United States. It is transmitted through contact
but eventually jaundice appears. Jaundice is a with infectious blood. Hepatitis E caused by the
condition in which the skin, whites of the eyes, hepatitis E virus (HEV) that usually results in an
and mucous membranes appear yellow. Liver acute infection but does not lead to a chronic in-
function can be permanently damaged by hepa- fection. HEV is rare in the United States, but is
titis, which can lead to other chronic, life-long more common in many parts of the world. HEV
illnesses. Several different viruses can cause is transmitted through ingestion of fecal matter,
hepatitis: A, B, C, D, and E. The most common even in small amounts.
types of hepatitis are A, B, and C. Your employer must offer you a free vaccine to
The virus causing hepatitis A is a result of protect you from hepatitis B. The HBV vaccine
fecal-oral contamination. For example, a person can prevent hepatitis B. Prevention is the best
washes her hands improperly after having a option for dealing with this disease. If you have
bowel movement. She then prepares and eats not received the hepatitis B vaccine and you are
food that has been contaminated by the fecal exposed to a body fluid with the virus, your
material left on her hands and/or under her chances of acquiring infection are over 30%.
nails. Hepatitis B can remain capable of causing infec-
tion on an environmental surface for up to seven
Hepatitis B is contracted through blood or nee- days in a dried state. Take the vaccine when it
dles that are contaminated with the virus, or by is offered. It is the best protection against HBV.
sexual contact with an infected person. Hepatitis There is no vaccine for hepatitis C, D, and E.
B (HBV) can cause short-term illness that leads
to:
11. Explain OSHA’s Bloodborne Pathogen
• Loss of appetite Standard
• Diarrhea and vomiting
The Occupational Safety and Health Ad-
• Fatigue ministration (OSHA) is a federal government
• Jaundice (yellow skin or eyes) agency that makes rules to protect workers from
• Pain in muscles, joints, and stomach hazards on the job. OSHA has set standards
for special procedures that must be followed in
It can also cause long-term illness that leads to: healthcare facilities. One of these is the Blood-
• Liver damage (cirrhosis) borne Pathogens Standard. This law requires
 5 72

that healthcare facilities protect employees from

bloodborne health hazards. By law, employers
must follow these rules to reduce or eliminate
the risk of exposure to infectious diseases. The
Preventing Infection

standard also guides employers and employees

through the steps to follow if exposed to infec-
tious material. Significant exposures include:
• Exposure by injection; a needle stick
Fig. 5-23. This label indicates that the material is poten-
• Mucous membrane contact tially infectious.
• Cut from an object containing a potentially
infectious body fluid (includes human bites) • Employers must keep a log of injuries from
contaminated sharps. The information re-
• Non-intact skin (OSHA includes acne as
corded must protect the confidentiality of
non-intact skin)
the injured employee. Employers are also
Guidelines employers must follow include: required to select safer needle devices and to
• Employers must have a written exposure involve employees in choosing these devices.
control plan designed to eliminate or re- • Employers must provide training for em-
duce employee exposure to infectious mate- ployees to explain the standard and its
rial. This plan also identifies what to do if an contents.
employee is exposed to infectious material.
If any potential exposures occur, you will need
This plan must be accessible to all employ-
to fill out an incident report or a special expo-
ees, and they must receive training on the
sure report form. Your employer will help you
plan.
find out if you have been infected and will take
• Employers must give all employees, visitors, steps to keep you from becoming sick. To pro-
and residents proper personal protective tect your health and that of others, report any
equipment (PPE) to wear when needed at no potential exposures right away. Steps will also be
cost. Employers must make sure the PPE is taken to help keep similar incidents from occur-
available in the appropriate sizes and is read- ring again. Your facility may require tests and
ily accessible. other measures to keep you healthy. For more
• Employers must make biohazard containers information on OSHA, visit their website—
available for disposal of sharps and other osha.gov.
infectious waste. These containers must be
puncture resistant, labeled or color-coded, 12. Define “tuberculosis” and list
and leakproof. infection control guidelines
• Employers must provide a free hepatitis B
Tuberculosis, or TB, is an airborne disease car-
vaccine to all employees after hire. This vac-
ried on very small mucous droplets suspended
cine must be made available at no cost to the
in the air. When a person infected with TB
employee.
talks, coughs, breathes, or sings, he may release
• Warning labels must be affixed to waste con- mucous droplets carrying the disease. TB usu-
tainers and refrigerators and freezers that ally infects the lungs, causing coughing, trouble
contain blood or any other potentially infec- breathing, fever, weight loss, and fatigue. If left
tious material (Fig. 5-23). untreated, TB may cause death.
 73 5

There are two types of TB: latent TB, also called

Guidelines:
TB infection, and active TB, also called TB
Tuberculosis
disease. Someone with latent TB (TB infection)
carries the disease but does not show symptoms

Preventing Infection
G Follow standard precautions and airborne
and cannot infect others. A person with active precautions.
TB (TB disease) shows symptoms of the disease
and can spread TB to others. TB infection can G Wear a mask and gown during resident care.
progress to TB disease. The signs and symptoms Special masks, such as N-95, high efficiency
of TB include the following: particulate air (HEPA), or other masks, may
be needed (Fig. 5-24). These masks filter out
• Fatigue very small particles, such as the germs that
• Loss of appetite cause TB. You must be fit-tested for these
special masks. You will also be trained on
• Weight loss
how to use the masks.
• Slight fever and chills
• Night sweats a. b.

• Prolonged coughing
• Coughing up blood
• Chest pain
• Shortness of breath
Fig. 5-24. a) N-95 respirator mask and b) PFR-95 respi-
• Trouble breathing rator mask.
Tuberculosis is more likely to be spread in small,
confined, or poorly ventilated places. TB is more G Use special care when handling sputum or
likely to develop in people whose immune sys- phlegm. Phlegm is thick mucus from the
tems are weakened by illness, malnutrition, respiratory passage.
alcoholism, or drug abuse. People with cancer
G Residents with TB will be placed in a special
or HIV/AIDS are more susceptible to develop-
airborne infection isolation room (AIIR).
ing active TB when exposed. This is due to their
Other names for the isolation room may
weakened immune systems.
be “Negative Air Pressure Room” or “Acid-
Multidrug-resistant TB (MDR-TB) is a type of Fast Bacillus (AFB) isolation room.” In this
TB that can develop when a person with active type of room, the flow of air is carefully con-
TB does not take all the prescribed medication. trolled. Airborne particles are not trapped in
Resistant means drugs no longer work to kill the room. The air is changed often through
the specific bacteria. When the full course of a special air system. The air is exhausted
medication is not taken, bacteria remains in directly outside or forced through filters to
the body and is less likely to be killed by the TB remove particles. The room will be identified
medication. If the TB bacilli develop a resistance with a special sign identifying it as a special
to the drugs that treat TB, fighting the disease respiratory isolation room. When entering
becomes more difficult. Surgery may be the only this room, do not open or close the door
option for treatment. However, if the disease is quickly. This pulls contaminated room air
widespread throughout both lungs, surgery may into the hallway. The door should remain
not be possible. closed.
 5 74

G Follow isolation procedures for airborne dis- water, is the single most important measure to
eases if directed. control MRSA. Keep cuts and abrasions clean
and covered with a proper dressing (e.g. ban-
G Help the resident remember to take all medi-
dage) until healed. Avoid contact with other peo-
Preventing Infection

cation prescribed. Failure to take all medica-

ple’s wounds or material that is contaminated
tion is a major factor in the spread of TB.
from wounds.
VRE stands for vancomycin-resistant entero-
13. Define the terms “MRSA,” “VRE,” and coccus. Enterococci are bacteria that live in the
“C. Difficile” digestive and genital tracts. They normally do
Multidrug-resistant organisms (MDROs) are not cause problems in healthy people. Vanco-
microorganisms, mostly bacteria, that are resis- mycin is a powerful antibiotic that is often the
tant to one or more antimicrobial agents that antibiotic of last resort. It is generally limited to
are commonly used for treatment. MDROs are use against bacteria that are resistant to other
increasing, and this is a serious problem. Two antibiotics. Vancomycin-resistant enterococcus is
common types of MDROs are MRSA and VRE. a genetically changed strain of enterococcus that
originally developed in people who were exposed
MRSA stands for methicillin-resistant Staphylo- to the antibiotic vancomycin.
coccus aureus. Staphylococcus aureus is a common
VRE is dangerous because it cannot be con-
type of bacteria that can cause illness. Methicil-
trolled with most of the antibiotics currently
lin is a powerful antibiotic drug. MRSA is an
in use. It causes life-threatening infections in
antibiotic-resistant infection often acquired by
those with weakened immune systems—the
people in hospitals and other healthcare facilities
very young, the very old, and the very ill. VRE is
who have weakened immune systems. However,
spread through direct and indirect contact. Once
MRSA infections also occur in otherwise healthy
it establishes itself, it is very difficult to elimi-
people who have not been recently hospital-
nate. Preventing VRE is much easier. You can
ized or had recent medical procedures. They
help prevent its spread by washing your hands
are sometimes acquired in fitness centers when
often. Wear PPE as directed. Disinfect items ac-
equipment has not been disinfected during use.
cording to facility policy.
These infections are known as community-
associated MRSA infections (CA-MRSA) and are Clostridium difficile (C-diff, C. difficile) is
usually skin infections, such as pimples or boils. a spore-forming bacteria which can be part of
the normal intestinal flora. When the normal
MRSA can spread among people having close
intestinal flora are altered, C. difficile can flour-
contact with infected people. MRSA is almost
ish in the intestinal tract. It produces a toxin that
always spread by direct physical contact, and
causes frequent, foul-smelling, watery stools.
not through the air. This means if a person has
Other symptoms include diarrhea that contains
MRSA on his skin, especially on the hands, and
blood and mucus and abdominal cramps. En-
touches someone, he may spread MRSA. Spread
emas, nasogastric tube insertion, and GI tract
also occurs through indirect contact by touch-
surgery increase a person’s risk of developing
ing objects (for example, towels, sheets, wound
the disease. The overuse of antibiotics may also
dressings, clothes) contaminated by the infected
alter the normal intestinal flora and increase the
skin of a person with MRSA.
risk of developing C. difficile diarrhea. C. difficile
You can help prevent MRSA by practicing good can also cause colitis, a more serious intestinal
hygiene. Handwashing, using soap and warm condition.
 75 5

C. difficile is spread by spores in feces that are fully when writing their policies and procedures.
difficult to kill. These spores can be carried on It is very important that you learn these and fol-
the hands of people who have direct contact with low them. They exist to protect you. Some of the
infected residents or with environmental sur- infection prevention requirements for you and

Preventing Infection
faces (floors, bedpans, toilets, etc.) contaminated your employer are listed below.
with C. difficile. C. difficile spores can remain
Employers’ responsibilities for infection control
viable for months in the environment in a spore
include the following:
state. Most disinfectants cause C. difficile to go
into a spore state without killing them. A bleach • Establish infection control procedures and
solution, if used before the spore formation, will an exposure control plan to protect workers.
eliminate the organism. However, once the or- • Provide continuing in-service education on
ganism has formed its spore state, the bleach so- infection control, including bloodborne and
lution is no longer effective. Frequently cleaning airborne pathogens.
surfaces with a bleach solution will kill those C.
• Have written procedures to follow should an
difficile spores that change back to their vegeta-
exposure occur, including medical treatment
tive form.
and plans to prevent similar exposures.
Proper handwashing and handling of contami-
nated wastes can help prevent the disease. Hand • Provide PPE for employees to use and teach
rubs have been shown to increase the risk of C. them when and how to properly use it.
difficile transmission on the hands of healthcare • Provide free hepatitis B vaccinations for all
workers. This is because many feel that a hand employees.
rub is all that is needed, rather than perform-
Employees’ responsibilities for infection control
ing proper handwashing. Hand rubs effectively
include the following:
smear C. difficile all over the hands. The alcohol
in hand rubs sends the C. difficile into an instant • Follow standard precautions.
spore state, which makes the alcohol ineffective. • Follow all of the facility’s policies and
Even though handwashing does not kill the C. procedures.
difficile, it does get it off the hands and down
the drain. Use a hand rub only after performing • Follow care plans and assignments.
proper handwashing. Limiting the use of antibi- • Use provided PPE as indicated or as
otics also helps lower the risk of developing C. appropriate.
difficile diarrhea.
• Take advantage of the free hepatitis B
vaccination.
14. List employer and employee • Immediately report any exposure you have to
responsibilities for infection control infection.
Several state and federal government agencies • Participate in annual education programs
have guidelines and laws concerning infection covering the control of infection.
prevention. OSHA requires employers to pro-
vide for the safety of their employees through
Chapter Review
rules and suggested guidelines. The CDC issues
guidelines for healthcare workers to follow on 1. Define the following terms: infection con-
the job. Some states have additional require- trol, microorganism, healthcare-associated
ments. Facilities consider these rules very care- infections, medical asepsis, clean, and dirty.
 5 76

2. How does infection occur? 24. What is hepatitis?

3. What is the chain of infection? 25. How is hepatitis B (HBV) contracted?
4. What is direct contact? What is indirect 26. Describe what an exposure control plan is.
Preventing Infection

contact?
27. List four guidelines employers must follow
5. Define “mucous membranes.” under the Bloodborne Pathogen Standard.
6. Why are elderly people at a higher risk for 28. In which people is tuberculosis more likely
infection? to develop?
7. List four signs of a localized infection and 29. In what kind of settings is TB most likely to
four signs of a systemic infection. spread?
8. Under standard precautions, what does the 30. What are multidrug-resistant organisms
phrase “body fluids” include? (MDROs)?
9. On whom should standard precautions be 31. What is one of the best ways to prevent the
practiced? spread of MRSA and VRE?
10. Under standard precautions, when should 32. List the factors that increase a person’s risk
gloves be worn? of developing C. difficile diarrhea.
11. What is the most important thing you can 33. List five employer responsibilities for infec-
do to prevent the spread of disease? tion control. List five employee responsibili-
ties for infection control.
12. What is hand hygiene? What is hand
antisepsis?
13. List ten situations that require nursing assis-
tants to wash their hands.
14. How many times can disposable gloves be
worn?
15. In what order should PPE be applied? In
what order should it be removed?
16. What is always the final step after removing
PPE?
17. Define sterilization. Define disinfection.
18. How should soiled linen be carried?
19. Describe three guidelines for cleaning spills.
20. What are transmission-based precautions?
List the three categories of transmission-
based precautions.
21. What are bloodborne pathogens?
22. How are bloodborne diseases transmitted?
23. What does HIV do to the immune system?
 77 6

Safety and Body Mechanics

Safety and Body Mechanics

1. Identify the persons at greatest risk not know the positions of their body parts. Their
for accidents and describe accident reflexes slow. It is more difficult to react in time
prevention guidelines to avoid accidents, such as falls. Visual or hear-
ing problems can also cause falls. Residents with
All staff members, including you, are respon- vision problems may not see hazards, such as an
sible for safety in a facility. Elderly people have object or water on the floor. Those who cannot
more safety concerns due to dementia, confu- hear well may not understand directions.
sion, illness, disability, and diminished senses.
Walking aids, such as crutches, walkers, canes, It is very important to try to prevent accidents be-
or boots for foot or leg injuries, put persons at fore they occur. Prevention is the key to safety. As
risk for falling. Residents who take medications you work, watch for safety hazards, and report
that cause dizziness and light-headedness are unsafe conditions to your supervisor promptly.
likely to have accidents. There are many accidents and injuries that may
Our senses—sight, hearing, touch, smell, and occur in a facility, including falls, burns/scalds,
taste—give us information about the world not identifying a resident before performing care
around us and help keep us safe. Normal or serving food, choking, poisoning, and cuts.
changes of aging can cause sensory losses. The Below you will find guidelines for preventing
senses of vision, hearing, taste and smell de- common types of accidents.
crease. Sensitivity to heat and cold decreases. In
addition to normal aging changes, diseases can Falls
cause diminished senses. Diseases of the circu-
The majority of accidents that occur in a facility
latory system, the integumentary system (the
are falls. Falls can be caused by an unsafe envi-
skin), and paralysis can reduce the skin’s ability
ronment, loss of abilities, diseases, and medica-
to feel. Paralysis is the loss of ability to move
tions. The consequences of falls can range from
all or part of the body, and often includes loss
minor bruises to fractures and life-threatening
of feeling in the affected area. Strokes and brain
injuries. A fracture is a broken bone. Older
or spinal injuries affect sensation and aware-
people are often more seriously injured by falls,
ness of surroundings. A loss of sensation can
as their bones are more fragile. Hip fractures are
lead to burns or other accidents. Drowsiness,
one of the most common type of fractures from
due to illness, lack of sleep, medications or even
falls. Hip fractures cause the greatest number of
feeling depressed can also cause a lack of aware-
deaths and can lead to severe health problems.
ness. Being in pain or unconscious may reduce
Be especially alert to the risk of falls.
awareness. Individuals who are less aware may
 6 78

Factors that raise the risk of falls include the G Mark uneven flooring or stairs with colored
following: tape to indicate a hazard.
• Clutter G Improve lighting where needed.
Safety and Body Mechanics

• Throw rugs G Lock wheelchairs before helping residents

into or out of them (Fig. 6-2).
• Exposed electrical cords
• Slippery or wet floors
• Uneven floors or stairs
• Poor lighting
• Call lights that are out of reach or not
promptly answered
Personal conditions that raise the risk of falls
include medications, loss of vision, walking or
balance problems, weakness, paralysis, and dis-
orientation. Disorientation means confusion Fig. 6-2. Always lock a wheelchair before transferring a
about person, place, or time. resident into or out of it.

G Lock bed wheels before helping a resident

Guidelines:
into and out of bed or when giving care
Preventing Falls
(Fig. 6-3).
G Keep all walking areas are free of clutter,
trash, throw rugs, and cords.
G Use rugs with a non-slip backing.
G Have residents wear non-slip, sturdy shoes.
Make sure shoelaces are tied.
G Residents should avoid wearing clothing that
is too long or drags on the floor.
G Keep frequently-used personal items close to Fig. 6-3. Always lock the bed wheels before helping a resi-
residents, including call lights (Fig. 6-1). dent into or out of bed, and before giving care.

G Before giving care, there are many times that

you will need to raise beds to make your job
easier and safer. After completing care, return
beds to their lowest positions.
G Get help when moving a resident; do not
assume you can do it alone. When in doubt,
Fig. 6-1. Keep call lights near residents so they can call ask for help. Keep residents’ walking aids,
you when needed. Answer call lights promptly. such as canes or walkers within their reach.

G Answer call lights right away. G Offer help with toileting regularly (Fig. 6-4).
Respond to requests for help immediately.
G Immediately clean up spills on the floor.
Think about how you would feel if you had to
G Report loose hand rails immediately. wait for help to go to the bathroom.
 79 6

G Report frayed electrical cords or unsafe-look-

ing appliances immediately, and do not use
them.

Safety and Body Mechanics

G Let residents know you are about to pour or
set down a hot liquid.
G Pour hot drinks away from residents.
G Keep hot drinks and liquids away from edges
of tables. Put a lid on them.
Fig. 6-4. Offer frequent trips to the bathroom. G Make sure residents are sitting down before
serving hot drinks.
G Leave furniture in the same place as you
found it. G If plate warmers or other equipment that pro-
duces heat are used, monitor them carefully.
G Know which residents are at risk for falls and
pay close attention so that you can give help
Resident Identification
often.
Residents must always be identified. Not iden-
G If a resident starts to fall, be in a good posi-
tifying residents before giving care or serving
tion to help support her. Never try to catch a
food can cause serious problems, even death. Fa-
falling resident. Use your body to slide her to
cilities have different methods of identification.
the floor. If you try to reverse a fall, you may
Some have ID bracelets. Some have pictures to
hurt yourself and/or the resident.
identify residents. Identify each resident before
Burns/Scalds beginning any procedure or giving any care (Fig.
6-5). Always identify residents before placing
Burns can be caused by dry heat (e.g. hot iron, meal trays or helping with feeding. Check the
stove, other electrical appliances), wet heat (e.g. diet card against the resident’s identification.
hot water or other liquids, steam), or chemicals Call the resident by name.
(e.g. lye, acids). Small children, older adults, or
people with loss of sensation due to paralysis are
at the greatest risk of burns.
Scalds are burns caused by hot liquids. It takes
five seconds or less for a serious burn to occur
when the temperature of liquid is 140°F. Coffee,
tea, and other hot drinks are usually served at
160°F to 180°F. These temperatures can cause
almost instant burns that require surgery. Pre-
venting burns is very important.

Guidelines:
Preventing Burns and Scalds Fig. 6-5. Some facilities will use ID bracelets to identify
residents; others will use other methods of identification.
G Always check water temperature with a water Identify all residents before giving care. (reprinted with permis-
sion of briggs corporation, 800-247-2343, www.briggscorp.com)
thermometer or on your wrist before using.
 6 80

Choking when at home. An abrasion is an injury which

rubs off the surface of the skin. Put any sharp
Choking can occur when eating, drinking, or
objects, including scissors, nail clippers, or
swallowing medication. Babies and young chil-
razors away after use. Take care when trans-
Safety and Body Mechanics

dren who put objects in their mouths are at

ferring residents into and out of beds, chairs,
great risk of choking. People who are weak, ill,
and wheelchairs. When moving a resident in a
or unconscious can choke on their own saliva. A
wheelchair, push the wheelchair forward. Do not
person’s tongue can also become swollen and ob-
pull it behind you. If using an elevator to get to
struct the airway. To guard against choking, resi-
another floor, turn the wheelchair around before
dents should eat sitting as upright as they can
entering the elevator, so the resident is facing
(Fig. 6-6). Residents with swallowing problems
forward.
may have special diets with liquids thickened
to the consistency of honey or syrup. Thickened Other general safety guidelines are:
liquids are easier to swallow. You will learn more • Do not run in halls, on stairs, or in the din-
about helping with feeding and thickened liq- ing room.
uids in Chapter 15.
• Keep paths clear and free of clutter.
• Wipe up spilled liquids right away.
• Discard trash properly.
• Follow instructions. Ask about anything you
do not understand.
• Report injuries immediately.
Promoting safety is one of your responsibilities.
Help make your workplace safer for everyone by
Fig. 6-6. Residents must be sitting up straight when eat- reporting hazards immediately.
ing, whether in a bed or a chair.
Residents’ Rights
Safety
Poisoning Residents have the right to a safe environment. Ob-
Facilities have many harmful substances that serve the environment carefully to eliminate safety
hazards. If you see any safety hazards, such as a
should not be swallowed. These include clean- frayed electrical cord on a resident’s radio, report
ers, paints, medicines, toiletries, and glues. them immediately. Residents have the right to have
These products should be stored or locked away personal items and to have these items treated with
from confused residents or those with limited respect. However, if a resident’s possession is a
potential safety hazard, report this to the nurse. The
vision. Do not leave cleaning products in resi- safety of all residents and staff members is most
dents’ rooms. Residents with dementia may hide important.
food and let it spoil in closets, drawers, or other
places. Investigate any odors you notice. The
number for the Poison Control Center should be 2. List safety guidelines for oxygen use
posted by all telephones.
Residents with breathing problems may receive
oxygen that is more concentrated than what is in
Cuts/Abrasions
the air. Oxygen is prescribed by a doctor. Nurs-
Cuts or abrasions typically occur in the bath- ing assistants never stop, adjust, or administer
room at a facility or in the kitchen or bathroom oxygen. Oxygen may be piped into a resident’s
 81 6

room through a central system. It may be in G Do not burn candles, light matches, or use
tanks or produced by an oxygen concentrator. lighters around oxygen. Any type of open
An oxygen concentrator is a box-like device that flame that is present around oxygen is a dan-
changes air in the room into air with more oxy- gerous fire hazard.

Safety and Body Mechanics

gen. You will learn more about oxygen delivery
G Learn how to turn oxygen off in case of fire if
in Chapter 14.
facility allows this. Never adjust the oxygen
Oxygen is a very dangerous fire hazard be- level.
cause it makes other things burn. Oxygen itself G Report if the nasal cannula or face mask is
does not burn; it merely supports combustion. causing skin irritation. Check behind ears for
Combustion means the process of burning. irritation from tubing (Fig. 6-8).
Working around oxygen requires special safety
precautions.

Guidelines:
Working Safely Around Oxygen

G Remove all fire hazards from the room or

area. Fire hazards include electric razors, hair
dryers, other electrical appliances, cigarettes,
matches, and flammable liquids (Fig. 6-7).
Flammable means easily ignited and capa-
ble of burning quickly. Alcohol and gasoline
are examples of flammable liquids. Notify the
nurse if a fire hazard is present and the resi-
dent does not want it removed.

Fig. 6-8. A resident with a nasal cannula.

3. Explain the Material Safety Data Sheet

(MSDS)
The Occupational Safety and Health Administra-
tion (OSHA) requires that all hazardous chemi-
cals must have a Material Safety Data Sheet
(MSDS) (Fig. 6-9). This sheet details the chemi-
cal ingredients, chemical dangers, emergency
Fig. 6-7. Examples of fire hazards. response actions to be taken, and safe handling
procedures for the product (Fig. 6-10). Some
G Post “No Smoking” and “Oxygen in Use” facilities use a toll-free number to access MSDS
signs. Never allow smoking where oxygen is information. MSDSs must be accessible in work
used or stored. areas for all employees.
 6
Safety and Body Mechanics
82

Fig. 6-9. A Material Safety Data Sheet.

 83 6

themselves. Restraints were also used to keep

residents from pulling out tubing that is needed
for treatment. However, abuse by caregivers and
injury to residents led to new restrictions and

Safety and Body Mechanics

laws on the use of restraints. In many states, re-
straints are illegal, and in general, the use of any
type of restraint has greatly decreased.

Fig. 6-10. OSHA requires that emergency eyewashes be

placed in all hazardous areas in case an eye injury occurs.
Employees must know where the closest eyewash station
is and how to get there with restricted vision. (reprinted with
permission of briggs corporation, 800-247-2343, www.briggscorp.com)

Important information about the MSDS includes

the following:
Fig. 6-11. Side rails are considered restraints because they
• Your employer must have an MSDS for
restrict movement.
every chemical used.
• Your employer must provide easy access to
the MSDS.
• You must know where your MSDSs are kept
and how to read them. If you do not know
how to read them, ask for help.
The list of hazardous chemicals that have to
have an MSDS will be updated as new chemicals
are purchased.
Fig. 6-12. When the tray table is attached or locked, a
geriatric chair, or geri-chair, is considered a restraint.
4. Define the term “restraint” and give
reasons why restraints were used Generally, restraints are only used as a last
A restraint is a physical or chemical way to resort. If restraint use is legal, a doctor must
restrict voluntary movement or behavior. Physi- prescribe it. Never use physical restraints unless
cal restraints are also called postural supports a doctor has ordered it in the care plan and you
or protective devices. Examples of physical have been trained in their use. It is against the
restraints are vests and jacket restraints, belt law for staff to apply restraints for convenience
restraints, wrist/ankle restraints, and mitt re- or to discipline a resident. Check with the nurse
straints. Side rails on a bed and special chairs, for laws and policies on the use of restraints.
such as geriatric chairs, are also considered
physical restraints (Figs. 6-11 and 6-12). Chemi- 5. List physical and psychological
cal restraints are medications given to control a
problems associated with restraints
person’s behavior.
In the past, restraints were commonly used There are many negative effects of restraint use,
to safeguard residents who wander, are prone including the following:
to falls, are violent, or are at risk of hurting • Reduced blood circulation
 6 84

• Stress on the heart studies have shown that the use of restraints is
• Incontinence no longer needed. People tend to respond bet-
ter to the use of creative ways to reduce tension,
• Constipation pulling at tubes, wandering, and boredom.
Safety and Body Mechanics

• Weakened muscles and bones

Examples of restraint alternatives include the
• Loss of bone mass following:
• Muscle atrophy (weakening or wasting of • Improve safety measures to prevent acci-
the muscle) dents and falls. Improve lighting.
• Pressure sores • Make sure the call light is within the resi-
• Risk of suffocation (suffocation is death dent’s reach, and answer call lights promptly.
from a lack of air or oxygen) • Ambulate the resident when he is restless.
• Pneumonia The doctor or nurse may add exercise into
the care plan.
• Less activity, leading to poor appetite and
malnutrition • Provide activities for those who wander at
night.
• Sleep disorders
• Encourage activities and independence.
• Loss of dignity
Escort the person to social activities. In-
• Loss of independence crease visits and social interaction.
• Increased agitation • Give frequent help with toileting. Help with
• Increased depression and/or withdrawal cleaning immediately after an episode of
• Poor self-esteem incontinence.

Some restraints have caused severe injury and • Offer food or drink. Offer reading materials.
even death. Never use a restraint unless your su- • Distract or redirect interest. Give the resi-
pervisor has told you to do so, and you have been dent a repetitive task.
instructed in the proper use of the restraint.
• Decrease the noise level. Listen to soothing
music. Offer back massages or use relax-
6. Define the terms “restraint-free” and ation techniques.
“restraint alternatives” and list examples
• Reduce pain levels through medication.
of restraint alternatives
Monitor the resident closely and report com-
Laws allow the use of restraints only when abso- plaints of pain to the nurse.
lutely necessary for the safety of the person, oth- • Offer one-on-one time with a caregiver.
ers around that person, and the staff. State and Provide familiar caregivers, and increase
federal agencies encourage facilities to take steps the number of caregivers with family and
toward a restraint-free environment. Restraint- volunteers.
free care means that restraints are not used
for any reason and are usually not kept in the • Use a team approach to meeting the person’s
facility. To reach this goal, many care facilities needs. Offer training to teach gentle ap-
have developed creative ideas to use instead of proaches to difficult people.
using restraints. Restraint alternatives are any There are also several types of pads, belts, spe-
intervention used in place of a restraint or that cial chairs, and alarms that can be used instead
reduces the need for a restraint. Many scientific of restraints (Fig. 6-13).
 85 6

a.
and you have been trained in its proper use. If
you are asked to apply a restraint, follow these
guidelines:

Safety and Body Mechanics

Guidelines:
Restraints

G Check to make sure there is a doctor’s order

b. for restraint use and that it is in the care plan
before applying restraints.
G If you are asked to apply a restraint, follow
the manufacturer’s instructions.
G Restraints can only be tied to the movable
part of a bed frame, not to the side rails or
other areas on the bed.
c.
G Check to make sure that the restraint is not
too tight. Place an open hand flat between
the resident and the restraint. This helps to
ensure that the device fits properly and is
comfortable.
G Make sure that the breasts or skin are not
caught in the restraint.
d. e.
G Place the call light where the resident can
easily access it. Answer call lights
immediately.
G Document restraint use according to facility
policy.
A restrained resident must be monitored con-
Fig. 6-13. a) A Posey Torso Support; b) A Posey Deluxe stantly; the resident must be checked at least
Wedge Cushion; c) A lap-top cushion; d) A chair alarm every 15 minutes. At regular, ordered intervals,
warns caregiver of chair exits; e) An under-mattress alarm the following must be done:
warns if person gets out of bed (photos a, b, and c courtesy of
north coast medical, inc., www.ncmedical.com, 800-821-9319. photos d and e
reprinted with permission of briggs corporation, 800-247-2343,
G Release the restraint (or discontinue use).
www.briggscorp.com)
G Offer help with toileting. Check for episodes
of incontinence. Provide incontinence care.
7. Describe guidelines for what must be G Offer fluids.
done if a restraint is ordered
G Check the skin for signs of irritation. Report
Remember that a restraint can never be applied any red, purple, blue-tinged, gray, or pale
without a doctor’s order. Do not use a restraint skin or any discolored areas to the nurse
unless the charge nurse has told you to do so immediately.
 6 86

G Check for swelling of the body part and and body in the direction you are moving. Avoid
report swelling to the nurse immediately. twisting at the waist.
G Reposition the resident.
Alignment
Safety and Body Mechanics

G Ambulate the resident if he is able.

If any problems occur with the restraint, especial-
Fulcrum
ly resident injury, notify the nurse and complete
an incident report as soon as possible.
8. Explain the principles of body
mechanics Lever

Back strain or injury is one of the greatest Center

of gravity
risks that nursing assistants face. In fact, the
increasing injury rate is one reason why many
Base of
long-term care facilities have decided to have support
“lift-free” or “zero-lift” policies. This means that
these facilities have set strict guidelines on the
use of lifts and transfers of residents in order to Fig. 6-14. Proper body alignment is important when
standing and sitting.
reduce injuries. Using proper body mechanics is
an important step in preventing back strain and
injury. Base of support: The base of support is the foun-
dation that supports an object. The feet are the
Body mechanics is the way the parts of the body’s base of support. The wider your support,
body work together whenever you move. Good the more stable you are. Standing with your legs
body mechanics help save energy and prevent in- shoulder-width apart allows for a greater base of
jury. Good body mechanics help you push, pull, support. You will be more stable than someone
and lift objects or people who cannot fully sup- standing with his feet together.
port or move their own bodies. Understanding
some basic principles of body mechanics will Fulcrum and lever: A lever moves an object by
help keep you and residents safe. resting on a base of support, called a fulcrum.
Think of a seesaw. The flat board you sit on is
Alignment: Alignment is based on the word
the lever. The triangular base the board rests
“line.” When you stand up straight, a vertical
on is the fulcrum. When two children sit on op-
line could be drawn through the center of your
posite sides of the seesaw, they easily move each
body and your center of gravity (Fig. 6-14). When
other up and down. This is because the fulcrum
the line is straight, the body is in alignment
and lever of the seesaw are doing the work.
and you are exhibiting good posture. Posture is
the way a person holds and positions his body. If you think of your body as a set of fulcrums
Whether standing, sitting, or lying down, try to and levers, you can find smart ways to lift with-
have your body in alignment and to have good out working as hard. Think of your arm as a
posture. This means that the two sides of the lever with the elbow as the fulcrum. When you
body are mirror images of each other, with body lift something, rest it against your forearm. This
parts lined up naturally. Maintain correct body will shorten the lever and make the item easier
alignment when lifting or carrying an object to lift than it would be if you were holding it in
by keeping it close to your body. Point your feet your hands.
 87 6

Center of gravity: The center of gravity in your Back muscles must lift Legs and thighs do the
body is the point where the most weight is con- the object and half of lifting
the body
centrated (Fig. 6-15). This point will depend on
the position of the body. When you stand, your

Safety and Body Mechanics

weight is centered in your pelvis. A low center
of gravity gives a more stable base of support.
Bending your knees when lifting an object low-
ers your pelvis and, therefore, lowers your center
of gravity. This gives you more stability. It makes
you less likely to fall or strain the working
muscles. Fig. 6-16. In this illustration, which person is lifting
correctly?

Do not twist when you are moving an object.

Always face the object or person you are moving.
Pivot your feet instead of twisting at the waist.
To help a resident sit up, stand up, or walk, pro-
tect yourself by assuming a good stance. Place
your feet twelve inches, or shoulder-width, apart.
Place one foot in front of the other, with your
knees bent. Your upper body should stay upright
and in alignment. Do this whenever you have to
Fig. 6-15. Holding things close to you moves weight support a resident’s weight. If the resident starts
toward your center of gravity. In this illustration, who is to fall, you will be in a good position to help sup-
more likely to strain his back muscles?
port her. Never try to “catch” a falling resident.
If the resident falls, assist her to the floor (Fig.
6-17). If you try to reverse a fall in progress, you
9. Apply principles of body mechanics to will probably injure yourself and/or the resident.
daily activities

By applying the principles of body mechanics

to your daily activities, you can avoid injury and
use less energy. Some examples of using good
body mechanics include the following:

When lifting a heavy object from the floor,

spread your feet shoulder-width apart. Bend
your knees. Using the strong, large muscles in
your thighs, upper arms, and shoulders, lift the
object. Pull it close to your body, to a point level
with your pelvis. By doing this, you keep the
object close to your center of gravity and base
of support. When you stand up, push with your
strong hip and thigh muscles. Raise your body
and the object together (Fig. 6-16). Fig. 6-17. Maintaining a wide base of support and low
center of gravity will enable you to help a falling resident.
 6 88

Bend your knees to lower yourself, rather than 10. Identify major causes of fire and list
bending from the waist. When a task requires fire safety guidelines
bending, use a good stance. This allows you to
use the big muscles in your legs and hips rather In order for a fire to occur, it requires three ele-
Safety and Body Mechanics

than straining the smaller muscles in your back. ments: heat, fuel, and oxygen. A fire can be pre-
vented or extinguished by removing any one of
If you are making an adjustable bed, adjust the these elements.
height to a safe working level, usually waist high.
If you are making a regular bed, lean or kneel to Recognize and report any fire hazards you ob-
support yourself at working level. Avoid bending serve. There are many potential fire hazards
at the waist. in facilities and in the home, including the
following:
Prevention of back strain and injury is very
important. Throughout this text you will learn • Careless smoking, smoking in bed, ciga-
correct procedures for assisting with resident rettes left burning, or confused residents
transfers, positioning, and ambulation. These smoking
procedures will include instructions for main- • Frayed or exposed electrical wires
taining proper body mechanics. In addition, al-
• Damaged electrical equipment
ways keep the following tips in mind:
• Oxygen use
• Use both arms and hands to lift, pull, push,
or carry objects. • Flammable liquids stored near appliances

• Hold objects close to you when you are lift- • Electrical sockets that are overloaded
ing or carrying them. In addition, in the home, these hazards may
• Push, slide, or pull objects rather than lifting exist:
them. • Wood stoves and kerosene, gas, or electric
• Avoid bending and reaching as much as pos- heaters that appear old, damaged, or faulty
sible. Move or position furniture so that you • Unvented heaters used in small, enclosed
do not have to bend or reach. areas or sleeping areas
• Avoid twisting at the waist. Instead, turn • Space heaters used near fabrics such as
your whole body. Your feet should point to- draperies, bedspreads, or towels, or used to
ward what you are lifting. dry clothing or towels
• Get help when possible for lifting or helping • Matches or lighters left within reach of chil-
residents. dren or incapacitated adults
• When moving a resident, let him know what • Careless cooking
you will do so he can help if possible. Count
to three. Lift or move on three so everyone All facilities have a fire safety plan, and all work-
moves together. ers need to know this plan. Your facility’s guide-
lines regarding fires and evacuations will be
Report to the nurse any task you feel that you explained to you. Evacuation routes are posted
cannot safely do. Never try to lift an object or a in facilities. Read and review them often. Attend
resident that you feel you cannot handle. fire and disaster in-services when they are of-
 89 6

fered. They will help you learn what to do in an • Sweep back and forth at the base of the
emergency. Get residents to safety first. A fast, fire.
calm and confident response by the staff saves
G In case of fire, the RACE acronym is a good
lives.

Safety and Body Mechanics

rule to follow:
• Remove residents from danger.
Guidelines:
Reducing Fire Hazards and Responding to Fires • Activate 911.
• Contain fire if possible.
G Never leave smokers unattended. If residents
• Extinguish, or fire department will extin-
smoke, make sure they are in the proper
guish.
area for smoking. Be sure that cigarettes are
extinguished. Empty ashtrays often. Before Follow these guidelines for helping residents exit
emptying ashtrays, make sure there are no the building safely:
hot ashes or hot matches in ashtray.
G Know the facility’s fire evacuation plan.
G Report frayed or damaged electrical cords
G Remain calm.
immediately. Report electrical equipment in
need of repair immediately. G Follow the directions of the fire department.

G Fire alarms and exit doors should not be G Know which residents need one-on-one help
blocked. If they are, report this to the nurse. or assistive devices. Immobile residents can
be moved in several ways. If they have a
G Every facility will have a fire extinguisher (Fig.
wheelchair, help them into it. You can also
6-18). The PASS acronym will help you under-
use other wheeled transporters, such as
stand how to use it:
carts, bath chairs, stretchers, or beds. A blan-
ket can be used as a stretcher or even pulled
across the floor with someone on it.
G Residents who can walk will also need assis-
tance getting out of the building. Those who
are hard of hearing or deaf may not hear the
warnings and instructions. Staff will need to
tell them directly what to do while guiding
them to the nearest safe exit. Individuals with
visual problems should be moved out of the
way of the wheelchairs, carts, etc. and helped
to the exit. Confused and disoriented resi-
dents will also need guidance.
G Remove anything blocking a window or door
Fig. 6-18. Know where the extinguisher is stored in your that could be used as a fire exit.
facility and how to use it. G Do not use elevators.

• Pull the pin. G If a door is closed, check for heat coming

from it before opening it. If the door or door-
• Aim at the base of fire when spraying.
knob feels hot to the touch, it is best to stay
• Squeeze the handle. in the room if there is no safe exit. Plug the
 6 90

doorway (use wet towels or clothing) to pre- 13. List six things that must be done at regular
vent smoke from entering. Stay in the room times if a resident is restrained.
until help arrives.
14. What does the phrase “body mechanics”
Safety and Body Mechanics

G Use the “stop, drop, and roll” fire safety tech- mean?
nique to use to extinguish a fire on clothing
15. What is the name for the point in the body
or hair. Stop running or stay still. Drop to the
where most weight is concentrated?
ground, lying down if possible. Roll on the
ground to try to extinguish the flames. 16. When lifting a heavy object from the floor,
how should the feet be placed? How should
G Use a damp covering over the mouth and
the knees be positioned?
nose to reduce smoke inhalation.
17. When a task requires bending, which of the
G After leaving the building, move away from it.
following demonstrates proper body me-
chanics: bending the knees or bending from
Chapter Review the waist?

1. List five reasons that elderly people have 18. Is it better to push an object or to lift an
more safety concerns than others do. object?

2. What type of accident occurs most fre- 19. What three elements are needed for a fire to
quently in long-term care facilities? occur?

3. List eleven guidelines to prevent falls. 20. List nine fire hazards that may exist in a fa-
cility or at home.
4. Describe five ways to guard against burns/
scalds. 21. List ten guidelines for reducing fire hazards
and responding to fires.
5. What should nursing assistants always do
before giving care or serving meal trays?
6. In what position should residents eat to
avoid choking?
7. What are three guidelines for working safely
around oxygen?
8. What is the purpose of the MSDS?
9. When can a restraint be used?
10. Can restraints be used if staff do not have
enough time to care for residents? Can re-
straints be used if the resident has made a
staff member mad by arguing with the staff
member or being in a bad mood?
11. List ten problems associated with restraint
use.
12. Define the terms “restraint-free” and “re-
straint alternatives.”
 91 7

Emergency Care and Disaster Preparation

Emergency Care and Disaster
Preparation
1. Demonstrate how to recognize and person about what happened. Obtain the per-
respond to medical emergencies son’s permission to touch him or her. (Anyone
who is unable to give consent for treatment, i.e.
Medical emergencies may be the result of ac- a child with no parent near or an unconscious
cidents or sudden illnesses. This chapter dis- or seriously injured person, may be treated with
cusses how to respond appropriately to medical “implied consent,” meaning that if the person
emergencies. Heart attacks, strokes, diabetic was able or the parent was present, they would
emergencies, choking, automobile accidents, and have given consent). Check the person for injury,
gunshot wounds are all medical emergencies. checking for the following:
Falls, burns, and cuts can also be emergencies • Severe bleeding
when they are severe. In an emergency situation,
• Changes in consciousness
it is important to remain calm, act quickly, and
communicate clearly. Knowing the following • Irregular breathing
steps will help you respond calmly and quickly • Unusual color or feel to the skin
in an emergency:
• Swollen places on the body
Assess the situation. Try to determine what has • Medical alert tags
happened. Make sure you are not in danger. No-
• Anything the person says is painful
tice the time.
If any of these conditions exists, you may need
Assess the victim. Ask the injured or ill person
professional medical help. Always get help/call
what has happened. If the person is unable to
the nurse before doing anything else.
respond, he may be unconscious. Being con-
scious means being mentally alert and having If the injured or ill person is conscious, he may
awareness of surroundings, sensations, and be frightened about his condition. Listen to the
thoughts. To determine whether a person is con- person. Tell him what actions are being taken to
scious, tap the person and ask if he is all right. help him. Be calm and confident. Reassure him
Speak loudly. Use the person’s name if you know that you are taking care of him.
it. If there is no response, assume the person is Once the emergency is over, you will need to
unconscious and that you have an emergency document the emergency in your notes and
situation. Call for help right away or send some- complete an incident report. Try to remember
one else to call. as many details as possible. Remember, report
If a person is conscious and able to speak, then the facts only. If you think a resident had a heart
he is breathing and has a pulse. Talk with the attack, write the signs and symptoms you ob-
 7 92

served and the actions you took. Knowing the Quick action is necessary. CPR must be started
kind of information you will have to document immediately after calling for help or sending
will help you remember the important facts dur- someone to call for help. Brain damage may
ing the emergency. For instance, it is especially occur within four to six minutes after the heart
Emergency Care and Disaster Preparation

important to remember the time at which a resi- stops beating and the lungs stop breathing. The
dent becomes unconscious. person can die within ten minutes.
Only properly trained people should administer
Reporting Emergencies
CPR. Your facility will probably arrange for you
If a resident needs emergency help, the nurse may to be trained in CPR. If your facility does not do
ask you to call emergency services. Know the proce- this, ask about American Heart Association or
dure for dialing an outside line. If you need to call
emergency medical services, dial 911. Red Cross CPR training or contact one of these
agencies yourself. CPR is an important skill to
When calling emergency services, be prepared to
give the following information:
learn. If you are not trained, do not attempt to
perform CPR. Performing CPR incorrectly can
• The phone number and address of the emer-
further injure a person.
gency, including exact directions or landmarks,
and the location within the building, if necessary
Beginning CPR
• The person’s condition, including any medical
background you know Know your facility’s policies on whether you can
initiate CPR if you have been trained. Some facili-
• Your name and position ties do not allow nursing assistants to begin CPR
• Details of any first aid being given without direction of the nurse. This is due, in part,
to residents’ advance directives. Some people have
The dispatcher you speak with may need other infor- made the decision that they do not want CPR. Notify
mation or may want to give you other instructions. the nurse immediately if an emergency occurs.
Do not hang up the phone until the dispatcher
hangs up or tells you to hang up. If you are in a This textbook is not a CPR course. The follow-
home, unlock the front door so emergency person- ing is intended as a brief review for people who
nel can get in when they arrive. have had CPR training. It is based on the Ameri-
If you are a home health aide working in a home, can Heart Association’s training guidelines for
remember this: when in doubt about calling for healthcare providers (HCP).
help, call! If you are alone, make the call yourself. If
you are not alone, shout for help and have someone 1. After making sure that the scene is safe,
make the call for you and then return to you. After check whether the person is responsive. Tap
calling 911, notify your supervisor of what is hap-
the person on the shoulder and shout, “Are
pening and that you have called 911 or emergency
services. She will be able to notify the family or you all right?”
friends who need to know this information.
2. If there is no response, call 911 immediately
or send someone to call 911. Remain calm.
2. Demonstrate knowledge of CPR and 3. After calling 911, get an automated external
first aid procedures defibrillator (AED) (if available and if trained
in its use) and return to the person to pro-
First aid is emergency care given immedi-
vide CPR. More information on the AED is
ately to an injured person. Cardiopulmonary
in step 10.
resuscitation (CPR) refers to medical proce-
dures used when a person’s heart or lungs have 4. The person should be on his back on a hard
stopped working. CPR is used until medical help surface (if he has no spinal injuries) before
arrives. CPR is started.
 93 7

5. Open the airway. Tilt the head back slightly

by lifting the chin with one hand while
pushing down on the forehead with the
other hand (head tilt-chin lift method) (Fig.

Emergency Care and Disaster Preparation

7-1). This method is used if a neck injury is
not suspected.

Fig. 7-2. Give two rescue breaths while covering the per-
son’s mouth and pinching the nose to keep air from
escaping.

Fig. 7-1. The head tilt-chin lift method.

6. Look, listen, and feel for signs of life for no

longer than 10 seconds:
• Look for the chest to rise and fall.
• Listen for sounds of breathing. Put your ear
near the person’s nose and mouth.
• Feel for the person’s breath on your cheek.
7. If you do not detect adequate breathing Fig. 7-3. This is one type of face mask.
within 10 seconds, you will have to breathe
for the person. Give two rescue breaths. To 8. After giving rescue breaths, look for signs
give rescue breaths: of circulation. The person may start mov-
ing, breathing normally, or coughing. If
• Pinch the nose to keep air from escaping
they do not respond to the rescue breaths,
from the nostrils. Cover the person’s mouth
give 30 chest compressions only if you have
completely with your mouth.
been trained to do so. Be sure the person
• Blow into the person’s mouth slowly, watch- is lying flat on a hard surface. To give chest
ing for the chest to rise (Fig. 7-2). Blow one compressions:
breath for about one second, take a “regular”
• Place the heel of one hand on the sternum
(not a deep) breath, and give a second res-
in the center of the person’s chest between
cue breath for about one second. Turn your
the nipples. Place the heel of the other hand
head to the side to listen for air. If the chest
on top of the positioned hand. Interlace your
does not rise when you give a rescue breath,
fingers (Fig. 7-4).
reopen the airway using the head tilt-chin
lift method. Try to give rescue breaths again. • Position your body directly over your hands.
You can also use a barrier device, such as a Lock your elbows and shoulders. Look down
special face mask, if available (Fig. 7-3). at your hands.
 7 94

If you are not trained, do not try to use the

AED.
Emergency Care and Disaster Preparation

Fig. 7-5. This is one type of defibrillator. (reprinted with permis-

sion of the briggs corporation, 800-247-2343, www.briggscorp.com)

Fig. 7-4. Interlace your fingers and keep your elbows

locked. When medical help arrives, follow their direc-
tions. Assist them as necessary. Report details of
• Use the heels of your hands to give 30 chest the incident.
compressions. Push in 2 inches with each
compression. Push hard and fast. Allow the Residents’ Rights
chest to recoil completely after each com- CPR
pression. Do not take your hands off the Protect the privacy of residents who need CPR by
chest between compressions. pulling the privacy curtain around the bed and clos-
ing the door. Anyone who is not directly involved in
9. Continue giving CPR in cycles of 30 com- giving care should leave the room. Remain calm and
pressions to 2 breaths, with 5 cycles taking be professional. Remember that the resident may be
able to hear what is being said. Some residents have
about two minutes. Do not stop CPR to do-not-resuscitate (DNR) orders in place, which
recheck anything. Continue until the scene means that no CPR may be given. This is a legal
becomes unsafe, the person recovers, para- order; the resident’s decision for a DNR order and
medics arrive with an AED and take over, other advance directives must be honored. Do not
judge these very personal decisions.
help arrives to assist you, or you become too
exhausted to continue. If you do see signs of
life, stop compressions, maintain an open Choking
airway, and turn the person onto his side, in When something is blocking the tube through
the recovery position. which air enters the lungs, the person has an
10. The AED may be used together with CPR. obstructed airway. When people are choking,
AED stands for “automated external defi- they usually put their hands to their throats and
brillator.” It is a computerized device that cough (Fig. 7-6). As long as a person can speak,
checks a person’s heart rhythm. It is able to breathe, or cough, do nothing. Encourage him to
recognize a rhythm that requires a shock. cough as forcefully as possible to get the object
The AED uses voice prompts, lights and text out. Stay with the person at all times, until he
messages to relay instructions to the rescuer stops choking or can no longer speak, cough, or
(Fig. 7-5). You must be trained in its use. breathe.
 95 7

2. Stand to one side of the person. Put one of

your arms under his arm, and reach across
the chest to the opposite shoulder. Have him
lean forward on your arm.

Emergency Care and Disaster Preparation

3. With the other forearm and heel of your
hand, give 5 sharp, separate blows to the
person’s back, between the shoulder blades
(back blows).

4. If the object does not come out, stand be-

hind the person and bring your arms under
his arms. Wrap your arms around the per-
son’s waist.

5. Make a fist with one hand. Place the flat,

thumb side of the fist against the person’s
abdomen, above the navel but below the
breastbone.
Fig. 7-6. People who are choking usually put their hands
6. Grasp the fist with your other hand. Pull both
to their throats and cough.
hands toward you and up, quickly and force-
If a person can no longer speak, cough, or fully (Fig. 7-7).
breathe, have someone call 911. Use the call
light or emergency cord to notify someone that
you need help. Do not leave a choking victim to
call for help.
Abdominal thrusts are a method of attempting
to remove an object from the airway of someone
who is choking. These thrusts work to remove
the blockage upward, out of the throat. Make
sure the person needs help before starting to
give abdominal thrusts. Ask, “Can you cough?
Can you speak? Can you breathe? Are you chok-
Fig. 7-7. When giving abdominal thrusts, pull both hands
ing? I know what to do. Can I help you?” This toward you and up (inward and upward), quickly and
is obtaining consent. If the person cannot speak forcefully.
or cough, or if his response is weak, start giving
abdominal thrusts. 7. Repeat 5 times, then alternate 5 back
blows and 5 abdominal thrusts until the
Performing abdominal thrusts for the conscious object is pushed out or the person loses
person consciousness.

1. Obtain consent to treat the victim. Ask, “Can 8. Report and document the incident properly.
you cough? Can you speak? Can you breathe?
Are you choking? I know what to do. Can I Do not practice this procedure on a live person;
help you?” this risks injury to the ribs or internal organs.
 7 96

If the person becomes unconscious while chok-

ing, help him to the floor gently. Lie him on
his back with his face up. Make sure help is
on the way. He may have a completely blocked
Emergency Care and Disaster Preparation

airway. He needs professional medical help

immediately.
If you are a home health aide working in the
home, you need to know how to clear an ob-
structed airway in an infant.
Fig. 7-9. Turn the infant on her back to give chest thrusts
Clearing an obstructed airway in a conscious if the obstruction is not expelled with back blows.
infant
4. Repeat alternating 5 back blows and 5 chest
1. Lie the infant face down on your forearm; if compressions until the object is pushed out
you are sitting, rest the arm holding the in- or the infant loses consciousness.
fant’s torso on your lap or thigh. Support her
jaw and head with your hand. Keep her head 5. Report and document the incident properly.
lower than the rest of her body.
Call 911 immediately if the infant loses con-
2. Using the heel of your free hand, deliver up
sciousness. Follow any instructions you are
to 5 back blows. Back blows are performed
given.
by striking the infant between the shoulder
blades (Fig. 7-8).
Emergency Codes
Facilities often use codes to inform staff of emergen-
cies while preventing panic and stress among resi-
dents and visitors. These codes are frequently coded
by color. For example, “Code Red” usually means
fire. “Code Blue” usually means cardiac arrest. How-
ever, the meanings of these codes vary from facility
to facility. Know the codes for your facility. Do not
panic when you hear codes announced. Respond
calmly and professionally.

Shock
Shock occurs when organs and tissues in the
body do not receive an adequate blood supply.
Fig. 7-8. Keeping the infant’s head below the rest of her
Bleeding, heart attack, severe infection, and fall-
body, deliver back blows.
ing blood pressure can lead to shock. Shock can
become worse when the person is frightened or
3. If the obstruction is not expelled with back
in severe pain.
blows, turn the infant onto her back while
supporting the head. Deliver up to 5 chest Shock is a dangerous, life-threatening situa-
thrusts by placing two or three fingers in the tion. Signs of shock include pale or bluish skin,
center of the breastbone (Fig. 7-9). This is staring, increased pulse and respiration rates,
the same position used for chest compres- low blood pressure, and extreme thirst. Always
sion during CPR. call for help if you suspect a person is experi-
 97 7

encing shock. To prevent or treat shock, do the Myocardial Infarction or Heart Attack
following:
Myocardial infarction (MI), or heart attack, oc-
curs when the heart muscle itself does not re-
Responding to shock

Emergency Care and Disaster Preparation

ceive enough oxygen because blood vessels are
1. Have the person lie down on her back. If blocked. You will learn more about MI in Chap-
the person is bleeding from the mouth or ter 18. A myocardial infarction is an emergency
vomiting, place her on her side (unless you that can result in serious heart damage or death.
suspect that the neck, back, or spinal cord is The following are signs and symptoms of MI:
injured). • Sudden, severe pain in the chest, usually on
the left side or in the center behind the ster-
2. Control bleeding. This procedure is described
num (breastbone)
later in the chapter.
• Pain or discomfort in other areas of the
3. Check pulse and respirations if possible (see
body, such as one or both arms, the back,
Chapter 14).
neck, jaw, or stomach
4. Keep the person as calm and comfortable as • Indigestion or heartburn
possible.
• Nausea and vomiting
5. Maintain normal body temperature. If the
• Dyspnea or difficulty breathing
weather is cold, place a blanket around the
person. If the weather is hot, provide shade. • Dizziness
• Skin color may be pale, gray, or bluish (cya-
6. Elevate the feet unless the person has a head
notic), indicating lack of oxygen
or abdominal injury, breathing difficulties, or
a fractured bone or back (Fig. 7-10). Elevate • Perspiration
the head and shoulders if a head wound or • Cold and clammy skin
breathing difficulties are present. Never el-
• Weak and irregular pulse rate
evate a body part if the person has a broken
bone. • Low blood pressure
• Anxiety and a sense of doom
• Denial of a heart problem
The pain of a heart attack is commonly de-
scribed as a crushing, pressing, squeezing, stab-
bing, piercing pain, or, “like someone is sitting
on my chest.” The pain may go down the inside
Fig. 7-10. If a person is in shock, elevate the feet unless of the left arm. A person may also feel it in the
he or she has head or abdominal injuries, breathing dif-
ficulties, or fractured bones or back. neck and/or in the jaw. The pain usually does
not go away.
7. Do not give the person anything to eat or As with men, women’s most common symp-
drink. tom is chest pain or discomfort. But women
are somewhat more likely than men to have
8. Call for help immediately. Victims of shock
shortness of breath, nausea/vomiting, and back,
should always receive medical care quickly.
shoulder or jaw pain. Some women’s symptoms
9. Report and document the incident properly. seem more flu-like, and women are more likely
to deny that they are having a heart attack.
 7 98

You must take immediate action if a resident ex-

Controlling bleeding
periences any of these symptoms. Follow these
steps: 1. Put on gloves. Take time to do this. If the
resident is able, he can hold his bare hand
Emergency Care and Disaster Preparation

Responding to a heart attack over the wound until you can put on gloves.

1. Call for or have someone call the nurse. If 2. Hold a thick sterile pad, a clean pad, or a
working in the home, call 911 immediately. clean cloth, handkerchief, or towel against
the wound.
2. Place the person in a comfortable position.
Encourage him to rest, and reassure him that 3. Press down hard directly on the bleeding
you will not leave him alone. wound until help arrives. Do not decrease
pressure (Fig. 7-12). Put additional pads over
3. Loosen clothing around neck (Fig. 7-11).
the first pad if blood seeps through. Do not
remove the first pad.

Fig. 7-12. Press down hard directly on the bleeding

wound; do not decrease pressure.

4. If you can, raise the wound above the level

Fig. 7-11. Loosen clothing around the person’s neck if you of the heart to slow down the bleeding. If the
suspect he is having an MI.
wound is on an arm, leg, hand, or foot, and
there are no broken bones, prop up the limb.
4. Do not give the person liquids or food.
Use towels, blankets, coats, or other absor-
5. Monitor the person’s breathing and pulse. If bent material.
the person stops breathing or has no pulse,
5. When bleeding is under control, secure the
perform CPR only if you are trained and your
dressing to keep it in place. Check for symp-
facility permits you to do so.
toms of shock (pale skin, increased pulse
6. Stay with the person until help arrives. and respiration rates, low blood pressure,
7. Report and document the incident properly. and extreme thirst). Stay with the person
until help arrives.
Some states allow nursing assistants to offer 6. Remove gloves and wash hands thoroughly.
heart medication, such as nitroglycerin, to a 7. Report and document the incident properly.
person having a heart attack. If you are allowed
to do this, offer the medication only. Never place
medication in someone’s mouth. Poisoning
As you learned in Chapter 6, facilities contain
Bleeding many harmful substances that should not be
Severe bleeding can cause death quickly and swallowed. Suspect poisoning when a resident
must be controlled. Call the nurse immediately, suddenly collapses, vomits, and has heavy, la-
then follow these steps to control bleeding: bored breathing.
 99 7

First aid kits in the home should contain syrup gree burns (Fig. 7-14). First degree burns involve
of ipecac, activated charcoal, and Epsom salts for just the outer layer of skin. The skin becomes
the treatment of accidental poisoning (Fig. 7-13). red, painful, and swollen, but no blisters occur.
Second degree burns extend from the outer layer

Emergency Care and Disaster Preparation

of skin to the next deeper layer of skin. The
skin is red, painful, swollen, and blisters occur.
Third degree burns involve all three layers of the
skin. These burns may extend to the bone. If
the nerves are destroyed, the person will not feel
pain. The skin is shiny and appears hard. It may
be white in color.

Fig. 7-13. Ipecac syrup causes vomiting. It should only

be used when directed by a doctor or by a poison control
center.

Always have the poison control center phone

number available and know if syrup of ipecac is
in the house.
If you suspect poisoning, take the following
steps:

Responding to poisoning

1. Notify the nurse immediately.

2. Look for a container that will help you find

out what the resident has taken or eaten. Fig. 7-14. Different degrees of burns.
Using gloves, check the mouth for chemical
burns and note the breath odor.
Burns in the Home
3. The nurse may have you call the local or state
When working in a home, you should call for emer-
poison control center. Follow instructions gency help in any of the following situations:
from poison control.
• An infant or child, or an elderly, ill, or weak per-
4. Report and document the incident properly. son has been burned, unless burn is very minor.
• The burn occurs on the head, neck, hands, feet,
face, or genitals, or burns cover more than one
Burns body part.

You first learned about preventing burns in • The person who has been burned is having trou-
ble breathing.
Chapter 6. Care of a burn depends on its depth,
size, and location. There are three types of • The burn was caused by chemicals, electricity, or
explosion.
burns: first degree, second degree, and third de-
 7 100

ing (Fig. 7-16). Again, never use any kind of

Treating burns
ointment, salve, or grease on a burn.
To treat a minor burn:
Emergency Care and Disaster Preparation

1. Use cool, clean water (not ice) to decrease

the skin temperature and prevent further
injury (Fig. 7-15). Ice will cause further skin
damage. Dampen a clean cloth and place it
over the burn.

Fig. 7-16. A dry cool pack may be used to treat a serious

burn.

6. Ask the person to lie down and elevate the

affected part if this does not cause greater
pain.
Fig. 7-15. Use cool, clean water, not ice, on a minor 7. If the burn covers a larger area, wrap the
burn.
person or the limb in a dry, clean sheet. Take
care not to rub the skin.
2. Once the pain has eased, you may cover the
area with dry, sterile gauze. 8. Wait for emergency medical help.

3. Never use any kind of ointment, salve, or 9. Report and document the incident properly.
grease on a burn.

For more serious burns: Chemical burns require special care. Call for
help immediately. The chemical must be washed
1. Remove the person from the source of the
away thoroughly. A shower or a hose may be
burn. If clothing has caught fire, smother it
needed when the burns cover a large area.
with a blanket or towel to put out flames.
Protect yourself from the source of the burn.
Fainting
2. Call for emergency help.
Fainting, also called syncope, occurs as a result
3. Check for breathing, pulse, and severe of decreased blood flow to the brain, causing a
bleeding. loss of consciousness. Fainting may be the re-
sult of hunger, fear, pain, fatigue, standing for a
4. Do not apply water. It may cause infection.
long time, poor ventilation, or overheating. Signs
5. Do not try to pull away any clothing from and symptoms of fainting include dizziness,
burned areas. Cover the burn with thick, dry, perspiration, pale skin, weak pulse, shallow
sterile gauze if available, or a clean cloth. respirations, and blackness in the visual field.
Apply the gauze or cloth lightly. A dry, insu- If someone appears likely to faint, follow these
lated cool pack may be used over the dress- steps:
 101 7

If a person does faint, lower her to the floor or

Responding to fainting
other flat surface. Position her on her back. El-
1. Have the person lie down or sit down before evate her legs eight to twelve inches. Loosen any
tight clothing. Check to make sure the person is

Emergency Care and Disaster Preparation

fainting occurs.
breathing. She should recover quickly, but keep
2. If the person is in a sitting position, have her
her lying down for several minutes. Report the
bend forward and place her head between her
incident to the nurse immediately. Fainting may
knees (Fig. 7-17). If the person is lying flat on
be a sign of a more serious medical condition.
her back, elevate the legs.

Nosebleed
A nosebleed can occur suddenly when the air is
dry or when injury has occurred. The medical
term for a nosebleed is epistaxis. If a resident
has a nosebleed, notify the nurse and take the
following steps:

Responding to a nosebleed

1. Elevate the head of the bed, or tell the per-

son to remain in a sitting position, leaning
forward slightly. Offer tissues or a clean cloth
to catch the blood. Do not touch blood or
bloody clothes, tissues, or cloths without
gloves.

2. Put on gloves. Apply firm pressure over the

bridge of the nose. Squeeze the bridge of the
nose with your thumb and forefinger (Fig.
7-18). You can have the resident do this until
you are able to put on gloves.

Fig. 7-17. Have the person bend forward and place her
head between her knees if she is sitting.

3. Loosen any tight clothing.

4. Have the person stay in position for at least

five minutes after symptoms disappear.

5. Help the person get up slowly. Continue to

observe her for symptoms of fainting. Stay
with the person until she feels better. If you
need help but cannot leave the person, use Fig. 7-18. With gloves on, squeeze the bridge of the nose
the call light. with your thumb and forefinger.
6. Report and document the incident properly.
3. Apply the pressure until the bleeding stops.
 7 102

4. Use a cool cloth or ice wrapped in a cloth • Cold, clammy skin

on the back of the neck, the forehead, or the
• Confusion
upper lip to slow the flow of blood. Never
apply ice directly to skin. • Trembling
Emergency Care and Disaster Preparation

5. If the bleeding does not stop, tell the nurse • Nervousness

immediately. • Blurred vision
6. Report and document the incident properly. • Numbness of the lips and tongue
• Unconsciousness
Insulin Reaction and Diabetic Ketoacidosis Diabetic ketoacidosis (DKA) (also called
Insulin reaction and diabetic ketoacidosis are hyperglycemia or diabetic coma) is caused by
complications of diabetes that can be life-threat- having too little insulin. It can result from undi-
ening. You will learn more about diabetes and agnosed diabetes, going without insulin or not
related care in Chapter 18. taking enough, eating too much food, not get-
ting enough exercise, or physical or emotional
Insulin reaction (also called hypoglycemia) can
stress. The signs of the onset of diabetic keto-
result from either too much insulin or too little
acidosis include increased thirst or urination,
food. It occurs when insulin is given and the
abdominal pain, deep or labored breathing, and
person skips a meal or does not eat all the food
breath that smells sweet or fruity. Other signs
required. Even when a regular amount of food
and symptoms include the following:
is eaten, physical activity may rapidly absorb the
food. This causes too much insulin to be in the • Hunger
body. Vomiting and diarrhea may also lead to in- • Weakness
sulin shock in people with diabetes.
• Rapid, weak pulse
The first signs of insulin reaction include feel-
• Headache
ing weak or different, nervousness, dizziness,
and perspiration. These signal that the resi- • Low blood pressure
dent needs food in a form that can be rapidly
• Dry skin
absorbed. A lump of sugar, a hard candy, or a
glass of orange juice should be consumed right • Flushed cheeks
away. A diabetic should always have a quick • Drowsiness
source of sugar handy. Call the nurse if the resi-
• Slow, deep, and difficult breathing
dent has shown signs of insulin reaction. Signs
and symptoms of insulin reaction include the • Nausea and vomiting
following:
• Abdominal pain
• Hunger
• Sweet, fruity breath odor
• Weakness
• Air hunger, or resident gasping for air and
• Rapid pulse being unable to catch his breath
• Headache • Unconsciousness
• Low blood pressure Inform the nurse immediately if you think a
• Perspiration resident is experiencing diabetic ketoacidosis.
 103 7

Seizures ment need to be given within a short time of

the stroke’s onset; early treatment may be able to
Seizures are involuntary, often violent, contrac-
reduce the severity of the stroke.
tions of muscles. They can involve a small area

Emergency Care and Disaster Preparation

or the entire body. Seizures are caused by an ab- A transient ischemic attack, or TIA, is a warn-
normality in the brain. They can occur in young ing sign of a CVA. TIA is also known as a “mini
children who have a high fever. Older children stroke.” It is the result of a temporary lack of
and adults who have a serious illness, fever, head oxygen in the brain. Symptoms may last up to 24
injury, or a seizure disorder such as epilepsy hours and include difficulty speaking, weakness
may also have seizures. on one side of the body, temporary loss of vision,
and numbness or tingling. These symptoms
The main goal of a caregiver during a seizure
should not be ignored. Report them to the nurse
is to make sure the resident is safe. During a
immediately.
seizure, a person may shake severely and thrust
arms and legs uncontrollably. He may clench his Signs that a CVA is occurring include the
jaw, drool, and be unable to swallow. The follow- following:
ing emergency measures should be taken if a
• Facial numbness or weakness, especially on
resident has a seizure:
one side
Responding to seizures • Arm numbness or weakness, especially on
one side
1. Lower the person to the floor. Lay him on his
side. • Slurred speech or difficulty speaking

2. Have someone call the nurse immediately or • Use of inappropriate words

use the call light. Do not leave a person dur- • Inability to understand spoken or written
ing a seizure unless you must do so to get words
medical help.
• Redness in the face
3. Move furniture away to prevent injury. If a pil-
• Noisy breathing
low is nearby, place it under his or her head.
• Dizziness
4. Do not try to restrain the person.
• Blurred vision
5. Do not force anything between the person’s
teeth. Do not place your hands in the per- • Ringing in the ears
son’s mouth for any reason. You could be • Headache
bitten.
• Nausea/vomiting
6. Do not give liquids or food.
• Seizures
7. When the seizure is over, check breathing.
• Loss of bowel and bladder control
8. Report and document the incident properly,
including how long the seizure lasted. • Paralysis on one side of the body
• Elevated blood pressure

CVA or Stroke • Slow pulse rate

You first learned about stroke, or cerebrovascular • Loss of consciousness

accident (CVA), in Chapter 4. A quick response See Chapter 18 for more information on CVA
to a suspected stroke is critical. Tests and treat- and related care.
 7 104

Falls grounds. If these symptoms are observed,

show this to the nurse before discarding the
You learned about the risk of falls and ways to
vomit. After disposing of vomit, wash and
prevent falls in Chapter 6. Falls can be minor or
store basin.
Emergency Care and Disaster Preparation

severe. Report all falls to the nurse immediately.

Complete an incident report. In the case of a 6. Remove and discard gloves.
severe fall, the nurse may ask you to call emer-
7. Wash your hands.
gency medical services. Take the following steps
to help a resident who is falling: 8. Put on fresh gloves.
• Widen your stance. Bring the resident’s body 9. Provide comfort to resident. Wipe face and
close to you to break the fall. Bend your mouth (Fig. 7-19). Position comfortably, and
knees. Support the resident as you lower her offer a drink of water. Provide oral care (see
to the floor. Chapter 13). It helps get rid of the taste of
• Do not try to reverse or stop a fall. You or the vomit in the mouth.
resident can suffer worse injuries if you do.
• Call for help. Do not attempt to get the resi-
dent up or move the resident after the fall.
Follow your facility’s policies and procedures.

Vomiting
Vomiting, or emesis, is the act of ejecting stom-
ach contents through the mouth. It can be a sign
of a serious illness or injury. Because you may
not know when a resident is going to vomit, you Fig. 7-19. Be calm and comforting when helping a client
may not have time to explain what you will do who has vomited.
and assemble supplies ahead of time. Talk to the
resident soothingly as you help him clean up. 10. Put soiled linen in proper containers.
Tell him what you are doing to help him. If a 11. Remove and discard gloves.
resident has vomited, notify the nurse and take
the following steps: 12. Wash your hands again.

13. Document time, amount, color, odor, and

Responding to vomiting consistency of vomitus. Look for blood in
1. Put on gloves. vomitus, blood-tinged vomitus, or vomitus
that looks like wet coffee grounds.
2. Place an emesis basin under the chin. Re-
move it when vomiting has stopped.
3. Describe disaster guidelines
3. Remove soiled linens or clothes and set
aside. Replace with fresh linens or clothes. Disasters can include fire, flood, earthquake,
hurricane, tornado, or severe weather. Acts of
4. If resident’s intake and output (I&O) is being
terrorism may also be considered disasters. The
monitored (Chapter 15), measure and note
disasters you may experience will depend on
amount of vomitus.
where you live. Nursing assistants need to be
5. Flush vomit down the toilet unless vomit competent and professional when a disaster oc-
is red, has blood in it, or looks like coffee curs. Facilities have disaster plans and you will
 105 7

be trained on these plans. Annual in-services Lightning

and disaster drills are often held at facilities.
If outdoors, follow these guidelines:
Take advantage of these sessions when offered,
and pay close attention to instructions. • Avoid the largest objects, such as trees, and

Emergency Care and Disaster Preparation

avoid open spaces.
During natural disasters, a nurse or the admin-
istrator will give directions. Listen carefully to • Stay out of the water.
all directions, and follow instructions. Facilities • Seek shelter in buildings.
may rely on local or state management groups
• Stay away from metal fences, doors, or other
and the American Red Cross to assume overall
objects.
responsibility for the ill and disabled.
• Avoid holding metal objects in your hands,
The following guidelines apply in any disaster
such as golf clubs.
situation:
• Stay in automobiles.
• Remain calm.
• It is safe to perform CPR on lightning vic-
• Know the locations of all exits and stairways.
tims; they carry no electricity.
• Know where the fire alarms and extinguish-
If indoors, stay inside and away from open doors
ers are located.
and windows. Avoid the use of electrical equip-
• Know the appropriate action to take in any ment such as hair dryers and televisions, and do
situation. not use the phone.
In addition, you will be required to apply specific
guidelines for the area in which you work. For Floods
example, an NA working where hurricanes are In the case of floods, follow these guidelines:
prevalent, such as Florida, needs to know the
• Fill the bathtub with fresh water.
guidelines for hurricane preparedness as well
as for storms and fires. The following general • Board up windows.
guidelines are separated by the type of disaster • Evacuate if advised to do so.
and can be applied to any particular geographi-
• Check the fuel level in automobiles.
cal area. Keep the radio or television tuned to a
local station to get the latest information. • Have a portable battery-operated radio, flash-
light, and cooking equipment available.
Tornadoes • Do not drink water or eat food that has been
In the case of tornadoes, follow these guidelines: contaminated with flood water.

• Seek shelter inside, ideally in a steel-framed • Do not handle electrical equipment.

or concrete building. • Do not turn off gas yourself, but ask the gas
• Stay away from windows. company to do so.

• Stand in the hallway or in a basement, or

Blackouts
take cover under heavy furniture.
In the case of blackouts, follow these guidelines:
• Do not stay in a mobile home or trailer.
• Get a flashlight. Take prompt action to keep
• Lie as flat as possible.
calm and provide light.
 7 106

• Use a backup pack for electrical medical • Locate disaster supplies. Ideally, a disaster
equipment such as an IV pump. Backup supply kit should meet your needs for at
packs do not last more than 24 hours, least three days. It should be assembled be-
so contact emergency personnel when fore disaster strikes and should include:
Emergency Care and Disaster Preparation

instructed.
• A three-day supply of water (one gallon
per person per day) and food that will not
Hurricanes
spoil
In the case of hurricanes, follow these
• One change of clothing and footwear per
guidelines:
person, and one blanket or sleeping bag
• Know what category the hurricane is and per person
track the expected path.
• A first aid kit that includes your family’s
• Know which residents or clients must go to prescription medications
shelters, hospitals, or other facilities, and
which need assistance. Be aware of people • Emergency tools, including a battery-pow-
with special needs. High-risk people include ered radio, flashlight, and plenty of extra
the elderly and those unable to evacuate on batteries
their own. High-risk areas include mobile • An extra set of car keys and a credit card,
homes or trailers. cash, or traveler’s checks
• Call your employer for instructions. • Sanitation supplies
• Fill the bathtub with fresh water. • Special items for infant, elderly, or dis-
• Board up windows. abled family members

• Evacuate if advised to do so. • An extra pair of glasses

• Check the fuel level in automobiles. • Important family documents in a water-

proof container
• Have a portable battery-operated radio, flash-
light, and cooking equipment available.
Chapter Review
In addition to the above, when working in the
home, follow these guidelines for disasters: 1. List two steps to follow when coming upon
• Listen to radio or television bulletins to keep an emergency situation.
informed. A battery-powered radio will help 2. What information should a nursing assistant
you to stay informed if power goes out. be prepared to give when calling emergency
• If a disaster is forecast (for example, a services?
tornado or hurricane), be ready. Wear ap- 3. Why should a nursing assistant not perform
propriate clothing and shoes. Have family CPR if she is not trained to do so?
members dressed and ready in case evacua-
tion is necessary. 4. What is the correct number of chest com-
pressions to rescue breaths when giving
• Stay in contact with your supervisor or oth-
CPR?
ers if possible. Let someone know where you
are, what conditions are, and where you will 5. How are abdominal thrusts used to help
go if you must evacuate. someone who is choking?
 107 7

6. If the person becomes unconscious while

choking, what should the nursing assistant
do?

Emergency Care and Disaster Preparation

7. List the signs of shock.
8. List seven signs that a person is having a
heart attack.
9. What can be done to a wound to slow the
bleeding?
10. Why should ice not be applied to burns?
11. If a person feels like he is going to faint, in
what position should he be placed?
12. Why should a nursing assistant put on
gloves if a resident has a nosebleed?
13. What causes insulin reaction? What causes
diabetic ketoacidosis?
14. Why should a nursing assistant not force
anything into the mouth of a person who is
having a seizure?
15. List symptoms of a transient ischemic attack
(TIA).
16. List signs that a CVA/stroke is occurring.
17. What should a nursing assistant do if a resi-
dent starts to fall?
18. What are three things that a nursing assis-
tant should observe for in a resident’s vomit?
19. What are four guidelines that apply in any
disaster situation?
 8 108

8
Human Needs and Human Development

Human Needs and Human

Development
1. Identify basic human needs • Self-reliance and independence in daily
living
People have different genes, physical appear-
ances, cultural backgrounds, ages, and social or • Contact with other people (Fig. 8-1)
financial positions. But all human beings have • Success and self-esteem
the same basic physical needs:
• Food and water
• Protection and shelter
• Activity
• Sleep and rest
• Safety
• Comfort, especially freedom from pain

You will be helping residents meet these basic Fig. 8-1. Interaction with other people is a basic psycho-
physical needs. Activities of daily living (ADLs), social need. Encourage your residents to be with friends or
such as eating, toileting, bathing, and grooming, relatives. Social contact is important.
are the ways we meet our most basic physical
Health and well-being affect how well psychoso-
needs. By assisting with ADLs or helping resi-
cial needs are met. Stress and frustration occur
dents learn to perform them independently, you
when basic needs are not met. This can lead to
help residents meet their basic needs.
fear, anxiety, anger, aggression, withdrawal, in-
People also have psychosocial needs, which in- difference, and depression. Stress can also cause
volve social interaction, emotions, intellect, and physical problems that may eventually lead to
spirituality. Psychosocial needs are not as easy illness.
to define as physical needs. However, all human
Abraham Maslow, a researcher of human be-
beings have the following psychosocial needs:
havior, wrote about human physical and psycho-
• Love and affection social needs. He arranged these needs into an
• Acceptance by others order of importance. He thought that physical
needs must be met before psychosocial needs
• Security
can be met. His theory is called “Maslow’s Hier-
archy of Needs” (Fig. 8-2).
 109 8

Self-actualization is the highest level. It means

that a person tries to be the best person he can
be, or tries to reach his full potential. This may
mean different things for each person. The

Human Needs and Human Development

quest to reach this need continues throughout a
person’s life and may change as a person enters
different stages of life.

2. Define “holistic care” and explain its

importance in health care
Holistic means considering a whole system,
such as a whole person, rather than dividing the
system up into parts. Holistic care means car-
ing for the whole person—the mind as well as
Fig. 8-2. Maslow’s Hierarchy of Needs.
the body (Fig. 8-3). A simple example of holistic
care is taking time to talk with your residents
After meeting physical needs, safety and secu- while helping them bathe. You are meeting the
rity needs must be met. Feeling safe means not physical need with the bath and meeting the
feeling afraid and unstable. Residents need to psychosocial need for interaction with others at
feel safe in facilities. Many things can cause a the same time.
person to feel unsafe. An illness or disability can Another way of practicing holistic care is con-
be frightening and make a person feel fearful sidering psychosocial factors in illness, as well
and insecure. Losing some independence and as physical factors. For example, Mr. Hartman
needing help from caregivers, such as NAs, may looks thin and tired. The cause might be depres-
cause some uncertainty or discomfort. Residents sion rather than an infection. You do not need to
need to feel safe with you and all other care determine the cause of his condition. However,
team members; they need to know that they and by talking with him you might learn something
their personal possessions will be protected. that would help the rest of the care team. For ex-
After physical and safety needs are met, the ample, you might learn that last year at this time
need for love and belonging is important. This his wife died, and he is still coping with that
level involves feeling accepted, needed, and cared loss. You can and should share this information
for. Regardless of their condition, residents need with the care team and document it.
to know that their contributions are meaningful.
The need for self-esteem is the next level. This 3. Explain why independence and self-
need involves respecting and valuing oneself, care are important
which comes from within, as well as from other Any big change in lifestyle, such as moving
people. Achievements that make a person feel into a long-term care facility, requires a huge
valued are important. For residents, being able emotional adjustment. Residents may be expe-
to do a task they were not able to do previously riencing fear, loss, and uncertainty, along with
may satisfy this need. Hearing praise from NAs a decline in health and independence. These
about this new achievement may also help meet feelings may cause them to behave differently
this need. than they have before. Be aware that dramatic
 8
Human Needs and Human Development
110

Fig. 8-3. Remember that residents are people, not just lists of illnesses and disabilities. They have many needs, like you.
Many have had rich and wonderful lives. Take time to know and care for your residents as whole people.

changes in a resident’s life may cause anger, • Loss of workplace and its relationships due
hostility, or depression. It is important to remain to retirement
supportive and encouraging. Be patient and
• Loss of ability to go to favorite places
empathic. Having empathy means being able to
enter into the feelings of others. • Loss of ability to attend services and meet-
ings at their faith communities
To best understand feelings residents may be
having, you must first understand how difficult • Loss of home and personal possessions
it is to lose one’s independence. Somebody else (Fig. 8-4)
must now do what residents did for themselves
all of their lives. Try to imagine what that would
be like. Think about having to call someone to
help every time you need to go to the bathroom.
The loss of independence is also difficult for
friends and family members. For example, a res-
ident may have been the main provider for his or
her family. A resident may have been the person
who did all of the cooking for the family. Other
losses residents may be experiencing include the
following:
• Loss of spouse, family members, or friends Fig. 8-4. Understand and be sympathetic to the fact that
due to death many residents had to leave familiar places.
 111 8

• Loss of health and the ability to care for Allowing residents to make choices is another
themselves way to promote independence. For example,
residents can choose where to sit while they
• Loss of ability to move freely
eat. They can choose what they eat and in what

Human Needs and Human Development

• Loss of pets order. Respect a resident’s right to make choices.
Independence often means not having to rely on
others for money, daily routine care, or participa- Residents’ Rights
tion in social activities. Activities of daily living Dignity and Independence
(ADLs) are the personal care tasks you do every Residents are adults; do not treat them like children.
day to care for yourself. People may take these Encourage them to do self-care without rushing
them. Remember that they have the right to refuse
activities for granted until they can no longer do
care and to make their own choices. Maintaining
them for themselves. ADLs include bathing or dignity and independence is your residents’ legal
showering, dressing, caring for teeth and hair, right. It is also the proper and ethical way for you to
toileting, eating and drinking, and moving from work.
place to place.
A loss of independence can cause the following
4. Explain ways to accommodate sexual
problems:
needs
• Poor self-image
In addition to the needs discussed earlier, people
• Anger toward caregivers, others, and self also have sexual needs. These needs continue
• Feelings of helplessness, sadness, and throughout their lives (Fig. 8-6). The ability to
hopelessness engage in sexual activity, such as intercourse
and masturbation, continues unless a disease or
• Feelings of being useless
injury occurs. Masturbation means to touch or
• Increased dependence rub sexual organs in order to give oneself or an-
• Depression other person sexual pleasure.

To prevent these feelings, encourage residents to

do as much as possible for themselves. Even if it
seems easier for you to do things for residents,
allow them to do tasks independently. Encourage
self-care, regardless of how long it takes or how
poorly they are able to do it. Be patient (Fig. 8-5).

Fig. 8-6. Human beings continue to have sexual needs

Fig. 8-5. Even if personal care tasks take a long time, en- throughout their lives.
courage residents to do what they can for themselves.
 8 112

To meet and respect residents’ sexual needs, you Heterosexual: A person who has a desire for persons
can do the following: of the opposite sex. This is also known as “straight.”
• Always knock or announce yourself before Homosexual: A person who has a desire for persons
Human Needs and Human Development

entering residents’ rooms. Listen and wait of the same sex. The terms “gay” and “lesbian” are
for a response before entering. usually preferable.
Lesbian: A woman whose sexual orientation is to
• If you encounter a sexual situation, provide
women.
privacy and leave. However, if you see sexual
abuse occurring, take the resident to a safe Bisexual: A person who desires persons of both
sexes.
place, and notify the nurse immediately.
Transsexual: 1. One who wishes to be accepted by
• Be open and nonjudgmental about residents’ society as a member of the opposite sex. 2. One who
sexual attitudes. Do not judge residents’ has undergone a sex change.
sexual orientation or any sexual behavior you
see.
• Honor “Do Not Disturb” signs. Residents’ Rights
Sexual Abuse
Residents have the right to choose how they ex-
press their sexuality. In all age groups, there is Residents must be protected from unwanted sexual
advances. If you see sexual abuse happening, re-
a variety of sexual behavior. This is true of your
move the resident from the situation. Take him or
residents also. An attitude that any expression of her to a safe place. Report to the nurse immediately
sexuality by the elderly is “disgusting” or “cute” after making sure the resident is safe and secure.
is inappropriate. It deprives residents of their
right to dignity and respect.
Illness and disability can affect sexual desires, 5. Identify ways to help residents meet
needs, and abilities. Residents may be sensitive their spiritual needs
about this. Sexual desire may not be lessened
Residents have spiritual needs, and you can as-
by a disability, although ability to meet sexual
sist with these needs, too. Spiritual means of, or
needs may be limited. Many people confined to
relating to, the spirit or soul. Helping residents
wheelchairs can have sexual and intimate rela-
meet their spiritual needs can help them cope
tionships, though adjustments may have to be
with illness or disability. Remember that spiritu-
made. Do not assume you know what impact a
ality is a sensitive area. Do not offend residents
physical disability has had on sexuality.
by making judgments or imposing your beliefs.
Sexual needs may also be affected by residents’
Residents may have strong beliefs in God, or
living environments. A lack of privacy and no
very little or no belief in God or a higher power.
available partner are often reasons for a lack of
Residents may consider themselves spiritual,
sexual expression in facilities. Be sensitive to
but may not believe in God or a higher power.
privacy needs.
The important thing for nursing assistants to re-
Sexual Identity member is to respect all residents’ beliefs, what-
ever they are. Do not make judgments about
Terms defining sexual identity include the following:
residents’ spiritual beliefs or try to push your be-
Gay: 1. A person who has a desire for persons of the liefs on residents. Following are some ways you
same sex. 2. A man whose sexual orientation is to
can help residents meet their spiritual needs:
men.
 113 8

• Learn about residents’ religions or beliefs 6. Identify ways to accommodate cultural

(Fig. 8-7). Listen carefully to what residents and religious differences
say.
You first learned about culture and cultural di-

Human Needs and Human Development

versity in Chapter 4. Cultural diversity has to do
with the wide variety of people living throughout
the world. You will take care of residents with
different backgrounds and traditions than your
own. It is important to respect and value each
person as an individual. Respond to differences
and new experiences with acceptance, not preju-
dice. Sometimes it is easier to accept different
practices or beliefs if you understand a little
Fig. 8-7. Be open to your residents’ spiritual needs. Be about them.
welcoming when they receive visits from a spiritual leader. There are so many different cultures that they
cannot all be listed here. One might talk about
• Assist with practices such as dietary restric-
American culture being different from Japanese
tions. Never make judgments about them.
culture. But within American culture there are
Also, respect your resident’s decision to re-
thousands of different groups with their own
frain from food-related rituals.
cultures: Japanese-Americans, African-Ameri-
• If residents are religious, encourage partici- cans, and Native Americans, to name just a few.
pation in religious services. Even people from a particular region, state, or
• Respect all religious items. city can be said to have a different culture (Fig.
8-8). The culture of the South is not the same as
• Report to the nurse (or social worker) if your the culture of New York City.
resident expresses the desire to see clergy.
• Get to know the priest, rabbi, or minister
who visits or calls your resident.
• Allow privacy for clergy visits.
• If asked, read religious materials aloud.
• If a resident asks you, help find spiritual
resources available in the area. The yellow
pages usually list churches, synagogues, and
other houses of worship. You can also refer
this request to the nurse or social worker.
You should never do any of the following:
• Try to change someone’s religion
• Tell residents their belief or religion is wrong
• Express judgments about a religious group
• Insist residents join religious activities
Fig. 8-8. There are many different cultures in the United
• Interfere with religious practices States.
 8 114

Cultural background affects how friendly people ends. Buddhism emphasizes meditation. Proper
are to strangers. It can affect how close they conduct and wisdom release a person from
want you to stand to them when talking. It can desire, suffering, and a repeating sequence of
affect how they feel about you performing care births and deaths (reincarnation). Nirvana is the
Human Needs and Human Development

for them or discussing their health with them. highest spiritual plane a person can reach. It is
For example, a care team member asks a resi- the state of peace and freedom from worry and
dent when he last had a bowel movement. One pain. The Dalai Lama is considered to be the
resident may freely answer this, while another highest spiritual leader.
may be embarrassed to have this discussion. A
Christianity: Christians believe Jesus Christ was
resident may be fine with you undressing him to
the son of God and that he died so their sins
help him bathe, while another may very uncom-
would be forgiven. Christians may be Catholic
fortable with this. These reactions may also just
or Protestant. There are many subgroups or de-
be a part of a person’s personality. Be sensitive
nominations (such as Baptists, Episcopalians,
to your residents’ backgrounds. You may have
Evangelicals, Lutherans, Methodists, Mormons,
to adjust your behavior around some residents.
and Presbyterians). Christians may go to church
Regardless of their background, you must treat
on Saturdays or Sundays. They may read the
all residents with respect and professionalism.
Bible, including the Old and New Testaments,
Expect them to treat you respectfully as well.
take communion as a symbol of Christ’s sacri-
A resident’s first language may be different from fice, and be baptized. Some Christians may try
yours. If he or she speaks a different language, to share their beliefs and convert others to their
an interpreter may be necessary. Take time to faith. Religious leaders may be called priests,
learn a few common phrases in a resident’s na- ministers, pastors, or deacons.
tive language. Picture cards and flash cards can
Hinduism: Hinduism is the dominant faith of
assist with communication.
India; it is also practiced elsewhere. Hindus fol-
Religious differences also influence the way low the teachings of ancient scriptures like the
people behave. Religion can be very important Vedas and Upanishads, as well as other major
in people’s lives, particularly when they are ill scriptures. Hindu beliefs vary widely; there may
or dying. Some people belong to a religious be a belief in only one God or in multiple gods.
group, but do not practice everything that reli- Worship can occur at a temple or at home. Hin-
gion teaches. Some people consider themselves dus believe in reincarnation, which is a belief
spiritual but not religious. Others do not believe that some part of a living being survives death to
in any religion or god and do not consider them- be reborn in a new body. Hindus also believe in
selves spiritual. You must respect the religious karma, which is the belief that all past and pres-
beliefs and practices of your residents, even if ent deeds affect one’s future and future lives.
they are different from your own. Understand- Hindus advocate respect for all life, and some
ing a little bit about common religious groups in Hindus are vegetarians. Vegetarians do not eat
America may be useful. Common types of reli- any meat. Hindus who do eat meat almost al-
gions, listed alphabetically, follow: ways refrain from eating beef.
Buddhism: Buddhism started in Asia but has Islam: Muslims, or followers of Mohammed,
many followers in other parts of the world. Bud- believe that Allah (God) wants people to follow
dhism is based on the teachings of Siddhartha the teachings of the prophet Mohammed as
Gautama, called “Buddha.” Buddhists believe recorded in the Koran. Many Muslims pray five
that life is filled with suffering that is caused times a day facing Mecca, the holy city for their
by desire, and that suffering ends when desire religion. Muslims worship at mosques and gen-
 115 8

erally do not drink alcohol or eat pork. There are • Many Jewish people eat kosher foods, do
other dietary restrictions, too. There is a variety not eat pork, and do not eat lobster, shrimp,
of Islamic religious leaders. and clams (shellfish). Kosher food is food
prepared in accordance with Jewish dietary

Human Needs and Human Development

Judaism: Judaism is divided into Reform, Con-
laws. Kosher and non-kosher foods cannot
servative, and Orthodox movements. Jews be-
come into contact with the same plates. Jews
lieve that God gave them laws through Moses
may not eat meat products at the same meal
and in the Bible, and that these laws should
with dairy products.
order their lives. Jewish services are held on Fri-
day evenings and sometimes on Saturdays, in • Mormons may not drink alcohol, coffee, or
synagogues or temples. Some Jewish men wear tea or eat chocolate. Mormons often abstain
a yarmulke, or small skullcap, as a sign of their from smoking tobacco.
faith. Some Jews follow special dietary restric- • Many Muslims do not eat pork or shellfish.
tions. Jewish people may not do certain things, Certain birds may need to be avoided, too.
such as work or drive, on the Sabbath. This lasts They may not drink alcohol. Muslims may
from Friday sundown to Saturday sundown. Re- have regular periods of fasting. Fasting
ligious leaders are called rabbis. means not eating food or eating very little
Confucianism, which is practiced in China and food.
Japan, is another major world religion. Native • Some people are vegetarians and do not
Americans follow many spiritual traditions. eat any meat for religious, moral, or health
As mentioned earlier, people have varying be- reasons.
liefs in religion, spirituality, and God. Some • Some people are vegans. Vegans do not eat
people may not believe in God or a higher power any animals or animal products, such as
and identify themselves as “agnostic.” Agnos- eggs or dairy products. Vegans may also not
tics claim that they do not know or cannot know use or wear any animal products, including
if God exists. They do not deny that God might wool and leather.
exist, but they feel there is no true knowledge of
God’s existence. Atheists are people who claim
that there is no God. This is different from what
7. Describe the need for activity
agnostics believe. Atheists actively deny the exis- Activity is an essential part of a person’s life; it
tence of God. For many atheists, this belief is as improves and maintains physical and mental
strongly held as any religious belief. health. Meaningful activities help promote in-
In addition to showing respect for different cul- dependence, memory, self-esteem, and quality
tural and religious traditions, be aware of and of life. In addition, physical activity can help
respect specific practices that affect your work. manage illnesses, such as diabetes, high blood
Many religious beliefs include dietary restric- pressure, or high cholesterol. Regular physical
tions. These are rules about what and when fol- activity can also help by:
lowers can eat. Some examples are listed below. • Lessening the risk of heart disease, colon
cancer, diabetes, and obesity
• Many Buddhists are vegetarians, though
some include fish in their diet. • Relieving symptoms of depression

• Some Catholics do not eat meat on Fridays • Improving mood and concentration
during Lent. • Improving body function
 8 116

• Lowering the risk of falls

• Improving sleep quality
• Improving ability to cope with stress
Human Needs and Human Development

• Increasing energy
• Increasing appetite and promoting better
eating habits
Just as activity aids physical and mental health,
inactivity and immobility can result in physical
and mental problems, such as:
• Loss of self-esteem
• Depression
• Boredom
• Pneumonia
• Urinary tract infection
• Constipation
• Blood clots
• Dulling of the senses
Most facilities have an activity department. The
activities are designed to help residents socialize
and keep them physically and mentally active.
Daily schedules are normally posted with activi-
ties for that particular day. Activities include ex-
ercise, arts and crafts, board games, newspapers,
magazines, books, TV and radio, pet therapy,
gardening, and group religious events. When
activities are scheduled, help residents with
grooming beforehand, as needed and requested.
Assist with any personal care that the resident
Fig. 8-9. Families come in all shapes and sizes.
requires. Help residents with walking and
wheelchairs, as necessary.
• Single-parent families include one parent
with a child or children.
8. Discuss family roles and their • Nuclear families include two parents with a
significance in health care child or children.
Families are the most important unit within our • Blended families include widowed or di-
social system (Fig. 8-9). Families play a huge role vorced parents who have remarried. There
in many people’s lives. Some examples of family may be children from previous marriages as
types are listed below: well as from this marriage.
 117 8

• Multigenerational families include parents, • Caring for their children while caring for an
children, and grandparents. elderly loved one (called the “sandwich gen-
eration”—being “sandwiched” between two
• Extended families may include aunts, un-
generations)

Human Needs and Human Development

cles, cousins, or even friends.
• Families may also be made up of unmarried
couples of the same sex or opposite sexes,
with or without children.
Today a family is defined more by support-
ing each other than by the particular people
involved. Your residents’ families may not look
like the kind of family you are used to. Residents
with no living relatives may have friends or
neighbors who act as a family. Whatever kinds of
Fig. 8-10. Family members may have a hard time adjust-
families your residents have, recognize the im- ing to the additional responsibilities when a loved one
portant part they can play. Family members help becomes ill or disabled.
in many ways:
Be sensitive to the big adjustments your resi-
• Helping residents make care decisions
dents and their families may be making. Help
• Communicating with the care team them by doing your job well. Be respectful and
• Giving support and encouragement nice to friends and family members, and allow
privacy for visits. After any visitor leaves, ob-
• Connecting the resident to the outside world
serve the effect the visit had on the resident.
• Offering assurance to dying residents that Report any noticeable effects to the nurse. Some
family memories and traditions will be val- residents have good relationships with their
ued and carried on families; others do not. If you notice any abusive
Illness or disability requires residents and fami- behavior from a visitor towards a resident, report
lies to make adjustments. Making these adjust- it immediately to the charge nurse.
ments may be difficult (Fig. 8-10). It depends on
the family’s emotional, spiritual, and financial 9. List ways to respond to emotional
resources. Some personal adjustments include needs of residents and their families
the following:
Residents or family members may come to you
• Accepting the illness or disability and its
with problems or needs. Changes in residents’
long-term consequences or results
health status can cause fear, uncertainty, stress,
• Finding money needed to pay the expenses and anger. Your response will depend on many
of hospitalization, or long-term or home care factors. These include how comfortable you feel
• Dealing with paperwork involved in insur- with emotions in general, how well you know
ance, Medicaid, or Medicare benefits the person, and what the need or problem is.
Try to empathize, or understand how the person
• Taking care of tasks the resident can no lon- feels. The following are good ways to respond to
ger handle this situation:
• Understanding medical information and Listen. Often just talking about a problem or
making difficult care decisions concern can make it easier to handle. Sitting
 8 118

quietly and letting someone talk or cry may be Everyone will go through the same stages of de-
the best help you can give (Fig. 8-11). Families velopment during their lives. However, no two
often seek out nursing assistants because they people will follow the exact same pattern or rate
are closest to the residents. This is an important of development. Each resident must be treated as
Human Needs and Human Development

responsibility. Show families that you have time an individual and a whole person who is grow-
for them, too. ing and developing. He or she should not be
treated as someone who is merely ill or disabled.

Infancy, Birth to 12 Months

Infants grow and develop very quickly. In one
year a baby moves from total dependence to the
relative independence of moving around, com-
municating basic needs, and feeding himself.
Physical development in infancy moves from the
head down. For example, infants gain control
over the muscles of the neck before the muscles
Fig. 8-11. Sometimes listening to someone is the best in their shoulders. Control over muscles in the
way to provide emotional support. trunk area, such as the shoulders, develops be-
fore control of arms and legs (Fig. 8-12). This
Offer support and encouragement. Saying things
head-to-toe sequence should be respected when
like, “You have really been under a lot of stress,
caring for infants. For example, newborns must
haven’t you?” or, “I can imagine that really is
be supported at the shoulders, head, and neck.
scary,” can provide a lot of comfort. Avoid using
Babies who cannot sit or crawl should not be en-
clichés like, “It’ll all work out.” Things may not
couraged to stand or walk.
all work out. It is more comforting if you admit
how hard the situation is. Do not simply dismiss
feelings with a cliché.
Refer the problem to a nurse or social worker.
When you feel that you cannot help the resident,
get someone else on the care team to handle the
situation. Say something like, “Mrs. Pfeiffer, I
think my supervisor would be better at getting
you the help you need.”

10. Describe the stages of human growth

and development and identify common Fig. 8-12. An infant’s physical development moves from
disorders for each group the head down.

Throughout their lives, people change physi-

cally and psychologically. Physical changes Common Disorders:
occur in the body. Psychological changes occur Infancy
in the mind and also in the person’s behavior.
These changes are called human growth and Babies who are born before 37 weeks gesta-
development. tion (more than three weeks before the due
 119 8

date) are considered premature. These Childhood

babies may weigh from one to six pounds,
The Toddler Period, Ages 1 to 3
depending on how early they are born. Often,
premature babies will remain in the hospital During the toddler years, children gain inde-

Human Needs and Human Development

for some time after birth. At home, pre- pendence. One part of this independence is
mature babies may need special care. This new control over their bodies. Toddlers learn
includes medication, heart monitoring, and to speak, gain coordination of their limbs, and
frequent feedings to ensure weight gain. gain control over their bladders and bowels (Fig.
8-13). Toddlers assert their new independence by
Babies born at full term but weighing less
exploring. Poisons and other hazards, such as
than five pounds are called low-birth-weight
sharp objects, must be locked away. Psychologi-
babies. Low-birth-weight babies can have
cally, toddlers learn that they are individuals,
many of the same problems premature
separate from their parents. Children of this age
babies have. They are cared for in much the
may try to control their parents. They may try to
same way as premature babies.
get what they want by throwing tantrums, whin-
The term “birth defects” is very general. It ing, or refusing to cooperate. This is a key time
includes many different conditions that affect for parents to set rules and standards.
an infant from birth. Some birth defects are
inherited from parents. Injury or disease
during pregnancy causes others. Some of
the conditions you may see when caring for
infants in the home include cerebral palsy,
Down syndrome, and cystic fibrosis.
Viral or bacterial infections can cause fever,
runny nose, coughing, rash, vomiting, diar-
rhea, or secondary infections of the sinuses
or ears. Bacterial infections can be treated
with antibiotics. Viral infections are treated
with extra rest and fluids.
Sudden infant death syndrome (SIDS)
or crib death, is a condition in which babies
stop breathing and die for no known reason
while asleep. Doctors do not know how to
Fig. 8-13. Toddlers gain coordination of their limbs.
prevent SIDS. However, studies have shown
that putting the baby to sleep on its back can
reduce the chances of SIDS. Because SIDS The Preschool Years, Ages 3 to 6
is more common among premature or low- Children in their preschool years develop new
birth-weight babies, these infants often wear skills. These will help them to become more
apnea monitors to alert parents if breathing independent and have social relationships (Fig.
stops. Another factor that may contribute 8-14). They learn new words and develop lan-
to SIDS is second-hand smoke. Parents guage skills. They learn to play in groups. They
and caregivers should never smoke around become more physically coordinated and learn
infants or children. to care for themselves. Preschoolers also develop
 8 120

ways of relating to family members. They begin Leukemia is a form of cancer. It refers to
to learn right from wrong. the inability of the body’s white blood cells
to fight disease. Children with leukemia may
be susceptible to infections and other disor-
Human Needs and Human Development

ders. Chemotherapy can be used to fight this

disease. See Chapter 18 for more information
on cancer.
Child abuse refers to physical, emotional,
and sexual mistreatment of children, as well
as neglect and maltreatment. Physical abuse
includes hitting, kicking, burning, or inten-
tionally causing injury to a child. Emotional
Fig. 8-14. Children in their preschool years develop social abuse includes withholding affection, con-
relationships. stantly criticizing, or ridiculing a child.
Sexual abuse includes engaging in or allow-
School-Age Children, Ages 6 to 12 ing another person to engage in a sexual
From ages 6 to about 12 years, children’s de- act with a child. Neglect and maltreatment
velopment is centered on cognitive (related to include not providing adequate food, cloth-
thinking and learning) and social development. ing, or support. They also include allowing
As children enter school, they also explore the children to use alcohol or drugs, leaving chil-
world around them. They relate to other children dren alone, or exposing them to danger. See
through games, peer groups, and classroom Chapters 3 and 27 for more information.
activities. In these years, children learn to get Measles, mumps, rubella, diphtheria, small-
along with each other. They also begin to behave pox, whooping cough, and polio are diseases
in ways common to their sex. They begin to de- that were once common during childhood.
velop a conscience, morals, and self-esteem. They can all be prevented now with
vaccinations.
Common Disorders:
Childhood Adolescence

Puberty
Chickenpox is a highly contagious viral ill-
ness that strikes nearly all children. It gener- During puberty, secondary sex characteristics,
ally has no serious effects for healthy chil- such as body hair, appear. Reproductive organs
dren. However, in adults or in anyone with a begin to function due to the secretion of the
weakened immune system it can have more reproductive hormones. The start of puberty oc-
serious effects. Taking the varicella-zoster curs between the ages of 10 and 16 for girls and
vaccine, commonly called the chickenpox vac- 12 and 14 for boys.
cine, can prevent chickenpox.
Adolescence, Ages 12 to 18
Children, as well as infants, may be suscep-
tible to infections caused by viruses or bac- Many teenagers have a hard time adapting to
teria. Bacterial infections can be treated with changes that occur in their bodies after puberty.
antibiotics. Viral infections are treated with Peer acceptance is important to them. Adoles-
extra rest, fluids, and over-the-counter medi- cents may be afraid that they are ugly or even
cations for cough or congestion. abnormal. This concern for body image and ac-
 121 8

ceptance, combined with changing hormones Girls who are sexually active and do not use
that influence moods, can cause rapid mood birth control, or do not use it properly, can
swings. Conflicting pressures develop as they become pregnant. Teenage pregnancy can
remain dependent on their parents and yet need have terrible consequences for adolescents,

Human Needs and Human Development

to express themselves socially and sexually. This their families, and the babies born to teen-
causes conflict and stress. Social interaction age parents. Teenagers should understand
between members of the opposite sex becomes that they can avoid pregnancy by using birth
very important (Fig. 8-15). control or by not having sexual intercourse.
Teenagers who choose to be sexually active
should know what birth control methods are
available and how to use them. Pregnancy
puts a great deal of stress on teenage bodies.
Adolescent girls are still children. Their bod-
ies are still developing. In most cases they
are not physically ready to bear a child. It is
common for teenage mothers to give birth to
premature or low-birth-weight babies.
Because of the many physical and emotional
Fig. 8-15. During adolescence, people express themselves changes they are experiencing, adolescents
socially and sexually. may become depressed and even attempt
suicide. Parents, teachers, and friends should
watch for the signs of depression. These
Common Disorders: include withdrawal, loss of appetite, weight
Adolescence gain or loss, sleep problems, moodiness, and
apathy. Teenagers who are depressed should
As their bodies change, adolescents, espe-
see a doctor, counselor, therapist, minister,
cially girls, may develop eating disorders.
or other trusted adult who can get them the
Anorexia is a disease in which a person
help they need.
does not eat or exercises excessively to lose
weight. A person with bulimia binges, eat- Adolescents can sustain trauma, or severe
ing huge amounts of foods or very fattening injury, to the head or spinal cord in car acci-
foods, and then purges, or eliminates the dents or sports injuries. These injuries can be
food by vomiting, using laxatives, or exer- temporarily or permanently disabling or even
cising excessively. Eating disorders can be fatal.
serious and even life-threatening. These dis-
orders must be treated with therapy and, in Adulthood
some cases, hospitalization.
Young Adulthood, Ages 18 to 40
Teenagers can contract sexually transmit-
By the age of 18, most young adults have
ted diseases (STDs) and infections (STIs),
stopped growing. Adopting a healthy lifestyle in
such as chlamydia, herpes, and AIDS if they
these years can make life better now and prevent
are sexually active. If teenagers are sexually
health problems in later adulthood. Psychologi-
active, only condoms offer some protection
cal and social development continues, however.
from sexually transmitted diseases and infec-
The tasks of these years include the following:
tions. See Chapter 18 for more information
on STDs and STIs. • Selecting an appropriate education
 8 122

• Selecting an occupation or career loss of strength and health, the death of loved
ones, retirement, and preparation for death.
• Selecting a mate (Fig. 8-16)
The developmental tasks of this age may seem
to deal largely with loss. But solutions to these
Human Needs and Human Development

problems often involve new relationships, friend-

ships, and interests. The disorders you are most
likely to see (AIDS, arthritis, Alzheimer’s dis-
ease, cancer, diabetes, and stroke) are discussed
in Chapters 18 and 19.

11. Distinguish between what is true and

Fig. 8-16. Young adulthood often involves finding long-
term mates.
what is not true about the aging process
Geriatrics is the study of health, wellness, and
• Learning to live with a mate or others
disease later in life. It includes the health care
• Raising children of older people and the well-being of their care-
• Developing a satisfying sex life givers. Gerontology is the study of the aging
process in people from mid-life through old age.
Middle Adulthood: 40 to 65 Years Gerontologists look at the impact of the aging
population on society.
In general, people in middle adulthood are more
comfortable and stable than they were in previ- Later adulthood covers an age range of as many
ous stages. Many of their major life decisions as 25 to 35 years. People in this age category
have already been made. In the early years of can have very different abilities, depending on
middle adulthood people sometimes experience their health. Some 70-year-old people enjoy ac-
a “mid-life crisis.” This is a period of unrest cen- tive sports, while others are not active. Many
tered on a subconscious desire for change and 85-year-old people can still live alone. Others
fulfillment of unmet goals. may live with family members or in long-term
care facilities.
Physical changes related to aging also occur in
middle adulthood. Adults in this age group may Ideas and stereotypes about older people are
notice that they have difficulty maintaining their often false. They create prejudices against the
weight or notice a decrease in strength and en- elderly that are as unfair as prejudices against
ergy. Metabolism and other body functions slow racial, ethnic, or religious groups. On television
down. Wrinkles and gray hair appear. Vision or in the movies older people are often shown
and hearing loss may begin. Women experience as helpless, lonely, disabled, slow, forgetful, de-
menopause, the end of menstruation. This oc- pendent, or inactive. However, research shows
curs when the ovaries stop secreting hormones. that most older people are active and engaged in
Many diseases and illnesses can develop in these work, volunteer activities, and learning and exer-
years. These disorders can become chronic and cise programs. Aging is a normal process, not a
life-threatening. disease. Most older people live independent lives
and do not need assistance (Fig. 8-17). Prejudice
Late Adulthood: 65 Years and Older toward, stereotyping of, and/or discrimination
Persons in late adulthood must adjust to the ef- against older persons or the elderly is called
fects of aging. These changes can include the ageism.
 123 8

• Levels of hormones decrease.

• Immunity weakens.
• Lifestyle changes occur.

Human Needs and Human Development

There are also changes that are NOT considered
normal changes of aging and should be reported
to the nurse. These include the following:
• Signs of depression
• Loss of ability to think logically
• Poor nutrition
• Shortness of breath
• Incontinence
Keep in mind that this is not a complete list.
Fig. 8-17. Older adults often remain active and engaged.
Your job includes reporting any change, nor-
You are likely to spend much of your time work- mal or not. You will learn more about normal
ing with elderly residents. You must know what changes of aging in Chapter 9.
is true about aging and what is not true. While
aging causes many changes, normal changes 12. Explain developmental disabilities and
of aging do not mean an older person must be- list care guidelines
come dependent, ill, or inactive. Knowing how
to tell normal changes of aging from signs of Developmental disabilities refer to disabilities
illness or disability will allow you to better help that are present at birth or emerge during child-
residents. Normal changes of aging include the hood. A developmental disability is a chronic
following: condition. It restricts physical or mental ability.
These disabilities prevent a child from develop-
• Skin is thinner, drier, more fragile, and less
ing at a “normal” rate. NAs help teach residents
elastic.
self-care and assist with ADLs.
• Muscles weaken and lose tone.
• Bones become more brittle. Mental Retardation
• Sensitivity of nerve endings in the skin According to the CDC, mental retardation is
decreases. the most common developmental disorder. Ap-
• Responses and reflexes slow. proximately one percent of the population has
mental retardation. It is neither a disease nor a
• Short-term memory loss occurs.
psychiatric illness. People with mental retarda-
• Senses of vision, hearing, taste, and smell tion develop at a below-average rate. They have
weaken. below-average mental functioning. They have
• Heart works less efficiently. difficulty in learning, communicating, moving,
• Oxygen in the blood decreases. and may have problems adjusting socially. The
ability to care for themselves may be affected.
• Appetite decreases.
The potential for living independently and for
• Urinary elimination is more frequent. financial independence may be limited. Despite
• Digestion takes longer and is less efficient. their special needs, people who are mentally
 8 124

retarded have the same emotional and physical • Profound mental retardation causes obvious
needs as others (Fig. 8-18). They experience the delays in most areas of development. The
same emotions, such as anger, sadness, love, person may not respond to his environment,
and joy, as others do. However, expression of and often there are physical problems as
Human Needs and Human Development

their emotions may be limited, depending on well. Walking may be mastered; communica-
their individual disabilities. tion skills are extremely basic. The person
may need nursing care and require help in
self-care. He will need a high level of sup-
port and supervision.
For residents who are mentally retarded, the
main goal of care is to help them have as normal
a life as possible. This means recognizing their
individuality, basic human rights, and physical
and emotional needs, as well as special needs.
Some residents and/or their families will pre-
fer not to use the term “mental retardation” or
“mentally retarded.” Other terms that may be
Fig. 8-18. People who are mentally retarded have the preferable are “intellectual disability” and “de-
same emotional and physical needs as others do.
velopmental disability.” Respect the resident’s
wishes on which term or terms to use.
There are different degrees of mental retarda-
tion; the four degrees are mild, moderate, severe,
and profound: Guidelines:
• Mild retardation usually causes a delay in Mental Retardation
walking and talking. With special support
G Treat adult residents as adults, regardless of
and education, the person can acquire aca-
their behavior.
demic skills up to the sixth grade level. With
some assistance, he can become fairly inde- G Praise and encourage often, especially posi-
pendent and have some social skills and abil- tive behavior.
ity to work. G Help teach ADLs by dividing a task into
• Moderate mental retardation causes delays smaller units.
in speech and motor development. Simple G Promote independence, but also assist resi-
communication skills may be acquired in dents with activities and motor functions that
childhood. With some support and super- are difficult.
vision, the person can usually work and G Encourage social interaction.
function successfully. He may be able to
G Repeat words to make sure they understand.
live alone, or may live in a facility or group
home. G Be patient.
• Severe mental retardation causes notice-
Down Syndrome
able delays in motor development, and the
person has few communication skills. Very People who are born with Down syndrome have
basic self-care skills, such as self-feeding, toi- different degrees of mental retardation, along
leting, and dressing may be mastered. The with physical symptoms. A person with Down
person may live in a facility or group home. syndrome typically has a small skull, a flattened
 125 8

nose, short fingers, and a wider space between G Avoid activities that are tiring or frustrating.
the first two fingers and the first two toes. Some G Be gentle when handling parts of the body
people with Down syndrome can become fairly that may be painful (Fig. 8-19).
independent.

Human Needs and Human Development

Guidelines:
Down Syndrome

G Give the same type of care and instruction as

for any other person with mental retardation.
G Praise and encourage often, especially posi-
tive behavior.
G Help teach ADLs by dividing a task into
smaller units. Fig. 8-19. Be gentle when moving body parts of a resident
who has cerebral palsy.
Cerebral Palsy
People with cerebral palsy have suffered brain G Promote independence and encourage
damage while in the uterus or during birth. socialization.
They may have both physical and mental dis-
abilities. Damage to the brain stops the develop- Spina Bifida
ment of the child. It can cause disorganized or Spina bifida literally means “split spine.” When
abnormal development. Muscle coordination part of the backbone is not well-developed at
and nerves are affected. People with cerebral birth, the spinal cord may bulge out of the back.
palsy may lack control of the head, and have Spina bifida can cause a range of disabilities.
trouble using the arms and hands, and have Some babies born with spina bifida will be able
poor balance or posture. They may be either stiff to walk and will have no lasting disabilities. Oth-
and spastic or limp and flaccid, and may have ers may be in a wheelchair. They may have little
impaired speech. Gait and mobility may be af- or no bladder or bowel control. In some cases,
fected. Intelligence may also be affected. With or complications of spina bifida may cause brain
without assistance, a person with cerebral palsy damage.
may be able to live independently.
Guidelines:
Guidelines: Spina Bifida
Cerebral Palsy
G If the resident is an adult, provide assistance
G Allow the resident to move slowly. People with range of motion exercises and ADLs.
with cerebral palsy take longer to adjust their If working in the home, help perform light
body position. They may repeat movements housecleaning duties.
several times.
G If an infant or child has spina bifida, perform
G Keep the resident’s body in as normal an tasks that help the parents manage and sta-
alignment as possible. bilize the home.
G Talk to the resident, even if he or she cannot G Be a positive role model for the resident and
speak. Be patient and listen. family in learning to deal with the resident’s
G Use touch as a form of communication. disabilities.
 8 126

13. Identify community resources 5. List six examples of losses that residents
available to help the elderly may experience.

The larger community—the local government or 6. What are six problems that a lack of inde-
Human Needs and Human Development

social service agencies, church or synagogue— pendence can cause?

can provide resources to help the elderly. These 7. List four ways to accommodate residents’
resources can help them through difficult times sexual needs.
and help solve problems. Some of these re-
8. How can nursing assistants help residents
sources include the following:
meet their spiritual needs?
• Local Area Agency on Aging
9. What is never allowed regarding residents’
• Ombudsman program spiritual or religious needs?
• Alzheimer’s Association 10. Pick three religions listed in Learning Objec-
• Local Hospice organization tive 6 and briefly describe them. Feel free to
add information that is not included in the
• Social workers Learning Objective.
• Resident advocacy organizations 11. If a resident is an atheist, but her NA be-
• Support groups lieves in God, is it okay for the NA to ask the
resident to pray with her?
• Meal or transportation services (Fig. 8-20)
12. List seven ways that regular physical activity
can help a person.
13. List seven ways that inactivity and immobil-
ity can cause problems for a person.
14. List four ways that families can help
residents.
15. Name three ways nursing assistants can
meet emotional needs of residents and their
families.
Fig. 8-20. “Meals on Wheels” and similar services provide
nutritious meals to people unable to cook for themselves. 16. For each stage of human development—in-
fancy, childhood, adolescence, adulthood—
If residents ask you for help, refer them to the name two common disorders.
nurse or social worker. If no one asks but you 17. What is ageism?
think help is needed, speak to your supervisor.
18. What is true/factual about most older
adults?
Chapter Review
19. List ten normal changes of aging.
1. List six basic human needs. 20. What are developmental disabilities?
2. What psychosocial needs do humans have? 21. What is the most common developmental
3. According to Maslow, which needs must be disorder?
met first, physical or emotional? 22. List four community resources that can help
4. What does giving holistic care mean? residents meet their needs.
 127 9

The Healthy Human Body

The Healthy Human Body

1. Describe body systems and define key 3. Nervous

anatomical terms 4. Cardiovascular or circulatory
Our bodies are organized into body systems. 5. Respiratory
Each system has a condition under which it 6. Urinary
works best. Homeostasis is the name for the
7. Gastrointestinal
condition in which all of the body’s systems are
working at their best. To be in homeostasis, the 8. Endocrine
body’s metabolism, or physical and chemical 9. Reproductive
processes, must be working at a steady level.
10. Immune and Lymphatic
When disease or injury occur, the body’s metab-
olism is disturbed. Homeostasis is lost. Body systems are made up of organs. An organ
has a specific function. Organs are made up of
Changes in metabolic processes are called signs
tissues. Tissues are made up of groups of cells
and symptoms. For instance, changes in body
that perform a similar task. For example, in the
temperature could indicate that the body is
circulatory system, the heart is one of the or-
fighting an infection. Noticing and reporting
gans. It is made up of tissues and cells. Cells are
changes in your residents is a very important
the building blocks of our bodies. Living cells
part of your job. The changes you notice could
divide, grow, and die, renewing the tissues and
be signs of significant problems.
organs of our body systems.
Each system in the body has its own unique
structure and function. There are also normal Anatomical Terms of Location
age-related changes for each body system. Know-
Anatomical terms of location are descriptive terms to
ing normal changes of aging will help you be help identify positions or directions of the body. Here
able to recognize any abnormal changes in your are some anatomical terms used to describe location
residents. This chapter also includes tips on in the human body:
how you can help residents with their normal • Anterior or ventral: the front of the body or body
changes of aging. part

The body’s systems can be broken down in dif- • Posterior or dorsal: the back of the body or body
part
ferent ways. In this book we divide the human
body into ten systems: • Superior: toward the head

1. Integumentary, or skin • Inferior: away from the head

2. Musculoskeletal • Medial: toward the midline of the body

 9 128

too high. This brings more blood to the body

• Lateral: to the side away from the midline of the
body surface to cool it off. The same blood vessels
• Proximal: closer to the torso constrict, or narrow, when the outside tempera-
ture is too cold. By restricting the amount of
The Healthy Human Body

• Distal: farther away from the torso

blood reaching the skin, the blood vessels help
This section discusses the structure and func- the body retain heat.
tion, as well as age-related changes, of each body The blood vessels, called capillaries, are located
system. The bulk of information on diseases and in the dermis, which is the inner layer of skin.
disorders of each system and related care will be The dermis also contains nerves, sweat glands,
discussed in Chapter 18. Chapters 16, 17, and 19 oil glands, and hair roots. Sweat glands help
also have information on diseases. control body temperature by secreting sweat.
Sweat is made up of mostly water, but it also
2. Describe the integumentary system contains salt and a small amount of waste prod-
ucts. Sweat comes to the body’s surface through
The largest organ and system in the body is the
pores, or tiny openings in the skin. It cools the
skin. The skin is a natural protective covering,
body as it evaporates. Oil glands in the der-
or integument. Skin prevents injury to internal
mis secrete oil. Oil comes to the skin surface
organs. It also protects the body against entry of
through hair follicles, or roots. Oil keeps the
bacteria. Skin also prevents the loss of too much
skin and hair soft.
water, which is essential to life. Skin is made up
of tissues and glands (Fig. 9-1). Glands secrete No blood vessels, and only a few nerve endings,
hormones. Hormones are chemical substances are located in the epidermis, which is the outer
created by the body that control numerous body layer of skin. Thinner than the dermis, the epi-
functions. dermis contains both dead and living cells. The
dead cells begin deeper in the epidermis. They
are pushed to the surface as other cells divide.
They are eventually worn off. The epidermis
also contains pigment cells that give the skin its
color.
Hair grows from roots located in the dermis. It
grows through hair follicles that extend through
the epidermis to the outside of the body. Hair
protects the body from heat and cold. Hair in-
side the nose and ears keeps out particles and
bacteria trying to enter the body.
Normal changes of aging include the following:
• Skin is thinner, drier, and more fragile. It is
more easily damaged.

Fig. 9-1. Cross-section showing details of the integumen- • Skin is less elastic.
tary system. • Protective fatty tissue is lost, so person feels
colder.
The skin is also a sense organ that feels heat,
cold, pain, touch, and pressure. Body tempera- • Hair thins and may turn gray.
ture is regulated in the skin. Blood vessels di- • Wrinkles and brown spots, or “liver spots”
late or widen, when the outside temperature is appear.
 129 9

• Nails are harder and more brittle. In ebony complexions, also look for any
change in the feel of the tissue, any change
• Reduced circulation to the skin can cause
in the appearance of the skin, such as an
dryness, itching, and irritation.
“orange-peel” look, a purplish hue, and

The Healthy Human Body

How You Can Help: NA’s Role extremely dry, crust-like areas that might be
covering a tissue break upon a closer look.
Older adults perspire less and do not need to bathe
as often. Most elderly people generally need a com-
plete bath only twice a week, with sponge baths every
3. Describe the musculoskeletal system
day. Muscles, bones, ligaments, tendons, and car-
Use lotions as ordered for moisture to relieve dry tilage give the body shape and structure. They
skin. Be gentle; elderly residents’ skin can be fragile work together to allow the body to move.
and tear easily. Hair also becomes drier and needs
to be shampooed less often. Gently brush dry hair to The skeleton, or framework, of the human body
stimulate and distribute the natural oils. Layer cloth- has 206 bones (Fig. 9-2). Besides allowing the
ing and bed covers for additional warmth. Keep bed
body to move, bones also protect organs. For ex-
linens wrinkle-free. Be careful if directed to give nail
care. Do not cut toenails. Encourage fluids. ample, the skull protects the brain and the verte-
brae protect the spinal cord. Bones are hard and
rigid, but are made up of living cells. Blood ves-
Observing and Reporting: sels supply oxygen and nutrients to the bones, as
Integumentary System well as other tissues of the body.

During daily care, a resident’s skin should be

observed for changes that may indicate disease.
Observe and report the following signs and
symptoms:
Pale, white or reddened, or purple areas, blis-
ters or bruises on the skin
Dry or flaking skin
Rashes or any skin discoloration
Cuts, boils, sores, wounds, abrasions
Fluid or blood draining from the skin
Changes in moistness/dryness
Swelling
Blisters Fig. 9-2. The skeleton is composed of 206 bones that help
movement and protect organs.
Changes in wound or ulcer (size, depth,
drainage, color, odor) Two bones meet at a joint (Fig. 9-3). Some joints
Redness or broken skin between toes or make movement possible in all directions, such
around toenails as the ball and socket joint. This joint is a type
of synovial joint. In this joint, the round end of
Scalp or hair changes
one bone fits into the hollow end of the other
Skin that appears different from normal or bone, which allows it to move in all directions.
that has changed The hip and shoulder joints are examples.
 9 130

teem, depression, pneumonia, and urinary tract

infections. They can also lead to constipation,
blood clots, dulling of the senses, and muscle
atrophy or contractures. When atrophy occurs,
The Healthy Human Body

the muscle wastes away, decreases in size, and

becomes weak. When a contracture develops,
the muscle shortens, becomes inflexible, and
“freezes” in position. This can cause permanent
disability of the limb.
Range of motion (ROM) exercises can help
prevent these conditions. With ROM exercises,
the joints are extended and flexed. Exercise in-
creases circulation of blood, oxygen, and nutri-
ents and improves muscle tone. See Chapter 21
for more information on ROM exercises.
Normal changes of aging include the following:
• Muscles weaken and lose tone.
• Body movement slows.
Fig. 9-3. Muscles are connected to bone by tendons.
Bones meet at different types of joints. The ball and • Bones lose density. They become more brit-
socket joint and the hinge joint are shown here. tle, making them more susceptible to breaks.
• Joints may stiffen and become painful.
Other joints permit movement in one direction
only. The hinge joint is another example of a • Height is gradually lost.
synovial joint. Like the hinge of a door, a hinge
joint permits movement in one direction only. How You Can Help: NA’s Role
The elbow and knee are hinge joints. They only
Falls can cause life-threatening complications, in-
bend in one direction. cluding fractures. Prevent falls by keeping items out
of residents’ paths. Keep furniture in the same place.
Muscles provide movement of body parts to
Keep walkers or canes where residents can easily
maintain posture and to produce heat. Muscles reach them. Encourage regular movement and self-
can be voluntary or involuntary. Voluntary mus- care. Encourage residents to perform as many ADLs
cles are also called skeletal muscles. They are as possible. To prevent or slow osteoporosis, the
condition that is responsible for fragile bones, en-
attached to bones. They can be moved when a
courage residents to walk and do other light exercise.
person wants them to move. Examples of volun- Exercise can strengthen bones as well as muscles.
tary muscles are the arm and leg muscles, which Help with range of motion (ROM) exercises as
are consciously controlled. Involuntary muscles needed.
cannot be consciously controlled. They automati-
cally regulate the movement of organs and blood Observing and Reporting:
vessels. Examples of involuntary muscles are the Musculoskeletal System
heart and the diaphragm. The diaphragm is the
muscle that makes humans breathe. Observe and report the following signs and
Exercise is important for improving and main- symptoms:
taining physical and mental health. Inactivity Changes in ability to perform routine move-
and immobility can result in a loss of self-es- ments and activities
 131 9

Any changes in residents’ ability to perform cord. The peripheral nervous system deals with
ROM exercises the periphery, or outer part of the body, via the
nerves that extend throughout the body.
Pain during movement

The Healthy Human Body

Any new or increased swelling of joints The Central Nervous System
White, shiny, red, or warm areas over a joint The brain is housed within the skull. The spinal
cord is housed within the spinal column. The
Bruising
spinal column extends from the brain into the
Aches and pains reported to you trunk of the body. Both the brain and the spinal
cord are covered by a protective membrane made
4. Describe the nervous system up of three layers. Between two of these layers
is the cerebrospinal fluid. This fluid circulates
The nervous system is the control and message around the brain and spinal cord. It provides a
center of the body. It controls and coordinates all cushion against injuries.
body functions. The nervous system also senses
The brain has three main sections: the cere-
and interprets information from outside the
brum, the cerebellum, and the brainstem (Fig.
human body (Fig. 9-4).
9-5). The largest section of the human brain is
the cerebrum. The outside layer of the cerebrum
is the cerebral cortex. The cerebral cortex is the
part of the brain in which thinking, analysis,
association of ideas, judgment, emotions, and
memory occur. The cerebral cortex also:
• Directs speech and emotions
• Interprets messages from the eyes, ears,
nose, tongue, and skin
• Controls voluntary muscle movement

Fig. 9-4. The nervous system includes the brain, spinal

cord, and nerves throughout the body.

The neuron, or nerve cell, is the basic unit of the

nervous system. Neurons send messages or sen-
sations from the receptors in different parts of
the body, through the spinal cord, to the brain.
Fig. 9-5. The three main sections of the brain: cerebrum,
The nervous system has two main parts: the brainstem, and cerebellum.
central nervous system (CNS) and the periph-
eral nervous system (PNS). The central ner- The cerebrum is divided into right and left
vous system is composed of the brain and spinal hemispheres. The right hemisphere controls
 9 132

movement and function in the left side of the They conduct messages between the brain and
body. The left hemisphere controls movement the body. Cranial nerves attach to the brain and
and function in the right side of the body (Fig. brain stem. Some of these nerves bring informa-
9-6). Any illness or injury to the right hemi- tion from the sense organs to the brain. Some
The Healthy Human Body

sphere affects functions on the left side of the control muscles and others are connected to
body. Illness or injury to the left hemisphere dis- glands or organs, such as the lungs. There are
rupts function on the right side. 12 pairs of cranial nerves. Nerves that are at-
tached to the spinal cord and connect the spinal
cord with other parts of the body are called spi-
nal nerves. The brain communicates with most
of the body through the spinal nerves. There are
31 pairs of spinal nerves.
Normal changes of aging include the following:
• Responses and reflexes slow.
• Sensitivity of nerve endings in skin
decreases.
• Person may show some memory loss, more
often with short-term memory. Long-term
memory, or memory for past events, usually
remains sharp.

How You Can Help: NA’s Role

Help with memory loss by suggesting residents

Fig. 9-6. The right hemisphere controls movement and make lists or write notes about things they want to
function in the left side of the body. The left hemisphere remember. Placing a calendar nearby may help. If
controls movement and function in the right side of the your residents enjoy reminiscing, take an interest in
body. their past by asking to see photos or hear stories.
Allow time for decision-making and avoid sudden
changes in schedule. Allow plenty of time for move-
The cerebellum controls balance and regulates
ment; never rush the person. Encourage reading,
the body’s voluntary muscles. It produces and thinking, and other mental activities.
coordinates smooth movements. Someone who
has a problem in the cerebellum will be uncoor-
dinated and have jerky movements and muscle Observing and Reporting:
weakness. Central Nervous System
The cerebrum and cerebellum are connected to
Observe and report the following signs and
the spinal cord by the brainstem. The brainstem
symptoms:
contains a kind of regulatory center. It controls
heart rate, breathing, swallowing, coughing, Fatigue or any pain with movement or
vomiting, and closing or opening of blood exercise
vessels. Shaking or trembling
The spinal cord is connected to the brain. It is Inability to speak clearly
protected by the bones of the spinal column.
Nerve pathways run through the spinal cord. Inability to move one side of body
 133 9

Disturbance or changes in vision or hearing iris, or the colored part of the eye. The pupil, or
black circle in the center of the iris, widens or
Changes in eating patterns and/or fluid
narrows to adjust the amount of light that enters
intake
the eye. Inside the back of the eye is the retina.

The Healthy Human Body

Difficulty swallowing The retina contains cells that respond to light
Bowel and bladder changes and send a message to the brain, where the pic-
ture is interpreted so you can “see.”
Depression or mood changes
The ear is a sense organ that provides balance
Memory loss or confusion
and hearing. It is divided into three parts: the
Violent behavior outer ear, the middle ear, and the inner ear (Fig.
Any unusual or unexplained change in 9-8). The outer ear is the funnel-shaped outer
behavior part, sometimes called the auricle or pinna. It
guides sound waves into the auditory canal. This
Decreased ability to perform ADLs canal is about one inch long and contains many
glands that secrete earwax. Earwax and hair in
The Nervous System: Sense Organs the ear protect the ear from foreign objects. The
The eyes, ears, nose, tongue, and skin are the eardrum, or tympanic membrane, separates the
body’s major sense organs. They are considered outer ear from the middle ear.
part of the central nervous system because they
receive impulses from the environment. They
relay these impulses to the nerves.
The eye, which is about an inch in diameter, is
located in a bony socket in the skull. The bony
socket protects the eye, which is surrounded by
muscles that control its movements (Fig. 9-7).

Fig. 9-8. The outer ear, middle ear, and inner ear are the
three main divisions of the ear.

The middle ear consists of the eustachian tube

and three ossicles, small bones that amplify
sound. The ossicles transmit sound to the inner
ear. The eustachian tube connects the middle
ear to the throat. It functions to allow air into
the middle ear to equalize pressure on the tym-
Fig. 9-7. The parts of the eye. panic membrane. The inner ear contains fluid
that carries sound waves from the middle ear
The outer part of the eye is called the sclera. The to the auditory nerve. The auditory nerve then
sclera appears white, except in front, where it is transmits the impulse to the brain. The inner
called the cornea. The cornea is actually clear, ear also contains structures that help in main-
but it appears colored because it lies over the taining balance.
 9 134

Normal changes of aging include the following: and nutrients. Waste products of cell metabolism
are not removed, and organs become diseased.
• Vision and hearing decreases. Sense of bal-
ance may be affected.
The Healthy Human Body

• Senses of taste, smell, and touch decrease.

• Sensitivity to heat and cold decreases.

How You Can Help: NA’s Role

Encourage the use of eyeglasses and keep them

clean. Bright colors and good lighting will also help.
Encourage the use of hearing aids and keep them
clean. Face the resident when speaking. Speak slowly
and clearly in a low-pitched voice; do not shout. Re-
peat words when necessary. Loss of senses of taste
and smell may lead to decreased appetite. Encourage
good oral care. Foods with a variety of tastes and
textures should be provided. Loss of smell may make
resident unaware of increased body odor. Assist as
needed with regular bathing. Due to decreased sense
of touch, be careful with hot drinks and hot bath
water. Residents may not be able to tell if something
is too hot for them.

Observing and Reporting:

Eyes and Ears
Fig. 9-9. The heart, blood vessels, and blood are the main
Observe and report the following signs and parts of the cardiovascular system.
symptoms:
Changes in vision or hearing The cardiovascular system performs the follow-
ing major functions:
Signs of infection
• Supplies food, oxygen, and hormones to cells
Dizziness
• Produces and supplies antibodies and other
Complaints of pain in eyes or ears
infection-fighting blood cells
• Removes waste products from cells
5. Describe the cardiovascular system
• Controls body temperature
The cardiovascular, or circulatory, system is
Blood contains blood cells and plasma. Plasma
made up of the heart, blood vessels, and blood
is the liquid portion of the blood. It carries many
(Fig. 9-9). The heart pumps blood through the
substances, including blood cells, nutrients, and
blood vessels to the cells. The blood carries food,
waste products. Analyzing these parts of blood
oxygen, and other substances cells need to func-
samples can help identify illness and infection:
tion properly. A healthy cardiovascular system is
essential for life. Cells, tissues, and organs need • Red blood cells carry oxygen from the lungs
good circulation to function well. If circulation to all parts of the body. Red blood cells are
is reduced, cells do not receive enough oxygen produced by bone marrow, a substance
 135 9

found inside hollow bones. Iron, found in the left atrium and right atrium. They receive
bone marrow and red blood cells, is essential blood. The two lower chambers, or ventricles,
to blood. It gives it its red color. Red blood pump blood. The right atrium receives blood
cells function for a short time, then die. from the veins. This blood, containing carbon

The Healthy Human Body

They are filtered out of the blood by the liver dioxide, then flows into the right ventricle. It is
and spleen. Iron in diets allows bodies to pumped to the blood vessels in the lungs. Car-
produce new red blood cells. bon dioxide is exchanged for oxygen. The heart’s
left atrium receives the oxygen-saturated blood.
• White blood cells defend the body against
It then flows into the left ventricle. There it is
foreign substances, such as bacteria and
pumped through the arteries to all parts of the
viruses. When the body becomes aware of
body. Two valves, one located between the right
these invaders, white blood cells rush to the
atrium and right ventricle and the other between
site of infection. They multiply rapidly. The
the left atrium and left ventricle, allow the blood
bone marrow, spleen, and thymus gland pro-
to flow in only one direction (Fig. 9-11).
duce white blood cells.
• Platelets are also carried by the blood. They
cause the blood to clot, preventing excess
bleeding. Platelets are also produced by the
bone marrow.
The heart is the pump of the circulatory system
(Fig. 9-10). The heart is a muscle. It is located
in the middle lower chest, on the left side. The
heart muscle is made up of three layers: the peri-
cardium, the myocardium and the endocardium.

Fig. 9-11. The flow of blood through the heart.

The heart functions in two phases: the contract-

ing phase or systole, when the ventricles pump
blood through the blood vessels and the resting
phase, or diastole, when the chambers fill with
blood. When a person’s blood pressure is taken,
the numbers measure these two phases. See
Chapter 14 for more information on how to take
Fig. 9-10. The four chambers of the heart connect to the
body’s largest blood vessels. blood pressure.
Three types of blood vessels are found in the
The interior of the heart is divided into four body: arteries, capillaries, and veins. Arteries
chambers. The two upper chambers are called carry oxygen-rich blood away from the heart.
 9 136

The blood is pumped from the left ventricle, Swelling of hands and feet
through the aorta, the largest artery. Blood is
Pale or bluish hands, feet, or lips
then pumped through other arteries that branch
off from it. The coronary arteries carry blood to Chest pain
The Healthy Human Body

the heart itself. Weight gain

Capillaries are tiny blood vessels that receive Shortness of breath, changes in breathing
blood from the arteries. Nutrients, oxygen, and patterns, inability to catch breath
other substances in the blood pass from the
capillaries to the cells. Waste products, includ- Severe headache
ing carbon dioxide, pass from the cells into the Inactivity (which can lead to cardiovascular
capillaries. problems)
Veins carry the blood containing waste prod-
ucts from the capillaries back to the heart. Near 6. Describe the respiratory system
the heart, the veins come together to form the
two largest veins, the inferior vena cava and the Respiration, the body taking in oxygen and
superior vena cava. These empty into the right removing carbon dioxide, involves breathing in,
atrium. The inferior vena cava carries blood inspiration, and breathing out, expiration. The
from the legs and trunk. The superior vena cava lungs accomplish this process (Fig. 9-12). The
carries blood from the arms, head, and neck. functions of the respiratory system are to bring
oxygen into the body and to eliminate carbon di-
Normal changes of aging include the following:
oxide produced as the body uses oxygen.
• Heart pumps less efficiently.
• Blood flow decreases.
• Blood vessels narrow.

How You Can Help: NA’s Role

Encourage movement and exercise. Walking, stretch-

ing, and even lifting light weights can help older peo-
ple maintain strength and mobility. Range of motion
exercises are important for residents who cannot get
out of bed. Allow enough time to complete activities.
Prevent residents from tiring. Layer clothing to keep
residents warm. Use socks, slippers, or shoes to
keep the feet warm.
Fig. 9-12. The respiratory process begins with inspiration
through the nose or mouth. The air travels through the
Observing and Reporting: trachea and into the lungs via the bronchi, which then
Cardiovascular System branch into bronchioles.

Observe and report the following signs and As the lungs inhale, the air is pulled in through
symptoms: the nose and into the pharynx, a tubular pas-
sageway for both food and air. From the phar-
Changes in pulse rate
ynx, air passes into the larynx, or voice box. The
Weakness, fatigue larynx is located at the beginning of the tra-
Loss of ability to perform activities of daily chea, or windpipe. The trachea divides into two
living (ADLs) branches at its lower portion, the right bronchus
 137 9

and the left bronchus, or bronchi. Each bronchus Shallow breathing or breathing through
leads into a lung and then subdivides into bron- pursed lips
chioles. These smaller airways subdivide fur- Coughing or wheezing
ther. They end in alveoli: tiny, one-cell sacs that

The Healthy Human Body

Nasal congestion or discharge
appear in grape-like clusters. Blood is supplied
to the alveoli by capillaries. Oxygen and carbon Sore throat, difficulty swallowing, or swollen
dioxide are exchanged between the alveoli and tonsils
capillaries. The need to sit after mild exertion
Oxygen-saturated blood then circulates through Pale, bluish, or gray color of the lips and
the capillaries and venules (small veins) of the arms and legs
lung, into the pulmonary vein and left side of
Pain in the chest area
the heart. The carbon dioxide is exhaled through
the alveoli into the bronchioles and bronchi of Discolored sputum, or the fluid a person
the lungs, the trachea, through the larynx, the coughs up from the lungs (green, yellow,
pharynx, and out the nose and mouth. blood-tinged, or gray)
Each lung is covered by the pleura, a membrane
with two layers. One is attached to the chest 7. Describe the urinary system
wall. One is attached to the surface of the lung. The urinary system is composed of two kidneys,
The space between the layers is filled with a thin two ureters, one urinary bladder, and a single
fluid that lubricates the layers, preventing them urethra. The urinary system has two important
from rubbing together during breathing. functions. Through urine, the urinary system
Normal changes of aging include the following: eliminates waste products created by the cells.
The urinary system also maintains the water
• Lung strength decreases.
balance in the body.
• Lung capacity decreases.
The kidneys are located in the upper part of
• Oxygen in the blood decreases. the abdominal cavity on each side of the spine.
• Voice weakens. These two bean-shaped organs are protected by
the muscles of the back and the lower part of the
How You Can Help: NA’s Role rib cage. When blood flows through the kidneys,
waste products and excess water are filtered out.
Provide rest periods as needed. Encourage exercise
and regular movement. Encourage and assist with
Necessary water and substances are reabsorbed
deep breathing exercises, as ordered. Make sure into the bloodstream. Waste and the remain-
people with acute or chronic upper respiratory condi- ing fluid form urine. The body must maintain
tions are not exposed to cigarette smoke or polluted a proper balance between water absorbed in the
air. People who have difficulty breathing will usually
be more comfortable sitting up than lying down.
body and waste fluids that are released from the
body. You will learn more about fluid intake and
output in Chapter 15.
Observing and Reporting: Each kidney has a ureter, which is attached to
Respiratory System the bladder. Urine flows through the ureters to
the bladder, a muscular sac in the lower part
Observe and report the following signs and of the abdomen. Urine flows from the bladder
symptoms: through the urethra. It then passes out of the
Change in respiratory rate body through the meatus, the opening at the
 9 138

end of the urethra (Figs. 9-13 and 9-14). In the

How You Can Help: NA’s Role
female, the meatus is located in the genital area
just in front of the opening of the vagina. In Encourage residents to drink plenty of fluids. Offer
the male, the meatus is located at the end of the frequent trips to the bathroom. If residents are
The Healthy Human Body

incontinent, do not show frustration or anger. Uri-

penis. nary incontinence is the inability to control the
bladder, which leads to an involuntary loss of urine.
Keep residents clean and dry.

Observing and Reporting:

Urinary System

Observe and report the following signs and

symptoms:
Weight loss or gain
Swelling in the upper or lower extremities
Fig. 9-13. The urinary system consists of two kidneys and
their ureters, the bladder, the urethra, and the meatus. Pain or burning during urination
This is an illustration of the male urinary system.
Changes in urine, such as cloudiness, odor,
or color
Changes in frequency and amount of urina-
tion
Swelling in the abdominal/bladder area
Complaints that bladder feels full or painful
Urinary incontinence/dribbling
Pain in the kidney or back/flank region
Inadequate fluid intake

Fig. 9-14. The female urethra is shorter than the male

urethra. Because of this, the female bladder is more likely 8. Describe the gastrointestinal system
to become infected by bacteria traveling up the urethra.
The gastrointestinal (GI) system, also called the
Normal changes of aging include the following: digestive system, is made up of the gastrointes-
tinal tract and the accessory digestive organs
• The ability of kidneys to filter blood
(Fig. 9-15). The gastrointestinal system has two
decreases.
functions: digestion and elimination. Digestion
• Bladder muscle tone weakens. is the process of preparing food physically and
chemically so that it can be absorbed into the
• Bladder holds less urine, which causes more
cells. Elimination is the process of expelling
frequent urination.
solid wastes made up of the waste products of
• Bladder may not empty completely, causing food that are not absorbed into the cells.
more chance of infection.
 139 9

churning the food to break it down into smaller

particles. The glands in the stomach lining aid
in digestion. They secrete gastric juices that
chemically break down food. This process turns

The Healthy Human Body

food into a semi-liquid substance called chyme.
Peristalsis continues in the stomach, pushing
the chyme into the small intestine.
The small intestine is about twenty feet long.
Here enzymes secreted by the liver and the pan-
creas finish digesting the chyme. Bile, a green
liquid produced by the liver, is stored in the
gallbladder and released into the small intestine.
Bile helps break down dietary fat. The liver con-
verts fats and sugars into glucose, a sugar that
can be carried to cells by the blood. The liver
also stores glucose. The pancreas produces insu-
Fig. 9-15. The GI system consists of all the organs needed
lin, an enzyme that regulates the body’s conver-
to digest food and process waste.
sion of sugar into glucose.
The gastrointestinal tract is a long passageway The chyme is moved by peristalsis through the
extending from the mouth to the anus, the small intestine. There villi, tiny projections lin-
opening of the rectum. Food passes from the ing the small intestine, absorb the digested food
mouth through the pharynx, esophagus, stom- into the capillaries.
ach, small intestine, large intestine, and out of
Peristalsis moves the chyme that has not been
the body as solid waste. The teeth, tongue, sali-
digested through the large intestine. In the
vary glands, liver, gall bladder, and pancreas are
large intestine most of the water in the chyme
the accessory organs to digestion. They help pre-
is absorbed. What remains is feces, a semi-solid
pare the food so that it can be absorbed.
material of water, solid waste material, bacteria,
Food is first placed in the mouth. The teeth and mucus. Feces passes by peristalsis through
chew it by cutting it, then chopping and grind- the rectum, the lower end of the colon. It moves
ing it into smaller pieces that can be swallowed. out of the body through the anus, the rectal
Saliva moistens the food and begins chemical opening.
digestion. The tongue helps with chewing and
swallowing by pushing the food around between Normal changes of aging include the following:
the teeth and then into the pharynx. • Decreased saliva production affects the abil-
The pharynx is a muscular structure located at ity to chew and swallow.
the back of the mouth. It extends into the throat. • Absorption of vitamins and minerals
It contracts with swallowing and pushes food decreases.
into the esophagus. The muscles of the esopha-
• Process of digestion takes longer and is less
gus then move food into the stomach through
efficient.
involuntary contractions called peristalsis.
• Body waste moves more slowly through
The stomach is a muscular pouch located in
the intestines, causing more frequent
the upper left part of the abdominal cavity.
constipation.
It provides physical digestion by stirring and
 9 140

cals that regulate essential body processes (Fig.

How You Can Help: NA’s Role
9-16). They are carried in the blood to the vari-
Encourage fluids and nutritious, appealing meals. ous organs, where they perform the following
Allow time to eat. Make mealtime enjoyable. Provide functions:
The Healthy Human Body

good oral care. Make sure dentures fit properly and

are cleaned regularly. Residents who have trouble • Maintaining homeostasis
chewing and swallowing are at risk of choking. Pro-
vide plenty of fluids with meals. Residents should eat • Influencing growth and development
a diet that contains fiber and drink plenty of fluids
to help prevent constipation. Encourage daily bowel • Regulating levels of sugar in the blood
movements. Give residents the opportunity to have a • Regulating levels of calcium in the bones
bowel movement around the same time each day.
• Regulating the body’s ability to reproduce
• Determining how fast cells burn food for
Observing and Reporting:
energy
Gastrointestinal System

Observe and report the following signs and

symptoms:
Difficulty swallowing or chewing (includ-
ing denture problems, tooth pain, or mouth
sores)
Fecal/anal incontinence (inability to control
the bowels, leading to involuntary passage of
stool)
Weight gain/weight loss
Anorexia (loss of appetite)
Abdominal pain and cramping
Diarrhea
Nausea and vomiting (especially vomitus
that looks like coffee grounds) Fig. 9-16. The endocrine system includes organs that pro-
duce hormones that regulate body processes.
Constipation
Flatulence The pituitary gland is located behind the eyes
at the base of the brain. It is called the “master”
Hiccups, belching
gland. It secretes key hormones that cause other
Abnormally-colored stool (bloody, black, or glands to produce other hormones. Some hor-
hard) mones secreted by the pituitary gland are:
Heartburn
• Growth hormone, which regulates growth
Poor nutritional intake and development
• Antidiuretic hormone (ADH), which con-
9. Describe the endocrine system trols the balance of fluids in the body
The endocrine system is made up of glands • Oxytocin, which causes the uterus to con-
that secrete hormones. Hormones are chemi- tract during and after childbirth
 141 9

The pituitary gland also produces hormones

Observing and Reporting:
that regulate the thyroid gland and the adrenal
Endocrine System
glands. The thyroid gland is located in the neck
in front of the larynx. It produces thyroid hor-

The Healthy Human Body

Observe and report the following signs and
mone, which regulates metabolism, the burning symptoms:
of food for heat and energy.
Headache*
The parathyroid glands secrete a hormone that
Weakness*
regulates the body’s use of calcium. Nerves and
muscles require calcium to function smoothly. Blurred vision*
A deficiency of this hormone can cause severe Dizziness*
muscle contractions and spasms. It can be fatal Hunger*
if untreated.
Irritability*
The pancreas, a gland located in the upper mid-
Sweating/excessive perspiration*
section of the abdomen, secretes insulin. Insulin
is a hormone that regulates the amount of sugar Change in “normal” behavior*
(glucose) available to the cells for metabolism. Confusion*
The cells cannot absorb sugar without insulin.
Weight gain/weight loss
Two adrenal glands are located at the tops of the
Loss of appetite/increased appetite
kidneys. They produce hormones that are es-
sential to life. These hormones are important be- Increased thirst
cause they help the body regulate carbohydrate Frequent urination
metabolism. They also control the body’s reac- Dry skin
tion to stress and regulate salt and water absorp-
Sluggishness or fatigue
tion in the kidneys. Adrenal glands also produce
the hormone adrenaline. It regulates muscle Hyperactivity
power, heart rate, blood pressure, and energy lev- * indicates signs and symptoms that should be
els during stressful situations or emergencies. reported immediately
Gonads, or sex glands, produce hormones that
regulate the body’s ability to reproduce. The tes- 10. Describe the reproductive system
tes in the male secrete testosterone. The ovaries
in the female secrete estrogen and progesterone. The reproductive system is made up of the re-
productive organs, which are different in men
Normal changes of aging include the following:
and women. The reproductive system allows
• Levels of hormones, such as estrogen and human beings to reproduce, or create new
progesterone, decrease. human life. Reproduction begins when a male’s
• Insulin production lessens. and female’s sex cells (sperm and ovum) join.
These sex cells are formed in the male and fe-
• Body is less able to handle stress. male sex glands. These sex glands are called the
gonads.
How You Can Help: NA’s Role

Encourage proper nutrition. Try to eliminate or re- The Male Reproductive System
duce stressors. Stressors are anything that causes In the male, the sex glands or gonads are the
stress. Offer encouragement and listen to residents.
testes or testicles. The two oval glands are lo-
 9 142

cated outside the body in the scrotum. The becomes filled with blood during sexual excite-
scrotum is a sac made of skin and muscle and ment. As the penis fills with blood, it becomes
it is suspended between the thighs. The testes enlarged and erect. It then can enter the vagina,
produce the male sex cells, called sperm, and the female reproductive tract, where it releases
The Healthy Human Body

testosterone (Fig. 9-17). Testosterone is the male semen containing sperm.

hormone needed for the reproductive organs to
function properly. Testosterone also promotes The Female Reproductive System
development of male secondary sex characteris-
In the human female, the gonads are two oval
tics, which include:
glands called the ovaries. There are two ovaries,
• Facial hair one on each side of the uterus (Fig. 9-18). The
• Pubic and underarm hair ovaries make the female sex cells or eggs (ova).
They release the female hormones, estrogen
• Hair on the chest, legs, and arms and progesterone. Each month from puberty to
• Deepening of the voice menopause, an egg is released from an ovary.
This cycle is maintained by estrogen and pro-
• Development of muscle mass
gesterone. These hormones control development
of female secondary sex characteristics, which
include:
• Increased breast size
• Wider and rounder hips
• Axillary and pubic hair
• A slightly deeper voice

Fig. 9-17. The male reproductive system.

Sperm travel from the testes through a coiled

tube, the epididymis, and another tube called
the vas deferens. Sperm then pass into the semi-
nal vesicle where semen is produced. Semen car-
Fig. 9-18. The female reproductive system.
ries sperm out of the body.
The ducts coming from each seminal vesicle Once an egg is released from an ovary, it travels
unite to form the ejaculatory ducts. They pass through the fallopian tube to the uterus. The
through the prostate gland, where more fluid is uterus is a hollow, pear-shaped, muscular organ
added to the semen. In the prostate, the ejacula- that is located within the pelvis. It lies behind
tory ducts join the urethra, the tube through the bladder and in front of the rectum. If sexual
which both urine and semen pass. The urethra intercourse takes place while the egg is in the
continues through the penis, the sex organ lo- fallopian tube, the egg may be fertilized by
cated outside the body, in front of the scrotum. sperm in the fallopian tube. The fertilized egg
The penis is composed of erectile tissue that then travels down into the uterus. It implants in
 143 9

the endometrium, the lining of the uterus. Stim-

fun of or judge any sexual behavior. Do report any
ulated by hormones, the endometrium builds up behavior that makes you uncomfortable or seems in-
during the menstrual cycle. It has many blood appropriate. Inappropriate behavior is not a normal
vessels supplying it for the growth and feeding sign of aging, and could be a sign of illness.

The Healthy Human Body

of an embryo. If the egg is not fertilized, the
hormones decrease. The blood supply to the en-
Observing and Reporting:
dometrium decreases. The endometrium then
Reproductive System
breaks up in a process called menstruation.
The main section of the uterus is the fundus. Observe and report the following signs and
This is where a baby develops after the fertilized symptoms:
egg is implanted. The narrow neck of the uterus Discomfort or difficulty with urination
extending into the vagina is the cervix. The cer-
Discharge from the penis or vagina
vix has an opening through which menstrual
fluid can pass and semen can enter the vagina. Swelling of the genitals
The vagina is the muscular canal that opens to Changes in menstruation
the outside of the body. The external vaginal
Blood in urine or stool
opening is partially closed by the hymen mem-
brane. The vagina is kept moist by secretions Breast changes, including size, shape, lumps,
from glands in the vaginal walls. The vagina or discharge from the nipple
receives the penis during sexual intercourse. It Sores on the genitals
also serves as the birth canal. The baby passes Resident reports of impotence, or inability of
through the cervix, which is made thin by pres- male to have sexual intercourse
sure from the baby’s head during contractions.
Resident reports of painful intercourse
Once the cervix opens, the baby can then move
out through the vagina.
Residents’ Rights
Normal changes of aging include the following: Sexual Expression and Privacy
Female Residents have the right to sexual freedom and ex-
pression. Residents have the right to privacy and to
• Menstruation ends. Menopause is when a meet their sexual needs.
female stops having menstrual periods.
• Decrease in estrogen may lead to a loss of
11. Describe the immune and lymphatic
calcium. This can cause brittle bones and,
systems
potentially, osteoporosis.
• Vaginal walls become drier and thinner. The immune system protects the body from
disease-causing bacteria, viruses, and organisms
Male
in two ways. Nonspecific immunity protects
• Sperm production decreases. the body from disease in general. Specific im-
• Prostate gland enlarges. munity protects against a particular disease that
is invading the body at a given time.
How You Can Help: NA’s Role
Nonspecific Immunity
Sexual needs and desires continue as people age.
Provide privacy when necessary for sexual activity. To protect itself against disease in general, the
Respect your residents’ sexual needs. Never make body has several defenses:
 9 144

• Anatomic barriers include the skin and the 2. You get a vaccine for the measles. This
mucous membranes. They provide a physi- causes your body to produce the same anti-
cal barrier to keep foreign materials—bac- bodies to protect you from the disease.
teria, viruses, or organisms—from invading
The Healthy Human Body

The lymphatic system removes excess fluids

the body. Saliva, tears, and mucous secre-
and waste products from the body’s tissues. It
tions also help protect the body by washing
also helps the immune system fight infection.
away substances.
It is closely related to both the immune and the
• Physiologic barriers include body tempera- circulatory systems (Fig. 9-19). The lymphatic
ture and acidity of certain organs. Most or- system consists of lymph vessels and lymph cap-
ganisms that cause disease cannot survive illaries in which a fluid called lymph circulates.
high temperatures or high acidity. When the Lymph is a clear yellowish fluid that carries
body senses foreign organisms, it can raise disease-fighting cells called lymphocytes.
its temperature (by running a fever) to kill
off the invaders. The acidity of organs like
the stomach keeps harmful bacteria from
growing there.
• Inflammatory response refers to the body’s
ability to fight infection by inflammation or
swelling of an infected area. When inflam-
mation occurs, it indicates that the body
has sent extra disease-fighting cells and
extra blood to the infected area to fight the
infection.

Specific Immunity
To protect itself against specific diseases, the
body makes different types of cells that will
fight a range of different invaders. Once it has Fig. 9-19. Lymph nodes are located throughout the body.
successfully eliminated an invader, the immune
system records the invasion in the form of anti- When the body is fighting an infection, swelling
bodies. Antibodies are carried within cells. They may occur in the lymph nodes. These are oval-
prevent a disease from threatening the body a shaped bodies that can be as small as a pinhead
second time. or as large as an almond. Located in the neck,
groin, and armpits, the lymph nodes filter out
Acquired immunity is a kind of specific immu-
germs and waste products carried from the tis-
nity. The body acquires it either by fighting an
sues by the lymph fluid. After lymph fluid has
infection or by vaccination. For example, you can
been purified in the lymph nodes, it flows into
acquire immunity to a disease like the measles
the bloodstream.
in two ways:
Unlike the circulatory system, in which the
1. You get the measles. Your body forms anti-
heart functions as a pump to move the blood,
bodies to the disease to make sure you will
the lymph system has no pump. Lymph fluid
not get it again; or
is circulated by muscle activity, massage, and
 145 9

breathing. A sore muscle may feel better if you 7. What are two functions of the nervous
rub it. The rubbing action helps the lymph fluid system?
circulate, carrying waste products away from the
8. List ten signs and symptoms to observe and
tired muscle.

The Healthy Human Body

report about the central nervous system.
Normal changes of aging include the following:
9. List three signs and symptoms to observe
• Immune system weakens, increasing the and report about the eyes and ears.
risk of all types of infections
10. What are four functions of the cardiovascu-
• Decreased response to vaccines lar system?
11. List seven signs and symptoms to observe
How You Can Help: NA’s Role
and report about the cardiovascular system.
Follow rules for preventing infection. Wash hands
12. What does “respiration” mean? What are the
often. Keep the resident’s environment clean to
prevent infection. Encourage and help with good per- two parts involved in respiration?
sonal hygiene. Encourage proper nutrition and fluid
13. List seven signs and symptoms to observe
intake to help residents stay healthy. A slight temper-
ature increase may indicate that a person is fighting and report about the respiratory system.
an infection. Take accurate vital sign measurements.
14. What are two functions of the urinary
system?
Observing and Reporting: 15. List seven signs and symptoms to observe
Immune and Lymphatic Systems and report about the urinary system.
16. What does digestion mean? What does elim-
Observe and report these signs and symptoms:
ination mean?
Recurring infections (such as fevers and
17. List nine signs and symptoms to observe
diarrhea)
and report about the gastrointestinal system.
Swelling of the lymph nodes
18. List eight signs and symptoms to observe
Increased fatigue and report immediately about the endocrine
system.
Chapter Review 19. What is the function of the reproductive
system?
1. What is homeostasis?
20. List seven signs and symptoms to observe
2. What are three functions of the skin, or
and report about the reproductive system.
integument?
21. What is nonspecific immunity? What is spe-
3. List ten signs and symptoms to observe and
cific immunity?
report about the integumentary system.
22. What is the function of the lymphatic
4. How many bones make up the skeleton of
system?
the human body?
23. List three signs and symptoms to observe
5. What type of exercises can help prevent con-
and report about the immune and lymphatic
tractures and muscle atrophy?
systems.
6. List five signs and symptoms to observe and
report about the musculoskeletal system.
10 146

10
Positioning, Lifting, and Moving

Positioning, Lifting, and Moving

1. Review the principles of body to increase support. Keep this stance when
mechanics walking. Make sure you and your resident are
wearing non-skid shoes.
This chapter deals with moving and position-
G Face what you are lifting. Your feet should
ing residents. It is important to always use good
always face the direction you are moving. Do
body mechanics when assisting with moving
not twist; twisting at the waist increases the
or positioning. This helps prevent injury and
likelihood of injury. Twisting should always be
protects both you and your residents. You first
avoided. Turn and face the area you are mov-
learned about body mechanics in Chapter 6. The
ing the object to, then set the object down.
following guidelines will help you review what
you have learned to remember to use good body G Keep your back straight, your head up, and
mechanics: your shoulders back. This will keep the back
in the proper position. Take a deep breath to
help you regain correct posture.
Guidelines:
Proper Body Mechanics G Begin in a squatting position. Bend at the
hips and knees. Use the strength of your leg
G Assess the load. Before lifting, assess the muscles to stand and lift the object. You will
weight of the load. Determine if you can safe- need to push your buttocks out to do this.
ly move the object without help. Know the lift Before you stand with the object you are lift-
policies at your facility. Never attempt to lift ing, remember that your legs, not your back,
someone you are not sure you can lift. will enable you to lift. You should be able to
feel your leg muscles working. Lifting with
G Think ahead, plan, and communicate the
the large leg muscles decreases stress on
move. Check for any objects in your path.
your back.
Look for any potential risks, such as a wet
floor. Make sure the path is clear. Watch for G Tighten your stomach muscles when begin-
hazards, such as high-traffic areas, combative ning the lift. This will help to take weight off
residents, or loose toilet seats or hand rails. the spine and maintain alignment.
Decide exactly what you and the resident are G Keep the object close to your body. This
going to do together. Agree on the verbal decreases stress to your back. Lift objects
cues you will use before attempting to to your waist. Carrying them any higher can
transfer. affect your balance.
G Check your base of support. Be sure you have G Push or pull when possible rather than lifting.
firm footing. Use a wide but balanced stance When you lift an object, you must overcome
 147 10

gravity to balance the load. Try to push or right to know exactly what care you will pro-
pull the object instead. Then you only need vide. Doing this also promotes understanding,
to overcome the friction between the sur- cooperation, and independence. Encouraging
face and the object. Use your body weight residents’ independence is important. Residents

Positioning, Lifting, and Moving

to move the object, not your lifting muscles. are more able to do things for themselves if they
Push rather than pull whenever possible. Stay know what needs to happen.
close to the object.
Provide for the resident’s privacy with curtain,
screen, or door. Doing this maintains residents’
2. Explain beginning and ending steps in rights to privacy and dignity. Providing for pri-
care procedures vacy is not simply a courtesy; it is a legal right.
If the bed is adjustable, adjust bed to a safe level,
Within most care procedures, there are begin-
usually waist high. If the bed is movable, lock
ning and ending steps that need to be repeated.
bed wheels. This prevents injury to you and to
Understanding why each step is important will
residents. Locking bed wheels is an important
help you remember to perform it every time care
safety measure. It ensures that the bed will not
is provided.
move as you are performing care.
Beginning Steps
Ending Steps
Wash your hands. Handwashing provides for
Make resident comfortable. Make sure sheets
infection control. Nothing fights infection like
are free from wrinkles and the bed free from
consistent, proper handwashing.
crumbs. Sheets that are damp, wrinkled, or
Identify yourself by name. Identify the resident bunched up are uncomfortable. They may pre-
by name. Residents have the right to know the vent the resident from resting or sleeping well.
identity of their caregivers. Addressing residents Sheets that do not lie flat under the resident’s
by name shows respect (Fig. 10-1). It also estab- body increase the risk of pressure sores because
lishes correct identification. This prevents care they cut off circulation. Other comfort measures
from being performed on the wrong person. include replacing bedding and pillows.
Return bed to lowest position. Remove privacy
measures. Lowering the bed provides for resi-
dents’ safety. Remove any extra privacy mea-
sures added during the procedure. This includes
anything you may have draped over and around
residents, as well as privacy screens.
Before leaving, place call light within resident’s
reach. A call light allows residents to commu-
nicate with staff as necessary. Remember that
the decision not to respond to a call light is con-
Fig. 10-1. Addressing resident by name shows respect and
establishes correct identification. This must be done each
sidered neglect. Unless residents are on fluid
time before care is performed. restrictions, provide fresh water before leaving
the room. Keeping beverages close by encour-
Explain procedure to the resident. Speak clearly, ages residents to drink more often. Make sure
slowly, and directly. Maintain face-to-face con- that the pitcher and cup are light enough for
tact whenever possible. Residents have a legal residents to lift.
10 148

Wash your hands. Again, handwashing is the (Fig. 10-2). You may also use pillows, rolled tow-
most important thing you can to do to prevent els, or washcloths to support his arms (especially
the spread of infection. Always wash your hands a weak or immobilized arm) or hands. The heels
after removing gloves and other PPE. should be “floating.” This means you must place
Positioning, Lifting, and Moving

Report any changes in resident to the nurse. a firm pillow under the calves so the heels do
Reporting promptly and accurately provides the not touch the bed. Pillows or a footboard can be
nurse with information to assess resident. Care used to keep the feet flexed.
plans are made based on your reports.
Document procedure using facility guidelines.
What you write is a legal record of what you
did. If you do not document it, legally it did not
happen.
Fig. 10-2. A person in the supine position is lying flat on
his or her back.
3. Explain positioning and describe how
to safely position residents 2. A resident in the lateral position is lying on
either side. There are many variations in this
Residents who spend a lot of time in bed often position. Pillows can be used to support the arm
need help getting into comfortable positions. and leg on the upper side, the back, and the
They also need to change positions periodically head (Fig. 10-3). Ideally, the knee on the upper
to avoid muscle stiffness and skin breakdown side of the body should be flexed. The leg is
or pressure sores. Too much pressure on one brought in front of the body and supported on a
area for too long can cause a decrease in circula- pillow. There should be a pillow under the bot-
tion, which can lead to the formation of pressure tom foot so that the toes are not touching the
sores, a serious condition. You will learn much bed. If the top leg cannot be brought forward, it
more about pressure sores and prevention guide- rests on the bottom leg. Pillows should be used
lines in Chapter 13. between the two legs. This relieves pressure and
Positioning means helping residents into posi- helps to avoid skin breakdown.
tions that will be comfortable and healthy for
them. Bed-bound residents should be reposi-
tioned at least every two hours. Document the
position and time every time there is a change.
Which positions a resident uses will depend on
the diagnosis, the condition, and the resident’s Fig. 10-3. A person in the lateral position is lying on his
preference. The care plan will give specific or her side.
instructions. Always keep principles of body
mechanics and alignment in mind when posi- 3. A resident in the prone position is lying on
tioning residents. Also, check skin for whiteness the stomach, or front side of the body (Fig. 10-4).
or redness, especially around bony areas, each This is not comfortable for many people, espe-
time you reposition a resident. cially elderly people. Never leave a resident in a
prone position for very long. In this position, the
The following are tips for positioning residents
arms are either at the sides or raised above the
in the five basic body positions:
head. The head is turned to one side. A small
1. In the supine position, the resident lies flat pillow may be used under the head and under
on his back. To maintain correct body position, the legs. This keeps the feet from touching the
support the head and shoulders with a pillow bed.
 149 10

Helping a resident sit up using the arm lock

1. Wash your hands.

Positioning, Lifting, and Moving

2. Identify yourself by name. Identify the resi-
Fig. 10-4. A person lying in the prone position is lying on dent by name.
his or her stomach.
3. Explain procedure to the resident. Speak
clearly, slowly, and directly. Maintain face-to-
4. A resident in the Fowler’s position is in a
face contact whenever possible.
semi-sitting position (45 to 60 degrees). The
head and shoulders are elevated. The resident’s 4. Provide for the resident’s privacy with cur-
knees may be flexed and elevated using a pil- tain, screen, or door.
low or rolled blanket as a support (Fig. 10-5).
5. If the bed is adjustable, adjust bed to a safe
The feet may be flexed and supported using a
level, usually waist high. Lock bed wheels
footboard or other support. The spine should be
(Fig. 10-7).
straight. In a true Fowler’s position, the upper
body is raised halfway between sitting straight
up and lying flat. In a high Fowler’s position, the
head is raised 80 to 90 degrees. In a semi-Fowl-
er’s position, head is elevated 30 to 45 degrees.

Fig. 10-7. Always lock bed wheels if bed is movable before

positioning or transferring a resident.

6. Stand facing the head of the bed, with your

legs about 12 inches apart and your knees
bent. The foot that is further from the bed
Fig. 10-5. A person lying in the Fowler’s position is par- should be slightly ahead of the other foot
tially reclined. (Fig. 10-8).

5. The Sims’ position is a left side-lying position.

The lower arm is behind the back and the upper
knee is flexed and raised toward the chest, using
a pillow as support. There should be a pillow
under the bottom foot so that the toes are not
touching the bed (Fig. 10-6).

Fig. 10-6. A person in the Sims’ position is lying on his or

her left side with one leg drawn up. Fig. 10-8.
10 150

7. Place your arm under the resident’s armpit if you think it is not safe to move the resident
and grasp the resident’s shoulder. Have the by yourself. If a resident is unable to help you,
resident grasp your shoulder in the same use a draw sheet or turning sheet (Fig. 10-10).
manner. This hold is called the arm lock or A draw sheet is an extra sheet placed on top
Positioning, Lifting, and Moving

lock arm (Fig. 10-9). of the bottom sheet. It allows you to reposition
the resident without causing shearing. Shear-
ing is rubbing or friction that results from the
skin moving one way and the bone underneath
it remaining fixed or moving in the opposite
direction.

Fig. 10-9.

8. Reach under the resident’s head and place

your other hand on the resident’s far shoul-
der. Have the resident bend her knees. Bend
Fig. 10-10. A draw sheet is a special sheet (or a regular
your knees. bed sheet folded in half ) that is used to help move resi-
dents in bed without causing shearing on the skin.
9. At the count of three, rock yourself backward
and pull the resident to a sitting position.
Use pillows or a bed rest to support the resi- Moving a resident up in bed
dent in the sitting position.
For residents who can help you move them up in
10. Check the resident for dizziness or weakness.
bed, follow these steps:
11. Make resident comfortable. Make sure sheets
1. Wash your hands.
are free from wrinkles and the bed free from
crumbs. 2. Identify yourself by name. Identify the resi-
dent by name.
12. Return bed to lowest position. Remove pri-
vacy measures. 3. Explain procedure to the resident. Speak
clearly, slowly, and directly. Maintain face-to-
13. Place call light within resident’s reach.
face contact whenever possible.
14. Wash your hands.
4. Provide for the resident’s privacy with cur-
15. Report any changes in resident to the nurse. tain, screen, or door.

16. Document procedure using facility 5. If the bed is adjustable, adjust bed to a safe
guidelines. level, usually waist high. Lock bed wheels.

6. Lower the head of bed to make it flat. Re-

Helping a resident move up in bed helps prevent move the pillow from under the head and
skin irritation that can lead to pressure sores. place it standing upright against the head of
You can use a helper if one is available. Get help the bed.
 151 10

7. If the bed has side rails, raise the rail on the 14. Place call light within resident’s reach.
far side of the bed.
15. Wash your hands.
8. Stand by bed with your feet apart, facing the 16. Report any changes in resident to the nurse.

Positioning, Lifting, and Moving

resident.
17. Document procedure using facility
9. Place one arm under resident’s shoulder guidelines.
blades. Place the other arm under resident’s
thighs. Use good body mechanics. When the resident cannot assist and there is no
one else around to help you move her up in bed,
10. Ask resident to bend her knees, brace feet on follow these steps:
the mattress, and push her feet and hands
on the count of three (Fig. 10-11). 1. Follow steps 1 through 6 above.
2. Stand behind the head of the bed with your
11. On the count of three, shift your body weight,
feet shoulder-width apart and one foot
and help move resident while she pushes
slightly in front of the other.
with her feet. Always allow her to do all she
can for herself. 3. Roll and grasp the top edge of the draw
sheet.
12. Make resident comfortable and replace pil-
low under resident’s head. Make sure sheets 4. With your knees bent and your back straight,
are free from wrinkles and the bed free from rock your weight from the front foot to the
crumbs. back foot in one smooth motion (Fig. 10-12).

13. Return bed to lowest position. Remove pri-

vacy measures.

Fig. 10-12.

5. Make resident comfortable and replace pil-

low under resident’s head. Unroll the draw
sheet and leave it in place for the next
repositioning.
6. Return bed to lowest position. Remove pri-
vacy measures.
7. Place call light within resident’s reach.
8. Wash your hands.
9. Report any changes in resident to the nurse.
10. Document procedure using facility
Fig. 10-11. Keep your back straight and your knees bent. guidelines.
10 152

When you have help from another person, you 5. Make resident comfortable and replace pillow
can modify the procedure as follows: under the head. Unroll the draw sheet and
1. Follow steps 1 through 6 above. leave it in place for the next repositioning.
Positioning, Lifting, and Moving

2. Stand on the opposite side of the bed from 6. Return bed to lowest position. Remove pri-
your helper. Each of you should be turned vacy measures.
slightly toward the head of the bed. For each 7. Place call light within resident’s reach.
of you, the foot that is closest to the head of
the bed should be pointed in that direction. 8. Wash your hands.
Stand with your feet shoulder-width apart and 9. Report any changes in resident to the nurse.
bend your knees slightly.
10. Document procedure using facility
3. Roll the draw sheet up to the resident’s side, guidelines.
and have your helper do the same on his side
of the bed. Grasp the sheet with your palms
up, and have your helper do the same. Moving a resident to the side of the bed
4. Shift your weight to your back foot (the foot Equipment: draw sheet
closer to the foot of the bed) and have your
helper do the same (Fig. 10-13). On the 1. Wash your hands.
count of three, you and your helper both shift 2. Identify yourself by name. Identify the resi-
your weight to your forward feet as you slide dent by name.
the draw sheet toward the head of the bed
3. Explain procedure to the resident. Speak
(Fig. 10-14).
clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.
4. Provide for the resident’s privacy with cur-
tain, screen, or door.
5. If the bed is adjustable, adjust bed to a safe
level, usually waist high. Lock bed wheels.
6. Lower the head of bed.
7. Stand on the same side of the bed to where
you are moving the resident.
Fig. 10-13.
8. With a draw sheet: Roll the draw sheet up
to the resident’s side, and grasp the sheet
with your palms up. One hand should be
at the resident’s shoulders, the other about
level with the resident’s hips. Apply one knee
against the side of the bed, and lean back
with your body. On the count of three, slowly
pull the draw sheet and resident toward you.
Without a draw sheet: Gently slide your
hands under the head and shoulders and
Fig. 10-14. move toward you (Fig. 10-15). Gently slide
your hands under the midsection and move
 153 10

toward you. Gently slide your hands under Residents may be turned on their sides in prepa-
the hips and legs and move them toward you ration for sitting up or to change position and
(Fig. 10-16). take pressure off their backs. This helps prevent
skin irritation and pressure sores.

Positioning, Lifting, and Moving

Turning a resident

1. Wash your hands.

2. Identify yourself by name. Identify the resi-

dent by name.

3. Explain procedure to the resident. Speak

clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.

4. Provide for the resident’s privacy with cur-

tain, screen, or door.

5. If the bed is adjustable, adjust bed to a safe

Fig. 10-15. level, usually waist high. Lock bed wheels.

6. Lower the head of bed.

7. Stand on side of bed opposite to where resi-

dent will be turned. If the bed has side rails,
raise the far side rail. Lower side rail nearest
you if it is up.

8. Move resident to side of bed nearest you

using previous procedure.

9. Turning resident away from you:

a. Cross resident’s arm over his or her chest.

Fig. 10-16. Move arm on side resident is being turned to
out of the way. Cross the leg nearest you over
9. Make resident comfortable. Make sure sheets the far leg (Fig. 10-17).
are free from wrinkles and the bed free from
crumbs.

10. Return bed to lowest position. Remove pri-

vacy measures.

11. Place call light within resident’s reach.

12. Wash your hands.

13. Report any changes in resident to the nurse. Fig. 10-17.

14. Document procedure using facility

b. Stand with feet about 12 inches apart. Bend
guidelines.
your knees.
10 154

c. Place one hand on the resident’s shoulder. 10. Position the resident properly and comfort-
Place the other hand on the resident’s near- ably, in good alignment. Proper positioning
est hip. includes the following:
Positioning, Lifting, and Moving

d. Gently push the resident toward the other • head supported by pillow
side of the bed. Shift your weight from your
• shoulder adjusted so resident is not lying
back leg to your front leg (Fig. 10-18).
on arm

• top arm supported by pillow

• back supported by supportive device

• top knee flexed

• supportive device between legs with top

knee flexed; knee and ankle supported

11. Make resident comfortable. Make sure sheets

Fig. 10-18. are free from wrinkles and the bed free from
crumbs.
Turning resident toward you:
12. Return bed to lowest position. Remove pri-
a. Cross resident’s arm over his or her chest. vacy measures.
Move arm on side resident is being turned
to out of the way. Cross the leg furthest from 13. Place call light within resident’s reach.
you over the near leg. 14. Wash your hands.
b. Stand with feet about 12 inches apart. Bend 15. Report any changes in resident to the nurse.
your knees.
16. Document procedure using facility
c. Place one hand on the resident’s far shoul- guidelines.
der. Place the other hand on the far hip.

d. Gently roll the resident toward you (Fig. 10- Some residents’ spinal columns must be kept in
19). Your body will block resident and prevent alignment. To turn these residents in bed, you
her from rolling out of bed. will use a procedure called logrolling. Logroll-
ing means moving a resident as a unit, without
disturbing the alignment of the body. The head,
back, and legs must be kept in a straight line.
This is necessary in cases of neck or back prob-
lems, spinal cord injuries, or after back or hip
surgeries. It is safer for two people to perform
this procedure together. A draw sheet assists
with moving.

Logrolling a resident with one assistant

Equipment: draw sheet, co-worker

Fig. 10-19. 1. Wash your hands.
 155 10

2. Identify yourself by name. Identify the resi-

dent by name.

3. Explain procedure to the resident. Speak

Positioning, Lifting, and Moving

clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.

4. Provide for the resident’s privacy with cur-

tain, screen, or door.

5. If the bed is adjustable, adjust bed to a safe

level, usually waist high. Lock bed wheels.

6. Lower the head of bed to make it flat.

Fig. 10-21.
7. If the bed has side rails and they are raised,
lower the side rail on side closest to you. 13. Make resident comfortable. Make sure sheets
8. Both workers stand on the same side of the are free from wrinkles and the bed free from
bed. One person stands at the resident’s crumbs.
head and shoulders. The other stands near 14. Return bed to lowest position. Return side
the resident’s midsection. rails to ordered position. Remove privacy
9. Place the resident’s arms across his or her measures.
chest. Place a pillow between the knees. 15. Place call light within resident’s reach.
10. Stand with your feet about 12 inches apart. 16. Wash your hands.
Bend your knees.
17. Report any changes in resident to the nurse.
11. Grasp the draw sheet on the far side
(Fig. 10-20). 18. Document procedure using facility
guidelines.

Before a resident who has been lying down

moves to a standing position, she should dangle.
To dangle means to sit up with the feet over the
side of the bed for a moment to regain balance.
It gives the resident time to adjust to being in an
upright position after lying down. For some resi-
dents who are unable to walk, dangling the legs
for a few minutes may be ordered.

Assisting a resident to sit up on side of bed:

Fig. 10-20.
dangling
12. On the count of three, gently roll the resident 1. Wash your hands.
toward you. Turn the resident as a unit
(Fig. 10-21). 2. Identify yourself by name. Identify the resi-
dent by name.
10 156

3. Explain procedure to the resident. Speak

clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.
Positioning, Lifting, and Moving

4. Provide for the resident’s privacy with cur-

tain, screen, or door.

5. Adjust bed height to lowest position. Lock

bed wheels.

6. Fanfold (fold into pleats) the top covers to

the foot of the bed. Ask the resident to turn Fig. 10-23.
onto her side, facing you. Assist as needed
11. On the count of three, slowly turn resident
(a procedure earlier in this chapter describes
into sitting position with legs dangling over
how to help a resident turn over).
side of bed. The weight of the resident’s legs
7. Tell the resident to reach across her chest hanging down from the bed helps the resi-
with her top arm and place her hand on the dent sit up (Fig. 10-24).
edge of the bed near her opposite shoulder.
Ask her to push down on that hand to raise
her shoulders up while swinging her legs
over the side of the bed (Fig. 10-22).

Fig. 10-24.

12. Ask resident to hold onto the edge of mat-

tress with both hands. Assist resident to put
on non-skid shoes or slippers.

13. Have resident dangle as long as ordered. The

Fig. 10-22. care plan may direct you to allow the resi-
dent to dangle for several minutes and then
8. Always allow the resident to do all she can return her to lying down, or it may direct you
for herself. However, if the resident needs as- to allow the resident to dangle in preparation
sistance, raise the head of the bed to a sitting for walking or a transfer. Follow the instruc-
position. tions in the care plan. Do not leave the resi-
dent alone. If the resident is dizzy for more
9. Stand with your legs about 12 inches apart, than a minute, have her lie down again and
with one foot six to eight inches in front of report to the nurse.
the other. Bend your knees.
14. Take vital signs as ordered (you will learn
10. Place one arm under resident’s shoulder how to take vital signs in Chapter 14).
blades. Place the other arm under resident’s
thighs (Fig. 10-23). 15. Remove slippers or shoes.
 157 10

16. Gently assist resident back into bed. Place set strict guidelines for lifting and transferring
one arm around resident’s shoulders. Place of residents. Lift-free polices vary; facilities de-
the other under resident’s knees. Slowly cide how they want to address reducing lifting
swing resident’s legs onto bed. and transferring of residents. Some allow no

Positioning, Lifting, and Moving

17. Make resident comfortable. Make sure sheets lifting at all and require that mechanical equip-
are free from wrinkles and the bed free from ment be used on every resident who needs to be
crumbs. transferred.

18. Leave bed in lowest position. Remove privacy The more restrictions placed on lifting, the less
measures. chance there is of injury. The amount and type
of equipment available also factor into reduc-
19. Place call light within resident’s reach.
ing workplace injuries. This learning objective
20. Wash your hands. teaches procedures for manual lifting and trans-
21. Report any changes in resident to the nurse. ferring of residents. It is important for nursing
assistants to carefully follow facility policies on
22. Document procedure using facility
lifting and to use equipment properly. If you are
guidelines.
unsure how to use equipment, ask for help. Al-
ways get help when you need it.
Residents’ Rights
Moving, Lifting and Transferring A transfer belt is a safety device used to trans-
When moving, lifting, and transferring residents, fer residents who are weak, unsteady, or unco-
make sure they are not unnecessarily exposed. Keep ordinated. It is called a gait belt when used to
them properly covered, dressed, or draped to protect
their privacy and to promote dignity. Pull the privacy
help residents walk. The belt is made of canvas
curtain around the bed when moving residents in or other heavy material. It sometimes has han-
bed. dles and fits around the resident’s waist outside
the clothing. The transfer belt is a safety device
4. Describe how to safely transfer that gives you something firm to hold on to.
residents Transfer belts cannot be used if a resident has
fragile bones or recent fractures.
Transferring a resident means that you are mov-
ing him from one place to another. Transfers Residents’ Rights
can move a resident from a wheelchair to a bed Communicate!
or stretcher, from a bed to a chair, from a wheel- Any time you help residents transfer, talk to them
chair to a shower or toilet, and so on. about what you would like to do. Promote their in-
dependence by letting them do what they can. The
Safety is one of the most important things to two of you must work together, especially during
consider during transfers. In 2002, OSHA an- transfers.
nounced new ergonomic guidelines for trans-
fers. Ergonomics is the science of designing
equipment and work tasks to suit the worker’s Applying a transfer belt
abilities. OSHA now says that manual lifting 1. Wash your hands.
of residents should be reduced in all cases and
eliminated when possible. Manual lifting, trans- 2. Identify yourself by name. Identify the resi-
ferring, and repositioning of residents may in- dent by name.
crease risks of pain and injury. 3. Explain procedure to the resident. Speak
To that end, many facilities today have adopted clearly, slowly, and directly. Maintain face-to-
“zero-lift” or “lift-free” policies. These policies face contact whenever possible.
10 158

4. Provide for the resident’s privacy with cur-

tain, screen, or door.
5. Assist the resident to a sitting position.
Positioning, Lifting, and Moving

6. Place the belt over the resident’s clothing

and around the waist. Do not put it over bare
skin.
7. Tighten the buckle until it is snug. Leave
enough room to insert two fingers comfort-
ably into the belt.
8. Check to make sure that a female’s breasts
are not caught under the belt. Fig. 10-26. You must always lock the wheelchair before a
9. For comfort, place the buckle off-center in the resident gets into or out of it.
front or back.
G To unfold a standard wheelchair, tilt the chair
slightly to raise the wheels on the opposite
A slide or transfer board may be used to help side. Press down on one or both seat rails
transfer residents who are unable to bear weight until the chair opens and the seat is flat. To
on their legs. Slide boards can be used for al- fold a standard wheelchair, lift up under the
most any transfer that involves moving from one center edge of the seat.
sitting position to another. For example, slide
boards can be helpful for transfers from bed to G To remove an armrest, release the arm lock
chair or wheelchair to car (Fig. 10-25.) by the armrest, and lift the arm from the cen-
ter. To replace the armrest, simply reverse the
procedure.
G To move a footrest out of the way, press or
pull the release lever and swing the foot-
rest out towards the side of the wheelchair.
To remove the footrest, lift it off when it
is towards the side of the wheelchair (Fig.
10-27). To replace a footrest, simply put it
back in the side position, then swing it back
Fig. 10-25. A sliding board can help with bed-to-chair to the front position, where it should lock
transfers. into place.

Guidelines:
Wheelchairs

G Learn how each wheelchair works. Residents

may use manual (require human power to
move them) or electric wheelchairs. Know
how to apply and release the brake and how
to operate the armrests and footrests. Always
lock a wheelchair before helping a resident
into or out of it (Fig. 10-26). After a transfer, Fig. 10-27. To remove a footrest, swing the footrest to-
unlock the wheelchair. ward the side of the wheelchair and lift it off.
 159 10

G To transfer to or from a wheelchair, the

Falls
resident must use the side or areas of the
body that can bear weight to support and lift Remember the following tips if a resident starts to
fall during a transfer:
the side or areas that cannot bear weight.

Positioning, Lifting, and Moving

Residents who can bear no weight with their • Widen your stance. Bring the resident’s body
close to you to break the fall. Bend your knees
legs may use leg braces or an overhead tra- and support the resident as you lower her to the
peze to support themselves during transfers. floor. You may need to drop to the floor with the
resident to avoid injury to you or the resident.
G Before any transfer, make sure the resident is
• Do not try to reverse or stop a fall. You or the res-
wearing non-skid footwear which is securely
ident can be injured if you try to stop a fall rather
fastened. This promotes residents’ safety and than break the fall.
reduces the risk of falls. • Call for help. Do not try to get the resident up
G During wheelchair transfers make sure the after the fall.
resident is safe and comfortable. Ask the
resident how you can assist. Some may only Some residents have one-sided weakness due to
want you to bring the chair to the bedside. paralysis or stroke. When transferring these resi-
Others may want you to be more involved. dents, move their stronger side first. The weaker
Always be sure the chair is as close as pos- (also called “involved” or “affected”) side follows.
sible to the resident and is locked in place.
Transferring a resident from bed to wheelchair
Use a transfer belt if you are going to assist
with the transfer. Be sure the transfer is done Equipment: wheelchair, transfer belt, non-skid
slowly, allowing time for the resident to rest. footwear
Check the resident’s alignment in the chair 1. Wash your hands.
when the transfer is complete. 2. Identify yourself by name. Identify the resi-
G When a resident is in a wheelchair, he or she dent by name.
should be repositioned every two hours or as 3. Explain procedure to the resident. Speak
needed. The reasons for doing this are: clearly, slowly, and directly. Maintain face-to-
• It promotes comfort. face contact whenever possible.
• It reduces pressure. 4. Provide for the resident’s privacy with cur-
tain, screen, or door. Check the area to be
• It increases circulation.
certain it is uncluttered and safe.
• It exercises the joints.
5. Remove wheelchair footrests close to the bed.
• It promotes muscle tone.
6. Place wheelchair near the head of the bed
G The resident’s body should be kept in good with arm of the wheelchair almost touching
alignment while in the wheelchair. Special the bed. The wheelchair should be placed on
cushions, pillows, and soft blankets can be resident’s stronger, or unaffected, side.
used for support. The hips should be posi-
7. Lock wheelchair wheels.
tioned well back in the chair. If the resident
needs to be moved back in the wheelchair, go 8. Raise the head of the bed. Adjust bed level
to the back of the chair. Gently reach forward so that the height of the bed is equal to
and down under the resident’s arms. Ask the or slightly higher than the chair. Lock bed
resident to place his feet on the ground and wheels.
push up. Gently pull the resident up in the 9. Assist resident to sitting position with feet
chair while the resident pushes. flat on the floor.
10 160

10. Put non-skid footwear on resident and fasten. 15. Tell the resident to take small steps in the
direction of the chair while turning her
11. With transfer (gait) belt:
back toward the chair. If more assistance is
a. Stand in front of resident. needed, help the resident to pivot to front
Positioning, Lifting, and Moving

b. Stand with feet about 12 inches apart. Bend of wheelchair with back of resident’s legs
your knees. against wheelchair (Fig. 10-29). Always allow
the resident to do all she can for herself.
c. Place belt around resident’s waist. Grasp belt
securely on both sides.
Without transfer belt:

a. Stand in front of resident.

b. Stand with feet about 12 inches apart. Bend

your knees.

c. Place your arms around resident’s torso

under the arms. Ask resident to use the bed
to push up (or your shoulders, if possible).
12. Provide instructions to allow resident to help
with transfer. Instructions may include:
“When you start to stand, push with your
hands against the bed.”
“Once standing, if you’re able, you can take
small steps in the direction of the chair.”
“Once standing, reach for the chair with your
Fig. 10-29. Pivoting is safer than twisting.
stronger hand.”
13. With your legs, brace resident’s lower legs to 16. Ask the resident to put hands on wheelchair
prevent slipping (Fig. 10-28). arm rests if able. When the chair is touching
the back of the resident’s legs, help the resi-
dent lower herself into the chair.
17. Reposition resident with hips touching back
of wheelchair. Remove transfer belt, if used.
18. Attach footrests and place the resident’s feet
on the footrests. Check that the resident is in
good alignment. Make resident comfortable.
Place a lap robe or folded blanket over the
resident’s lap as appropriate.
19. Remove privacy measures.
Fig. 10-28. Use your legs to brace the resident’s lower legs
to prevent slipping. 20. Place call light within resident’s reach.
21. Wash your hands.
14. Count to three to alert resident. On three,
slowly help resident to stand. 22. Report any changes in resident to the nurse.
 161 10

23. Document procedure using facility

Transferring a resident from bed to stretcher
guidelines.
1. Wash your hands.

Positioning, Lifting, and Moving

Stretchers 2. Identify yourself by name. Identify the resi-
A stretcher, also called a gurney, is a medical dent by name.
device used to move injured or ill persons from 3. Explain procedure to the resident. Speak
one place to another. Stretchers may be used for clearly, slowly, and directly. Maintain face-to-
serious injuries and illnesses and/or when a per- face contact whenever possible.
son cannot or should not walk but needs to be
4. Provide for the resident’s privacy with cur-
transported somewhere. Stretchers transfer resi-
tain, screen, or door.
dents within facilities or to other facilities.
5. Lower the head of bed so that it is flat. Lock
Guidelines: bed wheels.
Safe Use of a Stretchers
6. If the bed has side rails, lower the side rail on
G Lock the stretcher wheels before transferring side to which you will move resident.
a resident onto or off of a stretcher. 7. Move the resident to the side of the bed.
G Secure resident with the safety belt while in Have your co-workers help you do this. Refer
the stretcher. to the procedure “Moving a resident to the
side of the bed” in this chapter.
G Raise the safety rails.
G Cover the resident with a sheet. Hands, feet, 8. Lower the side rail on the other side of the
fingers, etc. should remain inside the sheet bed. Keep a hand on the resident at all times.
during transport. 9. Place stretcher solidly against the bed, and
G Keep the wheels locked at all times except lock stretcher wheels. Bed height should be
when moving the stretcher. equal to the height of the stretcher. Remove
stretcher safety belts.
G Get help if you cannot move the stretcher
alone. 10. Two workers should be on one side of resi-
G Move slowly and carefully. dent. Two workers should be standing behind
the stretcher.
G Push the stretcher from the head end.
11. Each worker should roll up the sides of the
G Go through doorways by opening the door,
draw sheet and prepare to move the resident
entering first, and pulling the stretcher
(Fig. 10-30). Protect the resident’s arms and
through.
legs during the transfer.
G Avoid hitting walls or doorways.
G Be cautious going down sloping areas.
G Stay with the resident at all times.
A draw sheet is used to transfer a resident to
a stretcher. The next procedure shows how to
transfer a resident to a stretcher from a bed
using four workers. At least three workers
are necessary to safely transfer a resident to a
Fig. 10-30.
stretcher.
10 162

12. On the count of three, the workers lift and helps prevent common workplace injuries and
move the resident to the stretcher. All should may be mandatory at your facility if it has a lift-
move at once. Make sure the resident is cen- free policy. Ask questions if there is anything
tered on the stretcher (Fig. 10-31). that you do not understand about the provided
Positioning, Lifting, and Moving

lift equipment.

Fig. 10-31.

13. Place a pillow under the resident’s head, and

cover the resident.
14. Place the safety straps across the resident.
Raise side rails on stretcher.
15. Unlock stretcher’s wheels. Move resident to
proper place, staying with him until another
staff member takes over.
16. Wash your hands.
17. Report any changes in resident to the nurse.
18. Document procedure using facility
guidelines.
To return the resident to bed, reverse the above
procedure.

Mechanical Lifts
Facilities may have mechanical, or hydraulic,
lifts available to transfer residents. This equip-
ment avoids wear and tear on your body. Lifts
help prevent injury to you and the resident.
Fig. 10-32. There are different types of lifts that transfer
If you are trained to do so, you may assist resi- completely dependent residents and residents who can
dents with many types of transfers using a me- bear some weight. (photos courtesy of VANCARE inc., 800-694-4525)
chanical lift. Never use equipment you have not
been trained to use. You or your resident could
get hurt if you use lifting equipment improperly. Guidelines:
Mechanical or Hydraulic Lifts
There are many different types of mechanical
lifts (Fig. 10-32). You must be trained on the spe- Be very careful when moving a resident by
cific lift you will be using. Using these devices mechanical lift. Use these safety precautions
 163 10

when assisting a resident with the use of a roll back to the middle of the bed. Spread out
hydraulic lift: the fanfolded edge of the sling.
G Keep the chair or wheelchair to which the res- 8. Roll the mechanical lift to bedside. Make sure

Positioning, Lifting, and Moving

ident is to be moved close to the bed so that the base is opened to its widest point. Push
the resident is only moved a short distance in the base of the lift under the bed.
the lift. 9. Position the overhead bar directly over the
G Check that the valves are working on the lift resident (Fig. 10-33).
before using it.
G Check the sling and straps for any fraying or
tears. Do not use the lift if there are tears or
holes.
G Open the legs of the stand to the widest
position before helping the resident into the
lift.
G Once the resident is in the sling and the
straps are connected, pump up the lift only
to the point where the resident’s body clears
the bed or chair.
Fig. 10-33.
Transferring a resident using a mechanical lift
10. With the resident lying on his back, attach
This is a basic procedure for transferring using a one set of straps to each side of the sling.
mechanical lift. Ask someone to help you before Attach one set of straps to the overhead bar.
starting. If available, have a co-worker support the
Equipment: wheelchair or chair, co-worker, mechan- resident at the head, shoulders, and knees
ical or hydraulic lift while being lifted. The resident’s arms should
be folded across his chest (Fig. 10-34). If the
1. Wash your hands.
device has “S” hooks, they should face away
2. Identify yourself by name. Identify the resi- from resident (Fig. 10-35). Make sure all
dent by name. straps are connected properly.
3. Explain procedure to the resident. Speak
clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.

4. Provide for the resident’s privacy with cur-

tain, screen, or door.

5. Lock bed wheels.

6. Position wheelchair next to bed. Lock brakes.

7. Help the resident turn to one side of the bed.

Position the sling under the resident, with the
edge next to the resident’s back, fanfolding if
necessary. Make the bottom of the sling even
Fig. 10-34.
with the resident’s knees. Help the resident
10 164

15. Be sure the resident is seated comfortably

and correctly in the chair or wheelchair. Re-
move privacy measures.
Positioning, Lifting, and Moving

16. Place call light within resident’s reach.

17. Wash your hands.

18. Report any changes in resident to the nurse.

19. Document procedure using facility

guidelines.

Fig. 10-35.
Toilet Transfers
11. Following manufacturer’s instructions, raise The bladder empties more efficiently when a
the resident two inches above the bed. Pause person is able to use the toilet. In order to use
a moment for the resident to gain balance. the toilet, residents must be able to bear some
weight on their legs. Falls may occur if a resi-
12. If available, a lifting partner can help support
dent has to wait to go to the bathroom. Offer
and guide the resident’s body while you roll
trips to the toilet often and respond to call lights
the lift so that the resident is positioned over
quickly. You will learn more about assisting with
the chair or wheelchair (10-36).
toileting in Chapter 16.

Transferring a resident onto and off of a toilet

Equipment: disposable gloves, toilet tissue, wheel-

chair, transfer belt

1. Wash your hands.

2. Identify yourself by name. Identify the resi-

dent by name.

3. Explain procedure to the resident. Speak

clearly, slowly, and directly. Maintain face-to-
face contact whenever possible. Make sure
resident is wearing non-skid shoes.

4. Provide for the resident’s privacy with cur-

Fig. 10-36. tain, screen, or door.

5. Position wheelchair at a right angle to the toi-

13. Slowly lower the resident into the chair or
let to face the hand bar/wall rail.
wheelchair. Push down gently on the resi-
dent’s knees to help the resident into a sit- 6. Remove wheelchair footrests. Lock wheels.
ting, rather than reclining, position.
7. Apply a transfer belt around the resident’s
14. Undo the straps from the overhead bar. waist. Grasp the belt. Put one of your hands
Leave the sling in place for transfer back to toward the resident’s back and one toward
bed. the resident’s front.
 165 10

8. Ask resident to push against the armrests of 11. Help resident to slowly sit down onto the toi-
the wheelchair and stand, reaching for and let. Allow privacy unless resident cannot be
grasping the hand bar (Fig. 10-37). left alone.

Positioning, Lifting, and Moving

12. When the resident is finished, apply gloves.
Assist with perineal care as necessary (see
Chapter 13). Ask her to stand and reach for
the hand bar.
13. Use toilet tissue or damp cloth to clean the
resident. Make sure he or she is clean and
dry before pulling up clothing. Remove and
dispose of gloves. Wash your hands.
14. Pull up resident’s clothing. Help resident to
the sink to wash hands.
15. Help resident back into wheelchair.
16. Wash your hands again.
17. Help resident to leave the bathroom. Make
Fig. 10-37. sure resident is comfortable. Remove privacy
measures.
9. Ask resident to pivot her foot and back up so 18. Place call light within resident’s reach.
that she can feel the front of the toilet with
19. Report any changes in resident to the nurse.
the back of her legs (Fig. 10-38).
20. Document procedure using facility
guidelines.

Car Transfers
When a resident is leaving a facility, you may
need to help him or her into a car. The front seat
is wider and is usually easier to get into.

Transferring a resident into a car

Equipment: car, wheelchair

1. Wash your hands.
2. Identify yourself by name. Identify the resi-
dent by name.
3. Explain procedure to the resident. Speak
Fig. 10-38.
clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.
10. Help resident to pull down underwear and
pants. You may need to keep one hand on 4. Place wheelchair close to the car at a 45-de-
the transfer belt while helping to remove gree angle. Open the door on the resident’s
clothing. stronger side.
10 166

5. Lock wheelchair. 10. See that door can be safely shut and shut the
door.
6. Ask the resident to push against the arm
rests of the wheelchair and stand 11. Return the wheelchair to the appropriate
Positioning, Lifting, and Moving

(Fig. 10-39). place for cleaning.

12. Wash your hands.

13. Document procedure using facility

guidelines.

5. Discuss how to safely ambulate

residents
Ambulation is walking. A resident who is am-
bulatory is one who can get out of bed and
Fig. 10-39. walk. Many older residents are ambulatory, but
need assistance to walk safely. Several tools, in-
7. Ask the resident to stand, grasp the car, cluding transfer or gait belts, canes, walkers, and
and pivot his foot so the side of the car seat crutches, assist with ambulation.
touches the back of the legs.
Check the care plan before helping a resident
8. The resident should then sit in the seat and ambulate. Discuss the resident’s abilities and
lift one leg, and then the other, into the ve- disabilities with the nurse, and know the resi-
hicle (Fig. 10-40). dent’s limitations. Any time you help a resident,
communicate what you would like to do, and
allow him to do what he can.

Assisting a resident to ambulate

Equipment: gait belt, non-skid shoes for the resident

1. Wash your hands.

2. Identify yourself by name. Identify the resi-

dent by name.

3. Explain procedure to resident. Speak clearly,

slowly, and directly. Maintain face-to-face con-
tact whenever possible.

4. Provide for resident’s privacy with curtain,

screen, or door.

5. Before ambulating, properly fasten non-skid

footwear on the resident.
Fig. 10-40.
6. Adjust bed to low position so that the feet
are flat on the floor. Lock bed wheels.
9. Carefully position the resident comfortably in
the car. Help secure seat belt. 7. Stand in front of and face the resident.
 167 10

8. Brace the resident’s lower extremities. Bend If the resident has a weaker side, stand on
your knees. Place one foot between the resi- that side. Use the hand that is not holding
dent’s knees. If the resident has a weak knee, the belt or the arm not on the back to offer
brace it against your knee. support on the weak side.

Positioning, Lifting, and Moving

9. With gait (transfer) belt: Place belt around 11. Observe the resident’s strength while you
resident’s waist. Bending your knees and walk together. Provide a chair if the resident
leaning forward, grasp the belt. Hold her becomes dizzy or tired.
close to your center of gravity. Tell the resi-
12. After ambulation, remove gait belt if used.
dent to lean forward, push down on the bed
Help resident to the bed or chair and make
with her hands, and stand, on the count of
resident comfortable.
three. When you start to count, begin to rock.
At three, rock your weight onto your back 13. Return bed to lowest position. Remove pri-
foot and assist the resident to a standing vacy measures.
position. 14. Place call light within resident’s reach.
Without transfer belt: Place arms around resi- 15. Wash your hands.
dent’s torso under armpits, while assisting
16. Report any changes in resident to nurse.
resident to stand.
17. Document procedure using facility
10. With transfer belt: Walk slightly behind and
guidelines.
to one side of resident for the full distance,
while holding onto the transfer belt (10-41).
When helping a visually-impaired resident walk,
let the person walk beside and slightly behind
you, as he rests a hand on your elbow. Walk at
a normal pace. Let the person know when you
are about to turn a corner, or when a step is ap-
proaching. Tell him whether you will be step-
ping up or down.
Residents who have difficulty walking may use
adaptive or assistive devices, such as canes, walk-
ers, or crutches to help themselves (Fig. 10-42).
Understanding the purpose of each device will
help you know how to use it properly.

Fig. 10-41. Walk behind and to one side while holding

onto the gait belt when assisting with ambulation.

Without transfer belt: Walk slightly behind

and to one side of resident for the full dis-
tance. Support the resident’s back with your Fig. 10-42. Residents who have difficulty walking may use
arm. canes, walkers, or crutches to help themselves.
10 168

The purpose of a cane is to help with balance. G Be sure the resident is wearing securely fas-
Residents using canes should be able to bear tened non-skid shoes.
weight on both legs. If one leg is weaker, the
G When using a cane, the resident should place
cane should be held in the hand on the strong
Positioning, Lifting, and Moving

it on his stronger side.

side.
G When using a walker, have the resident place
Types of canes include the C cane, the func- both hands on the walker. The walker should
tional grip cane, and the quad cane. The C cane not be over-extended; it should be placed no
is a straight cane with a curved handle at the more than 12 inches in front of the resident.
top. It has a rubber-tipped bottom to prevent
slipping. A C cane is used to improve balance. A G Stay near the resident on the weaker side.
functional grip cane is similar to the C cane, G Do not hang purses or clothing on the
except that it has a straight grip handle, rather walker.
than a curved handle. The grip handle helps
G If the height of the cane or walker does not
improve grip control and provides a little more
appear to be correct (too short, too tall, etc.),
support than the C cane. A quad cane, with
inform the nurse.
four rubber-tipped feet and a rectangular base,
is designed to bear more weight than the other
Assisting with ambulation for a resident using a
canes.
cane, walker, or crutches
A walker is used when the resident can bear
Equipment: transfer belt, non-skid shoes for resident,
some weight on the legs. The walker provides
cane, walker, or crutches
stability for residents who are unsteady or lack
balance. The metal frame of the walker may 1. Wash your hands.
have rubber-tipped feet and/or wheels. Crutches 2. Identify yourself by name. Identify resident by
are used for residents who can bear no weight or name.
limited weight on one leg. Some people use one
crutch, and some use two. 3. Explain procedure to resident. Speak clearly,
slowly, and directly. Maintain face-to-face con-
Whichever device is being used, your role is to tact whenever possible.
ensure safety. Stay near the person, on the weak
side. Make sure the equipment is in proper con- 4. Provide for resident’s privacy with curtain,
dition. It must be sturdy, and it must have rub- screen, or door.
ber tips or wheels on the bottom. 5. Before ambulating, properly fasten non-skid
When a resident uses a walker or cane, follow footwear on resident.
these guidelines. They will help keep the resi- 6. Adjust bed to low position so that the feet
dent safe. are flat on the floor. Lock bed wheels.
7. Stand in front of and face the resident.
Guidelines:
Cane or Walker Use 8. Brace the resident’s lower extremities. Bend
your knees. Place one foot between the resi-
G Be sure the walker or cane is in good condi- dent’s knees. If the resident has a weak knee,
tion. It must have rubber tips on bottom. The brace it against your knee.
tips should not be cracked. Walkers may have 9. Place gait belt around resident’s waist. Grasp
wheels. If so, roll the walker to make sure the the belt while helping the resident to stand as
wheels are moving properly. previously described.
 169 10

10. Help as needed with ambulation. c. Crutches. Resident should be fitted for
crutches and taught to use them correctly by
a. Cane. Resident places cane about 12 inches
a physical therapist or nurse. The resident
in front of his stronger leg. He brings weaker
may use the crutches several different ways,

Positioning, Lifting, and Moving

leg even with cane. He then brings stronger
depending on what his weakness is. No mat-
leg forward slightly ahead of cane. Repeat
ter how they are used, weight should be on
(Fig. 10-43).
the hands and arms. Weight should not be
on the underarm area (Fig. 10-45).

Fig. 10-43. The cane moves in front of the stronger leg

first. Fig. 10-45. When using crutches, weight should be on the
hands and arms, not on the underarms.

b. Walker. Resident picks up or rolls the walker

11. Whether the resident is using a cane, walker,
and places it about 12 inches in front of him.
or crutches, walk slightly behind and to one
All four feet or wheels of the walker should
side of resident. Stay on the weaker side if
be on the ground before resident steps for-
resident has one. Hold the gait belt if one is
ward to the walker. The walker should not be
used.
moved again until the resident has moved
both feet forward and is steady (Fig. 10-44). 12. Watch for obstacles in the resident’s path.
The resident should never put his feet ahead Ask the resident to look ahead, not down at
of the walker. his feet.

13. Encourage the resident to rest if he is tired.

When a resident is tired, it increases the
chance of a fall. Let the resident set the pace.
Discuss how far he plans to go based on the
care plan.

14. After ambulation, remove gait belt. Help resi-

dent to a position of comfort and safety.

15. Leave bed in lowest position. Remove privacy

measures.

16. Place call light within resident’s reach.

Fig. 10-44. The walker can be moved after the resident is
steady and both feet are forward. 17. Wash your hands.
10 170

18. Report any changes in resident to nurse. 17. Describe what a nursing assistant should do
if a resident starts to fall.
19. Document procedure using facility
guidelines. 18. If a resident has a weaker side, which side
Positioning, Lifting, and Moving

moves first in a transfer—the weaker or

stronger side?
Chapter Review 19. When may stretchers be used for residents?
1. List nine guidelines for using proper body 20. List five safety guidelines for using a me-
mechanics. chanical lift.
2. Why is handwashing an important step 21. What is one benefit of using the toilet rather
at the beginning and at the end of care than a bedpan or urinal?
procedures? 22. Define “ambulation.”
3. Why are beds usually adjusted to a low posi- 23. What is the purpose of canes?
tion at the end of care procedures?
24. Which type of adaptive device for walk-
4. What is positioning? ing can be used when a resident can bear
5. How often should bedbound residents be no weight on one leg—cane, walker, or
repositioned? crutches?
6. In which position is a resident lying on his/ 25. Which side should a nursing assistant stay
her side? by when a resident is using adaptive equip-
ment—the weaker or stronger side?
7. In which position is a resident lying on his/
her stomach?
8. In which position is a resident lying flat on
his/her back?
9. In which position is a resident lying on his/
her left side with the lower arm behind the
back and the upper knee bent and raised to-
ward the chest?
10. In which position is a resident in a semi-
sitting position (45 to 60 degrees) with the
head and shoulders up?
11. What is a draw sheet?
12. What is shearing?
13. When is logrolling necessary?
14. How does dangling benefit a resident?
15. How should a transfer belt be applied to a
person?
16. Before helping a resident into or out of a
wheelchair, what should a nursing assistant
do?
 171 11

11

Admitting, Transferring, and Discharging

Admitting, Transferring, and
Discharging
1. Describe how residents may feel when independence is restricted, and health declines,
entering a facility people may be faced with difficult decisions
about care. Moving into a facility is not an easy
Chapter 8 described some of the many feel- choice to make.
ings residents may be having as they make the
transition into a care facility. Losses, such as
the loss of a familiar environment, or the loss
of independence, can cause a person to feel
scared, angry, sad, lonely, worried, helpless, or
depressed. A new resident may yell at caregivers,
or may cry often. He or she may refuse to join in
activities and want to be left alone. A new resi-
dent may want to talk to staff members as much
as possible until he becomes more comfortable.
These are just a few of the ways that new resi-
dents may show their emotions.
Moving always requires an adjustment, but as
a person ages, it can be even harder (Fig. 11-1).
This is especially true if illness, disability, and
mobility problems are present. Imagine that at
age 45 you began to live alone as your children Fig. 11-1. A new resident must leave familiar places and
things. He may have just lost someone very close to him.
left the house. Then you lived alone, happily,
He may be experiencing other losses as well. Be support-
for 25 years before having a stroke. You were no ive and welcoming.
longer able to live alone safely, and your children
did not live nearby to help you with your daily Nursing assistants play an important role in
care. And living with your children was not an helping residents make a successful transition
option. You might have to move into a care facil- to a long-term care facility. Giving emotional
ity. You might feel worried and scared because support is a big part of this. Listening and being
you have never known any other home but the kind, compassionate, and helpful may make
one you lived in for so many years. You might new residents feel better about their new homes.
feel angry or depressed about moving into a More guidelines on assisting new residents are
new place filled with people you do not know. If found in the next learning objective.
11 172

2. Explain the nursing assistant’s role in room is tidy. Restock supplies that are low.
the admission process Make sure there is an admission kit available,
if used. Admission kits often contain per-
When a new resident is admitted, he or she is sonal care items, such as bath basin, emesis
Admitting, Transferring, and Discharging

first directed to the admitting office. Paperwork basin, water pitcher, drinking glass, tooth-
is signed. The admission staff member makes paste, soap, comb, lotion, and tissues (Fig.
copies of insurance information, Medicare cards, 11-2). They may also contain a urine speci-
and other types of information. Both parties men cup, label, and transport bag.
sign an agreement or contract, agreeing to the
services provided and the costs for them. Emer-
gency contact information and names of doctors
are obtained. Staff is required to explain infor-
mation on advance directives and to find out if
the resident has advance directives in place or
wants to create them. A copy of the resident’s
rights is given to the new resident and his or her
family. The rights are explained in a language
the resident can understand. A facility handbook
of policies and procedures may be given. The
procedure on how to file grievances and com-
plaints is explained. Pictures of new residents
may be taken, which are used to identify them
Fig. 11-2. An admission kit is usually placed in a resi-
and may be posted outside of their rooms. dent’s room before he or she is admitted. It may contain
Admission is often the first time you meet a personal care items that the resident will need. (reprinted
with permission of briggs corporation, 800-247-2343, www.briggscorp.com)
new resident. This is a time of first impressions.
Make sure a resident has a good impression of G When a new resident arrives at the facility,
you and your facility. Because change is difficult, note the time and her condition. Is she using
staff must communicate with new residents. Ex- a wheelchair, on a stretcher, or walking?
plain what to expect during the process, and an- Who is with her? Observe the new resident
swer any questions that are within your scope of for level of consciousness and if she seems
practice. If residents have questions you cannot confused. She will probably be feeling anxi-
answer, find the nurse. Ask questions to find out ety; look for signs of nervousness. Note any
a resident’s personal preferences and routines. tubes she has, such as IVs or catheters.
Your facility will have a procedure for admitting G Introduce yourself and state your position.
residents to their new home. These guidelines Smile and be friendly. Always call the person
will help make the experience pleasant and by her formal name until she tells you what
successful. she wants to be called.
G Never rush the process or the new resident.
Guidelines:
He should not feel like he is an inconve-
Admission
nience. Make sure that the new resident feels
welcome and wanted.
G Prepare the room before the resident arrives.
This helps him or her to feel expected and G Explain day-to-day life in the facility. Offer to
welcome. Make sure the bed is made and the take the resident on a tour (Fig. 11-3).
 173 11

Admitting, Transferring, and Discharging

Fig. 11-5. Some personal items may be stored in special
bags. Follow facility policy. (reprinted with permission of briggs cor-
Fig. 11-3. Make sure you include the location of the din- poration, 800-247-2343, www.briggscorp.com)

ing room when taking a new resident on a tour. Go over

posted dining schedules. G When setting up the room, ask her what she
likes. Place personal items where the resident
G Introduce the resident to other residents and wants them (Fig. 11-6).
staff members you see (Fig. 11-4). Introduce
the roommate if there is one.

Fig. 11-6. Handle personal items carefully, and set up the

room as she prefers.

G Admission is a stressful time. Be sure to

observe the resident as she could have a
problem that is missed with the emphasis on
Fig. 11-4. Introduce new residents to all other residents transporting, paperwork, etc. It is important
you see.
to observe the new resident’s condition in
order to recognize any changes that may take
G Handle personal items with care and respect.
place later. Report to the nurse if you notice
A resident has a legal right to have his per-
any of the following:
sonal items treated carefully. These are the
items he has chosen to bring with him. Some • Tubes that need to be reconnected
items may be stored in bags marked specifi- • Resident seems confused, combative,
cally for personal belongings (Fig. 11-5). Ask and/or unaware of surroundings
the new resident if she brought any valuables
with her. If so, offer to have them safely • Resident is having difficulty breathing or
stored according to your facility’s policy. If any other signs of distress
she refuses, follow the procedure to write an • Resident has missed a meal during
inventory, and get the necessary signatures. admission process
11 174

G Follow facility policy on any other tasks that • Obtain a urine specimen if required (see
are required during the admission process. Chapter 16).
G New residents may have good days followed • Complete the paperwork. Take an inventory
Admitting, Transferring, and Discharging

by not-so-good days. Let residents adapt to of all the personal items.

their new homes at their own pace. Everyone
• Help the resident put personal items away.
is different. Getting used to a new home may
take quite some time. • Provide fresh water (Fig. 11-7).

Residents’ Rights
Rights during Admission
Upon admission, residents must be told of their
rights. They must be provided with a written copy of
these rights. This includes rights about their funds
and the right to file a complaint with the state survey
agency.

Admitting a resident Fig. 11-7. Providing fresh water is something you should
do every time you leave a resident’s room, unless he is on
Equipment: may include admission paperwork a fluid restriction. Doing this helps prevent dehydration.
(checklist and inventory form), gloves and vital signs Make sure the pitcher and glass are light enough for the
equipment resident to lift. (reprinted with permission of briggs corporation, 800-247-
2343, www.briggscorp.com)

Often an admission kit will contain a urine speci-

men cup and transport bag, and personal care 6. Show the resident the room and bathroom.
items, such as bath basin, water pitcher, drinking Explain how to work the bed (and television if
glass, toothpaste and soap. there is one). Show the resident how to work
the call light and explain its use.
1. Wash your hands.
7. Introduce the resident to his roommate, if
2. Identify yourself by name. Identify the resi- there is one. Introduce other residents and
dent by name. staff.
3. Explain procedure to the resident. Speak 8. Make sure resident is comfortable. Remove
clearly, slowly, and directly. Maintain face-to- privacy measures. Bring the family back in-
face contact whenever possible. side if they were outside.
4. Provide for the resident’s privacy with cur- 9. Place call light within resident’s reach.
tain, screen, or door. If the family is present,
ask them to step outside until the admission 10. Wash your hands.
process is over. 11. Document procedure using facility
5. If part of facility procedure, do these things: guidelines.

• Take the resident’s height and weight (see

In addition to measuring weight and height at
procedures below).
admission, you will check them often as part of
• Take the resident’s baseline vital signs (see your care. Height is checked less frequently than
Chapter 14). Baseline signs are initial val- weight. Weight changes can be signs of illness,
ues that can then be compared to future so you must report any weight loss or gain, no
measurements. matter how small.
 175 11

9. Help resident to safely step off scale before

Measuring and recording weight of an
recording weight.
ambulatory resident
Equipment: standing scale or bathroom scale, pen 10. Record weight.

Admitting, Transferring, and Discharging

and paper
11. Remove privacy measures.
1. Wash your hands.
12. Place call light within resident’s reach.
2. Identify yourself by name. Identify the resi-
13. Wash your hands.
dent by name.
14. Report any changes in resident’s weight
3. Explain procedure to the resident. Speak
(when weighing resident after admission) to
clearly, slowly, and directly. Maintain face-to-
the nurse.
face contact whenever possible.
15. Document procedure using facility
4. Provide for resident’s privacy with curtain,
guidelines.
screen, or door.

5. If using a bathroom scale, set the scale on a Some residents will not be able to get out of
hard surface in a place the resident can get to a wheelchair easily and may be weighed on a
easily. wheelchair scale. With this scale, wheelchairs
are rolled onto the scale (Fig. 11-9). On some
6. Start with scale balanced at zero before
wheelchair scales, you will need to subtract
weighing resident.
the weight of the wheelchair from a resident’s
7. Help resident to step onto the center of the weight. In this case, weigh the empty wheelchair
scale, as needed. Be sure she is not holding, first. Then subtract the wheelchair’s weight
touching, or leaning against anything. This from the total. Some wheelchairs are marked
interferes with weight measurement. Do not with their weight.
force someone to let you go. If you are un-
able to obtain a weight, notify the nurse.

8. Determine the resident’s weight. Using a

standing scale: this is done by balancing the
scale. Make the balance bar level by moving
the small and large weight indicators until
the bar balances (Fig. 11-8). Add these two
numbers together. Using a bathroom scale:
read the weight when the dial has stopped
moving.

Fig. 11-9. A type of wheelchair scale.

Some residents will not be able to get out of bed.

Weighing these residents requires a special scale
(Fig. 11-10). Before using a bed scale, know how
Fig. 11-8. Move the small and large weight indicators to use it properly and safely. Follow your facility’s
until the bar balances.
procedure and any manufacturer’s instructions.
11 176

6. Make a pencil mark on the sheet at the top of

the head.

7. Make another mark at the resident’s heel

Admitting, Transferring, and Discharging

(Fig. 11-12).

Fig. 11-10. A type of bed scale. (photo courtesy of detecto,

www.detecto.com, 800-641-2008)

Fig. 11-12. Make marks on the sheet at the resident’s

Measuring and recording height of a resident head and feet.

Some residents will be unable to get out of bed. If 8. With the tape measure, measure the distance
so, height can be measured using a tape measure between the marks.
(Fig. 11-11).
9. Record height.

10. Remove privacy measures. Store equipment.

11. Place call light within resident’s reach.

12. Wash your hands.

13. Document procedure using facility

Fig. 11-11. A tape measure. guidelines.

For residents who can get out of bed, you will

Equipment: tape measure, pencil, pen and paper
measure height using a standing scale.
1. Wash your hands. Equipment: standing scale, pen and paper
2. Identify yourself by name. Identify the resi- 1. Wash your hands.
dent by name.
2. Identify yourself by name. Identify the resi-
3. Explain procedure to the resident. Speak dent by name.
clearly, slowly, and directly. Maintain face-to-
face contact whenever possible. 3. Explain procedure to the resident. Speak
clearly, slowly, and directly. Maintain face-to-
4. Provide for resident’s privacy with curtain, face contact whenever possible.
screen, or door.
4. Provide for resident’s privacy with curtain,
5. Position the resident lying straight in bed, flat screen, or door.
on his back with arms and legs at his sides.
Be sure the bed sheet is smooth underneath 5. Help resident to step onto scale, facing away
the resident. from the scale.
 177 11

6. Ask resident to stand straight, if possible. 3. Explain the nursing assistant’s role
Help as needed. during an in-house transfer of a resident
7. Pull up measuring rod from back of the scale Residents may be transferred to a different area

Admitting, Transferring, and Discharging

and gently lower the rod until it rests flat on of the facility. In cases of acute illness, they may
the resident’s head (Fig. 11-13). be transferred to a hospital. Change is difficult,
and this is especially true when a person has
an illness or her condition gets worse. Make the
transfer as smooth as possible for the resident.
Try to lessen the stress. Inform the resident of
the transfer as soon as possible so that she can
then begin to adjust to the idea. Explain how,
where, when, and why the transfer will occur.
For example, “Mrs. Jones, you will be moving to
a private room. You will be transferred to your
new room in a wheelchair. This will happen
on Wednesday around 10 a.m. The staff will
take good care of you and your things. We will
make sure you are comfortable. Do you have any
questions?”
Assist residents with packing their personal
items. Residents often worry about losing their
Fig. 11-13. To determine height on a standing scale,
belongings. Involve them with the packing pro-
gently lower the measuring rod until it rests flat on the
resident’s head. cess if appropriate. For example, let them see the
empty closet, drawers, etc.
8. Determine the resident’s height. The resident may be transferred in a bed, in
9. Assist the resident in stepping off scale be- a stretcher, or in a wheelchair. Find out the
fore recording height. Make sure that the method from the nurse so that you can plan the
measuring rod does not hit the resident in move ahead of time. After the resident is in her
the head. new room or area, make sure to introduce her to
all staff members you see. You want her to feel
10. Record height.
welcome, settled, and comfortable.
11. Remove privacy measures.
Residents’ Rights
12. Place call light within resident’s reach.
Changing Rooms or Roommates
13. Wash your hands. Residents have the right to receive notice of any
room or roommate change.
14. Document procedure using facility
guidelines.
Transferring a resident

The rod measures height in inches and fractions Equipment: may include a wheelchair, cart for be-
of inches. Record the total number of inches. If longings, the medical record, all of the resident’s
personal care items and packed personal items
you have to change inches into feet, remember
that there are 12 inches in a foot. 1. Wash your hands.
11 178

2. Identify yourself by name. Identify the resi- If the resident will be returning soon, change
dent by name. the bed linens, tidy the room, and restock
supplies.
3. Explain procedure to the resident. Speak
Admitting, Transferring, and Discharging

clearly, slowly, and directly. Maintain face-to-

face contact whenever possible. 4. Explain the nursing assistant’s role in
the discharge of a resident
4. Provide for resident’s privacy with curtain,
screen, or door. The day of discharge is usually a happy day for
a resident who is going home. When a resident
5. Collect the items to be moved onto the cart.
is discharged, he is released from the facility’s
Take them to the new location. If the resident
care by the doctor. You will collect the resident’s
is going into the hospital, the facility may
belongings and pack them carefully. Ask the
want them placed in temporary storage.
resident which personal care items to bring, and
6. Help the resident into the wheelchair pack those, too. Know what the resident’s condi-
(stretcher may be used for some residents). tion is at the time of discharge; find out if she
Take him or her to proper area. will be using a wheelchair or stretcher.

7. Introduce new residents and staff. When residents are discharged they may experi-
ence doubts or fear about not being cared for at
8. Help the resident to put personal items away.
the facility anymore. They may be concerned
9. Make sure that the resident is comfortable. that their health will suffer. Be positive; assure
Remove privacy measures. her that she is ready for this important change.
Remind her that her doctor believes she is ready.
10. Place call light within resident’s reach.
However, if she has specific questions about
11. Wash your hands. care, inform the nurse.

12. Report any changes in resident to the nurse. Before the resident is discharged, the nurse may
cover important information with the resident
13. Document procedure using facility and her family and friends. Some of the follow-
guidelines. ing areas may be discussed:
• Future doctor or physical, speech, and occu-
In addition to the above, when residents are pational therapy appointments (Fig. 11-14)
being transferred out of the facility, make sure
their clothing is clean and appropriate for the
weather. In addition, observe and report the fol-
lowing to the nurse:
• How did the resident leave the facility?
• Who was with her?
• Did she leave by stretcher or wheelchair?
• Did she seem to understand where she was
going?
• What belongings did she take with her?
• What were her vital signs before the Fig. 11-14. After a resident is discharged, she may con-
transfer? tinue to receive physical therapy.
 179 11

• Home care, skilled nursing care 11. Document procedure using facility guide-
lines. Include the following:
• Medications
• Ambulation instructions from the doctor • Time of discharge

Admitting, Transferring, and Discharging

• Medical equipment needed • Method of transport

• Medical transportation • Who was with the resident

• Any restrictions on activities • The vital signs at discharge

• Special exercises to keep the resident func- • What items the resident took with her (inven-
tioning at the highest level tory checklist)
• Special nutrition or dietary requirements
• Community resources Residents’ Rights
Privacy during Discharges
Discharging a resident It is important to always be aware of residents’ pri-
vacy. Close the door before talking about medical
Equipment: may include a wheelchair, cart for be- matters or other private things. Pull the privacy cur-
longings, the discharge paperwork, including the tain before the resident changes clothes or is bathed
inventory list done on admission, all of the resident’s before transfer or discharge.
personal care items
5. Describe the nursing assistant’s role in
1. Wash your hands.
physical exams
2. Identify yourself by name. Identify the resi-
dent by name. When arriving at a facility, a resident may have
a physical exam to help determine the resident’s
3. Explain procedure to the resident. Speak needs and the care plan. Doctors or nurses will
clearly, slowly, and directly. Maintain face-to- perform the exam. Nursing assistants may help
face contact whenever possible. by bringing the resident to the proper area, gath-
4. Provide for resident’s privacy with curtain, ering equipment, and providing emotional sup-
screen, or door. port. People can be scared about having physical
exams. They may fear what the examiner will
5. Compare the checklist to the items there. If do or what he or she will find. Exams can cause
all items are there, ask the resident to sign. discomfort and embarrassment. Assist residents
6. Put the items to be taken onto the cart and during this process. Be comforting and answer
take them to pick-up area. questions they have that are within your scope of
practice.
7. Help the resident dress and then into the
Your responsibilities will include gathering
wheelchair or stretcher, if used.
equipment for the nurse or doctor. Examples
8. Help the resident to say his goodbyes to the of equipment that may be needed include the
staff and residents. following:
9. Take resident to the pick-up area. Help her • Sphygmomanometer (used to measure blood
into vehicle. You are responsible for the pressure; you will learn about this in
resident until she is safely in the car and the Chapter 14)
door is closed. • Stethoscope
10. Wash your hands. • Alcohol wipes (Fig. 11-15)
11 180

• Vaginal speculum for females (opens the

vagina so that it and the cervix can be
examined)
Admitting, Transferring, and Discharging

• Gloves
• Drapes
You may be asked to position and drape resi-
dents in the correct position for the exam. Some
positions are embarrassing and uncomfortable.
You can help by explaining why the position is
needed and how long the resident can expect to
Fig. 11-15. Alcohol wipes can be used for infections and
stay in the position.
for minor wound care, among other uses. You may be
required to gather other supplies as well. (reprinted with permis- The dorsal recumbent position is used to ex-
sion of briggs corporation, 800-247-2343, www.briggscorp.com)
amine the breasts, chest, and abdomen. It is also
• Flashlight used to examine the perineal area (Fig. 11-17). A
resident in the dorsal recumbent position is flat
• Thermometer
on her back with her knees flexed and feet flat
• Tongue depressor on the bed. The drape is put over the resident,
covering her body. Her head remains uncovered.
• Eye chart
• Tuning fork (tests hearing with vibrations)
• Reflex, or percussion, hammer (taps body
parts to test reflexes) (Fig. 11-16)

Fig. 11-17. The dorsal recumbent position.

A lithotomy position is used to examine the

vagina (Fig. 11-18). The resident lies on her back.
Her hips are brought to the edge of the exam
table. Her legs are flexed, and her feet are in
padded stirrups. The drape is put over the resi-
Fig. 11-16. A reflex, or percussion, hammer is used to test dent, covering her body. Her head remains un-
reflexes. (reprinted with permission of briggs corporation, 800-247-2343,
www.briggscorp.com) covered. The drape is also brought down to cover
the perineal area and tops of the thighs.
• Otoscope (lighted instrument that examines
the outer ear and eardrum)
• Ophthalmoscope (lighted instrument that
examines the eye)
• Specimen containers
• Lubricant
• Special card to test for blood in stool Fig. 11-18. The lithotomy position.
 181 11

The knee-chest position is used to examine the G Put instruments in the proper place for the
rectum, or sometimes, the vagina (Fig. 11-19). examiner. Hand instruments to the examiner
A resident in the knee-chest position is lying as needed.
on her abdomen. The knees are pulled towards

Admitting, Transferring, and Discharging

G Take and label specimens as needed.
the abdomen and legs are separated. Arms are
pulled up and flexed. The head is turned to one G Follow standard precautions.
side. In the knee-chest position, the resident G For vision screenings, you may be asked to
will be wearing a gown and possibly socks. The check that needed equipment is in place.
drape should be applied in a diamond shape to Follow directions. Assist the screener to set
cover the back, buttocks and thighs. up any equipment, such as the eye chart.
If you transport residents to the site for
screening, make sure to take their current
eyeglasses or contact lenses with them. The
screener will instruct you where to seat the
residents or to have them stand. Operate the
light switch as instructed. Make sure that
the residents have their eyeglasses and other
Fig. 11-19. The knee-chest position. belongings when returned to their rooms.
G After the exam, the NA’s responsibilities
Before exams, offer residents drapes and other include:
privacy measures, such as closing the privacy
screen or curtain and closing the door to the • Help the resident clean up and get
room. Promote the resident’s right to privacy. dressed. Help the resident safely back to
Tell the resident that he or she will not be ex- his or her room.
posed more than necessary during the exam. • Dispose of any trash and disposable
equipment in the exam area.
Guidelines: • Bring all reusable equipment to the
Physical Exams appropriate cleaning room. Clean and
store reusable equipment according to
G Wash your hands before and after the exam. facility policy.
G Ask the resident to urinate before the exam. • Label and bring any specimens to the
Collect any urine needed for a specimen at desk to take to the lab.
this time.
G Provide privacy throughout the exam. Use Residents’ Rights
drapes and privacy screens for privacy. Exams
Expose only the body part being examined. Residents have the right to know why exams are
being done and who is doing them. Residents have
G Listen to and calm the resident throughout the right to choose examiners and to have family
the exam. members present during the exam.

G Follow the directions of the examiner.

G Help the resident into the proper positions Chapter Review
as needed.
1. How can nursing assistants help residents
G Protect the resident from falling. feel better about moving to a long-term care
G Provide enough light for the examiner. facility?
11 182

2. List eight guidelines for helping residents

during the admission process.
3. Why is it important to report any weight loss
Admitting, Transferring, and Discharging

or gain that a resident has, no matter how

small?
4. How many inches are in a foot?
5. How can nursing assistants make transfers
as smooth as possible for residents?
6. List eight types of information that the nurse
may cover with the resident and her family
and friends during the discharge process.
7. What are two ways that nursing assistants
can provide emotional support to residents
who are having a physical exam?
8. In which position is a resident lying on her
abdomen with her knees pulled towards the
abdomen, her arms pulled up and flexed,
and her head turned to one side?
9. Which position is generally used to examine
the vagina, with the woman’s feet in padded
stirrups?
10. In which position is a resident lying flat on
her back with her knees flexed and feet flat
on the bed?
 183 12

12

The Resident’s Unit

The Resident’s Unit

1. Explain why a comfortable environment • Turning off televisions when they are not
is important for the resident’s well-being in use

Illness and disability cause great stress. It helps G Odors may be caused by urine, feces, vomit,
residents feel better physically and psychologi- certain diseases, and wound drainage. Body
cally if their environments are clean and com- and breath odors may be offensive, too. You
fortable. A comfortable and clean environment can help control odors by:
aids in relaxation and helps to reduce stress. • Promptly cleaning up after episodes of
A soothing environment may also help relieve incontinence
pain and promote healing. Many things affect
• Changing incontinent briefs as soon as
residents’ comfort within their rooms. The more
they are soiled and disposing of them
you pay attention and try to improve their envi-
properly
ronments, the more positive impact it may have
on residents’ health and well-being. • Emptying and cleaning bedpans, urinals,
commodes, and emesis basins promptly
Many things can affect comfort level, such as
noise, odors, temperature, lighting, diet, medica- • Changing soiled bed linens and clothing
tions, illness, fear, and anxiety. Below are some as soon as possible
guidelines for avoiding problems and promoting • Giving regular oral care and personal care
comfort. to help avoid body and breath odors
G As people age and lose protective fatty tissue,
Guidelines: they may feel cold often. Illness can cause a
Promoting Comfort person to feel cold, too. You can help resi-
dents stay comfortable by:
G Common noises in facilities can upset and/or
irritate residents. You can help keep the noise • Layering clothing and bed covers for
level low by: warmth

• Not banging equipment or meal trays • Keeping residents away from drafty areas,
such as by doors and windows
• Keeping your voice low
• Offering blankets to persons in wheel-
• Promptly answering ringing telephones chairs
and call lights
• Keeping residents covered while giving
• Closing doors when residents ask you to personal care
12 184

G Good lighting is important to promote safety Always knock and wait to receive permission
and prevent falls. It also helps make a room before entering.
pleasant. Residents may prefer darker rooms You will need to keep a resident’s unit neat and
when they are ill, have a headache, or are
The Resident’s Unit

clean. After providing care for the resident, you

sleeping. Keep lighting controls within the will tidy the area. Clean and put equipment
resident’s reach. away. Providing a clean, safe, and orderly envi-
G Foods ordered in special diets for residents ronment is an essential part of your job.
may cause them discomfort. Heavy meals Equipment that you will generally find in each
can also cause discomfort. Report resident resident’s unit includes the following:
complaints about food to the nurse. You will
learn more about nutrition and special diets • Electric or manual bed: Electric beds, also
in Chapter 15. called hospital beds, are operated by controls
that hang on or near the side of the bed
G Foods and drinks that contain caffeine can
(Fig. 12-2). One pair of buttons operates the
prevent sleep or sleeping well. Caffeine may
head section and the other pair operates the
need to be decreased to promote better rest
foot section. By using the arrows, you can
(Fig. 12-1).
move these sections up or down (Fig. 12-3).
The middle pair of buttons operate the bed
height. Most electric beds have a way to in-
sert a crank so that they can be adjusted if
there is a power failure. Manual beds have
cranks to move them. The left crank usually
raises and lowers the head of the bed. The
right crank raises and lowers the foot of the
bed. If the bed has a center crank, it will ad-
just the bed height. Normally, beds are kept
in their lowest horizontal position. Lowering
the bed provides for residents’ safety and
helps reduce the risk of falls.

Fig. 12-1. Caffeinated drinks, such as coffee or some teas,

can prevent sleep and cause fatigue and irritability. They
may need to be limited if they cause problems.

G If residents seem sad, anxious, or fearful,

help them by talking with them and listening
to their concerns. Provide emotional support.
If you think residents require more assis-
tance than you can give, discuss this with the
nurse.

2. Describe a standard resident unit

A resident’s unit is the room or area where the
resident lives. It contains the resident’s furniture
and personal possessions. The unit is the resi- Fig. 12-2. Controls for an electric bed. (photo courtesy of inva-
care continuing care group, 1-800-347-5440, www.invacare-ccg.com)
dent’s home and must be treated with respect.
 185 12

The Resident’s Unit

Fig. 12-3. The head, foot and height of an electric bed
are generally easily adjusted. (photo courtesy of invacare continu- Fig. 12-5. Overbed tables are often used for residents’
ing care group, 1-800-347-5440, www.invacare-ccg.com.) meals; they must be kept clean. Do not place bedpans,
urinals, or soiled linens on overbed tables.
• Bedside stand: Small items are usually
stored in bedside stands. The water pitcher • Call light: The intercom system is the most
and cup are often placed on top of the bed- common call system used. When the resi-
side stand. A telephone and/or a radio, and dent presses the button, a light will be seen
other items, such as photos, may also be and/or a bell will be heard at the nurses’
placed there. These items may be stored in- station. The call light allows the resident to
side the bedside stand: communicate with staff whenever necessary.
It is important to always place the call light
• Urinal/bedpan and covers within the resident’s reach and to answer all
• Wash basin call lights immediately.
• Privacy screen or curtain: All residents in
• Emesis basin (Fig. 12-4)
a facility have the right to personal privacy.
• Soap dish and soap This means that they must always be pro-
• Bath blanket tected from public view when receiving care.
Each bed in the facility usually has a privacy
• Toilet paper curtain that extends all the way around the
• Personal hygiene items bed. Screens and curtains keep others from
seeing a resident undressed or while hav-
ing care procedures done. Keep this curtain
closed when you are giving care to protect
the resident’s privacy. Although curtains
and screens block vision, they do not block
sound. Take care not to violate the resident’s
right to confidentiality through careless con-
Fig. 12-4. An emesis basin is a kidney-shaped basin often
used when giving mouth care. (reprinted with permission of briggs versation. Close the door when possible to
corporation, 800-247-2343, www.briggscorp.com)
provide more complete privacy.

• Overbed table: The overbed table may be Tip

used for meals or personal care. It is a clean Bed Positions
area and it must be kept clean and free of You first learned about body positions in Chapter 10.
clutter (Fig. 12-5). Bedpans, urinals, soiled You may be asked to position electric beds in spe-
linen, and other contaminated items should cific positions. To position the bed in the Fowler’s
position, raise the head of the bed 45 to 60 degrees.
not be placed on overbed tables. To position the bed in the semi-Fowler’s position,
raise the head of the bed 30 to 45 degrees.
12 186

3. Discuss how to care for and clean unit G Report signs of insects or pests immediately
equipment to the nurse.
G Check to see if any personal supplies need
You will be taught the correct way to use many
The Resident’s Unit

to be restocked. Make sure the resident has

pieces of equipment. It is important to know
fresh drinking water and a clean cup within
how to use and care for all equipment properly.
reach and is able to lift the pitcher and the
This prevents infection and injury. If you do not
cup. Make sure that tissues, paper towels,
know how to use a particular piece of equip-
toilet paper, soap and other supplies that are
ment, ask for assistance. Do not try to use equip-
used daily are stocked before you leave.
ment that you do not know how to use.
G If trash needs to be emptied or the bathroom
Some equipment you will use will be disposable
needs to be cleaned, notify the housekeeping
or “single-use.” This means it is discarded after
department. Trash should be emptied at least
one use. Disposable razors and latex gloves are
daily.
examples of this type of equipment. Disposable
equipment is used to prevent the spread of mi- G Do not move resident’s belongings or dis-
croorganisms. Discard disposable equipment in card any personal items. Respect the resi-
proper containers. dent’s things. Ask residents where they want
items stored. Offer to help residents arrange
Some equipment will need to be cleaned after
their space in a way that is pleasing to them.
each use. Bedpans, urinals, and wash basins are
If residents control the heat and air condi-
examples of this. Wear gloves while rinsing and
tioning in their rooms, do not change it for
cleaning this equipment so that you do not come
your comfort.
into contact with infectious wastes. Rinse them
with water before cleaning them. After cleaning G Clean equipment and return it to proper stor-
reusable equipment, you may need to disinfect age. Tidy the area. Providing a clean, safe,
or sterilize it. Follow facility policy. and orderly environment is part of your job.

Guidelines: 4. Explain the importance of sleep and

Resident’s Unit factors affecting sleep
Sleep is a natural period of rest for the mind and
G Clean the overbed table after use. Place it
body. As a person sleeps, the mind and body’s
within the resident’s reach before leaving.
energy is restored. During sleep, vital functions
G Keep equipment clean and in good condition. are performed, such as repairing and renewing
If any equipment appears broken or dam- cells, processing information, and organizing
aged, report it to the nurse and/or file the memory. Sleep is essential to a person’s health
proper paperwork to get it repaired. Do not and well-being.
use broken or damaged equipment.
The circadian rhythm is an important factor in
G Keep the call light within the resident’s reach determining sleep patterns of humans. The cir-
at all times. Check to see that the resident cadian rhythm is the 24-hour day-night cycle.
can reach the call light every time you are It also affects body temperature and hormone
going to leave the room. production, among other things.
G Remove meal trays right after meals. Check When a person is sleep-deprived or suffers from
to make sure that there are no crumbs in the insomnia (lack of ability to fall asleep or stay
bed. Straighten bed linens as needed. Change asleep), or other sleep disorders, problems result.
linens if they become wet, soiled, or wrinkled. These include decreased mental function, re-
 187 12

duced reaction time, and irritability. Sleep depri- 2. Microorganisms thrive in moist, warm
vation also decreases immune system function. places. Bedding that is damp or unclean may
cause infection and disease.
The elderly may take longer to go to sleep and

The Resident’s Unit

can have more irregular sleep patterns. Some 3. Residents who spend long hours in bed are
will take short naps during the day. Many elderly at risk for pressure sores. Sheets that do
persons, especially those who are living away not lie flat increase this risk by cutting off
from their homes, have sleep problems. Many circulation.
things can affect sleep, such as fear, stress,
noise, diet, medications, and illness. Sharing a
room with another person can disturb sleeping.

Observing and Reporting:

Sleep Issues

When a resident complains that he or she is not

sleeping well, observe and report the following:
Sleeping too much in daytime Fig. 12-6. Multiple layers of bedding, including a draw
sheet, are used for residents who spend a lot of time in
Eating or drinking items that contain too
bed.
much caffeine late in the day
Wearing night clothes during the day
Guidelines:
Eating heavy meals late at night Bedmaking
Refusing to take medication ordered for sleep
G Keep linens wrinkle-free and tidy. Change
Taking new medications linen whenever wet, damp, wrinkled, or dirty.
TV, radio, or light on late at night G Wash your hands before handling clean linen.
Pain G Hold soiled linens away from your body and
place it in the proper container immediately.
If dirty linen touches your uniform, your uni-
5. Describe bedmaking guidelines and
form becomes contaminated (Fig. 12-7).
perform proper bedmaking
When residents spend much or all of their time
in bed, careful bedmaking is essential to their
comfort, cleanliness, and health (Fig. 12-6).
Linens should always be changed after personal
care procedures such as bed baths, or any time
bedding or sheets are damp, soiled, or in need
of straightening. The following are three reasons
why it is important that bed linens be changed
frequently:
1. Sheets that are damp, wrinkled, or bunched
up under a resident are uncomfortable. They
may keep the resident from sleeping well. Fig. 12-7. Carry dirty linen away from your uniform.
12 188

G Do not shake linen or clothes. is in the bed. If the resident can be moved, your
G Put on gloves before removing bed linens job will be easier.
from beds.
Making an occupied bed
The Resident’s Unit

G Look for personal items, such as dentures,

Equipment: clean linen—mattress pad, fitted or flat
hearing aids, jewelry, and glasses, before
bottom sheet, waterproof bed protector if needed,
removing linens. cotton draw sheet, flat top sheet, blanket(s), bath
G When removing linen, fold or roll linen so blanket, pillowcase(s), gloves
that the dirtiest area is inside. Rolling puts 1. Wash your hands.
the dirtiest surface of the linen inward. This
2. Identify yourself by name. Identify the resi-
lessens contamination.
dent by name.
G Bag soiled linen at the point of origin. Do not
3. Explain procedure to the resident. Speak
take it to other residents’ rooms.
clearly, slowly, and directly. Maintain face-to-
G Sort soiled linen away from resident care face contact whenever possible.
areas.
4. Provide for the resident’s privacy with cur-
G Place wet linen in leak-proof bags. tain, screen, or door.
G Disposable bed protectors or pads are used 5. Place clean linen on clean surface within
for residents who are incontinent. Change the reach (e.g., bedside stand, overbed table, or
bed protectors as soon as they are soiled or chair).
wet, and dispose of them in the proper con-
6. Adjust bed to a safe working level, usually
tainer. Put a clean bed protector on the bed
waist high. Lower head of bed. Lock bed
when you change linens. (Fig. 12-8).
wheels.
7. Put on gloves.
8. Loosen top linen from the end of the bed on
the working side. Unfold bath blanket over
the top sheet to cover the resident, and re-
move the top sheet.
9. You will make the bed one side at a time. If
the bed has side rails, raise the side rail on
Fig. 12-8. Disposable absorbent pads help protect sheets far side of bed. After raising side rail, go to
from sweat, urine, feces, or other fluids. the other side. Help resident to turn onto
her side, moving away from you toward the
If a resident cannot get out of bed, you must raised side rail (Fig. 12-9).
change the linens with the resident in bed. An
occupied bed is a bed made while the resident
is in the bed. When making the bed, use a wide
stance. Bend your knees to avoid injury. Avoid
bending from the waist, especially when tucking
sheets or blankets under the mattress. Raise the
height of the bed to make it easier and safer.
Mattresses can be heavy. It is easier to make an
empty bed than one with a resident in it. An un-
Fig. 12-9.
occupied bed is a bed made while no resident
 189 12

10. Loosen bottom soiled linen, mattress pad 13. Smooth the bottom sheet out toward the
and protector if present on the working side. resident. Be sure there are no wrinkles in the
mattress pad. Roll the extra material toward
11. Roll bottom soiled linen toward resident.
the resident. Tuck it under the resident’s

The Resident’s Unit

Tuck it snugly against the resident’s back.
body (Fig. 12-11).
12. Place and tuck in clean bottom linen. Finish
with bottom sheet free of wrinkles. If you are
using a flat bottom sheet, leave enough over-
lap on each end to tuck under the mattress.
If the sheet is only long enough to tuck in at
one end, tuck it in securely at the top of the
bed. Make hospital corners to keep bottom
sheet wrinkle-free (Fig. 12-10).

Fig. 12-11.

14. If using a waterproof pad, unfold it and

center it on the bed. Tuck the side near you
under the mattress. Smooth it out toward the
resident. Tuck as you did with the sheet.

15. If using a draw sheet, place it on the bed.

Tuck in on your side, smooth, and tuck as
you did with the other bedding.

16. Raise side rail nearest you. Go to the other

side of the bed and lower the side rail. Help
resident to turn onto clean bottom sheet
(Fig. 12-12). Protect the resident from any
soiled matter on the old linens.

Fig. 12-12.

Fig. 12-10. Hospital corners help keep the flat sheet 17. Loosen the soiled linen. Check for any per-
smooth under the resident. They help prevent a resident’s sonal items. Roll linen from head to foot
feet from being restricted by or tangled in linen when get- of the bed. Avoid contact with your skin or
ting in and out of bed. clothes. Place it in a hamper or bag. Never
12 190

shake it. Soiled bed linens are full of microor- of the pillow. Pull the pillowcase over it with
ganisms that should not be spread to other your free hand (Fig. 12-14). Do the same for
parts of the room. any other pillows. Place them under resi-
dent’s head with open end away from door.
The Resident’s Unit

18. Pull and tuck in clean bottom linen just like

the other side. Finish with bottom sheet free
of wrinkles.

19. Ask resident to turn onto her back. Assist as

needed. Keep resident covered and comfort-
able, with a pillow under the head. Raise side
rail.

20. Unfold the top sheet. Place it over the resi-

dent. Ask the resident to hold the top sheet.
Slip the blanket or old sheet out from under- Fig. 12-14.
neath (Fig. 12-13). Put it in the hamper or
bag. 24. Make resident comfortable.

25. Return bed to lowest position. Remove pri-

vacy measures.

26. Place call light within resident’s reach.

27. Take laundry bag or hamper to proper area.

28. Wash your hands.

29. Report any changes in resident to the nurse.

Fig. 12-13.
30. Document procedure using facility
guidelines.
21. Place a blanket over the top sheet, match-
ing the top edges. Tuck the bottom edges
of top sheet and blanket under the bottom Making an unoccupied bed
of the mattress. Make hospital corners on Equipment: clean linen—mattress pad, fitted or flat
each side. Loosen the top linens over the bottom sheet, waterproof bed protector if needed,
resident’s feet. This prevents pressure on the blanket(s), cotton draw sheet, flat top sheet,
feet. At the top of the bed, fold the top sheet pillowcase(s), gloves
over the blanket about six inches. 1. Wash your hands.
22. Remove the pillow. Do not hold it near your 2. Place clean linen on clean surface within
face. Remove the soiled pillowcase by turning reach (e.g., bedside stand, overbed table, or
it inside out. Place it in the hamper or bag. chair).
Remove your gloves.
3. Adjust bed to a safe working level, usually
23. With one hand, grasp the clean pillowcase at waist high. Put bed in flattest position. Lock
the closed end. Turn it inside out over your bed wheels.
arm. Next, using the same hand that has the
pillowcase over it, grasp one narrow edge 4. Put on gloves.
 191 12

5. Loosen soiled linen. Roll soiled linen (soiled bed is opened to receive residents by loosening
side inside) from head to foot of bed. Avoid the linens on one side and folding them to the
contact with your skin or clothes. Place it in a other side. This leaves one side open. See Chap-
hamper or bag. ter 10 for information on transferring residents

The Resident’s Unit

into bed from a stretcher.
6. Remove and discard gloves. Wash your
hands.
Making a surgical bed
7. Remake the bed. Spread mattress pad and
bottom sheet, tucking under mattress. Make Equipment: clean linen (see procedure: Making an
unoccupied bed), gloves
hospital corners to keep the bottom sheet
wrinkle-free. Put on mattress protector and 1. Wash your hands.
draw sheet. Smooth and tuck under sides of
2. Place clean linen on clean surface within
bed.
reach (e.g., bedside stand, overbed table, or
8. Place top sheet and blanket over bed. Center chair).
these, tuck under end of bed and make hos-
3. Adjust bed to a safe working level, usually
pital corners. Fold down the top sheet over
waist high. Lock bed wheels.
the blanket about six inches. Fold both top
sheet and blanket down so resident can eas- 4. Put on gloves.
ily get into bed. If resident will not be return-
5. Remove all soiled linen, rolling it (soiled side
ing to bed immediately, leave bedding up.
inside) from head to foot of bed. Avoid con-
9. Remove pillows and pillowcases. Put on tact with your skin or clothes. Place it in a
clean pillowcases. Replace pillows. hamper or bag.

10. Return bed to lowest position. 6. Remove and discard gloves. Wash your
hands.
11. Take laundry bag or hamper to proper area.
7. Make an unoccupied, closed bed. See proce-
12. Wash your hands.
dure: Making an unoccupied bed.
13. Document procedure using facility
8. Loosen linens on the side of bed that is away
guidelines.
from the door (where the stretcher will be).

A closed bed is a bed completely made with the 9. Fanfold linens lengthwise to the side away
bedspread and blankets in place. It is made for from door (Fig. 12-15). Fanfolded means
residents who will be out of bed most of the day. folded several times into pleats.
It is also made when a resident is discharged.
A closed bed is converted to an open bed by
fanfolding the linen down to the foot of the bed.
An open bed is a bed that is ready to receive a
resident who has been out of bed all day or who
is being admitted to the facility.
A surgical bed is made to accept residents who
are returning to bed on stretchers, or gurneys.
These residents may be coming from a hospital
or returning from a test or procedure. A surgical Fig. 12-15.
12 192

10. Put on clean pillowcases (as described

above). Replace pillows.

11. Leave bed in its locked position with both

The Resident’s Unit

side rails down.

12. Make sure the pathway to the bed is clear.

13. Take laundry bag or hamper to proper area.

14. Wash your hands.

15. Document procedure using facility

guidelines.

Chapter Review
1. What are three ways that nursing assistants
can keep the noise level low in facilities?
2. What are three ways that nursing assistants
can help control odors in facilities?
3. How do electric bed controls usually work?
4. Why are beds usually kept in their lowest
positions?
5. What is the overbed table used for? Can bed-
pans and soiled linen be placed on an over-
bed table?
6. Where should call lights always be placed?
7. How do screens and curtains help protect
residents’ privacy?
8. What can the use of disposable equipment
help prevent?
9. List two functions that sleep performs for
the body.
10. What problems can result from not getting
enough sleep?
11. What are three reasons why bed linens
should be changed often?
12. Define the following terms: occupied bed,
unoccupied bed, closed bed, open bed, and
surgical bed.
13. Which way should pillows face while under
residents’ heads?
 193 13

13

Personal Care Skills

Personal Care Skills

1. Explain personal care of residents tasks every day. These activities are often called
“a.m. care” or “p.m. care,” which refers to the
Personal care is different from taking vital signs time of day when they are done.
or tidying a resident’s unit, which are other tasks
that NAs may perform for residents. The term Assisting with a.m. care includes the following:
“personal” refers to tasks that are concerned • Offering a bedpan or urinal or helping the
with the person’s body, appearance, and hygiene, resident to the bathroom
and suggests privacy may be important. Hy-
• Helping the resident to wash face and hands
giene is the term used to describe practices to
keep our bodies clean and healthy. Bathing and • Assisting with mouth care before or after
brushing teeth are two examples. Grooming breakfast, as the resident prefers
refers to practices like caring for fingernails and Assisting with p.m. care includes the following:
hair. Hygiene and grooming activities, as well as
dressing, eating, transferring, and toileting are • Offering a bedpan or urinal or helping the
called activities of daily living (ADLs). resident to the bathroom

Some people who are recovering from an illness • Helping the resident to wash face and hands
or an accident may not have the energy to care • Giving a snack
for themselves. Other reasons someone may
• Assisting with mouth care
need personal care include the following:
• Giving a back rub
• A person has a long-term, chronic condition
Some residents may never be able to care for
• A person is frail because of advanced age
themselves, and you will assist them as needed.
• A person is permanently disabled However, some residents will regain strength
• A person is dying and be able to perform their own personal care.
An important part of your job is to help resi-
These residents may need assistance with their dents be as independent as possible. This means
personal care, or they may need you to provide encouraging residents to care for themselves.
it for them entirely. You may provide any or all Promoting independence is part of your care.
of the personal care, including bathing, perineal
care (care of genitals and anal area), toileting, We all have routines for personal care and ac-
mouth care, shampooing and combing the hair, tivities of daily living. We also have preferences
nail care, shaving, dressing, eating, walking, and for how they are done. These routines remain
transferring. You will assist residents with these important even when we are elderly, sick, or
13 194

disabled. Be aware of your residents’ individual

preferences concerning their personal care. Resi-
dents may prefer certain soaps or skin care prod-
ucts. They may choose to bathe in the morning
Personal Care Skills

or at night. It is important to ask residents about

their routines and preferences.
Many people have been doing personal care
tasks for themselves their entire lives. They may
feel embarrassed or uncomfortable about having Fig. 13-1. Let the resident make as many decisions as
anyone do or help them do these tasks. Some possible about the personal care you will perform.
residents may not like to be touched by someone
else. It is important to understand how stressful Personal care gives you the opportunity to ob-
it may be for some people to have help with per- serve your resident’s skin, mental state, mobility,
sonal care. Be sensitive to this. Be professional flexibility, comfort level, and ability to perform
when helping with these tasks. ADLs. While assisting with personal care, look
for any problems or changes that have occurred.
Before you begin any task, explain to the resi-
Communication is especially important during
dent exactly what you will be doing. Explaining
personal care. Some residents will talk about
care to a resident is not only his legal right, but
symptoms they are experiencing during per-
it may also help lessen anxiety. Ask if he or she
sonal care. They may tell you that they have been
would like to use the bathroom or bedpan first.
itching or their skin feels dry. They may com-
Provide the resident with privacy. Let him or her
plain of numbness and tingling in a certain part
make as many decisions as possible about when,
of the body. Keep a small note pad in a pocket
where, and how a procedure will be done (Fig.
to jot down exactly how the resident describes
13-1). This promotes dignity and independence.
these symptoms. Make notes right after the pro-
Encourage residents to do as much as they are
cedure. Report these comments to the nurse and
able to do while giving care. Other ways to pro-
document them properly.
mote respect, dignity, and privacy include:
Observe the resident’s mental and emotional
• Knocking before entering the resident’s
state at this time. Is the resident depressed or
room
confused? Can the resident concentrate on the
• Not interrupting residents while they are in activity or hold a conversation? Is the resident
the bathroom short of breath? Does the resident tremble or
• Leaving the room when residents receive or shake? Focus on changes from the resident’s
make phone calls normal state. Is there a change in behavior, level
of activity, skin color, movement, or anything
• Respecting residents’ private time and per- else? You are in the best position to observe,
sonal things report, and document any small change in your
• Not interrupting residents while they are resident. No matter what care task is assigned to
dressing you, performing it is only half the job.

• Encouraging residents to do things for them- During the procedure, if the resident appears
selves and being patient tired, stop and take a short rest. Never rush a
resident. After care, always ask if the resident
• Keeping residents covered whenever possible
would like anything else. Leave the resident’s
when you help with dressing
area clean and tidy. Make sure the call light is
 195 13

within reach. Check to see that the room has

good lighting and is a comfortable temperature.
Make sure that there are not electrical cords or
other objects in the walkways. Leave the bed in

Personal Care Skills

its lowest position unless instructed otherwise.

Observing and Reporting:

Personal Care

Skin color, temperature, redness (more infor-

mation listed in next learning objective)
Mobility
Flexibility
Comfort level, or pain or discomfort
Strength and the ability to perform ADLs
Fig. 13-2. Pressure sore danger zones.
Mental and emotional state
When skin begins to break down, it becomes
Resident complaints
pale, white, or a reddened color. Darker skin may
look purple. The resident may also feel tingling
2. Identify guidelines for providing good or burning in the area. This discoloration does
skin care and preventing pressure sores not go away, even when the resident’s position
is changed. If pressure is allowed to continue,
Immobility reduces the amount of blood that
the area will further break down. The result-
circulates to the skin. Residents who have re-
ing wound is called a pressure sore, bed sore,
stricted mobility have a higher risk of skin dete-
or decubitus ulcer. Once a pressure sore forms,
rioration at pressure points. Pressure points are
it can get bigger, deeper, and infected. Most
areas of the body that bear much of its weight.
pressure sores occur within a few weeks of ad-
Pressure points are mainly located at bony
mission to a nursing home. Pressure sores are
prominences. Bony prominences are areas of
painful and difficult to heal. They can lead to
the body where the bone lies close to the skin.
life-threatening infections. Prevention is the key
These areas include elbows, shoulder blades,
to skin health.
tailbone, hip bones, ankles, heels, and the back
of the neck and head. The skin here is at a much There are four accepted stages of pressure sores
higher risk for skin breakdown. (Fig. 13-3):

Other areas at risk are the ears, the area under • Stage 1: Skin is intact but there is redness
the breasts, and the scrotum (Fig. 13-2). The that is not relieved within 15 to 30 minutes
pressure on these areas reduces circulation, after removing pressure.
decreasing the amount of oxygen the cells re- • Stage 2: There is partial skin loss involving
ceive. Warmth and moisture also contribute to the outer and/or inner layer of skin. The
skin breakdown. Once the surface of the skin ulcer is superficial. It looks like a blister or a
is weakened, pathogens can invade and cause shallow crater.
infection. When infection occurs, the healing • Stage 3: There is full skin loss involving
process is slower. damage or death of tissue that may extend
13 196

down to but not through the tissue that Any change in the appearance of the skin,
covers muscle. The ulcer looks like a deep such as the “orange-peel” look or a purplish
crater. hue
Personal Care Skills

• Stage 4: There is full skin loss with major Extremely dry, crust-like areas that might be
destruction, tissue death, damage to muscle, covering a tissue break upon closer look
bone, or supporting structures.
Breaks in the skin can cause serious, even life-
Stage 1 Stage 2 threatening, complications. It is much better to
prevent skin problems and keep the skin healthy
than it is to treat skin problems. The following
are guidelines for basic skin care:

Guidelines:
Stage 3 Stage 4
Basic Skin Care

G Report any changes in a resident’s skin.

G Provide regular, daily care for skin to keep it
clean and dry. When complete baths are not
Fig. 13-3. Pressure sores are categorized by four stages.
(photos courtesy of dr. tamara d. fishman and the wound care institute, inc.) taken every day, check the resident’s skin.
G Reposition immobile residents often (at least
Observing and Reporting: every two hours).
Resident’s Skin
G Give frequent and thorough skin care as
Report any of these to the nurse: often as needed for incontinent residents.
Change clothing and linens often as well.
Pale, white, reddened, or purple areas, blis-
Check on them every two hours or as needed.
ters or bruises on the skin
G Do not scratch or irritate the skin in any way.
Complaints of tingling, warmth, or burning of
Keep rough, scratchy fabrics away from the
the skin
resident’s skin. Report to the nurse if a resi-
Dry or flaking skin dent wears shoes that cause blisters or sores.
Itching or scratching G Massage the skin often. Use light, circular
Rash or any skin discoloration strokes to increase circulation. Use little or
no pressure on bony areas. Do not massage
Swelling
a white, red, or purple area or put any pres-
Fluid or blood draining from skin sure on it. Massage the healthy skin and tis-
Broken skin sue around the area.
Wounds or ulcers on the skin G Be careful during transfers. Avoid pulling or
Changes in wound or ulcer (size, depth, tearing fragile skin.
drainage, color, odor) G Residents who are overweight may have poor
Redness or broken skin between toes or circulation and extra folds of skin. The skin
around toenails under the folds may be difficult to clean and
to keep dry. Pay careful attention to these
In darker complexions, also look for: areas and give regular skin care. Report signs
Any change in the feel of the tissue of skin irritation.
 197 13

G Residents should eat well-balanced meals. G Relieve pressure under bony prominences.
Proper nutrition is important for keeping Place foam rubber or sheepskin pads under
skin healthy. Nutrition affects the color and them. Heel and elbow protectors made of
texture of the skin. Very thin residents may foam and sheepskin are available (Fig. 13-5).

Personal Care Skills

be malnourished, which puts them at risk
for skin injuries. Be gentle when moving and
positioning them. You will learn more about
nutrition in Chapter 15.
G Keep plastic or rubber materials from coming
into contact with the resident’s skin. These
materials prevent air from circulating, which
causes the skin to sweat.
G The care plan may include instructions on Fig. 13-5. Padded heel protectors help keep feet properly
giving special skin care for dry, closed aligned and prevent pressure sores. (reprinted with permission of
briggs corporation, 800-247-2343, www.briggscorp.com)
wounds or other conditions. The skin may
have to be washed with a special soap, or a
G A bed or chair can be made softer with flota-
brush may have to be used on the skin.
tion pads.
Follow the care plan and nurse’s instructions.
G Use a bed cradle to keep top sheets from
For residents who are not mobile or cannot
rubbing the resident’s skin.
change positions easily, remember:
G Keep the bottom sheet tight and free from G Residents seated in chairs or wheel-
wrinkles. Keep the bed free from crumbs. chairs need to be repositioned often, too.
Keep clothing or gowns free of wrinkles, too. Reposition residents every 15 minutes if
they are in a wheelchair or chair and cannot
G Do not pull the resident across sheets during change positions easily.
transfers or repositioning. This causes shear-
ing, which can lead to skin breakdown. Applying Nonprescription Ointments, Lotions
G Place a sheepskin, chamois skin, or bed pad or Powders
under the back and buttocks to absorb mois-
You may be assigned to apply ointments, lotions or
ture or perspiration that may build up and powders to a resident’s skin (Fig. 13-6). Not all nurs-
to protect the skin from irritating bed linens ing assistants are allowed to do this. Make sure you
(Fig. 13-4). understand the rules in your facility. If instructed to
apply an ointment, lotion, or powder by the nurse,
follow these rules. Ask questions if anything is
unclear.
• Read the directions.
• Know exactly where it is to be applied
• Know if it should be rubbed in or left on the top
of the skin.
• Wash your hands before and after application
• Wear gloves.
Fig. 13-4. A sheepskin or chamois skin may be placed
under the resident to absorb moisture. (reprinted with permis- • Avoid getting any on clothing as it may stain.
sion of briggs corporation, 800-247-2343, www.briggscorp.com)
13 198

feet and ankles that causes difficulty with the

ability to flex the ankles and walk normally.
Rolled blankets or pillows can also be used
as footboards.
Personal Care Skills

Fig. 13-7. Footboards help prevent pressure sores. (reprinted

with permission of briggs corporation, 800-247-2343, www.briggscorp.com)

G Handrolls keep the fingers from curling

Fig. 13-6. There are many types of ointments, creams, tightly. A rolled washcloth, gauze bandage, or
and lotions that are used to treat, soften, and protect the a rubber ball placed inside the palm may be
skin. (reprinted with permission of briggs corporation, 800-247-2343, used to keep the hand in a natural position
www.briggscorp.com)
(Fig. 13-8).
Many positioning devices are available to help
make residents more comfortable and safe.

Guidelines
Positioning Devices:

G Backrests provide support and can be regular

pillows or special wedge-shaped foam
pillows.
G Bed cradles are used to keep the bed covers
from pushing down on a resident’s feet.
Fig. 13-8. Handrolls help keep fingers from curling too
G Use draw sheets, or turning sheets, under tightly. (reprinted with permission of briggs corporation, 800-247-2343,
www.briggscorp.com)
residents who cannot help with turning, lift-
ing, or moving up in bed. Draw sheets help G Splints are a type of orthotic device (Fig.
prevent skin damage from shearing. A regu- 13-9). An orthotic device is a device, such
lar bed sheet folded in half can be used as a as a splint or brace, that helps support and
draw sheet. align a limb and improve its functioning.
G Footboards are padded boards placed against Orthotics also help prevent or correct defor-
the resident’s feet to keep them properly mities. Splints and the skin area around them
aligned and to prevent foot drop (Fig. 13-7). should be cleaned at least once daily and as
Foot drop is a weakness of muscles in the needed.
 199 13

3. Explain guidelines for assisting with

bathing
Bathing promotes good health and well-being.

Personal Care Skills

It removes perspiration, dirt, oil, and dead skin
cells that collect on the skin. It helps to prevent
skin irritation and body odor. Bathing can also
be relaxing. The bed bath is an excellent time
for moving arms and legs and increasing circu-
lation. Bathing gives you an opportunity to ob-
Fig. 13-9. One type of splint. (photo courtesy of lenjoy medical
engineering “comfy splints tm” 800-582-5332, www.comfysplints.com) serve residents’ skin carefully.
Residents may be given a complete bath in bed,
G Trochanter rolls keep a resident’s hips from or they may take a shower or have a tub bath.
turning outward (Fig. 13-10). A rolled towel They may have a partial bath, which is a bath
works well, too. given on days when a complete bed bath, tub
bath, or shower is not done. It includes wash-
ing the face, hands, axillae (underarms), and
perineum. The perineum is the genital and anal
area.
Most people have specific preferences for bath-
ing. Some like to take long hot baths, while
Fig. 13-10. Trochanter rolls help keep the hips in their others prefer a quick shower. Usually they have
proper position.
been bathing the same way most of their lives.
G Knee pillows can help keep spine, hips, and Doctors have factors to consider about whether
knees in the proper position and ease pain in or not to honor residents’ personal preferences
the back, leg, hip and knee areas (Fig. 13-11). regarding bathing. They include the resident’s
capabilities and his or her safety, as well as the
safety of the caregiver. The doctor, along with
the resident, will decide which type of bath is
appropriate.
A doctor may order a special bath using an ad-
ditive. An additive is a substance added to an-
other substance, changing its effect. Examples of
some common bath additives and their purpose
include the following:
• Bran helps to relieve itching.
• Oatmeal baths are used for inflamed skin.
Oatmeal helps in relieving itching and irrita-
tion and is soothing.
• Sodium bicarbonate (baking soda) is used to
Fig. 13-11. Knee pillows help keep the knees, hip, and treat psoriasis (non-contagious skin disorder
spine in the proper alignment. (reprinted with permission of briggs that causes red scaly patches on the skin)
corporation, 800-247-2343, www.briggscorp.com)
and helps relieve itching.
13 200

• Epsom salts baths or soaks reduce pain and

Giving a complete bed bath
swelling and relax muscles.
Equipment: bath blanket, bath basin, soap, bath
• Pine products help refresh, calm and cool. thermometer, 2-4 washcloths, 2-4 bath towels, clean
Personal Care Skills

• Tar coal baths are used to treat eczema and gown or clothes, gloves, orangewood stick or emery
other skin conditions. board, lotion, deodorant

• Sulfur baths may be used for skin rashes, 1. Wash your hands.
eczema, and to help relieve inflammation 2. Identify yourself by name. Identify the resi-
related to arthritis. dent by name.

3. Explain procedure to the resident. Speak

Guidelines: clearly, slowly, and directly. Maintain face-to-
Bathing face contact whenever possible.

G The face, hands, underarms, and perineum 4. Provide for the resident’s privacy with cur-
should be washed every day. A complete bath tain, screen, or door. Be sure the room is a
or shower can be taken every other day or comfortable temperature and there are no
even less often. drafts.

G Older skin produces less perspiration and 5. Adjust bed to a safe level, usually waist high.
oil. Elderly people with dry and fragile skin Lock bed wheels.
should bathe only once or twice a week. This
6. Place a bath blanket or towel over resident
prevents further dryness. Be gentle with the
(Fig. 13-12). Ask him to hold onto it as you
skin when bathing residents.
remove or fold back top bedding. Remove
G Use only products approved by the facility or gown, while keeping resident covered with
that the resident prefers. bath blanket (or top sheet).
G Before bathing a resident, make sure the
room is warm enough.
G Be familiar with available safety and assistive
devices.
G Before bathing, make sure the water tempera-
Fig. 13-12. Cover the resident with a cotton blanket be-
ture is safe and comfortable. Test the water
fore removing top bedding.
temperature to make sure it is not too hot,
then have the resident test the water tem-
7. Fill the basin with warm water. Test water
perature. His or her sense of touch may be
temperature with thermometer or your wrist
different than yours. The resident is best able
and ensure it is safe. Water temperature
to choose a comfortable water temperature.
should be 105° to 110° F. It cools quickly.
G Gather supplies before giving a bath so the Have resident check water temperature. Ad-
resident is not left alone. just if necessary. Change the water when it
becomes too cool, soapy, or dirty.
G Make sure all soap is removed from the skin
before completing the bath. 8. Put on gloves.
G Keep a record of the bathing schedule for 9. Ask and assist resident to participate in
each resident. Follow the care plan. washing.
 201 13

10. Uncover only one part of the body at a time.

Place a towel under the body part being
washed.

Personal Care Skills

11. Wash, rinse, and dry one part of the body at a
time. Start at the head. Work down, and com-
plete the front first. Fold the washcloth over
your hand like a mitt and hold it in place with
the thumb (Fig. 13-13).

Fig. 13-15. Support the wrist while washing the shoulder,

arm, underarm, and elbow.

Wash the hand in a basin: Clean under the

nails with an orangewood stick or nail brush
Fig. 13-13. Fold the washcloth to make a mitt.
if available (Fig. 13-16). Rinse and pat dry.
Give nail care (see procedure later in this
Eyes and Face: Wash face with wet washcloth
chapter) if it has been assigned. Do not give
(no soap). Begin with the eye farther away
nail care to a diabetic resident. Repeat for
from you. Wash inner aspect to outer aspect
the other arm. Put lotion on the resident’s
(Fig. 13-14). Use a different area of the wash-
elbows and hands if ordered.
cloth for each eye. Wash the face from the
middle outward. Use firm but gentle strokes.
Wash the neck and ears and behind the ears.
Rinse and pat dry.

Fig. 13-16. Wash the hand in a basin. Thoroughly clean

under the nails with a nail brush.

Chest: Place the towel again across the resi-

dent’s chest. Pull the blanket down to the
waist. Lift the towel only enough to wash the
Fig. 13-14. Wash the eye from the inner part to the outer
chest. Rinse it, and pat dry. For a female resi-
part.
dent, wash, rinse, and dry breasts and under
breasts. Check the skin in this area for signs
Arms: Remove the resident’s top clothing.
of irritation and chafing.
Cover him with the bath blanket or towel.
With a soapy washcloth, wash the upper arm Abdomen: Fold the blanket down so that it
and underarm. Use long strokes from the still covers the pubic area. Wash the abdo-
shoulder down to the wrist (Fig. 13-15). Rinse men, rinse, and pat dry. If the resident has an
and pat dry. ostomy, or opening in the abdomen for get-
13 202

ting rid of body wastes, give skin care around raise the rail on the far side for safety. Fold
the opening (Chapter 17 includes more in- the blanket away from the back. Place a towel
formation about ostomies). Cover with the lengthwise next to the back. Wash the back,
towel. Pull the cotton blanket up to the resi- neck, and buttocks with long, downward
Personal Care Skills

dent’s chin. Remove the towel. strokes. Rinse and pat dry (Fig. 13-19). Apply
lotion if ordered.
Legs and Feet: Expose one leg and place a
towel under it. Wash the thigh. Use long
downward strokes. Rinse and pat dry. Do the
same from the knee to the ankle (Fig. 13-17).

Fig. 13-17. Use long downward strokes when washing the Fig. 13-19. Wash the back with long downward strokes.
legs.
12. Place the towel under the buttocks and upper
Place another towel under the foot. Move thighs. Help the resident turn onto his back.
the basin to the towel. Place the foot into the Ask if he is able to wash the perineal area. If
basin. Wash the foot and between the toes the resident is able to do this, place a basin
(Fig. 13-18). Rinse foot and pat dry. Make of clean, warm water and a washcloth and
sure area between toes is dry. Give nail care towel within reach. Leave the room if the
(see procedure later in this chapter) if it resident desires. If the resident has a urinary
has been assigned. Do not give nail care to catheter in place, remind him not to pull it.
a diabetic resident. Never clip a resident’s
toenails. Apply lotion to the foot if ordered, 13. If the resident is unable to provide perineal
especially at the heels. Do not apply lotion care, you must do so. Put on gloves first (if
between the toes. Repeat steps for the other you have not already done so). Provide pri-
leg and foot. vacy at all times.

14. Perineal area and buttocks: Change the bath

water. Wash, rinse, and dry perineal area,
working from front to back.

For a female resident: Wash the perineum

with soap and water. Work from front to back,
using single strokes (Fig. 13-20). Do not
wash from the back to the front. This may
cause infection. Use a clean area of wash-
Fig. 13-18. Washing the feet includes cleaning between cloth or a clean washcloth for each stroke.
the toes. First wipe the center of the perineum, then
each side. Then spread the labia majora, the
Back: Help resident move to the center of outside folds of perineal skin that protect
the bed. Ask resident to turn onto his side the urinary meatus and the vaginal opening.
so his back is facing you. If the bed has rails, Wipe from front to back on each side. Rinse
 203 13

the area in the same way. Dry entire perineal 16. Empty, rinse, and dry bath basin. Place basin
area moving from front to back. Use a blot- in designated dirty supply area or return to
ting motion with towel. Ask resident to turn storage, depending on facility policy.
on her side. Wash, rinse, and dry buttocks

Personal Care Skills

17. Place soiled clothing and linens in proper
and anal area. Cleanse the anal area without
containers.
contaminating the perineal area.
18. Remove and dispose of gloves properly. Wash
your hands.
19. Put clean gown on resident. Provide resident
with deodorant. Brush or comb the resident’s
hair (see procedure later in this chapter).
20. Make resident comfortable. Make sure sheets
are free from wrinkles and the bed free from
crumbs.
Fig. 13-20. Always work from front to back when per- 21. Return bed to lowest position. Remove pri-
forming perineal care. This helps prevent infection. vacy measures.

For a male resident: If the resident is uncir- 22. Place call light within resident’s reach.
cumcised, pull back the foreskin first. Gently 23. Wash your hands.
push skin towards the base of penis. Hold
24. Report any changes in resident to the nurse.
the penis by the shaft. Wash in a circular mo-
tion from the tip down to the base. Use a 25. Document procedure using facility
clean area of washcloth or clean washcloth guidelines.
for each stroke (Fig. 13-21). Rinse the penis.
If resident is uncircumcised, gently return A back rub can help relax residents. It can make
foreskin to normal position. Then wash the them more comfortable and increase circulation.
scrotum and groin. The groin is the area Back rubs are often given after baths. After giv-
from the pubis (area around the penis and ing a back rub, make sure to note any changes
scrotum) to the upper thighs. Rinse and in a resident’s skin.
pat dry. Ask the resident to turn on his side.
Giving a back rub
Wash, rinse, and dry buttocks and anal area.
Cleanse the anal area without contaminating Equipment: cotton blanket or towel, lotion
the perineal area. 1. Wash your hands.
2. Identify yourself by name. Identify the resi-
dent by name.
3. Explain procedure to the resident. Speak
clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.
4. Provide for resident’s privacy with curtain,
Fig. 13-21. Wash the penis in a circular motion from the screen, or door.
tip down to the base. 5. Adjust bed to a safe working level, usually
waist high. Lower the head of the bed. Lock
15. Cover the resident with the blanket. bed wheels.
13 204

6. Position resident in the prone position (lying Move upward together along each side of the
on his stomach). If this is uncomfortable, spine. Apply gentle downward pressure with
have him lie on his side. Cover with a cotton fingers and thumbs. Follow same direction
blanket, then fold back bed covers. Expose as with the long smooth strokes, circling at
Personal Care Skills

the back to the top of the buttocks. Back rubs shoulders and buttocks.
can also be given with the resident sitting up.
10. Gently massage bony areas (spine, shoulder
7. Warm lotion by putting bottle in warm water blades, hip bones). Use circular motions of
for five minutes. Run your hands under warm fingertips. If any of these areas are red, mas-
water. Pour lotion on your hands and rub sage around them, rather than on them. The
them together. Always put lotion on your redness indicates that the skin is already ir-
hands rather than on resident’s skin. ritated and fragile. Include this information in
your report to the nurse.
8. Place your hands on each side of upper part
of the buttocks. Make long, smooth upward 11. Let the resident know when you are almost
strokes with both hands. Move along each through. Finish with some long smooth
side of the spine, up to the shoulders (Figs. strokes, like the ones you used at the begin-
13-22 and 13-23). Circle your hands outward. ning of the massage.
Then move back along outer edges of the 12. Dry the back if extra lotion remains on it.
back. At buttocks, make another circle. Move
your hands back up to the shoulders. With- 13. Remove blanket and towel.
out taking your hands from resident’s skin, 14. Help the resident get dressed. Make resident
repeat this motion for three to five minutes. comfortable. Make sure sheets are free from
wrinkles and the bed free from crumbs.
15. Store supplies. Place soiled clothing and lin-
ens in proper containers.
16. Return bed to lowest position. Remove pri-
vacy measures.
17. Place call light within resident’s reach.
Fig. 13-22. A resident on his side.
18. Wash your hands.
19. Report any changes in resident to the nurse.
20. Document procedure using facility
guidelines.

Hair care is an important part of cleanliness.

Shampooing the hair removes dirt, bacteria,
oils, and other materials from the hair. Resi-
dents who can get out of bed may have their hair
shampooed in the sink, tub, or shower. For resi-
dents who cannot get out of bed, special troughs
Fig. 13-23. A resident on his stomach.
exist for shampooing hair in bed. Troughs fit
under the resident’s head and neck and have a
9. Knead with the first two fingers and thumb of spout or hose that drains the water into a basin
each hand. Place them at base of the spine. at the side of the bed (Fig. 13-24). There are also
 205 13

special types of shampoo that do not require the 3. Explain procedure to the resident. Speak
use of water (Fig. 13-25). Follow the care plan on clearly, slowly, and directly. Maintain face-to-
what type of shampoo to use. face contact whenever possible.

Personal Care Skills

4. Provide for the resident’s privacy with cur-
tain, screen, or door. Be sure the room is a
comfortable temperature and there are no
drafts.

5. Test water temperature with thermometer or

your wrist. Ensure it is safe. Water tempera-
ture should be 105° F. Have resident check
water temperature. Adjust if necessary.
Fig. 13-24. An inflatable bed shampoo trough can be
used to shampoo hair while the person is in bed. (reprinted 6. Position the resident and wet the resident’s
with permission of briggs corporation, 800-247-2343, www.briggscorp.com)
hair.

a. For washing hair in the sink, seat the resident

in a chair covered with a protective plastic
drape or sheet. Use a pillow under the plastic
to support the head and neck. Have the resi-
dent lean her head back toward the sink. Give
the resident a folded washcloth to hold over
her forehead or eyes. Wet hair using a plastic
cup or a hand-held sink attachment
(Fig. 13-26).

Fig. 13-25. One type of shampoo that does not require

water. (reprinted with permission of briggs corporation, 800-247-2343,
www.briggscorp.com)

Shampooing hair

Equipment: shampoo, hair conditioner (if re- Fig. 13-26. Make sure the resident’s head and neck are
supported and her eyes covered when washing hair in the
quested), 2 bath towels, washcloth, bath thermom-
sink.
eter, pitcher or handheld shower or sink attachment,
waterproof pad (if washing hair in bed), bath blan-
ket (if washing hair in bed), trough and catch basin b. For washing hair in bed, arrange the supplies
(for washing hair in bed), protective plastic sheet or within reach on a nearby table. Remove all
drape (if washing hair in sink) comb and brush, hair pillows, and place the resident in a flat posi-
dryer tion. Adjust bed to a safe level, usually waist
1. Wash your hands. high. Lock bed wheels. Place a waterproof
pad beneath the resident’s head and shoul-
2. Identify yourself by name. Identify the resi- ders. Cover the resident with the blanket, and
dent by name. fold back the top sheet and regular blankets.
13 206

Place the trough under the resident’s head 10. Remove the hair towel and gently rub scalp
and connect trough to the catch basin. Place and hair with the towel. Comb or brush hair
one towel across the resident’s shoulders. (see procedure later in the chapter).
Protect resident’s eyes with a dry wash-
Personal Care Skills

11. Dry hair with a hair dryer on the low setting.

cloth. Using the pitcher or attachment, pour
Style hair as the resident prefers.
enough water on the resident’s hair to make
it thoroughly wet. 12. Make resident comfortable. Make sure sheets
are free from wrinkles and the bed free from
7. Apply a small amount of shampoo to your
crumbs.
hands and rub them together. Using both
hands, massage the shampoo to a lather 13. Return bed to lowest position. Remove pri-
in the resident’s hair. With your fingertips, vacy measures.
massage the scalp in a circular motion, from
14. Place call light within resident’s reach.
front to back (Fig. 13-27). Do not scratch the
scalp. 15. Empty, rinse, and wipe bath basin/pitcher.
Take to proper area.

16. Clean comb/brush. Return hair dryer and

comb/brush to proper storage.

17. Place soiled linen in proper container.

18. Wash your hands.

19. Report any changes in resident to nurse.

20. Document procedure using facility

guidelines.

Many people prefer showers or tub baths to bed

baths (Fig. 13-28). Check with the nurse first to
make sure a shower or tub bath is allowed.

Fig. 13-27. Use your fingertips to work shampoo into a

lather. Be gentle so that you do not scratch the scalp.

8. Rinse the hair in the same way you wet it.

Rinse until water runs clear. Repeat the
shampoo, rinse again, and use conditioner if
the resident wants it. Be sure to rinse the hair
thoroughly to prevent the scalp from getting
dry and itchy.
9. Wrap the resident’s hair in a towel. If sham-
pooing at the sink, return the resident to
an upright position. If shampooing in bed,
remove the trough. Using the washcloth or
a face towel, wipe water from the head and Fig. 13-28. A common style of tub in nursing homes.
(photo courtesy of lee penner of penner tubs)
neck.
 207 13

2. Place equipment in shower or tub room.

Guidelines:
Clean shower or tub area and shower chair.
Safety for Showers and Tub Baths
3. Wash your hands.

Personal Care Skills

G Clean tub or shower before and after use.
4. Go to resident’s room. Identify yourself by
G Make sure bathroom or shower room floor is name. Identify the resident by name.
dry.
5. Explain procedure to the resident. Speak
G Be familiar with available safety and assistive clearly, slowly, and directly. Maintain face-to-
devices. Check that hand rails, grab bars, and face contact whenever possible.
lifts are in working order.
6. Provide for resident’s privacy with curtain,
G Have resident use safety bars to get into or screen, or door.
out of the tub or shower.
7. Help resident to put on nonskid footwear.
G Place all needed items within reach.
Transport resident to shower or tub room.
G Do not leave the resident alone.
For a shower:
G Bath oils and lotions are used to moistur-
8. If using a shower chair, place it into position.
ize dry skin. Powders are drying and may be
Lock wheels (Fig. 13-29). Safely transfer resi-
applied to moist or oily skin. Both lotions
dent into shower chair.
and powders reduce friction. They help pro-
tect the skin from injury when it is in contact
with bed sheets or in skin folds. However,
do not use bath oils, lotions, or powders in
showers or tubs. They make surfaces slippery
and dangerous.
G Test water temperature with thermometer or
your wrist before resident gets into shower.
Water temperature should be no more than
105° F. Make sure temperature is comfort-
able for resident.

Residents’ Rights
Privacy when Bathing
Privacy is very important when transporting resi-
dents to the shower or tub room and during the
shower or tub bath. Keep residents covered and
Fig. 13-29. A shower chair must be locked before trans-
make sure their bodies are not unnecessarily
ferring a resident into it. (photo courtesy of innovative products
exposed. unlimited)

9. Turn on water. Test water temperature with

Giving a shower or tub bath
thermometer. Water temperature should be
Equipment: bath blanket, soap, shampoo, bath no more than 105° F. Have resident check
thermometer, 2-4 washcloths, 2-4 bath towels, clean water temperature.
gown and robe or clothes, non-skid footwear, gloves,
lotion, deodorant For a tub bath:

1. Wash your hands. 8. Safely transfer resident onto chair or tub lift.
13 208

9. Fill the tub halfway with warm water. Test Tip

water temperature with thermometer. Water
Shower Chairs
temperature should be no more than 105°F.
A shower chair is a sturdy chair designed to be
Have resident check water temperature.
Personal Care Skills

placed in a bathtub or shower. It is water- and slip-

resistant. The chair or bench enables a person who
Remaining steps for either procedure:
is unable to get into a tub or is too weak to stand in
10. Put on gloves. a shower to bathe in the tub or shower, rather than
in bed. The types used in the home may look differ-
11. Help resident remove clothing and shoes. ent than ones in care facilities (Fig. 13-30).

12. Help the resident into shower or tub. Put

shower chair into shower and lock wheels.
13. Stay with resident during procedure.
14. Let resident wash as much as possible. Help
to wash his or her face.
15. Help resident shampoo and rinse hair.
16. Help to wash and rinse the entire body. Move
from head to toe.
17. Turn off water or drain the tub. Cover resi- Fig. 13-30. In the home, showers chairs can be placed
directly into the tub. (reprinted with permission of briggs corporation,
dent with bath blanket while tub drains. 800-247-2343, www.briggscorp.com)

18. Unlock shower chair wheels, if used. Roll

resident out of shower, or help resident out Some residents will have whirlpool baths. In a
of tub and onto a chair. whirlpool bath, the action of the water cleanses
and helps stimulate circulation and wound heal-
19. Give resident towel(s) and help to pat dry. ing. To take a whirlpool bath, a resident is cov-
Pat dry under the breasts, between skin folds, ered, placed in a chairlift, and lowered into the
in the perineal area, and between toes. whirlpool. If you assist with this type of bath, do
20. Apply lotion and deodorant as needed. not leave the resident alone. The resident may
feel faint or dizzy after the bath. Help as needed,
21. Place soiled clothing and linens in proper
and do not rush him or her. The tub and chair
containers.
must be cleaned after use.
22. Remove gloves and dispose of them.
23. Wash your hands. 4. Explain guidelines for assisting with
24. Help resident dress and comb hair before
grooming
leaving shower room. Put on non-skid foot- Grooming affects the way people feel about
wear. Return resident to room. themselves and how they look to others. A well-
25. Make sure resident is comfortable. groomed person is more likely to feel better
physically and emotionally (Fig. 13-31). When
26. Place call light within resident’s reach.
helping with grooming, always let residents do
27. Report any changes in resident to nurse. all they can for themselves. Let them make as
many choices as possible. Follow the care plan’s
28. Document procedure using facility
instructions for what care to give. Remember
guidelines.
that some residents may be embarrassed or de-
 209 13

pressed because they need help with grooming 3. Explain procedure to the resident. Speak
tasks they have done for themselves most their clearly, slowly, and directly. Maintain face-to-
lives. Be sensitive to this. Be professional and face contact whenever possible.
respectful while assisting your residents with

Personal Care Skills

4. Provide for resident’s privacy with curtain,
grooming. Your attitude can go a long way to-
screen, or door.
ward helping residents maintain self-respect and
feel good about themselves. 5. If resident is in bed, adjust bed to a safe
level, usually waist high. Lock bed wheels.

6. Fill the basin halfway with warm water. Test

water temperature with thermometer or your
wrist to ensure it is safe. Water temperature
should be 105° F. Have resident check water
temperature. Adjust if necessary.

7. Place basin at a comfortable level for the resi-

dent. Soak the resident’s nails in the water.
Soak all 10 fingertips for at least five minutes.

8. Remove hands. Wash hands with soapy

washcloth. Rinse. Pat hands dry with towel,
Fig. 13-31. A well-groomed appearance helps a person including between fingers. Remove the hand
feel good about herself. basin.

Fingernails can harbor bacteria. It is important 9. Put on gloves.

to keep hands and nails clean to help prevent in- 10. Place the resident’s hands on the towel. Use
fection. Nail care should be given when assigned the pointed end of the orangewood stick or
and when nails are dirty or have jagged edges. a nail brush to remove dirt from under the
Never cut a resident’s toenails. Poor circulation nails (Fig. 13-32).
can lead to infection if skin is accidentally cut
while caring for nails. In a diabetic resident,
such an infection can lead to a severe wound or
even amputation. See Chapter 18 for more infor-
mation on diabetes. If you are told to give nail
care, know exactly what care you are to provide.
Never use the same nail equipment on more
than one resident.

Providing fingernail care

Equipment: orangewood stick, emery board, lotion,

Fig. 13-32. Be gentle when removing dirt from under the
basin, soap, washcloth, 2 towels, bath thermometer,
nails with an orangewood stick.
gloves

1. Wash your hands. 11. Wipe orangewood stick on towel after clean-
ing under each nail. Wash resident’s hands
2. Identify yourself by name. Identify the resi-
again. Dry them thoroughly.
dent by name.
13 210

12. Shape nails with file or emery board. File in Blood or drainage
a curve. Finish with nails smooth and free of
Long, ragged toenails
rough edges.
Ingrown toenails
Personal Care Skills

13. Apply lotion from fingertips to wrist.

Differences in temperature of the feet
14. Empty, rinse, and dry basin. Place basin in
designated dirty supply area or return to stor-
Providing foot care
age, depending on facility policy.
Equipment: basin, bath mat, soap, lotion, wash-
15. Place soiled clothing and linens in proper cloth, 2 towels, bath thermometer, clean socks,
containers. gloves
16. Remove and dispose of gloves properly. Wash Support the foot and ankle throughout
your hands. procedure.
17. Make resident comfortable. Make sure sheets 1. Wash your hands.
are free from wrinkles and the bed free from
crumbs. 2. Identify yourself by name. Identify the resi-
dent by name.
18. Return bed to lowest position. Remove pri-
vacy measures. 3. Explain procedure to the resident. Speak
clearly, slowly, and directly. Maintain face-to-
19. Place call light within resident’s reach.
face contact whenever possible.
20. Wash your hands.
4. Provide for resident’s privacy with curtain,
21. Report any changes in resident to the nurse. screen, or door.
22. Document procedure using facility 5. If resident is in bed, adjust bed to a safe
guidelines. level, usually waist high. Lock bed wheels.

6. Fill the basin halfway with warm water. Test

Careful foot care is extremely important; it water temperature with thermometer or your
should be a part of daily care of residents. Keep- wrist to ensure it is safe. Water temperature
ing the feet clean and dry helps prevent compli- should be 105° F. Have resident check water
cations, especially for diabetic residents. When temperature. Adjust if necessary.
providing foot care, observe the feet for any of
the following: 7. Place basin on a bath mat or bath towel on
the floor (if the resident is sitting in a chair)
Observing and Reporting: or on a towel at the foot of the bed (if the
Foot Care resident is in bed).

8. Remove resident’s socks. Completely sub-

Report any of these to the nurse:
merge resident’s feet in water. Soak the feet
Dry, flaking skin for five to ten minutes. Add warm water to
Non-intact or broken skin the basin as necessary.

Discoloration of the feet, such as reddened, 9. Put on gloves.

gray, white, or black areas
10. Remove one foot from water. Wash entire
Blisters foot, including between the toes and around
Bruises nail beds, with soapy washcloth (Fig. 13-33).
 211 13

Before assisting with shaving, make sure the

resident wants you to shave him or help him
shave. Respect personal preferences for shaving.
Always wear gloves when shaving a resident.

Personal Care Skills

If you nick or cut a resident during shaving,
there is chance you could come into contact with
blood. Wearing gloves when shaving residents is
a part of following standard precautions; it helps
prevent infection.
If a resident has a beard or mustache, it will
Fig. 13-33. Soak the resident’s feet before washing the
entire foot, including the nail beds. need daily care. Washing and combing a beard
or mustache every day is usually enough. Ask
11. Rinse entire foot, including between the toes. the resident how he would like it done. Do not
trim or shave a beard or mustache without his
12. Dry entire foot, including between the toes.
permission.
13. Repeat steps 10 through 12 for the other Check with the nurse to know which type of
foot. razor the resident uses:
14. Put lotion in one hand and warm lotion by • A safety razor has a sharp blade, but with
rubbing hands together. a special safety casing to help prevent cuts.
15. Massage lotion into entire foot (top and bot- This type of razor requires shaving cream or
tom), except between the toes. Remove ex- soap.
cess, if any, with a towel. • A disposable razor requires shaving cream
16. Empty, rinse, and dry basin. Place basin in or soap. It is discarded in a biohazard con-
designated dirty supply area or return to stor- tainer after use.
age, depending on facility policy. • An electric razor is the safest and easiest
17. Place soiled clothing and linens in proper type of razor to use. It does not require soap
containers. or shaving cream. Do not use an electric
razor near any water, when oxygen is in use,
18. Remove and dispose of gloves properly. Wash or if resident has a pacemaker. Electricity
your hands. near water may cause electrocution. Elec-
19. Make resident comfortable. Make sure sheets tricity near oxygen may cause an explosion.
are free from wrinkles and the bed free from Electricity near some pacemakers may cause
crumbs. an irregular heartbeat.

20. Return bed to lowest position. Remove pri-

Shaving a resident
vacy measures.
Equipment: razor, basin filled halfway with warm
21. Place call light within resident’s reach. water (if using a safety or disposable razor),2 tow-
22. Wash your hands. els, washcloth, bath thermometer, mirror, shaving
cream or soap (if using a safety or disposable razor),
23. Report any changes in resident to the nurse. after-shave lotion, gloves, razor
24. Document procedure using facility 1. Wash your hands.
guidelines. 2. Identify yourself by name. Identify the resi-
dent by name.
13 212

3. Explain procedure to the resident. Speak Shaving using an electric razor:

clearly, slowly, and directly. Maintain face-to-
8. If using an electric razor, use a small brush
face contact whenever possible.
to clean it. Do not use an electric razor near
Personal Care Skills

4. Provide for resident’s privacy with curtain, any water source, when oxygen is in use, or if
screen, or door. resident has a pacemaker.

5. If resident is in bed, adjust bed to safe level, 9. Turn on the razor and hold skin taut. Shave
usually waist high. Raise the head of the bed with smooth, even movements (Fig. 13-35).
so that the resident is sitting up. Lock bed Shave beard with back and forth motion in
wheels. direction of beard growth with foil shaver.
Shave beard in circular motion with three-
6. Place towel across the resident’s chest, under
head shaver. Shave the chin and under the
his chin.
chin.
7. Put on gloves.
8. Shaving using a safety or disposable razor:
8. If using a safety or disposable razor, use a
blade that is sharp. A dull blade is hard on
the skin. Soften the beard with a warm, wet
washcloth on the face for a few minutes be-
fore shaving. Lather the face with shaving
cream or soap and warm water. Warm water
Fig. 13-35. Shave, or have the resident shave, with
and lather make shaving more comfortable. smooth, even movements.
9. Hold skin taut. Shave in the direction of hair
growth. Shave beard in downward strokes on 10. When you have finished, offer a mirror to the
face and upward strokes on neck (Fig. 13-34). resident.
Rinse the blade often in the basin to keep it Final steps:
clean and wet.
11. If the resident wants after-shave lotion,
moisten your palms with the lotion and pat it
onto the resident’s face.
12. Remove the towel. Place the towel and wash-
cloth in proper container.
13. Clean the equipment and store it. For safety
razor: rinse the razor. For disposable razor:
dispose of it in a biohazard container if avail-
able. For electric razor: clean head of razor.
Remove whiskers from razor. Recap shaving
Fig. 13-34. Holding the skin taut, shave in downward head and return razor to case.
strokes on face and upward strokes on neck.
14. Remove and dispose of gloves properly. Wash
your hands.
10. When you have finished, wash, rinse, and dry
the resident’s face with a warm, wet wash- 15. Make resident comfortable. Make sure sheets
cloth or let him use the washcloth himself. are free from wrinkles and the bed free from
Offer a mirror to the resident. crumbs.
 213 13

16. Return bed to lowest position. Remove pri- 2. Identify yourself by name. Identify the resi-
vacy measures. dent by name.
17. Place call light within resident’s reach. 3. Explain procedure to the resident. Speak

Personal Care Skills

clearly, slowly, and directly. Maintain face-to-
18. Report any changes in resident to the nurse.
face contact whenever possible.
19. Document procedure using facility
guidelines. 4. Provide for resident’s privacy with curtain,
screen, or door.

Nursing assistants help keep residents’ hair 5. If the bed is adjustable, adjust bed to a safe
clean and styled. Use hair ornaments only as level, usually waist high. Lock bed wheels.
requested. Do not comb or brush residents’ hair 6. Raise head of bed so the resident is sitting
into a childish style. When assisting with comb- up. Place a towel under the head or around
ing, brushing, or styling hair, handle it gently. the shoulders.
Pediculosis is an infestation of lice. Lice are
7. Remove any hair pins, hair ties, and clips.
tiny bugs that bite into the skin and suck blood
to live and grow. Three types of lice are head 8. Remove tangles first by dividing hair into
lice, body lice, and crab or pubic lice. Head lice small sections. Hold lock of hair just above
are usually found on the scalp. Lice are hard to the tangle so you do not pull at the scalp.
see. Symptoms include itching, bite marks on Gently comb or brush through the tangle. If
the scalp, skin sores, and matted, bad-smelling resident agrees, you can use a small amount
hair and scalp. If you notice any of these symp- of detangler or leave-in conditioner on the
toms, tell the nurse immediately. Lice can spread tangle.
very quickly. Special lice cream, shampoo, or
9. After tangles are removed, brush two-inch
lotion may be used to treat the lice. People who
sections of hair at a time. Brush from roots
have lice spread it to others. To help prevent the
to ends (Fig. 13-36). Residents who have dry,
spread of lice, do not share residents’ combs,
brittle hair may require a special treatment
brushes, clothes, wigs, or hats.
with oil or hair lotion. Residents whose hair
Dandruff is an excessive shedding of dead skin is tightly curled may use a comb with large
cells from the scalp. It is the result of the normal teeth, or a pick.
growing process of the skin cells of the scalp.
The most common symptom is flaking of small,
round, white patches from the head. Itching
can also occur. Dandruff is a natural process.
It cannot be stopped; it can only be controlled.
Residents who have dandruff may use a special
medicated dandruff shampoo to help control it.

Combing or brushing hair

Equipment: comb, brush, towel, mirror, hair care Fig. 13-36. Gently brush hair from roots to ends.
items requested by resident.
10. Each resident may prefer a different hairstyle.
Use hair care products that the resident prefers
Style hair in the way the resident prefers (Fig.
for his or her type of hair.
13-37). Avoid childish hairstyles. Offer mirror
1. Wash your hands. to the resident.
13
Personal Care Skills
214

Fig. 13-37. Assist the resident in styling her hair as she

prefers it.

11. Make resident comfortable. Make sure sheets

are free from wrinkles and the bed free from
crumbs.
Fig. 13-38. When dressing, start with the involved
12. Return bed to lowest position. Remove pri- (weaker) side first.
vacy measures.

13. Place call light within resident’s reach. Guidelines:

14. Return supplies to proper storage. Clean hair Dressing and Undressing
from brush/comb.
G As with all care, the resident’s wishes should
15. Dispose of soiled linen in the proper be asked and followed. Remember: resident-
container. directed care is the resident’s legal right and
16. Wash your hands. your responsibility.

17. Report any changes in resident to nurse. G Let the resident to choose clothing for the
day. However, check to see if it is clean,
18. Document procedure using facility appropriate for the weather, and in good
guidelines. condition.
G Encourage the resident to dress in regular
clothes rather than nightclothes. Wearing reg-
5. List guidelines for assisting with ular daytime clothing encourages more activ-
dressing ity and out-of-bed time. Elastic-waist pants or
skirts are easy to pull on over legs and hips.
When helping a resident with dressing, know
Be sure the waistband of underpants, slip,
what limitations he or she has. If he has a
pantyhose, pants, or skirt fits comfortably at
weakened side from a stroke or injury, that side
the waist. Clothing that is a size larger than
is called the affected side. It will be weaker.
the resident would normally wear is easier to
Never refer to the weaker side as the “bad side,”
put on.
or talk about the “bad” leg or arm. Use the terms
weaker or involved to refer to the affected side. G The resident should do as much to dress or
The weaker arm is usually placed through a undress himself as possible. It may take lon-
sleeve first (Fig. 13-38). When a leg is weak, it is ger, but it helps maintain independence and
easier if the resident sits down to pull the pants regain self-care skills. Ask where your help is
over both legs. needed.
 215 13

G Provide privacy. If the resident has just had a

Dressing a resident with an affected (weak)
bath, cover him with the bath blanket. Put on
right arm
undergarments first. Never expose more than
you need to. Equipment: clean clothes of resident’s choice, non-

Personal Care Skills

skid footwear
G When putting on socks or stockings, roll or
fold them down. They can then be slipped When putting on all items, move resident’s body
over the toes and foot, then unrolled up into gently and naturally. Avoid force and over-exten-
place. Make sure toes, heels, and seams of sion of limbs and joints.
socks or stockings are in the right place. 1. Wash your hands.
G For a female resident, make sure bra cups 2. Identify yourself by name. Identify the resi-
fit over the breasts. Front-fastening bras are dent by name.
easier for residents to work by themselves.
Bras that fasten in back can be put around the 3. Explain procedure to the resident. Speak
waist and fastened first. Then rotate around clearly, slowly, and directly. Maintain face-to-
and move bra up. Put arms through the straps face contact whenever possible.
last. This can be reversed for undressing. 4. Provide for resident’s privacy with curtain,
G For residents who have weakness or paralysis screen, or door.
on one side, place the weaker, or affected, 5. Ask resident what she would like to wear.
arm or leg through the garment first. Then Dress her in outfit of choice (Fig 13-40).
help with the strong arm or leg. When
undressing, do the opposite—start with the
stronger, or unaffected side.
G Several types of adaptive aids for dressing
are available. These help residents maintain
independence in dressing themselves (Fig.
13-39). An occupational therapist may teach
residents to perform ADLs using adaptive
equipment.
Fig. 13-40. Residents have a legal right to choose the
clothing they want to wear for the day.

6. Remove resident’s gown without completely

exposing the resident. Remove from the
stronger (unaffected) side first when un-
dressing. Then remove gown from the weaker
(affected) side.
7. Help resident to put the right (affected/
weaker) arm through the right sleeve of the
shirt, sweater, or slip before placing garment
on left (unaffected) arm.
8. Help resident put on skirt, pants, or dress.
Fig. 13-39. Special dressing aids promote independence
by helping residents dress themselves. (photo courtesy of north 9. Place bed at the lowest position. Lock bed
coast medical, inc., www.ncmedical.com, 800-821-9319)
wheels.
13 216

10. Have resident sit down and help to apply quent oral care. Also, if they are not taking any
non-skid footwear. Tie laces. fluids by mouth or are taking medications which
dry their mouths, they will need oral care more
11. Finish with resident dressed appropriately.
often. When you perform oral care, observe the
Personal Care Skills

Make sure clothing is right-side-out and zip-

resident’s mouth carefully.
pers/buttons are fastened.

12. Place gown in soiled linen container.

Observing and Reporting:
13. Keep bed in lowest position. Remove privacy Oral Care
measures.
Report any of these to the nurse:
14. Place call light within resident’s reach.
Irritation
15. Wash your hands.
Infection
16. Report any changes in resident to the nurse.
Raised areas
17. Document procedure using facility
Coated or swollen tongue
guidelines.
Ulcers, such as canker sores or small, pain-
ful, white sores
6. Identify guidelines for good oral care Flaky, white spots

Oral care, or care of the mouth, teeth, and Dry, cracked, bleeding, or chapped lips
gums, is performed at least twice each day. Oral Loose, chipped, broken, or decayed teeth
care should be done after breakfast and after
Swollen, irritated, bleeding, or whitish gums
the last meal or snack of the day. It may also be
done before a resident eats. Oral care includes Breath that smells bad or fruity
brushing teeth, tongue, and gums; flossing
Resident reports of mouth pain
teeth; and caring for dentures (Fig. 13-41). When
giving oral care, wear gloves. Follow standard
Providing oral care
precautions.
Equipment: toothbrush, toothpaste, emesis basin,
gloves, towel, glass of water
1. Wash your hands.
2. Identify yourself by name. Identify the resi-
dent by name.
3. Explain procedure to the resident. Speak
clearly, slowly, and directly. Maintain face-to-
Fig. 13-41. Some supplies needed for oral care.
face contact whenever possible.
Proper, regular oral care can help prevent dis- 4. Provide for resident’s privacy with curtain,
ease and bad breath (halitosis). Oral care also screen, or door.
helps by preventing poor appetite and malnutri-
5. Adjust bed to a safe level, usually waist high.
tion. Cleaning the mouth removes particles and
Lock bed wheels. Make sure resident is in an
leftover food, and makes eating more pleasant.
upright sitting position.
Residents who are unconscious, are on oxygen,
or have tubes in their nose or mouths need fre- 6. Put on gloves.
 217 13

7. Place towel across the resident’s chest. 19. Document procedure using facility
guidelines.
8. Wet toothbrush and put on small amount of
toothpaste.

Personal Care Skills

Oral care does not just involve taking care of the
9. Clean entire mouth (including tongue and all
teeth. Residents who do not have teeth will need
surfaces of teeth). Use gentle strokes. First
oral care performed too. Edentulous means
brush upper teeth, then lower teeth, using
having no teeth. You will clean the mouth,
short strokes. Brush back and forth.
tongue, and gums using mouthwash or other
10. Give the resident water to rinse the mouth solution on gauze or swabs. The gauze can be
and place the emesis basin under the resi- wrapped on a tongue blade and moistened with
dent’s chin. Have resident spit water into mouthwash or solution if swabs are not available.
emesis basin (Fig. 13-42). Wipe resident’s
Although residents who are unconscious cannot
mouth and remove towel.
eat, breathing through the mouth causes saliva
to dry in the mouth. Good mouth care needs
to be performed more frequently to keep the
mouth clean and moist. Swabs with a mixture of
lemon juice and glycerine or other solutions are
sometimes used to soothe the gums. Some solu-
tions further dry the gums if used too often. Fol-
low the care plan regarding the use of swabs.
With unconscious residents, it is important
to use as little liquid as possible when giving
mouth care. Because the person’s swallowing
Fig. 13-42. Rinsing and spitting removes food particles
and toothpaste. reflex is weak, he or she is at risk for aspiration.
Aspiration is the inhalation of food or drink
11. Dispose of soiled linen in the proper into the lungs. Aspiration can cause pneumonia
container. or death.

12. Clean and return supplies to proper storage.

Providing oral care for the unconscious resident
13. Remove gloves and dispose of gloves prop-
Equipment: sponge swabs, padded tongue blade
erly. Wash your hands. (Fig. 13-43), towel, emesis basin, gloves, lip mois-
14. Make resident comfortable. turizer, cleaning solution (check the care plan)

15. Return bed to lowest position. Remove pri-

vacy measures.

16. Place call light within resident’s reach.

17. Wash your hands.

18. Report any problems with teeth, mouth,

tongue, and lips to nurse. This includes
Fig. 13-43. To make a padded tongue blade, place two
odor, cracking, sores, bleeding, and any wooden tongue blades together and wrap the upper por-
discoloration. tion with gauze. Tape the gauze in place.
13 218

1. Wash your hands. 10. Rinse with clean swab dipped in water.
2. Identify yourself by name. Identify the resi- 11. Remove the towel and basin. Pat lips or face
dent by name. Even residents who are uncon- dry if needed. Apply lip moisturizer.
Personal Care Skills

scious may be able to hear you. Always speak

12. Dispose of soiled linen in the proper
to them as you would to any resident.
container.
3. Explain procedure to the resident. Speak
13. Clean and return supplies to proper storage.
clearly, slowly, and directly. Maintain face-to-
face contact whenever possible. 14. Remove and dispose of gloves properly. Wash
your hands.
4. Provide for resident’s privacy with curtain,
screen, or door. 15. Make sure sheets are free from wrinkles and
the bed free from crumbs.
5. Adjust bed to a safe level, usually waist high.
Lock bed wheels. 16. Return bed to lowest position. Remove pri-
vacy measures.
6. Put on gloves.
17. Place call light within resident’s reach.
7. Turn resident’s head to the side. Place a
towel under his cheek and chin. Place an 18. Wash your hands.
emesis basin next to the cheek and chin for
19. Report any problems with teeth, mouth,
excess fluid.
tongue, and lips to nurse. This includes
8. Hold mouth open with padded tongue blade. odor, cracking, sores, bleeding, and any
discoloration.
9. Dip swab in cleaning solution. Wipe teeth,
gums, tongue, and inside surfaces of mouth. 20. Document procedure using facility
Change swab often. Repeat until the mouth guidelines.
is clean (Fig. 13-44).

Dental floss is a special kind of string used

to clean between teeth. Flossing the teeth re-
moves plaque and tartar buildup around the
gum line and between the teeth. Teeth may be
flossed right after or before they are brushed,
as the resident prefers. Flossing should not be
done for certain residents. Follow the care plan’s
instructions.

Flossing teeth

Equipment: floss, cup with water, emesis basin,

gloves, towel
1. Wash your hands.
2. Identify yourself by name. Identify the resi-
dent by name.
3. Explain procedure to the resident. Speak
Fig. 13-44. Wipe all inside surfaces of the mouth to clean clearly, slowly, and directly. Maintain face-to-
the mouth, stimulate the gums, and remove mucus. face contact whenever possible.
 219 13

4. Provide for resident’s privacy with curtain,

screen, or door.

5. Adjust the bed to a safe level, usually waist

Personal Care Skills

high. Lock bed wheels. Make sure the resi-
dent is in an upright sitting position.

6. Put on gloves.

7. Wrap the ends of floss securely around each

index finger (Fig. 13-45). Fig. 13-47. Floss gently in the space between the gum
and tooth. This removes food and prevents tooth decay.

9. After every two teeth, unwind floss from your

fingers. Move it so you are using a clean
area. Floss all teeth.

10. Occasionally offer water so that the resident

can rinse the mouth. Ask the resident to spit
it into the basin.

11. Offer resident a face towel when done floss-

Fig. 13-45. Before beginning, wrap floss securely around ing all teeth.
each index finger.
12. Discard floss. Empty basin into the toilet.
8. Starting with the back teeth, place floss be- Clean and store basin and supplies.
tween teeth. Move it down the surface of
13. Dispose of soiled linen in the proper
the tooth. Use a gentle sawing motion (Fig.
container.
13-46).
14. Remove and dispose of gloves properly. Wash
your hands.

15. Make resident comfortable. Make sure sheets

are free from wrinkles and the bed free from
crumbs.

16. Return bed to lowest position. Remove pri-

vacy measures.

17. Place call light within resident’s reach.

18. Wash your hands.

Fig. 13-46. Being gentle protects the gums.
19. Report any problems with teeth, mouth,
tongue, and lips to nurse. This includes
Continue to the gum line. At the gum line,
odor, cracking, sores, bleeding, and any
curve the floss into a letter C. Slip it gently
discoloration.
into the space between the gum and tooth.
Then go back up, scraping that side of the 20. Document procedure using facility
tooth (Fig. 13-47). Repeat this on the side of guidelines.
the other tooth.
13 220

7. Define “dentures” and explain how to

care for dentures
Dentures are artificial teeth. They are expen-
Personal Care Skills

sive, so it is important to take good care of them.

Handle dentures carefully to avoid breaking or
chipping them. When dentures break, a person
cannot eat. Wear gloves when handling and
cleaning dentures. Notify the nurse if a resi-
dent’s dentures do not fit properly, are chipped, Fig. 13-48. Brush dentures on all surfaces to properly
clean them.
or are missing.
Ask the resident how you can assist with denture 7. Rinse all surfaces of dentures under cool run-
care. Each person has his own preference about ning water. Do not use hot water.
when and how it should be done. When storing
8. Rinse denture cup before placing clean den-
dentures, place them in a denture cup labeled
tures in it.
with the resident’s name and room number.
Make sure you match the dentures to the correct 9. Place dentures in clean denture cup with so-
resident. Store them in solution or cool water. lution or cool water. Make sure cup is labeled
Hot water may damage dentures. with resident’s name and room number (Fig.
13-49). Put denture cup where it is normally
Residents’ Rights stored.
Oral Care
Oral care is very personal. Always pull the privacy
curtain and close the door before beginning. Many
people who have dentures do not want to be seen
without their teeth in place. When you remove the
teeth, clean and return them immediately.

Cleaning and storing dentures

Equipment: denture brush or toothbrush, denture Fig. 13-49. Dentures should be stored in solution in a
denture cup that is properly labeled with the resident’s
cleanser or tablet, labeled denture cup, 2 towels,
name and room number.
gloves

1. Wash your hands. 10. Clean and return the equipment to proper
storage.
2. Put on gloves.
11. Drain sink. Dispose of towels in proper
3. Line the sink or a basin with towels and fill
container.
with water. The towel and water will prevent
the dentures from breaking if they slip from 12. Remove and dispose of gloves properly. Wash
your hands and fall into the sink. your hands.

4. Rinse dentures in cool running water before 13. Report any changes in appearance of den-
brushing them. Do not use hot water. tures to the nurse.

5. Apply toothpaste or cleanser to toothbrush. 14. Document procedure using facility

guidelines.
6. Brush dentures on all surfaces (Fig. 13-48).
 221 13

4. What are five things about a resident that a

Removing and reinserting dentures
nursing assistant should observe during per-
If you are allowed to do so, and if a resident can- sonal care?
not remove his or her dentures, you must do it. Ask

Personal Care Skills

resident to sit upright, and apply gloves. Remove the 5. Why is preventing pressure sores extremely
lower denture first. The lower denture is easier to important?
remove because it floats on the gum line of the lower
jaw. Grasp the lower denture with a gauze square 6. When skin begins to break down, what does
(for a good grip) and remove it. Place it in a denture it look like?
cup filled with solution or cool water.
7. List ten signs to observe and report about a
The upper denture is sealed by suction. Firmly grasp
the upper denture with a gauze square. Give a slight resident’s skin.
downward pull to break the suction. Turn it at an
8. At a minimum, how often should residents
angle to take it out of the mouth.
be repositioned?
When inserting dentures, ask resident to sit as up-
right as possible. Apply gloves. Apply denture cream 9. List four examples of positioning devices
or adhesive to the dentures if needed. When the and explain how they can help.
resident’s mouth is open, place upper denture into
the mouth by turning it at an angle. Straighten it and 10. Why is it unnecessary for many elderly peo-
press it onto the upper gum line firmly and evenly ple to have a complete bath or shower every
(Fig. 13-50). Insert the lower denture onto the gum day?
line of the lower jaw. Press firmly.
11. How often should the perineum be washed?
12. Why should residents, as well as NAs, test
the water temperature before bathing?
13. Why should the nursing assistant wipe from
front to back when giving perineal care?
14. List two benefits of back rubs.
15. Why should bath oils, lotions, or powders
NOT be used in showers or tubs?
16. In what ways can good grooming affect a
person?
Fig. 13-50. Press upper denture onto the upper gum line
firmly and evenly. 17. Explain why NAs must be especially careful
while giving nail care to diabetic residents.
18. Why should gloves be worn while shaving
Chapter Review residents?
1. List four examples of activities of daily living 19. List the reasons why electric razors should
(ADLs). not be used near water, when oxygen is in
2. List five reasons that a resident may need use, or if a resident has a pacemaker.
help with personal care. 20. What are the symptoms of head lice?
3. Give four examples of how to promote dig- 21. If a resident has an affected side due to a
nity and independence while giving personal stroke or an injury, how should an NA refer
care. to that side?
13 222

22. When dressing a resident with a weaker

side, which arm is usually placed through
the sleeve first—the weaker or stronger arm?
Personal Care Skills

23. What is the minimum number of times per

day that oral care is done?
24. List nine signs and symptoms that should be
observed and reported during oral care.
25. How can NAs help prevent aspiration during
oral care of unconscious residents?
26. Explain why hot water should not be used
when handling or cleaning dentures.
 223 14

14

Basic Nursing Skills

Basic Nursing Skills

1. Explain the importance of monitoring Normal Ranges for Adult Vital Signs
vital signs
Temperature Fahrenheit Celsius
Nursing assistants monitor, document, and Oral 97.6°–99.6° 36.5°–37.5°
report residents’ vital signs. Vital signs are im- Rectal 98.6°–100.6° 37.0°–38.1°
portant. They show how well the vital organs of Axillary 96.6°–98.6° 36.0°–37.0°
the body, such as the heart and lungs, are work- Pulse: 60–100 beats per minute
ing. They consist of the following: Respirations: 12–20 respirations per minute

• Taking the body temperature Blood Pressure

Normal: Systolic 100–139 Diastolic 60–89
• Counting the pulse
High: 140/90 or above
• Counting the rate of respirations Low: Below 100/60
• Taking the blood pressure
Residents’ Rights
• Observing and reporting the level of pain
Vital Signs
Watching for changes in vital signs is very im- Protect residents’ privacy while taking vital signs by
portant. Changes can indicate a resident’s condi- not exposing them. If you need to take blood pres-
tion is worsening. You will not make diagnoses sure or move clothing out of the way, pull the privacy
based on vital signs, but you will record accurate curtain around the bed and close the door. Do not
discuss residents’ vital signs measurements while in
measurements and report changes and observa- earshot of other people. Report the information to
tions to the nurse. You should always notify the the nurse.
nurse if:
• The resident has a fever (temperature is
2. List guidelines for taking body
above average for the resident or outside the
normal range)
temperature

• The resident has a respiratory or pulse rate Body temperature is normally very close to
that is too rapid or too slow 98.6°F (Fahrenheit) or 37°C (Celsius). Body tem-
perature reflects a balance between the heat
• The resident’s blood pressure changes
created by our bodies and the heat lost to the
• The resident’s pain is worse or is not re- environment. Many factors affect temperature;
lieved by pain management age, illness, stress, environment, exercise, and
14 224

the circadian rhythm can all cause changes in Using mercury glass or glass bulb thermometers
body temperature. The circadian rhythm is the to take oral or rectal temperatures used to be
24-hour day-night cycle. Average temperature common. However, because mercury is a dan-
readings change throughout the day. People gerous, toxic substance, thousands of healthcare
Basic Nursing Skills

tend to have lower temperatures in the morning. facilities now discourage the use of products
Increases in body temperature may indicate an containing mercury. In fact, many states have
infection or disease. passed laws to ban the sale of mercury ther-
mometers. Today, mercury-free glass thermom-
There are four sites for taking body temperature:
eters are more common (Fig. 14-1). They can be
1. The mouth (oral) used to take an oral or rectal temperature, and
2. The rectum (rectal) they are considered much safer.

3. The armpit (axillary)

4. The ear (tympanic)
The different sites require different thermom-
eters. Temperatures are most often taken orally.
Do not take an oral temperature on a person
who:
• Is unconscious
• Has recently had facial or oral surgery
• Is younger than 5 years old
• Is confused
• Is heavily sedated
Fig. 14-1. A mercury-free oral thermometer and a mer-
• Is coughing cury-free rectal thermometer. Thermometers are usually
color-coded to show which is for oral and which is for
• Is being administered oxygen rectal use. Oral thermometers are usually green or blue;
rectal thermometers are usually red. (photos provided by rg
• Has facial paralysis medical diagnostics of southfield, mi.)

• Has a nasogastric tube (a feeding tube that is

Although some mercury-free thermometers are
inserted through the nose and goes into the
slightly larger than glass bulb thermometers,
stomach)
they operate identically. Numbers on the ther-
There are several types of thermometers, such mometer let you read the temperature after it
as the following: registers. Most thermometers show the tempera-
• Mercury-free glass ture in degrees Fahrenheit (F). Each long line
represents one degree and each short line rep-
• Mercury glass (glass bulb)
resents two-tenths of a degree. Some thermom-
• Battery-powered, digital, or electronic eters show the temperature in degrees Celsius
(C), with the long lines representing one degree
• Disposable
and the short lines representing one-tenth of a
• Tympanic degree. The small arrow points to the normal
• Temporal artery temperature: 98.6°F and 37°C (Fig. 14-2).
 225 14

The thermometer will beep or flash when the

temperature has registered. Digital thermom-
eters may be used to take oral, rectal, or axillary
temperatures. Follow the manufacturer’s guide

Basic Nursing Skills

for proper use of these thermometers.

Fig. 14-2. You read a mercury-free and a mercury glass

thermometer the same way.

Home Care Focus

Mercury glass thermometers may still be used in Fig. 14-3. A digital thermometer with a disposable sheath
the home, so you may benefit from knowing a little underneath it.
bit about them. Mercury glass thermometers have
a stem and a bulb. The stem has a column for the
mercury to go up and down; the bulb stores the
mercury. The bulb is available in either a long, slim
shape or a blunt shape.
It is very important that you never use a thermom-
eter that has the long, slim bulb to take a rectal or
axillary temperature. This is because the slender
bulb could break in the rectum or armpit and cause
injuries. Only use the thermometers with long, slim
bulbs to take oral temperatures.
Fig. 14-4. An electronic thermometer.
The thermometers with the blunt bulbs should be
used to take rectal and axillary temperatures. You can The tympanic thermometer, or ear thermom-
also use the blunt bulb for oral temperatures. How-
ever, if you typically use a thermometer with a blunt eter, also registers a temperature quickly (Fig.
bulb to take a rectal temperature, never use the same 14-5). These thermometers may not be as com-
thermometer to take an oral temperature. mon. They also require more practice to be able
If you must use a mercury glass thermometer, be to take accurate temperatures.
careful. If you break a glass thermometer, never
touch the mercury or broken glass. Know your
agency’s policies and procedures regarding safe dis-
posal of mercury.
When cleaning a mercury glass thermometer, wipe it
with alcohol wipes from clean to dirty (stem to bulb).
Never use hot water on a mercury thermometer be-
cause hot water can heat the mercury and break the
thermometer.

Battery-powered, digital, or electronic thermom- Fig. 14-5. A tympanic thermometer.

eters are other types of thermometers (Figs. 14-3
and 14-4). These thermometers display results Disposable thermometers register temperatures
digitally. They register the temperature more in 60 seconds. Usually a colored dot shows the
quickly than mercury-free or glass bulb ther- temperature. Disposable thermometers are often
mometers. Digital thermometers usually take individually wrapped. They are only used once
two to sixty seconds to register the temperature. and then discarded in the proper container.
14 226

Disposable, or single-use, equipment helps pre- 2. Identify yourself by name. Identify the resi-
vent infection. dent by name.
Temporal artery thermometers determine tem- 3. Explain procedure to the resident. Speak
Basic Nursing Skills

perature readings by measuring the heat from clearly, slowly, and directly. Maintain face-to-
the skin over the temporal artery. This is done face contact whenever possible.
by a gentle stroke or scan across the forehead
4. Provide for resident’s privacy with curtain,
(Fig. 14-6). Temporal artery thermometers are
screen, or door.
non-invasive, which means that they are not in-
serted into the body. 5. Put on gloves.

6. Mercury-free thermometer: Hold the ther-

mometer by the stem. Before inserting the
thermometer in the resident’s mouth, shake
thermometer down to below the lowest num-
ber (at least below 96°F or 35°C). To shake
the thermometer down, hold it at the side
opposite the bulb with the thumb and two
fingers. With a snapping motion of the wrist,
shake the thermometer (Fig. 14-7). Stand
away from furniture and walls while doing so.
Fig. 14-6. A temporal artery thermometer. (photo courtesy of
exergen corporation, 800-422-3006, www.exergen.com)

Remember that there is a range of normal tem-

peratures. Some people’s temperatures normally
run low. Others in good health will run slightly
higher temperatures. Normal temperature read-
ings also vary by the method used to take the
temperature. A rectal temperature is considered
to be the most accurate, but taking a rectal tem-
perature on an uncooperative person, such as a
resident with dementia or a small child, can be
dangerous. An axillary temperature is consid-
Fig. 14-7. Shake thermometer down to below the lowest
ered the least accurate.
number before inserting in a resident’s mouth.

Taking and recording an oral temperature

Digital thermometer: Put on the disposable
Do not take an oral temperature on a resident sheath. Turn on thermometer and wait until
who has smoked, eaten or drunk fluids, chewed “ready” sign appears.
gum, or exercised in the last 10-20 minutes. Electronic thermometer: Remove the probe
Equipment: clean mercury-free, glass, digital, or from base unit. Put on probe cover.
electronic thermometer, gloves, disposable plastic
sheath/cover for thermometer, tissues, pen and 7. Mercury-free thermometer: Put on disposable
paper sheath, if available. Insert bulb end of the
thermometer into resident’s mouth, under
1. Wash your hands.
tongue and to one side (Fig. 14-8).
 227 14

10. Mercury-free thermometer: Rinse the ther-

mometer in lukewarm water and dry. Return
it to a plastic case or container.

Basic Nursing Skills

Digital thermometer: Using a tissue, remove
and dispose of sheath. Replace the thermom-
eter in case.

Electronic thermometer: Press the eject but-

Fig. 14-8. Insert thermometer under the resident’s tongue ton to discard the cover (Fig. 14-9). Return
and to one side. the probe to the holder.

Digital thermometer: Insert the end of digital

thermometer into resident’s mouth, under
tongue and to one side.

Electronic thermometer: Insert the end

of electronic thermometer into resident’s
mouth, under tongue and to one side.

8. Mercury-free thermometer: Tell the resident

to hold the thermometer in mouth with lips
closed. Assist as necessary. Resident should Fig. 14-9. Eject the probe cover and dispose of it properly
breathe through his nose. Ask the resident after use.
not to bite down or to talk. Leave the ther-
mometer in place for at least three minutes. 11. Remove gloves and discard.
Digital thermometer: Leave in place until 12. Wash your hands.
thermometer blinks or beeps.
13. Immediately record the temperature, date,
Electronic thermometer: Leave in place until time and method used (oral).
you hear a tone or see a flashing or steady
14. Place call light within resident’s reach.
light.
15. Report any changes in resident to the nurse.
9. Mercury-free thermometer: Remove the ther-
mometer. Wipe with a tissue from stem to
bulb or remove sheath. Dispose of the tissue You may need to take a rectal temperature.
or sheath. Hold the thermometer at eye level. Rectal temperatures can be necessary for uncon-
Rotate until line appears, rolling the ther- scious residents, residents who have seizures,
mometer between your thumb and forefinger. residents with poorly-fitted dentures or missing
Read the temperature. Remember the tem- teeth, infants and young children, and anyone
perature reading. having trouble breathing through the nose.
Always explain what you will do before start-
Digital thermometer: Remove the thermom-
ing this procedure. You need the resident’s co-
eter. Read temperature on display screen.
operation to take a rectal temperature. Ask the
Remember the temperature reading.
resident to hold still. Reassure him or her that
Electronic thermometer: Read the tempera- the task will only take a few minutes. Keep your
ture on the display screen. Remember the hand on the thermometer the entire time you
temperature reading. Remove the probe. are taking the temperature.
14 228

11. Separate the buttocks. Gently insert ther-

Taking and recording a rectal temperature
mometer into rectum 1 inch (1/2 inch for a
Equipment: clean rectal mercury-free, glass, or digi- child). Stop if you meet resistance. Do not
tal thermometer, lubricant, gloves, tissue, disposable force the thermometer in (Fig. 14-11).
Basic Nursing Skills

sheath/cover, pen and paper

1. Wash your hands.

2. Identify yourself by name. Identify the resi-

dent by name.

3. Explain procedure to the resident. Speak

clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.

4. Provide for resident’s privacy with curtain,

screen, or door.

5. If the bed is adjustable, adjust to a safe level,

usually waist high. If the bed is movable, lock
bed wheels.

6. Help the resident to the left-lying (Sims’) po-

sition (Fig. 14-10).
Fig. 14-11. Gently insert a rectal thermometer one inch
into the rectum. Do not force it into the rectum.

12. Replace the sheet over buttocks while holding

on to the thermometer. Hold on to the ther-
mometer at all times.

13. Mercury-free thermometer: Hold thermom-

Fig. 14-10. The resident must be in the left-lying (Sims’) eter in place for at least three minutes.
position.
Digital thermometer: Hold thermometer in
place until thermometer blinks or beeps.
7. Fold back the linens to expose only the rectal
area. 14. Gently remove the thermometer. Wipe with
tissue from stem to bulb or remove sheath.
8. Put on gloves.
Dispose of tissue or sheath.
9. Mercury-free thermometer: Hold thermom-
eter by stem. Shake the thermometer down 15. Read the thermometer at eye level as you
to below the lowest number. would for an oral temperature. Remember
the temperature reading.
Digital thermometer: Put on the disposable
sheath. Turn on thermometer and wait until 16. Mercury-free thermometer: Rinse the ther-
“ready” sign appears. mometer in lukewarm water and dry. Return
it to plastic case or container.
10. Apply a small amount of lubricant to tip of
bulb or probe cover (or apply pre-lubricated Digital thermometer: Discard probe cover.
cover). Replace the thermometer in case.
 229 14

17. Remove gloves and discard.

18. Wash your hands.

19. Assist the resident to a position of safety and

Basic Nursing Skills

comfort.

20. Immediately record the temperature, date,

time and method used (rectal).

21. Place call light within resident’s reach.

22. Report any changes in resident to the nurse. Fig. 14-12. Straighten the ear canal by pulling up and
back on the outside edge of the ear.

Tympanic thermometers can take fast and ac- 8. Hold thermometer in place either for one
curate temperature readings. As always, explain second or until thermometer blinks or beeps
what you will do before beginning the proce- (depends on model).
dure. Tell the resident that you will be placing 9. Read temperature. Remember the tempera-
a thermometer in the ear canal. Reassure the ture reading.
resident that this is painless. The short tip of the
thermometer will only go into the ear one-quar- 10. Dispose of sheath. Return the thermometer
ter to one-half inch. Thermometer models vary. to storage or to the battery charger if ther-
Follow the manufacturer’s instructions. mometer is rechargeable.
11. Remove gloves and discard.
Taking and recording a tympanic temperature 12. Wash your hands.
Equipment: tympanic thermometer, gloves, dispos- 13. Immediately record the temperature, date,
able probe sheath/cover, pen and paper time and method used (tympanic).
1. Wash your hands. 14. Place call light within resident’s reach.
2. Identify yourself by name. Identify the resi- 15. Report any changes in resident to the nurse.
dent by name.

3. Explain procedure to the resident. Speak Axillary temperatures are much less reliable
clearly, slowly, and directly. Maintain face-to- than temperatures taken at other sites. The axil-
face contact whenever possible. lary site is usually used as a last resort.

4. Provide for resident’s privacy with curtain, Taking and recording an axillary temperature
screen, or door.
Equipment: clean mercury-free, glass, digital, or
5. Put on gloves. electronic thermometer, gloves, tissues, disposable
sheath/cover, pen and paper
6. Put a disposable sheath over earpiece of the
thermometer. 1. Wash your hands.

7. Position the resident’s head so that the ear 2. Identify yourself by name. Identify the resi-
is in front of you. Straighten the ear canal by dent by name.
pulling up and back on the outside edge of 3. Explain procedure to the resident. Speak
the ear (Fig. 14-12). Insert the covered probe clearly, slowly, and directly. Maintain face-to-
into the ear canal. Press the button. face contact whenever possible.
14 230

4. Provide for resident’s privacy with curtain, Electronic thermometer: Leave in place until
screen, or door. you hear a tone or see a flashing or steady
5. Put on gloves. light.
Basic Nursing Skills

6. Remove resident’s arm from sleeve of gown 10. Mercury-free thermometer: Remove the ther-
or top to allow skin contact with the end of mometer. Wipe with a tissue from stem to
the thermometer. Wipe axillary area with tis- bulb or remove sheath. Dispose of the tissue
sues before placing the thermometer. or sheath. Read the thermometer at eye level
as you would for an oral temperature. Re-
7. Mercury-free thermometer: Hold the ther- member the temperature reading.
mometer by the stem. Shake the thermom-
eter down to below the lowest number. Digital thermometer: Remove the thermom-
eter. Read temperature on display screen.
Digital thermometer: Put on the disposable Remember the temperature reading.
sheath. Turn on thermometer and wait until
“ready” sign appears. Electronic thermometer: Read the tempera-
ture on the display screen. Remember the
Electronic thermometer: Remove the probe temperature reading. Remove the probe.
from base unit. Put on probe cover.
11. Mercury-free thermometer: Rinse the ther-
8. Position thermometer (bulb end for mercury- mometer in lukewarm water and dry. Return
free) in center of the armpit. Fold resident’s it to plastic case or container.
arm over her chest.
Digital thermometer: Using a tissue, remove
9. Mercury-free thermometer: Hold the ther- and dispose of sheath. Replace the thermom-
mometer in place, with the arm close against eter in case.
the side, for eight to 10 minutes (Fig. 14-13).
Electronic thermometer: Press the eject but-
ton to discard the cover. Return the probe to
the holder.
12. Remove gloves and discard.
13. Wash your hands.
14. Put resident’s arm back into sleeve of gown.
15. Immediately record the temperature, date,
time and method used (axillary).
16. Place call light within resident’s reach.
17. Report any changes in resident to the nurse.

3. List guidelines for taking pulse and

respirations
The pulse is the number of heartbeats per min-
Fig. 14-13. After inserting the thermometer, fold the resi-
ute. The beat that you feel at certain pulse points
dent’s arm over his chest and hold it in place for eight to
10 minutes. in the body represents the wave of blood mov-
ing as a result of the heart pumping. The most
Digital thermometer: Leave in place until common site for monitoring the pulse is on the
thermometer blinks or beeps. inside of the wrist, where the radial artery runs
 231 14

just beneath the skin. This is called the radial has heart disease or takes drugs that affect the
pulse. The procedure for taking this pulse is lo- heart. It may also be taken on residents who
cated later in this chapter. The brachial pulse is have a weak radial pulse or an irregular pulse.
the pulse inside the elbow, about 1 - 1 1/2 inches

Basic Nursing Skills

above the elbow. The radial and brachial pulses
are involved in taking blood pressure. Blood
pressure is explained later in this chapter. Other
common pulse sites are shown in Fig. 14-14.

Fig. 14-15. For adults, use the larger round side of the
stethoscope to hear a pulse and to take blood pressure.
The smaller side is used for children or infants.

Taking and recording apical pulse

Equipment: stethoscope, watch with second hand,

alcohol wipes, pen and paper
1. Wash hands.

Fig. 14-14. Common pulse sites. 2. Identify yourself by name. Identify the resi-
dent by name.
For adults, the normal pulse rate is 60–100
3. Explain procedure to the resident. Speak
beats per minute. Small children have more
clearly, slowly, and directly. Maintain face-to-
rapid pulses, in the range of 100–120 beats per
face contact whenever possible.
minute. A newborn baby’s pulse may be as high
as 120–140 beats per minute. Many things can 4. Provide for resident’s privacy with curtain,
affect the pulse rate, including exercise, fear, screen, or door.
anger, anxiety, heat, medications, and pain. An 5. Fit the earpieces of the stethoscope snugly
unusually high or low rate does not necessarily in your ears. Place the flat metal diaphragm
indicate disease. However, sometimes the pulse on the left side of the chest, just below the
rate can be a signal that serious illness exists. nipple (Fig. 14-16). Listen for the heartbeat.
For example, a rapid pulse may result from fever,
infection, or heart failure. A slow or weak pulse
may indicate dehydration, infection, or shock.
The apical pulse is heard by listening directly
over the heart with a stethoscope. This is often
the easiest method for measuring the pulse in
infants and small children because their pulse
points are harder to find. A stethoscope is an
instrument designed to listen to sounds within
the body, such as the heart beating or air mov-
ing through the lungs (Fig. 14-15). For adults, Fig. 14-16. Count the heartbeats for one full minute to
measure the apical pulse.
the apical pulse may be taken when the person
14 232

6. Use the second hand of your watch. Count 3. Explain procedure to the resident. Speak
beats for one full minute. Each “lubdub” that clearly, slowly, and directly. Maintain face-to-
you hear is counted as one beat. A normal face contact whenever possible.
heartbeat is rhythmical. Leave the stetho-
Basic Nursing Skills

4. Provide for resident’s privacy with curtain,

scope in place to count respirations (see pro-
screen, or door.
cedure later in chapter).
5. Place fingertips on the thumb side of resi-
7. Record pulse rate, date, time, and method
dent’s wrist. Locate pulse (Fig. 14-17).
used (apical). Note any irregularities in the
rhythm.

8. Clean earpieces and diaphragm of stetho-

scope with alcohol wipes. Store stethoscope.

9. Wash your hands.

10. Place call light within resident’s reach.

11. Report any changes in resident to the nurse.

Respiration is the process of breathing air into

the lungs, or inspiration, and exhaling air out
of the lungs, or expiration. Each respiration Fig. 14-17. Take the radial pulse by placing fingertips on
consists of an inspiration and an expiration. The the thumb side of the wrist.
chest rises during inspiration and falls during
expiration. 6. Count the beats for one full minute.
The normal respiration rate for adults ranges 7. Keep your fingertips on the resident’s wrist.
from 12 to 20 breaths per minute. Infants and Count respirations for one full minute (Fig.
children have a faster respiratory rate. Infants 14-18). Observe for the pattern and character
normally breathe at a rate of 30 to 40 respira- of the resident’s breathing. Normal breathing
tions per minute. People may breathe more is smooth and quiet. If you see signs of trou-
quickly if they know they are being observed. bled breathing, shallow breathing, or noisy
Because of this, count respirations immediately breathing, such as wheezing, report it.
after taking the pulse. Keep your fingers on
a resident’s wrist or on the stethoscope over
the heart. Do not make it obvious that you are
watching the resident’s breathing.

Taking and recording radial pulse and counting

and recording respirations
Equipment: watch with a second hand, pen and
paper

1. Wash your hands.

Fig. 14-18. Count the respiratory rate directly after tak-
2. Identify yourself by name. Identify the resi- ing the radial pulse. Do not make it obvious that you are
dent by name. watching her breathing.
 233 14

8. Record pulse rate, date, time, and method Many factors can increase blood pressure. These
used (radial). Record the respiratory rate and include aging, exercise, physical or emotional
the pattern or character of breathing. stress, pain, medications, and the volume of
blood in circulation. Loss of blood will lead to

Basic Nursing Skills

9. Place call light within resident’s reach.
abnormally low blood pressure, or hypoten-
10. Wash your hands. sion. Hypotension can be life-threatening if not
11. Report to the nurse if the pulse is less than corrected.
60 beats per minute, over 100 beats per min- Blood pressure is taken using a stethoscope and
ute, if the rhythm is irregular, or if breathing a blood pressure cuff, or sphygmomanometer
is irregular. (Fig. 14-19). Inside the cuff is an inflatable bal-
loon. It expands when air is pumped into the
cuff. Two pieces of tubing are connected to the
4. Explain guidelines for taking blood cuff. One leads to a rubber bulb that pumps air
pressure into the cuff. A pressure control button lets you
Blood pressure is an important measure of a control the release of air from the cuff after it is
person’s health. Blood pressure is measured inflated. The other piece of tubing is connected
in millimeters of mercury (mmHg). The mea- to a pressure gauge with numbers. The gauge is
surement shows how well the heart is work- either a mercury column or a round dial.
ing. There are two parts of blood pressure, a) b)
the systolic measurement and the diastolic
measurement.
In the systolic phase, the heart is at work. It
contracts and pushes the blood from the left ven-
tricle of the heart. The reading shows the pres-
sure on the walls of arteries as blood is pumped Fig. 14-19. a) A sphygmomanometer and b) an elec-
tronic sphygmomanometer.
through the body. The normal range for systolic
blood pressure is 100–119 mmHg.
There may be an electronic sphygmomanom-
The second measurement reflects the diastolic eter available. The systolic and diastolic pres-
phase—when the heart relaxes. The diastolic sure readings and pulse are displayed digitally.
measurement is always lower than the systolic Some units automatically inflate and deflate.
measurement. It shows the pressure in the arter- You do not need a stethoscope with an electronic
ies when the heart is at rest. The normal range sphygmomanometer. Ask for instructions on the
for adults is 60–79 mmHg. proper use of the equipment.
People with high blood pressure, or hyperten- When taking blood pressure, the first clear
sion, have elevated systolic and/or diastolic sound you will hear is the systolic pressure (top
blood pressures. A blood pressure level of 140/90 number). When the sound changes to a soft
mmHg or higher is considered high. muffled thump or disappears, this is the dia-
stolic pressure (bottom number). Blood pressure
However, if blood pressure is between 120/80
is recorded as a fraction. The systolic reading is
mmHg and 139/89 mmHg, it is called prehy-
on top, and the diastolic reading is on the bot-
pertension. This means that the person does
tom (for example: 120/80).
not have high blood pressure now but is likely
to have it in the future. Report to the nurse if a Never measure blood pressure on an arm that
resident’s blood pressure is 140/90 or above. has an IV, a dialysis shunt, or any medical
14 234

equipment. Avoid a side that has a cast, recent

trauma, paralysis from a stroke, burn(s), or
breast surgery (mastectomy).
Basic Nursing Skills

This textbook includes two methods for taking

blood pressure: the one-step method and the
two-step method. If using the two-step method,
you will get an estimate of the systolic blood
pressure before you start. After getting an esti-
mated systolic reading, you will deflate the cuff
and begin again. If using the one-step method,
you will not get an estimated systolic reading be- Fig. 14-20. Place the center of the cuff over the brachial
fore obtaining the blood pressure reading. Your artery.
state may require that you know one or both of
these methods. Some states do not allow NAs 9. Before using stethoscope, wipe diaphragm
to measure blood pressure. Know your scope of and earpieces with alcohol wipes.
practice and follow your facility’s policies. 10. Locate brachial pulse with fingertips.
11. Place diaphragm of stethoscope over brachial
Taking and recording blood pressure artery.
(one-step method)
12. Place earpieces of stethoscope in ears.
Equipment: sphygmomanometer (blood pressure
13. Close the valve (clockwise) until it stops. Do
cuff ), stethoscope, alcohol wipes, pen and paper
not tighten it (Fig. 14-21).
1. Wash your hands.
2. Identify yourself by name. Identify the resi-
dent by name.
3. Explain procedure to the resident. Speak
clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.
4. Provide for resident’s privacy with curtain,
screen, or door.
5. Ask the resident to roll up his or her sleeve.
Do not measure blood pressure over
clothing. Fig. 14-21. Close the valve, but do not tighten it; tight
valves are difficult to release.
6. Position resident’s arm with palm up. The
arm should be level with the heart.
14. Inflate cuff to 30 mmHg above the point at
7. With the valve open, squeeze the cuff. Make which the pulse is last heard or felt.
sure it is completely deflated.
15. Open the valve slightly with thumb and index
8. Place blood pressure cuff snugly on resi- finger. Deflate cuff slowly.
dent’s upper arm. The center of the cuff is
16. Watch gauge. Listen for sound of pulse.
placed over the brachial artery (1-1½ inches
above the elbow toward inside of elbow) (Fig. 17. Remember the reading at which the first clear
14-20). pulse sound is heard. This is the systolic
pressure.
 235 14

18. Continue listening for a change or muffling placed over the brachial artery (1-1½ inches
of pulse sound. The point of change or the above the elbow toward inside of elbow).
point the sound disappears is the diastolic
9. Locate the radial (wrist) pulse with your
pressure. Remember this reading.

Basic Nursing Skills

fingertips.
19. Open the valve to deflate cuff completely. Re-
10. Close the valve (clockwise) until it stops. In-
move cuff.
flate cuff while watching gauge.
20. Record both the systolic and diastolic pres-
11. Stop inflating when you can no longer feel
sures. Write the numbers like a fraction, with
the pulse. Note the reading. The number is
the systolic reading on top and the diastolic
an estimate of the systolic pressure. This
reading on the bottom (for example: 120/80).
estimate helps you not to inflate the cuff too
Note which arm was used. Write “RA” for
high later in this procedure. Inflating the cuff
right arm and “LA” for left arm.
too high is painful and may damage small
21. Wipe diaphragm and earpieces of stetho- blood vessels.
scope with alcohol. Store equipment.
12. Open the valve to deflate cuff completely. Re-
22. Place call light within resident’s reach. move cuff.
23. Wash your hands. 13. Write down the estimated systolic reading.
24. Report any changes in resident to the nurse. 14. Before using stethoscope, wipe diaphragm
and earpieces of stethoscope with alcohol
wipes.
Taking and recording blood pressure
(two-step method) 15. Locate brachial pulse with fingertips.
Equipment: sphygmomanometer (blood pressure 16. Place the earpieces of the stethoscope in
cuff ), stethoscope, alcohol wipes, pen and paper your ears.
1. Wash your hands. 17. Place the diaphragm of the stethoscope over
2. Identify yourself by name. Identify the resi- the brachial artery.
dent by name. 18. Close the valve (clockwise) until it stops. Do
3. Explain procedure to the resident. Speak not tighten it.
clearly, slowly, and directly. Maintain face-to- 19. Inflate the cuff to 30 mmHg above your esti-
face contact whenever possible. mated systolic pressure.
4. Provide for resident’s privacy with curtain, 20. Open the valve slightly with thumb and index
screen, or door. finger. Deflate cuff slowly. Releasing the valve
5. Ask the resident to roll up his or her sleeve. slowly allows you to hear beats accurately.
Do not measure blood pressure over 21. Watch the gauge. Listen for sound of pulse.
clothing.
22. Remember the reading at which the first clear
6. Position resident’s arm with palm up. The pulse sound is heard. This is the systolic
arm should be level with the heart. pressure.
7. With the valve open, squeeze the cuff. Make
23. Continue listening for a change or muffling
sure it is completely deflated.
of pulse sound. The point of change or the
8. Place blood pressure cuff snugly on resi- point the sound disappears is the diastolic
dent’s upper arm. The center of the cuff is pressure. Remember this reading.
14 236

24. Open the valve to deflate cuff completely. Re- pain, ask the following questions to get the most
move cuff. accurate information. Immediately report the in-
formation to the nurse. Sustained pain may lead
25. Record both the systolic and diastolic pres-
to withdrawal, depression, and isolation.
Basic Nursing Skills

sures. Write the numbers like a fraction, with

the systolic reading on top and the diastolic
reading on the bottom (for example: 120/80).
Note which arm was used. Write “RA” for
right arm and “LA” for left arm.
26. Wipe diaphragm and earpieces of stetho-
scope with alcohol. Store equipment.
27. Place call light within resident’s reach.
28. Wash your hands. Fig. 14-22. Believe residents when they say they are in
pain and take quick action to help them. Being in pain is
29. Report any changes in resident to the nurse.
unpleasant. Be empathetic.

• Where is the pain?

Tip
• When did the pain start?
Orthostatic Blood Pressures
You may be asked by the nurse to take an orthostatic • Is the pain mild, moderate, or severe? To
blood pressure measurement. To do this, the resi- help find out, ask the resident to rate the
dent must first lie down. Take the blood pressure pain on a scale of 1 to 10, with 10 being the
reading with the resident lying down. Record the
systolic and diastolic pressures. Next, have the resi- most severe.
dent stand up. Wait two minutes, and take the blood • Ask the resident to describe the pain. Make
pressure measurement again. Record both pressures
again. Orthostatic blood pressures must be checked
notes if you need to. Use the resident’s
in this order: lying down first, then standing up. words when reporting to the nurse.
• Ask the resident what he or she was doing
before the pain started.
5. Describe guidelines for pain
management • Ask the resident how long the pain lasts and
how often it occurs.
Pain is often referred to as vital sign because it
• Ask the resident what makes the pain better
is so important to monitor. Pain is uncomfort-
and what makes the pain feel worse.
able. It is also a personal experience, which
means it is different for each person. Because Residents may have concerns about managing
you spend the most time with residents, you their pain. These concerns may make them hesi-
play an important role in pain monitoring and tant to report their pain. Some barriers to man-
prevention. Care plans are made based on your aging pain include the following:
reports. It is important to observe and report • Fear of addiction to pain medication
carefully on a resident’s pain.
• Feeling that pain is a normal part of aging
Pain is not a normal part of aging. When resi-
dents complain of pain, treat their complaints • Worrying about constipation and fatigue
seriously (Fig. 14-22). Listen to what residents from pain medication
are saying about the way they feel. Take action • Feeling that caregivers are too busy to deal
to help them. If a resident says he or she is in with their pain
 237 14

• Feeling that too much pain medication will • Gently position the body in good alignment.
cause death Use pillows for support. Assist in frequent
Be patient and caring when helping residents changes of position if the resident desires it.

Basic Nursing Skills

who are in pain. If they are worried about the • Give back rubs.
effects of pain medication or if they have ques- • See if the resident would like to take a warm
tions about it, tell the nurse. bath or shower.
Understand that some people do not feel com- • Assist the resident to the bathroom or com-
fortable saying that they are in pain. A person’s mode or offer the bedpan or urinal.
culture affects how he or she responds to pain.
• Encourage slow, deep breathing.
Some cultures believe that it is best not to react
to pain. Other cultures believe in expressing • Provide a calm and quiet environment. Use
pain freely. Watch for body language or other soft music to distract the resident.
messages that residents may be in pain. Signs • Be patient, gentle, kind, and responsive to
and symptoms of pain are important to observe residents who are in pain.
and report.
6. Explain the benefits of warm and cold
Observing and Reporting:
Pain
applications
Applying heat or cold to injured areas can have
Report any of these to the nurse:
several good effects. Heat relieves pain and mus-
Increased pulse, respirations, and/or blood cular tension. It reduces swelling, elevates the
pressure temperature in the tissues, and increases blood
Sweating flow. Increased blood flow brings more oxygen
and nutrients to the tissues for healing. Cold
Nausea
applications can help stop bleeding. They help
Vomiting prevent swelling, reduce pain, and bring down
Tightening the jaw high fevers.
Squeezing eyes shut Warm and cold applications may be dry or
Holding a body part tightly moist. Moisture strengthens the effect of heat
Frowning and cold. This means that moist applications are
more likely to cause injury. Paralysis, numbness,
Grinding teeth
disorientation, confusion, dementia, and other
Increased restlessness conditions may cause a person not to be able to
Agitation or tension feel, notice, or understand damage that is occur-
Change in behavior ring from a warm or cold application. For exam-
ple, a resident recovering from a stroke who has
Crying
paralysis on one side may not be able to feel if a
Sighing warm pack is burning his skin. A resident with
Groaning Alzheimer’s disease may not understand that he
is being burned and/or be able to communicate
Breathing heavily
pain clearly. Be very careful when using these
Difficulty moving or walking applications. Know how long the application
Use the following measures to help reduce pain: should be performed. Use the correct tempera-
• Report complaints of pain immediately. ture as given in the care plan. Check on the ap-
14 238

plication often, especially for residents who have For warm compresses, you may use a washcloth
conditions that may make them unaware of pos- or a commercial warm compress. There are dif-
sible injury. ferent types of commercial compresses available
(Fig. 14-23). If these are provided, follow the
Basic Nursing Skills

Types of moist applications are:

package directions and the nurse’s instructions.
• Compresses (warm or cold)
• Soaks (warm or cold)
• Tub baths (warm)
• Sponge baths (warm or cold)
• Sitz baths (warm)
• Ice packs (cold)
Types of dry applications are:
• Aquamatic K-pad ® (warm or cold)
• Electric heating pad (warm)
Fig. 14-23. Disposable heat compresses are used only
• Disposable warm pack (warm) once and then discarded. The compress shown here must
be squeezed to activate and then applied. It maintains
• Ice bag (cold) heat for a certain amount of time, usually up to 20 min-
• Disposable cold pack (cold) utes. (reprinted with permission of briggs corporation, 800-247-2343,
www.briggscorp.com)

Some states allow nursing assistants to prepare

and apply warm and cold applications. Never
Applying warm compresses
perform a procedure you are not trained or al-
lowed to do. Only perform procedures that are Equipment: washcloth or compress, plastic wrap,
assigned to you. towel, basin, bath thermometer

1. Wash your hands.

Observing and Reporting:
Warm and Cold Applications 2. Identify yourself by name. Identify the resi-
dent by name.
Report the following to the nurse:
3. Explain procedure to the resident. Speak
Excessive redness clearly, slowly, and directly. Maintain face-to-
Pain face contact whenever possible.
Blisters 4. Provide for the resident’s privacy with cur-
Numbness tain, screen, or door.
If you observe these signs, the application may 5. Fill basin one-half to two-thirds full with hot
be causing tissue damage. water. Test water temperature with thermom-
eter or your wrist. Ensure it is safe. Water
Residents’ Rights
temperature should be no more than 105°F.
Keep them covered.
Have resident check water temperature.
When applying warm or cold applications, keep
Adjust if necessary.
residents’ bodies covered. Only expose the area that
needs treatment. Doing this promotes dignity, and
6. Soak the washcloth in the water and wring it
honors a resident’s right to privacy.
out. Immediately apply it to the area needing
 239 14

a warm compress. Note the time. Quickly

Administering warm soaks
cover the washcloth with plastic wrap and the
towel to keep it warm (Fig. 14-24). Equipment: towel, basin, bath thermometer, bath
blanket

Basic Nursing Skills

1. Wash your hands.

2. Identify yourself by name. Identify the resi-

dent by name.

3. Explain procedure to the resident. Speak

clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.

4. Provide for the resident’s privacy with cur-

tain, screen, or door.
5. Fill the basin half full of warm water. Test
water temperature with thermometer or your
wrist. Ensure it is safe. Water temperature
should be no more than 105°F. Have resident
check water temperature. Adjust if necessary.
6. Immerse the body part in the basin. Pad the
edge of the basin with a towel if needed (Fig.
14-25). Use a bath blanket to cover the resi-
dent if needed for extra warmth.
Fig. 14-24. Cover compresses to keep them warm.

7. 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.
8. Remove privacy measures. Make resident
comfortable.
9. Place soiled towels in proper container. Fig. 14-25. Pad the edge of the basin to make the resi-
dent more comfortable.
10. Empty, rinse, and wipe basin. Return to
proper storage. Discard plastic wrap. 7. Check water temperature every five minutes.
11. Place call light within resident’s reach. Add hot water as needed to maintain the
temperature. Never add water hotter than
12. Wash your hands.
105°F to avoid burns. To prevent burns, tell
13. Report any changes in resident to the nurse. the resident not to add hot water. Observe
the area for redness. Discontinue the soak if
14. Document procedure using facility
the resident has pain or discomfort.
guidelines.
8. Soak for 15-20 minutes, or as ordered.
14 240

9. Remove basin. Use the towel to dry resident. Check that tubing between pad and unit is
intact.
10. Remove privacy measures. Make resident
comfortable. 6. Remove cover of control unit to check level of
Basic Nursing Skills

water. If it is low, fill it with distilled water to

11. Place soiled towel in proper container.
the fill line.
12. Empty, rinse, and wipe basin. Return to
proper storage. Discard plastic wrap. 7. Put the cover of control unit back in place.

13. Place call light within resident’s reach. 8. Plug unit in and turn pad on. Temperature
should have been pre-set. If it was not, check
14. Wash your hands. with the nurse for proper temperature.
15. Report any changes in resident to the nurse. 9. Place the pad in the cover. Do not pin the
16. Document procedure using facility pad to the cover.
guidelines. 10. 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
Applying an Aquamatic K-Pad ® coiled on the bed.
Equipment: K-Pad ® and control unit (Fig. 14-26), 11. Return and check area every five minutes. Re-
covering for pad, distilled water
move the pad if the area is red or numb or if
the resident reports pain or discomfort.

12. Check water level. Refill when necessary.

13. Remove pad after 20 minutes.

14. Remove privacy measures. Make resident

comfortable.

15. Clean and store supplies.

16. Place call light within resident’s reach.

17. Wash your hands.

Fig. 14-26. An Aquamatic K-Pad®.
18. Report any changes in resident to the nurse.
1. Wash your hands.
19. Document procedure using facility
2. Identify yourself by name. Identify the resi- guidelines.
dent by name.

3. Explain procedure to the resident. Speak Another type of heat application is a sitz bath.
clearly, slowly, and directly. Maintain face-to- This is a warm soak of the perineal area. Sitz
face contact whenever possible. baths clean perineal wounds and reduce inflam-
mation and pain. Circulation in the perineal
4. Provide for the resident’s privacy during pro-
area is increased. Voiding may be stimulated
cedure with curtain, screen, or door.
by a sitz bath. Persons with perineal swelling
5. Place the control unit on the bedside table. (such as hemorrhoids) or perineal wounds (such
Make sure cords are not frayed or damaged. as those that occur during childbirth) may be
 241 14

ordered to take sitz baths. Because the sitz bath 4. Provide for the resident’s privacy with cur-
causes increased blood flow to the pelvic area, tain, screen, or door.
blood flow to other parts of the body decreases.
5. Put on gloves.
Residents may feel weak, faint, or dizzy after a

Basic Nursing Skills

sitz bath. Always wear gloves when helping with 6. Fill the sitz bath two-thirds full with hot
a sitz bath. water. Place the disposable sitz bath on the
toilet seat. Water temperature should be no
Assisting with a sitz bath more than 105°F. Check the water tempera-
ture using the bath thermometer. If having a
A disposable sitz bath fits on the toilet seat and sitz bath to help relieve pain and to stimulate
is attached to a rubber bag containing warm circulation, the water temperature may need
water (Fig. 14-27). to be higher. Follow instructions in the care
plan.
7. Help the resident undress and be seated
on the sitz bath. A valve on the tubing con-
nected to the bag allows the resident or you
to fill the sitz bath again with hot water.
8. You may be required to stay with the resi-
dent 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. Stay with a resident who
seems unsteady.
9. Help the resident out of the sitz bath in 20
minutes. Provide towels. Help with dressing
if needed.
10. Make sure resident is comfortable.
11. Clean and store supplies.
12. Remove gloves.
13. Wash your hands.
Fig. 14-27. A disposable sitz bath. (reprinted with permission of
briggs corporation, 800-247-2343, www.briggscorp.com) 14. Place call light within resident’s reach.
15. Report any changes in resident to the nurse.
Equipment: disposable sitz bath, bath thermometer,
towels, gloves 16. Document procedure using facility
1. Wash your hands. guidelines.

2. Identify yourself by name. Identify the resi-

dent by name. For applying ice packs, you may use a commer-
cial cold pack. There are different types of com-
3. Explain procedure to the resident. Speak mercial packs available (Fig. 14-28). If these are
clearly, slowly, and directly. Maintain face-to- provided, follow the package directions and the
face contact whenever possible. nurse’s instructions.
14 242

7. Check the area after ten minutes for blisters

or pale, white, or gray skin. Stop treatment if
resident reports numbness or pain.
Basic Nursing Skills

8. Remove ice after 20 minutes or as ordered.

9. Remove privacy measures. Make resident

comfortable.
Fig. 14-28. Some types of reusable packs may be used for
heat or cold. They can be microwaved to heat or stored in 10. Store ice pack. Place towel in proper
the freezer for cold. (reprinted with permission of briggs corporation,
800-247-2343, www.briggscorp.com) container.

11. Place call light within resident’s reach.

Applying ice packs
12. Wash your hands.
Equipment: ice pack or sealable plastic bag and
crushed ice, towel to cover pack or bag 13. Report any changes in resident to the nurse.

1. Wash your hands. 14. Document procedure using facility

guidelines.
2. Identify yourself by name. Identify the resi-
dent by name.
You may use a washcloth dipped in cold water
3. Explain procedure to the resident. Speak
as a cold compress; you may also use a dispos-
clearly, slowly, and directly. Maintain face-to-
able or reusable compress (Fig. 14-30). Follow
face contact whenever possible.
instructions on the package.
4. Provide for the resident’s privacy with cur-
tain, screen, or door.

5. Fill plastic bag or ice pack 1/2 to 2/3 full with

crushed ice. Seal bag. Remove excess air.
Cover bag or ice pack with towel (Fig. 14-29).

Fig. 14-30. This type of cold compress is disposable. You

squeeze it to activate and it will last up to 30 minutes.
It remains flexible when activated. (reprinted with permission of
briggs corporation, 800-247-2343, www.briggscorp.com)

Applying cold compresses

Fig. 14-29. Seal the bag filled with ice and cover it with
a towel. Equipment: basin filled with water and ice, two
washcloths, disposable bed protector, towels
6. Apply bag to the area as ordered. Note the 1. Wash your hands.
time. Use another towel to cover bag if it is
too cold. 2. Identify yourself by name. Identify the resi-
dent by name.
 243 14

3. Explain procedure to the resident. Speak 7. Explain how to apply non-sterile

clearly, slowly, and directly. Maintain face-to- dressings and discuss sterile dressings
face contact whenever possible.
Sterile dressings cover open or draining wounds.

Basic Nursing Skills

4. Provide for the resident’s privacy with cur-
A nurse changes these dressings. Non-sterile
tain, screen, or door.
dressings are applied to dry, closed wounds that
5. Place bed protector under area to be treated. have less chance of infection. Nursing assistants
Rinse washcloth in basin and wring out (Fig. may help with non-sterile dressing changes.
14-31). Cover the area to be treated with a
cloth sheet or towel. Apply cold washcloth
Changing a dry dressing using non-sterile
to the area as directed. Change washcloths
technique
often to keep area cold.
Equipment: package of square gauze dressings, ad-
hesive tape, scissors, 2 pairs of gloves

1. Wash your hands.

2. Identify yourself by name. Identify the resi-

dent by name.

3. Explain procedure to the resident. Speak

clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.

Fig. 14-31. Wring out the washcloth before applying it to 4. Provide for resident’s privacy with curtain,
the area to be treated. screen, or door.

6. Check the area after five minutes for blisters, 5. Cut pieces of tape long enough to secure the
pale, white, or gray skin. Stop treatment if dressing. Hang tape on the edge of a table
resident complains of numbness or pain. within reach. Open four-inch gauze square
package without touching gauze. Place the
7. Remove compresses after 20 minutes or as open package on a flat surface.
ordered in the care plan. Give resident towels
as needed to dry the area. 6. Put on gloves.

8. Remove privacy measures. Make resident 7. Remove soiled dressing by gently peeling
comfortable. tape toward the wound. Lift dressing off the
wound. Do not drag it over wound. Observe
9. Clean and store basin. Place towels in proper
dressing for any odor or drainage. Notice
container.
color and size of the wound. Dispose of used
10. Place call light within resident’s reach. dressing in proper container. Remove and
dispose of gloves.
11. Wash your hands.
12. Report any changes in resident to the nurse. 8. Put on new gloves. Touching only outer
edges of new four-inch gauze, remove it from
13. Document procedure using facility package. Apply it to wound. Tape gauze in
guidelines. place. Secure it firmly (Fig. 14-32).
14 244

• Binders are stretchable pieces of fabric that

can be fastened. They hold dressings in
place and give support to surgical wounds.
Binders can also reduce swelling and ease
Basic Nursing Skills

discomfort.
• Medical-grade adhesive tape panels (some-
times called “Montgomery Straps”) help
Fig. 14-32. Tape gauze in place to secure the dressing. Do keep frequently-changed dressings in place.
not completely cover all areas of the dressing with tape. The adhesive is not removed with each
dressing change so that skin is less likely to
9. Remove and dispose of gloves properly. become irritated.
10. Wash your hands. When gathering sterile supplies, keep the follow-
11. Remove privacy measures. Make resident ing tips in mind:
comfortable. • If the wrapper on the supply is torn, it is
no longer considered sterile and cannot be
12. Place call light within resident’s reach.
used.
13. Report any changes in resident to the nurse.
• The wrapper on the supply cannot be
14. Document procedure using facility opened and closed again. Once a wrapper
guidelines. is opened, the supplies inside are no longer
sterile.
Even though nursing assistants do not change • If a wrapper is wet or has wrinkles or marks
sterile dressings, they can gather and store that indicate it was once wet, it is no longer
equipment and supplies, observe and report considered sterile.
about the dressing site and they may be allowed • If the date on the supply shows it has ex-
to clean the equipment. Duties may also include pired, it is no longer considered sterile.
properly positioning the resident, cutting the Commercially prepared supplies are all
tape, and disposing of the soiled dressing. Sup- dated. A sterile supply that has expired
plies that may be needed for changing a sterile should not be used.
dressing include:
• If you are unsure whether a wrapper is ster-
• Special gauze has one side that has a shiny, ile or not, do not use it.
non-stick surface, which will not stick to
wounds when removed. Sterile dressings cover open or draining wounds.
Because of the way the wound and the skin
• Abdominal pads (ABDs) are large, heavy around it may look, the resident may feel embar-
gauze dressings that cover smaller gauze rassed about having others see the area. Promote
dressings and help keep them in place and the resident’s comfort and dignity when assist-
provide absorbency. ing the nurse with a sterile dressing change by
• Cotton bandages (sometimes called “Kerlix” being professional and matter-of-fact. Do not
or “Kling” bandages) can stretch and mold to show any discomfort, even if you are bothered by
a body part and help hold it in place; these the appearance of the resident’s skin.
are often used on bony areas, such as the Observing and documenting your observations
knees and elbows. are very important parts of your job. While you
 245 14

are assisting with changing a sterile dressing,

Guidelines:
observe for any changes in the wound, especially
Elastic Bandages
the following:

Basic Nursing Skills

• Skin that has changed color G Keep the area to be wrapped clean and dry.

• Scab that has come off G Apply elastic bandages snugly enough to
control bleeding and prevent movement of
• Bleeding dressings. However, make sure that the body
• Swelling part is not wrapped too tightly, which can
decrease circulation.
• Odor
G Wrap the bandage evenly so that no part of
• Drainage
the wrapped area is pinched.
G Do not tie the bandage because this cuts off
8. Discuss guidelines for non-sterile circulation to the body part; the end is held in
bandages place with special clips or tape.
Elastic, or non-sterile, bandages (sometimes G Remove the bandage as often as indicated in
called “ACE® bandages”) are used to hold dress- the care plan.
ings in place, secure splints, and support and G Check the bandage often because it can
protect body parts. In addition, these bandages become wrinkled or loose, which causes it
may decrease swelling that occurs with an injury to lose effectiveness, and bunched-up, which
(Fig. 14-33). causes pressure and possible discomfort.
G Check on the resident 15 minutes after the
bandage is first applied to see if there are any
signs of poor circulation. Signs and symp-
toms of poor circulation include:
• Swelling
• Bluish, or cyanotic, skin
• Shiny, tight skin
• Skin cold to touch
• Sores
• Numbness
Fig. 14-33. One type of elastic bandage. • Tingling
• Pain or discomfort
NAs may be required to assist with the use of
an elastic bandage. Duties may include bring- Loosen the bandage if you note any signs of
ing the bandage to the resident, positioning poor circulation, and notify the nurse imme-
the resident to apply the bandage, washing and diately.
storing the bandage, and documenting observa-
tions about the bandage. Some states allow NAs 9. List care guidelines for a resident who
to apply and remove elastic bandages. Follow is on an IV
your facility’s policies and the care plan regard-
ing elastic bandages. If you are allowed to assist IV stands for intravenous, or into a vein. A resi-
with these bandages, know the following safety dent with an IV is receiving medication, nutri-
guidelines. tion, or fluids through a vein.
14 246

When a doctor prescribes an IV, a nurse inserts The IV fluid is not dripping.
a needle or tube into a vein. This allows direct
The IV fluid is nearly gone.
access to the bloodstream. Medication, nutrition,
or fluids either drip from a bag suspended on a The pump beeps, indicating a problem.
Basic Nursing Skills

pole or are pumped by a portable pump through The pump is dropped.

a tube and into the vein (Fig. 14-34). Some resi-
As always, document your observations and
dents with chronic conditions have a permanent
the care provided. Do not get the IV site wet or
opening for IVs. This opening has been surgi-
lower the bag below the IV site. Never discon-
cally created to allow easy access for IV fluids.
nect the IV from the pump or turn off a beeping
Nursing assistants never insert or remove IV
alarm. Do not take a resident’s blood pressure
lines. You will not be responsible for care of
on an arm that has an IV. Having an IV in place
the IV site. Your only responsibility for IV care
makes some basic care procedures more diffi-
is to report and document any observations of
cult. Always be careful not to pull or catch on IV
changes or problems with the IV.
tubing when performing or assisting with care
of residents with IVs.

Assisting in changing clothes for a resident

who has an IV
Equipment: clean clothes

1. Wash your hands.

2. Identify yourself by name. Identify the resi-

dent by name.
Fig. 14-34. A resident receiving IV therapy. 3. Explain procedure to the resident. Speak
clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.
Observing and Reporting:
4. Provide for resident’s privacy with curtain,
IVs
screen, or door.
The tube/needle falls out or is removed. 5. If the bed is adjustable, adjust to a safe level,
The tubing disconnects. usually waist high. If the bed is movable, lock
bed wheels.
The dressing around the IV site is loose or
not intact. 6. Assist resident to sitting position with feet
flat on the floor.
Blood is present in the tubing or around the
site of the IV. 7. Have the resident remove the arm without
The site is swollen or discolored. the IV from clothing. Assist as necessary.

The resident complains of pain. 8. Help the resident gather the clothing on the
arm with the IV. Carefully lift the clothing over
The bag is broken, or the level of fluid does the IV site and move it up the tubing toward
not seem to decrease. the IV bag (Fig. 14-35).
 247 14

16. Assist the resident with changing the rest of

his clothing, as necessary.

17. Place soiled clothes in proper container.

Basic Nursing Skills

18. Make resident comfortable. Make sure sheets
are free from wrinkles and the bed free from
crumbs.

19. Return bed to lowest position. Remove pri-

vacy measures.
Fig. 14-35. Make sure clothing does not catch on tubing.
20. Place call light within resident’s reach.
9. Lift the IV bag off its pole, keeping it higher 21. Wash your hands.
than the IV site. Carefully slide the clothing
over the bag. Place the bag back on the pole. 22. Report any changes in resident to the nurse.

10. Set the used clothing aside to be placed with 23. Document procedure using facility
soiled laundry. guidelines.

11. Gather the sleeve of the clean clothing.

Special gowns with sleeves that snap and un-
12. Lift the IV bag off its pole and, keeping it snap are available to lessen the risk of pulling
higher than the IV site, carefully slide the out IVs.
clothing over the bag (Fig. 14-36). Place the
IV bag back on the pole. Residents’ Rights
IVs
Protect the rights of a resident with an IV by helping
him or her be as independent as possible. Set up the
area so the resident may still feed him- or herself,
help with bathing and hair care, if able, etc. Ask the
nurse how to transport the resident to the activities
he or she wants to attend. Assure privacy for proce-
dures by pulling the privacy curtain and closing the
door.

10. Discuss oxygen therapy and explain

Fig. 14-36. Always keep the IV bag higher than the IV related care guidelines
site.
As you learned in Chapter 6, some residents
13. Carefully move the clean clothing down the may receive oxygen therapy. Oxygen therapy
IV tubing, over the IV site, and onto the resi- is the administration of oxygen to increase the
dent’s arm. supply of oxygen to the lungs. This increases the
availability of oxygen to the body tissues. Oxygen
14. Have the resident put his other arm in the therapy is often used to treat breathing difficul-
clothing. Assist as necessary. ties and is prescribed by a doctor. Nursing assis-
15. Check that the IV is dripping properly. Make tants never stop, adjust, or administer oxygen.
sure none of the tubing is dislodged and the Oxygen may be piped into a resident’s room
IV site dressing is in place. through a central system. It may be in tanks or
14 248

produced by an oxygen concentrator. An oxygen Follow these guidelines for oxygen tanks, oxygen
concentrator is a box-like device that changes concentrators, and liquid oxygen:
air in the room into air with more oxygen. Oxy-
gen concentrators are quiet machines. They can
Basic Nursing Skills

Guidelines:
be larger units or portable ones that can move
Oxygen Delivery Devices
or travel with the resident. Oxygen concentrators
typically plug into wall outlets and are turned on For residents using oxygen tanks:
and off by a switch. It may take a while for the
oxygen concentrator to reach full power after it is G Take and record pulse and respirations before
turned on. and after resident uses the oxygen tank to
see if there are any changes.
Some residents receive oxygen through a nasal
cannula. A nasal cannula is a piece of plastic G The flow meter shows how much oxygen is
tubing that fits around the face and is secured flowing out to the resident at any time. It
by a strap that goes over the ears and around the should be set at the amount stated on the
back of the head. The face piece has two short care plan. If it is not, report this to the nurse.
prongs made of tubing. These prongs fit inside Do not adjust oxygen level.
the nose, and oxygen is delivered through them. G Make sure the humidifying bottle has sterile
A respiratory therapist fits the cannula. The water in it and is attached correctly . Wash
length of the prongs (usually no more than half the humidifying bottle according to the care
an inch) is adjusted for the resident’s comfort. plan or equipment supplier’s instructions.
The resident can talk and eat while wearing the
G Change the nasal cannula when ordered. It
cannula.
will need to be changed when it is hard or
Residents who do not need concentrated oxygen cracked, at least once per week.
all the time may use a face mask when they
G Make sure the oxygen tank is secured and
need oxygen. The face mask fits over the nose
will not tip over.
and mouth. It is secured by a strap that goes
over the ears and around the back of the head. For residents using oxygen concentrators:
The mask should be checked to see that it fits G Take and record pulse and respirations before
snugly on the resident’s face, but it should not and after resident uses the oxygen concentra-
pinch the face. It is difficult for a resident to talk tor to see if there are any changes.
when wearing an oxygen face mask. The mask
G The oxygen concentrator dial must be set at
must be removed for the resident to eat or drink
the same rate as indicated in the care plan.
anything.
If it is not, report this to the nurse. Do not
Oxygen can be irritating to the nose and mouth. adjust oxygen level.
The strap of a nasal cannula or face mask can
G Check the humidifying bottle each time the
also cause irritation around the ears. Wash and
device is used to see that it has sterile water
dry skin carefully, and provide frequent mouth
in it and that it is screwed on tightly. Sterile
care. Offer the resident plenty of fluids. Report
water must be used, not tap water, because
and document any irritation you observe.
minerals in tap water may clog the tubing.
Oxygen is a very dangerous fire hazard because
G Make sure the concentrator is in a well-ven-
it makes other things burn (supports combus-
tilated area, at least six inches from a wall.
tion). Observe the safety guidelines for oxygen
Because the air filter cleans the air going
use found in Chapter 6.
 249 14

into the machine, brush it off daily to remove 4. What is the most common site for monitor-
dust. ing the pulse? Where is it located?
For residents using liquid oxygen: 5. List the normal pulse rate range for adults.

Basic Nursing Skills

G Turn off supply valves when the reservoir is 6. Why should respirations be counted imme-
not in use. diately after measuring the pulse rate?
G Do not tip the reservoir on its side. 7. List the two parts of measuring blood pres-
sure and briefly define both phases.
G Make sure the reservoir is not in a closet,
cupboard, or other closed-in space. 8. Define the following terms: hypertension,
prehypertension, and hypotension.
G Do not cover the reservoir with bed linens or
clothing. 9. List the two pieces of equipment normally
used to monitor blood pressure.
G When lifting the reservoir, lift with two hands.
Do not roll the reservoir or walk it on edge. 10. How are blood pressure numbers written
and recorded?
G Do not touch frosted parts of the equipment,
because the cold can cause frostbite. Do not 11. List 15 signs that may show that a resident is
touch liquid oxygen; it can cause frostbite. in pain.
Report if the reservoir is leaking.
12. List seven measures to reduce pain.

Humidifiers 13. What are the benefits of warm applications?

What are the benefits of cold applications?
A humidifier is a device that puts moisture into the
air. Residents who use oxygen equipment or who 14. What four signs should an NA watch for at
have breathing problems may use humidifiers. Mak- the site of a warm or cold application?
ing the air moist or humid can make them more
comfortable. 15. What is the purpose of a sitz bath?
There are different types of humidifiers; some hu- 16. When are non-sterile dressings usually
midifiers put warm moisture into the air and some used?
put cool moisture into the air.
17. What duties may a nursing assistant have
Follow the care plan’s instructions for cleaning and
care of a humidifier. Because pathogens grow in regarding sterile dressings?
moist areas, the water tank of the humidifier should
18. List six signs of poor circulation that an NA
be washed often. Your other responsibilities may
include adding water to the humidifier when needed, should observe for when an elastic bandage
and possibly adding special tablets to prevent min- is applied.
eral buildup.
19. What is a nursing assistant’s responsibility
with IV care?
Chapter Review 20. List seven things to observe and report about
1. List five vital signs that must be monitored. a resident’s IV.

2. What are the four sites for taking the body’s 21. What is an oxygen concentrator?
temperature? 22. What is a nasal cannula?
3. Which temperature site is considered to be 23. Why is oxygen a dangerous fire hazard?
the most accurate?
15 250

15
Nutrition and Hydration

Nutrition and Hydration

1. Describe the importance of good (Fig. 15-1). Whole grain cereals, pastas, rice, and
nutrition breads contain some proteins, too.

Good nutrition is very important. Nutrition is

how the body uses food to maintain health. Bod-
ies need a well-balanced diet with essential nu-
trients and plenty of fluids. This helps us grow
new cells, maintain normal body function, and
have energy for activities. Good nutrition in early
life helps ensure good health later in life. For the
ill or elderly, a well-balanced diet helps maintain
muscles and skin tissues and prevent pressure Fig. 15-1. Sources of protein.
sores. A good diet promotes healing of wounds.
It also helps us cope with stress. 2. Carbohydrates. Carbohydrates supply fuel
for the body’s energy needs. They supply extra
2. List the six basic nutrients and explain protein and help the body use fat efficiently.
the USDA’s MyPyramid Carbohydrates also provide fiber, which is neces-
sary for bowel elimination. Carbohydrates can
A nutrient is something found in food that be divided into two basic types: complex and
provides energy, promotes growth and health simple carbohydrates (Fig. 15-2). Complex car-
and helps regulate metabolism. Metabolism bohydrates are found in bread, cereal, potatoes,
is the physical and chemical process by which rice, pasta, vegetables, and fruits. Simple car-
nutrients are broken down to be used by the bohydrates are found in sugars, sweets, syrups,
body for energy and other needs. The body and jellies. Simple carbohydrates do not have the
needs the following six nutrients for growth and same nutritional value that complex carbohy-
development: drates do.
1. Protein. Proteins are part of every body cell.
They are needed for tissue growth and repair.
Proteins also supply energy for the body. Excess
proteins are excreted by the kidneys or stored
as body fat. Sources of protein include fish, sea-
food, poultry, meat, eggs, milk, cheese, nuts, nut
butters, peas, dried beans or legumes, and soy
Fig. 15-2. Sources of carbohydrates.
products (tofu, tempeh, veggie burgers)
 251 15

3. Fats. Fat helps the body store energy. Body fat Without it, a person can only live a few days.
also provides insulation. It protects body organs. Water helps in the digestion and absorption of
In addition, fats add flavor to food and are im- food. It helps with waste elimination. Through
portant for the absorption of certain vitamins. perspiration, water also helps maintain normal

Nutrition and Hydration

Excess fat in the diet is stored as fat in the body. body temperature. Keeping enough fluid in our
Examples of fats are butter, margarine, salad bodies is necessary for good health (Fig. 15-4).
dressings, oils, and animal fats in meats, dairy
products, fowl, and fish (Fig. 15-3). Monoun-
saturated vegetable fats (including olive oil and
canola oil) and polyunsaturated vegetable fats
(including corn and safflower oils) are healthier.
Saturated fats, including animal fats like but-
ter, lard, bacon, and other fatty meats, are not as
healthy. They should be limited in most diets.

Fig. 15-4. Water is the most essential nutrient for life.

Drinking plenty of water promotes good health.

The fluids we drink—water, juice, soda, cof-

Fig. 15-3. Sources of fat. fee, tea, and milk—provide most of the water
our bodies use. Some foods are also sources of
4. Vitamins. Vitamins are substances the body water, including soup, celery, lettuce, apples, and
needs to function. The body cannot make most peaches.
vitamins; they can only be gotten from food. Vi- Most foods contain several nutrients, but no one
tamins A, D, E, and K are fat-soluble vitamins. food contains all the nutrients that are necessary
This means they are carried and stored in body to maintain a healthy body. That is why it is im-
fat. Vitamins B and C are water-soluble vitamins portant to eat a daily diet that is well-balanced.
that are broken down by water in our bodies. There is not one single dietary plan that is right
They cannot be stored in the body. They are for everyone. People have different nutritional
eliminated in urine and feces. needs depending upon their age, gender, and
5. Minerals. Minerals form and maintain body activity level.
functions. They provide energy and control pro- In 1980, the U.S. Department of Agriculture
cesses. Zinc, iron, calcium, and magnesium are (USDA) developed the Food Guide Pyramid to
examples of minerals. Minerals are found in help promote healthy eating practices. In 2005,
many foods. in response to new scientific information about
6. Water. One-half to two-thirds of our body nutrition and health and new technology for
weight is water. We need about 64 ounces, or support tools, MyPyramid was developed (Fig.
eight glasses, of water or other fluids a day. 15-5). MyPyramid replaces the Food Guide Pyra-
Water is the most essential nutrient for life. mid. MyPyramid is a personalized version of the
15 252

Food Guide Pyramid that offers individual plans The new Pyramid also emphasizes the impor-
based on age, gender, and activity level. tance of physical activity, as represented by the
figure climbing the stairs. Physical activity goes
hand-in-hand with diet to make up an overall
Nutrition and Hydration

healthy lifestyle. The USDA recommends at least

30 minutes per day of vigorous activity for every-
one. Sixty minutes or more is even better.
Grains: The grains group includes all foods
made from wheat, rice, oats, corn, barley, and
other grains. Examples are bread, pasta, oatmeal,
breakfast cereals, tortillas, and grits. One slice of
bread, one cup of ready-to-eat cereal, or ½ cup of
cooked rice, pasta, or cooked cereal can be con-
sidered a one-ounce equivalent from the grains
Fig. 15-5. MyPyramid was developed to help promote group.
healthy eating practices. It offers individual plans based
on age, gender, and activity level. At least half of all grains consumed should be
whole grains. Words on food labels that ensure
The Pyramid is made up of six bands of differ- that grains are whole grains are: brown rice,
ent widths and colors. Each color represents a wild rice, bulgur, oatmeal, whole-grain corn,
food group—orange for grains, green for veg- whole oats, whole wheat, and whole rye.
etables, maroon for fruits, yellow for oils, blue
Vegetables: The vegetable group includes all
for milk, and purple for meat and beans. The
fresh, frozen, canned, and dried vegetables,
different widths indicate that not all groups
and vegetable juices. One cup of raw or cooked
should make up an equal part of a healthy diet.
vegetables or vegetable juice or two cups of raw
The orange band, grains, is the widest, which
leafy greens can be counted as one cup from the
means that grains should make up the highest
vegetable group. There are five subgroups within
proportion of the diet. The smaller bands, such
the vegetable group. They are organized by nutri-
as the purple band representing meat and beans,
tional content. These are dark green vegetables,
should make up a smaller part of the diet. The
orange vegetables, dry beans and peas, starchy
smallest band, the yellow one, represents oils.
vegetables, and other vegetables. A variety of
Oils contain essential fatty acids. However, this
vegetables from these subgroups should be eaten
band is not emphasized because the body needs
every day. Dark green vegetables, orange veg-
fats and oils in smaller quantities.
etables, and dried beans and peas have the best
The bands of the Pyramid are wide at the bot- nutritional content.
tom and narrow into a point at the top. This is a
Vegetables are low in fat and calories and have
reminder that there are a great variety of foods
no cholesterol (although sauces and seasonings
that make up each group. Many choices are
may add fat, calories, and cholesterol). They are
available to help meet the daily requirements.
good sources of dietary fiber, potassium, vitamin
Foods that are nutrient-dense and low in fat and
A, vitamin E, and vitamin C.
calories should form the “base” of a healthy diet.
They are represented by the wide base of the Fruits: The fruit group includes all fresh, frozen,
Pyramid. Foods that are high in fat and sugar canned, and dried fruits, and fruit juices. One
and have less nutritional value are at the narrow cup of fruit or 100 percent fruit juice or ½ cup
top. They should be eaten less often. of dried fruit can be counted as one cup from
 253 15

the fruit group. Most choices should be whole or group or as part of the vegetable group. If meat
cut-up fruit rather than juice for the additional is eaten regularly, dry beans and peas should be
dietary fiber provided. included with vegetables. If not, they should be
included as part of this group.

Nutrition and Hydration

Fruits, like vegetables, are naturally low in fat,
sodium, and calories and have no cholesterol. Most meat and poultry choices should be lean or
They are important sources of dietary fiber low-fat. Diets that are high in saturated fats raise
and many nutrients, including folic acid and “bad” cholesterol levels in the blood. Fish, nuts,
vitamin C. and seeds contain healthy oils. These foods are
a good choice instead of meat or poultry. Some
Milk: The milk group includes all fluid milk
nuts and seeds (flax, walnuts) are excellent
products and foods made from milk that re-
sources of essential fatty acids. These acids may
tain their calcium content, such as yogurt and
reduce the risk of cardiovascular disease. Some
cheese. Foods made from milk that have little
(sunflower seeds, almonds, hazelnuts) are good
to no calcium, such as cream cheese, cream,
sources of vitamin E.
and butter, are not part of the group. Most milk
group choices should be fat-free or low-fat (Fig. Vegetarians get enough protein from this group
15-6). One cup of milk or yogurt, 1½ ounces as long as the variety and amounts of foods
of natural cheese, or two ounces of processed selected are adequate. Protein sources for veg-
cheese can be counted as one cup from the milk etarians from this group include eggs (for ovo-
group. vegetarians), beans, nuts, nut butters, peas, and
soy products (tofu, tempeh, veggie burgers).
Oils: Oils include fats that are liquid at room
temperature, such as canola, corn, olive, soy-
bean, and sunflower oil (Fig. 15-7). Some foods
are naturally high in oils, like nuts, olives, some
fish, and avocados. Foods that are mainly oil in-
clude mayonnaise, certain salad dressings, and
soft margarine.

Fig. 15-6. Low-fat yogurt is a good source of calcium.

Foods in the milk group provide nutrients that

are vital for the health and maintenance of your
body. These nutrients include calcium, potas-
sium, vitamin D, and protein. Calcium is used
for building bones and teeth and in maintain-
ing bone mass. Milk products are the primary
source of calcium in American diets. Fig. 15-7. Canola oil and olive oil are healthier types of
oils to use in cooking and baking.
Meat and Beans: One ounce of lean meat, poul-
try, or fish; one egg; one tablespoon of peanut Most of the fats you eat should be polyunsatu-
butter; ¼ cup cooked dry beans; or ½ ounce of rated (PUFA) or monounsaturated (MUFA) fats.
nuts or seeds can be counted as a one ounce Oils are the major source of MUFAs and PUFAs
equivalent from the meat and beans group. Dry in the diet. PUFAs contain some fatty acids that
beans and peas can be included as part of this are necessary for health. These are called “es-
15 254

sential fatty acids.” Most Americans consume • Metabolism slows. Muscles weaken and lose
enough oil in the foods they eat, such as nuts, tone, and body movement slows. Reduced
fish, cooking oil, and salad dressings. activity or exercise affects appetite.
Nutrition and Hydration

Activity: Physical activity and nutrition work to- • A loss of vision may affect the way food
gether for better health. Being active increases looks, which can decrease appetite.
the amount of calories burned. As people age, • Weakened senses of smell and taste af-
their metabolism slows. Maintaining energy bal- fect appetite. Medication may impair these
ance requires moving more and eating less. For senses (Fig. 15-8).
health benefits, physical activity should be mod-
• Less saliva production affects chewing and
erate or vigorous and add up to at least 30 min-
swallowing.
utes a day. For more information on MyPyramid,
visit mypyramid.gov. • Dentures, tooth loss, or poor dental health
make chewing difficult.
Because older adults have different nutritional
needs, Tufts University developed a version of • Digestion takes longer and is less efficient.
MyPyramid that is specifically designed for older • Certain medications or limited activity cause
adults. Due to slower metabolism and less activ- constipation. Constipation often interferes
ity, the elderly need to eat less to maintain body with appetite. Fiber, fluids, and exercise can
weight. Although calories can be reduced, daily improve this common problem.
needs for most nutrients do not decrease. The
“Modified MyPyramid for Older Adults” has a
narrower base to reflect a decrease in energy
needs. It emphasizes nutrient-dense foods, fiber,
and water. Dietary supplements may be appro-
priate for many older people. For more infor-
mation on the “Modified MyPyramid for Older
Adults,” visit nutrition.tufts.edu.

3. Identify nutritional problems of the

elderly or ill
Aging and illness can lead to emotional and
physical problems that affect the intake of food.
Fig. 15-8. Many elderly people take a variety of medica-
For example, people who are lonely or who suf-
tions, which can affect the way food smells and tastes.
fer from illnesses that affect their ability to
chew and swallow may have little interest in Unintended weight loss is a serious problem
food. Weaker hands and arms due to paralysis for the elderly. Weight loss can mean that the
or tremors make it hard to eat. People with ill- resident has a serious medical condition. It can
nesses that affect their ability to chew and swal- lead to skin breakdown, which leads to pressure
low may not want to eat. In addition, people who sores. It is very important to report any weight
are ill are often fatigued, nauseated, or in pain, loss, no matter how small. If a resident has dia-
which contributes to poor fluid and food intake. betes, chronic obstructive pulmonary disease,
Other problems that affect nutritional intake in- cancer, HIV, or other diseases, he is at a greater
clude the following: risk for malnutrition. (See Chapter 18 for more
information on these diseases.)
 255 15

G Help residents who have trouble feeding

Observing and Reporting:
themselves.
Unintended Weight Loss
G Food should look, taste, and smell good. The

Nutrition and Hydration

Report any of these to the nurse: person may have a poor sense of taste and
Resident needs help eating or drinking smell.

Resident eats less than 70% of meals/snacks G Season foods to residents’ preferences.
served G Allow enough time for residents to finish
Resident has mouth pain eating.

Resident has dentures that do not fit G Tell the nurse if residents have trouble using
utensils.
Resident has difficulty chewing or swallowing
G Record the meal/snack intake.
Resident coughs or chokes while eating
G Give oral care before and after meals.
Resident is sad, has crying spells, or with-
draws from others G Position residents sitting upright for feeding.

Resident is confused, wanders, or paces G If a resident has had a loss of appetite and/or
seems sad, ask about it.

Guidelines: Care must be taken in meal planning to ensure

Preventing Unintended Weight Loss good nutrition for the elderly and ill. Many ill-
nesses require restrictions in fluids, proteins,
G Report observations and warning signs to the certain minerals, or calories. Conditions that
nurse. make eating or swallowing difficult include the
following:
G Encourage residents to eat. Talk about food
served in a positive tone of voice, using posi- • Stroke, or CVA, which can cause facial weak-
tive words (Fig. 15-9). ness and paralysis
• Nerve and muscle damage from head and
neck cancer
• Multiple sclerosis
• Parkinson’s disease
• Alzheimer’s disease
You will learn more about these diseases in
Chapters 18 and 19. If a resident has trouble
swallowing, soft foods and liquids that have
been thickened may be easier to swallow. Thick-
ening improves the ability to control fluid in the
Fig. 15-9. Be social, friendly, and positive while helping mouth and throat. Thickened liquids include
residents with eating. This helps promote appetite and milk shakes, pureed foods, sherbet, gelatin, thin
prevent weight loss. hot cereal, cream soups, and fruit juices that
have been frozen to a slushy consistency. You
G Honor residents’ food likes and dislikes.
will learn more about swallowing problems and
G Offer different kinds of foods and beverages. thickened liquids later in the chapter.
15 256

When the digestive system does not function clean and store used equipment and supplies. In
properly, hyperalimentation, or total parenteral addition, you should observe, report, and docu-
nutrition (TPN) may be necessary. With TPN ment any observation of changes in the resident
a solution of nutrients is administered directly or problems with the feeding. Make sure the
Nutrition and Hydration

into the bloodstream. It bypasses the digestive tubing is not coiled or kinked or resting under-
system. neath the resident.
When a person is unable to swallow, he or she
may be fed through a tube. A nasogastric Observing and Reporting:
tube is inserted into the nose, past the throat, Tube Feedings
and down into the stomach. A tube can also be
placed through the skin directly into the stom- Report any of these to the nurse:
ach. This is called a percutaneous endoscopic Redness or drainage around the opening
gastrostomy (PEG) tube. The opening in
Skin sores or bruises
the stomach and abdomen is called a gastros-
tomy (Fig. 15-10). Tube feedings are used when Cyanotic skin
residents cannot swallow but can digest food. Resident complaints of pain or nausea
Conditions that may prevent residents from
Choking
swallowing include coma, cancer, stroke, refusal
to eat, or extreme weakness. Remember that Tube falls out
residents have to the right to refuse treatment, Problems with equipment
which includes insertion of tubes.
Feeding pump alarm sounds (report to the
nurse immediately)

4. Describe factors that influence food

preferences
Culture, ethnicity, income, education, religion,
and geography all affect ideas about nutrition.
Food preferences may be formed by what you ate
as a child, by what tastes good, or by personal
beliefs about what should be eaten (Fig. 15-11).
Some people choose not to eat any animals or
animal products, such as steak, chicken, butter,
or eggs. These people are vegetarians or vegans.

Fig. 15-10. Nasogastric tubes are inserted through the

nose, and PEG tubes are inserted through the skin di-
rectly into the stomach.

Nursing assistants are not responsible for insert-

ing tubes, doing the feeding, or cleaning the
tubes. You may be assigned to take the person’s
temperature or assemble equipment and sup-
plies and hand them to the nurse. You may need Fig. 15-11. Food likes and dislikes are influenced by what
to position the resident. You may also discard or you ate as a child.
 257 15

The region or culture you grow up in often along with individual likes and dislikes. Meals
influences your food preference. For example, must be balanced to provide proper nutrition,
people from the southwestern United States and the food has to be prepared in a way that
may like spicy foods. “Southern cooking” may each resident can manage it. Food must also

Nutrition and Hydration

include fried foods, like fried chicken or fried look appealing. The dietary department must
okra. Ethnic groups often share common foods. follow strict infection prevention procedures
These may be eaten at certain times of the year when preparing food.
or all the time. Religious beliefs affect diet, too. The dietary department also makes diet cards
For example, some Muslims and Jewish people (Fig. 15-12). Diet cards list the resident’s name
do not eat any pork. Mormons may not drink al- and information about special diets, allergies,
cohol, tea, or coffee. likes and dislikes, and other instructions.
Food preferences may change while a resident
is living at a facility. Just as you may decide that
you like some foods for a time and then change
your mind, so may residents. Whatever your res-
idents’ food preferences may be, respect them.
Do not make fun of personal preferences. If you
notice that certain food is not being eaten—no
matter how small the amount—report it to the
nurse.

Residents’ Rights
Fig. 15-12. Sample diet cards. (reprinted with permission of briggs
Food Choices corporation, 800-247-2343, www.briggscorp.com)

Residents have the legal right to make choices about

their food. They can choose what kind of food they
want to eat and they can refuse the food and drink 6. Explain special diets
being offered. You must honor a resident’s personal
beliefs and preferences about selecting and avoid- A doctor sometimes places residents who are ill
ing specific foods. Although residents have the right on special diets. These diets are known as ther-
to refuse, it is best to ask questions when they do. apeutic, modified, or special diets. Certain
Communication is the key to understanding why a nutrients or fluids may be restricted or elimi-
resident refuses something. For example, if a resi-
dent refuses his dinner, ask if there is something nated. Some medications may also interact with
wrong with the food. He may tell you he is Jewish certain foods, which then must be restricted.
and cannot eat a pork chop because it’s not kosher. Residents who do not eat enough may be placed
Respond to requests for different food in a pleasant on a special supplementary diet. Diets are also
way. Explain that you will report to the nurse and will
get him another meal as quickly as possible. Remove prescribed for weight control and food allergies.
the tray and take it to the dietician or dietary depart- Several types of modified diets are available for
ment so that an alternative may be offered. different illnesses. Some residents may be on a
combination of restricted diets. The care plan
should specify any special diet the resident is on.
5. Explain the role of the dietary
It should also explain any eating problems that a
department
resident may have and how the resident’s eating
The dietary department is responsible for plan- habits can be improved (Fig. 15-13). Never mod-
ning meals for all residents. Residents have dif- ify a resident’s diet yourself. Therapeutic diets
ferent nutritional needs. When planning meals, can only be prescribed by doctors and planned
the dietary department considers these needs, by dietitians. Follow the resident’s diet plan
15 258

without making judgments. Report observations that their bodies could be depleted of potassium.
to the nurse. Examples of special diets are listed Other residents may be placed on a high-potas-
below. sium diet for different reasons.
Nutrition and Hydration

Foods high in potassium include bananas,

grapefruit, oranges, orange juice, prune juice,
prunes, dried apricots, figs, raisins, dates, can-
taloupes, tomatoes, potatoes with skins, sweet
Fig. 15-13. The care plan specifies special diets or dietary
restrictions.
potatoes and yams, winter squash, legumes, avo-
cados, and unsalted nuts. “K+” is the common
Low-Sodium Diet: Residents with high blood abbreviation for this diet.
pressure, heart disease, kidney disease, or fluid Low-Protein Diet: In addition to restricted intake
retention may be placed on a low-sodium diet. of fluids, sodium, and potassium, people who
Many foods have sodium, but people are most have kidney disease may also be on low-protein
familiar with it as an ingredient in table salt. diets. Protein is restricted because it breaks
Salt is the first food to be restricted in a low- down into compounds that may further dam-
sodium diet because it is high in sodium. For age the kidneys. The extent of the restrictions
residents on a low-sodium diet, salt will not be depends on the stage of the disease and if the
used. Salt shakers or packets will not be on the resident is on dialysis.
diet tray. Common abbreviations for this diet are
Exchange lists show foods that can be ex-
“Low Na,” which means low sodium or “NAS,”
changed for one another on a meal plan. They
which stands for “No Added Salt.”
are used extensively in special diets for people
Fluid-Restricted Diets: The fluid consumed with diabetes. Exchange lists have also been de-
through food and fluids must equal the fluid veloped for residents on diets modified for pro-
that leaves the body through perspiration, stool, tein, potassium, and sodium.
urine, and expiration. This is fluid balance.
Low-Fat/Low-Cholesterol Diet: People who have
When fluid intake is greater than fluid output,
high levels of cholesterol in their blood are at
body tissues become swollen with fluid. In addi-
risk for heart attacks and heart disease. People
tion, people with severe heart disease and kidney
with gallbladder disease, diseases that interfere
disease may have trouble processing fluid. To
with fat digestion, and liver disease are also
prevent further damage, doctors may restrict
placed on low-fat/low-cholesterol diets.
fluid intake. For residents on fluid restriction,
you will need to measure and document exact Low-fat/low-cholesterol diets permit skim milk,
amounts of fluid intake and report excesses to low-fat cottage cheese, fish, white meat of turkey
the nurse. Do not offer additional fluids or foods and chicken, veal, and vegetable fats (especially
that count as fluids, such as ice cream, pud- monounsaturated fats such as olive, canola, and
dings, gelatin, etc. If the resident complains of peanut oils) (Fig. 16-26).
thirst or requests fluids, tell the nurse. A com-
Residents may be advised to limit their diets in
mon abbreviation for this diet is “RF,” which
the following ways:
stands for “Restrict Fluids.” You will learn more
about intake and output later in this chapter. • Eat lean cuts of meat including lamb, beef,
and pork, and eat these only three times a
High-Potassium Diets (K+): Some residents are
week.
on diuretics, which are medications that reduce
fluid volume, or on blood pressure medications. • Limit egg yolks to three or four per week (in-
These residents may be excreting so much fluid cluding eggs used in baking).
 259 15

• Avoid organ meats, shellfish, fatty meats, erages containing caffeine, such as coffee, tea,
cream, butter, lard, meat drippings, coconut and soft drinks; citrus juices; spicy foods; and
and palm oils, and desserts and soups made spicy seasonings such as black pepper, cayenne,
with whole milk. and chili pepper. Three meals or more a day are

Nutrition and Hydration

usually advised. If alcohol is allowed, it should
• Avoid fried foods and sweets.
be drunk with meals.
People who have gallbladder disease or other
Dietary Management of Diabetes. People with
digestive problems may be placed on a diet that
diabetes must be very careful about what they
restricts all fats. A common abbreviation for this
eat (Fig. 15-14). Calories and carbohydrates are
diet is “Low-Fat/Low-Chol.”
carefully controlled in the diets of diabetic resi-
Modified Calorie Diet: Some residents may dents. Protein and fats are also regulated. The
need to reduce calories to lose weight or prevent foods and the amounts are determined by nu-
weight gain. Other residents may need to in- tritional and energy needs. A dietitian and the
crease calories because of malnutrition, surgery, resident will make up a meal plan, taking into
illness, or fever. Residents with certain condi- account the person’s health status, activity levels,
tions need more protein to promote growth and and lifestyle. It will include all the right types
repair of tissue and regulation of body functions. and amounts of food for each day. The resident
Common abbreviations for this diet are “Low- uses exchange lists, or lists of similar foods that
Cal” or “High-Cal.” can substitute for one another, to make up a
menu. Using meal plans and exchange lists, a
Nutritional Supplements
person with diabetes can control his diet while
Illness often causes residents to need extra nutrients, still making food choices.
as well as additional calories. Sometimes a resident
will be advised by his doctor or dietician to add a
high-nutrition supplement to the regular or modified
diet. Usually this is done to encourage weight gain or
the intake of proteins, vitamins, or minerals.
Nutritional supplements may come in a powdered
or liquid form. Supplements may be pre-mixed and
ready to consume. Some powdered supplements
need to be mixed with a liquid before being taken;
the care plan will include instructions on how much
liquid to add. When preparing supplements, make
sure the supplement is mixed thoroughly.
Make sure the resident takes the supplement at the
ordered time. Residents who are ill, tired, or in pain
may not have much of an appetite. It may take a long
time for him or her to drink a large glass of a thick
liquid. Be patient and encouraging. If a resident does Fig. 15-14. Diabetics must be very careful about what
not want to drink the supplement, do not insist that they eat. They should also keep their weight in a healthy
he do so, but do report this to the nurse. range. Dietitians will help diabetics manage their illness.

Bland Diet: Gastric and duodenal ulcers can be

Sample Exchange List
irritated by foods that produce or increase levels
of acid in the stomach. People who have ulcers Following the meal plan for how many servings of
usually know the foods that cause them discom- each type of food to eat, the person chooses specific
foods and determines serving sizes using the ex-
fort. Doctors will probably advise them to avoid change lists.
these foods as well as the following: alcohol; bev-
15 260

can Diabetic Association. See Chapter 18 for

Exchange List Sample Items
more information on diabetes.
Starch list: 1 slice of bread, ½ bagel, ½ cup cereal, ½
cup pasta, ½ cup rice, 1 baked potato, 3 cups pop- Low-Residue (Low-Fiber) Diet: This diet de-
Nutrition and Hydration

corn, 15-20 fat-free potato chips creases the amount of fiber, whole grains, raw
Milk list: 1 cup milk (skim, 1%, 2%, or whole, de- fruits and vegetables, seeds, and other foods,
pending on other dietary guidelines), ¾ cup yogurt such as dairy and coffee. The low-residue diet is
Fruit list: ½ cup unsweetened applesauce, 1 small used for people with bowel disturbances.
banana, ½ cup orange juice, 2 tablespoons raisins,
1 small orange, ½ cup canned pears
High-Residue (High-Fiber) Diet: High-residue
diets increase the intake of fiber and whole
Vegetable list: ½ cup cooked vegetables or vegetable
juice, 1 cup raw vegetables (not included are corn, grains, such as whole grain cereals, bread,
potatoes, and peas, which are on the starch ex- and raw fruits and vegetables. This diet helps
change list instead) with problems such as constipation and bowel
Meat list: 1 ounce meat, fish, poultry, or cheese, 1 disorders.
egg, or ½ cup dried beans
Diets may also be modified in consistency:
Fat list: 1 teaspoon margarine or butter, 2 teaspoons
peanut butter, 2 tablespoons sour cream, 1 teaspoon Liquid Diet: A liquid diet is usually ordered for a
mayonnaise, 10 peanuts short time due to a medical condition or before
or after a test or surgery. It is ordered when a
To keep their blood glucose levels near normal, resident needs to keep the intestinal tract free of
diabetic residents must eat the right amount of food. A liquid diet consists of foods that are in
the right type of food at the right time. They a liquid state at body temperature. Liquid diets
must eat all that is served. Encourage them are usually ordered as “clear” or “full.” A clear
to do so. Do not offer other foods without the liquid diet includes clear juices, broth, gelatin,
nurse’s approval. If a resident will not eat what is and popsicles. A full liquid diet includes all the
directed, or if you think that he or she is not fol- liquids served on a clear liquid diet with the ad-
lowing the diet, tell the nurse. dition of cream soups, milk, and ice cream.

Diabetics should avoid foods that are high in Soft Diet and Mechanical Soft Diet. The soft diet
sugar, such as candy, because sugary foods can is soft in texture and consists of soft or chopped
cause problems with insulin balance. Foods and foods that are easier to chew and swallow. Foods
drinks high in sugar include candy, ice cream, that are hard to chew and swallow, such as raw
cakes, cookies, jellies, jams, fruits canned in fruits and vegetables and some meats, will be re-
heavy syrup, soft drinks, and alcoholic bever- stricted. High-fiber foods, fried foods, and spicy
ages. Many foods are high in sugar that do not foods may also be limited to help with digestion.
appear to be so, such as canned vegetables, Doctors order this diet for residents who have
many breakfast cereals, and ketchup. trouble chewing and swallowing due to dental
problems or other medical conditions. It is also
A diabetic’s meal tray may have artificial sweet-
ordered for people who are making the transi-
ener, low-calorie jelly, and maple syrup. When
tion from a liquid diet to a regular diet.
serving coffee or tea to a diabetic resident, use
artificial sweeteners rather than sugar. The com- The mechanical soft diet consists of chopped
mon abbreviations for this diet on a diet card or blended foods that are easier to chew and
are “NCS,” which stands for “No Concentrated swallow. Foods are prepared with blenders, food
Sweets” or the amount of calories followed by processors, or cutting utensils. Unlike the soft
the abbreviation “ADA,” which stands for Ameri- diet, the mechanical soft diet does not limit
spices, fat, and fiber. Only the texture of foods
 261 15

is changed. For example, meats and poultry can 7. Explain thickened liquids and identify
be ground and moistened with sauces or water three basic thickened consistencies
to ease swallowing. This diet is used for people
recovering from surgery or who have difficulty Residents with swallowing problems may be

Nutrition and Hydration

chewing and swallowing. restricted to consuming only thickened liquids.
Thickening improves the ability to control fluid
Pureed Diet: To puree a food means to chop,
in the mouth and throat. A doctor orders the
blend, or grind it into a thick paste of baby food
necessary thickness after the resident has been
consistency. The food should be thick enough
evaluated by a speech therapist.
to hold its form in the mouth. This diet does
not require a person to chew his or her food. A Special products are used for thickening. Some
pureed diet is often used for people who have beverages arrive already thickened from the
trouble chewing and/or swallowing more tex- dietary department. In other facilities, the thick-
tured foods. ening agent is added on the nursing unit before
serving. If thickening is ordered, it must be used
Some special diets are based on a person’s reli-
with all liquids. You need to know what thick-
gious, moral, or other beliefs:
ened liquids mean. Do not offer these residents
• Many Jewish people eat kosher foods. They regular liquids. Do not offer water, water pitch-
do not eat pork or shellfish, and do not eat ers, or any beverages to a resident who must
meat products at the same meal with dairy have thickened liquids. Follow the directions for
products. Kosher food is food prepared ac- each resident as ordered. Three basic thickened
cording to Jewish dietary laws. consistencies are:
• Many Muslims do not eat pork or shellfish. 1. Nectar Thick: This consistency is thicker
They may not drink alcohol. Muslims may than water. It is the thickness of a thick
have regular periods of fasting. Fasting juice, such as a pear nectar or tomato juice.
means not eating food or eating very little A resident can drink this from a cup.
food.
2. Honey Thick: This consistency has the thick-
• Some Catholics do not eat meat on Fridays. ness of honey. It will pour very slowly. A
• Some people are vegetarians. Vegetarians resident will usually use a spoon to consume
do not eat meat, fish, or poultry. They may it.
or may not eat eggs and dairy products. 3. Pudding Thick: With this consistency, the
Vegans are vegetarians who do not eat or liquids have become semi-solid, much like
use any animal products, including milk, pudding. A spoon should stand up straight
cheese, other dairy items, eggs, wool, silk, in the glass when put into the middle of the
and leather. Reasons that a person may be a drink. A resident must consume these liq-
vegetarian include the following: uids with a spoon.
• Health issues
• Religious issues 8. Describe how to make dining enjoyable
• Dislike of meat for residents
• Compassion for animals Mealtime is often an important part of a resi-
dent’s day. Not only is it the time for getting
• Belief in non-violence
proper nourishment, but it is also a time for
• Financial issues socializing, which has a positive effect on eating.
15 262

It can help prevent weight loss, dehydration, and

malnutrition. It can also prevent loneliness and
boredom.
Nutrition and Hydration

Promoting healthy eating is an important part

of your job. Mealtime should be a pleasant time.
Use the following tips to help promote appetites
and to make dining enjoyable:

Guidelines:
Promoting Appetites

G Check the environment. The temperature Fig. 15-15. Residents should be positioned upright before
should be comfortable. Address any odors. eating. Residents seated in geriatric chairs, or geri-chairs,
like the one shown here, also need to be sitting upright.
Keep noise level low. Television sets should
be off. Do not shout or raise your voice. Do G Give the resident proper eating tools. Use
not bang plates or cups. Some facilities play adaptive utensils if needed (Fig. 15-16).
quiet music while residents are dining.
G Assist residents with grooming and hygiene
tasks before dining, as needed.
G Help residents wash hands before eating.
G Give oral care before eating.
G Offer a trip to the bathroom or help with toi-
leting before eating. Fig. 15-16. Cups with lids to avoid spills and utensils with
thick handles that are easier to hold are two examples of
G Encourage the use of dentures, glasses, and adaptive devices that help with eating and drinking.
hearing aids. If these are damaged, notify the (photos courtesy of north coast medical, inc., 800-821-9319, www.ncmedical.com)

nurse.
G Be cheerful, positive, and helpful. Make con-
G Properly position residents for eating. versation if the resident wishes.
Usually, the proper position is upright, at a
90-degree angle. This helps prevent swal- G Give more food when requested.
lowing problems. If residents use a wheel-
chair, make sure they are sitting at a table 9. Explain how to serve meal trays and
that is the right height. Most facilities have
assist with eating
adjustable tables for wheelchairs. Residents
who use “geri-chairs”—reclining chairs on Food may be served on trays or carried to resi-
wheels—should be upright, not reclined, dents from the kitchen. To make sure that food
while eating (Fig. 15-15). is served at the right temperature you will have
G Seat residents next to their friends or people to work quickly. You do not want to make resi-
with like interests. Encourage conversation. dents wait for their food. Serve all residents who
are sitting together at one table before serving
G Serve food at the correct temperature.
another table. Residents will then be able to eat
G Plates and trays should look appetizing. together and not have to watch others eat.
 263 15

Before you begin serving or helping residents, do not touch them directly with your fin-
wash your hands. As you learned earlier in this gers. Some residents may not be able to use
textbook, it is very important to identify resi- straws due to swallowing problems. This
dents before serving a meal tray. Feeding a resi- should be noted on their diet cards, and no

Nutrition and Hydration

dent the wrong food can cause serious problems, straws should be on the tray. Residents may
even death. Identify each resident before placing want you to pour the beverage into a cup. Do
food in front of him or her. so if the resident wishes.
Before you deliver trays or plates, check them • Butter roll, bread, and vegetables as the resi-
closely. Make sure that you have the correct resi- dent likes.
dent and the correct food and beverages for that
• Open any condiment packets. Offer to sea-
person. Trays and plates should also be closely
son food as resident likes, including pureed
checked for added sugar and salt packets (Fig.
food.
15-17). Be aware of residents who are on special
diets. Watch for foods in residents’ rooms or in Residents will need different levels of help with
the dining room that are not permitted by their eating. Some residents will not need any help.
doctors. Report any problems to the nurse. Other residents will only need help setting up;
they may only need help opening cartons and
cutting and seasoning their food. Once that is
done, they can feed themselves. If this is the
case, check in with these residents from time to
time to see if they need anything else.
Other residents will be completely unable to feed
themselves, and it will be your job to feed them.
Residents who must be fed are often embar-
rassed and depressed about their dependence on
another person. Be sensitive to this. Give privacy
while the resident is eating. Do not rush him or
her through the meal.
Fig. 15-17. Observe residents’ plates carefully to make
sure they are receiving the correct food. Only give assistance as specified, when neces-
sary, or when the resident requests it. Encourage
Before helping a resident to eat, prepare the food residents to do what they can. For example, if a
by following these steps. Only do what the resi- resident can hold and use a napkin, she should.
dent cannot do for himself. If she can hold and eat finger foods, offer them.
There are devices that help residents eat more
• Remove the food and drink if it is on a tray
independently (see Fig. 15-16 on previous page).
and set it out on the table.
More adaptive devices are shown in Chapter 21.
• Cut food into small, bite-sized portions. Only
Mealtime involves more than eating. It is a
cut meat and vegetables when necessary. If
chance for social interaction. Residents look for-
you know residents need their food cut, cut
ward to their interaction with you and with oth-
it before bringing it to the table. This pro-
ers. It may be the highlight of their day. To avoid
motes dignity.
weight loss and dehydration, you must do all
• Open milk or juice cartons. Open and insert that you can to increase food and drink intake.
a straw if the resident uses one. Place straws Cheerful company and conversation can greatly
in the container using the paper wrapper; increase how much a resident eats and drinks.
15 264

Fewer digestive problems may occur. They also G Do not rush the meal. Allow time for the
have a positive effect on residents’ attitudes. resident to chew and swallow each bite. Be
The reverse is also true. Negative attitudes and relaxed.
poor communication can decrease how much a
Nutrition and Hydration

G Be social and friendly. Make simple conver-

resident consumes. Do not make negative com- sation if the resident wishes to do so (Fig.
ments, such as, “I don’t know how you can eat 15-18). Try not to ask questions that require
this” or, “This looks awful.” Do not judge a resi- long answers. Use appropriate topics, such
dent’s food preferences. as the news, weather, the resident’s life,
things the resident enjoys, and food prefer-
Guidelines: ences. Say positive things about the food
Assisting a Resident with Eating being served, such as, “This smells really
good,” and, “The [type of food] looks so
G Never treat the resident like a child. This is fresh.”
embarrassing and disrespectful. It is hard for
many people to accept help with feeding. Be
supportive and encouraging.
G Sit at a resident’s eye level. Resident should
be sitting upright, at a 90-degree angle. Make
eye contact with the resident.
G If the resident wishes, allow time for prayer.
G Verify that you have the right resident. Check
the diet card against the resident’s ID photo
or bracelet. Ask the resident to state his Fig. 15-18. Be friendly and social while helping residents
with eating. Encourage them to do whatever they can for
name. Check that the diet on the tray is cor- themselves.
rect and matches the diet card.
G Test the temperature of the food by putting G Give the resident your full attention while he
your hand over the dish to sense the heat. or she is eating. Do not talk to other staff
Do not touch food to test its temperature. If members while helping residents eat.
you think the food is too hot, do not blow on G Alternate offering food and drink. Alternating
it to cool it. Offer other food to give it time to cold and hot foods or bland foods and
cool. sweets can help increase appetite.
G Cut foods and pour liquids as needed. G If the resident wants a different food from
G Identify the foods and fluids that are in front what is being served, inform the dietitian so
of the resident. Call pureed foods by the cor- that an alternative may be offered.
rect name. For example, ask, “Would you like
Residents’ Rights
green beans?” rather than referring to it as
“some green stuff.” Clothing Protectors
Residents have the right to refuse to wear a clothing
G Ask the resident which food he prefers to eat protector (Fig. 15-19). Offer a clothing protector, but
first. Allow him to make the choice, even if he do not insist that a resident wear one. Respect the
wants to eat dessert first. resident’s wishes. In addition, use the term “clothing
protector” instead of “bib.” This promotes residents’
G Do not mix foods unless the resident dignity and avoids treating them like children.
requests it.
 265 15

10. Sit facing resident at the resident’s eye level

(Fig. 15-20). Sit on the stronger side if the
resident has one-sided weakness.

Nutrition and Hydration

Fig. 15-19. Residents have the right to choose whether
or not to use a clothing protector. Respect each resident’s
decision. (reprinted with permission of briggs corporation, 800-247-2343, Fig. 15-20. The resident should be sitting upright and you
www.briggscorp.com)
should be sitting at her eye level.

Feeding a resident who cannot feed self 11. Tell the resident what foods are on tray and
ask what resident would like to eat first.
Equipment: meal tray, clothing protector, 1-2 wash-
cloths or wipes 12. Offer the food in bite-sized pieces, telling the
resident the content of each bite of food of-
1. Wash your hands.
fered (Fig. 15-21). Alternate types of food, al-
2. Identify yourself by name. Identify the resi- lowing for resident’s preferences. Do not feed
dent by name. all of one type before offering another type.
Report any swallowing problems to the nurse
3. Explain procedure to the resident. Speak
immediately.
clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.

4. Pick up diet card and ask resident to state his

or her name. Verify that resident has received
the right tray.

5. Raise the head of the bed. Make sure resi-

dent is in an upright sitting position (at a
90-degree angle).

6. Adjust bed height to where you will be to able

to sit at resident’s eye level. Lock bed wheels. Fig. 15-21. Offer the food in bite-sized pieces, and tell
resident the content of each bite of food.
7. Help resident to clean hands with hand
wipes if resident cannot do it on her own. 13. Offer drink of beverage to resident through-
out the meal.
8. Place meal tray where it can be easily seen by
the resident, such as on the overbed table. 14. Make sure resident’s mouth is empty before
next bite or sip.
9. Help resident to put on clothing protector, if
desired. 15. Talk with resident during meal (Fig. 15-22).
15 266

Food trays and plates should also be observed

after the meal. It is important to observe food
trays and plates after a meal. This helps to
identify residents with poor appetites. It may
Nutrition and Hydration

also signal illness, a problem, such as dentures

that do not fit properly, or a change in food
preferences.

Fig. 15-22. Talking with the resident makes mealtime 10. Describe how to assist residents with
more enjoyable and helps promote appetite. special needs

16. Use washcloths or wipes to wipe food from Residents with specific diseases or conditions,
resident’s mouth and hands as needed dur- such as stroke, Parkinson’s disease, Alzheimer’s
ing the meal. Wipe again at the end of the disease or other dementias, head trauma, blind-
meal (Fig. 15-23). ness, or confusion may need special assistance
when eating. Follow these techniques for help-
ing residents with special needs:

Guidelines:
Dining Techniques

G Residents with the diseases or conditions

listed above may benefit from physical and
verbal cues. The hand-over-hand approach
is an example of physical cuing. If a resident
Fig. 15-23. Wiping food from the mouth during the meal
can help lift the utensils, put your hand over
helps to maintain the resident’s dignity.
his to help with eating. After the spoon is in
17. Remove clothing protector if used. Dispose the resident’s hand, place your hand over the
of protector in proper container. resident’s hand. Help the resident in getting
some food on the spoon. Steer the spoon
18. Remove food tray. Check for eyeglasses, den- from the food to the mouth and back. This
tures, or any personal items before removing promotes independence (Fig. 15-24).
tray. Place tray in proper area.
19. Make resident comfortable. Make sure sheets
are free from wrinkles and the bed free from
crumbs.
20. Return bed to lowest position. Remove pri-
vacy measures.
21. Place call light within resident’s reach.
22. Wash your hands.
23. Report any changes in resident to the nurse.
24. Document procedure using facility Fig. 15-24. The hand-over-hand approach is used when
guidelines. a resident can help by lifting utensils. It helps promote
independence.
 267 15

G Verbal cues must be short and clear and Make sure food is swallowed before offering
prompt the resident to do something. Give another bite.
verbal cues one at a time. Wait until the resi-
G If a resident has “blind spots,” place food
dent has finished one task before asking him

Nutrition and Hydration

in the resident’s field of vision (Fig. 15-26).
or her to do another. Examples of appropriate
The nurse will determine a resident’s field of
verbal cues include the following:
vision.
• “Pick up your spoon.”
• “Put some carrots on your spoon.”
• “Raise the spoon to your lips.”
• “Open your mouth.”
• “Place the spoon in your mouth.”
• “Close your mouth.”
• “Take the spoon out of your mouth.”
• “Chew.” Fig. 15-26. A resident who has had a stroke may have a
limited field of vision. The nurse will determine the resi-
• “Swallow.”
dent’s field of vision. Make sure the resident can see what
• “Drink some water.” you place in front of him.

G Use assistive devices such as utensils with

G Tremors or shaking make it very difficult
built-up handle grips, plate guards, and
for a person to eat. For residents who have
drinking cups. These are ordered for specific
Parkinson’s disease, tremors or shaking can
residents and should be included on the
make it very difficult to eat. Help by using
meal tray.
physical cues. Place food and drinks close so
G For visually-impaired residents, use the face that the resident can easily reach them. Use
of an imaginary clock to explain the position assistive devices as needed.
of what is in front of them (Fig. 15-25).
G If a resident has poor sitting balance, seat
him or her in a regular dining room chair
with armrests, rather than in a wheelchair.
Proper position in chair means hips at a
90-degree angle, knees flexed, and feet and
arms fully supported. Push the chair under
the table. Place forearms on the table. If a
resident tends to lean to one side, ask him or
her to keep elbows on the table.
G If a resident has poor neck control, a neck
brace may be used to stabilize the head. Use
assistive devices as needed. If resident is in a
geri-chair, a wedge cushion behind the head
Fig. 15-25. Use the face of an imaginary clock to explain
and shoulders may be used.
the position of food to visually-impaired residents.
G If the resident bites down on utensils, ask
G For residents who have had a stroke and have him to open his mouth. Do not pull the
a paralyzed or weaker side, place food in the utensil out of the mouth. Wait until the jaw
unaffected, or stronger, side of the mouth. relaxes.
15 268

G If the resident pockets food in his cheeks, ask • Coughing during or after meals
him to chew and swallow the food. Touch the • Choking during meals
side of his cheek. Ask him to use his tongue
to get the food. Using your fingers on the • Dribbling saliva, food, or fluid from the
Nutrition and Hydration

cheek (near the lower jaw), gently push food mouth

toward teeth. • Food residue inside the mouth or cheeks
during and after meals
G If the resident holds food in his mouth, ask
him to chew and swallow the food. You may • Gurgling sound in voice during or after
need to trigger swallowing. To do this, gently meals or loss of voice
press down on the tongue when taking the • Slow eating
spoon out of the mouth. You can also try to
• Avoidance of eating
gently press down on the top of his head with
your hand. Make sure the resident has swal- • Spitting out pieces of food
lowed the food before offering more. • Several swallows needed per mouthful

Residents’ Rights • Frequent throat clearing during and after

meals
Residents with Special Needs
Residents have the right to be treated with dignity • Watering eyes when eating or drinking
and as adults. They have the right to self-determina-
• Food or fluid coming up into the nose
tion. This means, in part, that they should be given
the opportunity to choose and state their prefer- • Visible effort to swallow
ences for care and services. For example, a blind
resident may want to feed herself without using • Shorter or more rapid breathing while eating
utensils. This may not look dignified to others, but it or drinking
is the resident’s choice.
• Difficulty chewing food
• Difficulty swallowing medications
11. Define “dysphagia” and identify signs
Swallowing problems put residents at high risk
and symptoms of swallowing problems for choking on food or drink. Inhaling food or
Residents may have conditions that make eat- drink into the lungs is called aspiration. Aspira-
ing or swallowing difficult. Dysphagia means tion can cause pneumonia or death. Alert the
difficulty in swallowing. A stroke, or CVA, can nurse immediately if any problems occur while
cause weakness on one side of the body and feeding. Follow these guidelines to help prevent
paralysis. Nerve and muscle damage from head aspiration:
and neck cancer, multiple sclerosis, Parkinson’s
or Alzheimer’s disease may also be present. If Guidelines:
a resident has difficulty swallowing, they will Preventing Aspiration
probably eat soft foods and drink thickened liq-
uids. A straw or special cup will help make swal- G Position residents properly in a straight,
lowing easier. upright position when eating or drinking.
Do not try to feed residents in a reclining
You need to be able to recognize and report
position.
signs that a resident has a swallowing problem.
G Offer small pieces or spoonfuls of food.
If you notice any of the following signs and
symptoms of swallowing problems, notify the G Do not rush the eating process; feed the resi-
nurse immediately: dent slowly.
 269 15

G Place food in the unaffected, or stronger, side

of the mouth.

G Make sure the resident has swallowed and

Nutrition and Hydration

that the mouth is empty before offering
another bite of food or sip of drink.

G If possible, keep residents in the upright

position for about 30 minutes after eating
and drinking.

12. Explain intake and output (I&O)

To maintain health, the body must take in a
certain amount of fluid each day. Fluid comes
in the form of liquids you drink and is also
found in semi-liquid foods like gelatin, soup, ice
cream, pudding, and yogurt. Generally, a healthy
person needs to take in from 64 to 96 ounces
(oz.) of fluid each day. The fluid a person con-
sumes is called intake, or input. When a per-
son’s intake is not in a healthy range, he or she
can become dehydrated. Dehydration is a serious Fig. 15-27. A sample intake and output (I&O) form.
medical condition that requires immediate atten-
tion. More information on dehydration is in the
Fluids are usually measured in milliliters (mL or
next learning objective.
ml). Ounces (oz.) are often converted to millili-
All fluid taken in each day cannot remain in the ters. To convert ounces to milliliters, multiply by
body. It must be eliminated as output. Output 30. For example, you serve Mrs. Wyant a glass of
includes urine, feces (including diarrhea), and milk. You know the glass holds six ounces. She
vomitus. It also includes perspiration and mois- finishes most but not all of the milk. You guess
ture in the air we exhale. If a person’s intake ex- that she drank four ounces. What was her input?
ceeds his or her output, fluid builds up in body To convert ounces to milliliters, multiply four by
tissues. This fluid retention can cause medical 30. The answer is 120 milliliters (mL or ml). You
problems and discomfort. would document “120 mL milk” on your input
sheet.
Fluid balance is maintaining equal input and
output, or taking in and eliminating equal Conversions
amounts of fluid. Most people do this naturally.
But some residents must have their intake and A milliliter (mL or ml) is a unit of measure equal to
one cubic centimeter (cc). Follow your facility’s poli-
output, or I&O, monitored and recorded. To do
cies on whether to document using “mL” or “cc”.
this, you will need to measure and document all
fluids the resident takes by mouth, as well as all 1 oz. = 30 mL or 30 cc
urine and vomitus the resident produces. This is 2 oz. = 60 mL
recorded on an Intake/Output (I&O) sheet 3 oz. = 90 mL
(Fig. 15-27).
15 270

4. Provide for resident’s privacy with curtain,

4 oz. = 120 mL
screen, or door.
5 oz. = 150 mL
5. Using the graduate, measure how much fluid
6 oz. = 180 mL
Nutrition and Hydration

a resident is served. Note the amount on

7 oz. = 210 mL paper.
8 oz. = 240 mL 6. When resident has finished a meal or snack,
¼ cup = 2 oz. = 60 mL measure any leftover fluids. Note this
amount on paper.
½ cup = 4 oz. = 120 mL
7. Subtract the leftover amount from the
1 cup = 8 oz. = 240 mL
amount served. If you have measured in
Before beginning, explain to the resident that ounces, convert to milliliters (mL) by multi-
you need to keep track of his intake. Ask the plying by 30.
resident to let you know when he drinks some- 8. Document amount of fluid consumed (in
thing (if it is not something you served to him) mL) in input column on I&O sheet. Record
and how much it was. the time and what fluid was taken. Report
anything unusual that was observed, such as
Measuring and recording intake and output the resident refusing to drink, drinking very
Monitoring fluid balance begins with measuring little, feeling nauseated, etc.
intake. 9. Wash your hands.
Equipment: I&O sheet, graduate (measuring con- Measuring output is the other half of monitoring
tainer) (Fig. 15-28), pen and paper to record your
fluid balance.
findings
Equipment: I&O sheet, graduate, gloves, pen and
paper
1. Wash your hands.
2. Put on gloves before handling bedpan/urinal.
3. Pour the contents of the bedpan or urinal
into measuring container. Do not spill or
splash any of the urine.
4. Measure the amount of urine. Keep container
level (Fig. 15-29).

Fig. 15-28. A graduate is a measuring container.

1. Wash your hands.

2. Identify yourself by name. Identify the resi-
dent by name.
Fig. 15-29. Keep container level while measuring output.
3. Explain procedure to the resident. Speak
clearly, slowly, and directly. Maintain face-to- 5. After measuring urine, empty measuring con-
face contact whenever possible. tainer into toilet. Do not splash.
 271 15

6. Rinse measuring container and pour rinse It helps prevent constipation and urinary incon-
water into toilet. Clean container using facility tinence. Without enough fluid, urine becomes
guidelines. concentrated. More concentrated urine creates a
higher risk for infection. Proper fluid intake also

Nutrition and Hydration

7. Rinse bedpan/urinal. Pour rinse water into
helps to dilute wastes and flush out the urinary
toilet. Use approved disinfectant.
system. It may even help prevent confusion.
8. Return bedpan/urinal and measuring con-
The sense of thirst can lessen as people age. In-
tainer to proper storage.
fection, fever, diarrhea, and some medications
9. Remove and dispose of gloves. will also increase the need for fluid intake. Re-
mind elderly residents to drink fluids often (Fig.
10. Wash hands before recording output.
15-30). However, some residents will have an
11. Document the time and amount of urine in order to force fluids (FF) or restrict fluids (RF)
output column on sheet. For example: 3:45 because of medical conditions. Force fluids
p.m. 200 mL urine. To measure vomitus, means to encourage the resident to drink more
pour from basin into measuring container, fluids. Restrict fluids means the person is al-
then discard in the toilet. If resident vomits lowed to drink, but must limit the daily amount
on the bed or floor, estimate the amount. to a level set by the doctor. When a resident
Document emesis and amount on the I&O has a restrict fluids order, you cannot give the
sheet. resident any extra fluids or a water pitcher un-
less the nurse approves it. Make sure you know
12. Report any changes in resident to the nurse.
which residents have these orders.

All facilities keep track of how much food and

liquid a resident consumes. The method var-
ies. Some facilities use a percentage method,
for example: “R” Refused = 0% No food eaten;
“P” Poor = 25% Very little food eaten; “F” Fair
= 50% Half of the food eaten; “G” Good = 75%
Most of the food eaten; and “A” All = 100% En-
tire meal eaten.
Other facilities may document the percentage
of specific foods eaten—protein, carbohydrates,
Fig. 15-30. Encourage residents to drink every time you
fats, etc. Your instructor will explain your facil-
see them.
ity’s documentation. Follow your facility’s policy
and document food intake very carefully and ac- The abbreviation “NPO “ stands for “Nothing
curately. Report to the charge nurse if a resident by Mouth.” This means that a resident is not
eats less than 70% of his or her meal. allowed to have anything to eat or drink. Some
residents have such a severe problem with swal-
13. Identify ways to assist residents in lowing that it is unsafe to give them anything by
maintaining fluid balance mouth. These types of residents will receive nu-
trition through a feeding tube or intravenously.
Most residents should be encouraged to drink Some residents may be NPO for a short time be-
at least 64 ounces, or eight glasses, of water or fore a medical test or surgery. You need to know
other fluids a day. Remember that water is es- this abbreviation. Never offer any food or drink
sential for life. Proper fluid intake is important. to a resident with this order, not even water.
15 272

Dehydration occurs when a person does not have other types of beverages, such as juice,
enough fluid in the body. Dehydration is a seri- soda, tea, or milk. Report to the nurse if the
ous condition and is a major problem among the resident tells you he does not like the fluids
elderly. People can become dehydrated if they being served. Offer drinks that the resident
Nutrition and Hydration

do not drink enough or if they have diarrhea enjoys. Some residents do not want ice in
or are vomiting. Preventing dehydration is very their drinks. Honor this preference.
important.
G Record fluid intake and output.
G Ice chips, frozen flavored ice sticks, and
Observing and Reporting: gelatin are also forms of liquids. Offer them
Dehydration often. Do not offer ice chips or sticks if a resi-
dent has a swallowing problem.
Report any of the following immediately:
G If appropriate, offer sips of liquid between
Resident drinks less than six 8-ounce glasses
bites of food at meals and snacks.
of liquid per day
G Make sure pitcher and cup are near enough
Resident drinks little or no fluids at meals
and light enough for the resident to lift (Fig.
Resident needs help drinking from a cup or 15-31).
glass
Resident has trouble swallowing liquids
Resident has frequent vomiting, diarrhea, or
fever
Resident is easily confused or tired
Report if resident has any of the following:
Dry mouth
Cracked lips
Sunken eyes
Fig. 15-31. Insulated cups and pitchers can help keep
Dark urine drinks cold or warm, depending on the drink and the resi-
dent’s preference. However, as with all glasses and cups,
Strong-smelling urine
they must be light enough for the resident to be able to
Weight loss lift them. (reprinted with permission of briggs corporation, 800-247-2343,
www.briggscorp.com)

Guidelines: G Offer assistance if resident cannot drink with-

Preventing Dehydration out help. Use adaptive cups as needed.

G Report observations and warning signs to the Serving fresh water

nurse immediately.
Equipment: water pitcher, ice scoop, glass, straw,
G Encourage residents to drink every time you gloves
see them.
1. Wash your hands.
G Offer fresh water or other fluids often. Be
aware that residents have different prefer- 2. Identify yourself by name. Identify the resi-
ences. Some may not like water and prefer dent by name.
 273 15

3. Put on gloves. Weight gain (daily weight gain of one to two

pounds)
4. Scoop ice into water pitcher. Add fresh water.
Decreased urine output
5. Use and store ice scoop properly. Do not

Nutrition and Hydration

allow ice to touch your hand and fall back Shortness of breath
into container. Place scoop in proper recep- Increased heart rate
tacle after each use.
Skin that appears tight, smooth, and shiny
6. Take pitcher to resident.

7. Pour glass of water for resident. Leave pitcher Chapter Review

and glass at the bedside.
1. How does a well-balanced diet help the ill
8. Make sure that pitcher and glass are light and the elderly?
enough for resident to lift. Leave a straw if
2. List the six basic nutrients and identify
the resident desires.
which nutrient is the most essential for life.
9. Place call light within resident’s reach.
3. Identify what each of the six colored bands
10. Remove gloves. of MyPyramid stand for. Which color band is
the smallest and why?
11. Wash your hands.
4. How much activity per day does MyPyramid
recommend?
Residents’ Rights
Fluid Intake 5. How can vegetarians fulfill requirements of
As you have learned, offering fresh fluids often the meat and beans group?
helps prevent dehydration, and helps keep residents
6. List four problems that may affect an elderly
healthy. Encourage, but do not force, fluids. Ask
residents which beverages they prefer and arrange person’s nutritional intake.
for those to be available. Respond to drink requests
7. Why is it important for an NA to report any
from residents, unless there is a doctor’s order re-
stricting fluid intake. If this is the case, inform the weight loss, no matter how small?
resident about the order, and report the request to 8. Describe ten ways that an NA can help pre-
the nurse. If fluid intake is increased, offer additional
trips to the bathroom and promote privacy. If urine vent unintended weight loss.
is being measured, do it with the door closed. 9. What are two ways a resident may be fed if
he has a digestive system that does not func-
Fluid overload occurs when the body cannot
tion properly or he cannot swallow?
handle the amount of fluid consumed. This con-
dition often affects people with heart or kidney 10. List three factors that influence food
disease. preferences.
11. What information do diet cards contain?
Observing and Reporting:
12. What is the first food to be restricted in a
Fluid Overload
low-sodium diet?

Report any of the following to the nurse: 13. Why might a resident be placed on a low-fat/
low-cholesterol diet?
Swelling/edema of extremities (ankles, feet,
fingers, hands); edema is swelling caused by 14. List four things that are carefully regulated
excess fluid in body tissues in a diabetic diet.
15 274

15. What is the difference between a clear liquid weaker (affected) or stronger (unaffected)
diet and a full liquid diet? side?
16. How is the mechanical soft diet different 31. What is the medical term that means “diffi-
Nutrition and Hydration

from the soft diet? culty in swallowing?”

17. List five reasons that a person may choose to 32. List 12 signs and symptoms of swallowing
be a vegetarian. problems that should be reported to the
nurse.
18. How can thickened liquids help a person
with swallowing problems? 33. Describe five ways to help prevent
aspiration.
19. In addition to eating, what does mealtime
involve? 34. How many ounces of fluid does a healthy
person need each day?
20. How should a resident be positioned for
eating? 35. What is fluid balance?
21. How can being cheerful and positive while 36. How many milliliters (mL) equal one ounce
a resident eats affect the amount of food (oz.)?
consumed?
37. What counts as output?
22. How can a nursing assistant verify that she
38. What does the abbreviation “NPO” stand
has the correct resident for the meal tray that
for? What does it mean for a resident?
she is serving?
39. List five signs that a nursing assistant should
23. How should a nursing assistant test the tem-
report immediately about dehydration.
perature of food?
40. Describe six ways that a nursing assistant
24. Give two examples of appropriate topics for
can help prevent dehydration.
a nursing assistant to discuss with a resident
during mealtime. 41. List four signs that a nursing assistant
should report about fluid overload.
25. What should the nursing assistant do if a
resident wants a different food from what is
being served?
26. Should a nursing assistant insist that a resi-
dent wear a clothing protector if he does not
want to wear one? Why or why not?
27. When feeding a resident, how should the
bed height be adjusted?
28. How does giving verbal cues assist a resident
with eating?
29. When assisting a resident who is visually-
impaired, how should the nursing assistant
explain the position of food and objects in
front of the resident?
30. To which side of the mouth should food be
directed if a resident has a weaker side—the
 275 16

16

Urinary Elimination
Urinary Elimination

1. List qualities of urine and identify signs Normal urine should be clear or transparent
and symptoms about urine to report when freshly voided and should have a faint
smell. Urine that is cloudy or murky or that
Urination, also known as micturition or void- smells bad or fruity can be a sign of infection or
ing, is the act of passing urine from the bladder illness. If you observe these signs, report to the
through the urethra to the outside of the body. nurse right away.
Urine is made up of water and waste products
filtered from the blood by the kidneys. Normal
Observing and Reporting:
urine output varies with age and the amount
Urine
and type of liquids consumed. Adults should
produce about 1200 to 1500 mL of urine per day, Report any of these to the nurse:
although elderly adults may produce less.
Cloudy urine
Urine is normally pale yellow to amber in color
(Fig. 16-1). However, there are many factors that Dark or rust-colored urine
can cause urine to be an abnormal color, such as Strong-, offensive-, or fruity-smelling urine
medications, certain foods or food dyes, and vi-
Pain, burning, or pressure when urinating
tamins and supplements. For example, beets can
make urine appear pink or red, and B vitamins Blood, pus, mucus, or discharge in urine
can make urine very bright yellow. Unusual Protein or glucose in urine (you will learn
urine color can also be a sign of illness. more about these things later in the chapter)
Urinary incontinence (the inability to control
the bladder, which leads to an involuntary
loss of urine)

2. List factors affecting urination

and demonstrate how to assist with
elimination
There are many factors that can affect normal
urination, including the following:
Fig. 16-1. Urine is normally light or pale yellow in color. Normal changes of aging: The ability of the
It should be clear, not cloudy.
kidneys to filter blood decreases. The bladder
16 276

muscle tone weakens. The bladder is not able to venting urinary tract infections. Follow any fluid
hold the same amount of urine as it did when restrictions.
people were younger. Elderly people may need to
urinate more frequently. Many awaken several
Urinary Elimination

times during the night to urinate. The bladder

may not empty completely, causing susceptibility
to infection.
To help promote normal urination, offer fre-
quent trips to the bathroom or bedpans and
urinals. The best position for women to have
normal urination is sitting. For men, it is stand-
ing. Avoid the supine (lying on the back) posi-
tion if possible because in this position, a person
cannot put pressure on the bladder. This works
against gravity. Follow a toileting schedule for
residents if there is one.
Fig. 16-2. Drinking plenty of fluids is important to pro-
Assist with perineal care, when necessary. Pro-
moting a healthy urinary system.
mote proper hygiene to help prevent infection;
always wipe from front to back. Help resident to Medications: Medications can affect urinary
wash hands after urinating. output. For example, a resident who is taking
Psychological factors: A lack of privacy, new envi- diuretics (medications that reduce fluid in the
ronments, stress, anxiety, and depression can all body) will frequently need to urinate. To pro-
affect urination. To promote normal urination, mote normal urination, offer a trip to the bath-
it is very important to provide plenty of privacy room, or a bedpan or urinal often. Encourage
for elimination. Close the bathroom door if resi- fluid intake. Report any changes in output or
dents are in the bathroom. If the resident needs discoloration of urine to the nurse.
to use a bedpan or urinal, pull the privacy cur- Disorders: Many disorders and illnesses affect
tain and close the door. Do not rush or interrupt urination, such as bladder disease, infections,
residents when they are in the bathroom. Report arthritis, congestive heart disease, neurologi-
signs of depression and anxiety (Chapter 20), as cal diseases, and diabetes. You will learn more
well as any changes in output. about these diseases in Chapter 18.
Fluid intake: As you learned in the last chap-
ter, the sense of thirst lessens as a person ages. Assisting with Elimination
When a person drinks fewer fluids, urinary out- Residents who cannot get out of bed to go to
put decreases, and dehydration may result. Some the bathroom may be given a bedpan, a fracture
beverages, such as those containing alcohol and pan, or a urinal. A fracture pan is a bedpan
caffeine, increase urine output. that is flatter than the regular bedpan. It is used
To promote normal urination, encourage resi- for residents who cannot assist with raising their
dents to drink fluids often. Remember that a hips onto a regular bedpan (Fig. 16-3). Women
healthy person needs to take in from 64 to 96 will generally use a bedpan for urination and
ounces of fluid each day (Fig. 16-2). Provide bowel movements. Men will generally use a uri-
fresh water and juices often. Beverages that are nal for urination and a bedpan for a bowel move-
high in vitamin C are especially good for pre- ment (Fig. 16-4).
 277 16

to get to the bathroom or use the commode,

b. offer to help often. This can avoid accidents and
embarrassment.

Urinary Elimination
a.

Fig. 16-3. a) Standard pan and b) fracture pan.

Fig. 16-5. A portable commode. (photo courtesy of nova ortho

med, inc.)

Fig. 16-4. Two types of urinals.

Elimination equipment should be rinsed with a

facility-approved disinfectant after each use. It
is usually kept in the bathroom between uses.
Residents who share bathrooms may need to
have urinals and bedpans labeled. Follow your
facility’s policy for storage. Never place this
equipment on an overbed table or on top of a
side table.
Some residents are able to get out of bed, but
may still need help walking to the bathroom and Fig. 16-6. A raised toilet seat makes it easier for a resi-
dent to get up and down. (photo courtesy of north coast medical,
using the toilet. Others who are able to get out of inc., www.ncmedical.com, 800-821-9319)

bed but cannot walk to the bathroom may use a

portable commode. A portable commode is a Wastes such as urine and feces can carry in-
chair with a toilet seat and a removable container fection. Always dispose of wastes in the toilet,
underneath (Fig. 16-5). Toilets can be fitted and be careful not to spill or splash the wastes.
with raised seats to make it easier for residents Always wear gloves when handling bedpans,
to get up and down (Fig. 16-6). Hand rails can urinals, or basins that contain wastes, including
also be installed next to the toilet. Observe and dirty bath water. Wash these containers thor-
report if these assistive devices are needed but oughly with an approved disinfectant. Rinse and
not present. When residents need assistance dry them and return them to storage.
16 278

Residents’ Rights where the resident will lie on his back. The
side of protective pad nearest the resident
Rights with Elimination
should be fanfolded (folded several times
Residents have the right to privacy and to be treated
into pleats) (Fig. 16-7).
Urinary Elimination

with dignity. Remember that residents may be em-

barrassed about needing assistance with bodily
functions. Always be professional when giving assis-
tance. Provide as much privacy as possible.
Treat residents as adults. Be aware of the language
you use when assisting with toileting needs. Do not
use childish words. Use the proper terms for bodily
functions. Although it is important that the resident
understand the words that are used, some non-
medical words for bodily functions sound crude and
unprofessional.
Fig. 16-7. Fanfold the bed protector near the resident’s
back.
Assisting a resident with the use of a bedpan
Ask the resident to roll onto his back, or roll
Equipment: bedpan, bedpan cover, protective pad or
sheet, bath blanket, toilet paper, disposable wash- him as you did before. Unfold the rest of pro-
cloths or wipes, soap, towel, 2 pairs of gloves tective pad so it completely covers the area
under and around the resident’s hips.
1. Wash your hands.
(Fig. 16-8)
2. Identify yourself by name. Identify the resi-
dent by name.

3. Explain procedure to the resident. Speak

clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.

4. Provide for resident’s privacy with curtain,

screen, or door.

5. Adjust bed to a safe working level, usually

waist high. Before placing bedpan, lower the
head of the bed. Lock bed wheels. Fig. 16-8. Unfold the rest of the bed protector so it com-
pletely covers area under and around the resident’s hips.
6. Put on gloves.
9. Ask the resident to remove undergarments or
7. Cover the resident with the bath blanket. Ask
help him do so.
him to hold it while you pull down the top
covers underneath. Do not expose more of 10. Place bedpan near his hips in the correct po-
the resident than you have to. sition. Standard bedpan should be positioned
with the wider end aligned with the resident’s
8. Place a protective pad under the resident’s
buttocks. Fracture pan should be positioned
buttocks and hips. To do this, have the resi-
with handle toward foot of bed.
dent roll toward you. If the resident cannot
do this, you must turn the resident toward 11. If resident is able, ask him to raise hips by
you (see Chapter 10). Be sure resident can- pushing with feet and hands at the count of
not roll off the bed. Move to the empty side three (Fig. 16-9). Slide the bedpan under his
of bed. Place the protective pad on the area hips.
 279 16

15. Place the call light within resident’s reach.

Ask resident to signal when done. Leave the
room.

Urinary Elimination
16. When called by the resident, return and put
Wid
er E on clean gloves.
nd
17. Lower the head of the bed. Make sure resi-
dent is still covered. Do not overexpose the
resident.
Fig. 16-9. On the count of three, slide the bedpan under
the resident’s hips. The wider end of bedpan should be 18. Remove bedpan carefully and cover bedpan.
aligned with the resident’s buttocks. 19. Provide perineal care if assistance is needed.
For female residents, wipe from the front to
If the resident cannot do this himself, place the back. Dry the perineal area with a towel.
your arm under the small of his back and Help the resident put on undergarment.
tell him to push with his heels and hands on Place the towel in a hamper or bag, and dis-
your signal as you raise his hips (Fig. 16-10). card disposable supplies.
Place the bedpan underneath the resident.
20. Take bedpan to the bathroom. Empty the
bedpan carefully into the toilet unless a
specimen is needed. Note color, odor, and
consistency of contents before flushing. If
you notice anything unusual about the stool
or urine (for example, the presence of blood),
do not discard it. You will need to inform the
nurse.
Fig. 16-10. If a resident cannot raise his hips, you can 21. Turn the faucet on with a paper towel. Rinse
raise his hips while he pushes with his heels and hands.
the bedpan with cold water first and empty
it into the toilet. Place bedpan in proper area
If a resident cannot help you in any way, keep
for cleaning or clean it according to facility
the bed flat and roll the resident onto the
policy.
far side. Slip the bedpan under the hips and
gently roll the resident back onto the bedpan, 22. Remove and discard gloves.
keeping the bedpan centered underneath. 23. Wash your hands.
12. Remove and discard gloves. Wash your 24. Make resident comfortable. Remove bath
hands. blanket and cover resident.
13. Raise the head of the bed. Prop the resident 25. Return bed to lowest position. Remove pri-
into a semi-sitting position using pillows. vacy measures.
14. Check the bedpan to be certain it is in the 26. Place call light within resident’s reach.
correct position. Make sure the blanket is still
covering the resident. Place toilet tissue and 27. Report any changes in resident to the nurse.
washcloths or wipes within resident’s reach. 28. Document procedure using facility
Ask resident to clean his hands with the hand guidelines.
wipe when finished, if he is able.
16 280

12. Remove urinal or have resident hand it to

Assisting a male resident with a urinal
you. Empty contents into toilet unless speci-
Equipment: urinal, protective pad or sheet, wash- men is needed or the urine is being mea-
cloths or wipes, 2 pairs of gloves sured for intake/output monitoring. Note
Urinary Elimination

1. Wash your hands. color, odor, and qualities (for example, cloud-
iness) of contents before flushing.
2. Identify yourself by name. Identify the resi-
dent by name. 13. Turn the faucet on with a paper towel. Rinse
the urinal with cold water first and empty
3. Explain procedure to the resident. Speak
it into the toilet. Place urinal in proper area
clearly, slowly, and directly. Maintain face-to-
for cleaning or clean it according to facility
face contact whenever possible.
policy.
4. Provide for resident’s privacy with curtain,
screen, or door. 14. Remove and discard gloves.

5. Adjust bed to a safe working level, usually 15. Wash your hands.
waist high. Lock bed wheels. 16. Make resident comfortable.
6. Put on gloves.
17. Return bed to lowest position. Remove pri-
7. Place a protective pad under the resident’s vacy measures.
buttocks and hips, as in earlier procedure.
18. Place call light within resident’s reach.
8. Hand the urinal to the resident. If the resi-
19. Report any changes in resident to the nurse.
dent is not able to help himself, place urinal
between his legs and position penis inside 20. Document procedure using facility
the urinal (Fig. 16-11). Replace covers. guidelines.

Assisting a resident to use a portable commode

or toilet
Equipment: portable commode with basin, toilet
paper, washcloths or wipes, gloves

1. Wash your hands.

Fig. 16-11. Position the penis inside the urinal if the resi-
dent cannot do it himself. 2. Identify yourself by name. Identify the resi-
dent by name.
9. Remove and discard gloves. Wash your
3. Explain procedure to the resident. Speak
hands.
clearly, slowly, and directly. Maintain face-to-
10. Place wipes within resident’s reach. Ask the face contact whenever possible.
resident to clean his hands with the hand
wipe when finished, if he is able. Leave call 4. Provide for resident’s privacy with curtain,
light within reach while resident is using uri- screen, or door.
nal. Ask resident to signal when done. Leave 5. Help resident out of bed and to the portable
the room. commode or bathroom. Make sure resident
11. When called by the resident, return and put is wearing non-skid shoes and that the laces
on clean gloves. are tied.
 281 16

6. If needed, help resident remove clothing and control the bladder, which leads to an involun-
sit comfortably on toilet seat. Put toilet tissue tary loss of urine. Incontinence can occur in
within reach. residents who are confined to bed, ill, elderly,
paralyzed, or who have circulatory or nervous

Urinary Elimination
7. Provide privacy. Leave call light within reach
system diseases or injuries. There are different
while resident is using commode. Ask resi-
types of incontinence, including the following:
dent to signal when done. Leave the room.
• Stress incontinence is the loss of urine due
8. When called by resident, return and apply
to an increase in intra-abdominal pressure,
gloves.
for example, when sneezing, laughing, or
9. Give perineal care if help is needed. Wipe fe- coughing.
male residents from front to back. • Urge incontinence is involuntary voiding
10. Help resident to wash hands after using com- from an abrupt urge to void.
mode. Dispose of soiled washcloth or wipes • Mixed incontinence is a combination of both
properly. urge incontinence and stress incontinence.
11. Help resident back to bed. Make resident • Functional incontinence is urine loss caused
comfortable. Make sure sheets are free from by things outside the urinary tract.
wrinkles and the bed free from crumbs.
• Overflow incontinence is loss of urine due to
12. Remove waste container. Empty into toi- overflow or over-distention of the bladder.
let. Note color, odor, and consistency of
Incontinence is not a normal part of aging. Al-
contents.
ways report incontinence. It may be a sign or
13. Rinse container. Pour rinse water into toilet. symptom of an illness. Urinary incontinence is a
Place container in proper area for cleaning or major risk factor for pressure sores. Cleanliness
clean it according to facility policy. and good skin care are important for residents
who are incontinent. Keep residents clean and
14. Remove and dispose of gloves properly.
dry. In addition, follow these guidelines:
15. Wash your hands.

16. Return bed to lowest position. Remove pri- Guidelines:

vacy measures. Urinary Incontinence
17. Place call light within resident’s reach.
G Offer a bedpan, urinal, commode or trip to
18. Report any changes in resident to the nurse. the bathroom often.

19. Document procedure using facility G Follow toileting schedules.

guidelines. G Answer call lights and requests for assistance
immediately.
3. Describe common diseases and G Rules for documenting incontinence have
disorders of the urinary system changed. The Minimum Data Set (MDS)
counts any time a resident’s skin or anything
Urinary Incontinence touching a resident’s skin (pad, brief, or
When people cannot control the muscles of the underwear) is wet from urine as an episode
bowels or bladder, they are said to be inconti- of incontinence. This is true even if it is a
nent. Urinary incontinence is the inability to small amount of urine. This is important to
16 282

help prevent pressure sores. Document care- 4. Provide for resident’s privacy with curtain,
fully and accurately. screen, or door.
G Urine is very irritating to the skin. It should 5. Adjust bed to a safe level, usually waist high.
Urinary Elimination

be washed off immediately and completely. Lock bed wheels.

Keep residents clean, dry, and free from odor.
Observe the skin carefully when bathing and 6. Lower head of the bed. Position resident lying
giving perineal care. flat on his or her back.

G Incontinent residents who are bedbound 7. Test water temperature with thermometer or
should have a plastic, latex, or disposable your wrist to ensure safety. Water tempera-
sheet placed under them to protect the bed. ture should be 105°F. Have resident check
Place a draw sheet over it to absorb moisture water temperature. Adjust if necessary.
and protect the skin. 8. Put on gloves.
G Disposable incontinence pads or briefs for
9. Cover resident with bath blanket. Move top
adults are available. They keep body wastes
linens to foot of bed.
away from the skin (Fig. 16-12). Change wet
briefs immediately. Never refer to an incon- 10. Remove soiled protective pad from under
tinence brief or pad as a “diaper.” Residents resident by turning resident on his side,
are not children. This is disrespectful. away from you. (See procedure “Turning a
resident” in Chapter 10.) Roll soiled pad into
itself with wet side in/dry side out.

11. Place clean protective pad under his or her

buttocks.

12. Return resident to lying on his back.

13. Expose perineal area only; avoid overexpo-

Fig. 16-12. A type of incontinent pad.
sure of the resident. Clean the perineal area.

G Residents who are incontinent need reassur- For a female resident: Wash the perineum
ance and understanding. Be professional and with soap and water from front to back. Use
kind when dealing with incontinence. single strokes (Fig. 16-13). Do not wash from
the back to the front. This may cause infec-
Providing perineal care for an incontinent tion. Use a clean area of washcloth or clean
resident washcloth for each stroke. First wipe the cen-
Equipment: 2 clean protective pads, 4 washcloths or ter of the perineum, then each side. Spread
wipes, 1 towel, gloves, basin with warm water, soap, the labia majora, the outside folds of perineal
bath blanket, bath thermometer skin that protect the urinary meatus and the
1. Wash your hands. vaginal opening. Wipe from front to back on
each side. Rinse the area in the same way.
2. Identify yourself by name. Identify the resi- Dry entire perineal area. Move from front to
dent by name. back, using a blotting motion with towel. Ask
3. Explain procedure to the resident. Speak resident to turn on her side. Wash, rinse, and
clearly, slowly, and directly. Maintain face-to- dry buttocks and anal area. Cleanse the anal
face contact whenever possible. area without contaminating the perineal area.
 283 16

17. Replace top covers and remove bath blanket.

18. Place soiled linens, clothing and protective

pads in proper containers.

Urinary Elimination
19. Empty, rinse, and wipe basin. Return to
proper storage.

20. Remove and dispose of gloves properly.

21. Wash your hands.

Fig. 16-13. Using single strokes, wipe from front to back
when cleaning. 22. Return bed to lowest position. Remove pri-
vacy measures.
For a male resident: If the resident is uncir-
23. Place call light within resident’s reach.
cumcised, retract the foreskin. Gently push
skin towards the base of penis. 24. Report any changes in resident to the nurse.

Hold the penis by the shaft. Wash in a cir- 25. Document procedure using facility
cular motion from the tip down to the base guidelines.
(Fig. 16-14). Use a clean area of washcloth
or clean washcloth for each stroke. Rinse
the penis. If the resident is uncircumcised, Urinary Tract Infection (UTI)
gently return foreskin to its normal position.
Then wash the scrotum and groin. Rinse and Urinary tract infection (UTI) causes inflam-
pat dry. Ask the resident to turn on his side. mation of the bladder and the ureters. This re-
Wash, rinse, and dry buttocks and anal area. sults in painful burning during urination and
Cleanse the anal area without contaminating the frequent feeling of needing to urinate. UTI
the perineal area. or cystitis, also inflammation of the bladder,
may be caused by a bacterial infection. Certain
situations, such as being bedbound, can cause
urine to stay in the bladder too long. This pro-
vides an ideal environment for bacteria to grow.

Cystitis is more common in women because the

urethra is much shorter in women (three to four
inches) than in men (seven to eight inches). Bac-
teria can reach a woman’s bladder more easily.
Fig. 16-14. Wash the penis in a circular motion from the
To avoid infection, women should wipe the peri-
tip down to the base. neal area from front to back after bladder and
bowel elimination.
14. Turn resident on his side away from you.
Remove the wet protective pad after drying
Guidelines:
buttocks.
Preventing UTIs
15. Place a dry protective pad under the resident.
G Encourage residents to wipe from front to
16. Reposition the resident and make the resi- back after elimination (Fig. 16-15). When you
dent comfortable. give perineal care, make sure you do this too.
16 284

• Burning during urination, painful urination

• Frequent urination

• Blood in the urine

Urinary Elimination

• Nausea, vomiting

• Chills, fever

Fig. 16-15. After elimination, wipe from front to back to Urine straining is the process of pouring all
prevent infection. urine through a fine filter to catch any particles.
This is done to detect the presence of calculi that
G Give careful perineal care when changing can develop in the urinary tract. Kidney stones
incontinence briefs. can be as small as grains of sand or as large as
golf balls. If any stones are found, they are saved
G Encourage plenty of fluids. Drinking plenty of
and then sent to a laboratory for examination.
fluids helps prevent UTIs. Drinking cranberry
and blueberry juice acidifies urine, which If straining urine is listed on your assignment
helps to prevent infection. Vitamin C also has sheet, you will first collect a routine urine speci-
this effect. men (see more information later in the chapter).
Then you will go into the bathroom and pour
G Offer bedpan or a trip to the toilet at least
the specimen through a strainer or a 4x4-inch
every two hours. Answer call lights promptly.
piece of gauze into a specimen container. Any
G Taking showers, rather than baths, helps pre- stones that are found are wrapped in the filter
vent UTIs. and are placed in the specimen container to go
to the lab.
G Report cloudy, dark, or foul-smelling urine,
or if a resident urinates often and in small Treatment of calculi includes drinking plenty
amounts. of water to produce greater quantities of urine.
Pain relievers may be ordered. Kidney stones
Calculi usually pass on their own, but if they do not,
surgery may be required.
Calculi, or kidney stones, form when urine
crystallizes in the kidneys. Kidney stones can Nephritis
block the kidneys and ureters, causing severe
Nephritis is an inflammation of the kidneys.
pain. Kidney stones can be caused by some of
Symptoms include a decrease in urine output,
the same conditions that cause cystitis. They can
rusty-colored urine, and a burning feeling dur-
also be the result of a vitamin deficiency, min-
ing urination. A person with nephritis often has
eral imbalance, structural abnormalities of the
a swollen face, eyelids, and hands because she is
urinary tract, or infection.
retaining fluid. Children and young adults usu-
Symptoms of calculi may not be felt until they ally recover without problems. Older people can
begin to move down the ureter, causing pain. develop a chronic form of nephritis.
Symptoms include the following:

• Abdominal pain Renovascular Hypertension

Renovascular hypertension is a condition
• Flank or back pain
in which a blockage of arteries in the kidneys
• Groin pain causes high blood pressure. Medications may
 285 16

be used to help control blood pressure. Further 4. Describe guidelines for urinary catheter
treatment may include surgery. You will learn care
more about hypertension and its symptoms,
treatment, and related care in Chapter 18. Some residents you care for may have a urinary

Urinary Elimination
catheter. A catheter is a thin tube inserted into
Chronic Kidney Failure or Chronic Renal Failure the body that is used to drain fluids or inject
fluids. A urinary catheter is used to drain urine
Chronic kidney failure, or chronic renal fail- from the bladder. A straight catheter does not
ure, occurs because the kidneys become un- remain inside the person. It is removed imme-
able to eliminate certain waste products from diately after urine is drained. An indwelling
the body. This disease can develop as the result catheter remains inside the bladder for a period
of chronic urinary tract infections, nephritis, of time (Fig. 16-16). The urine drains into a bag.
or diabetes. Excessive salt in the diet can also Nursing assistants do not insert, remove, or irri-
cause damage to the kidneys. Over time, the gate catheters. You may be asked to provide daily
disease becomes worse. Symptoms include the care for the catheter, cleaning the area around
following: the urethral opening and emptying the drainage
• High blood pressure bag.

• Decreased urine output or no urine output a) b)

• Darkly colored urine

• Anemia
• Nausea, vomiting
• Loss of appetite
• Weight changes
Fig. 16-16. a) An indwelling catheter (female). b) An in-
• Fatigue and weakness
dwelling catheter (male).
• Headaches
An external, or condom catheter (also called a
• Difficulty sleeping
Texas catheter), has an attachment on the end
• Back pain that fits onto the penis (Fig. 16-17). The attach-
• Edema ment is fastened with tape. The external catheter
is changed daily or as needed.
• Stool that is bloody or black
Kidney dialysis, an artificial means of remov-
ing the body’s waste products, can improve and
extend life for several years. Residents will be on
fluid restrictions of different degrees. Chronic
kidney failure can progress to end-stage kidney
disease, which is fatal without kidney dialysis or
Fig. 16-17. An external or condom catheter.
a kidney transplant.
16 286

3. Explain procedure to the resident. Speak

Guidelines:
clearly, slowly, and directly. Maintain face-to-
Catheters
face contact whenever possible.
Urinary Elimination

G The drainage bag must always be kept lower 4. Provide for resident’s privacy with curtain,
than the hips or bladder. Urine must never screen, or door.
flow from the bag or tubing back into the
bladder. This can cause infection. 5. Adjust bed to a safe working level, usually
waist high. Lock bed wheels.
G Keep the drainage bag off the floor.
6. Lower head of bed. Position resident lying flat
G Tubing should be kept as straight as possible
on his back.
and should not be kinked. Kinks, twists, or
pressure on the tubing (such as from the 7. Remove or fold back top bedding. Keep resi-
resident sitting or lying on the tubing) can dent covered with bath blanket.
prevent urine from draining.
8. Test water temperature with thermometer
G The genital area must be kept clean to pre- or your wrist and ensure it is safe. Water
vent infection. Because the catheter goes all temperature should be 105° F. Have resident
the way into the bladder, bacteria can enter check water temperature. Adjust if necessary.
the bladder more easily. Daily care of the
9. Put on gloves.
genital area is especially important.
10. Ask the resident to flex his knees and raise
the buttocks off the bed by pushing against
Observing and Reporting:
the mattress with his feet. Place clean protec-
Catheters
tive pad under his buttocks.
Report any of these to the nurse: 11. Expose only the area necessary to clean the
Blood in the urine or any other unusual catheter; avoid overexposure of resident.
appearance of the urine 12. Place towel or pad under catheter tubing be-
Catheter bag does not fill after several hours fore washing.
Catheter bag fills suddenly 13. Apply soap to wet washcloth. Clean area
Catheter is not in place around meatus. Use a clean area of the wash-
cloth for each stroke.
Urine leaks from the catheter
14. Hold catheter near meatus to avoid tugging
Resident reports pain or pressure the catheter.
Odor
15. Clean at least four inches of catheter nearest
meatus. Move in only one direction, away
Providing catheter care from meatus. Use a clean area of the cloth
Equipment: bath blanket, protective pad, bath for each stroke.
basin, soap, bath thermometer, 2-4 washcloths or
16. Dip a clean washcloth in the water. Rinse
wipes, 1 towel, gloves
area around meatus, using a clean area of
1. Wash your hands. washcloth for each stroke.
2. Identify yourself by name. Identify the resi- 17. Dip a clean washcloth in the water. Rinse at
dent by name. least four inches of catheter nearest
 287 16

meatus. Move in only one direction, away Residents’ Rights

from meatus (Fig. 16-18). Use a clean area of
Urinary Catheters
the cloth for each stroke.
Protect privacy when a resident has a urinary cath-

Urinary Elimination
eter. Keep the tubing and bag covered. Close doors
and pull privacy screens when giving catheter care.

Emptying the catheter drainage bag

Equipment: graduate (measuring container), alco-

hol wipes, paper towels, gloves
1. Wash your hands.
2. Identify yourself by name. Identify the resi-
dent by name.
3. Explain procedure to the resident. Speak
clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.
4. Provide for resident’s privacy with curtain,
screen, or door.
5. Put on gloves.
6. Place paper towel on the floor under the
drainage bag. Place measuring container on
Fig. 16-18. Hold the catheter near the meatus, so that the paper towel.
you do not tug it. Moving in only one direction, away 7. Open the drain or spout on the bag. Allow
from meatus, helps prevent infection.
urine to flow out of the bag into the measur-
ing container (Fig. 16-19). Do not let spout
18. Remove towel or pad from under catheter
touch the measuring container.
tubing. Replace top covers and remove bath
blanket.
19. Dispose of linen in proper containers.
20. Empty, rinse, and wipe basin. Return to
proper storage.
21. Remove and dispose of gloves.
22. Wash your hands.
23. Return bed to lowest position. Remove pri-
vacy measures.
24. Place call light within resident’s reach.
25. Report any changes in resident to the nurse.
26. Document procedure using facility
guidelines. Fig. 16-19. Keep the spout from touching the graduate
while draining urine.
16 288

8. When urine has drained, close spout. Using 13. Move pubic hair away from the penis so it
alcohol wipe, clean the drain spout. Replace does not get rolled into the condom.
the drain in its holder on the bag.
14. Hold penis firmly. Place condom at tip of
Urinary Elimination

9. Note the amount and the appearance of the penis and roll towards base of penis. Leave
urine. Empty into toilet. space between the drainage tip and glans of
penis to prevent irritation. If resident is not
10. Clean and store measuring container.
circumcised, be sure that foreskin is in nor-
11. Remove and dispose of gloves. mal position.
12. Wash your hands. 15. Gently secure condom to penis with tape
provided (Fig. 16-20).
13. Document procedure and amount of urine.

Applying a condom catheter

Equipment: condom catheter and collection bag,

catheter tape, gloves, plastic bag, bath blanket, sup-
plies for perineal care
1. Wash your hands.
2. Identify yourself by name. Identify the resi-
dent by name.
3. Explain procedure to the resident. Speak
clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.
4. Provide for resident’s privacy with curtain,
Fig. 16-20. Leave enough room between the drainage tip
screen, or door. and the glans of the penis to prevent irritation.
5. Adjust bed to a safe level, usually waist high.
Lock bed wheels. 16. Connect catheter tip to drainage tubing.
Make sure tubing is not twisted or kinked.
6. Lower head of bed. Position resident lying flat
on his back. 17. Discard used supplies in plastic bag. Place
soiled clothing and linens in proper contain-
7. Remove or fold back top bedding. Keep resi-
ers. Clean and store supplies.
dent covered with bath blanket.
8. Put on gloves. 18. Remove and dispose of your gloves.

9. Adjust bath blanket to expose only genital 19. Wash your hands.
area. 20. Make resident comfortable. Make sure sheets
10. If condom catheter is present, gently remove are free from wrinkles and the bed free from
it. Place it in the plastic bag. crumbs.

11. Help as necessary with perineal care. 21. Return bed to lowest position. Remove pri-
vacy measures.
12. Attach collection bag to leg.
 289 16

22. Place call light within resident’s reach. nal, commode, or “hat.” A “hat” is a plastic col-
lection container sometimes put into a toilet to
23. Report any changes in resident to the nurse.
collect and measure urine or stool (Fig. 16-21).
24. Document procedure using facility Some residents will be able to collect their own

Urinary Elimination
guidelines. urine specimens. Others will need your help. Be
sure to explain exactly how the specimen must
You may be asked to collect a urine specimen be collected (Fig. 16-22).
from a resident who is wearing a catheter. If the
nurse requests you do this, and it is within your
scope of practice, you will disconnect the tubing
from the drainage bag. Allow the specimen to
drip directly into the specimen container. If the
resident’s input and output are being monitored,
measure the amount of urine collected. Collect-
ing a specimen this way may take some time.
Do not collect a urine sample from the drainage
bag unless ordered to do so.
Fig. 16-21. A “hat” is a container that is placed under
the toilet seat to collect and measure urine or stool. Hats
5. Identify types of urine specimens that should be labeled and must be cleaned after each use.
are collected
You may be asked to collect a specimen from a
resident. A specimen is a sample that is used
for analysis in order to try to make a diagnosis.
Different types of specimens are used for differ-
ent tests.
There are factors to consider when collecting
specimens. Body wastes and elimination needs
are very private matters for most people. Hav-
ing another person handle body wastes may
make residents embarrassed and uncomfortable. Fig. 16-22. Specimens must always be labeled with the
Be sensitive to this, and be empathetic. Think resident’s name, room number, the date, and the time,
about how difficult this may be for the resident. before being taken to the lab. (reprinted with permission of briggs
corporation, 800-247-2343, www.briggscorp.com)
When collecting specimens, behave profession-
ally and matter-of-factly. If you feel that this is
an unpleasant task, do not make it known. Do Collecting a routine urine specimen
not make faces or frown. Do not use words that
Equipment: urine specimen container and lid, label
let the resident know you are uncomfortable. Re-
(labeled with resident’s name, room number, date
maining professional when collecting specimens and time), gloves, bedpan or urinal (if resident can-
can help put residents at ease. not use a portable commode or toilet), “hat” for
toilet (if resident can get to the bathroom), 2 plastic
Urine specimens may be routine, clean catch
bags, washcloth, towel, paper towel, supplies for
(mid-stream), or 24-hour. A routine urine perineal care, lab slip, if required
specimen is collected anytime the resident
voids. The resident will void into a bedpan, uri- 1. Wash your hands.
16 290

2. Identify yourself by name. Identify the resi- Residents’ Rights

dent by name.
Specimens
3. Explain procedure to the resident. Speak When collecting specimens, first explain how you
Urinary Elimination

clearly, slowly, and directly. Maintain face-to- will be collecting the specimen. Do this in private,
keeping your voice low. Close the door to the bath-
face contact whenever possible.
room or bedroom and pull the privacy curtain. Be
4. Provide for resident’s privacy with curtain, discreet when removing the specimen from the
room.
screen, or door.
5. Put on gloves. The clean catch specimen is called “mid-
stream” because the first and last urine are not
6. Help the resident to the bathroom or com-
included in the sample. Its purpose is to deter-
mode, or offer the bedpan or urinal.
mine the presence of bacteria in the urine.
7. Have resident void into “hat,” urinal, or bed-
pan. Ask the resident not to put toilet paper Collecting a clean catch (mid-stream) urine
in with the sample. Provide a plastic bag to specimen
discard toilet paper.
Equipment: specimen kit with container and lid,
8. After urination, help as necessary with label (labeled with resident’s name, room number,
perineal care. Help resident wash his or her date and time), cleansing solution, gauze or tow-
hands. Make the resident comfortable. elettes, gloves, bedpan or urinal (if resident cannot
use a portable commode or toilet), plastic bag,
9. Take bedpan, urinal, or commode pail to the washcloth, paper towel, towel, supplies for perineal
bathroom. care, lab slip, if required
10. Pour urine into the specimen container. Spec- 1. Wash your hands.
imen container should be at least half full.
2. Identify yourself by name. Identify the resi-
11. Cover the urine container with its lid. Do not dent by name.
touch the inside of container. Wipe off the
3. Explain procedure to the resident. Speak
outside with a paper towel.
clearly, slowly, and directly. Maintain face-to-
12. Place the container in a plastic bag. face contact whenever possible.
13. If using a bedpan or urinal, discard extra 4. Provide for resident’s privacy with curtain,
urine. Rinse and clean equipment. Store. screen, or door.
14. Remove and dispose of gloves. 5. Put on gloves.
15. Wash your hands.
6. Open the specimen kit. Do not touch the in-
16. Return bed to lowest position if adjusted. Re- side of the container or lid.
move privacy measures.
7. If the resident cannot clean his or her peri-
17. Place call light within resident’s reach. neal area, you will need to do it. Using the
18. Report any changes in resident to the nurse. towelettes or gauze and cleansing solution,
clean the area around the meatus. For fe-
19. Take specimen and lab slip to proper area. males, separate the labia. Wipe from front
Document procedure using facility guide- to back along one side. Discard towelette/
lines. Note amount and characteristics of gauze. With a new towelette or gauze, wipe
urine. from front to back along the other side.
 291 16

Using a new towelette or gauze, wipe down lines. Note amount and characteristics of
the middle. urine.
For males, clean the head of the penis. Use

Urinary Elimination
circular motions with the towelettes or gauze. A 24-hour urine specimen tests for certain
Clean thoroughly. Change towelettes/gauze chemicals and hormones by collecting all the
after each circular motion. Discard after use. urine voided by a resident in a 24-hour period.
If the man is uncircumcised, gently pull back Usually the collection begins at 7:00 a.m. and
the foreskin of the penis before cleaning. runs until 7:00 a.m. the next day. When begin-
Hold it back during urination. Make sure ning a 24-hour urine specimen collection, the
it is pulled back down after collecting the resident must void and discard the first urine so
specimen. that the collection begins with an empty bladder.
8. Ask the resident to urinate into the bedpan, All urine must be collected and stored properly.
urinal, or toilet, and to stop before urination If any is accidentally thrown away or improperly
is complete. stored, the collection will have to be done over
again.
9. Place the container under the urine stream.
Have the resident start urinating again. Fill
Collecting a 24-hour urine specimen
the container at least half full. Have the resi-
dent finish urinating in bedpan, urinal, or Equipment: 24-hour specimen container with lid,
toilet. bedpan or urinal (for residents confined to bed),
“hat” for toilet (if resident can get to the bath-
10. Cover the urine container with its lid. Do not room), plastic bag, gloves, washcloth, towel, sup-
touch the inside of container. Wipe off the plies for perineal care, sign to alert other team
outside with a paper towel. members that a 24-hour urine specimen is being
collected, lab slip, if required
11. Place the container in a plastic bag.
1. Wash your hands.
12. If using a bedpan or urinal, discard extra
urine. Rinse and clean equipment. Store. 2. Identify yourself by name. Identify the resi-
dent by name.
13. After urination, assist as necessary with peri-
neal care. 3. Explain procedure to the resident. Speak
clearly, slowly, and directly. Maintain face-to-
14. Remove and dispose of gloves.
face contact whenever possible. Emphasize
15. Wash your hands. Help resident wash his or that all urine must be saved.
her hands.
4. Provide for resident’s privacy with curtain,
16. Make resident comfortable. Make sure sheets screen, or door.
are free from wrinkles and the bed free from
5. Place a sign on the resident’s bed to let all
crumbs.
care team members know that a 24-hour
17. Return bed to lowest position if adjusted. Re- specimen is being collected. Sign may read
move privacy measures. “Save all urine for 24-hour specimen.”
18. Place call light within resident’s reach. 6. When starting the collection, have the resi-
19. Report any changes in resident to the nurse. dent completely empty the bladder. Discard
the urine. Note the exact time of this voiding.
20. Take specimen and lab slip to proper area. The collection will run until the same time
Document procedure using facility guide- the next day (Fig. 16-23).
16 292

7. Label the container. Write resident’s name,

room number, and dates and times the col-
lection period began and ended.
Urinary Elimination

8. Put on gloves each time the resident voids.

9. Pour urine from bedpan, urinal, or toilet at-
tachment into the container. Container may
be stored on ice when not used. The ice will
keep the specimen cool. Follow facility policy.
10. After each voiding, help as necessary with
perineal care. Help the resident wash his or
her hands.
11. Clean equipment according to facility policy,
after each voiding.
12. Remove gloves.
13. Wash your hands.
14. After the last void of the 24-hour period, add
the urine to the specimen container. Remove
the sign.
15. Place container in plastic bag.
16. Remove and dispose of gloves.
17. Wash your hands.
18. Make resident comfortable. Make sure sheets
are free from wrinkles and the bed free from
crumbs.
19. Return bed to lowest position if adjusted. Re-
move privacy measures.
20. Place call light within resident’s reach.
21. Report any changes in resident to the nurse.
22. Take specimen and lab slip to proper area.
Document procedure using facility guide-
lines. Make sure to include the time of the
last void of the 24-hour collection period.

6. Explain types of tests performed on

urine

Fig. 16-23. One type of form to record urine output over Different types of tests can be used to detect
24 hours. (reprinted with permission of briggs corporation, 800-247-2343, different things in urine. Your facility may use
www.briggscorp.com)
dip strips to test for such things as pH level,
 293 16

glucose, ketones, blood, and specific gravity. In addition to strip testing, a double-voided (also
These strips, called reagent strips, have different called “fresh-fractional”) urine specimen may be
sections that change color when they react with used to test for glucose. A double-voided speci-
urine (Fig. 16-24). men is a urine specimen that is collected after

Urinary Elimination
first emptying the bladder and then waiting
until another specimen can be collected. This
may be ordered because testing urine that has
been in the bladder for some time may not ac-
curately reflect the amount of glucose present.
With a double-voided specimen, after the person
has voided, he is encouraged to drink fluids.
Then approximately 30 minutes later, a second
(double-voided) specimen is collected and tested.

Testing for blood: Blood should not be present

in normal urine. Conditions like illness and dis-
ease can cause blood to appear in urine. Some
Fig. 16-24. Reagent strips change color when they react blood is hidden, or occult, which can be detected
with urine. The color is then compared to a color chart to
by testing the urine.
determine levels of each chemical factor. (photo courtesy of lw
scientific, inc., www.lwscientific.com, 800-726-7345)
Specific gravity: A urine specific gravity (also
Testing pH levels: The term “pH” means “parts called urine density) test is performed to mea-
Hydrogen.” The pH scale ranges from 0 to 14, sure the concentration of particles in the urine.
and the lower the number, the more acidic the The test evaluates the body’s water balance and
fluid. The higher the number, the more alkaline urine concentration by showing how the urine
the fluid. Normal pH range for urine is 4.6–8.0. compares to water. Normal values range from
A disruption of pH may be due to medication, 1.002 to 1.028. The test usually requires a clean-
food, or illness. catch urine specimen.

Testing for glucose and ketones: In diabetes mel-

litus, commonly called diabetes, the pancreas Testing urine with reagent strips
does not produce enough insulin (see Chapter Equipment: urine specimen as ordered, reagent
18). Insulin is the substance the body needs to strip, gloves
convert glucose, or natural sugar, into energy.
1. Wash your hands.
Without insulin to process glucose, these sugars
collect in the blood. Some sugar appears in the 2. Put on gloves.
urine.
3. Take a strip from the bottle and recap bottle.
Diabetics may also have ketones in the urine.
Close it tightly.
Ketones are produced when the body burns fat
for energy or fuel. Ketones are produced when 4. Dip the strip into the specimen.
there is not enough insulin to help the body
5. Follow manufacturer’s instructions for when
use sugar for energy. Without enough insulin,
to remove strip. Remove strip at correct time.
glucose builds up in the blood. Since the body
cannot use glucose for energy, it breaks down fat 6. Follow manufacturer’s instructions for how
instead. When this occurs, ketones form in the long to wait after removing strip. After proper
blood and spill into the urine. time has passed, compare strip with color
16 294

chart on bottle. Do not touch bottle with

strip.

7. Read results.
Urinary Elimination

8. Discard used items. Discard specimen in the

toilet.

9. Remove and dispose of gloves.

10. Wash your hands.

11. Document procedure using facility Fig. 16-25. Offer regular trips to the bathroom.
guidelines.
G Encourage the resident to drink plenty of
fluids. Do this even if urinary incontinence is
a problem. About 30 minutes after fluids are
7. Explain guidelines for assisting with
taken, offer a trip to the bathroom or a bed-
bladder retraining pan or urinal.
Injury, illness, or inactivity may cause a loss of G Answer call lights promptly. Residents cannot
normal bladder function. Residents may need wait long when the urge to go to the bath-
help in re-establishing regular routine and nor- room occurs. Leave call lights within reach
mal function. Problems with elimination can be (Fig. 16-26).
embarrassing or difficult to discuss. Be sensitive
to this. Always be professional when handling
incontinence or helping to re-establish routines.
It is hard enough for residents to handle inconti-
nence without having to worry about your reac-
tions. Never show anger or frustration toward
residents who are incontinent.

Guidelines:
Bladder Retraining

G Follow Standard Precautions. Wear gloves Fig. 16-26. Leave call lights within reach, and answer call
lights promptly.
when handling body wastes.
G Explain the bladder training schedule to the G Provide privacy for elimination—both in the
resident. Follow the schedule carefully. bed and in the bathroom.
G Keep a record of the resident’s bladder hab- G If a resident has trouble urinating, try run-
its. When you see a pattern of elimination, ning water in the sink. Have him or her lean
you can predict when the resident will need a forward slightly. This puts pressure on the
bedpan or a trip to the bathroom. bladder.
G Offer a commode or a trip to the bathroom G Do not rush the resident during voiding.
before beginning long procedures (Fig. G Help residents with good perineal care. Urine
16-25). is irritating to the skin, and giving good care
 295 16

helps prevents skin breakdown and promotes 4. Briefly describe four factors that affect urina-
proper hygiene. Carefully observe for skin tion and how to promote normal urination.
changes.
5. In what direction should a person be wiped

Urinary Elimination
G Discard wastes according to facility rules. during perineal care?
G Discard clothing protectors and incontinence 6. What will women who are unable to get out
briefs properly. Some facilities require double of bed use for urination? What will men
bagging these items. This stops odors from use?
collecting.
7. What is a fracture pan and when it is used?
G Some facilities use washable bed pads or
8. How should a standard bedpan be posi-
briefs. Follow Standard Precautions when
tioned under a resident? How should a frac-
rinsing before placing these items in the
ture pan be positioned under a resident?
laundry.
9. List and define five types of incontinence.
G Keep an accurate record of urination. This
includes episodes of incontinence. 10. Is urinary incontinence a normal part of
aging?
G Offer positive words for successes or for
attempts to control bladder. However, do not 11. Why should a nursing assistant never refer
talk to residents as if they are children. Keep to an incontinence brief as a “diaper?”
your voice low and do not draw attention to 12. What are four ways that nursing assistants
any aspect of retraining. can help prevent urinary tract infections?
G Never show frustration or anger toward resi-
13. Why should the catheter drainage bag always
dents who are incontinent. The problem is
be kept lower than the hips or the bladder?
out of their control. Your negative reactions
will only make things worse. Be positive. 14. Why should catheter tubing be kept as
straight as possible?
When the resident is incontinent or cannot
toilet when asked, be positive. Never make the 15. List five signs and symptoms to report to the
resident feel like a failure. Praise and encour- nurse about catheters.
agement are essential for a successful program. 16. What is a clean catch urine specimen?
Some residents will always be incontinent. Be
17. How can nursing assistants help reduce dis-
patient. Offer these persons extra care and atten-
comfort and embarrassment when assisting
tion. Skin breakdown may lead to pressure sores
with specimen collection?
without proper care. Always report changes in
skin. 18. What is the normal pH range for urine?
19. List four things reagent strips can test for in
Chapter Review urine.

1. What is the normal color of urine? 20. Why do incontinent residents need good
perineal care?
2. List five things to observe and report to the
nurse about urine. 21. About how long after fluids are taken should
you offer to take a resident to the bathroom?
3. What is the best position for women to have
normal urination? What is the best position 22. Out of the list of guidelines for bladder re-
for men? training, list two that help promote dignity.
17 296

17
Bowel Elimination

Bowel Elimination

1. List qualities of stools and identify Fecal/anal incontinence (inability to control

signs and symptoms to report about stool the bowels, leading to involuntary passage of
stool)
Defecation, or bowel elimination, is the act of
passing feces from the large intestine out of the
body through the anus. Feces, also called stool 2. List factors affecting bowel elimination
or bowel movements, are semi-solid material There are many factors that can affect normal
made up of water, solid waste material, bacteria, bowel elimination, including the following:
and mucus. The number of bowel movements a
person has varies with age and with the amount Normal changes of aging: As a person ages,
and type of foods consumed. peristalsis slows. Peristalsis refers to the invol-
untary contractions that move food through the
Stool is normally brown, soft, and formed in gastrointestinal system. Digestion takes longer
a tubular shape from its passage through the and is less efficient. Proteins, vitamins, and
colon. However, food, medications, and supple- minerals are not absorbed as well. Decreased
ments, as well as illness, can cause a change saliva production affects the ability to chew and
in the normal color of stool. For example, iron swallow, as does tooth loss. Medication use and
supplements can cause stool to appear black. dulled sense of taste may result in poor appetite.
Red food coloring, beets, and tomato juice can
make stool red. To help promote normal bowel elimination, en-
courage fluids and nutritious, appealing meals.
Dentures should fit properly and be cleaned
Observing and Reporting:
regularly. Give regular oral care. Help make
Stool
mealtimes enjoyable. Residents who have trouble
Report any of these to the nurse: chewing and swallowing are at risk of choking.
Provide plenty of fluids with meals and cut food
Whitish, black, red, or hard stools into smaller pieces if ordered. Follow a toileting
Liquid stools (diarrhea) schedule for residents if there is one.
Constipation (the inability to have a bowel Promote proper hygiene and assist with perineal
movement) care, when necessary. Residents who have anal
incontinence or diarrhea must be kept clean and
Flatulence
dry. To prevent infection, always wipe from front
Pain when having a bowel movement to back. It is important to help resident to wash
Blood, pus, mucus, or discharge in stool hands after having bowel movements.
 297 17

Psychological factors: Stress, anger, fear, and Some foods can cause constipation, such as
depression all affect gastrointestinal function. foods high in animal fats (dairy products, meats,
Stress, anger, and fear can increase peristalsis and eggs) or foods high in refined sugar but
and elimination, while depression may decrease low in fiber. Inadequate fluid intake not only

Bowel Elimination
it. A lack of privacy can greatly affect elimina- contributes to dehydration, but also can cause
tion, too. constipation.
To promote normal bowel elimination, it is very To promote normal bowel elimination, residents
important to provide plenty of privacy. Close should eat a diet that contains fiber and drink
the bathroom door if residents are in the bath- plenty of fluids to help prevent constipation.
room. If the resident needs to use a bedpan, pull Offer drinks to residents every time you see
the privacy curtain and close the door. Do not them, as long as they are not on fluid restric-
rush or interrupt residents when they are in the tions. Remember that a healthy person needs
bathroom. Report signs of depression (Chap- from 64 to 96 ounces of fluid each day.
ter 20), as well as any changes in frequency of
Physical activity: Regular physical activity helps
elimination.
bowel elimination (Fig. 17-2). It strengthens
Food and fluids: What a person consumes abdominal and pelvic muscles, which helps peri-
greatly affects bowel elimination. Fiber intake stalsis. Immobility and a lack of exercise weak-
improves bowel elimination. Foods high in fiber ens these muscles and may slow elimination.
include fruits, whole grains, and raw vegetables
(Fig. 17-1). Some high-fiber foods cause flatu-
lence, or gas, which can aid elimination, but can
also cause discomfort. Foods that may cause gas
include the following:
• Beans
• Fruits (e.g., pears, apples, peaches)
• Whole grains
• Vegetables (e.g., broccoli, cabbage, onions,
asparagus) Fig. 17-2. Regular exercise and activity is important for
promoting normal bowel elimination.
• Dairy products
To promote normal bowel elimination, encour-
• Carbonated drinks
age regular activity and assist as needed. Try to
make it fun. A walk can be a chore or it can be
the highlight of the day.
Personal habits: The time of day that bowel
movements occur varies from person to per-
son. For example, one person may have a bowel
movement early in the day, while another has
one in the early afternoon. Another person may
have a few bowel movements throughout the
day. This depends on the person, his habits, and
Fig. 17-1. Raw fruits and vegetables are high in fiber, the amount of food and drink consumed. Elimi-
which helps with bowel elimination. nation usually occurs after meals.
17 298

The position of the body affects elimination. A An enema or suppository may be ordered to
person who is supine (flat on his back) will have help with constipation. An enema is a specific
the most trouble with bowel elimination. It is amount of water, with or without an additive,
almost impossible to contract muscles in this that is introduced into the colon to eliminate
Bowel Elimination

position. stool. A suppository is a medication given rec-

tally to cause a bowel movement.
To promote normal bowel elimination, allow
residents to have an opportunity to have a bowel
movement at the time of day that is normal for Fecal Impaction
them. The best position for elimination is squat- A fecal impaction is a hard stool that is stuck
ting and leaning forward. If the person cannot in the rectum and cannot be expelled. It results
get out of bed, raise the head of the bed for from unrelieved constipation. Symptoms include
elimination. That way, the resident does not have no stool for several days, oozing of liquid stool,
to work against gravity. cramping, abdominal swelling, and rectal pain.
Medications: Medications affect the bowel elimi- When an impaction occurs, a nurse or doctor
nation. Laxatives are used to cause bowel move- will insert one or two gloved fingers into the rec-
ments and may cause excessive elimination. tum and break the mass into fragments so that
Other medications, such as pain relievers, can it can be passed. Prevention of fecal impactions
slow elimination. Antibiotics may cause diar- often includes the same measures as those used
rhea. To promote normal bowel elimination, for preventing constipation, i.e. high-fiber diet,
offer a trip to the bathroom or a bedpan often. plenty of fluids, an increase in activity level, and
Report any changes in appearance or frequency possibly medication.
of bowel elimination.
Hemorrhoids
Disorders and illnesses affect bowel elimina-
tion. You will learn more about these in the next Hemorrhoids are enlarged veins in the rectum
Learning Objective. that may also be visible outside the anus. Hem-
orrhoids can develop from an increase in pres-
sure in the lower rectum due to straining during
3. Describe common diseases and bowel movements. Chronic constipation, obesity,
disorders of the gastrointestinal system pregnancy, and sitting for long periods of time
on the toilet are other causes. Signs and symp-
Constipation toms include rectal itching, burning, pain, and
Constipation is the inability to eliminate stool bleeding. Treatment may include medications,
(have a bowel movement), or the difficult and compresses, and sitz baths. Surgery may be nec-
painful elimination of a hard, dry stool. Consti- essary to correct hemorrhoids. When cleaning
pation occurs when the feces move too slowly the anal area, be very careful to avoid causing
through the intestine as the result of decreased pain and bleeding from hemorrhoids.
fluid intake, poor diet, inactivity, medications,
aging, certain diseases, or ignoring the urge to Diarrhea
eliminate. Signs of constipation include abdomi- Diarrhea is the frequent elimination of liquid or
nal swelling, gas, irritability, and record of no semi-liquid feces. Abdominal cramps, urgency,
recent bowel movement. nausea, and vomiting can accompany diarrhea,
Treatment often includes increasing the amount depending on the cause. Bacterial and viral
of fiber eaten and fluids consumed, increas- infections, microorganisms in food and water,
ing the activity level, and possibly medication. irritating foods, and certain medications can
 299 17

cause diarrhea. Treatment usually involves medi- Heartburn

cation and a change of diet. A diet of bananas,
Heartburn is the result of a weakening of the
rice, apples, and tea/toast (BRAT diet) is often
sphincter muscle, which joins the esophagus
recommended.

Bowel Elimination
and the stomach. When healthy, this muscle
prevents the leaking of stomach acid and other
Anal/Fecal Incontinence contents back into the esophagus. Stomach acid
Anal, or fecal, incontinence is the inability to causes a burning sensation, commonly called
control the bowels, leading to involuntary pas- heartburn, in the esophagus. If heartburn oc-
sage of stool. Common causes are constipation, curs frequently and remains untreated, it can
muscle and nerve damage, loss of storage ca- cause scarring or ulceration.
pacity in the rectum, and diarrhea. Treatment
includes a change in diet, medication, bowel Gastroesophageal Reflux Disease
training, or surgery. Gastroesophageal reflux disease, commonly
referred to as GERD, is a chronic condition in
Flatulence which the liquid contents of the stomach back
Flatulence, also called flatus or gas, is air in up into the esophagus. The liquid can inflame
the intestine that is passed through the rectum, and damage the lining of the esophagus. It can
which can result in cramping or abdominal cause bleeding or ulcers. In addition, scars from
pain. Flatulence may have any of the following tissue damage can narrow the esophagus and
causes: make swallowing difficult.

• Swallowing air while eating Heartburn is the most common symptom of

GERD. Heartburn and GERD must be reported
• Eating high-fiber foods to the nurse. These conditions are usually
• Eating foods that a person cannot tolerate, treated with medications. Serving the evening
for example, when a person who has lactose meal three to four hours before bedtime may
intolerance eats dairy products (Lactose in- help. The resident should not lie down until at
tolerance is the inability to digest lactose, a least two to three hours after eating. Provide res-
type of sugar found in milk and other dairy idents with an extra pillow so the body is more
products. It is caused by a deficiency of lac- upright during sleep. Serving the largest meal
tase enzyme.) of the day at lunchtime, serving several meals of
small portions throughout the day, and reducing
• Antibiotics
fast foods, fatty foods, and spicy foods may also
• Colitis, or irritable bowel syndrome, which help.
is a chronic form of stomach upset that gets
worse from stress Peptic Ulcers
• Malabsorption, which means that the body Peptic ulcers are raw sores in the stomach or
cannot absorb or digest a particular nutrient the small intestine. A dull or gnawing pain oc-
properly; it is often accompanied by diarrhea curs one to three hours after eating, accompa-
Excessive flatulence, depending on the cause, is nied by belching or vomiting. Food, antacids,
often treated with change of diet, medication, and medications temporarily relieve the pain.
and reducing the amount of air swallowed. A Ulcers are caused by excessive acid production.
return-flow enema (also called a “Harris flush”) Residents with peptic ulcers should avoid smok-
may be ordered to expel the flatus. ing and drinking too much alcohol and caffeine,
which increase the production of gastric acid.
17 300

A bland diet may be ordered (Chapter 15). Pep- sure to follow policies and procedures. Discuss
tic ulcers may cause bleeding. Feces, or bowel any questions you may have with the nurse be-
movements, may appear black and tarry because fore giving an enema.
of the bleeding.
Bowel Elimination

Doctors will write an enema order. Cleansing

enemas include tap water enemas (TWE) and
Ulcerative Colitis and Colitis
saline (salt water) enemas. A tap water enema
Ulcerative colitis is a chronic inflammatory uses approximately 500-1000 mL of water from
disease of the large intestine. Symptoms include a faucet, and a saline enema contains the same
cramping, diarrhea, pain occurring to one side amount of water, but with two teaspoons of salt
of the lower abdomen, rectal bleeding, and loss added. A soapsuds or soap solution enema (SSE)
of appetite. Ulcerative colitis is a serious illness is another type of cleansing enema. This enema
that can cause intestinal bleeding and death if has 500-1000 mL of water with 5 mL of mild
left untreated. Medications can relieve symp- castile soap added.
toms, but they cannot cure ulcerative colitis. Sur-
A commercially-prepared enema (commercial
gical treatment may include a colostomy, which
enema) usually has 120 mL solution and may
is the diversion of waste to an artificial opening
have additives. These enemas come prepackaged
(stoma) through the abdomen. All bowels are
and do not require mixing (Fig. 17-3). An oil re-
diverted through the stoma instead of the anus.
tention enema has a type of oil in it to soften the
See later in this chapter for more information on
stool to allow it to pass more easily. It is often
colostomy care.
used when a person has been constipated for a
Colitis, or irritable bowel syndrome, has symp- long time, resulting in a stool that is very hard,
toms similar to but milder than those of ulcer- or when a person has a fecal impaction.
ative colitis. Diet and/or medication can usually
control colitis.

Colorectal Cancer
Colorectal cancer, also known as colon cancer,
is cancer of the gastrointestinal tract. Signs and
symptoms include changes in normal bowel
patterns, cramps, abdominal pain, and rectal
bleeding. Colorectal cancer must be treated with
surgery. See Chapter 18 for more information on
cancer.

Fig. 17-3. Commercially prepared enemas may come

4. Discuss how enemas are given with additives, such as saline (on the left) and mineral oil
(on the right). (reprinted with permission of briggs corporation, 800-247-
An enema is putting fluid into the colon in 2343, www.briggscorp.com)

order to eliminate stool or feces. Enemas may

be given prior to surgery or a medical test, or Equipment used for giving cleansing enemas
when a person cannot eliminate stool on his or includes an IV pole, the enema solution, tubing
her own. Depending upon the state and facility and a clamp. Commercially-prepared enemas
in which you work, you may be trained to give do not require an IV pole, tubing, or clamp, be-
enemas. If you are allowed to give enemas, make cause they are prepackaged and pre-mixed.
 301 17

G Report any of the following to the nurse:

Guidelines:
Enemas • Resident could not tolerate enema
because of cramping.

Bowel Elimination
G Keep the bedpan nearby or make sure that • The enema had no results.
the bathroom is vacant before assisting with
• The amount of stool was very small.
an enema.
• Stool was hard, streaked with red, very
G The resident will be placed in Sims’ (left side-
dark or black.
lying) position (Fig. 17-4). Positioning on the
left side means that the water does not have Giving a cleansing enema
to flow against gravity.
Equipment: 2 pair of gloves, bath blanket, IV pole,
enema solution, tubing and clamp, bed protector,
bedpan, lubricating jelly, bath thermometer, tape
measure, toilet paper, 2 washcloths, robe, non-skid
footwear
1. Wash your hands.
2. Identify yourself by name. Identify the resi-
dent by name.
Fig. 17-4. The Sims’ position (left side-lying position) is
the proper position in which to place a resident for an 3. Explain procedure to the resident. Speak
enema. clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.
G The enema solution should be warm, not hot
4. Provide for resident’s privacy with curtain,
or cold.
screen, or door.
G The enema bag should not be raised to more
5. Adjust bed to a safe level, usually waist high.
than the height listed in the care plan.
Lock bed wheels.
G The tip of the tubing should be lubricated
6. If the bed has side rails, raise side rail on far
with lubricating jelly, if not already pre-lubri-
side of bed. Lower side rail nearest you.
cated.
7. Help resident into left-sided Sims’ position.
G Unclamp the tube and allow a small amount
Cover with a bath blanket.
of solution run through the tubing. Then re-
clamp the tube. This gets rid of the air before 8. Place the IV pole beside the bed. Raise the
it is inserted (the air could cause cramping). side rail.
G The solution should flow in slowly; the resi- 9. Clamp the enema tube. Prepare the enema
dent will be less likely to have cramps. solution. Fill bag with 500-1000 mL of warm
G Hold the enema tubing in place while giving water (105° F), and mix the solution.
the enema. Stop immediately if the resident 10. Unclamp the tube. Let a small amount of so-
has pain or if you feel resistance. Report to lution run through the tubing. Re-clamp the
the nurse if this happens. tube.
G The resident should take slow deep breaths 11. Hang the bag on IV pole. The bottom of
when taking an enema to help hold the solu- the enema bag should not be more than 12
tion longer. inches above the resident’s anus (Fig. 17-5).
17 302

18. Unclamp the tubing. Allow the solution to

flow slowly into the rectum. Ask resident to
take slow, deep breaths. If resident complains
of cramping, clamp the tubing and stop for a
Bowel Elimination

couple of minutes. Encourage him or her to

take as much of the solution as possible.
19. Clamp the tubing when the solution is al-
most gone. Remove the tip from the rectum.
Place the tip into the enema bag. Do not con-
Fig. 17-5. Bottom of the bag should not be more than 12 taminate yourself, resident, or bed linens.
inches above the anus.
20. Ask the resident to hold the solution inside
12. Put on gloves. as long as possible.

13. Lower the side rail. Uncover resident enough 21. Help resident to use bedpan, commode, or
to expose anus only. get to the bathroom. If the resident uses a
commode or bathroom, apply robe and non-
14. Place bed protector under resident. Place
skid footwear. Lower the bed to its lowest
bedpan close to resident’s body.
position before the resident gets up.
15. Lubricate tip of tubing with lubricating jelly.
22. Place toilet tissue and washcloths or wipes
16. Ask the resident to breathe deeply. This re- within resident’s reach. Ask the resident to
lieves cramps during procedure. clean his hands with the hand wipe when
17. Place one hand on the upper buttock. Lift to finished, if he is able. If the resident is using
expose the anus (Fig. 17-6). Ask the resident the bathroom, ask him not to flush the toilet
to take a deep breath and exhale. Using other when finished.
hand, gently insert the tip of the tubing two 23. Place the call light within resident’s reach.
to four inches into the rectum. Stop imme- Ask resident to signal when done. Leave the
diately if you feel resistance or if the resident room.
complains of pain. If this happens, clamp the
tube. Tell the nurse immediately. 24. Discard disposable equipment. Clean area.
25. Remove gloves. Wash your hands.
26. When called by the resident, return and put
on clean gloves. Assist with perineal care as
needed.
27. Take bedpan to the bathroom. Empty the
bedpan carefully into the toilet. Note color,
odor, and consistency of contents before
flushing. If resident used toilet, check toilet
contents.
28. Turn the faucet on with a paper towel. Rinse
the bedpan with cold water first and empty
Fig. 17-6. Lift the upper buttock to expose the anus. Ask it into the toilet. Place bedpan in proper area
the resident to take a deep breath before inserting the for cleaning or clean it according to facility
tubing. policy.
 303 17

29. Remove and discard gloves. 6. If the bed has side rails, raise side rail on far
side of bed. Lower side rail nearest you.
30. Wash your hands.
7. Help resident into left-sided Sims’ position.
31. Make resident comfortable. Remove bath

Bowel Elimination
Cover with a bath blanket.
blanket and cover resident.
8. Put on gloves.
32. Return bed to lowest position. Remove pri-
vacy measures. 9. Lower the side rail. Uncover resident enough
to expose anus only.
33. Place call light within resident’s reach.
10. Place bed protector under resident. Place
34. Report any changes in resident to the nurse.
bedpan close to resident’s body.
35. Document procedure using facility
11. Lubricate tip of bottle with lubricating jelly.
guidelines.
12. Ask resident to breathe deeply to relieve
cramps during procedure.
Residents’ Rights 13. Place one hand on the upper buttock. Lift to
Giving Enemas expose the anus. Ask the resident to take a
Protecting a resident’s rights when giving an enema deep breath and exhale. Using other hand,
includes providing plenty of privacy during this pro-
gently insert the tip of the tubing about one
cedure. Keep the resident covered with a bath blan-
ket or sheet, only exposing the anal area. Pull the and a half inches into the rectum. Stop if you
privacy curtain around the bed and close the door. feel resistance or if the resident complains of
Answer any questions that the resident has about pain. Tell the nurse immediately.
the procedure. If any questions are not within your
scope of practice to answer, refer them to the nurse 14. Slowly squeeze and roll the enema container
before beginning. so that the solution runs inside the resident.
Only release pressure after removing tip from
the rectum.
Giving a commercial enema
15. When tip is removed, place bottle inside the
Equipment: 2 pairs of gloves, bath blanket, standard box upside-down (Fig. 17-7).
or oil retention commercial enema kit, bed protec-
tor, bedpan, lubricating jelly, washcloths or wipes,
toilet tissue, robe, non-skid footwear

1. Wash your hands.

2. Identify yourself by name. Identify the resi-

dent by name.

3. Explain procedure to the resident. Speak

clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.

4. Provide for resident’s privacy with curtain,

Fig. 17-7. Place enema bottle upside-down in the box.
screen, or door.

5. Adjust bed to a safe level, usually waist high. 16. Ask the resident to hold the solution inside
Lock bed wheels. as long as possible.
17 304

17. Help resident to use bedpan, commode, or 5. Demonstrate how to collect a stool
get to the bathroom. If the resident uses a specimen
commode or bathroom, apply robe and non-
skid footwear. Lower the bed to its lowest Stool (feces) specimens are collected so that the
Bowel Elimination

position before the resident gets up. stool can be tested for blood, pathogens, and
other things, such as worms or amebas. Worms
18. Place toilet tissue and washcloths or wipes
and amebas can be detected with an ova and
within resident’s reach. Ask the resident to
parasites test. If the specimen is to be examined
clean his hands with the hand wipe when
for ova and parasites, take it to the lab immedi-
finished, if he is able. If the resident is using
ately. This examination must be made while the
the bathroom, ask him not to flush the toilet
stool is still warm.
when finished.
If the resident uses a bedpan or portable com-
19. Place the call light within resident’s reach.
mode for elimination, you will take the stool
Ask resident to signal when done. Leave the
specimen from there. If the resident uses the
room.
toilet, you will use a hat for collection. When col-
20. Discard disposable equipment. Clean area. lecting a stool specimen, ask the resident not to
get urine or tissue in the sample because they
21. Remove gloves. Wash your hands.
can ruin the sample.
22. When called by the resident, return and put
on clean gloves. Assist with perineal care as
Collecting a stool specimen
needed.
23. Take bedpan to the bathroom. Empty the Equipment: specimen container and lid, label (la-
beled with resident’s name, room number, date, and
bedpan carefully into the toilet. Note color,
time), 2 tongue blades, 2 pairs of gloves, bedpan (if
odor, and consistency of contents before resident cannot use portable commode or toilet),
flushing. If resident used toilet, check toilet “hat” for toilet (if resident uses toilet or commode),
contents. 2 plastic bags, toilet tissue, washcloth or towel, sup-
plies for perineal care, lab slip, if required
24. Turn the faucet on with a paper towel. Rinse
the bedpan with cold water first and empty Ask the resident to let you know when he can
it into the toilet. Place bedpan in proper area have a bowel movement. Be ready to collect the
for cleaning or clean it according to facility specimen.
policy.
1. Wash your hands.
25. Remove and discard gloves.
2. Identify yourself by name. Identify the resi-
26. Wash your hands.
dent by name.
27. Make resident comfortable. Remove bath
blanket and cover resident. 3. Explain procedure to the resident. Speak
clearly, slowly, and directly. Maintain face-to-
28. Return bed to lowest position. Remove pri- face contact whenever possible.
vacy measures.
4. Provide for resident’s privacy with curtain,
29. Place call light within resident’s reach.
screen, or door.
30. Report any changes in resident to the nurse.
5. Put on gloves.
31. Document procedure using facility
guidelines. 6. When the resident is ready to move bowels,
ask him not to urinate at the same time and
 305 17

not to put toilet paper in with the sample. blood in stool may be an indication of colorectal
Provide a plastic bag for toilet paper. cancer, or of other illnesses.

7. Fit hat to toilet or commode, or provide resi- The Hemoccult® fecal occult blood test helps

Bowel Elimination
dent with bedpan. Ask the resident to signal to detect blood in stool. Stool specimens may be
when he is finished with the bowel move- sent to the laboratory for this test; however, you
ment. Make sure call light is within reach and may be asked to perform this test at your facility,
leave the room. if you are trained and allowed to do so.

8. When called by resident, return and help with

Testing a stool specimen for occult blood
perineal care, if needed. Help resident wash
his hands. Equipment: labeled stool specimen, Hemoccult®
test kit (Fig. 17-8) or other ordered test kit
9. Remove and dispose of gloves. (Fig. 17-9), 1 or 2 tongue blades, paper towel, plas-
10. Wash your hands. tic bag, gloves

11. Put on clean gloves.

12. Using the two tongue blades, take about two

tablespoons of stool, and put it in the con-
tainer. Cover it tightly.

13. Place the container in a plastic bag.

14. Wrap the tongue blades in toilet paper and

throw them away. Empty the bedpan or con-
tainer into the toilet. Rinse and clean equip-
ment. Store.
Fig. 17-8. A Hemoccult® test kit.
15. Remove and dispose of gloves.

16. Wash your hands.

17. Return bed to lowest position if adjusted. Re-

move privacy measures.

18. Place call light within resident’s reach.

19. Report any changes in resident to the nurse.

20. Take specimen and lab slip to proper area.

Document procedure using facility guide-
lines. Note amount and characteristics of
stool.
Fig. 17-9. This is another type of screening test for occult
blood. Use the test that is ordered at your facility. (reprinted
with permission of briggs corporation, 800-247-2343, www.briggscorp.com)

6. Explain occult blood testing 1. Wash your hands.

Occult blood testing is performed to detect blood 2. Put on gloves.
in stool. Occult means something that is hidden
or difficult to see or observe. Hidden, or occult, 3. Open the test card.
17 306

4. Pick up a tongue blade. Get small amount of 7. Define the term “ostomy” and list care
stool from specimen container. guidelines
5. Using tongue blade, smear a small amount An ostomy is an operation to create an opening
Bowel Elimination

of stool onto Box A of test card (Fig. 17-10). from an area inside the body to the outside. The
terms “colostomy” and “ileostomy” refer to the
surgical removal of a portion of the intestines. It
may be necessary due to bowel disease, cancer,
or trauma. In a resident with one of these osto-
mies, the end of the intestine is brought out of
the body through an artificial opening in the ab-
domen. This opening is called a stoma. Stool, or
feces, are eliminated through the ostomy rather
than through the anus. (When an ureter is
opened to abdomen for urine to be eliminated, it
is called a ureterostomy.)
The terms “colostomy” and “ileostomy” indicate
what part of the intestine was removed and the
type of stool that will be eliminated. In a colos-
tomy, stool will generally be semi-solid. With an
ileostomy, stool may be liquid and irritating to
Fig. 17-10. Smear a small amount of stool onto Box A.
the skin.
6. Flip tongue blade, or use a new tongue blade. Residents who have had an ostomy wear a dis-
Get some stool from another part of speci- posable bag or pouch that fits over the stoma to
men. Smear small amount of stool onto Box collect the feces (Fig. 17-11). The bag is attached
B of test card. to the skin by adhesive. A belt may also be used
to secure it.
7. Close the test card. Turn over to other side.

8. Open the flap, and open the developer. Apply

developer to each box. Follow manufacturer’s
instructions.

9. Wait the amount of time listed in instruc-

tions, usually between 10 and 60 seconds.

10. Watch the squares for any color changes. Re-

cord color changes. Follow instructions.

11. Place tongue blade and test packet in plastic

bag, and dispose of plastic bag properly.
Fig. 17-11. The top of this photo shows the front and
12. Remove and dispose of gloves. back of one type of drainage pouch for an ostomy. An
example of a skin barrier is at the bottom of the photo.
13. Wash your hands. (photos courtesy of hollister incorporated, libertyville, illinois)

14. Document procedure using facility Many people manage the ostomy appliance by
guidelines. themselves. You should receive training before
 307 17

you provide this care. Use the following general paper or gauze squares, basin of warm water, soap
guidelines if you are providing ostomy care. or cleanser, washcloth, skin cream as ordered, 2
towels, plastic disposable bag, gloves

Bowel Elimination
Guidelines: 1. Wash your hands.
Ostomies 2. Identify yourself by name. Identify the resi-
dent by name.
G Make certain that the resident receives good
skin care and hygiene. The ostomy bag 3. Explain procedure to the resident. Speak
should be emptied and cleaned or replaced clearly, slowly, and directly. Maintain face-to-
whenever a stool is eliminated. face contact whenever possible.
G Always wear gloves and wash hands carefully 4. Provide for resident’s privacy with curtain,
when providing ostomy care. Follow Standard screen, or door.
Precautions.
5. Adjust bed to a safe level, usually waist high.
G Teach proper handwashing techniques to Lock bed wheels.
residents with ostomies.
6. Place bed protector under resident. Cover
G Skin barriers protect the skin around the
resident with a bath blanket. Pull down the
stoma from irritation of the waste products
top sheet and blankets. Only expose ostomy
and/or the adhesive material that is used
site. Offer resident a towel to keep clothing
to secure the pouch to the body. Barriers
dry.
may come in the form of a powder, gel, ring,
paste, wafer, or square. 7. Put on gloves.
G Residents who have an ileostomy may expe- 8. Remove ostomy bag carefully. Place it in plas-
rience food blockage. A food blockage is a tic bag. Note the color, odor, consistency, and
large amount of undigested food, usually amount of stool in the bag.
high-fiber food, that collects in the small
9. Wipe the area around the stoma with toilet
intestine and blocks the passage of stool.
paper or gauze squares. Discard paper/gauze
Food blockages can occur if the resident eats
in plastic bag.
large amounts of foods that are high-fiber
and/or if the resident does not chew the food 10. Using a washcloth and warm soapy water,
well. Follow the diet instructions in the care wash the area in one direction, away from
plan and the nurse’s instructions for assist- the stoma (Fig. 17-12). Pat dry with another
ing with feeding. towel. Apply cream as ordered.
G Many residents with ostomies feel they have
lost control of a basic bodily function. They
may be embarrassed or angry about the
ostomy. Be sensitive and supportive when
working with these residents. Always provide
privacy for ostomy care.

Fig. 17-12. Wash away from the stoma.

Caring for an ostomy

Equipment: bedpan, disposable bed protector, bath 11. Place the clean ostomy appliance on resident.
blanket, clean ostomy bag and belt/appliance, toilet Make sure the bottom of the bag is clamped.
17 308

12. Remove disposable bed protector and dis-

if a resident has a bowel movement in her bed, she
card. Place soiled linens in proper container. probably feels extremely embarrassed about this and
the fact that you have to clean her and change the
13. Remove bag and bedpan. Discard bag in
sheets. You can help the resident keep her dignity by
Bowel Elimination

proper container. Empty bedpan into toilet. being kind and supportive. The resident has the right
to privacy. Do not violate that by discussing her ac-
14. Rinse bedpan and pour rinse water into toi- cident in a public area.
let. Place container in proper area for clean-
ing or clean it according to facility policy.

15. Remove and dispose of gloves. Guidelines:

Bowel Retraining
16. Wash your hands.
G Follow Standard Precautions. Wear gloves
17. Make resident comfortable. Make sure sheets
when handling body wastes.
are free from wrinkles and the bed free from
crumbs. G Explain the bowel training schedule to the
resident. Follow the schedule carefully.
18. Return bed to lowest position. Remove pri-
vacy measures. G Keep a record of the resident’s bowel habits.
When you see a pattern of elimination, you
19. Place call light within resident’s reach.
can predict when the resident will need a
20. Report any changes in resident to the nurse. bedpan or a trip to the bathroom.
Report if stoma is very red or blue, or if swell- G Encourage the resident to drink plenty of
ing or bleeding is present. fluids.
21. Document procedure using facility G Encourage the resident to eat foods that are
guidelines. high in fiber. Encourage residents to follow
special diets, as ordered. Chapter 15 has
more information on diet and nutrition.
8. Explain guidelines for assisting with G Answer call lights promptly. Leave call lights
bowel retraining within reach.
Residents who have had a disruption in their G Provide privacy—both in the bed and in the
bowel routines from illness, injury, or inactivity bathroom.
may need help to re-establish a regular routine
G Do not rush the resident during elimination.
and normal function. To assist with bowel re-
training, the doctor may order suppositories, G Help residents with good perineal care. This
laxatives, stool softeners, or enemas. Remember prevents skin breakdown and promotes prop-
that bowel elimination issues may be difficult er hygiene. Carefully watch for skin changes.
to discuss. Be sensitive to this and promote resi- G Discard wastes according to facility rules.
dents’ privacy. Be professional when assisting
G Discard clothing protectors and incontinence
residents with bowel retraining.
briefs properly.
Residents’ Rights G Some facilities use washable bed pads or
Bowel Retraining briefs. Follow Standard Precautions when
Residents who have problems controlling their bow- placing these items in the laundry.
els need to be treated with dignity. Think about how
you might feel in the same situation. For example, G Keep an accurate record of elimination.
 309 17

G Praise successes or attempts to control bow- 14. What two things should not be included in a
els. However, do not talk to residents as if stool specimen?
they are children. Keep your voice low and
15. If a stool specimen needs to be tested for ova
do not draw attention to any aspect of bowel

Bowel Elimination
and parasites, what should be done immedi-
retraining.
ately and why?
G Never show frustration or anger toward
16. What may occult blood in stool indicate?
residents who are incontinent or have “acci-
dents.” The problem is out of their control. 17. What are three reasons that a resident may
Your negative reactions will only make things need a colostomy or ileostomy?
worse. Be positive. 18. How often should an ostomy bag be
emptied?
Chapter Review 19. List 10 guidelines for bowel retraining.

1. How does stool normally appear?

2. List five things to observe and report to the
nurse about stool.
3. What is the best position for bowel elimina-
tion? What should be done if a person can-
not get out of bed for defecation?
4. Briefly describe four factors that affect bowel
elimination and how to promote normal
defecation.
5. List three possible treatments for
constipation.
6. List three signs of a fecal impaction.
7. List three causes of diarrhea.
8. What is gastroesophageal reflux disease
(GERD)?
9. What are two things that people with peptic
ulcers should avoid?
10. What are three symptoms of colorectal
cancer?
11. List the equipment used for giving cleansing
enemas.
12. In what position must the resident be placed
for an enema?
13. What should the nursing assistant do if a
resident feels pain or if the nursing assistant
feels resistance while giving an enema?
18 310

18
Common Chronic and Acute Conditions

Common Chronic and

Acute Conditions
Residents in long-term care may have many 1. Describe common diseases and
different diseases and conditions. Diseases and disorders of the integumentary system
conditions are either acute or chronic. An acute
illness or condition means an illness has severe Pressure sores, a common disorder of the in-
symptoms that last a relatively short time. It is tegumentary system, are covered in Chapter 13.
usually treated immediately. A chronic illness is Burns are covered in Chapter 7.
long-term or long-lasting. Symptoms are man-
aged and are usually less severe from day to day, Scabies
although there may be short periods of severity. Scabies is a skin condition caused by a tiny
The person may need to be hospitalized to stabi- mite called Sarcoptes scabiei. The mite burrows
lize the disease. This textbook describes diseases into the skin, where it lays eggs. Scabies is con-
or conditions according to the body system in tagious and is spread through direct contact
which they are located. You first learned about with an infected person. It can spread quickly in
these body systems in Chapter 9: crowded places, such as long-term care facilities
• Integumentary and child care facilities. Signs and symptoms of
scabies include intense itching and a skin rash
• Musculoskeletal
that may look like thin burrow tracks. These
• Nervous tracks typically appear in the folds of the skin.
• Cardiovascular or circulatory Treatment of scabies involves medications, often
in the form of prescription creams and lotions
• Respiratory
(Chapter 13 has information on applying lo-
• Endocrine tions). Oral medications may be used, too, if the
• Reproductive person does not respond to the creams and/or
lotions.
• Immune and Lymphatic
The list above is only a partial list; you learned Shingles
about common diseases of the urinary and gas-
Shingles, also called herpes zoster, is a skin
trointestinal systems in Chapters 16 and 17.
rash caused by the varicella-zoster virus (VZV),
If you think of the body system under which a which is the same virus that causes chickenpox.
disease is classified, the signs and symptoms (Herpes zoster is not the same virus that causes
will be easier to remember. the sexually transmitted disease.) Any person
who has had chickenpox is at risk for develop-
 311 18

ing shingles. After having chickenpox, the virus Wounds

remains in the body, where it usually does not A wound is a type of injury to the skin. Wounds
cause problems. However, it can reappear later are classified as either open or closed. Open
in life and cause shingles.

Common Chronic and Acute Conditions

wounds can be categorized in the following
Initial signs and symptoms of shingles include ways: incisions, lacerations, abrasions, and punc-
pain, tingling, or itching in an area, which later ture wounds. Incisions are caused by a knife or
develops into a rash of fluid-filled blisters that is razor, such as a cut made during surgery with
similar to chickenpox (Fig. 18-1). The rash usu- a surgical instrument. Lacerations are irregu-
ally goes away within two to four weeks. lar wounds caused by ripping or blunt trauma,
such as tearing of skin during childbirth. Abra-
sions are wounds in which the top layer of skin
is scraped or worn off, often by coming into
moving contact with a rough surface. Puncture
wounds are breaks in the skin caused by a nail
or a needle.
Closed wounds can be contusions (bruises) or
hemotomas. Contusions are caused by blunt
force trauma that damages tissue under the
skin. Hemotomas are caused by damage to a
blood vessel that causes blood to collect under
the skin.
Wounds are examined and cleaned with vari-
ous solutions, such as tap water, sterile saline,
Fig. 18-1. Shingles in blister form. (photo courtesy of dr. jere or antiseptic solution. Bleeding may need to be
mammino, do)
stopped. Dressings, bandages, sutures, staples,
Shingles cannot be transmitted to other people. or special strips or glue may need to be applied.
However, if a person has never had chickenpox,
Dermatitis
he may acquire chickenpox from a person who
has active shingles (when the rash is in the blis- Dermatitis is a general term that refers to an
ter phase). The risk of getting shingles increases inflammation, or swelling, of the skin. There
as a person ages. People with immune systems are different types of dermatitis, including atopic
weakened by diseases such as cancer and HIV dermatitis, also known as eczema, and stasis
are at greater risk of getting shingles. dermatitis. Dermatitis usually involves swollen,
reddened, irritated, and itchy skin.
Keeping the rash covered, especially while it is
in blister form, is important. The rash should Eczema commonly occurs along with allergies,
not be scratched or touched, and the person including asthma or chronic hay fever. Physical
should wash her hands often. and mental stressors may also cause eczema,
and it may be inherited. Eczema usually begins
Shingles is treated with medication, which
in childhood and may not be as severe later in
should be started as soon as possible. A vaccine
life. Symptoms include dry, itchy, and inflamed
for the varicella-zoster virus (VZV) was approved
skin, usually on the cheeks, arms, and legs,
by the Food and Drug Administration (FDA) in
although it can cover other parts of the body.
2006 to give to people 60 years or older who have
Symptoms improve and worsen at various times.
had chickenpox.
Atopic dermatitis is not contagious.
18 312

Special lotions are used to treat this condition.

Further measures to help cracked skin may be
prescribed, such as wet dressings. Antihista-
mines may help intense itching.
Common Chronic and Acute Conditions

Stasis dermatitis is a skin condition that com-

monly affects the lower legs and ankles. The
condition occurs due to a build up of fluid under
the skin. This build-up causes problems with
circulation, and poor circulation results in skin
that is fragile and poorly nourished. Stasis der- Fig. 18-2. Ringworm is a fungal infection that causes
red, ring-like patches to appear on the upper body, hands
matitis can also lead to severe skin problems and/or feet. (photo courtesy of dr. jere mammino, do)
such as open ulcers and wounds.
Early signs of stasis dermatitis include a rash, Fungi can be difficult to kill. Treatment gener-
a scaly, red area, and itching. Other signs are: ally consists of applying antifungal drugs di-
swelling of the legs, ankles, or other areas; thin, rectly on the infection, such as the skin, inside
tissue-like skin; darkening skin at ankles or the mouth, or in the vagina. Medication may
legs; thickening skin at ankles or legs; signs of also need to be taken orally or injected if the in-
skin irritation; and leg pain. Report any of these fection is more serious.
signs to the nurse.
Residents’ Rights
Treatment of stasis dermatitis includes surgery Diseases and Disorders
for varicose veins and medications, such as di- Respect the privacy of residents who are ill. Do not
uretics, to reduce fluid in the body. Stockings discuss their condition where you can be overheard.
and shoes should fit properly and not be too Do not make negative comments or show negative
facial reactions to unpleasant symptoms, such as
tight. The resident may need to keep his feet
vomiting, or to conditions like skin disorders.
elevated, and he should not cross his legs. You
may need to apply special elastic stockings to
help promote circulation. The person may be on 2. Describe common diseases and
a low-sodium diet. disorders of the musculoskeletal system

Fungal Infections Arthritis

Mushrooms, mold, and yeasts (Candida) are all Arthritis is a general term that refers to inflam-
examples of fungi. Some types of fungi, such mation, or swelling, of the joints. It causes stiff-
as Candida, normally live in and on the body, in ness, pain, and decreased mobility. Arthritis
such places as the skin and in the vagina and may be the result of aging, injury, or an autoim-
intestines. However, sometimes normal bal- mune illness. During an autoimmune illness,
ances of fungi can change, resulting in fungal the body’s immune system attacks normal tissue
infections, such as athlete’s foot or vaginal yeast in the body. There are several types of arthritis.
infections. Ringworm is another example of a
Osteoarthritis is a common type of arthritis
fungal infection (Fig. 18-2). These imbalances
that affects the elderly. It may occur with aging
that result in infections can be caused by a weak-
or as the result of joint injury. Hips and knees,
ened immune system or by taking antibiotics.
which are weight-bearing joints, are usually af-
 313 18

fected. Joints of the fingers, thumbs, and spine G Encourage activity. Gentle activity can help
can also be affected. Pain and stiffness seem to reduce the effects of arthritis. Follow care
increase in cold or damp weather. plan instructions carefully. Use canes or other
walking aids as needed.

Common Chronic and Acute Conditions

Rheumatoid arthritis can affect people of
all ages. Joints become red, swollen, and very G Adapt activities of daily living (ADLs) to allow
painful (Fig. 18-3). Movement is eventually re- independence. Many devices are available
stricted. Fever, fatigue, and weight loss are also to help residents to bathe, dress, and feed
symptoms. Rheumatoid arthritis usually affects themselves even when they have arthritis
the smaller joints first, then progresses to larger (Chapter 21).
ones. The heart, lungs, eyes, kidneys, and skin G Choose clothing that is easy to put on and
may also be affected. fasten. Encourage use of handrails and safety
bars in the bathroom. Special utensils make
it easier for residents to feed themselves
(Fig. 18-4).

Fig. 18-3. Rheumatoid arthritis. (photo courtesy of frederick

miller, md)
Fig. 18-4. Special equipment can help a person with ar-
thritis be independent. (photo courtesy of north coast medical, inc.,
Arthritis is generally treated with some or all of www.ncmedical.com, 800-821-9319)

the following:
G Treat each resident as an individual. Arthritis
• Anti-inflammatory medications such as aspi- is very common among elderly residents. Do
rin or ibuprofen not assume that each resident has the same
• Local applications of heat to reduce swelling symptoms and needs the same care.
and pain G Help maintain resident’s self-esteem by
• Range of motion exercises (Chapter 21) encouraging self-care. Have a positive atti-
tude. Listen to the resident’s feelings. You
• Regular exercise and/or activity routine
can help him or her remain independent for
• Diet to reduce weight or maintain strength as long as possible.

Osteoporosis
Guidelines:
Caring for Residents with Arthritis Osteoporosis is a disease that causes bones
to become porous and brittle. Brittle bones can
G Watch for stomach irritation or heartburn break easily. Weakness in the bones may be
caused by aspirin or ibuprofen. Some resi- due to age, lack of hormones, lack of calcium in
dents cannot take these medications. Report bones, alcohol consumption, or lack of exercise.
signs of stomach irritation or heartburn
Osteoporosis is more common in women after
immediately.
menopause. Menopause is the stopping of men-
18 314

strual periods. Extra calcium and regular exer- fractured bone together. The bone must be un-
cise can help prevent osteoporosis. Signs and able to move for this healing to occur. This is
symptoms of osteoporosis include low back pain, often accomplished by the use of a cast.
stooped posture, and becoming shorter over
Common Chronic and Acute Conditions

Two common types of casts are made of plas-

time (Fig. 18-5).
ter and fiberglass. Plaster casts take longer to
dry, up to one to two days. Fiberglass casts dry
quickly. A cast must be completely dry before a
person can bear weight on it. As a cast dries, it
gives off heat. This heat must escape or it will
burn the skin. Never cover a cast with any mate-
rial until it has completely dried.

Guidelines:
Caring for a Resident who has a Cast

G Do not cover a cast until it is dry. Follow

Fig. 18-5. Stooped posture, or “dowager’s hump” is a
common sign of osteoporosis. (photos courtesy of jeffrey t. instructions with position changes. Assist the
behr, md)
resident to change positions as ordered; this
allows the cast to dry evenly. Place the cast
To prevent or slow osteoporosis, encourage
on pillows. A hard surface alters the shape of
residents to walk and do other light exercise,
the cast. Use the palms of the hands to lift
as ordered. Exercise can strengthen bones as
the cast. Fingers will dent it, and dents will
well as muscles. Nursing assistants must move
cause pressure on the resident’s skin.
residents with osteoporosis very carefully. Medi-
cation, calcium, and fluoride supplements are G Elevate the extremity that is in a cast. This
used to treat osteoporosis. helps stop swelling (Fig. 18-6). If the resident
is in bed, elevate the arm or leg slightly above
Fractures the level of the heart.
Fractures are broken bones caused by accidents
or by osteoporosis. A closed fracture is a bro-
ken bone that does not break the skin. An open
fracture, also known as a compound fracture, is
a broken bone that penetrates the skin. An open
fracture carries a high risk of infection and usu-
ally requires immediate surgery.
Preventing falls, which can lead to fractures,
is very important. Fractures of arms, elbows,
legs, and hips are the most common. Signs and
symptoms of a fracture are pain, swelling, bruis-
ing, changes in skin color at the site, and limited
movement.
When bones are fractured, they must be placed
in alignment so the body can heal. The body can Fig. 18-6. To help stop swelling, elevate the extremity
grow new bone tissue and fuse the sections of that is in a cast.
 315 18

G Observe the affected extremity for swelling,

redness, pale or blue-tinged skin, cast tight-
ness or pressure, sores, skin that feels hot
or cold, pain, burning, numbness or tingling,

Common Chronic and Acute Conditions

drainage, bleeding, or odor. Compare to the
extremity that does not have a cast. Report
any of these to the nurse, along with any
signs of infection, such as fever or chills.
G Protect the skin from the rough edges of the
cast. The stocking that lines the inside of the
cast can be pulled up and over the edges and
secured with tape. Tell the nurse if cast edges
irritate the resident’s skin.
Fig. 18-7. An illustration of a fractured hip.
G Keep the cast dry. Wet casts lose their shape.
Keep the cast clean. • Fractured hip from an injury or fall that does
not heal properly
G Do not insert or allow the resident to insert
anything inside the cast, even when skin itch- • Weakened hip due to aging
es. Pointed or blunt objects may injure dry
• Hip is painful and stiff because the joint is
and fragile skin. Skin can become infected
weak and the bones are no longer strong
under the cast.
enough to bear the person’s weight
G Tell the nurse prior to moving or exercising if
After the surgery, the person cannot stand on
pain medication is needed. Help with range
that leg while the hip heals. A physical therapist
of motion exercises as ordered. Allow plenty
will assist after surgery. The goals of care in-
of time for movement. Assist resident with
clude slowly strengthening the hip muscles and
cane, walker, or crutches as needed.
getting the resident walking on that leg.
G Use bed cradles as needed.
Be familiar with the resident’s care plan. It
will state when the resident may begin putting
Hip Fractures weight on the hip. It will also give instructions
Weakened bones make hip fractures more com- on how much the resident is able to do. It is im-
mon (Fig. 18-7). A sudden fall can result in a portant to help with personal care and using as-
fractured hip that takes months to heal. Prevent- sistive devices, such as walkers or canes.
ing falls is very important. Hip fractures can
also occur because of weakened bones that frac- Guidelines:
ture and cause a fall. A hip fracture is a serious Caring for Residents Recovering from Hip
condition. The elderly heal slowly. They are also Replacements
at risk for secondary illnesses and disabilities.
Most fractured hips need surgery. Total hip re- G Keep often-used items, such as medications,
placement is surgery that replaces the head of telephone, tissues, call light, and water,
the long bone of the leg (femur) where it joins within easy reach. Avoid placing items in high
the hip. This surgery is often performed for the places.
following reasons: G Dress starting with the affected side first.
18 316

G Never rush the resident. Use praise and of the bed can be raised to allow the resident
encouragement often. Do this even for small to move her legs over the side of the bed
tasks. with the thighs still separated. It is better to
transfer from the bed on the side where the
Common Chronic and Acute Conditions

G Ask the nurse to give pain medication prior

to moving and positioning if needed. unaffected hip is so that the strong side leads
in standing, pivoting, and sitting.
G Have the resident sit to do tasks if allowed.
This saves energy. G With chair or toilet transfers, the opera-
tive leg/knee should be straightened. The
G Follow the care plan exactly, even if the resi- strong leg should stand first (with a walker
dent wants to do more. Follow orders for or crutches) before bringing the foot of the
weight-bearing. An order may be written as affected leg back to the walking position.
partial weight bearing (PWB) or non-weight
bearing (NWB). Partial weight bearing
means the resident is able to support some Observing and Reporting:
weight on one or both legs. Non-weight Hip Replacement
bearing means the resident is unable to
Report any of these to the nurse:
support any weight on one or both legs. Full
weight bearing (FWB) means that one or If the incision or area around it is red, drain-
both legs can bear 100 percent of the body ing, bleeding, or warm
weight on a step. Assist resident as needed An increase in pain
with cane, walker, or crutches.
Numbness or tingling
G Never perform range of motion exercises on
Abnormal vital signs, especially change in
a leg on the side of a hip replacement unless
temperature
directed by the nurse.
If the resident cannot use equipment prop-
G Caution the resident not to sit with his or
erly and safely
her legs crossed or turn toes inward. The
hip cannot be bent or flexed more than 90 If the resident is not following doctor’s
degrees. It cannot be turned inward or out- orders for activity and exercise
ward (Fig. 18-8). Any problems with appetite
Increasing strength and improving ability to
walk
A cast or traction may also be used to immobi-
lize a fractured hip. Traction helps to immobilize
a fractured bone, relieve pressure, and lessen
muscle spasms due to injury. A resident in trac-
tion will require special care.
If traction is used, the traction assembly must
Fig. 18-8. The hip must maintain a 90-degree angle in never be disconnected. Keep the weights off the
the sitting position. floor and do not add or remove weights. Keep
the resident in good alignment. Good skin care
G When preparing to transfer the resident from and repositioning according to the care plan
the bed, a pillow should be used between the are essential for all residents who are immo-
thighs to keep the legs separated. The head bilized. Skin will rapidly deteriorate over pres-
 317 18

sure points. Perform range of motion exercises G Encourage fluids, especially cranberry and
as directed. Report to the nurse if the resident orange juices, which contain vitamin C, to
complains of pain, numbness or tingling, or prevent urinary tract infections (UTIs).
burning. Report if swelling, redness, bleeding or

Common Chronic and Acute Conditions

G Assist with deep breathing exercises as
sores are present. ordered.

Knee Replacement G Continuous passive motion (CPM) may be

ordered after a knee replacement. This is a
Knee replacement is the surgical insertion of a treatment method using a machine to con-
prosthetic knee. A prosthesis is a device that stantly move the knee through a range of
replaces a body part that is missing or deformed motion (Fig. 18-9). The person does not have
because of an accident, injury, illness, or birth to actively help; the machine does the work.
defect. It is used to improve a person’s ability to CPM can help speed recovery. The goal is to
function and/or to improve appearance. Knee re- decrease stiffness, increase range of motion
placement surgery is performed to relieve pain. and promote healing. The nurse or physical
It also restores motion to a knee damaged by in- therapist will set the rate and position the
jury or arthritis. It can help stabilize a knee that resident. You may be asked to stay with the
buckles or gives out repeatedly. resident while the machine is turned on.
Care is similar to that for the hip replace-
ment, but the recovery time is much shorter.
These residents have more ability to care for
themselves.

Guidelines:
Caring for Residents Recovering from Knee
Replacements

G To prevent blood clots, apply special stock-

ings as ordered. One type is a compression
stocking. It is a plastic, air-filled, sleeve-like
device that is applied to the legs and hooked
to a machine. This machine inflates and Fig. 18-9. One type of CPM machine. (photo courtesy of the
medcom group, ltd., 800-231-4276, www.medcomgroup.com)
deflates on its own. It acts in the same way
that the muscles usually do under normal G Ask the nurse to give pain medication prior
circumstances. The sleeves are normally to moving and positioning if needed.
applied after surgery while the resident is in
G Report to the nurse if you notice redness,
bed. Anti-embolic stockings are another type
swelling, heat, or deep tenderness in one or
of special stocking. They aid circulation. See
both calves.
later in the chapter for more information on
this type of stocking.
Muscular Dystrophy (MD)
G Perform ankle pumps as ordered. These are
Muscular dystrophy (MD) refers to several pro-
simple exercises that promote circulation to
gressive diseases that cause a variety of physical
the legs. Ankle pumps are done by raising the
disabilities due to muscle weakness. MD is an
toes and feet toward the ceiling and lowering
inherited disease. It causes a gradual wasting of
them again.
18 318

muscle, weakness, and deformity. The muscles

ventional treatments prescribed by a doctor. Alter-
of the hands are impaired, and there may be native medicine refers to practices and treatments
twitching of the hand and arm muscles. Legs used instead of conventional methods. Your resi-
may be weak and stiff. The person may be in a dents may use any of the following:
Common Chronic and Acute Conditions

wheelchair. • Chiropractic medicine concentrates on the spine

and musculoskeletal system. Chiropractors be-
Most forms of MD are present at birth or be- lieve that a misaligned spine can interfere with
come apparent during childhood. Many forms of the body’s proper function. Chiropractors do not
MD are very slow to progress. Often people with use drugs or surgery; they use hands-on manipu-
MD can live to middle or even late adulthood. lations, also called adjustments, of the spine or
other joints. They also teach exercises and pro-
In the early stages of this disease, help with vide nutrition and other health counseling.
ADLs or range of motion exercises. In the more Heat, cold, and muscle stimulation are used to
advanced stages, help with skin care and posi- improve function. Chiropractors are frequently
tioning and perform ADLs for the resident. consulted for back, neck, and joint pain, as well
as for headaches.
Amputation • Massage therapy manipulates soft body tissues
with touch and pressure and is used to reduce
Amputation is the removal of some or all of a stress and to promote relaxation and pain relief.
body part, usually a foot, hand, arm or leg. Am-
• Acupuncture is a very old Chinese healing tech-
putation may be the result of an injury or dis-
nique used to restore health, relieve pain, or
ease. After amputation, some people feel that the treat other conditions. Very fine needles are in-
limb is still there. They may feel pain in the part serted into specific points on the body.
that has been amputated. This is called “phan- • Homeopathy involves giving small doses of
tom sensation.” It may last for a short time or a substance to stimulate the body’s ability to
for several years. The pain or sensation, which heal itself. If given in large doses, the substance
is caused by remaining nerve endings, is real. It would produce symptoms of an illness or the ill-
ness itself.
should not be ignored or ridiculed.
• Herbs and other dietary supplements may be
Residents who have had a body part amputated taken for prevention as well as treatment of dis-
must make many physical, psychological, social, eases or conditions. If you know that a resident
and occupational adjustments. Be supportive. is taking herbs or supplements, report this to
the nurse as some can cause serious problems if
When a body part has been amputated, day-to-
taken with certain medications.
day activities may be limited. A resident will
need special care to help him adjust to these If residents are using complementary or alterna-
tive medicine, do not make judgments about their
changes. When the condition is new, a physical treatment or discuss your opinions. Do not make
and/or occupational therapist may work with the recommendations about these methods. If you have
resident. concerns, talk to the charge nurse.

Assist residents in performing their ADLs. Fol-

low the care plan for care of the prosthesis and
the stump. See Chapter 21 for more information 3. Describe common diseases and
on prosthetics and related care. disorders of the nervous system
Chapter 19 has information on dementia and
Complementary or Alternative Health Practices
Alzheimer’s disease. Dementia and Alzheimer’s
Many people now use complementary or alternative disease are common disorders of the nervous
health practices. Complementary medicine refers system.
to treatments that are used in addition to the con-
 319 18

CVA or Stroke G Never refer to the weaker side as the “bad

side.” Do not talk about the “bad” leg or
As you learned in Chapters 4 and 7, the medical
arm. Use the terms “weaker” or “involved” to
term for a stroke is a cerebrovascular accident, or
refer to the side with paralysis or paresis.

Common Chronic and Acute Conditions

CVA. CVA, or stroke, is caused when the blood
supply to the brain is cut off suddenly by a clot G Residents with speech loss or communica-
or a ruptured blood vessel. Without blood, part tion problems may receive speech therapy.
of the brain gets no oxygen. This causes brain You may be asked to help. This includes help-
cells to die. Brain tissue is further damaged by ing residents recognize written words, as well
leaking blood, clots, and swelling. These cause as helping them to speak. Speech therapists
pressure on surrounding areas of healthy tissue. will also evaluate a resident’s swallowing abil-
Strokes can be mild or severe. ity. They will decide if therapy or thickened
liquids are needed.
Afterward, a resident may experience paraly-
sis, weakness, inability to speak or understand G Use verbal and nonverbal communication to
words, trouble swallowing, and loss of bowel or express your positive attitude. Let the resi-
bladder control. Review Chapter 4 for a more dent know you have confidence in his or her
comprehensive list of how a CVA may affect a abilities through smiles, touches, and ges-
person. tures. Gestures and pointing can also help
you convey information or allow the resident
The two sides of the brain control different
to speak to you. More ideas for communicat-
functions. Symptoms that a person experiences
ing with residents recovering from stroke are
depend on which side of the brain the CVA af-
listed in Chapter 4.
fected. Weaknesses on the right side show that
the left side of the brain was affected. Weak- G Experiencing confusion or memory loss is
nesses on the left side show that the right side of upsetting. People often cry for no apparent
the brain was affected. reason after suffering a stroke. Be patient and
understanding. Your positive attitude will be
If the stroke was mild, the resident may experi-
important. Keeping a routine may help resi-
ence few, if any, of complications. Physical ther-
dents feel more secure.
apy may help regain physical abilities. Speech
and occupational therapy can also help a person G Encourage independence and self-esteem.
learn to communicate and perform ADLs again. Let the resident do things for him- or her-
self whenever possible, even if you could do
a better or faster job. Make tasks less dif-
Guidelines:
ficult for the resident to do. Appreciate and
Residents Recovering from Stroke
acknowledge residents’ efforts to do things
for themselves even when they are unsuc-
G Residents with paralysis, weakness, or loss of
cessful. Praise even the smallest successes to
movement will usually have physical or occu-
build confidence.
pational therapy. You may be asked to assist
residents in performing exercises. Range of G Always check on the resident’s body align-
motion exercises will help strengthen mus- ment. Sometimes an arm or leg can be
cles and keep joints mobile. Residents may caught and the resident is unaware.
also perform leg exercises to aid circulation. G Pay special attention to skin care and observe
Safety is always important when post-CVA for changes in the skin if a resident is unable
residents are exercising. to move.
18 320

G If residents have a loss of touch or sensation, and then remove the weaker arm or leg from
check for potentially harmful situations (for clothing to prevent the limb from being
example, heat and sharp objects). If residents stretched and twisted.
are unable to sense or move a part of the
Common Chronic and Acute Conditions

G Use assistive equipment to help the resident

body, assist with changing positions to pre-
dress himself (see Chapters 13 and 21).
vent pressure sores.
Encourage self-care.
G Adapt procedures when caring for resi-
When assisting with eating, remember the
dents with one-sided paralysis or weakness.
following:
Carefully assist with shaving, grooming, and
bathing. Diminished sensation or paraly- G Place food in the resident’s field of vision.
sis causes lack of awareness about such G Use assistive devices such as silverware
things as water temperature and sharpness with built-up handle grips, plate guards, and
of razors. Take care so that injury does not drinking cups.
occur.
G Watch for signs of choking.
When assisting with transfers or walking, remem-
G Serve soft foods if swallowing is difficult.
ber the following:
G Always place food in the unaffected, or non-
G Always use a gait belt for safety.
paralyzed, side of the mouth.
G Stand on the weaker side. Support the weaker
G Make sure food is swallowed before offering
(involved) side.
more bites.
G Lead with the stronger (uninvolved) side
(Fig. 18-10). Home Care Focus

Monitoring the home safety of clients who have had

a stroke is essential. Clients who are unsteady, weak,
or confused are at risk of falling. Clients with loss of
sensation are at risk of burning themselves in the
bathroom or at the stove. Some safety tips include:
• Remove any hazards from the home, including
unnecessary clutter or throw rugs.
• Unplug appliances like toasters and coffee mak-
ers when not in use.
• Check the refrigerator and cabinets for spoiled
food. A stroke may impair the senses of smell
and taste.
• Report any suspected safety hazards to your
supervisor.
Fig. 18-10. When helping a resident transfer, support the
weak side while leading with the stronger side. See Chapters 4 and 7 for more information on
CVA.
When assisting with dressing, remember the fol-
lowing: Parkinson’s Disease
G Dress the weaker side first. Place the weaker Parkinson’s disease is a progressive disease. It
arm or leg into the clothing first. This pre- causes a section of the brain to degenerate, and
vents unnecessary bending and stretching it affects the muscles, causing them to become
of the limb. Undress the stronger side first, stiff. In addition, it causes stooped posture and
 321 18

a shuffling gait, or walk. It can also cause pill- the brain breaks down over time. Without this
rolling. This is a circular movement of the tips covering, or sheath, nerves cannot send mes-
of the thumb and the index finger when brought sages to and from the brain in a normal way.
together, which looks like rolling a pill. Tremors

Common Chronic and Acute Conditions

Residents with MS have varying abilities. Mul-
or shaking make it hard for a person to perform
tiple sclerosis is usually diagnosed when a per-
ADLs such as eating and bathing. A person
son is in his or her early twenties to thirties.
with Parkinson’s may have a mask-like facial
It progresses slowly and unpredictably. Symp-
expression.
toms include blurred vision, fatigue, tremors,
poor balance, and trouble walking. Weakness,
Guidelines: numbness, tingling, incontinence, and behavior
Parkinson’s Disease changes are also symptoms. MS can cause blind-
ness, contractures, and loss of function in the
G Residents are at a high risk for falls. Protect arms and legs (Fig. 18-12).
residents from any unsafe areas and
conditions.
G Help with ADLs as needed.
G Assist with range of motion exercises exactly
as ordered to prevent contractures and to
strengthen muscles (Fig. 18-11).

Fig. 18-12. MS is an unpredictable disease that causes

Fig. 18-11. Range of motion exercises help prevent con- varying symptoms and impairments. MS can cause a
tractures, strengthen muscles, and increase circulation. range of problems, including fatigue, poor balance, and
trouble walking.
G Encourage self-care. Be patient with self-care
and communication. Allow the resident time
to do and say things. Listen. Guidelines:
Multiple Sclerosis
Multiple Sclerosis (MS)
G Assist with ADLs as needed.
Multiple sclerosis (MS) is a progressive dis-
G Be patient with self-care and movement.
ease that affects the central nervous system.
When a person has MS, the protective covering G Allow enough time for tasks. Offer rest peri-
for the nerves, spinal cord, and white matter of ods as necessary.
18 322

G Give resident plenty of time to communicate.

People with MS may have trouble forming
their thoughts. Be patient. Do not rush him
or her.
Common Chronic and Acute Conditions

G Prevent falls, which may due to a lack of

coordination, fatigue, or vision problems.
G Stress can worsen the effects of MS. Be calm.
Listen to residents when they want to talk.
G Encourage a healthy diet with plenty of fluids.
G Give excellent skin care to prevent pressure
sores.
G Assist with range of motion exercises exactly Fig. 18-13. Loss of function depends on where the spine
as ordered to prevent contractures and to is injured.
strengthen muscles.
Rehabilitation is needed for residents with spinal
cord injuries. It will help them maintain muscle
Head and Spinal Cord Injuries
function and to live as independently as possible.
Diving, sports injuries, falls, car and motorcycle Residents will need emotional support as they
accidents, industrial accidents, war, and criminal adjust to their disability. Their specific needs
violence are common causes of injuries. Prob- will vary.
lems from these injuries range from mild con-
fusion or memory loss to coma, paralysis, and Guidelines:
death. Head or Spinal Cord Injury
Head injuries can cause permanent brain dam-
G Give emotional support, as well as physical
age. Residents who have had a head injury may
help. Frustration and anger may surface as
have the following problems: mental retardation;
residents with these injuries deal with the
personality changes; breathing problems; sei-
reality of their lives. Do not take it personally.
zures; coma; memory loss; loss of consciousness;
paresis; and paralysis. Paresis is paralysis, or G Be patient with all care.
loss of ability, that affects only part of the body.
G Safety is very important. Be very careful that
Often, paresis describes a weakness or loss of
residents do not fall or burn themselves.
ability on one side of the body.
Because these residents have no sensation,
The effects of spinal cord injuries depend on the they are unable to feel a burn.
force of impact and the location of the injury. G Be patient with self-care. Allow as much inde-
The higher the injury, the greater the loss of pendence as possible with ADLs.
function is. People with spinal cord injuries may
have paraplegia, or loss of function of lower G Give good skin care. It is needed to prevent
body and legs. These injuries may also cause pressure sores when mobility is limited.
quadriplegia, in which the person is then un- G Assist residents to change positions at least
able to use his legs, trunk, and arms (Fig. 18-13). every two hours to prevent pressure sores. Be
gentle when turning and repositioning.
 323 18

G Perform passive range of motion exercises Vision Impairment

exactly as ordered to prevent contractures
You first learned about vision impairment in
and to strengthen muscles.
Chapter 4. Vision impairment can affect people

Common Chronic and Acute Conditions

G Immobility leads to constipation. Encourage of all ages. Some vision impairment causes peo-
fluids and a high-fiber diet, if ordered. ple to wear corrective lenses, such as eyeglasses
or contact lenses (Figs. 18-14 and 18-15). Some
G Loss of control of urination may lead to the people need eyeglasses all the time. Others only
need for a urinary catheter. Urinary tract need them to read or for things such as driving
infections are common. Encourage a high that require seeing distant objects.
intake of fluids and give extra catheter care as
needed.

G Lack of activity leads to poor circulation and

fatigue. Offer rest periods as necessary. You
may be directed to use special stockings to
help increase circulation.

G Difficulty coughing and shallow breathing can

lead to pneumonia. Encourage deep breath-
ing exercises as ordered.

G Male residents may have involuntary erec-

tions, which may cause them to feel embar-
rassed. These are not deliberate. Provide for Fig. 18-14. Nearsightedness (the ability to see objects
nearby better than objects in the distance) and farsight-
privacy and be sensitive to this. edness (the ability to see objects in the distance better
than objects nearby) are often corrected by the use of
G Assist with bowel and bladder training if
eyeglasses.
needed.

Epilepsy

Epilepsy is an illness of the brain that causes

seizures. Epileptic seizures can be mild tremors,
brief blackouts, or violent convulsions lasting
several minutes. The cause of most cases of
epilepsy is unknown. Excessive alcohol use, sub-
stance abuse, brain tumors, or injuries may be
factors.

During a seizure, the main goal of the caregiver

Fig. 18-15. Contact lenses are made of many types of
is to make the resident safe. Moving furniture
plastic. Some can be worn and disposed of daily. Others
away can help prevent injury. A pillow can be are worn for longer periods.
placed under the resident’s head. Do not try to
restrain the resident or force anything between People over the age of 40 are at risk for develop-
his teeth because you could be bitten. Notice the ing certain serious vision problems. These in-
time a seizure begins so that you can report the clude cataracts, glaucoma, and blindness. When
length of the seizure. a cataract develops, the lens of the eye becomes
18 324

cloudy. This prevents light from entering the eye 4. Describe common diseases and
(Fig. 18-16). Vision blurs and dims initially. All disorders of the cardiovascular system
vision is eventually lost. This disease can occur
in one or both eyes. It is corrected with surgery,
Common Chronic and Acute Conditions

Hypertension (HTN) or High Blood Pressure

in which a permanent lens is usually implanted.
When blood pressure is consistently 140/90 or
Glaucoma is a disease that causes the pressure higher, a person is diagnosed as having hyper-
in the eye to increase. This eventually damages tension, or high blood pressure. If blood pres-
the retina and the optic nerve. It causes blind- sure is between 120/80 and 139/89 mmHg, it
ness. Glaucoma can occur suddenly, causing is called prehypertension. This means that the
severe pain, nausea, and vomiting. It can also person does not have high blood pressure now
occur gradually. Symptoms include blurred vi- but is likely to develop it in the future.
sion, tunnel vision, and blue-green halos around
Hypertension may be caused by atherosclero-
lights. Glaucoma is treated with medication and
sis, or a hardening and narrowing of the blood
sometimes surgery.
vessels (Fig. 18-18). It can also result from kid-
ney disease, tumors of the adrenal gland, and
complications of pregnancy. Hypertension can
develop in persons of any age.

Fig. 18-16. When a cataract develops, the lens of the eye

becomes cloudy. This prevents light from entering the eye.

Braille

For residents who are visually impaired, books on Fig. 18-18. Arteries may become hardened or narrower
tape, large-print books, and Braille books are avail- because of a build-up of plaque. Hardened arteries are
able. Braille is a system of writing for the blind using one cause of high blood pressure.
raised dots, which was developed by Louis Braille
(1809-1852). Each letter is represented as a raised Signs and symptoms of high blood pressure are
pattern that can be read by touching with the fingers not always obvious. This is especially true in the
(Fig. 18-17). Reading Braille takes a long time and
early stages. Often it is only discovered when a
requires special training.
blood pressure measurement is taken. Persons
with the disease may complain of headaches,
blurred vision, and dizziness.

Guidelines:
Hypertension

Fig. 18-17. Examples of words in Braille. G High blood pressure can lead to serious
conditions such as CVA, heart attack, kidney
See Chapter 4 for information on assisting resi- disease, or blindness. Treatment to control it
dents with vision and hearing impairments. is vital. Residents may take diuretics or medi-
 325 18

cation that lowers cholesterol. Diuretics are bone. Some people have pain extending down
drugs that reduce fluid in the body. the inside of the left arm or to the neck and left
side of the jaw. A person suffering from angina
G Residents may also have a prescribed exer-
pectoris may perspire or look pale. The person

Common Chronic and Acute Conditions

cise program or be on a low-fat, low-sodium
may feel dizzy and have trouble breathing.
diet. You may need to take blood pressure
measurements often. You can also help by Risk factors for getting CAD include increasing
encouraging residents to follow their diet and age, gender (men are more likely to get CAD
exercise programs. than women), family history of heart disease, to-
bacco use, high cholesterol, high blood pressure,
Coronary Artery Disease (CAD) lack of activity, obesity, and diabetes.

Coronary artery disease occurs when the blood

vessels in the coronary arteries narrow. This low- Guidelines:
ers the supply of blood to the heart muscle and Angina Pectoris
deprives it of oxygen and nutrients. Over time,
G Rest is extremely important. Rest reduces
as fatty deposits block the artery, the muscle that
the heart’s need for extra oxygen. It helps
was supplied by the blood vessel dies. CAD can
the blood flow return to normal, often within
lead to heart attack or stroke.
three to fifteen minutes.
The heart muscle that is not getting enough oxy-
G Medication is also needed to relax the walls
gen causes chest pain, pressure, or discomfort,
of the coronary arteries. This allows them to
called angina pectoris. The heart needs more
open and get more blood to the heart. This
oxygen during exercise, stress, excitement, or a
medication, nitroglycerin, is a small tablet
heavy meal. In CAD, narrow blood vessels pre-
that the resident places under the tongue.
vent the extra blood with oxygen from getting to
There it dissolves and is rapidly absorbed.
the heart (Fig. 18-19).
Residents with angina pectoris may keep
nitroglycerin on hand to use as soon as
symptoms arise. Nursing assistants are not
allowed to give any medication unless they
have had special training. Tell the nurse if a
resident needs help taking the medication.
Nitroglycerin is also available as a patch. Do
not remove the patch. Tell the nurse imme-
diately if the patch comes off. Nitroglycerin
may also come in the form of a spray that the
resident sprays onto or under the tongue.
G Residents may also need to avoid heavy
meals, overeating, intense exercise, and cold
or hot and humid weather.

Fig. 18-19. Angina pectoris results from the heart not get-
Myocardial Infarction (MI) or Heart Attack
ting enough oxygen.
When blood flow to the heart muscle is blocked,
The pain of angina pectoris is usually described oxygen and nutrients fail to reach cells in that
as pressure or tightness in the left side or the region (Fig. 18-20). Waste products are not re-
center of the chest behind the sternum or breast- moved and the muscle cells die. This is called a
18 326

myocardial infarction, or MI, or heart attack. may damage the heart. When the heart muscle
The area of dead tissue may be large or small, has been severely damaged, it fails to pump ef-
depending on the artery involved. A myocardial fectively. Blood backs up into the heart instead
infarction is an emergency that can result in se- of circulating. This is called congestive heart
Common Chronic and Acute Conditions

rious heart damage or death. See Chapter 7 for failure, or CHF. It can occur on one or both
warning signs of an MI. sides of the heart.

Signs and symptoms of congestive heart failure

include the following:

• Trouble breathing; coughing or gurgling

with breathing

• Dizziness, confusion, and fainting

• Pale or blue skin

• Low blood pressure

• Swelling of the feet and ankles (edema)

• Bulging veins in the neck

• Weight gain

Fig. 18-20. A heart attack occurs when the blood flow to

Guidelines:
the heart or a portion of the heart is cut off.
CHF

Guidelines: G Although CHF is a serious illness, it can

Myocardial Infarction be treated and controlled. Medications can
strengthen the heart muscle and improve its
G Generally, residents who have had an MI will pumping.
be placed on a regular exercise program.
G Medications help remove excess fluids. This
G Residents may be on a diet that is low in fat means more trips to the bathroom. Answer
and cholesterol and/or a low-sodium diet. call lights promptly. Keep a portable com-
G Medications may be used to regulate heart mode nearby if the resident is weak and has
rate and blood pressure. trouble getting out of bed and walking to the
G Quitting smoking will be encouraged. bathroom. Assist resident as needed.

G A stress management program may be start- G A low-sodium diet or fluid restrictions may be
ed to help reduce stress levels. prescribed.

G Residents recovering from a heart attack may G A weakened heart may make it hard for resi-
need to avoid exposure to cold temperatures. dents to walk, carry items, or climb stairs.
Limited activity or bedrest may be prescribed.
Congestive Heart Failure (CHF) Allow for a period of rest after an activity.

Coronary artery disease, myocardial infarc- G Intake and output of fluids may need to be
tion, high blood pressure, or other disorders measured (see Chapter 15).
 327 18

G Resident may be weighed daily at the same

Putting elastic stockings on a resident
time to watch for weight gain from fluid
retention. Equipment: elastic stockings

Common Chronic and Acute Conditions

1. Wash your hands.
G Elastic leg stockings may be used to reduce
swelling in feet and ankles. 2. Identify yourself by name. Identify resident by
name.
G Range of motion exercises improve muscle
3. Explain procedure to resident. Speak clearly,
tone when activity and exercise are limited.
slowly, and directly. Maintain face-to-face con-
G Extra pillows may help residents who have tact whenever possible.
trouble breathing. Keeping the head of the 4. Provide for resident’s privacy with curtain,
bed elevated may also help with breathing. screen, or door.
G Help with personal care and ADLs as needed. 5. With resident lying down, remove his or her
socks, shoes, or slippers, and expose one leg.
A common side effect of medications for CHF is
dizziness. This may result from a lack of potas- 6. Turn stocking inside out at least to heel area
sium. High-potassium foods and drinks such as (Fig. 18-21).
bananas or raisins, orange juice, or other citrus
juices can help. These foods should be eaten as
a preventive measure as well. Follow the instruc-
tions in the care plan.

Peripheral Vascular Disease (PVD)

Peripheral vascular disease (PVD) is a disease

in which the legs, feet, arms, or hands do not
have enough blood circulation. This is due to Fig. 18-21. Turning the stocking inside out allows stocking
to roll on gently.
fatty deposits in the blood vessels that harden
over time. The legs, feet, arms, and hands feel 7. Gently place the foot of the stocking over
cool or cold. Nail beds and/or feet become ashen toes, foot, and heel (Fig. 18-22). Make sure
or blue. Swelling occurs in the hands and feet. the heel is in the right place (heel of foot
Ulcers of the legs and feet may develop and can should be in heel of stocking).
become infected. Pain may be very severe when
walking; however, it is usually relieved with rest.

Some changes in health may lead to inactivity.

A lack of mobility may contribute to PVD. For
some cases of poor circulation to legs and feet,
elastic stockings are ordered. These stockings
help prevent swelling and blood clots and aid
circulation. These stockings are called “anti-
embolic hose” or “elastic stockings.” They need
to be put on before the resident gets out of bed. Fig. 18-22. Gently place the foot of the stocking over
Follow manufacturer’s instructions and illustra- toes, foot, and heel. Promote the resident’s comfort and
tions on how to put on stockings. safety by avoiding force and over-extension of joints.
18 328

8. Gently pull the top of stocking over foot, is a form of bronchitis that is usually caused by
heel, and leg. cigarette smoking. Symptoms include persistent
9. Make sure there are no twists or wrinkles coughing that brings up sputum (phlegm) and
mucus. Breathlessness and wheezing may be
Common Chronic and Acute Conditions

in stocking after it is applied (Fig. 18-23). It

must fit smoothly. present. Treatment includes stopping smoking
and possibly medications.
Emphysema is a chronic disease of the lungs
that usually results from chronic bronchitis and
cigarette smoking. People with emphysema have
trouble breathing. Other symptoms are cough-
ing, breathlessness, and a fast heartbeat. There
is no cure for emphysema. Treatment includes
managing symptoms and pain. Oxygen therapy
may be ordered, as well as medications. Quitting
smoking is very important.
Over time, a resident with either of these lung
Fig. 18-23. Make stocking smooth. Twists or wrinkles disorders becomes chronically ill and weakened.
cause the stocking to be too tight, which reduces There is a high risk for acute lung infections,
circulation. such as pneumonia. Pneumonia is an illness
that can be caused by a bacterial, viral, or fun-
10. Repeat for the other leg. gal infection. Acute inflammation occurs in
11. Place call light within resident’s reach. lung tissue. The affected person develops a high
fever, chills, cough, greenish or yellow sputum,
12. Wash your hands.
chest pains, and rapid pulse. Treatment includes
13. Report any changes in resident to nurse. antibiotics, along with plenty of fluids. Recov-
14. Document procedure using facility ery from pneumonia may take longer for older
guidelines. adults and persons with chronic illnesses.
When the lungs and brain do not get enough
oxygen, all body systems are affected. Residents
5. Describe common diseases and may have a constant fear of not being able to
disorders of the respiratory system breathe. This can cause them to sit upright to
improve their ability to expand the lungs. These
residents can have poor appetites. They usu-
Chronic Obstructive Pulmonary Disease (COPD)
ally do not get enough sleep. All of this can add
Chronic obstructive pulmonary disease, or to feelings of weakness and poor health. They
COPD, is a chronic disease. This means the may feel they have lost control of their bodies,
resident may live for years with it but never and particularly their breathing. They may fear
be cured. Residents with COPD have trouble suffocation.
breathing, especially in getting air out of the
Residents with COPD may experience the fol-
lungs. There are two chronic lung diseases that
lowing symptoms:
are grouped under COPD: chronic bronchitis
and emphysema. • Chronic cough or wheeze

Bronchitis is an irritation and inflammation • Difficulty breathing, especially when inhal-

of the lining of the bronchi. Chronic bronchitis ing and exhaling deeply
 329 18

• Shortness of breath, especially during physi- G Remind residents to avoid situations where
cal effort they may be exposed to infections, espe-
cially colds and the flu. Ensure that residents
• Pale or cyanotic skin or reddish-purple skin
always have help ready, especially in case of a

Common Chronic and Acute Conditions

• Confusion breathing crisis.
• General state of weakness G Encourage pursed-lip breathing. Pursed-lip
• Difficulty completing meals due to shortness breathing is placing the lips as if kissing and
of breath taking controlled breaths. A nurse should
teach residents how to do this type of
• Fear and anxiety
breathing.
G Encourage residents to save energy for
Guidelines: important tasks. Encourage residents to rest
Caring for Residents with COPD during tasks.

G Colds or viruses can make residents very ill

quickly. Always observe and report signs of Observing and Reporting:
symptoms getting worse. COPD

G Help residents sit upright or lean forward. Report any of the following to the nurse:
Offer pillows for support (Fig. 18-24).
Temperature over 101°F
Changes in breathing patterns, including
shortness of breath
Changes in color or consistency of lung
secretions
Changes in mental state or personality
Refusal to take medications as ordered
Excessive weight loss
Fig. 18-24. It helps residents with COPD to sit upright
and lean forward slightly. Increasing dependence upon caregivers and
family
G Offer plenty of fluids and small, frequent
meals. Asthma

G Encourage a well-balanced diet. Asthma is a chronic inflammatory disease. It

occurs when the respiratory system is hyper-
G Keep oxygen supply available as ordered. reactive (that is, reacts quickly and strongly) to
G Being unable to breathe or fearing suffoca- irritants, infection, cold air, or to allergens such
tion is very frightening. Be calm, reassuring, as pollen and dust. Exercise and stress can also
and supportive. bring on asthma attacks. The bronchi become
irritated. They constrict, making it difficult to
G Use good infection control, especially with
breathe. As a response to irritation and inflam-
handwashing by the resident and the dispos-
mation, the mucous membrane produces thick
al of used tissues.
mucus. This further inhibits respiration. As
G Encourage as much independence with ADLs a result, air is trapped in the lungs, causing
as possible. coughing and wheezing (Fig. 18-25).
18 330

tasis causes chronic coughing, which produces

thick white or green sputum. A person with this
disorder may have recurrent pneumonia and
weight loss.
Common Chronic and Acute Conditions

Treatment of bronchiectasis includes controlling

infections and preventing complications. Antibi-
otics may be prescribed. Postural drainage may
be ordered to eliminate fluid from the lungs.
Postural drainage involves using different body
positions to drain mucus from the lungs or to
loosen it so that it can be coughed up.

Fig. 18-25. When a person has asthma, air passages in

the lungs become inflamed and swollen. Upper Respiratory Infection (URI)
Upper respiratory infection (URI) is com-
The exact cause of asthma is unknown. It may monly called a cold. It is the result of a bacte-
be caused by a combination of factors, such as rial or viral infection of the nose, sinuses, and
family history and certain environmental ex- throat. Symptoms usually include nasal dis-
posures. Treatment for asthma includes medi- charge, sneezing, sore throat, fever, and fatigue.
cations that are given directly into the lungs For most people, it can be dealt with by the
using sprays or inhalers (Fig. 18-26). Residents body’s immune system with the help of rest and
with asthma should avoid triggers that bring on extra fluids. Antibiotics may be required if the
asthma attacks, such as allergens, smoke, strong infection is bacterial.
odors, and strenuous exercise.
Lung Cancer
Lung cancer is the development of abnormal
cells or tumors in the lungs. Symptoms of lung
cancer include chronic cough, shortness of
breath, and bloody sputum. You will learn more
about cancer and treatment later in the chapter.

Tuberculosis (TB)
Fig. 18-26. People with asthma should carry their inhal-
Tuberculosis (TB) is a highly contagious lung
ers with them at all times.
disease. Symptoms include coughing, low-
grade fever, shortness of breath, weight loss,
Bronchiectasis and fatigue. Chapter 5 includes more informa-
tion about tuberculosis, care guidelines, and
Bronchiectasis is a condition in which the
treatment.
bronchial tubes are abnormally enlarged. A
person may have it in childhood or may acquire For residents with TB, you may need to collect
it later in life as a result of chronic infections a sputum specimen. Sputum is thick mucus
and inflammation. Cystic fibrosis is a common coughed up from the lungs. It is not the same
cause of bronchiectasis. This abnormal state of as saliva, which comes from the mouth. People
the bronchial tubes is permanent. Bronchiec- with colds or respiratory illnesses may cough up
 331 18

large amounts of sputum. Sputum specimens 7. When you have obtained a good sample
may help diagnose respiratory problems, illness, (about two tablespoons of sputum), cover
or evaluate the effects of medication. the container tightly. Wipe any sputum off the
outside of the container with tissues. Discard

Common Chronic and Acute Conditions

Early morning is the best time to collect spu-
the tissues. Put the container in the plastic
tum. The resident should cough up the sputum
bag and seal the bag.
and spit it directly into the specimen container.
Because sputum may be infectious, do not let 8. Remove and dispose of gloves and mask.
the resident cough on you. Standing behind the
9. Wash your hands.
resident during the collection process may pre-
vent sputum from coming into contact with you. 10. Place call light within resident’s reach.
Wear the proper PPE when collecting sputum.
11. Report any changes in resident to the nurse.
The required PPE is gloves and, sometimes, a
mask. Follow Standard Precautions. Make sure 12. Document procedure using facility
that both your hands and the specimen con- guidelines.
tainer are clean before beginning this procedure.

Collecting a sputum specimen 6. Describe common diseases and

Equipment: specimen container and lid with label
disorders of the endocrine system
(labeled with resident’s name, room number, date
and time), tissues, plastic bag, gloves, mask Diabetes
1. Wash your hands. In diabetes mellitus, commonly called diabe-
tes, the pancreas does not produce enough or
2. Identify yourself by name. Identify resident by
properly use insulin. Insulin is a hormone that
name.
converts glucose, or natural sugar, into energy
3. Explain procedure to resident. Speak clearly, for the body. Without insulin to process glucose,
slowly, and directly. Maintain face-to-face con- these sugars collect in the blood. This causes
tact whenever possible. problems with circulation and can damage vital
organs.
4. Provide for resident’s privacy with curtain,
screen, or door. Diabetes is common in people with a family his-
tory of the illness, in the elderly, and in people
5. Put on mask and gloves. If the resident has
who are obese. Two major types of diabetes are:
known or suspected TB or another infec-
tious disease, wear a mask when collecting a 1. Type 1 diabetes is usually diagnosed in chil-
sputum specimen. Coughing is one way TB dren and young adults. It was formerly known as
droplets can enter the air. Stand behind the juvenile diabetes because it most often appears
resident if the resident can hold the speci- before age 20. However, a person can develop
men container by himself. Type 1 diabetes up to age 40. In Type 1 diabetes,
the body does not produce enough insulin. The
6. Ask the resident to cough deeply, so that
condition will continue throughout a person’s
sputum comes up from the lungs. To prevent
life. Type 1 diabetes is treated with insulin and a
the spread of infectious material, give the
special diet.
resident tissues to cover his or her mouth.
Ask the resident to spit the sputum into the 2. Type 2 diabetes, also known as adult-onset
container. diabetes, is the most common form of diabetes.
18 332

In Type 2 diabetes, either the body does not

produce enough insulin, or the body fails to
properly use insulin. This is known as “insulin
resistance.” Type 2 diabetes usually develops
Common Chronic and Acute Conditions

slowly and is the milder form of diabetes. It typi-

cally develops after age 35. The risk of getting Fig. 18-27. Increased thirst, hunger, and urination are all
this type increases with age. However, the num- symptoms of diabetes.
ber of children with Type 2 diabetes is growing
rapidly. Type 2 diabetes often occurs in obese Diabetes can lead to further complications:
people or those with a family history of the dis- • Changes in the circulatory system can cause
ease. Type 2 diabetes can usually be controlled heart attack and stroke, reduced circulation,
with diet and/or oral medications. poor wound healing, and kidney and nerve
Pre-diabetes occurs when a person’s blood damage.
glucose levels are above normal but not high • Damage to the eyes can cause vision loss
enough for a diagnosis of Type 2 diabetes. Re- and blindness.
search indicates that some damage to the body,
• Poor circulation and impaired wound heal-
especially to the heart and circulatory system,
ing may cause leg and foot ulcers, infected
may already be occurring during pre-diabetes.
wounds, and gangrene. Gangrene can lead
Pregnant women who have never had diabetes to amputation.
before but who have high blood sugar (glucose) • Insulin reaction and diabetic ketoacidosis
levels during pregnancy are said to have gesta- can be serious complications of diabetes. See
tional diabetes. Chapter 7 for signs and symptoms of each.
People with diabetes mellitus may have these Diabetes must be carefully controlled to prevent
signs and symptoms (Fig. 18-27): complications and severe illness. When working
with people with diabetes, follow care plan in-
• Excessive thirst
structions carefully.
• Extreme hunger
• Frequent urination Guidelines:
• Weight loss Diabetes

• High levels of blood sugar G Follow diet instructions exactly. The intake of
• Sugar in the urine carbohydrates, including breads, potatoes,
grains, pasta, and sugars, must be regulated.
• Sudden vision changes Meals must be eaten at the same time each
• Tingling or numbness in hands or feet day. The resident must eat all that is served.
If a resident will not eat what is served, or if
• Feeling very tired much of the time
you suspect that he or she is not following
• Very dry skin the diet, tell the nurse. More information on
diabetic diets is found in Chapter 15.
• Sores that are slow to heal
G Encourage the resident to follow his or her
• More infections than usual
exercise program. A regular exercise program
is important. This may include 30 to 60
 333 18

minutes of activity on most days of the week.

Exercise affects how quickly bodies use food.
Exercise also improves circulation. Exercise
may include walking or other active exercise

Common Chronic and Acute Conditions

(Fig. 18-28). It may also include passive
range of motion exercises. Help with exercis-
es as necessary. Be positive and try to make
it fun and appealing.

Fig. 18-28. Exercise is very important for diabetic resi-

dents. It helps to increase circulation and maintain a
healthy weight.
Fig. 18-29. There are different types of equipment to
G Observe the resident’s management of insu- measure glucose levels in the blood. (reprinted with permission of
briggs corporation, 800-247-2343, www.briggscorp.com)
lin. Doses are calculated exactly. They are
given at the same time each day. Nursing
assistants should know when residents take G Perform foot care as directed. Diabetics have
insulin and when their meals should be poor circulation. Because of this, even a
served. There must be a balance between the small sore on the leg or foot can grow into
insulin level and food intake. Unless you have a large wound. It can require amputation.
had special training, you will not inject Careful foot care, including regular, daily
insulin. inspection, is vital. The goals of diabetic foot
care are to check for irritation or sores, to
G Perform urine and blood tests only as direct- promote blood circulation, and to prevent
ed (Fig. 18-29). A fingerstick blood glucose infection (Fig. 18-30).
test is one type of blood test that may be
used to check blood sugar. This is a simple G Encourage diabetics to wear comfortable,
test that is performed by quickly piercing well-fitting leather shoes that do not hurt
the fingertip, then placing the blood on a their feet. Leather shoes breathe and help
chemically active disposable strip. The strip to prevent build-up of moisture. To avoid
will indicate the result. Sometimes the care injuries to the feet, diabetics should never
plan will specify a daily blood or urine test go barefoot. Cotton socks are best to absorb
for insulin levels. Not all states allow you to sweat. You should never trim or clip any resi-
do this. Know your state’s rules. Your facility dent’s toenails, but especially not a diabetic’s
will train you if you need to do these tests. toenails. Only a nurse or doctor should do
Perform tests only as directed and allowed. this.
18 334

washcloth, soft towel, lotion, cotton socks, shoes or

slippers, gloves

Support the foot and ankle throughout

Common Chronic and Acute Conditions

procedure.

1. Wash your hands.

2. Identify yourself by name. Identify resident by

name.

3. Explain procedure to resident. Speak clearly,

Fig. 18-30. Observe the legs and feet carefully when giv- slowly, and directly. Maintain face-to-face con-
ing care. Poor circulation can increase the risk of infection tact whenever possible.
and the loss of toes, feet, or legs to gangrene.
4. Provide for resident’s privacy with curtain,
screen, or door.
Observing and Reporting: 5. Put on gloves.
Diabetes
6. Using the washcloth and soap, wash the feet
Report any of these to the nurse: gently. Rinse with the warm water.

Skin breakdown 7. Pat the feet dry gently, wiping between the
toes.
Change in appetite (person overeating or not
eating enough) 8. Starting at the toes and working up to the
ankles, gently rub lotion into the feet with cir-
Increased thirst
cular strokes. Your goal is to increase circula-
Change in urine output tion, so take several minutes on each foot.
Nausea or vomiting Do not put lotion between the toes.

Weight changes 9. Observe the feet, ankles, and legs for dry
skin, irritation, blisters, redness, sores, corns,
Change in mental status
discoloration, or swelling.
Irritability
10. Help resident put on socks and shoes or
Nervousness or anxiety slippers.
Feeling faint or dizzy 11. Put soiled linens in appropriate container.
Visual changes Pour water into the toilet. Clean and store
basin and supplies.
Change in mobility
12. Remove and dispose of gloves.
Change in sensation
Sweet or fruity breath 13. Wash your hands.

Numbness or tingling in arms or legs 14. Place call light within resident’s reach.

15. Report any changes in resident to the nurse.

Providing foot care for the diabetic resident
16. Document procedure using facility
Equipment: basin of warm water (water tempera- guidelines.
ture should be no more than 105° F), mild soap,
 335 18

Hyperthyroidism Chlamydia infection is caused by organisms

in the mucous membranes of the reproductive
When the thyroid produces too much thyroid
tract. Chlamydia can cause serious infection,
hormone, the cells burn too much food. Weight
including pelvic inflammatory disease (PID) in

Common Chronic and Acute Conditions

loss, nervousness, and hyperactivity occur. This
women. PID can cause sterility. Signs of chla-
condition is called hyperthyroidism. Hyper-
mydia infection are yellow or white discharge
thyroidism is usually treated with medication.
from the penis or vagina and burning with uri-
Occasionally, part of the thyroid is surgically
nation. It is treated with antibiotics.
removed.
Syphilis can be treated effectively in the early
Hypothyroidism stages, but if left untreated, it can cause brain
damage, mental illness, and even death. Babies
When the thyroid produces too little thyroid
born to mothers with syphilis may be born blind
hormone, body processes slow down. Weight
or with other serious birth defects. Syphilis is
gain and physical and mental sluggishness
easier to detect in men than in women. This is
result. This condition is called hypothyroid-
due to open sores called chancres that form on
ism. Hypothyroidism is sometimes treated with
the penis soon after infection.
medication.
The chancres are painless and can go unnoticed.
If untreated, the infection spreads to the heart,
7. Describe common diseases and brain, and other vital organs. Common symp-
disorders of the reproductive system toms at this stage include rash, sore throat, or
fever. When detected, syphilis can be treated
Sexually Transmitted Diseases (STDs) and with penicillin or other antibiotics. The sooner
Infections (STIs) it is treated, the better the chances of prevent-
Sexually transmitted diseases (STDs), also ing long-term damage and avoiding infection of
called venereal diseases, are diseases passed others.
through sexual contact with an infected person. Gonorrhea, like syphilis, can be treated with
This contact includes sexual intercourse, contact antibiotics and is easier to detect in men than
of the mouth with the genitals or anus, and con- in women. If untreated, gonorrhea can cause
tact of the hands to the genitals. A person may sterility in both men and women. Most women
be infected, and may potentially infect others, with gonorrhea show no early symptoms. This
without showing signs of the disease. This is makes it easy for women to spread the disease.
called a sexually transmitted infection (STI). Men with gonorrhea will often show a greenish
Using latex condoms during sexual contact can or yellowish discharge from the penis within a
reduce the chances of being infected with or week after infection. Burning with urination is
passing on some STDs and STIs. The human another common symptom in men.
immunodeficiency virus (HIV), acquired im- Herpes simplex 2, unlike the other STDs dis-
mune deficiency syndrome (AIDS), and some cussed here, is caused by a virus. It cannot be
kinds of hepatitis can be sexually transmitted. treated with antibiotics. Once infected with the
(HIV/AIDS is discussed in detail in the next herpes virus, a person cannot be cured. The per-
learning objective.) STDs are very common. son may have repeated outbreaks of the disease
They can cause serious health problems. Resi- for the rest of his or her life. A herpes outbreak
dents may be unaware of or embarrassed by includes burning, painful, red sores on the geni-
symptoms of an STD. tals. These heal in about two weeks. The sores
18 336

are infectious, but a person with herpes virus discomfort is called a “douche” or a “vaginal ir-
can also spread the infection when sores are not rigation.” After the solution is inserted, it is im-
present. mediately returned out of the vagina.
Common Chronic and Acute Conditions

Some people infected with herpes never have If you are trained to do so, and depending upon
repeated outbreaks. The later episodes may not the rules in your state and at your facility, you
be as painful as the first outbreak. Antiviral may be allowed to assist with or give a douche.
drugs can help people stay symptom-free lon- If trained and allowed to give a douche, follow
ger. Babies born to women infected with herpes these guidelines:
simplex 2 can be infected during birth. Pregnant
women experiencing a herpes outbreak are usu-
Guidelines:
ally delivered by cesarean section, or C-section.
Vaginal Douche
Benign Prostatic Hypertrophy
G Provide plenty of privacy for this procedure.
Benign prostatic hypertrophy is a disorder Pull the curtain and close the door.
that occurs in men as they age. The prostate be-
G Wear gloves while assisting with this proce-
comes enlarged and causes pressure on the ure-
dure.
thra. The pressure leads to frequent urination,
dribbling of urine, and difficulty in starting the G The woman will be placed in the dorsal
flow of urine. Urinary retention (urine remain- recumbent position (Fig. 18-31).
ing in the bladder) may also occur, causing
urinary tract infection. Urine can also back up
into the ureters and kidneys, causing damage to
these organs. Benign prostatic hypertrophy can
be treated with medications or surgery. A test is
also available to screen for cancer of the prostate.
As men age, they are at increased risk for pros-
tate cancer. Prostate cancer is usually slow-grow- Fig. 18-31. The dorsal recumbent position is when the
ing and responsive to treatment if detected early. person is flat on her back with her knees flexed and
slightly separated. The feet are flat on bed.

Vaginitis
G Inspect the nozzle or tip of the douche for
Vaginitis is an infection of the vagina. It may any breaks, cracks, or rough edges before
be caused by a bacteria, protozoa (one-celled ani- use. This helps prevent injury to the vagina.
mals), or fungus (yeast). It may also be caused If you observe any problems with the nozzle,
by hormonal changes after menopause. Women do not use it, and notify the nurse.
who have vaginitis have a white vaginal dis-
G Clean the container, tubing, and nozzle
charge, accompanied by itching and burning.
before using to prevent infection. Reusable
Report these symptoms to the nurse. Treatment
equipment should be washed with hot, soapy
of vaginitis includes oral medications, as well as
water after use.
vaginal gels or creams.
G Follow the care plan’s instructions to make
Douches sure the douche solution is at the right
temperature.
Putting a solution into the vagina in order to
cleanse the vagina, introduce medication to G If using a commercially-prepared douche, fol-
treat an infection or condition, or to relieve low instructions on the package.
 337 18

G Allow some of the solution to run through When the virus weakens the immune system
the tubing to remove air before the tubing is in later stages, a group of problems may appear.
inserted. These include opportunistic infections, tumors,
and central nervous system symptoms. These

Common Chronic and Acute Conditions

G Do not force the nozzle of the douche into
the vagina if you meet resistance. If you are would not occur if the immune system were
unable to insert the nozzle, stop and notify healthy. This stage of the disease is known as
the nurse. AIDS.

G The same amount of douche solution should In the late stages of AIDS, damage to the central
return as was put into the vagina. The solu- nervous system may cause memory loss, poor
tion should be the same color as before it coordination, paralysis, and confusion. These
was inserted. It should be clear with a mild symptoms together are known as AIDS demen-
odor. tia complex.

G Report any of the following to the nurse: The following are signs and symptoms of HIV
infection and AIDS:
• Fatigue
• Appetite loss
• Pain
• Involuntary weight loss of 10 pounds or
• Anything unusual about the returned
more
douche solution: amount; color (pink
or streaked with red); odor; presence of • Vague, flu-like symptoms, including fever,
material, such as mucus or particles cough, weakness, and severe or constant
fatigue
8. Describe common diseases and • Night sweats
disorders of the immune and lymphatic • Swollen lymph nodes in the neck, under-
systems arms, or groin
• Severe diarrhea
HIV and AIDS
• Dry cough
Acquired immune deficiency syndrome, or
AIDS, is an illness caused by the human im- • Skin rashes
munodeficiency virus, or HIV. HIV attacks the • Painful white spots in the mouth or on the
body’s immune system and gradually disables tongue
it. Eventually the HIV-infected person has less
resistance to other infections. Death may be • Cold sores or fever blisters on the lips and
the result of these infections. HIV is a sexually- flat, white ulcers on a reddened base in the
transmitted disease. It is also spread through in- mouth
fected blood, infected needles, or to a fetus from • Cauliflower-like warts (caused by the human
an infected mother. papilloma virus) on the skin and in the
In general, HIV affects the body in stages. The mouth
first stage involves symptoms similar to the flu, • Inflamed and bleeding gums
with fever, muscle aches, cough, and fatigue.
• Low resistance to infection, particularly
These are symptoms of the immune system
pneumonia, but also tuberculosis, herpes,
fighting the infection. As the infection worsens,
bacterial infections, and hepatitis
the immune system overreacts. It attacks not
only the virus, but also normal tissue. • Bruising that does not go away
18 338

• Kaposi’s sarcoma, a rare form of skin can- take six months after contact with the virus
cer that appears as purple or red skin lesions for an HIV test to show positive results.
(Fig. 18-32) Ways to protect against the spread of HIV and
Common Chronic and Acute Conditions

• AIDS dementia complex AIDS include the following:

• Never share needles for injections of any
type of drug.
• Practice safer sex. Use latex condoms during
sexual contact.
• Stay in a monogamous relationship with
a partner who has tested negative for HIV.
Being monogamous means having only one
sexual partner.

Fig. 18-32. A purple or red skin lesion called Kaposi’s

• Practice abstinence. Abstinence means not
sarcoma can be a sign of AIDS. having sexual contact with anyone.
• Get tested if you think you may have been
Opportunistic infections, such as pneumonia, infected with HIV. It can take up to six
tuberculosis, or hepatitis, invade the body when months from the time you are infected for
the immune system is weak and cannot defend the antibodies to be detected in your blood.
itself. These illnesses worsen AIDS. They fur- Get re-tested periodically if necessary. It is
ther weaken the immune system. It is difficult especially important that pregnant women
to treat these infections. Generally, over time, a get tested.
person develops a resistance to some antibiot-
• Follow Standard Precautions at work to pro-
ics. These infections often cause death in people
tect yourself.
with AIDS.
People with HIV are treated with drugs that Residents’ Rights
slow the progress of the disease but do not Handshakes and Hugs
cure it. The medicines must be taken at precise Understanding the facts about HIV/AIDS is impor-
times. They have many unpleasant side effects. tant. This will help you not to feel afraid of a person
with this disease. A handshake or a hug cannot
For some people, the medications work less well spread the AIDS virus. The disease cannot be trans-
than for others. Other aspects of HIV treatment mitted by telephones, doorknobs, tables, chairs, toi-
are relief of symptoms and prevention and treat- lets, mosquitoes, or by breathing the same air as an
ment of infection. infected person. Spend time with residents who have
HIV/AIDS. They need the same thoughtful, personal
Behaviors that put people at high risk for HIV/ attention you give to all your residents.
AIDS infection include the following:
• Sharing drug needles Guidelines:
• Having unprotected sex (not using latex con- HIV/AIDS
doms during sexual contact)
G People with poor immune systems are more
• Sexual contact with many partners sensitive to infections. Wash your hands
• Any sexual activity that involves exchange often. Follow Standard Precautions. Keep
of body fluids with a partner who has not everything clean.
tested negative for HIV or who has had G Involuntary weight loss occurs in almost
many sexual partners. Be aware that it may all people who develop AIDS. High-protein,
 339 18

high-calorie, and high-nutrient meals can kets cause pain, a bed cradle can keep sheets
help maintain a healthy weight. and blankets from resting on legs and feet
G Some people with HIV/AIDS lose their (Fig. 18-33).

Common Chronic and Acute Conditions

appetites and have difficulty eating. These
residents should be encouraged to relax
before meals and to eat in a pleasant setting.
Familiar and favorite foods should be served.
Report appetite loss or difficulty eating to the
nurse. If appetite loss continues to be a prob-
lem, the doctor may prescribe an appetite
stimulant.
G Residents with infections of the mouth may
need food that is low in acid and neither
Fig. 18-33. A bed cradle help keep covers from resting on
cold nor hot. Spicy seasonings should not
the feet.
be used. Soft or pureed foods may be easier
to swallow. Liquid meals and fortified drinks G Residents with HIV/AIDS may have anxiety
may help ease the pain of chewing. Warm and depression. They often suffer the judg-
salt water or other rinses may ease the pain ments of family, friends, and society. Some
of mouth sores. Good mouth care is vital. people blame them for their illness. People
G Someone who has nausea or vomiting with HIV/AIDS may have tremendous stress.
should eat small, frequent meals, if possible. They may feel uncertainty about their illness,
The person should eat slowly. The person health care, and finances. They may also have
should avoid high-fat and spicy foods, and lost people in their social support network
eat a soft, bland diet. When nausea and vom- of friends and family. Residents with this
iting persist, liquids and salty foods should disease need support from others. This may
be encouraged. Residents should eat small, come from family, friends, religious and com-
frequent meals and drink fluids in between munity groups, and support groups, as well
meals. Care must be taken to maintain prop- as the care team. Treat all your residents with
er intake of fluids. respect. Help give the emotional support
G Residents with mild diarrhea may need fre- they need.
quent small meals that are low in fat, fiber, G Withdrawal, apathy, avoidance of tasks, and
and milk products. If diarrhea is severe, the mental slowness are early symptoms of HIV
doctor may order a “BRAT” diet (a diet of infection. Medications may also cause side
bananas, rice, apples, and toast). This diet is effects of this type. AIDS dementia complex
helpful for short-term use. may cause further mental symptoms. There
G Diarrhea rapidly depletes the body of fluids. may also be muscle weakness and loss of
Fluid replacement is necessary. Good re- muscle control, making falls a risk. Residents
hydration fluids include water, juice, soda, will need a safe environment and close
and broth. Caffeinated drinks should be supervision in their ADLs.
avoided. The right to confidentiality is especially impor-
G Neuropathy, or numbness, tingling, and tant to people with HIV/AIDS. Others may pass
pain in the feet and legs is usually treated judgment on people with this disease. A person
with medication. Going barefoot or wearing with HIV/AIDS cannot be fired because of the
loose, soft slippers may be helpful. If blan- disease. However, a healthcare worker with
18 340

HIV/AIDS may be reassigned to job duties with There is no known cure for cancer, but some
a lower risk of transmitting the disease. treatments are effective. They are discussed later
in the chapter.
HIV testing requires consent. This means no
Common Chronic and Acute Conditions

one can test you for HIV unless you agree. Risk factors for cancer include the following:
HIV test results are confidential. They cannot • Tobacco use
be shared with a person’s family, friends, or
• Exposure to sunlight (Fig. 18-34)
employer without his or her consent. If you are
HIV-positive, you might want to tell your super- • Excessive alcohol use
visor. Your tasks can be adjusted to avoid putting • Exposure to some chemicals and industrial
you at high risk for exposure to other infections. agents
Everyone has a right to privacy about his or her
• Some food additives
health status. Never discuss a resident’s status
with anyone. • Radiation
• Poor nutrition
Home Care Focus
• Lack of physical activity
When working in the home, it is extremely important
to carefully follow guidelines for safe food prepa-
ration and storage when working with a resident
who has HIV/AIDS. Food-borne illnesses caused
by improperly cooking or storing food can cause
death for someone with HIV/AIDS. (See Chapter 28
for safe food handling practices.) Wash your hands
frequently. Keep everything clean, especially coun-
tertops, cutting boards, and knives after they have
been used to cut meat. Thaw food in the refrigerator,
and wash and cook foods thoroughly. When storing
food, keep cold foods cold and hot foods hot. Use
small containers that seal tightly. Check expiration
Fig. 18-34. Prolonged sun exposure puts a person at risk
dates, and remember “when in doubt, throw it out.”
for skin cancer.

Cancer When diagnosed early, cancer can often be

Cancer is a general term used to describe many treated and controlled. The American Cancer
types of malignant tumors. A tumor is a group Society has identified some warning signs of
of abnormally growing cells. Benign tumors are cancer:
considered non-cancerous. They usually grow • Unexplained weight loss
slowly in local areas. Malignant tumors are • Fever
cancerous. They grow rapidly and invade sur-
• Fatigue
rounding tissues.
• Pain
Cancer invades local tissue, and can spread to
other parts of the body. When it spreads from • Skin changes
the site where it first appeared, it can affect • Change in bowel or bladder habits
other body systems. In general, treatment is • Sores that do not heal
more difficult and cancer is more deadly after
this has occurred. Cancer often appears first in • Unusual bleeding or discharge
the breast, colon, rectum, uterus, prostate, lungs, • Thickening or lump in the breast or other
or skin. part of the body
 341 18

• Indigestion or difficulty swallowing

Guidelines:
• Recent change in a wart or mole Cancer
• Nagging cough or hoarseness

Common Chronic and Acute Conditions

G Each case is different. Cancer is a general
People with cancer can live longer and some- term. It refers to many separate situations.
times recover if they are treated early. Often Residents may live many years or only several
these treatments are combined. months. Treatment affects each person dif-
Surgery is the first line of defense against most ferently. Do not make assumptions about a
forms of cancer. It is the key treatment for resident’s condition.
malignant tumors of the skin, breast, bladder, G Residents may want to talk or may avoid talk-
colon, rectum, stomach, and muscle. Surgeons ing. Respect each resident’s needs. Listen if a
remove as much of the tumor as they can to resident wants to share feelings or experienc-
keep cancer from spreading. es with you. However, never push a resident
Chemotherapy refers to medications given to to talk. Be honest. Never say, “Everything will
fight cancer. Some drugs destroy cancer cells be okay.” Be sensitive. Remember that cancer
and limit the rate of cell growth. However, many is a disease, and we do not know its cause.
of these drugs are toxic to the body. They kill Have a positive attitude. Focus on concrete
healthy cells as well as cancer cells. Chemother- details; for example, comment if a resident
apy can have severe side effects, including nau- seems stronger, or mention that the sun is
sea, vomiting, diarrhea, hair loss, and decreased shining outside.
resistance to infection. G Good nutrition is important for residents
Radiation therapy directs radiation to a limited with cancer. Follow the care plan carefully.
area to kill cancer cells. However, other normal Residents frequently have poor appetites.
or healthy cells in its path are also destroyed Encourage a variety of nutritious foods.
(Fig. 18-35). By controlling cell growth, radiation Liquid nutrition supplements may be used in
can reduce pain. Radiation can cause the same addition to, not in place of, meals. If nausea
side effects as chemotherapy. The skin of the or swallowing is a problem, foods such as
area that is exposed to radiation may become soups, gelatin, or starches may appeal to the
sore, irritated, and sometimes burned. resident. Use plastic utensils for a resident
receiving chemotherapy. It makes food taste
better. Silver utensils cause a bitter taste.
G Cancer can cause great pain, especially in
the late stages. Watch for signs of pain.
Report them to the nurse. Help with comfort
measures, such as repositioning and provid-
ing conversation, music, or reading materi-
als (Fig. 18-36). Report if pain seems to be
uncontrolled.
G Offer back rubs to provide comfort and
increase circulation. For residents who spend
many hours in bed, moving to a chair for
some period of time may improve comfort as
Fig. 18-35. Radiation is targeted at cancer cells, but it well. Residents who are very weak or immo-
also destroys some healthy cells in its path. bile need to be repositioned every two hours.
18 342

ics. Get to know what interests your residents

have. As always, report any signs of depres-
sion immediately.
Common Chronic and Acute Conditions

G If visitors help cheer your resident, encourage

them. Do not intrude. If some times of day
are better than others, suggest this. Support
groups exist for people with cancer. Check
with the nurse for groups in your area.
G Having a family member with cancer can be
very difficult. Be alert to needs that are not
Fig. 18-36. Distractions such as conversation can help a being met or stresses created by the illness.
resident with cancer deal with pain.

G Use lotion regularly on dry or delicate skin. Observing and Reporting:

Do not apply lotion to areas receiving radia- Cancer
tion therapy. Do not remove any markings
that are used in radiation therapy. Follow any Report any of these to the nurse:
special skin care orders (for example: no hot Increased weakness or fatigue
or cold packs, no soap or cosmetics, no tight
stockings). Weight loss

G Help residents brush and floss teeth regular- Nausea, vomiting, or diarrhea
ly. Medications, nausea, vomiting, or mouth Changes in appetite
infections may cause pain and a bad taste in
Fainting
the mouth. You can help ease discomfort by
using a soft-bristled toothbrush, rinsing with Signs of depression (see Chapter 20)
baking soda and water, or using a prescribed Confusion
rinse. Do not use a commercial mouthwash
if it has alcohol in it. Alcohol can further irri- Blood in stool or urine
tate a resident’s mouth. For residents with Change in mental status
mouth sores, using oral swabs, rather than
Changes in skin
toothbrushes, may be preferable. The swabs
can be dipped in a rinse and gently wiped New lumps, sores, or rashes
across the gums. Mouth sores can make oral Increase in pain, or unrelieved pain
care very painful; be very gentle when giving
residents oral care. Mastectomy
G People with cancer may have a low self-image A mastectomy is the surgical removal of all or part
because they are weak and their appear- of the breast and sometimes other surrounding tis-
ance has changed. For example, hair loss is sue. This operation is usually performed because
of a tumor. After a mastectomy, the care plan may
a common side effect of chemotherapy. Be include arm exercises for the side of the body on
sensitive. Provide help with grooming if it is which the surgery was performed. The goal of arm
desired. Your concern and interest can help exercises is to strengthen the arm and chest mus-
improve self-image. cles and reduce swelling in the arm and underarm.
Exercises may include raising the arm, opening and
G It may help a person with cancer to think of closing the hand, and bending and straightening the
something else for a while. Pursue other top- elbow. The resident should wear loose, comfortable
 343 18

2. What are signs and symptoms of scabies?

clothing while doing any arm exercises. Follow the
care plan and the nurse’s instructions regarding How is scabies spread?
care after a mastectomy. Instructions may include
3. What causes shingles?
keeping the arm on the affected side raised on pil-

Common Chronic and Acute Conditions

lows to decrease swelling. The resident may use a 4. Briefly define these categories of open
sling to keep the arm elevated. In addition, deep
wounds: incisions, lacerations, abrasions,
breathing exercises may be ordered.
and puncture wounds.
5. What is dermatitis and how does it generally
9. Identify community resources for look?
residents who are ill
6. What can cause fungal infections?
Numerous services and support groups are avail- 7. What causes arthritis?
able for people who are ill and their families
8. What health problems can anti-inflammatory
or caregivers. These resources can help them
medications cause?
through difficult times and help solve problems.
Social service agencies, hospitals, hospice pro- 9. What can happen to bones when they are
grams, churches, and synagogues offer many brittle?
resources. These include meal services, trans-
10. What can a nursing assistant do to prevent
portation to doctors’ offices or hospitals, coun-
or slow osteoporosis?
seling, and support groups.
11. Why should casts not be covered until they
For cancer, visit the American Cancer Society are dry?
online at cancer.org, or call the local or state
chapter. The National Association of Area Agen- 12. What type of surface can a cast be placed on?
cies on Aging, n4a.org, operates the Eldercare 13. Why should extremities in casts be elevated?
Locator, which is a free national service that
14. Why is a hip fracture a serious condition for
links older adults and caregivers to aging infor-
an elderly person?
mation and resources in their own communities.
15. A person recovering from a hip replacement
Depending on the community, many resources
should not sit at an angle less than how
and services may be available for people with
many degrees?
HIV/AIDS. These may include counseling, meal
services, access to experimental drugs, and any 16. When dressing a person who has just had
number of other services. Look in the phone a hip replacement, which side should be
book or on the Internet for resources available in dressed first: the affected/weaker side or the
your area. Speak to the nurse if you feel a resi- unaffected/stronger side?
dent with HIV/AIDS needs more help. A social 17. Which of the following medical orders mean
worker or another member of the care team may that a person can bear some weight on one
be able to coordinate services for residents with or both legs: partial weight bearing (PWB),
HIV/AIDS. non-weight bearing (NWB), or full weight
bearing (FWB)?
Chapter Review 18. How can traction help fractured bones?

1. What is an acute illness? What is a chronic 19. List reasons that knee replacements are
illness? performed.
18 344

20. List three physical problems that muscular 38. What are some effects of having chronic ob-
dystrophy can cause. structive pulmonary disease (COPD)?
21. What is phantom sensation? Is it real? 39. List four care guidelines for a resident who
Common Chronic and Acute Conditions

22. What is complementary medicine? What is has COPD.

alternative medicine? 40. What are two causes of emphysema?
23. What causes a CVA (stroke)? 41. How is asthma treated?
24. What terms should an NA use to refer to 42. How is bronchiectasis treated?
the weaker side of a person who has had a
43. What is sputum?
stroke?
44. When is the best time of day to collect a spu-
25. When helping a resident who has had a
tum specimen?
stroke with transfers or walking, on which
side should an NA stand—the weaker or 45. Briefly describe the two major types of
stronger? diabetes.
26. When dressing a resident with a one-sided 46. Why is good foot care especially important
weakness, which side should an NA dress for a resident with diabetes?
first?
47. List eight signs or symptoms of diabetes that
27. In which side of the mouth should food a nursing assistant needs to report.
be placed if a resident has a one-sided
48. What two things are true of a diabetic resi-
weakness?
dent’s diet?
28. Why may people with Parkinson’s disease
49. What are three types of sexual contact that
have trouble eating and bathing themselves?
can transmit STDs and STIs?
29. List six care guidelines for a person with
50. Why are antibiotics not used to treat herpes
multiple sclerosis.
simplex 2?
30. List 10 care guidelines for a person with a
head or spinal cord injury. 51. What are three signs and symptoms that
should be reported when giving a douche?
31. What should a nursing assistant NOT do
when a resident is having a seizure? 52. How is HIV spread?

32. What is hypertension? What does prehyper- 53. List four ways to protect against the spread
tension mean? of HIV/AIDS.

33. List two care guidelines for a resident who 54. Because people who have HIV/AIDS are sen-
has high blood pressure. sitive to infections, what should the nursing
assistant do?
34. List three care guidelines for a resident with
angina pectoris. 55. Is it possible to get AIDS by breathing the
same air as an infected person?
35. List two care guidelines for a resident recov-
ering from a myocardial infarction. 56. What are some things that should be done
when a person with HIV/AIDS loses his or
36. List seven care guidelines for a resident who
her appetite and has difficulty eating?
has congestive heart failure.
57. What is a tumor? Which kind of tumor is
37. What are two ways that elastic stockings can
considered non-cancerous? Which kind is
benefit a person?
considered cancerous?
 345 18

58. List the risk factors for cancer.

59. What are the side effects of chemotherapy
and radiation?

Common Chronic and Acute Conditions

60. For each of these topics in the care guide-
lines for a resident with cancer, list one way
that a nursing assistant can help: individual-
ity of each case; communication; nutrition;
pain control; comfort; skin care; oral care;
and self-image.
61. List ten signs and symptoms that a nursing
assistant should observe and report about
cancer.
19 346

19
Confusion, Dementia, and Alzheimer’s Disease

Confusion, Dementia, and

Alzheimer’s Disease
1. Describe normal changes of aging in when a person is in the hospital. Some causes of
the brain confusion include the following:
• Low blood sugar
As we age, we may lose some of our ability to
think logically and quickly. This ability is called • Head trauma or head injury
cognition. When we lose some of this ability we
• Dehydration
are said to have cognitive impairment. How
much ability is lost depends on the individual. • Nutritional problems
Cognitive impairment affects concentration and • Fever
memory. Elderly residents may lose their memo-
ries of recent events, which can be frustrating • Sudden drop in body temperature
for them. You can help by encouraging them to • Lack of oxygen
make lists of things to remember and writing
• Medications
down names, events and phone numbers.
• Infections
Other normal changes of aging in the brain in-
clude slower reaction time, difficulty finding or • Brain tumor
using the right words, and sleeping less.
• Illness
• Loss of sleep
2. Discuss confusion and delirium
• Seizures
Confusion is the inability to think clearly. A
confused person has trouble focusing his at-
Guidelines:
tention and may feel disoriented. Confusion
Confusion
interferes with the ability to make decisions. Per-
sonality may change. The person may not know
G Do not leave a confused resident alone.
his name, the date, other people, or where he is.
A confused person may be angry, depressed, or G Stay calm. Provide a quiet environment.
irritable. G Speak in a lower tone of voice. Speak clearly
Confusion may come on suddenly or gradually and slowly.
and can be temporary or permanent. Confusion G Introduce yourself each time you see the
is more common in the elderly. It may occur resident.
 347 19

G Remind the resident of his or her location,

and speak clearly in simple sentences. Use facial
name, and the date. A calendar can help. expressions and body language to aid in understand-
G Explain what you are going to do, using sim- ing. Reduce distractions in the environment by tak-
ing action, such as turning down the TV. Be gentle

Confusion, Dementia, and Alzheimer’s Disease

ple instructions.
and try to decrease fears.
G Do not rush the resident.
G Talk to confused residents about plans for 3. Describe dementia and define related
the day. Keeping a routine may help.
terms
G Encourage the use of glasses and hearing
Dementia is a general term that refers to a seri-
aids. Make sure they are clean and are not
ous loss of mental abilities such as thinking, re-
damaged.
membering, reasoning, and communicating. As
G Promote self-care and independence. dementia advances, these losses make it difficult
G Report observations to the nurse. to perform ADLs such as eating, bathing, dress-
ing, and toileting. Dementia is not a normal part
Delirium is a state of severe confusion that oc-
of aging (Fig. 19-1).
curs suddenly; it is usually temporary. Possible
causes include infections, disease, fluid imbal-
ances, and poor nutrition. Drugs and alcohol
may also cause delirium. Symptoms include the
following:
• Agitation
• Anger
• Depression
• Irritability
• Disorientation
• Trouble focusing
• Problems with speech
• Changes in sensation and perception
• Changes in consciousness
• Decrease in short-term memory Fig. 19-1. Some loss of cognitive ability is normal; how-
ever, dementia is not a normal part of aging.
Report these signs to the nurse. The goal of
treatment is to control or reverse the cause. Here are some terms that are related to
Emergency care may be needed, as well as a stay dementia:
in a hospital.
Progressive: Once they begin, progressive dis-
Tip eases advance. They tend to spread to other parts
of the body and affect many body functions.
Confusion and Delirium
When communicating with a person who is con- Degenerative: Degenerative diseases get con-
fused or disoriented, keep your voice low. Do not tinually worse. They eventually cause a break-
raise your voice or shout. Use the person’s name,
down of body systems. They cause a greater and
19 348

greater loss of mental and physical health and nerve fibers and protein deposits to form in the
abilities. Degenerative diseases can cause death. brain. They eventually cause dementia. There
is no known cause of AD, and there is no cure.
Onset: The onset of a disease is the time the
Diagnosis is difficult, involving many physical
Confusion, Dementia, and Alzheimer’s Disease

signs and symptoms begin.

and mental tests to rule out other causes. How-
Irreversible: An irreversible disease or condi- ever, the only sure way to determine AD at this
tion cannot be cured. Someone with irreversible time is by autopsy. The length time it takes AD
dementia (like Alzheimer’s) will either die from to progress from onset to death varies greatly. It
the disease or die with the disease. may take anywhere from three to 20 years.
The following are a few of the common causes Symptoms of AD appear gradually and gener-
of dementia: ally begin with memory loss. As the disease
• Alzheimer’s disease progresses the symptoms get worse. People with
• Multi-infarct or vascular dementia (a series AD may get disoriented. They may be confused
of strokes causing damage to the brain) about time and place. Communication prob-
lems are common, and the ability to read, write,
• Lewy body dementia
speak, or understand may be lost. Mood swings
• Parkinson’s disease occur and behavior changes. Aggressiveness,
• Huntington’s disease wandering, and withdrawal are all part of AD.
AD progresses to complete loss of all ability to
A diagnosis of dementia involves getting a pa-
care for oneself. The person eventually requires
tient’s medical history and having a physical ex-
constant care.
amination, as well as a neurological exam. Blood
tests and imaging tests (CT or MRI scan, for Each person with Alzheimer’s disease will show
example), may be ordered. Electroencephalogra- different signs at different times. For example,
phy (EEG), a test using electrodes on the scalp to one resident with Alzheimer’s may be able to
trace brain wave activity, may be performed. Di- read, but cannot use the phone or recall her ad-
agnosis is a process of ruling out other possible dress. Another may have lost the ability to read,
diseases that mimic symptoms of dementia. but can still do simple math. Skills a person
has used often over a lifetime are usually kept
longer. Thus some people with Alzheimer’s can
4. Describe Alzheimer’s disease and play an instrument with some help long after
identify its stages they have lost much of their memory (Fig. 19-2).
Alzheimer’s disease (AD) is the most com-
mon cause of dementia in the elderly. The Al-
zheimer’s Association (alzheimers.org) estimates
that as many as 5.2 million people in the U.S.
are living with Alzheimer’s, and one in eight
persons age 65 and over has Alzheimer’s dis-
ease. Women are more likely than men to have
Alzheimer’s disease and dementia. The risk of
getting AD increases with age, but it is not a
normal part of aging.
Alzheimer’s disease is a progressive, degenera- Fig. 19-2. Even when a person loses much of her mem-
tive, and irreversible disease. AD causes tangled ory, she may still keep skills she has used her whole life.
 349 19

Encourage residents with AD to do ADLs. Help Stage II

them keep their minds and bodies as active as
• Increased memory loss, may forget family
possible. Working, socializing, reading, problem
members and friends
solving, and exercising should all be encour-

Confusion, Dementia, and Alzheimer’s Disease

aged (Fig. 19-3). Having residents with AD do as • Slurred speech
much as possible for themselves may even help • Difficulty finding right word, finishing
slow the progression of the disease. Look for thoughts, or following directions
tasks that are challenging but not frustrating.
• Tendency to make statements that are
Help your residents succeed in doing them.
illogical
• Inability to read, write, or do math
• Inability to care for self or perform ADLs
without assistance
• Incontinence
• Dulled senses (for example, cannot distin-
guish between hot and cold)
• Restlessness, wandering, and/or agitation
(increase of these in the evening is called
“sundowning”)
• Sleep problems
Fig. 19-3. Encourage reading and thinking activities for • Lack of impulse control (for example, swears
residents with AD.
excessively or is sexually aggressive or rude)
Alzheimer’s disease generally progresses in • Obsessive repetition of movements, words,
three stages: or behavior
Stage I • Temper tantrums
• Recent (short-term) memory loss • Hallucinations or delusions
• Disorientation to time Stage III
• Lack of interest in doing things, including • Total disorientation to time, place, and
work, dressing, recreation person
• Inability to concentrate • Apathy
• Mood swings • Total dependence on others for care
• Irritability • Total incontinence
• Petulance, or peevish, ill-humored, and rude • Inability to speak or communicate, except
behavior for grunting, groaning, or screaming
• Tendency to blame others • Total immobility/confined to bed
• Carelessness in personal habits • Inability to recognize family or self
• Poor judgment • Increased sleep disturbances
19 350

• Difficulty swallowing, which produces risk of

choking
• Seizures
Confusion, Dementia, and Alzheimer’s Disease

• Coma
• Death

5. Identify personal attitudes helpful in

caring for residents with Alzheimer’s
disease
These attitudes will help you give the best pos- Fig. 19-4. Treat each resident with AD as an individual.
sible care to your residents with AD: They will not have the same symptoms at the same time;
work with symptoms you see.
Do not take things personally. Alzheimer’s dis-
ease is a devastating mental and physical disor- Work as a team. Always report and document
der. It affects everyone who surrounds and cares your observations. Symptoms and behavior
for the one with AD. People with Alzheimer’s change daily. Observing and reporting carefully
disease do not have control over their words and to all team members, as well as listening to
actions. They may often be unaware of what they others’ reports, can help the team to develop so-
say or do. If a resident with Alzheimer’s does not lutions. For example, a resident with AD may re-
know you, does not do what you say, ignores you, fuse to eat her meals. You might discover that if
accuses you, or insults you, remember that it is you sit next to her and eat something while she
the disease acting, not the person. has food in front of her, she will also eat. You
may also notice that she always eats her bite-
Put yourself in their shoes. Think about what it
sized sandwiches. This is important to report to
would be like to have Alzheimer’s disease. Imag-
the team, and can help the team provide better
ine being unable to do ADLs and being depen-
nutrition for the resident. You are in a great posi-
dent on others for care. Think how frustrating it
tion to give details about your residents. Being
would be to have no memory of recent events or
with residents often allows you be an expert on
to be unable find words for what you want to say.
each case. Make the most of this opportunity.
Assume that people with AD have insight and
Residents with AD may not be able to recognize
are aware of the changes in their abilities. Treat
or distinguish between aides, nurses, or admin-
residents with AD with dignity and respect.
istrators. Be prepared to help when needed.
Work with the symptoms and behaviors you see.
Take care of yourself. Caring for someone with
Each person with Alzheimer’s disease is an in-
dementia can be both physically and emotionally
dividual. People with AD will not all show the
exhausting, as well as incredibly stressful. Take
same symptoms at the same times (Fig. 19-4).
care of yourself so you can continue giving the
Each resident will do some things that others
best care (Fig. 19-5). Be aware of your body’s sig-
will never do. The best plan is to work with what
nals to slow down, rest, or eat better. Your feel-
you see each day. For example, an Alzheimer’s
ings are real; you have a right to them. Use your
resident may want to go for a walk one day,
mistakes as learning experiences. Unmanaged
when the day before he did not want to go to the
stress can cause physical and emotional prob-
bathroom without help. If it is allowed, try to go
lems. Talk to your supervisor if you need help
for a walk with him. Notice and report changes
addressing stress or would like to find support
in behavior, mood, and independence.
 351 19

groups in your area. See Chapter 31 for more in- • Always approach from the front, and do not
formation on handling stress. startle the resident.
• Determine how close the resident wants you

Confusion, Dementia, and Alzheimer’s Disease

to be.
• If possible, communicate in a calm place
with little background noise and distraction.
• Always identify yourself, and use the resi-
dent’s name.
• Speak slowly, using a lower tone of voice
than normal. This is calming and easier to
understand.
In addition, communication with residents with
AD can be helped by using these techniques for
specific situations:
If the resident is frightened or anxious:
• Try to keep him or her calm. Speak slowly
in a low, calm voice. Find a room with little
background noise and distraction. Get rid of
noise and distractions, such as televisions or
radios (Fig. 19-6).

Fig. 19-5. Regular exercise is an important part of taking

care of yourself.

Work with family members. Family members

can be a wonderful resource. They can help you
learn more about your resident. They also give
stability and comfort to the resident with Al-
zheimer’s. Build relationships with family mem-
bers. Keep the lines of communication open.
Remember the goals of the care plan. Along with Fig. 19-6. Try to find a room with little background noise
practical tasks you will perform, the care plan and distraction when communicating with residents with
AD.
will also call for maintaining residents’ dignity
and self-esteem. Help them to be independent.
• Try to see and hear yourself as they might.
Always describe what you are going to do.
6. List strategies for better • Use simple words and short sentences. If
communication with residents with doing a procedure or helping with self-care,
Alzheimer’s disease list steps one at a time.
Some general communication guidelines for • Check your body language. Make sure you
residents with AD include the following: are not tense or hurried.
19 352

If the resident forgets or shows memory loss: • Use short words and sentences, and allow
• Repeat yourself. Use the same words if you time to answer.
need to repeat an instruction or question. • Note the communication methods that are
Confusion, Dementia, and Alzheimer’s Disease

However, you may be using a word the resi- effective. Use them.
dent does not understand, such as “tired.” • Watch for nonverbal cues as the ability to
Try other words like “nap,” “lie down,” talk lessens. Observe body language—eyes,
“rest,” etc. hands, and face.
• Repetition can also be soothing for a resi- • Use signs, pictures, gestures, or written
dent with Alzheimer’s. Many residents with words. Use pictures, such as a drawing of a
AD will repeat words, phrases, questions, or toilet on the bathroom door. Use gestures,
actions. This is called perseveration. If your such as holding up a shirt when you want
resident perseverates, do not try to stop him. to help your resident dress. Combine verbal
Answer his questions, using the same words and nonverbal communication. For example,
each time, until he stops. saying “Let’s get dressed now,” as you hold
• Keep messages simple. Break complex tasks up clothes.
into smaller, simpler ones. If the resident wants to say something but
If the resident has trouble finding words or cannot:
names: • Ask him or her to point, gesture, or act it
• Suggest a word that sounds correct. If this out.
upsets the resident, learn from it. Try not • If the resident is upset but cannot explain
to correct a resident who uses an incorrect why, offer comfort with a hug or a smile, or
word. As words (written and spoken) be- try to distract. Verbal communication may be
come more difficult, smiling, touching, and frustrating.
hugging can help show love and concern
If the resident does not remember how to per-
(Fig. 19-7). Remember, however, that some
form basic tasks:
people find touch frightening or unwelcome.
• Break each activity into simple steps. For in-
stance, “Let’s go for a walk. Stand up. Put on
your sweater. First the right arm...” Always
encourage the person to do what he can.
If the resident insists on doing something that is
unsafe or not allowed:
• Try to limit the times you say “don’t.” In-
stead, redirect activities toward something
else.
If the resident hallucinates (sees or hears things
Fig. 19-7. Touch, smiles, hugs, and laughter will be un- that are not really happening), is paranoid or
derstood longer, even after a resident’s speaking abilities
accusing:
decline.
• Do not take it personally.
If the resident seems not to understand basic in-
• Try to redirect behavior or ignore it. Atten-
structions or questions:
tion span is limited. This behavior often
• Ask the resident to repeat your words. passes quickly.
 353 19

If the resident is depressed or lonely: • Assume people with AD can understand

more than they can express. Never talk about
• Take time, one-on-one, to ask how he or she
them as though they were not there.
is feeling. Really listen.

Confusion, Dementia, and Alzheimer’s Disease

• Try to involve the resident in activities.
7. Explain general principles that will help
• Always report signs of depression to the assist residents with personal care
nurse. You will learn more about depression
Use the same procedures for personal care and
in Chapter 20.
ADLs for residents with Alzheimer’s disease as
If the resident is verbally abusive, or uses bad you would with other residents. However, there
language: are some guidelines to keep in mind when as-
• Remember it is the dementia speaking and sisting these residents. Three general principles
not the person. Try to ignore the language, will help you give the best care:
and redirect attention to something else 1. Develop a routine and stick to it. Being con-
(Fig. 19-8). sistent is important for residents who are
confused and easily upset.
2. Promote self-care. Help your residents to
care for themselves as much as possible.
This will help them cope with this difficult
disease.
3. Take good care of yourself, both mentally
and physically. This will help you give the
best care.

8. List and describe interventions for

Fig. 19-8. If a resident with AD says something abusive or problems with common activities of daily
uses bad language, try to ignore it and redirect interest. living (ADLs)
Remember that it is the disease talking.
As Alzheimer’s disease worsens, residents will
If the resident has lost most verbal skills: have trouble doing their ADLs. By knowing in-
terventions, you can provide better care. An in-
• Use nonverbal skills. As speaking abilities
tervention means a way to change an action or
decline, people with AD will still understand
development.
touch, smiles, and laughter for much longer.
Remember that some people do not like to
Problems with Incontinence
be touched. Approach touching slowly. Be
gentle. Softly touch the hand or place your • Encourage fluids. Never withhold or discour-
arm around the resident. A hug or a kiss on age fluids because a resident is incontinent.
the hand or cheek can show affection and If you notice the resident is not drinking flu-
caring. A smile can say you want to help. ids, tell the nurse.

• Even after verbal skills are lost, signs, la- • Note when the resident is incontinent over
bels, and gestures can reach people with two to three days. Check him or her every
dementia. 30 minutes. This can help determine “bath-
19 354

room times.” Take the resident to the bath-

room just before his or her “bathroom time.”
• Take the resident to the bathroom before and
Confusion, Dementia, and Alzheimer’s Disease

after meals and just before bed.

• Make sure the resident actually urinates be-
fore getting off the toilet.
• Mark the restroom with a sign or a picture.
This is a reminder of where it is and to use
it.
• Family or friends may be upset by their
loved one’s incontinence. Be matter-of-fact Fig. 19-9. When a resident has AD, she may be fright-
about cleaning after episodes of inconti- ened or not understand what you are trying to do. Stay
calm. Gently explain what you are trying to do.
nence. Do not show any disgust or irritation.
• For incontinence during the night, observe • Give the resident a washcloth to hold. This
toilet patterns for two to three nights to try can distract him or her while you finish the
to determine nighttime bathroom times. bath.
• Make sure there is enough light in the bath- • Be safe. Always follow safety precautions.
room and on the way there. Ensure safety by using non-slip mats, tub
seats, and hand-holds.
• Put lids on trash cans, waste baskets, or
other containers if the resident urinates in • Be flexible about when you bathe. Your resi-
them. dent may not always be in the mood. Also,
be aware that not everyone bathes with the
Problems with Bathing same frequency. Understand if your resident
does not want to bathe.
• Schedule bathing when the resident is least
agitated. Be organized so the bath can be • Be relaxed. Allow the resident to enjoy the
quick. Give sponge baths if the resident re- bath. Offer encouragement and praise.
sists a shower or tub bath. • Let the resident do as much as possible dur-
• Prepare the resident before bathing. Hand ing the bath.
him or her the supplies (washcloth, soap, • While bathing, check the skin regularly for
shampoo, towels). This serves as a visual aid. signs of irritation.
• Take a walk with the resident down the hall.
Stop at the tub or shower room, rather than Problems with Dressing
asking directly about the bath. • Show the resident clothing to put on. This
• Make sure the bathroom is well-lit and is at a brings up the idea of dressing.
comfortable temperature. • Avoid delays or interruptions while dressing.
• Provide privacy during the bath. • Provide privacy. Close doors and curtains.
• Be calm and quiet when bathing. Keep the Dress the resident in the resident’s room.
process simple. • Encourage the resident to pick clothes to
• Be sensitive when talking to your resident wear. Simplify this by giving just a few
about bathing (Fig. 19-9). choices. Make sure the clothing is clean and
 355 19

appropriate. Lay out clothes in the order in Problems with Eating

which they are put on (Fig. 19-10). Choose
Food may not interest a resident with Alzheim-
clothes that are simple to put on. Some peo-
er’s disease at all. It may be of great interest, but
ple with Alzheimer’s disease make a habit of

Confusion, Dementia, and Alzheimer’s Disease

a resident may only want to eat a few types of
layering clothing regardless of the weather.
food. In either case, a resident with AD is at risk
Underwear for malnutrition. Nutritious food intake should
be encouraged. The following are ideas for im-
T-shirt proving eating habits:
• Have meals at regular, consistent times each
day. You may need to remind the resident
Socks
that it is mealtime. Serve familiar foods.
Foods should look and smell appetizing.
Elastic-Waist • Make sure there is adequate lighting.
Pants
• Keep noise and distractions low during meals.
• Keep the task of eating simple. If restless-
Pullover
Shirt ness prevents getting through an entire meal,
try smaller, more frequent meals. Finger
foods (foods that are easy to pick up with the
fingers) may be easier to eat and can allow
eating while moving around. They allow
residents to choose the food they want to eat.
Examples of finger foods that may be good
to serve are sandwiches cut into fourths,
chicken nuggets or small pieces of cooked
boneless chicken, fish sticks, cheese cubes,
Fig. 19-10. Lay out clothes in the order in which they halved hard-boiled eggs, and fresh fruit and
should be put on. soft vegetables cut into bite-sized pieces.

• Break the task down into simple steps. In- • Do not serve steaming or very hot foods or
troduce one step at a time. Do not rush the drinks.
resident. • Use dishes without a pattern. White usually
works best. Use a simple place setting with
• Use a friendly, calm voice when speaking.
a single eating utensil. Remove other items
• Praise and encourage the resident at each from the table (Fig. 19-11).
step.

Residents’ Rights
Rights with Alzheimer’s Disease
Protect the privacy rights of residents with AD by
keeping them dressed or covered with a sheet when
in bed. Residents may not be aware that they are
exposed. Do not discuss their personal information
with others. Allow residents with AD to make the de-
Fig. 19-11. Simple place settings with white plates on a
cisions they are able to make, such as what shirt to
solid-colored placemat may help avoid confusion and dis-
wear or where to sit to eat.
traction during eating.
19 356

• Put only one item of food on the plate at a • Maintain self-esteem. Encourage indepen-
time. Multiple kinds of food on a plate or a dence in ADLs.
tray may be overwhelming.
• Share in fun activities, looking at pictures,
Confusion, Dementia, and Alzheimer’s Disease

• Residents with AD may not understand how talking, and reminiscing.

to eat or use utensils. Give simple, clear in-
• Reward positive and independent behav-
structions. Help the resident taste a sample
ior with smiles, hugs, warm touches, and
of the meal first. To get him to eat, place a
thanks (Fig. 19-12).
spoon to the lips. This will encourage the
resident to open his mouth. Ask him to open
his mouth.
• Guide the resident through the meal. Pro-
vide simple instructions. Offer regular
drinks of water, juice, and other fluids to
avoid dehydration.
• Use adaptive equipment, such as special
spoons and bowls, as needed.
• If a resident needs to be fed, do so slowly.
Give small pieces of food.
• Make mealtimes simple and relaxed. Allow
time for eating. Give the resident time to
swallow before each bite or drink. Fig. 19-12. Reward positive behavior with warm touches,
smiles, and thanks.
• Seat residents with AD with others at small
tables. This encourages socializing.
• Observe for eating or swallowing prob- 9. List and describe interventions for
lems. Report them to the nurse as soon as common difficult behaviors related to
possible. Alzheimer’s disease
• Observe and report changes or problems in Below are some common difficult behaviors
eating habits. that you may face with Alzheimer’s residents.
In addition, use the following tips when caring Remember that each resident is different. Work
for residents with AD: with each person as an individual. Report behav-
ior in detail to the nurse.
• Help with grooming. Help the people in
your care feel attractive and dignified. Agitation: A resident who is excited, restless,
or troubled is said to be agitated. Situations
• Prevent infections. Follow Standard
that lead to agitation are triggers. Triggers may
Precautions.
include change of routine or caregiver, new or
• Observe the resident’s physical health. Re- frustrating experiences, or even television. Re-
port any potential problems. People with sponses that may help calm a person who is agi-
dementia may not notice their own health tated include the following:
problems.
• Try to remove triggers. Keep routine con-
• Maintain a daily exercise routine. stant and avoid frustration (Fig. 19-13).
 357 19

Catastrophic Reactions: When a person with AD

overreacts to something in an unreasonable way
it is called a catastrophic reaction. It may be
triggered by any of the following:

Confusion, Dementia, and Alzheimer’s Disease

• Fatigue
• Change of routine, environment, or
caregiver
• Overstimulation (too much noise or activity)
• Difficult choices or tasks
Fig. 19-13. Nonverbal clues, such as facial expressions
or body language, can warn you of increasing agitation. • Physical pain
Take steps early to calm down a resident who is becoming
agitated. • Hunger
• Need for toileting
• Focus on a soothing, familiar activity, such
as sorting things or looking at pictures. You can respond to catastrophic reactions as you
would to agitation or sundowning. For example,
• Stay calm. Use a low, soothing voice to speak remove triggers. Help the resident focus on a
to and reassure the resident. soothing activity.
• An arm around the shoulder, patting, or Violent Behavior. A resident who attacks, hits,
stroking may soothe some residents. or threatens someone is violent. Violence may
Sundowning: When a person gets restless and be triggered by many situations. These include
agitated in the late afternoon, evening, or night, frustration, overstimulation, or a change in rou-
it is called sundowning. Sundowning may tine, environment, or caregiver. The following
be caused by hunger or fatigue, a change in are appropriate responses to violent residents:
routine or caregiver, or any new or frustrating • Block blows but never hit back (Fig. 19-14).
situation. These are some effective responses to
sundowning: • Step out of reach.

• Remove triggers. Give snacks or encourage • Call for help if needed.

rest. • Do not leave resident alone.
• Avoid stressful situations during this time. • Try to remove triggers.
Limit activities, appointments, trips, and
• Use techniques to calm residents as you
visits.
would for agitation or sundowning.
• Play soft music.
• Set a bedtime routine and keep it.
• Recognize when sundowning occurs. Plan a
calming activity just before.
• Remove caffeine from the diet.
• Give a soothing back massage.
• Distract the resident with a simple, calm ac-
tivity like looking at a magazine.
• Maintain a daily exercise routine. Fig. 19-14. Block blows but do not hit back.
19 358

Pacing and Wandering: A resident who walks residents attempt to leave the bed or chair or
back and forth in the same area is pacing. A open a door. They also help prevent falls and de-
resident who walks aimlessly around the facil- crease the need for side rails. If a resident is or-
ity or the facility grounds is wandering. Pacing dered to have a body alarm (bed or chair), make
Confusion, Dementia, and Alzheimer’s Disease

and wandering may have some of the following sure it is on the resident and turned on.
causes:
• Restlessness
• Hunger
• Disorientation
• Need for toileting
• Constipation
• Pain
• Forgetting how or where to sit down
• Too much daytime napping
Fig. 19-16. This Posey Door Guard helps remind residents
• Need for exercise
with dementia not to exit or enter a restricted area.
(reprinted with permission of briggs corporation, 800-247-2343,
Remove causes when you can. For example, give www.briggscorp.com)

nutritious snacks, encourage an exercise routine,

and maintain a toileting schedule. If residents If a resident wanders away from the protected
pace and wander, let them do so in a safe and se- area, or elopes, notify the nurse immediately.
cure (locked) area where you can keep an eye on Follow the facility’s policies and procedures for
them (Fig. 19-15). Suggest another activity, such missing residents.
as going for a walk together. Hallucinations or Delusions: A resident who sees
things that are not there is having hallucina-
tions (Fig 19-17). A resident who believes things
that are not true is having delusions (Fig. 19-
18). You can respond to hallucinations and delu-
sions in the following ways:
• Ignore harmless hallucinations and
delusions.
• Reassure a resident who seems agitated or
worried.
Fig. 19-15. Make sure residents are in a safe, secured
area if they pace or wander. • Do not argue with a resident who is imagin-
ing things. The feelings are real to him or
Marking rooms with signs or pictures may pre- her. Do not tell the resident that you can see
vent residents from wandering into areas where or hear his or her hallucinations. Redirect
they should not go (Fig. 19-16). Bed, body, or resident to other activities or thoughts.
door alarms can be used in beds or on wheel-
• Be calm. Reassure resident that you are
chairs, chairs, or doors. They help by alerting
there to help.
staff with an alarm when confused or demented
 359 19

You can respond to depression in a number of

ways:
• Report signs of depression to the nurse im-

Confusion, Dementia, and Alzheimer’s Disease

mediately. It is an illness that can be treated
with medication.
• Encourage independence, self-care, and
activity.
• Talk about moods and feelings if the resident
Fig. 19-17. Hallucinating is seeing or hearing things that
wishes. Be a good listener.
are not really there. For example, a resident may think • Encourage social interaction.
he is hearing his mother calling him to dinner. You know
that his mother died 20 years ago, but to him this is very Perseveration or Repetitive Phrasing: A resident
real. who repeats a word, phrase, question, or activity
over and over is perseverating. Repeating a word
or phrase is also called repetitive phrasing.
Such behavior may be caused by several factors,
such as disorientation or confusion. Respond to
this with patience. Do not try to silence or stop
the resident. Answer questions each time they
are asked. Use the same words each time.
Disruptiveness: Disruptive behavior is anything
that disturbs others, such as yelling, banging
on furniture, slamming doors, etc. Often this
behavior is triggered by a wish for attention, by
pain or constipation, or by frustration. When a
resident is being disruptive, gain his attention.
Fig. 19-18. A delusion is a belief in something that is not Be calm and friendly, and try to find out why the
true, or is out of touch with reality. For example, a resi- behavior is occurring. Gently direct the resident
dent thinks that her long-deceased sister is stealing from
to a more private area, if possible. Ask the resi-
her room, like she did when they were young.
dent about it, if possible. There may be a physi-
Depression: When residents become withdrawn, cal reason, such as pain or discomfort.
have no energy, or do not eat or do things they The following are appropriate ways to help pre-
used to enjoy, they may be depressed. Chapter vent or respond to disruptive behavior:
20 has more information on depression and its
• Notice and praise improvements in the
symptoms. Depression may have many causes,
resident’s behavior. Be tactful and sensitive
including the following:
when you do this. Avoid treating the resident
• Loss of independence like a child.
• Inability to cope • Tell the resident about any changes in
• Feelings of failure, fear schedules, routines, or the environment in
advance. Involve the resident in developing
• Reality of facing a progressive, degenerative routine activities and schedules, if possible.
illness
• Encourage the resident to join in indepen-
• Chemical imbalance dent activities that are safe (for example,
19 360

folding towels). This helps the resident feel not be considered stealing. A person with Al-
in charge. It can prevent feelings of power- zheimer’s disease cannot and does not steal.
lessness. Independence is power. Stealing is planned and requires a conscious ef-
fort. In most cases, the person with AD is only
Confusion, Dementia, and Alzheimer’s Disease

• Help the resident find ways to cope. Focus

on positive activities he or she may still be collecting something that catches his attention.
able to do, such as knitting, crocheting, It is common for those with AD to wander in
crafts, etc. This can provide a diversion. and out of rooms collecting things. They may
Inappropriate Social Behavior: Inappropriate carry these objects around for a while, and
social behavior may be cursing, name-calling, then leave them in other places. This is not in-
or other unpleasant behavior. As with violent or tentional. People with AD will often take their
disruptive behavior, there may be many reasons own things and leave them in another room,
why a resident is behaving in this way. Try not not knowing what they are doing. You can help
to take it personally. The resident may only be lessen problems by doing the following:
reacting to frustration or other stress, not to you. • Label all personal belongings with the resi-
Remain calm and be reassuring. Try to find out dent’s name and room number. This way
what caused the behavior (for example, too much there is no confusion about what belongs to
noise, too many people, too much stress, pain, or whom.
discomfort). If possible, gently direct the resident
• Place a label, symbol, or object on the resi-
to a private area if he or she is disturbing others.
dent’s door. This helps the resident find his
Respond positively to any appropriate behavior.
or her own room.
Report any physical abuse or serious verbal
abuse to the nurse. • Do not tell family that their loved one is
“stealing” from others.
Inappropriate Sexual Behavior: Inappropriate
sexual behavior, such as removing clothes or • Prepare the family so they are not upset
touching one’s own genitals, can be embarrass- when they find items that do not belong to
ing or uncomfortable to those who see it. Be their family member.
matter-of-fact when dealing with such behavior.
• Ask the family to tell staff if they notice
Do not over-react, as this may reinforce the be-
strange items in the room.
havior. Be sensitive to the nature of the problem.
Is the behavior actually intentional? Is it consis- • Regularly check areas where residents store
tent? Try to distract the resident. If this does not items. They may store uneaten food in
work, gently direct him or her to a private area. these places. Provide a rummage drawer—a
Tell the nurse. A resident may be reacting to a drawer with items that are safe for the resi-
need for physical stimulation or affection. Con- dent to take with him or her.
sider other ways to provide physical stimulation.
Try backrubs, a soft doll or stuffed animal to Safety in the Home for a Person with AD
cuddle, comforting blankets, pieces of cloth, or A nurse should assess a home’s safety before a
physical touch that is appropriate. home health aide visits a client with Alzheimer’s.
She will indicate changes that need to be made.
Pillaging and Hoarding: Pillaging is taking
Examples include using gates on stairways, putting
things that belong to someone else. A person locks on certain doors, and removing clutter. When
with dementia may honestly think something the client’s condition changes, report this to your
belongs to him, even when it clearly does not. supervisor. Another visit will be made to reassess
the home and make further changes. In general, fol-
Hoarding is collecting and putting things away
low these safety guidelines:
in a guarded way. Pillaging and hoarding should
 361 19

For disoriented clients:

10. Describe creative therapies for
residents with Alzheimer’s disease
• Use signs to mark rooms, including stop signs
on rooms that should not be entered. Although Alzheimer’s cannot be cured, there are

Confusion, Dementia, and Alzheimer’s Disease

• Use calendars and other reminders of day, date, many ways to improve the quality of life for resi-
and location.
dents with AD.
• Put bells on the door to indicate when someone
is coming or going. Reality orientation involves the use of calendars,
clocks, signs, and lists to help residents remem-
• Keep pictures and familiar objects around.
ber who and where they are. It is useful in early
• Put stickers or brightly colored tape on glass
doors, large windows, or glass furniture
stages of AD when residents are confused but
For clients who wander: not totally disoriented. In later stages, reality ori-
entation may only frustrate residents.
• Use locks on doors. These can be installed lower
or higher than usual, so the client will not see Example: Each day when you go into Mrs. El-
them. kin’s room, you show her the calendar and point
• Install alarms that sound when exit doors are out what day of the week it is. On the calendar
opened. or another piece of paper, list all the things you
• Have clients wear identification. Sew labels into will do today, for example, take a shower, eat
clothes.
lunch, and go for a walk. When you speak to her,
• Alert neighbors that client may wander. Show call her by her name: Mrs. Elkin. When helping
them a recent photo of the client. Keep a recent
with tasks, explain why you do things as you
photo handy, as well as a piece of clothing the
client has worn. These can help police and police do. For example, “We use a shower chair in the
dogs track a client who has wandered away. shower so you don’t have to stand up for so long,
For clients who pace: Mrs. Elkin.”
• Remove clutter and throw rugs. Benefits: Using the calendar, making lists, and
• Do not rearrange furniture. using names frequently all help your resident
• Do not wax floors. stay in touch with the world around her. This
• Be sure shoes and slippers fit and have non-slip will help her feel more in control of her life. It
soles. will also allow her to do as much as possible for
For clients who have difficulty walking: herself. Explaining what you do and why you do
• Keep areas well lit, even at night. it as you assist her will make her feel more like a
participant in her care and less like an invalid.
• Block access to stairs with a gate.
• Clear walkways of electrical cords and clutter. Validation therapy means letting residents be-
General tips: lieve they live in the past or in imaginary cir-
• Keep medications and other chemicals out of cumstances. Validating means giving value to
reach. or approving. When using validation therapy,
• Display emergency numbers, including poison make no attempt to reorient the resident to
control, and home address near the phone. actual circumstances. Explore the resident’s be-
• Use red tape around radiators or heating vents liefs. Do not argue with him or her. Validating
to prevent burns. can give comfort and reduce agitation. It is use-
• Check refrigerator and potential “hiding places” ful in cases of moderate to severe disorientation.
for spoiled food.
Example: Mr. Baldwin tells you he does not want
• Prevent kitchen accidents by removing knobs on to eat lunch today because he is going out to a
stove, unplugging toasters and other small appli-
restaurant with his wife. You know his wife has
ances, and supervising kitchen visits.
been dead for many years and that Mr. Baldwin
19 362

can no longer eat out. Instead of telling him that medal, times he was scared, and how much he
he is not going out to eat, you ask what restau- missed his wife and daughter (Fig. 19-20).
rant he is going to and what he will have. You
suggest that he eat a good lunch now because
Confusion, Dementia, and Alzheimer’s Disease

sometimes the service is slow in restaurants

(Fig. 19-19).

Fig. 19-20. Reminiscence therapy encourages a resident

to remember and talk about his past.

Benefits: By asking questions about Mr. Benton’s

Fig. 19-19. Validation therapy accepts a resident’s fanta-
sies without attempting to reorient him to reality. experiences in the war, you show an interest
in him as a person, not just as a resident. You
Benefits: By “playing along” with Mr. Baldwin’s let him show you that he is a person who was
fantasy, you let him know that you take him seri- competent, social, responsible, and brave. This
ously. You do not think of him as a crazy person boosts his self-esteem. You also learn that Mr.
or a child who does not know what is happening Benton cared very much for his wife and daugh-
in his own life. You also learn more about your ter. He probably would enjoy more visits from
resident. He used to enjoy eating out in restau- his daughter, which you can pass along to the
rants. He liked to order certain dishes. Eating nurse.
out is something he probably associates with Activity therapy uses activities the resident en-
being with his wife. These things can help you joys to prevent boredom and frustration. These
give Mr. Baldwin better care in the future. activities also promote self-esteem. Help the
Reminiscence therapy involves encouraging resident take walks, listen to music, read, or do
residents to remember and talk about the past. other things he or she enjoys (Fig. 19-21). Activi-
Explore memories by asking about details. Focus ties may be done in groups or one-on-one. Activ-
on a time of life that was pleasant. Work through ity therapy is useful in most stages of AD.
feelings about a hard time in the past. It is use-
ful in many stages of AD, but especially with
moderate to severe confusion.
Example: Mr. Benton, an 82-year-old man with
Alzheimer’s, fought in World War II. In his
room are many mementos of the war. He has
pictures of his war buddies, a medal he was
given, and more. You ask him to tell you where
he was sent in the war. He tells you about being
in the Pacific. You ask him more detailed ques-
tions. Eventually he tells you a lot: the friends Fig. 19-21. Activities that are not frustrating can be help-
he made in the service, why he was given the ful for residents with AD. They promote mental exercise.
 363 19

Example: Mrs. Hoebel, a 70-year-old woman money needed to pay expenses of home care or
with AD, was a librarian for almost 45 years. adult daycare can be difficult. Families do not
She loves books and reading, but she cannot know what goes on when no one is in the home.
read much anymore. You bring in books that They may be afraid that the person is not caring

Confusion, Dementia, and Alzheimer’s Disease

are filled with pictures. She sits with the books, for him- or herself, may not take medications
sorting them and turning pages and looking at properly, could wander away, or cause a fire.
pictures.
A person with AD may be living with the fam-
Benefits: Mrs. Hoebel can enjoy an activity that ily, which can cause stress and other emotional
always brought her pleasure. She feels compe- difficulties for all involved. It is difficult to care
tent, because she is sorting books and looking at for a person with Alzheimer’s. The household
books, which are tasks she can handle. You show schedule has to change; family members will
her that you care about her by taking the time to lose the freedom to come and go as they please.
show an interest in her past. She will associate Family members must monitor the loved one’s
positive feelings with you. That will make caring activities and provide constant care. They may
for her much easier. lose sleep, as well as lose time to do their own
activities and time to relax.
Tip
Alzheimer’s introduces other stressors, too. It
Music Therapy
is very difficult to watch a loved one’s personal-
Music therapy involves using music to accomplish
specific goals, such as managing stress and improv- ity change, and his or her health and abilities
ing mood and cognition. This type of therapy has deteriorate. It is also hard to switch roles—to go
been used with Alzheimer’s patients with success, from being a child who was once cared for by
although studies are still being performed. Music the parent to being the one caring for the parent.
is a form of sensory stimulation. Hearing familiar
songs can cause a response in people with dementia Families may make the decision to place a loved
who do not respond well or do not respond at all to one with AD into a long-term care facility for
other treatments. Music therapists, who are trained
health professionals, perform music therapy.
any number of reasons. They may have safety
concerns, or may not be able to care for the
person at home. The family may not be able to
11. Discuss how Alzheimer’s disease may handle the issues that AD causes, such as the
affect the family problem behaviors, or the inability to perform
personal care. The person with AD may not
Alzheimer’s disease requires the person’s family want his or her family to do the needed personal
to make difficult adjustments. care. There may be no available family caregiver.
The disease progresses at different rates, and After making the decision to place a person with
people with AD will need more care as the dis- AD in a long-term care facility, family members
ease progresses. Eventually all people with AD usually feel guilty, even if they know that place-
need continuous care. How well the family is ment is necessary. The person with AD may be
able to cope with the effects of the disease de- angry and unable to understand the decision.
pends, in part, on the family’s emotional and Families worry about mistreatment, and are sen-
financial resources. sitive to being judged by others. They also feel
A person with AD may be living alone, which loss and a change in the relationship with their
can cause the family to worry about the person’s family member.
health and safety. Financial resources may be Family members are making emotional ad-
limited, which adds to stress levels. Finding justments, just as residents are. They may be
19 364

experiencing frustration, fear, sadness, anger, 4. What is dementia?

loneliness, and depression. It is important for
5. Alzheimer’s disease is a progressive, degen-
families to be able to express their feelings.
erative, and irreversible disease. What does
Refer to Chapter 8 to learn ways to respond to
Confusion, Dementia, and Alzheimer’s Disease

this mean?
emotional needs of families. Be sensitive to the
big adjustments your residents and their fami- 6. What type of skills does a person with Al-
lies are making. Refer them to your supervisor if zheimer’s disease usually retain?
help is needed. 7. What can nursing assistants encourage resi-
dents to do that may help slow the progres-
12. Identify community resources sion of AD?
available to people with Alzheimer’s 8. Helpful personal attitudes when working
disease and their families with residents who have AD are described in
Learning Objective 5. They are:
There are many resources, such as organiza-
tions, books, counseling, and support groups, • Do not take things personally.
available for people with Alzheimer’s disease • Put yourself in their shoes.
and their families. The Alzheimer’s Association
• Work with the symptoms and behaviors
has a helpline that is available 24 hours a day,
you see.
seven days at week for information, referral, and
support. The number is 800-272-3900, or visit • Work as a team.
the website at alz.org. The National Institute • Take care of yourself.
on Aging has information and resources avail-
• Work with family members.
able at their Alzheimer’s Disease Education and
Referral (ADEAR) Center website, or by calling • Remember the goals of the care plan.
800-438-4380. Counseling, support groups, and
List one example of what an NA can do to
healthcare professionals can also be of assis-
express each attitude.
tance. Support groups are often helpful because
many people in the group are experiencing the 9. Possible communication challenges for
same kinds of emotions and problems. People residents with AD are listed in Learning
often feel that it is helpful to know that they are Objective 6. They include challenges with a
not alone in what they are going through. People resident who may:
in support groups often share tips and ideas for • Be frightened or anxious
care and interventions for problems, which can
• Forget or show memory loss
be beneficial. Inform the nurse if you think resi-
dents and/or their families could benefit from a • Have trouble finding words or names
list of community resources. • Seem not to understand basic questions
or instructions
Chapter Review • Want to say something but cannot
1. What does cognitive impairment affect? • Not remember how to perform basic
tasks
2. How can confusion affect a person?
• Insist on doing something that is unsafe
3. Define the term “delirium” and list five
or not allowed
causes.
 365 19

• Hallucinate, or be paranoid or accusing

• Be depressed or lonely
• Be verbally abusive, or use bad language

Confusion, Dementia, and Alzheimer’s Disease

• Have lost most verbal skills
For each communication challenge, list one
tip that may help.
10. List three general principles that will assist
residents with personal care.
11. List four interventions for each of the follow-
ing topics: incontinence, bathing, dressing,
and eating.
12. For each of the following common difficult
behaviors seen in residents with AD, list one
intervention: agitation; pacing and wander-
ing; hallucinations or delusions; sundown-
ing; catastrophic reactions; depression;
perseveration; violent behavior; disruptive-
ness; inappropriate social behavior; inap-
propriate sexual behavior; and pillaging and
hoarding.
13. Describe these four creative therapies for
AD: reality orientation, validation therapy,
reminiscence therapy, and activity therapy.
14. What difficulties might families of people
who have AD face?
15. List two community resources that may help
a person who has AD.
20 366

20
Mental Health and Mental Illness

Mental Health and

Mental Illness
1. Identify seven characteristics of mental 2. Identify four causes of mental illness
health
While it involves the emotions and mental func-
Mental health is the normal functioning of tions, mental illness is a disease. It is like any
emotional and intellectual abilities. Traits of a physical disease. It produces signs and symp-
person who is mentally healthy include the abili- toms and affects the body’s ability to function. It
ties to: responds to proper treatment and care. Mental
illness disrupts a person’s ability to function at a
• Get along with others (Fig. 20-1)
normal level in the family, home, or community.
• Adapt to change It often causes inappropriate behavior. Some
• Care for self and others signs and symptoms of mental illness are confu-
sion, disorientation, agitation, and anxiety.
• Give and accept love
However, signs and symptoms like those of
• Deal with situations that cause anxiety, dis-
mental illness can also occur when mental ill-
appointment, and frustration
ness is not present. A personal crisis, temporary
• Take responsibility for decisions, feelings, physical changes in the brain, side effects or in-
and actions teractions from medications, and severe change
in the environment may cause a situation re-
• Control and fulfill desires and impulses
sponse. In a situation response, the signs and
appropriately
symptoms are temporary.
Mental illness can be caused or made worse by
chronic stress from any of these conditions:
1. Physical factors: Illness, disability, or aging
can cause stress that may lead to mental
illness. Substance abuse or a chemical
imbalance can also cause mental illness.
Self-respect and self-worth are the building
blocks of mental health. They are challenged
when ill or disabled people have difficulty
with their activities of daily living (ADLs).
Fig. 20-1. The ability to interact well with other people is They may fear the future. They may worry
a characteristic of mental health.
about their dependence on others.
 367 20

2. Environmental factors: Weak interpersonal • Mental retardation is present at birth or emerges

or family relationships, or traumatic early in childhood. Mental illness may occur any time
life experiences (such as being abused as a during a person’s life.
child) can lead to mental illness.

Mental Health and Mental Illness

• Mental retardation affects mental ability. Mental
illness may or may not affect mental ability.
3. Heredity: Mental illness can occur repeatedly
in some families. This may be due to inher- • There is no cure for mental retardation, although
ited traits or family influence. persons who are mentally retarded can be
helped. Many mental illnesses can be cured with
4. Stress: People can tolerate different levels treatment, such as medications and therapy.
of stress. People have different ways of han- Mental retardation and mental illness are different
dling stress. When the amount of stress is conditions; however, persons who have either con-
too great, a person may not be able to cope dition need emotional support, as well as care and
treatment.
with it, and mental illness may arise.

3. Distinguish between fact and fallacy 4. Explain the connection between mental
concerning mental illness and physical wellness
A fallacy is a false belief. The greatest fallacy Mental health is important to physical health.
about mental illness is that people who are men- Reducing stress can help prevent some physical
tally ill can control it. Mentally ill people cannot illnesses (Fig. 20-2). It can help people cope if ill-
simply choose to be well. Mental illness is a dis- ness or disability occur. Mental health can help
ease like any other. Mentally healthy people are protect and improve physical health. The reverse
able to control their emotions and actions. Men- is also true. Physical illness or disability can
tally ill people may not have this control. Know- cause or worsen mental illness. The stress these
ing mental illness is a disease helps you work conditions create takes a toll on mental health.
with mentally ill residents.

Fact and Fallacy

Fact: Mental illness is a disease like any physical ill-

ness. People with mental illness cannot control their
illness.
Fallacy: People with mental illness can control their
illness. They can choose to be well.

Mental Retardation and Mental Illness

Sometimes people confuse the terms “mental retar- Fig. 20-2. Social interaction can promote mental and
dation” and “mental illness.” They are not the same. physical health.
Mental retardation is a developmental disability that
causes below-average mental functioning. It may
affect a person’s ability to care for himself, as well 5. List guidelines for communicating with
as to live independently. Mental retardation is not
a type of mental illness. Here are some ways that it mentally ill residents
differs from mental illness:
Different types of mental illness will affect how
• Mental retardation is a permanent condition; well residents communicate. Treat each resident
mental illness can be temporary.
20 368

as an individual. Tailor your approach to the problems and actions. If a person is unable to
situation. Use these guidelines to communicate recognize problems, he or she will not address
with residents who are mentally ill (Fig. 20-3). them, and the problems may get worse. Com-
mon defense mechanisms include:
Mental Health and Mental Illness

Denial: Completely rejecting the thought or

feeling—”I’m not upset with you!”
Projection: Seeing feelings in others that are re-
ally one’s own—”My teacher hates me.”
Displacement: Transferring a strong negative
feeling to a safer situation—for example, an un-
happy employee cannot yell at his boss for fear
Fig. 20-3. Practice good communication skills with men-
tally ill residents. of losing his job so he later yells at his wife.
Rationalization: Making excuses to justify a situ-
ation—for example, after stealing something,
Guidelines: saying “Everybody does it.”
Mental Illness
Repression: Blocking painful thoughts or feel-
G Do not talk to adults as if they are children. ings from the mind—for example, not remem-
bering sexual abuse.
G Use simple, clear statements and a normal
tone of voice. Regression: Going back to an old, usually imma-
ture behavior—for example, throwing a temper
G Be sure that what you say and how you say it tantrum as an adult.
show respect and concern.
G Sit or stand at a normal distance from the
7. Describe the symptoms of anxiety,
resident. Be aware of your body language.
depression, and schizophrenia
G Be honest and direct, as you would with any
resident. There are many degrees of mental illness, from
mild to severe. A person with severe mental ill-
G Avoid arguments. ness may lose touch with reality and become un-
G Maintain eye contact. able to communicate or make decisions. Some
people with mild mental illness, however, seem
G Listen carefully.
to function normally, although they may some-
times become overwhelmed by stress or overly
6. Identify and define common defense emotional. Many signs of mental illness are sim-
mechanisms ply extreme behaviors most people experience
some of the time. Being able to recognize such
Defense mechanisms are unconscious behav-
behavior may make it easier to understand the
iors used to release tension or cope with stress.
mentally ill.
They help to block uncomfortable or threatening
feelings. All people use them at times. However, Anxiety-related Disorders: Anxiety is uneasi-
people who are mentally ill use them to a greater ness or fear, often about a situation or condition.
degree. Overuse of these mechanisms keeps When a mentally healthy person feels anxiety,
people from understanding their emotional he or she usually knows the cause. The anxiety
fades once the cause is removed. A mentally ill
 369 20

person may feel anxiety all the time. He or she with anxiety. For example, a person may wash
may not know the reason for feeling anxious. his hands over and over as a way of dealing with
Physical signs and symptoms of anxiety-related anxiety. Anxiety-related disorders may also be
disorders include shakiness, muscle aches, caused by a traumatic experience. This type

Mental Health and Mental Illness

sweating, cold and clammy hands, dizziness, of anxiety is known as post-traumatic stress
fatigue, racing heart, cold or hot flashes, a chok- disorder.
ing or smothering sensation, and a dry mouth
Depression: Clinical depression is a serious
(Fig. 20-4).
mental illness. It may cause intense mental,
emotional, and physical pain and disability.
Sweating
Depression also makes other illnesses worse. If
untreated, it may result in suicide. The National
Dizziness
Institute of Mental Health lists depression as
Dry Mouth one of the most common links with suicide in
Choking or
older adults.
smothering
sensation Racing heart
Clinical depression is not a normal reaction to
stress. Sadness is only one sign of this illness.
Not all people who have depression complain of
sadness or appear sad. Other common symp-
Fatigue toms of clinical depression include (Fig. 20-5):

Shakiness • Pain, including headaches, abdominal pain,

and other body aches
Cold,
clammy Muscle • Low energy or fatigue
hands aches
• Apathy, or lack of interest in activities
• Irritability
• Anxiety
• Loss of appetite or overeating
Fig. 20-4. Common symptoms of anxiety.
• Problems with sexual functioning and desire
Phobias are an intense form of anxiety. Many • Sleeplessness, difficulty sleeping, or exces-
people are very afraid of certain things or situ- sive sleeping
ations. Examples include a fear of dogs or of
• Lack of attention to basic personal care
flying. For a mentally ill person, a phobia is a
tasks (e.g. bathing, combing hair, changing
disabling terror. It keeps the person from partici-
clothes)
pating in normal activities. For example, the fear
of being in a confined space, claustrophobia, • Intense feelings of despair
may make using an elevator a terrifying task.
• Guilt
Other anxiety-related disorders include panic
• Difficulty concentrating
disorder, in which a person is terrified for no
known reason. Obsessive compulsive disor- • Withdrawal and isolation
der is obsessive behavior a person uses to cope • Repeated thoughts of suicide and death
20 370

Repeated Schizophrenia is a brain disorder that affects

Sleeplessness or thoughts of death a person’s ability to think and communicate
excessive sleeping
clearly. It also affects the ability to manage emo-
Difficulty tions, make decisions, and understand reality.
Mental Health and Mental Illness

concentrating
Pain, including It affects a person’s ability to interact with other
headaches or people. Treatment makes it possible for many
Guilt
stomachaches people to lead relatively normal lives.
Irritability
Some of the signs of schizophrenia are easy to
Apathy see (Fig. 20-6). Hallucinations are illusions a
Low energy person sees or hears. A person may see someone
or fatigue or something that is not really there, or hear
a conversation that is not real. Delusions are
persistent false beliefs. For example, a person
may believe that other people are reading his
thoughts. Paranoid schizophrenia is a form of
the disease that centers mainly on hallucinations
Fig. 20-5. Common symptoms of clinical depression. and delusions. Not all hallucinations or delu-
sions are related to schizophrenia, though.
Depression can occur along with other illnesses.
Cancer, HIV or AIDS, Alzheimer’s disease, dia-
betes, and heart attack are among the illnesses Inability to express
logical thoughts
often associated with depression. Depression is Hallucination
very common among the elderly. and delusions
Lack of
There are different types and degrees of depres- energy
Little interest in
sion. Major depression may cause a person to surroundings
lose interest in everything he once cared about.
Manic depression, or bipolar disorder, causes Slow, repetitive,
Little
a person to swing from deep depression to ex- rhythmic
emotion
treme activity. These manic episodes include movements
high energy, little sleep, big speeches, rapidly
changing moods, high self-esteem, overspend-
ing, and poor judgment.
People cannot overcome depression through
sheer will. Depression is an illness like any other
illness. It can be treated successfully. People who
suffer from depression need compassion and
support. Know the symptoms so that you can
recognize the beginning or worsening of depres-
sion. Any suicide threat should be taken seri-
Fig. 20-6. Common symptoms of schizophrenia.
ously and reported immediately. It should not be
regarded as an attempt to get attention. Other symptoms of schizophrenia include dis-
Schizophrenia: Despite popular belief, schizo- organized thinking and speech. This makes
phrenia does not mean “split personality.” a person unable to express logical thoughts.
 371 20

Disorganized behavior means a person moves Residents’ Rights

slowly, repeating gestures or movements. People
Mental Illness
with schizophrenia may also show less emotion,
Residents have the right to participate in the plan-
have less interest in their environment, and lack

Mental Health and Mental Illness

ning of their care. They also have the right to have
energy. their medical and personal records handled confi-
dentially. A resident with a history of mental illness
has the right to go to his care plan meetings, and
8. Explain how mental illness is treated state his or her preferences for care and treatment.
He or she also has the right to refuse care and treat-
It is extremely important to remember that ment. The fact that the resident has a mental illness
mental illness can be treated. Medication and is confidential information. Do not share this infor-
mation with anyone.
psychotherapy are common treatment methods.
Medication is widely used for several diseases
and can have a very positive effect. These drugs 9. Explain your role in caring for residents
affect the brain and have been successful in who are mentally ill
treating the symptoms and behaviors of many
people with mental disorders. Medication may Personal care of residents who are mentally ill is
allow mentally ill people to function more com- like care of any resident. The care plan and your
pletely. Medication used to treat mental illness assignment sheet will tell you what to do. You
must be taken properly to promote benefits and will also have some special responsibilities, as
reduce side effects. You may be assigned to ob- described in these guidelines:
serve residents taking their medications.
Psychotherapy is a method of treating mental Guidelines:
illness that involves talking about one’s problems Mentally Ill Residents
with mental health professionals. Individuals,
G Observe residents carefully for changes in
groups, couples, or families meet with trained,
condition or abilities. Document and report
licensed professionals to work on their problems.
your observations.
Therapists work with their clients to identify
problems and causes. They use different tech- G Support the resident and his or her family
niques to help clients learn more about them- and friends. Coping with mental illness can
selves and to teach them new ways to handle be very frustrating. Your positive, professional
problems and be more in control of their lives. attitude encourages the resident and the fam-
ily. If you need help coping with stress of car-
There are other methods of treating mental ill-
ing for someone who is mentally ill, speak to
ness that are not as widely used as medication
the nurse.
and psychotherapy. Electroconvulsive (shock)
treatment (EST) causes seizures by applying G Encourage residents to do as much as pos-
electrical impulses to the brain. It is used for sible for themselves. Progress may be very
the treatment of depression and other mental ill- slow. Be patient, supportive, and positive.
nesses. Many people do not approve of EST. It is
Home Care Focus
generally used only when other treatments have
not been successful. When working in the home, remember that a stable
home environment is important in managing many
Psychosurgery is brain surgery that is performed forms of mental illness. By assisting the family with
to improve chronic mental disorders. There are meeting their basic needs, you help the recovery
new techniques being developed and used that process. This is true even if your care is not physi-
cally directed to the recovering person. For example,
have less risk than older methods.
20 372

knowing that their children are being well cared for

can greatly assist persons being treated for depres-
sion. You may be assigned to provide the following
services:
Mental Health and Mental Illness

• Food shopping, meal planning, and preparation

• Housecleaning and laundry

• Assistance with ADLs and personal care such as

bathing

• Caring for children and other family members

If assisting in a client’s home, help preserve the
client’s role and authority in the family. Remember Fig. 20-7. Withdrawal is an important change to report.
that you are not replacing the client. You are only
filling in until the client is well enough to resume his
or her role in the family.
11. List the signs of substance abuse
Substance abuse is the repeated use of legal
10. Identify important observations that
or illegal drugs, cigarettes, or alcohol in a way
should be made and reported that is harmful to oneself or others. The harm
Carefully observe your residents. Report the caused by substance abuse may come in many
facts of your observations, but do not draw con- forms: damage to the abuser’s health; legal prob-
clusions about the cause of the behavior. Include lems; and damage to the abuser’s relationships
what you saw or heard, how long it lasted, and with family and friends. Chemical dependency
how often it occurred. is more severe, and may involve needing greater
amounts of the drug and having symptoms,
even when not using it. Chemical dependency
Observing and Reporting:
is a disease. It affects a person physically, men-
Mentally Ill Residents
tally, and emotionally. Like many other diseases,
chemical dependency can develop at any age. It
Changes in ability
is treatable but frequently requires diagnosis and
Positive or negative mood changes, especially care by specialists. Treatment is not as simple as
withdrawal (Fig. 20-7) just stopping the drug.
Behavior changes, including changes in per- A substance need not be illegal for it to be
sonality, extreme behavior, and behavior that abused (Fig. 20-8). Alcohol and cigarettes are
does not seem to fit the situation legal for adults, but are often abused. Over-the-
Comments, including jokes, about hurting counter medications, including diet aids and de-
self or others congestants, can be addictive and harmful. Even
substances such as paint or glue are sometimes
Failure to take medicine or improper use of abused, causing injury and death.
medicine
You may be in a position to observe signs of
Real or imagined physical symptoms substance abuse in residents. Report these signs
Events, situations, or people that upset or to the nurse. You can report your observations
excite residents without accusing anyone. Simply report what
you see, not what you think the cause may be.
 373 20

Changes in appearance (red eyes, dilated

pupils, weight loss)
Odor of cigarettes, liquor, or other substanc-

Mental Health and Mental Illness

es on breath or clothes
Reduced sense of smell
Unexplained changes in vital signs
Loss of appetite
Inability to function normally
Need for money
Confusion/forgetfulness
Blackouts or memory loss
Frequent accidents
Problems with family/friends
It is important to know that some of the same
signs listed above may also indicate other prob-
lems. Depression, dementia, medication issues
or medical conditions can also produce many of
these same symptoms.

Residents’ Rights
Rights with Alcohol
Most residents in long-term care facilities are adults
and have the legal right to drink alcohol. However,
there are instances when alcohol is not allowed. A
doctor may have written an order for a resident not
to drink alcohol. A facility may have policies against
any alcohol being consumed, which would have
been known and agreed to by potential residents be-
fore admission.
If a doctor has not written an order stating that a
resident may not have alcohol and the facility has
no rules against it, a resident may drink alcohol. If
a resident is allowed to do so and enjoys having an
Fig. 20-8. Prescription drugs, cigarettes, and alcohol are alcoholic beverage, do not make judgments. Do not
examples of legal substances that may be abused. gossip about it with other residents or staff mem-
bers. However, if you know that a resident should
not be drinking alcohol, report this to the nurse.
Observing and Reporting:
Substance Abuse Chapter Review
Changes in personality, moodiness, strange 1. Give one example of behavior that demon-
behavior, disruption of routines strates each of the seven characteristics of
Irritability mental health in Learning Objective 1.
20 374

2. What are four possible causes of mental

illness?
3. What is the most common fallacy about
Mental Health and Mental Illness

mental illness?
4. How does mental health affect physical
health?
5. List six guidelines for communicating with a
resident who is mentally ill.
6. What are defense mechanisms?
7. List three signs and symptoms of each of
these mental illnesses: anxiety, depression,
and schizophrenia.
8. What are the most common treatments for
mental illness?
9. List three care guidelines for mentally ill
residents.
10. List five important observations to make
about mentally ill residents.
11. List four legal substances than can be
abused.
12. List ten signs and symptoms of substance
abuse.
 375 21

21

Rehabilitation and Restorative Care

Rehabilitation and
Restorative Care
1. Discuss rehabilitation and restorative Both rehabilitation and restorative care take a
care team approach (Fig. 21-1). The physician and
nurses will establish goals of care. This includes
When a resident loses some ability to function promoting independence in activities of daily
due to illness or injury, rehabilitation may be living (ADLs) and restoring health to optimal
ordered. Rehabilitation is care that is managed condition. The physical therapist, occupational
by professionals to help to restore a person to the therapist, or speech language pathologist will
highest possible level of functioning. It involves work with the resident to help restore or adapt
helping residents move from illness, disability, specific abilities. Social workers or other coun-
and dependence toward health, ability, and in- selors may see the resident to help promote at-
dependence. Rehabilitation involves all parts of titudes of independence and acceptance. The
the person’s disability, including physical (e.g. effects of the illness or injury cannot always be
eating, elimination) and psychosocial (e.g. inde- reversed. Social workers and counselors help
pendence, self-esteem), needs. people adjust to trauma and loss.
Goals of a rehabilitative program include the
following:
• To help a resident regain function or recover
from illness
• To develop and promote a resident’s
independence
• To allow a resident to feel in control of his or
her life
• To help a resident accept or adapt to the Fig. 21-1. A team of specialists, including doctors, physi-
limitations of a disability cal therapists, and other kinds of therapists, helps resi-
dents with rehabilitation.
Rehabilitation will be used for many of your
residents, particularly those who have suffered Because you spend many hours with these resi-
a stroke, accident, or trauma. Restorative care dents, you are a very important part of the team.
usually follows rehabilitation. The goal is to keep You play a critical role in helping residents re-
the resident at the level achieved by rehabilitative cover and regain independence. When assisting
services.
21 376

with restorative care, these guidelines are critical encouragement to fit each person’s
to your residents’ progress: personality.
G Encourage independence. A resident’s
Rehabilitation and Restorative Care

Guidelines: independence may help his or her ability to

Restorative Care be active in the process of rehabilitation.
Independence improves self-image and atti-
G Be patient. Progress may be slow, and it will tude. It also helps speed recovery.
seem slower to you and to your residents if
G Involve residents in their care. Residents
you are impatient. Your residents must do as
who feel involved and valued may be more
much as possible for themselves. Encourage
motivated to work hard in rehabilitation.
independence and self-care, regardless of
Fears may be eased by including family and
how long it takes or how poorly they are able
friends in the rehabilitation program. A team
to do it. The more patient you are, the easier
approach is inspiring.
it will be for them to regain abilities and
confidence.
Residents’ Rights
G Be positive and supportive. A positive atti- Call Lights
tude can set the tone for success. Family Residents may need help often, and not just while
members, friends, and residents will take in rehabilitation and restorative care. It is never ac-
cues from you. If you are encouraging and ceptable to unplug a resident’s call light, no matter
how often he or she uses it, or how demanding the
positive, you help create an atmosphere for resident is. Staff must respond kindly and promptly
successful rehabilitation. to call lights every time they are used. This response
can even save lives.
G Focus on small tasks and small accomplish-
ments. For example, getting dressed may
seem overwhelming to some residents. Break Observing and Reporting:
the task down into smaller steps. Today’s Restorative Care
goal might be putting on a shirt without but-
toning it. Next week the goal could be but- Any increase or decrease in abilities (for
toning the shirt if that seems manageable. example, “Yesterday Mr. Martinez used the
When the resident can put the shirt on with- portable commode without help. Today he
out help, congratulate him. Take everything asked for the bedpan.”)
one step at a time.
Any change in attitude or motivation, positive
G Recognize that setbacks occur. Progress or negative
occurs at different rates. Sometimes a resi-
Any change in general health, such as chang-
dent can do something one day but cannot
es in skin condition, appetite, energy level, or
do it the next. Reassure residents that set-
general appearance
backs are normal. However, document any
decline in a resident’s abilities. Signs of depression or mood changes

G Be sensitive to the resident’s needs. Some Rehabilitation and restorative care is one of the
residents may need more encouragement great joys of working as a caregiver. Enjoy seeing
than others. Some may be embarrassed by residents progress toward independence or re-
encouragement. Get to know your residents. covery. Take pride in your contributions to their
Understand what motivates them. Adapt your improving health.
 377 21

Tip can also cause problems with independence and

self-esteem.
Rehabilitation
Residents receiving rehabilitation and restorative The staff’s job is to keep residents as active as

Rehabilitation and Restorative Care

care services have been ill or injured and are likely to possible—whether they are bedbound or are able
feel tired, afraid, depressed, or be in pain. Help them
to get out of bed and walk (ambulate). Regu-
feel safe and secure by being kind, patient, and help-
ful. For example, if therapy schedule interferes with lar ambulation and exercise help improve the
mealtimes, collect the resident’s meal and/or reheat following:
it cheerfully if needed. A resident who is frightened
may benefit from an unrushed conversation. If a
• Quality and health of the skin
resident says she is in pain, talk to the nurse. Take • Circulation
action to help her. Offer comfort measures, such as
a back rub. • Strength
• Sleep and relaxation

2. Describe the importance of promoting • Mood

independence and list ways exercise • Self-esteem
improves health • Appetite

Maintaining independence is vital during and • Elimination

after rehabilitation and restorative services. When • Blood flow
an active and independent person is dependent, • Oxygen level
physical and mental problems may result. The
body becomes less mobile and the mind is less Promoting social interactions and thinking
focused. Studies show that the more active a per- abilities is important, too. Most facilities have
son is, the better the mind and body work. activities geared to residents’ ages and abilities.
Social involvement should be encouraged. When
Exercise is important for improving and main- possible, nursing assistants should join in activi-
taining physical and mental health. Inactivity ties with residents. This promotes independence.
and immobility can result in loss of self-esteem, It also gives NAs a chance to observe residents’
depression, pneumonia, urinary tract infection, abilities.
constipation, blood clots, and dulling of the
senses. People who are in bed for long periods of Basic Exercise Principles
time are more likely to develop muscle atrophy
It is important to get a doctor’s approval before
or contractures. When atrophy occurs, the mus-
starting a new exercise or activity program. It is not
cle wastes away, decreases in size, and becomes safe to exercise with certain heart conditions. Exer-
weak. When a contracture develops, the muscle cising with high blood pressure can be risky. Caution
shortens, becomes inflexible, and “freezes” in must be used after surgery. It is also necessary to
limit exercise with unstable bones, in the case of
position. This can cause permanent disability of
fractures or osteoporosis, and with extreme breath-
the limb. ing problems.

A lack of mobility may cause other problems as Warming up should be done before doing any other
exercises. This consists of light exercise, such as
well. Immobility reduces the amount of blood walking. The warm-up begins to increase heart rate
that circulates to the skin. Residents who have and breathing. It helps prevent injury. Some people
restricted mobility have an increased risk for like to stretch at the beginning of their workout.
pressure sores. In addition, a lack of mobility Stretching should not be done until the muscles are
warm.
21 378

Supportive devices, such as canes, walkers, and

Cool-down exercises are done to slowly lower the
heart rate. They return other body functions to nor- crutches, are used to assist residents with am-
mal. Suddenly ending an exercise session without bulation (see Chapter 10). Safety devices, such
cooling down can cause blood to pool in the large as shower chairs and gait or transfer belts, help
Rehabilitation and Restorative Care

leg muscles. This may cause dizziness or even faint-

prevent accidents. Safety bars/grab bars are
ing. It is good to stretch after the cool-down, while
the muscles are still warm. Stretching keeps muscles often installed in and near the tub and toilet to
flexible and helps them relax. give the resident something to hold on to while
changing position. The items shown in Fig. 21-2
can be useful as residents relearn old skills or
3. Describe assistive devices and adapt to new limitations.
equipment
Tip
Many devices are available to help people who
Walking Aids
are recovering from or adapting to a physical
Residents using new ambulatory aids, such as canes,
condition. You first learned about assistive or walkers, boots, crutches, etc. are likely to be off-
adaptive equipment in Chapter 2. This equip- balance. Stay close by to be sure they are using these
ment helps residents perform their ADLs. Each appliances safely. Observe residents for signs of diz-
adaptive device is made to support a particular ziness. To avoid falls, clear pathways, and wipe up
spills immediately.
disability. Raised seating, for example, makes it
simpler for a resident with weak legs to stand.
Personal care equipment includes long-handled Tip
brushes and combs. Plate guards prevent food Trapeze
from being pushed off the plate and make it A trapeze is a triangular piece of equipment that
easier to scoop food onto utensils. Reachers can hangs over the head of the bed. It may be mounted
to the bed or freestanding. People in bed can grasp
help put on underwear or pants. A sock aid can the trapeze with their hands, which enables them to
pull on socks, and a long-handled shoehorn as- lift themselves. The trapeze assists with reposition-
sists in putting shoes on without bending. Long- ing and exercise activities.
handled sponges help with bathing.

Fig. 21-2. Many adaptive items are available to help residents adapt to physical changes. (Photos courtesy of North Coast
Medical, Inc. 800-821-9319)
 379 21

4. Explain guidelines for maintaining G Prevent external rotation of hips. When legs
proper body alignment and hips turn outward during bedrest, hip
contractures can result. A contracture is the
Residents who are confined to bed need to main- permanent and often very painful stiffening

Rehabilitation and Restorative Care

tain proper body alignment. This aids recovery of a joint and muscle. A rolled blanket or
and prevents injury to muscles and joints. Chap- towel tucked alongside the hip and thigh can
ter 10 gives specific instructions for positioning keep the leg from turning outward.
residents. The following guidelines help resi-
G Change positions often to prevent muscle
dents maintain good alignment and make prog-
stiffness and pressure sores. This should be
ress when they can get out of bed.
done at least every two hours. The position
used will depend on the resident’s condition
Guidelines:
and preference. Check the skin every time
Alignment and Positioning
you reposition the resident.
G Observe principles of alignment. Remember
that proper alignment is based on straight 5. Explain care guidelines for prosthetic
lines. The spine should be in a straight line. devices
Pillows or rolled or folded blankets can sup-
A prosthesis is a device that replaces a body part
port the small of the back and raise the knees
that is missing or deformed because of an ac-
or head in the supine position. They can sup-
cident, injury, illness, or birth defect. It is used
port the head and one leg in the lateral posi-
to improve a person’s ability to function and/or
tion (Fig. 21-3).
to improve appearance. Examples of prostheses
include the following:
• Artificial limbs, such as for the hands, arms,
feet, and legs, are made to resemble the body
part that they are replacing (Fig. 21-5). Many
advances have been made and continue to be
made in the field of prosthetic limbs. Today’s
Fig. 21-3. Pillows or rolled or folded blankets help provide artificial limbs are usually made of strong
extra support. and lightweight plastics and other materials,
such as carbon fiber. Most artificial limbs
G Keep body parts in natural positions. In a are attached by belts, cuffs, or suction. Direct
natural hand position, the fingers are slightly bone attachment is a newer method of at-
curled. Use a rolled washcloth, gauze ban- taching the limb to the body.
dage, or rubber ball inside the palm to sup-
port the fingers in this position (Fig. 21-4).
Use footboards to keep covers from resting
on feet in the supine position.

Fig. 21-5. One type of prosthetic arm. (Motion Control Utah

Arm. Photo by Kevin Twomey.)

• An artificial breast is made of a lightweight,

soft, spongy material. It usually fits into a
regular bra or in the pocket of a special bra
Fig. 21-4. Handrolls keep fingers from curling tightly. called a mastectomy bra.
21 380

• A hearing aid is a small, battery-operated is removed. It may be cleaned more often, if

device that amplifies sound for persons with needed. Follow the care plan and the nurse’s
hearing loss. Many elderly residents have instructions.
hearing aids.
Rehabilitation and Restorative Care

G If ordered, apply a stump sock before putting

• Eyeglasses are an optical instrument worn in on the prosthesis.
front of the eyes for correcting vision. They G Observe the skin on stump. Watch for signs
consist of frames that hold a pair of lenses. of skin breakdown caused by pressure and
Many people wear eyeglasses. abrasion. Report any redness or open areas.
• An artificial eye, or ocular prosthetic, re- Never try to fix a prosthesis. Report any prob-
places an eye that has been lost to disease or lems to the nurse.
injury. It is usually made of plastic, although G Do not show negative feelings about the
some are made of glass. It is held in place stump during care.
by suction. An ocular prosthetic does not
G If the person has a hearing aid, make sure
provide vision. It can, however, improve
he or she is wearing it and that it is working
appearance.
properly.
• Dentures are artificial teeth. They may be
G If the resident has eyeglasses, make sure they
necessary when a tooth or teeth have been
are clean and that he or she wears them.
damaged, lost, or must be removed. Many
elderly residents have dentures. G If instructed to care for an artificial eye, first
wash your hands. Provide privacy for the resi-
See Chapter 4 for more information on eye-
dent. Put on gloves before beginning care.
glasses and hearing aids and Chapter 13 for
Artificial eyes are held in by suction. They will
more information on denture care.
come out quickly when pressure is applied
below the lower eyelid. Wash eye with solu-
Guidelines: tion and rinse in warm water. Never clean or
Amputation and Prosthesis Care soak the eye in alcohol. It will crack the plas-
tic and destroy it. Moisten the artificial eye
G If residents have had a body part amputated, and place it far under upper eyelid. Pull down
they must make many physical, psychologi- on lower eyelid and the eye should slide into
cal, social, and occupational adjustments to place.
their disability. Be supportive.
G If the artificial eye is to be removed and not
G Because prostheses are specially-fitted, reinserted, line an eye cup or basin with a
expensive pieces of equipment (some cost soft cloth or a piece of 4x4 gauze. This pre-
tens of thousands of dollars), only care for vents scratches and damage. Fill with water
them as assigned. Handle them carefully. or saline solution. Place the eye in the con-
Follow the care plan. tainer and close the container. Make sure the
G A nurse or therapist will demonstrate applica- container is labeled with the resident’s name
tion of a prosthesis. Follow instructions to and room number.
apply and remove the prosthesis. Follow the G If the artificial eye is removed, wash the eye
manufacturer’s care directions. socket with warm water or saline. Use a clean
G Keep a prosthesis and the skin under it gauze square to clean it. Clean the eyelid with
dry and clean. The socket of the prosthesis a clean cotton ball. Wipe gently from inner
must be cleaned daily when the prosthesis corner (canthus) outward.
 381 21

6. Describe how to assist with range of • Extension: straightening a body part

motion exercises • Flexion: bending a body part
Range of motion (ROM) exercises are exer- • Pronation: turning downward

Rehabilitation and Restorative Care

cises that put a joint through its full arc of mo-
tion. The goal of ROM exercises is to decrease • Supination: turning upward
or prevent contractures, improve strength, and
increase circulation. Passive range of motion
(PROM) exercises are used when residents
cannot move on their own; a staff member per-
forms these exercises without the resident’s help. • Abduction • Adduction • Dorsiflexion • Rotation
When helping with PROM exercises, support
the resident’s joints and move them through
the range of motion. Active range of motion
(AROM) exercises are performed by a resident • Extension • Flexion • Pronation • Supination
himself. Your role in AROM exercises is to en- Fig. 21-6. Different range of motion body movements.
courage the resident. Active assisted range of
motion (AAROM) exercises are done by the
resident with some assistance and support from Assisting with passive range of motion
a staff member. exercises

You will not do ROM exercises without an order 1. Wash your hands.
from a doctor, nurse, or physical therapist. Fol-
2. Identify yourself by name. Identify the resi-
low the care plan. You will repeat each exercise
dent by name.
three to five times, once or twice a day. You will
work on both sides of the body. During ROM 3. Explain procedure to resident. Speak clearly,
exercises, begin at the resident’s head and work slowly, and directly. Maintain face-to-face con-
down the body. Exercise the upper extremities tact whenever possible.
(arms) before the lower extremities (legs). Give
4. Provide for resident’s privacy with curtain,
support above and below the joint. Move the
screen, or door.
joints gently, slowly, and smoothly through the
range of motion to the point of resistance. Stop 5. Adjust bed to a safe level, usually waist high.
the exercises if the resident complains of pain. Lock bed wheels.
Report pain to the nurse.
6. Position the resident lying supine—flat on
Range of motion exercises are specific for each his or her back—on the bed. Use proper
body area. They include the following move- alignment.
ments (Fig. 21-6):
7. Repeat each exercise at least 3 times. While
• Abduction: moving a body part away from supporting the limbs, move all joints gently,
the midline of the body slowly, and smoothly through the range of
motion to the point of resistance. Stop if any
• Adduction: moving a body part toward the
pain occurs.
midline of the body
8. Shoulder. Support the resident’s arm at the
• Dorsiflexion: bending backward
elbow and wrist during ROM for the shoul-
• Rotation: turning a joint der. Place one hand under the elbow and
21 382

the other hand under the wrist. Raise the Exercise the forearm by moving it so the
straightened arm from the side position for- palm is facing downward (pronation) and
ward to above the head and return arm to then the palm is facing upward (supination)
side of the body (flexion/extension) (Fig. 21-10).
Rehabilitation and Restorative Care

(Fig. 21-7).

Fig. 21-10.

10. Wrist. Hold the wrist with one hand and use
the fingers of the other hand to help the joint
through the motions. Bend the hand down
Fig. 21-7. (flexion); bend the hand backwards (exten-
sion) (Fig. 21-11).
Raise the arm to side position above head
and return arm to side of the body (abduc-
tion/adduction) (Fig. 21-8).

Fig. 21-11.
Fig. 21-8.
Turn the hand in the direction of the thumb
9. Elbow. Hold the resident’s wrist with (radial flexion). Then turn it in the direction
one hand, the elbow with the other hand. of the little finger (ulnar flexion) (Fig. 21-12).
Bend the elbow so that the hand touches
the shoulder on that same side (flexion).
Straighten the arm (extension) (Fig. 21-9).

Fig. 21-9. Fig. 21-12.

 383 21

11. Thumb. Move the thumb away from the Spread the fingers and the thumb far apart
index finger (abduction). Move the thumb from each other (abduction). Bring the fin-
back next to the index finger (adduction) gers back next to each other (adduction)
(Fig. 21-13). (Fig. 21-17).

Rehabilitation and Restorative Care

Fig. 21-13. Fig. 21-17.

Touch each fingertip with the thumb (opposi- 13. Hip. Support the leg by placing one hand
tion) (Fig. 21-14). under the knee and one under the ankle.
Straighten the leg and raise it gently upward.

Move the leg away from the other leg (abduc-

tion). Move the leg toward the other leg (ad-
duction) (Fig. 21-18).

Fig. 21-14.

Bend thumb into the palm (flexion) and out

to the side (extension) (Fig. 21-15).

Fig. 21-15.

12. Fingers. Make the hand into a fist (flexion).

Gently straighten out the fist (extension)
(Fig. 21-16).

Fig. 21-16. Fig. 21-18.

21 384

Gently turn the leg inward (internal rotation), toes pointed down (plantar flexion)
then turn the leg outward (external rotation) (Fig. 21-21).
(Fig. 21-19).
Rehabilitation and Restorative Care

Fig. 21-21.

Turn the inside of the foot inward toward the

body (supination). Bend the sole of the foot
so that it faces away from the body (prona-
tion) (Fig. 21-22).

Fig. 21-19.

14. Knees. Support the leg under the knee and

under the ankle while performing ROM for
the knee. Bend the leg to the point of resis-
tance (flexion). Return leg to resident’s nor-
mal position (extension) (Fig. 21-20).

Fig. 21-22.

16. Toes. Curl and straighten the toes (flexion

and extension) (Fig. 21-23).

Fig. 21-20.

15. Ankles. Push/pull foot up toward the head Fig. 21-23.

(dorsiflexion). Push/pull foot down, with the
 385 21

Gently spread the toes apart (abduction) you have not been trained. Ask the nurse for
(Fig. 21-24). instructions.

Rehabilitation and Restorative Care

Fig. 21-25. Incentive spirometers are used for deep
breathing exercises.

Fig. 21-24. Chapter Review

1. What does rehabilitation involve?
17. Return resident to comfortable position. Re-
turn bed to lowest position. Remove privacy 2. What attitudes can a NA adopt to help with
measures. restorative care? Give an example of each.

18. Place call light within resident’s reach. 3. List 10 problems that a lack of mobility can
cause.
19. Wash your hands.
4. What are some benefits of regular exercise?
20. Report any changes in resident to nurse.
5. Look at the adaptive devices in Figure 21-2.
21. Document procedure using facility guide- Choose one and briefly describe how it
lines. Note any decrease in range of motion might help a resident recovering from or
or any pain experienced by the resident. No- adapting to a physical condition.
tify the nurse or the physical therapist if you 6. List three guidelines to follow to help resi-
find increased stiffness or physical resistance. dents maintain good alignment.
Resistance may be a sign that a contracture
7. List and describe four prosthetic devices.
is developing.
8. What should be observed about the skin on
the stump of an amputated body part?

7. Describe the benefits of deep breathing 9. Why should alcohol not be used to clean an
exercises artificial eye?
10. What is the goal of ROM exercises?
Deep breathing exercises help expand the lungs,
clearing them of mucus and preventing infec- 11. When performing ROM exercises, where
tions (such as pneumonia). Residents who are should the NA begin? Which parts of the
paralyzed or who have had surgery are often told body should be exercised first?
to do deep breathing exercises regularly to ex- 12. Describe the difference between passive,
pand the lungs. active, and active assisted range of motion
The care plan may include using a deep breath- exercises.
ing device called an incentive spirometer (Fig. 13. Why are deep breathing exercises
21-25). Do not assist with these exercises if performed?
22 386

22
Special Care Skills

Special Care Skills

1. Understand the types of residents who 2. Discuss reasons for and types of
are in a subacute setting surgery
Subacute care is a kind of specialized care that There are many reasons why surgery is per-
falls between acute care and long-term care. formed, including the following:
This type of care can take place in hospitals and • To relieve symptoms of a disease
in skilled nursing facilities. People in subacute
settings require more treatment, monitoring, • To repair or remove problem tissues and
and services than regular long-term care pro- structures
vides. Subacute care may be necessary due to • To improve appearance or correct function of
recent surgery, injuries, or chronic illnesses, damaged tissues
such as AIDS (Fig. 22-1). Complex wound care, • To diagnose disease
specialized infusion therapy, dialysis, and me-
• To cure a disease
chanical ventilation may also require subacute
care. Dialysis cleanses the body of waste that the Surgeries generally fall into three categories:
kidneys cannot remove due to chronic kidney elective, urgent, and emergency. Elective surgery
failure. A mechanical ventilator is a machine is surgery that is chosen by the patient and is
that assists with or replaces breathing when a planned in advance. Generally, the surgery is
person cannot breathe on his own. not absolutely necessary. Plastic surgery, such
as having a facelift, is an example of an elective
surgery.
Urgent surgery is surgery that must be per-
formed for health reasons, but is not an emer-
gency. Urgent surgery may even be planned and
scheduled in advance, as with heart surgery,
such as coronary artery bypass surgery.
Emergency surgery is unexpected and unsched-
uled surgery that is performed immediately to
save a patient’s life or a limb. A gunshot wound,
car accident, or ruptured appendix are examples
Fig. 22-1. Subacute care provides a higher level of care; it of situations that can require emergency surgery.
may be necessary due to surgery, illness, serious wounds,
When a person has surgery, anesthesia will usu-
dialysis or mechanical ventilation.
ally be given. Anesthesia involves the use of
 387 22

medication to block pain during surgery and a resident’s concerns. Report any concerns or
other medical procedures. Local anesthesia questions to the nurse. Also report to the nurse
involves the injection of an anesthetic directly if the person requests a visit from clergy.
into the surgical site or area to block pain. It

Special Care Skills

is used for minor surgical procedures, and the
person may remain awake during the surgery.
Regional anesthesia involves injection of an an-
esthetic into a nerve or group of nerves to block
sensation in a particular region of the body. It
is limited to an area, but to a larger area than
for a local anesthetic. One example of a regional
anesthetic is an epidural, which is used during
childbirth to block pain in the body in the lower
half of the body, from the waist down. General
Fig. 22-2. Patients often have many worries before sur-
anesthesia is inhaled or injected directly into a
gery. A compassionate response by staff may help allevi-
vein and affects the brain and the entire body. ate concerns.
The person is unaware of his surroundings and
does not feel any pain. It blocks any memory of A person who is having surgery will require
the procedure. This type of anesthesia is stopped preoperative physical preparation, as well. Follow
when the surgery has been completed. these general guidelines to assist with physically
preparing a resident for surgery:
3. Discuss preoperative care
Depending on where you work, your duties may Guidelines:
include giving preoperative, or before surgery, Preoperative Care
care. Preoperative care includes both physical
G Before surgery, there will be an order for the
and psychological preparation. Before a person
resident to receive NPO (nothing by mouth).
has surgery, a doctor will explain the procedure,
This time usually ranges anywhere from two
the risks and benefits, and what to expect after
to eight hours. Having this medical order
surgery. The person will be encouraged to ask
means that nothing is allowed by mouth,
questions and give opinions. This is part of in-
including water, ice chips, food, etc. Remove
formed consent (Chapter 3), a process in which
the water pitcher, glass, and any other food
a person, with the help of a doctor, makes in-
and fluids from the immediate area. Explain
formed decisions about his or her health care.
to the resident why you are doing this. Report
The person must sign a written consent form
any concerns to the nurse.
for surgery, or have one signed by a guardian or
someone with medical power of attorney. G Assist the resident with urinating before
surgery.
People who are going to have surgery often ex-
perience anxiety, fear, worry, and sadness, and G For some residents having surgery of the
other emotions (Fig. 22-2). It is often helpful gastrointestinal tract, the bowels may need
to express these concerns to members of the to be cleared. An enema or suppository may
healthcare team. Being prepared psychologically be ordered. Assist as trained, ordered, and
may help the resident cope better after surgery. allowed. Be ready to bring the bedpan or por-
As a nursing assistant, part of your role in as- table commode when needed. Provide plenty
sisting with this preparation means listening to of privacy.
22 388

G Assist with bathing as needed. Dressing the While the resident is in recovery, your duties
person in loose-fitting clothes may make it will include changing bed linens and gathering
easier to change into a gown later. equipment. Equipment needed may include the
following:
Special Care Skills

G Make sure call light is within reach every time

before you leave the room. • Bed protector

G Measure and record vital signs as ordered. • Towels and washcloths

G Remove dentures, glasses, contact lenses, • Vital signs equipment

hearing aids, jewelry, hairpieces, hairpins, • Emesis basin
and any other personal items. Store these • Pillows and other positioning devices
safely according to facility policy. For local or
regional anesthetic, the doctor may want the • Warming blankets
person to wear hearing aids and dentures, so • IV pole
that communication will be easier. • Oxygen and suction equipment
G Assist person to change into gown, if When the resident returns to the room, use the
required. following guidelines to assist with postoperative
G Transfer to a stretcher/gurney if necessary. care:

G Make sure the resident’s identification brace-

let is accurate and on the wrist or ankle prior Guidelines:
to transport. You may need to verify if the Postoperative Care
resident has any known allergies by asking
G Move furniture as needed to allow for the
this question or verifying what is written on
transfer back into bed from the stretcher.
an allergy bracelet.
G Assist with transferring the resident back into
bed. (Chapter 10 has information on stretch-
4. Describe postoperative care er transfers.)
Postoperative, or after surgery, care begins G Return dentures, glasses, contact lenses, and
immediately following surgery. The goal of hearing aids to the resident. Remember that
postoperative care is to prevent infections, pro- without these items, residents may not be
mote healing, and return the person to a state able to talk, eat, see, or hear.
of health. Immediate postoperative concerns are
G Measure and record vital signs often after
problems with breathing, mental status, pain,
surgery as directed. The schedule may look
and wound healing. Complications of surgery
like this: every 15 minutes for the first hour,
can also include urinary retention or infections,
every 30 minutes for the next hour to two
constipation, blood pressure variances, and
hours, every hour for the next four hours, and
blood clots. Careful postoperative monitoring is
then every four hours. Report any changes
critical.
immediately.
After surgery, the resident is taken to the recov-
G Reposition the resident every hour to two
ery room and may remain there for some time.
hours, or as ordered. Elevate the extremities
This depends on the type of surgery the resident
as ordered.
had, as well as how long the surgery was, what
type and how much anesthetic was used, and G Assist with deep breathing and coughing
the resident’s level of consciousness. exercises (Chapter 21).
 389 22

G Apply anti-embolic hose to reduce the risk of 5. List care guidelines for pulse oximetry
blood clots, if ordered. Assist with leg exer-
cises as instructed. When residents have had surgery, are on oxygen,
are in intensive care, or have cardiac or respira-

Special Care Skills

G Apply binders as ordered. Binders are stretch- tory problems, a pulse oximeter may be used.
able pieces of fabric that can be fastened. A pulse oximeter is a noninvasive device that
They hold dressings in place and give sup- uses a light to determine the amount of oxygen
port to surgical wounds. Binders can also in the blood (also called oxygen saturation). A
reduce swelling and ease discomfort. pulse oximeter also measures a person’s pulse
G Encourage proper nutrition and fluid intake. rate.
Proper food and fluid intake can speed the A sensor is clipped on a person’s finger, earlobe,
recovery process. The resident may be on a or toe (Fig. 22-3). A light passes through the
high-protein diet to promote wound healing. skin, and the percentage of oxygen in the blood
G Assist with elimination. Always provide plenty and the pulse rate are displayed. An alarm will
of privacy for elimination. sound if the oxygen level becomes less than
optimal.
G Help with bathing and grooming as request-
ed and as ordered.
G Assist with ambulation as needed and as
ordered. Be encouraging and positive.

Observing and Reporting:

Postoperative Care

Report the following signs and symptoms of Fig. 22-3. A pulse oximeter.
complications to the nurse immediately:
Normal blood oxygen level usually measures be-
Changes in vital signs tween 95% and 100%. However, what is normal
Difficulty breathing may differ from person to person. Report any in-
crease or decrease in oxygen levels to the nurse.
Mental changes, such as confusion or
disorientation Guidelines:
Changes in consciousness Pulse Oximeter

Pale or bluish skin G Report to the nurse immediately if the alarm

Skin that is cold or clammy on the pulse oximeter sounds.

Increase in amount of drainage G Tell the nurse if the pulse oximeter falls off or
if the resident requests you remove it.
Swelling at IV site
G Check the skin around the device often.
IV that is not dripping
Report any of the following:
Nausea or vomiting
Swelling
Numbness or tingling
Bluish, or cyanotic, skin
Resident complaints of pain
Shiny, tight skin
22 390

Skin that is cold to the touch 7. Explain artificial airways and list care
Sores, redness, or irritation guidelines
Numbness or tingling An artificial airway is any plastic, metal, or
Special Care Skills

Pain or discomfort rubber device inserted into the respiratory tract

to maintain or promote breathing. Artificial
G Check vital signs as ordered. Report changes
airways keep the airway open. This is necessary
to the nurse.
when the airway is obstructed due to illness,
injury, secretions, or aspiration. Some residents
6. Describe telemetry and list care
who are unconscious will need an artificial
guidelines
airway.
Telemetry is used to measure the heart rhythm
The artificial airway is inserted using a method
and rate on a continuous basis. Wires are at-
called intubation. Intubation involves the pas-
tached to the chest with sticky pads or patches.
sage of a plastic tube through the mouth, nose,
The wires are connected to a battery-powered
or an opening in the neck and into the trachea
portable unit, which sends data to computer
(windpipe). There are different types of artificial
screens at a monitoring station. This data is
airways (Fig. 22-4). One common type is a tra-
monitored and assessed at all times by specially
cheostomy, which is a surgically-created open-
trained staff.
ing through the neck into the trachea. A hollow
Telemetry may be necessary due to chest pain, tube, called a tracheostomy tube, is inserted
heart or lung disease, heart or lung surgery, ir- through this opening into the trachea. It is also
regular heartbeats, or certain medications that called a “trach tube.” More information on this
affect heart rhythm or rate. type of artificial airway may be found in the
next Learning Objective.
Guidelines:
Telemetry

G Report to the nurse if the pads become wet

or soiled. Report if pads appear loose or fall
off.
Fig. 22-4. An endotracheal tube is a type of artificial air-
G Report if the alarm sounds. The alarm may way that is inserted through the mouth and then into the
sound if the pads disconnect, or if the battery trachea. (photo courtesy of rusch - a teleflex company.)
is low.
G Check the skin around the pads often. Report
any of the following: Guidelines:
Artificial Airways
Swelling
Sores, redness, or irritation G Observe the resident closely. If the tubing
falls out, tell the nurse immediately.
Fluid or blood draining from skin
Broken skin G Check vital signs as ordered. Report changes
to the nurse.
G Report resident complaints of chest pain or
discomfort, as well as any difficulty breathing. G Perform oral care often, as directed.

G Check vital signs as ordered. Report changes G Watch for biting and tugging on tube. If a
to the nurse. resident is doing this, tell the nurse.
 391 22

G Use other methods of communication if This procedure is usually temporary, but it can
the person cannot speak. Try writing notes, be permanent. It is easier to suction and attach
drawing pictures, and using communication respiratory equipment with a tracheostomy than
boards. Watch for hand and eye signals. with other artificial airways.

Special Care Skills

G Be supportive and reassuring. It can be When the tracheostomy is first placed, it may be
frightening and uncomfortable to have an difficult for the resident to adapt to breathing
artificial airway. Some residents may choke through the tube. This can cause anxiety and
or gag. Be empathetic. Imagine how it might frustration. It may be difficult for the resident to
feel to have a tube in your nose, mouth, or talk at first, which also causes fear. During this
throat. time, be especially supportive and encouraging.
Use other methods of communication, such as
writing notes, drawing pictures, using commu-
8. Discuss care for a resident with a
nication boards, and using hand and eye signals.
tracheostomy Check on the resident often, and answer call
A tracheostomy is a type of artificial airway com- lights immediately. People can usually learn to
monly seen in long-term care (Fig. 22-5). Trache- talk through a trach tube.
ostomies may be necessary for many reasons, Care of the tracheostomy may include skin care
including the following: around the opening, helping with dressing
• Tumors/cancer changes, and cleaning the device. Suctioning
may be required. Nursing assistants do not per-
• Infection
form suctioning or trach care. Your responsibili-
• Severe neck or mouth injuries ties will mostly include observing and reporting.
• Facial surgery and facial burns
• Long-term unconsciousness or coma Observing and Reporting:
Tracheostomies
• Obstruction in the airway
• Paralysis of muscles related to breathing Report any of the following to the nurse:
• Aspiration as a result of muscle or sensory Shortness of breath
problems in the throat Trouble breathing
• Severe allergic reaction Gurgling sounds
• Gunshot wound Any signs of skin breakdown around the
opening, such as irritation, rash, cracks,
breaks, sores, or bleeding on the skin
The type and amount of discharge the resi-
dent coughs up through the tracheostomy
(normal discharge looks like white mucus or
saliva)
Any increase in the amount of discharge
Discharge that is thick, yellow, green, bloody,
Fig. 22-5. A tracheostomy tube is inserted through a or has an odor (this may indicate an infection
surgically-created opening in the neck into the trachea. or other problem in the lungs)
(photo courtesy of rusch - a teleflex company)
Mouth sores or discomfort
22 392

It is very important to prevent infection when Residents on a ventilator are often heavily se-
caring for residents with tracheostomies. They dated. A sedative is an agent or drug that helps
are prone to respiratory infections. Wash your calm and soothe a person and may cause sleep.
hands often and wear gloves when indicated. Being sedated helps prevent people on ventila-
Special Care Skills

Keep equipment clean. Anything that is dropped tors from feeling discomfort and anxiety. Even
on the floor must be sterilized before it can be if a resident seems unaware of what is happen-
used in contact with the tubes. Great care must ing, continue to speak to him or her and explain
be taken so that nothing gets into the tube what you are doing.
which can cause an infection in the lungs.

9. List care guidelines for residents Guidelines:

requiring mechanical ventilation Mechanical Ventilator

Residents in a subacute unit may be on a me- G Ventilators cause an increased risk for a
chanical ventilator (Fig. 22-6). Mechanical special type of pneumonia. Wash your
ventilation is using a machine to assist with or hands often when working with residents on
replace breathing (inflate and deflate the lungs) mechanical ventilators.
when a person is unable to do this on his own. A
person may require mechanical ventilation due G Report to the nurse if the alarm sounds.
to cardiac or respiratory arrest, lung injuries and G If you notice tubing that is disconnected or
diseases, or head and spinal cord injuries. loose, report it immediately.

G Answer the call light promptly.

G Follow the care plan for repositioning instruc-

tions. Give regular, careful skin care to pre-
vent pressure sores. Check the skin around
the intubation site often, as well as on the
rest of the body. Report any of the following:
Fig. 22-6. A mechanical ventilator. (photo courtesy of Swelling
pulmonetic systems)

Sores, redness, irritation

Residents will not be able to speak while on the
mechanical ventilator. This is because air will no Fluid or blood draining from skin
longer reach the larynx (vocal cords). Not being
Broken skin
able to speak may increase anxiety. The resident
may think that no one will know if he or she is G Report if the resident is pulling on or biting
having trouble breathing. Being on a ventila- the tube. Report if the resident is anxious,
tor has been compared to breathing through a fearful, or upset.
straw. Think about how that might feel. Resi-
G Be patient during communication. Observe
dents will need a lot of support while connected
body language. Watch for hand or eye sig-
to the ventilator. Enter the room often so that the
nals.
resident can see you. This reassures residents
that they are being carefully observed. Clip- G Check on the resident often, so that the resi-
boards, notepads, and communication boards dent can see you are there. Be supportive,
will help with communication. kind, and empathetic.
 393 22

10. Describe suctioning and list signs of • Retracting (chest appears to sink in below
respiratory distress the neck with each breath)

Subacute care units include residents who re- • Sweating

Special Care Skills

quire suctioning by nurses or respiratory thera- • Wheezing
pists. Suctioning removes mucus and secretions
from the lungs when a person cannot do this on
his own. A person who has a tracheostomy may Guidelines:
require suctioning. Suctioning can be performed Suctioning
through the nose, mouth, or throat.
G Report signs of respiratory distress to the
Suctioning is normally a sterile procedure. nurse immediately.
Nurses or respiratory therapists will perform
the suctioning. A portable pump, operated on G Monitor vital signs closely, especially respira-
battery power or electrical power, may be used tory rate. Report changes.
to suction the resident (Fig. 22-7). A canister
G Follow Standard Precautions. Don gloves,
or bottle on the pump collects the mucus and
gown, mask, or goggles as directed.
secretions.
G Assist the nurse with suctioning as needed.
You may be asked to have a towel or wash-
cloth ready to clean the resident after suc-
tioning. Give oral care as ordered.

G Report resident complaints of pain or diffi-

culty breathing.

11. Describe chest tubes and explain

Fig. 22-7. This is one type of suctioning pump. Nursing related care
assistants do not perform suctioning. They help by report-
ing signs of respiratory distress and monitoring vital signs. Chest tubes are hollow drainage tubes that
(photo courtesy of laerdal medical corporation)
are inserted into the chest during a sterile pro-
A person who needs frequent suctioning may cedure. They can be inserted at the bedside or
show signs of respiratory distress. Signs of respi- during surgery. Chest tubes drain air, blood, or
ratory distress include the following: fluid that has collected inside the pleural cavity
• Gurgling sound of secretions or space. The pleural cavity is the space between
the layers of the pleura, the thin membrane that
• Difficulty breathing covers and protects the lungs. Chest tubes are
• Elevated respiratory rate also inserted to allow a full expansion of the
lungs. Some conditions that require chest tube
• Pale, bluish, or gray skin around the eyes,
insertion include the following:
mouth, fingernails or toenails
• Nostrils flaring (nostrils opening wider when • Pneumothorax: air or gas in the pleural
breathing in may show that a person is hav- space
ing to work harder to breathe) • Hemothorax: blood in the pleural space
22 394

• Empyema: pus in the pleural space G Report if there is an increase or decrease in

bubbling in the drainage system. Report if
• Certain types of surgery
there are clots in the tubing.
• Chest trauma or injuries
Special Care Skills

G Follow the repositioning schedule. Be very

A doctor normally inserts chest tubes. The chest gentle with turning and repositioning. You
tube is connected to a bottle of sterile water. must move the resident and the tubes at the
Suction is sometimes attached to the system to same time to prevent tubes from coming out.
encourage drainage. This system must be sealed Always get enough help.
so that air cannot enter the pleural cavity. The
G Report odor in the chest tube area.
system must be airtight.
G Provide rest periods as needed.
When X-rays show that the air, blood, or fluid
has been drained, the tube is removed. Medica- G Follow fluid intake orders. Measure intake
tions may be used to prevent or treat infection. and output carefully as ordered.
G If asked to help with coughing and deep
Guidelines: breathing exercises, be encouraging and
Chest Tubes patient.
Other residents who require more direct care
G Be aware of the number and location of chest
and close observation by staff include residents
tubes. Tubes may be in the front, back, or
with IVs (Chapter 14) and residents with tube
side of the body.
feedings (Chapter 15).
G Check vital signs as directed. Report any
changes immediately to the nurse.
Chapter Review
G Report signs of respiratory distress to the
nurse immediately. Report complaints of 1. What is different about the type of care
pain. provided in a subacute setting as compared
to the type of care provided in regular long-
G Keep the drainage system below the level of term care?
the resident’s chest.
2. Briefly describe three types of surgeries.
G Make sure drainage containers remain
upright and level at all times. 3. Which type of anesthesia is inhaled or in-
jected directly into a vein and affects the
G Make sure that tubing is not kinked. If tub- brain and entire body?
ing becomes kinked, report to the nurse right
away. 4. List eight guidelines for assisting with pre-
operative care.
G Watch for disconnected tubing. If this hap-
pens, report it immediately. 5. List eight guidelines for assisting with post-
operative care.
G Certain equipment is kept nearby in case
tubes are pulled out. Do not remove these 6. List 10 signs and symptoms to report about
items from the area. a resident after surgery.

G Observe chest drainage for color and 7. List two reasons why a resident may need a
amount. Report any changes in color or pulse oximeter.
amount immediately.
 395 22

8. What is important to report about the skin

when a resident is using a telemetry unit?
9. What are alternate methods of communica-

Special Care Skills

tion nursing assistants can use with resi-
dents who have artificial airways?
10. What are a nursing assistant’s responsibili-
ties with tracheostomy care?
11. In what ways can a nursing assistant show
support for a resident who is on a ventilator?
12. Why might a resident be anxious while on a
ventilator?
13. List five signs of respiratory distress.
14. What types of fluids are drained by chest
tubes?
15. List 12 guidelines for caring for residents
with chest tubes.
23 396

23
Death and Dying

Death and Dying

1. Discuss the stages of grief to not take it personally. This is the “Why me?”
stage.
Death can occur suddenly without warning, or
it can be expected. Older people, or those with Bargaining. Once people have begun to believe
terminal illnesses, may have time to prepare for that they really are dying, they may make prom-
death. A terminal illness is a disease or condi- ises to God. They may somehow try to bargain
tion that will eventually cause death. Preparing for recovery. This is the “Yes me, but...” stage.
for death is a process. It affects the dying per- Depression. As dying people become physically
son’s emotions and behavior. weaker and their symptoms get worse, they
Dr. Elisabeth Kubler-Ross researched and wrote may become deeply sad or depressed (Fig. 23-
about the grief process. Her book, On Death and 1). They may cry or withdraw or be unable to
Dying, describes five stages that dying people do even simple things. They need physical and
and their families or friends may experience be- emotional support. Listen to residents and be
fore death. These five stages are described below. understanding.
Not all residents go through all the stages. Some
may stay in one stage until death. Residents may
move back and forth between stages during the
process.
Denial. People in this stage may refuse to be-
lieve they are dying. They often think that a mis-
take has been made. They may demand lab work
be repeated. They may talk about the future and
avoid discussion about their illnesses. They may
simply act like it is not happening. This is the
“No, not me” stage.
Anger. Once they start to face the possibility of
their death, people become angry. They may be
angry because they think they are too young or
that they have always taken care of themselves.
Anger may be directed at staff, visitors, room-
Fig. 23-1. A person who is dying may become depressed
mates, family, or friends. Anger is a normal, and withdrawn. Give emotional support to these resi-
healthy reaction. The caregiver must learn not dents. Listen closely and be kind and compassionate.
 397 23

Acceptance. Most people who are dying are may wish we had done more for the dying per-
eventually able to accept death and prepare for it. son. We may simply feel that he or she did not
They may ask to see an attorney or accountant. deserve to die. We may feel guilty that we are
They may arrange with loved ones for the care still living.

Death and Dying

of important people or things. They may plan Regret. Often we regret what we did or did not
for their last days or for the ceremonies to follow. do for the dying person. We may regret things
At this stage, people who are dying may seem we said or did not say. Many people carry regrets
detached. with them for years.
These stages of dying may not be possible for Sadness. Feeling depressed is very common
someone who dies suddenly, unexpectedly, or after a death. We may cry or feel emotionally
quickly. You cannot force anyone to move from unstable. We may have headaches or insomnia
stage to stage. You can only listen, and be ready when we cannot express our sadness.
to offer your help.
Loneliness. Missing someone who has died is
very normal. It can bring up other feelings, such
2. Describe the grief process as sadness or regret. Many things may remind
us of the person who died. The memories may
Dealing with grief after the death of a loved one be painful at first. With time, we usually feel
is a process as well. Grieving is an individual less lonely and memories are less painful.
process. No two people will grieve in exactly the
same way. Clergy, counselors, or social workers
3. Discuss how feelings and attitudes
can help people who are grieving. Family mem-
bers or friends may have any of the following
about death differ
reactions to the death of a loved one: Death is a very sensitive topic; many people find
Shock. Even when death is expected, family it hard to discuss. Feelings and attitudes about
members and friends may still be shocked after death can be formed by many factors.
it occurs. Many of us do not know what to expect Experience with death. Someone who has been
after the death of a loved one. We may be sur- through other deaths may have a different un-
prised by our feelings. derstanding of death than someone who has not.

Denial. Sometimes we want to think that every- Personality type. Open, expressive people may
thing will quickly return to normal after a death. have an easier time talking about and coping
Denying or refusing to believe we are grieving with death than those who are very reserved or
can help people deal with the hours or days after quiet. Sharing feelings is one way of working
a death. But eventually we must face our feel- through fears and concerns.
ings. Grief can be overwhelming. Some people Religious beliefs. Religious practices and beliefs
may take years to face their feelings. Profes- affect a person’s experience with death (Fig. 23-
sional help can be very valuable. 2). This includes the dying process, rituals at the
Anger. Although it is hard to admit it, many of time of death, burial or cremation, services after
us feel angry after a death. We may be angry death, and mourning customs. For example,
with ourselves, at God, at the doctors, or even some Catholics do not believe in cremation. Or-
at the person who died. There is nothing wrong thodox Jews may not believe in viewing the body
with feeling anger as a part of grief. after death. Beliefs about what happens after
death can also influence grieving. Those who
Guilt. It is very common for families, friends, believe in an afterlife, such as heaven, may be
and caregivers to feel guilty after a death. We comforted by this.
23 398

Guidelines:
Dying Resident
Death and Dying

G Diminished senses. Reduce glare and keep

room lighting low (Fig. 23-4). Hearing is usu-
ally the last sense to leave the body. Speak in
a normal tone. Tell resident about any pro-
cedures that are being done. Describe what
is happening in the room. Do not expect an
answer. Ask few questions. Encourage family
to speak to the resident, but to avoid subjects
that are disturbing. Observe body language
to anticipate a resident’s needs.

Fig. 23-2. Religious beliefs influence a person’s feelings

about death.

Cultural background. The practices we grow up

with will affect how we deal with death. Cultural
groups may have different practices to deal with
death and grieving. Some groups have meals
and other services but say very little about a per- Fig. 23-4. Keep a dying resident’s room softly lit without
glare.
son’s death. In other groups, talking about and
remembering the person who has died may be a
G Care of the mouth and nose. Give mouth care
comfort to family and friends (Fig. 23-3).
often. If the resident is unconscious, give
mouth care every two hours. The lips and
nostrils may be dry and cracked. Apply lubri-
cant, such as lip balm, to lips and nose.
G Skin care. Give bed baths and incontinence
care as needed. Bathe perspiring residents
often. Skin should be kept clean and dry.
Change sheets and clothes for comfort. Keep
sheets wrinkle-free. Skin care to prevent pres-
sure sores is important.

Fig. 23-3. Looking at photos and sharing stories about G Comfort. Pain relief is critical. Residents may
a person who is dying or who has died is one way family not be able to tell you that they are in pain.
and friends may grieve. Observe for signs of pain. Report them.
Frequent changes of position, back massage,
4. Discuss how to care for a dying skin care, mouth care, and proper body align-
resident ment may help.
Follow the care plan when caring for a dying Body temperature usually rises. Many resi-
resident. However, keep these guidelines in dents are more comfortable with light covers.
mind to help make the resident as comfortable However, fever may cause chills. Use extra
as possible: blankets if residents need more warmth.
 399 23

To control pain, residents may be connected Some dying residents may seek spiritual
to a patient-controlled analgesia (PCA) device comfort from clergy. Tell the nurse imme-
(Fig. 23-5). A PCA is a method of pain control diately if resident requests a clergy person.
that allows patients to administer pain medi- Give privacy for visits from clergy, family, and

Death and Dying

cation to themselves. They press a button to friends. Do not discuss your religious or spir-
give themselves a dose of pain medication. itual beliefs with residents or their families or
Report any complaints of pain or discomfort make recommendations.
to the nurse immediately. Take the time to sort out your own feelings
about death. If you are not comfortable with
the topic, dying residents will feel it. Speak to
the nurse if you need resources to help you
deal with your feelings.

Advance Directives

Fig. 23-5. A patient-controlled analgesia (PCA) device. You first learned about advance directives and DNR
(photo courtesy of mckinley medical www.mckinleymed.com) orders in Chapter 3. Advance directives allow people
to choose what medical care they want or do not
G Environment. Put favorite objects and pho- want if they cannot make those decisions them-
selves. A DNR order tells medical professionals not
tographs where the resident can easily see to perform CPR. DNR orders may be written for a
them. They may give comfort. Make sure the person who has a terminal illness, someone who al-
room is comfortable, appropriately lit, and most certainly will not be saved by CPR, a person not
well ventilated. When leaving the room, place expected to live long, and/or a person who simply
wants to let nature take its course.
the call light within reach, even if the resident
is unaware of his or her surroundings. If a resident has an advance directive in place, you
may be asked to continue to monitor vital signs,
G Emotional and spiritual support. Residents such as temperature, pulse, respirations, and blood
who are dying may be afraid of what is hap- pressure, and report the readings to the nurse.
Comfort measures, such as pain medication, will
pening and of death. Listening may be one of continue to be used. However, depending on what
the most important things you can do for a the advance directive states, performing CPR or any
dying resident. Pay attention to these conver- extraordinary measures may be prohibited, no mat-
sations. Report any comments about fear to ter how the vital signs have changed or declined.
Extraordinary measures are measures used to pro-
the nurse. long life when there is no reasonable expectation of
People who are dying may also need the recovery. When a person with a DNR order stops
breathing or the heart stops, he or she will die unless
quiet, reassuring, and loving presence of the heart or breathing restarts on its own. This is not
another person. Touch can be very important. likely to happen. By law, advance directives and DNR
Holding your resident’s hand can be comfort- orders must be honored. Respect each resident’s de-
ing. cisions about advance directives.

Do not avoid the dying person or his or her

family. Do not deny that death is approach- 5. Describe ways to treat dying residents
ing, and do not tell the resident that anyone and their families with dignity and honor
knows how or when it will happen. Do give their rights
accurate information in a reassuring way. No
Working in a long-term care facility with elderly
one can take away another’s fear of death.
and ill residents will probably expose you to
However, your supportive and reassuring
death more often than other people are exposed
presence can help.
to it. You can treat residents with dignity when
23 400

they are approaching death by respecting their • Expect continuing medical and nursing at-
rights and their preferences. There are some tentions even though “cure” goals must be
legal rights to remember when caring for the changed to “comfort” goals.
terminally ill:
Death and Dying

• Not die alone.

The right to refuse treatment. Remember that
• Be free from pain.
whether you agree or disagree with a resident’s
decisions, the choice is not yours. It belongs to • Have my questions answered honestly.
the person involved. Sometimes, when a resi- • Not be deceived.
dent is not able to make a decision, he has told
• Have help from and for my family in accept-
family members how he wishes things to be
ing my death.
done. Be supportive of family members. Do not
judge them. They are most likely following the • Die in peace and dignity.
resident’s wishes. • Retain my individuality and not be judged
The right to have visitors. When death is close, for my decisions, which may be contrary to
it is an emotional time for all those involved. the beliefs of others.
Saying goodbye can be a very important part • Discuss and enlarge my religious and/or
of dealing with a loved one’s death. It may also spiritual experiences, whatever these may
be very reassuring to the dying person to have mean to others.
someone in the room, even if they do not seem
to be aware of their surroundings. • Expect that the sanctity of the human body
will be respected after death.
The right to privacy. Privacy is a basic right, but
privacy for visiting, or even when the person is • Be cared for by caring, sensitive, knowledge-
alone, may be even more important now. able people who will attempt to understand
my needs and will be able to gain some sat-
Other rights of a dying person are listed below isfaction in helping me face my death.
in “The Dying Person’s Bill of Rights.” This was
created at a workshop on “The Terminally Ill Ways to treat dying residents and their families
Patient and the Helping Person,” sponsored by with dignity include the following:
Southwestern Michigan In-Service Education • Respect their wishes in all possible ways.
Council, and appeared in the American Journal Communication between staff is extremely
of Nursing, Vol. 75, January 1975, p. 99. important at this time so that everyone un-
I have the right to: derstands what the resident’s wishes are.
Listen carefully for ideas on how to provide
• Be treated as a living human being until I simple gestures that may be special and
die. appreciated.
• Maintain a sense of hopefulness, however • Do not isolate or avoid a resident who is
changing its focus may be. dying. Enter his or her room regularly.
• Be cared for by those who can maintain a • Be careful not to make promises that cannot
sense of hopefulness, however changing this or should not be kept.
might be.
• Continue to involve the dying person in fa-
• Express my feelings and emotions about my cility activities. Be resident-centered. Do not
approaching death in my own way. talk with other staff members about your
• Participate in decisions concerning my care. personal life when caring for a resident.
 401 23

• Listen if a dying resident wants to talk but 6. Define the goals of a hospice program
do not offer advice. Do not make judgmental
comments. Hospice is the term for the special care that a
dying person needs. It is a compassionate way to

Death and Dying

• Do not babble or be especially cheerful or care for dying people and their families. Hospice
sad. Sometimes you may be nervous when care uses a holistic approach. It treats the per-
you know that a resident is dying. That ner- son’s physical, emotional, spiritual, and social
vousness may lead to giggling or talking needs.
too much. If you let your emotions get out
Hospice care can be given seven days a week, 24
of hand, you may be so sad and upset that
hours a day. There is always a nurse on call to
you cannot be any help to the resident who
answer questions, make a visit, or solve a prob-
needs you. Remain professional.
lem. Hospice care may be given in a hospital,
• Keep the resident as comfortable as possible. at a care facility, or in the home. A hospice can
The nurse needs to know immediately if be any location where a person who is dying is
pain medication is requested. Keep the resi- treated with dignity by caregivers. Hospice care
dent clean and dry. is available with a doctor’s order.
• Assure privacy when it is desired. Any caregiver may give hospice care, but often
• Respect the privacy of the family and other specially-trained nurses, social workers, and
visitors. They may be upset and not want to volunteers provide hospice care. The hospice
be social at this time. They may welcome a team may include doctors, nurses, social work-
friendly smile, however, and should not be ers, counselors, nursing assistants, home
isolated, either. health aides, therapists, clergy, dietitians, and
volunteers.
• Help with the family’s physical comfort. If
requested, get them coffee, water, chairs, Hospice care helps to meet all needs of the
blankets, etc. dying resident. Family and friends, as well as the
resident, are directly involved in care decisions.
The resident is encouraged to participate in fam-
Residents’ Rights
ily life and decision-making as long as possible.
Life Support Measures
Life support measures are used when vital body In long-term care, goals focus on recovery, or on
systems are not working well enough to support life the resident’s ability to care for him- or herself
on their own. These measures include feeding tubes, as much as possible. However, in hospice care,
mechanical ventilation, dialysis, etc. The decision to
the goals are the comfort and dignity of the resi-
remain on life support or to discontinue life support
is often part of a person’s advance directives. When dent. This type of care is called palliative care.
the decision is made to discontinue life support This is an important difference. You will need
and the body is not able to function without these to change your mindset when caring for hospice
supports, the person will die. This may happen im-
residents. Focus on pain relief and comfort,
mediately or the resident may live for a short time.
As with any advance directive and personal decision rather than on teaching them to care for them-
regarding treatment, do not judge a resident’s (or selves. Report complaints or signs of pain to the
a family member’s) choice to remain on or discon- nurse immediately. Residents who are dying
tinue life support. This is a private and personal
need to feel independent for as long as possible.
decision. Respect the resident’s wishes. Do not
make comments about his or her choices to anyone, Caregivers should allow residents to have as
including family members, other residents, or staff. much control over their lives as possible. Eventu-
ally, caregivers may have to meet all basic needs.
23 402

Other attitudes and skills useful in hospice care its. Respect them. Discuss your feelings of frus-
include the following: tration or grief with another care team member.
Be a good listener. It is hard to know what to say Recognize the stress. Just realizing how stress-
Death and Dying

to someone who is dying or to his or her loved ful it is to work with people who are dying is
ones. Most often, people need someone to listen a first step toward caring for yourself. Talking
to them (Fig. 23-6). Review the listening skills in with a counselor about your experiences at work
Chapter 4. A good listener can be a great com- can help you understand and work through your
fort. Some people, however, will not want to con- feelings. Remember, however, that you must
fide in you. Never push someone to talk. keep specific information confidential. Your su-
pervisor may be able to refer you to a counselor
or support group.
Take good care of yourself. Eating right, exercis-
ing, and getting enough rest are ways of taking
care of yourself (Fig. 23-7). Remember to care
for your emotional and spiritual health, too. Talk
about and acknowledge your feelings. Take time
out to do things for yourself, such as reading
a book, taking a bubble bath, or whatever you
enjoy. Spiritual needs may be met by attending
religious services, reading, praying, meditating,
or just taking a quiet walk. Meeting your needs
Fig. 23-6. Being a good listener can be a great help to a allows you to best meet other people’s needs.
dying resident and his or her family.

Respect privacy and independence. Relatives,

friends, clergy, or others may visit a dying resi-
dent. Make it easy for these difficult visits to
take place. Stay out of the way when you can. Do
not join in the conversation unless you are asked
to do so. Understand that some people wish
to be alone with their dying loved ones. Dying
residents can have some independence even
when they need total care. Let the resident make
choices when possible, such as when to bathe or
what to eat or drink.
Be sensitive to individual needs. Different resi-
dents and families will have different needs. The Fig. 23-7. Taking good care of yourself, including eating
more you know what is needed, the more you right, drinking plenty of water, and relaxing, is a way to
can help. Some residents need a quiet and calm help you tend to your own needs when caring for people
who are dying.
atmosphere. Others like a cheery presence. They
might like you to talk or stay close by. Ask fam-
Take a break when you need to. Find ten min-
ily members or friends how you can help.
utes to sit down and relax or stand up and
Be aware of your own feelings. Caring for people stretch. These ideas may be enough of a break in
who are dying can be draining. Know your lim- some situations.
 403 23

Tip • Perspiration
Hospice cares. • Incontinence (both urine and stool)
According to the National Hospice and Palliative • Disorientation or confusion

Death and Dying

Care Organization, approximately 400,000 hospice
volunteers provided care to an estimated 1.2 million
people in the United States in 2005. Hospice volun- 8. List changes that may occur in the
teers go through a training program to prepare them
for hospice work. The volunteers provide a variety of human body after death
services. This includes caring for the home or family
of a dying person, driving or doing errands, and pro- When death occurs, the body will not have heart-
viding emotional support. Visit nhpco.org for more beat, pulse, respiration, or blood pressure. The
information on hospice care. muscles in the body become stiff and rigid. This
is a temporary condition called “rigor mortis”
7. Explain common signs of approaching which is Latin for “stiffness of death.” The eye-
lids may remain open or partially open with the
death
eyes in a fixed stare. The mouth may remain
Death can be sudden or gradual. Physical open. The body may be incontinent of both
changes occur that can be signs of approaching urine and stool.
death. Vital signs and skin color are often af-
Though these things are a normal part of death,
fected. Disorientation, confusion, and reduced
they can be frightening. Tell the nurse immedi-
responsiveness may occur. Vision, taste, and
ately to help confirm the death.
touch usually diminish. However, hearing is
often present until death occurs.
9. Describe postmortem care
Common signs of approaching death include the
following: Postmortem care is care of the body after
• Blurred and failing vision death. Be sensitive to the needs of the family
and friends after death. They may wish to sit by
• Unfocused eyes
the bed to say goodbye. They may wish to stay
• Impaired speech with the body for a while. Allow them to do so.
• Diminished sense of touch Be aware of religious and cultural practices that
the family wants to observe. Facilities will have
• Loss of movement, muscle tone, and feeling
different policies on postmortem care. Always
• A rising or below-normal body temperature follow your facility’s policies and procedures.
• Decreasing blood pressure Perform assigned tasks.

• Weak pulse that is abnormally slow or rapid

Guidelines:
• Slow, irregular respirations or rapid, shal-
Postmortem Care
low respirations, called Cheyne-Stokes
respirations
G Rigor mortis may make the body difficult to
• A “rattling” or “gurgling” sound as the per- move. Talk to the nurse if you need help per-
son breathes forming postmortem care.
• Cold, pale skin G Bathe the body. Be very gentle to avoid
• Mottling (bruised appearance), spotting, bruising.
or blotching of the skin caused by poor G Place drainage pads where needed. This is
circulation most often under the head and/or under the
23 404

perineum (the genital and anal area). Be sure

talking very much. Listen patiently and do not inter-
to follow standard precautions. rupt (Fig. 23-8). The family may want to repeat what
G Do not remove any tubes or other equip- happened and how it occurred. It is helpful for them
to repeat this story.
Death and Dying

ment. A nurse or the funeral home will do

What you say is not as important as is being sin-
this. cere. Simply saying “I am so sorry,” is fine. Avoid
G Put dentures back in the mouth if instructed clichés such as, “It is for the better.” If you can say
it honestly, saying something like “your mother will
by the nurse. Close the mouth. You may need be missed here,” is supportive and kind. Ask your
to place a rolled towel under the chin to sup- supervisor before sending a sympathy card to a fam-
port the closed mouth position. If this is not ily or attending the funeral service. It is important to
possible, place dentures in a denture cup respect professional boundaries.
near the head.
G Close the eyes carefully.
G Position the body on the back with legs
straight. Fold arms across the abdomen.
Put a small pillow under the head.
G Follow facility policy on personal items.
Check to see if you should remove jewelry.
Always have a witness if personal items
are removed or given to a family member.
Document what was given and to whom.
G Strip the bed after the body has been Fig. 23-8. Be available for family and friends if they want
removed. to talk. Allow them to express their feelings.

G Open windows to air the room, as needed.

Straighten up. Home Care Focus
G Respect the wishes of family and friends. After a client has died, ask family members or friends
Be sensitive to their needs. Only perform how you can be of help. If you are working with a
assigned tasks. hospice program, you may be asked to answer the
phone, make coffee or a meal, supervise children,
G Document according to your facility’s policy. or keep family members company. Do not leave the
home until the client’s body has been removed or
until your supervisor says you may leave.
Residents’ Rights
Comforting Others
After a loved one has died, show family and friends Chapter Review
to a comfortable place to sit and talk privately. Ask if
you can contact anyone for them. Provide water or 1. Describe one behavior a nursing assistant
another beverage. If family members want to be left might see at each stage of dying.
alone with the deceased, provide privacy by leaving
the room and closing the door. Family and friends 2. Describe five possible feelings/emotions in
should not feel they are being rushed out of the the grief process.
facility.
It is natural to feel upset and not know what to say 3. How would you describe your personality
when someone has died. Many people talk a lot type? What helps you work through difficult
when feeling stressed. Show your support without feelings like those associated with grief?
 405 23

4. Which sense is usually present until death

occurs?
5. What are some of the ways to give emotional

Death and Dying

and spiritual support for a dying resident?
6. What measures may help a dying resident
who is in pain?
7. List three legal rights to remember when
caring for the terminally ill.
8. What is the focus in palliative care? How
does it differ from the usual care nursing as-
sistants provide?
9. List 10 common signs of approaching death.
10. List five changes that may occur in the
human body after death.
11. What is postmortem care?
12. Where are drainage pads most often needed
during postmortem care?
24 406

24
Introduction to Home Care

Introduction to Home Care

1. Explain the purpose of and need for the physical and emotional stress of caregiving.
home health care Many home health aides also work in assisted
living facilities. Assisted living facilities allow
Institutional health care delivered in hospitals independent living in a home-like environment,
and long-term care facilities is expensive. To with professional care available as needed. Home
reduce costs, hospitals have begun to discharge health aides may be former nursing assistants
patients earlier. Many people who are discharged who decided to make a change from working in
have not fully recovered their strength and stam- facilities or hospitals to working in the home.
ina. Many require skilled assistance or monitor-
ing. Others need only short-term assistance at As advances in medicine and technology ex-
home. Most insurance companies are willing to tend the lives of people with chronic illnesses,
pay for a part of this care because it is less ex- the number of people needing health care will
pensive than a long hospital or facility stay. increase. Home services will be needed to pro-
vide continued care and assistance as chronic
The growing numbers of older people and illnesses progress. For example, people with
chronically ill people are also creating a demand acquired immunodeficiency syndrome (AIDS), a
for home care services. Family members who chronic illness that is infecting more and more
in the past would care for aging or ill relatives people throughout the world, will require in-
frequently leave home towns to live and work in home assistance. They will also require disease-
distant areas. In addition, they often have other specific health care as their illnesses progress.
responsibilities or problems that interfere with Improvements in medications and better man-
their ability to provide care. For example, family agement of the disease have already shown that
members who work or who care for young chil- people with AIDS can live longer, with an im-
dren may be unable to look after aging relatives proved quality of life.
as they become frail and less functional.
One of the most important reasons for health
Most people who need some medical care prefer care in the home is that most people who are
the familiar surroundings of home to an institu- ill or disabled feel more comfortable at home
tion. They choose to live alone or receive care (Fig. 24-1). Health care in familiar surround-
from a relative or friend. Home health aides can ings improves mental and physical well-being.
provide assistance to the chronically ill, the el- It has proven to be a major factor in the healing
derly, and family caregivers who need relief from process.
 407 24

basic nursing care, personal care, and house-

keeping services. Larger agencies may provide
speech, physical, and occupational therapies, and
medical social work. Some common services in-

Introduction to Home Care

clude the following:
• Physical, occupational, and speech therapy
• Medical-surgical nursing care, including
medication management, wound care, care
of different types of tubes, catheterization,
and management of clients with AIDS, dia-
betes, chronic obstructive pulmonary disease
Fig. 24-1. People who are ill or disabled often feel more
comfortable being cared for in their own homes, where (COPD), and congestive heart failure (CHF)
everything is familiar. • Intravenous infusion therapy
• Maternal, pediatric, and newborn nursing
care
2. Describe a typical home health agency
• Nutrition therapy/dietary counseling
Many home health aides are employed by home
health agencies. Home health agencies are • Medical social work
businesses that provide health care and per- • Personal care, including bathing; taking vital
sonal services in the home. Healthcare services signs; skin, nail and hair care; meal prepara-
provided by home health agencies may include tion; light housekeeping; ambulation; and
nursing care, specialized therapy, specific medi- range of motion exercises
cal equipment, pharmacy and intravenous (IV) • Homemaker/companion services
products, and personal care. Personal care ser-
vices may include housekeeping, shopping, help • Medical equipment rental and service
with activities of daily living, and cooking. • Pharmacy services
Clients who need home care are referred to a • Hospice services
home health agency by their doctors. They can All home health agencies have professional staff
also be referred by a hospital discharge planner, who make decisions about what services are
a social services agency, the state or local depart- needed. These professionals, who may be doc-
ment of public health, the welfare office, a local tors, nurses, or other licensed professionals, also
agency on aging, or a senior center. Clients and reassess clients’ needs for service, write care
family members can also choose an agency that plans, and schedule services.
meets their needs.
Once staff determine the amount and types of
Once an agency is chosen and the doctor has care needed, assignments are given. A home
made a referral, a staff member performs an health aide may be assigned to spend a certain
assessment of the client. This determines how number of hours each day or week with a client
the care needs can best be met. The home en- providing care and services. While the care plan
vironment will also be evaluated to determine and the assignments are developed by the super-
whether it is safe for the client. The services visor or case manager, input from all members
home health agencies provide depend on the of the care team is needed. All HHAs are under
size of the agency. Small agencies may provide the supervision of a skilled professional: either
24 408

a nurse, a physical therapist, a speech language laundry, and grocery shopping, for at least some
pathologist or therapist, or an occupational ther- of your clients.
apist. Figure 24-2 shows a typical home health Family contact: You may have a lot more con-
agency organization chart.
Introduction to Home Care

tact with clients’ families in the home than you

would in a facility.
3. Explain how working for a home health Independence: You will work independently as
agency is different from working in other a home health aide. Your supervisor will moni-
types of facilities tor your work, but you will spend most of your
hours working with clients without direct su-
In some ways, working as a home health aide is pervision. Thus, you must be a responsible and
similar to working as a nursing assistant. Most independent worker.
of the basic medical procedures and many of
Communication: Good written and verbal com-
the personal care procedures you perform will
munication skills are important. Keep informed
be the same. However, some aspects of working
of changes in the client care plan. You must
in the home are very different from working in
keep others informed of changes you observe in
other care facilities.
the client and the client’s environment.
Housekeeping: You may have housekeeping Transportation: You will have to get yourself
responsibilities, including cooking, cleaning, from one client’s home to another. You will need

Executive Director

Medical Director
Performance
Improvement
Professional Advisory
Coordinator
Board

Intermittent Visit Private Duty Office Manager

Services Manager Services Manager

Supervisor Billers/Scheduler
Supervisor
Filing Clerk
Receptionist
RN Case Manager/Care RN Case Manager/Care
Coordinators Coordinators
Nurses (RN, LPN/LVN) Nurses (RN, LPN/LVN)
Therapists (PT, OT, SLP) Therapists (PT, OT, SLP)
Social Service (MSW) Social Service (MSW)
Home Health Aides Home Health Aides

Clients

Fig. 24-2. A typical home health agency organization chart.

 409 24

to have a dependable car or know how to use Clients’ comfort: One of the best things about
public transportation. You may also face bad home care is that it allows clients to stay in the
weather conditions. Clients need your care— familiar and comfortable surroundings of their
rain, snow, or sleet. own homes. This can help most clients recover

Introduction to Home Care

Safety: You need to be aware of personal safety or adapt to their condition more quickly.
when you are traveling alone to visit clients. You
may be visiting clients in high-crime areas. Be 4. Discuss the client care plan and
aware of your surroundings, walk confidently, explain how team members contribute to
and avoid dangerous situations, such as visits the care plan
after dark. Just as residents in long-term care have a per-
Flexibility: Each client’s home will be different. sonal care plan, so does the client in home
You will need to adapt to the changes in environ- health care. The care plan is individualized for
ment. In a care facility, you know what supplies each client. It is developed to help achieve the
will be available and what kind of cleanliness goals of care. It lists tasks that team members,
and organization to expect at work. In home including home health aides, must perform. It
care, you may not know until you get there. states how often these tasks should be done and
how they should be carried out. For example, the
Working environment: Long-term care facilities
care plan for a client who has had a stroke may
are built to make caregiving easier and safer.
list the following HHA responsibilities:
They have wide doors, large bathing facilities,
and special equipment for transferring residents. • Range of motion exercises to be performed
If needed, other caregivers are close by and can daily
help move a resident or answer questions you • Vital signs, such as temperature, pulse, and
may have. In home care, the layout of rooms, blood pressure, to be taken once a day or
stairs, lack of equipment, cramped bathrooms, more
rugs, clutter, and even pets can complicate
• Diet and fluid requirements
caregiving.
The care plan is a guide to help the client attain
Client’s home: In a client’s home, you are a
and maintain the best level of health possible.
guest (Fig. 24-3). You need to be respectful of
Activities not listed on the care plan should not
the client’s property and customs. The client is
be performed. The HHA care plan is part of
in control most of the time. If there are any cus-
this overall plan of care. It must be followed very
toms that seem unsafe, talk to your supervisor.
carefully.
Care planning should involve input from the cli-
ent and/or the family, as well as from health pro-
fessionals. Professionals will assess the client’s
physical, financial, social, and psychological
needs. After the doctor prescribes treatment, the
supervisor, nurses, and other care team mem-
bers create the care plan.
Many factors are considered when creating a
care plan. These include the following:

Fig. 24-3. In a client’s home, the HHA is a guest and • The client’s health and physical condition
must respect customs and property. • The client’s diagnosis and treatment
24 410

• The client’s goals or expectations Care plans must be updated as the client’s condi-
• Whether additional services and resources, tion changes. Reporting changes and problems
including transportation, equipment, or to the supervisor is a very important role of the
home health aide. That is how the care team
Introduction to Home Care

supplementary income, are needed (for

example, a social worker may arrange trans- revises care plans to meet the client’s changing
portation for the client to and from appoint- needs (Fig. 24-4).
ments with his or her doctor)
Assessment:
The psychological (mental and emotional) and What is the client’s
status, including
socio-economic (social and economic) status of
health, environ-
the client and the family are other important ment, and family
considerations. The agency will assess how the support?
Evaluation:
client and family are reacting to the medical What signs should
problems. Family members may be absent or we look for to check Diagnosis:
that we are on the The problem(s)
unavailable for some clients. For example, a cli- right path? Are we have been identi-
ent may have only elderly and ailing relatives to meeting our goals? fied after looking
help with care. Family members may have jobs Evaluation, observa- at all of the client's
tions, documentation needs.
to go to or children to care for. Some families of care, changes in
may have relatives who are unwilling to assist in client status, unex- Planning:
care. For some families, problems like alcohol- pected outcomes. What are the
ism and substance abuse can make it difficult to Implementation: goals (expected
How will we achieve outcomes) of
provide care. Housing and financial resources providing care?
these goals? (Steps in
may also be lacking. A medical social worker the care plan)
may be sent to the home to assess the situation
and make referrals. The medical social worker Fig. 24-4. The care planning process.
can assist with long-term care planning.
Input from all members of the care team is Clients’ Rights
needed to develop the client care plan. For in- Care Team and Client
stance, a 250-pound, elderly client requests a For a review of care team members and responsi-
bilities, see Chapter 2 in this textbook. Just as the
tub bath. The supervisor assigns it. The home
resident is an important team member in long-term
health aide finds that the client has no adaptive care, the client is the focus in home health care. The
equipment and is unable to move to the tub. client has the right to make decisions and choices
The assignment puts the home health aide and about his or her own care. The client’s family may
also be involved in these decisions. The care team
the client at risk of injury. The home health aide
revolves around the client and his or her condition,
must communicate this. The assignment needs treatment, and progress. Remember, without the cli-
to be changed to a sponge bath or shower, or ent, there is no care team.
the client needs to get adaptive equipment. The
supervisor is responsible for reassessing the as-
signment and making changes to the care plan. 5. Describe the role of the home health
aide and explain typical tasks performed
Multiple care plans may be necessary for some
clients. In these situations, the supervisor will The role of home health aides is to improve or
coordinate the client’s overall care. There will be maintain the independence, health, and well-
one care plan for the home health aide to follow. being of clients. This is done by providing or as-
There will be separate care plans for other pro- sisting with personal care, assisting with ADLs
viders, such as the physical therapist. (activities of daily living), and performing as-
 411 24

signed tasks. It is also accomplished by promot- skills. For example, encouraging clients to do
ing self-care. HHAs can reinforce the teachings tasks for themselves helps ensure that health
of other team members and promote behavior will be maintained between visits.
that improves health, such as diet and exercise.

Introduction to Home Care

In addition, home health aides teach by example.
Home health aides provide services directly to By performing procedures and giving help ef-
their clients in several ways: ficiently and cheerfully, they provide the family
with a model for caregiving. Home health aides
HHAs provide care or assist with self-care,
are not intended to replace a family member.
depending on the care plan. A care plan may
Rather, HHAs support and strengthen the
include the following, depending on your state’s
family.
regulations:
In Chapter 2 you learned about scope of practice.
• Bathing
A scope of practice defines the things you are al-
• Dressing lowed to do and how to do them correctly. Laws
• Grooming and regulations on what aides can and cannot
do vary from state to state. However, some pro-
• Toileting cedures are not performed by home health aides
• Assisting with range of motion (ROM) exer- under any circumstances. Tasks that are said to
cises and ambulation (walking) be outside the scope of practice of a home health
aide include the following:
• Transferring from bed to chair or wheelchair
• HHAs do not administer medications un-
• Measuring vital signs (temperature, pulse
less trained and assigned to do so. Only a
rate, respiratory rate, blood pressure, and
few states allow home health aides to do
pain level)
this. However, it always requires additional
• Feeding training. Home health aides may assist the
• Reminding the client about medications clients with self-administered medications in
certain situations.
• Giving skin care
• HHAs do not insert or remove tubes or
• Using medical supplies and equipment, objects (other than a thermometer) in a cli-
such as walkers and wheelchairs ent’s body. These procedures are called “in-
• Changing of simple dressings vasive,” and are performed only by licensed
professionals.
• Making and changing beds
• HHAs do not honor a request to do some-
• Light cleaning, including dusting, vacuum-
thing outside the scope of practice, not
ing, washing dishes
listed in the job description, or not on the
• Teaching home management assignment sheet. In this situation an HHA
should explain that he or she cannot do the
HHAs maintain a safe, secure, and comfortable
task requested. The request should then be
home life for clients and their families. This
reported to a supervisor. This is true even if
may include light housekeeping, food shopping,
a nurse or doctor asks the HHA to perform
meal preparation, and doing laundry.
the task. The HHA should refuse to perform
Home health aides are also role models. They the task and explain why. Refusing to do
promote clients’ independence by practicing something that the HHA cannot legally do is
good housekeeping, nutrition, and healthcare the HHA’s right and responsibility.
24 412

• HHAs do not perform procedures that re- expected to follow. Common policies at home
quire sterile technique. For example, chang- health agencies include the following:
ing a sterile dressing on a deep, open wound • Keep all information confidential. Keeping
requires sterile technique.
Introduction to Home Care

information confidential means not telling

• HHAs do not diagnose or prescribe treat- anyone about it. This is not only an agency
ments or medications. rule, it is also the law. See Chapter 3 for
• HHAs do not tell the client or the family more information on confidentiality, includ-
the diagnosis or the medical treatment plan. ing the Health Insurance Portability and
This is the responsibility of the doctor or Accountability Act (HIPAA). The agency and
nurse. all its employees must keep all information
about clients and their families confidential.
Know which tasks are outside your scope of Be careful where you keep your notes and
practice and do not perform them. Many of assignment sheets. Keeping your paperwork
these specialized tasks require more training. in the open where someone could read it,
It is important to learn how to refuse a task for or losing your notes or assignments, is a
which you have not been trained, or which is breach of confidentiality. Confidentiality also
outside your scope of practice. extends to the agency’s personnel files and
clinical records. This means your employer
Tip
cannot give out information about you from
Setting Boundaries
your job application or other records.
In professional relationships, boundaries must be
set. Boundaries are the limits to or within the rela- • Follow the client’s care plan. Home health
tionships. Home health aides, like other profession- aides should perform all tasks assigned by
als, are guided by ethics and laws which set limits
the care plan. They should not do any tasks
for their relationships with clients. These boundaries
help support a healthy client-worker relationship. that are not included or approved by the case
Working in clients’ homes may make it more dif- manager or supervisor. If the client or fam-
ficult to honor the boundaries of professional rela- ily requests changes, they should be told to
tionships. Clients may feel that you are their friend
speak to the supervisor.
because you are in their homes. If the worker and
client become personally involved with each other, • Report to the supervisor at regular arranged
it makes it more difficult to enforce rules. You may times, and more frequently if necessary. For
want to give your client extra help or let her skip the
exercise she dislikes. The client may expect you to example, home health aides must report the
break the rules because she thinks you are friends. following to their supervisors: important
Emotional attachments to clients weaken your judg- events or changes in clients and their fami-
ment and are unprofessional. Be friendly, warm, and lies; an accident on the job; and anything
caring with clients. But behave professionally and
stay within the limits of set boundaries. Follow your that delays or prevents them from going to
agency rules and the care plan’s instructions. They or completing an assignment.
are in place for everyone’s protection. Ask your su-
• Do not discuss personal problems with the
pervisor for help if your client asks you to do things
you are not allowed to do. client or the client’s family. Discussing your
personal problems is unprofessional. You
must act in a professional manner. Clients
6. Explain common policies and should see you as someone whose job is to
procedures for home health aides provide care, rather than as a friend.
You will be told where to locate a list of poli- • Be punctual and dependable. Employers ex-
cies and procedures that all staff members are pect this of all employees.
 413 24

• Follow deadlines for documentation and helps you be most efficient. It is also helpful to
paperwork. Timely and accurate documenta- include the client in your planning. A client may
tion is very important. not cooperate with your schedule if he or she has
different priorities. It takes good communica-

Introduction to Home Care

• Provide all client care in a pleasant, profes-
tion, and sometimes negotiation, to arrange a
sional manner.
schedule that works.
• Do not give or accept gifts. Gift giving and
receiving is not allowed because it is un-
professional. Gift giving can cause other
problems as well. For example, a client may
forget giving an object as a gift and report it
as stolen. Some clients who give gifts may
believe they deserve special treatment.
Your employer will have policies and procedures
for every client care situation. These have been
developed to give quality care and protect client
safety. You must always follow your employer’s
policies and procedures. For more on profes-
sionalism and professional behavior, including
proper grooming, see Chapter 2.

7. Demonstrate how to organize care

Fig. 24-5. Making a list of tasks to be done will help you
assignments organize to perform them efficiently.
To finish all your assignments each day, you
If you run out of time with a client, you have to
have to work efficiently. To be efficient, you need
stay late to finish all your tasks. That makes you
to decide the order in which to do your tasks.
late to your next assignment. You then do not
For example, you are assigned to work with an
have enough time to do everything the next cli-
elderly client from 2:00 to 4:00 p.m. on Monday.
ent needs. Completing assignments efficiently
Your supervisor has told you that this client
means you are not always running late. It means
needs some housekeeping, dinner preparation,
you will do a better job.
and personal care. When you arrive at the cli-
ent’s home, you see what tasks need to be done.
It is a good idea to make a list of the tasks you 8. Identify an employer’s responsibilities
will do and the order in which you will do them
(Fig. 24-5). Agencies should teach home health aides about
their policies and procedures. Agencies must
Two hours is not a lot of time to do all those make sure that HHAs are educated and are able
tasks. You will have to work quickly. You will to perform all assigned tasks. Your employer’s
not have any extra time to turn on the televi- responsibilities include the following:
sion or sit down and have coffee. If you had not
planned the tasks before you started, you might • Provide a written job description. The job
have spent too long cleaning the kitchen and description tells what you are expected to do
never have made dinner. Making a list of tasks during your working hours (Fig. 24-6).
24 414

with clients to assure the goals of the care

plan are being met. They will also check to
see that clients are satisfied with the care
they are receiving.
Introduction to Home Care

• Provide information about supervision. Your

employer should tell you when and where
you will meet with your supervisor and what
you will discuss in these meetings. You
should also be told how the supervisor can
be reached for help, and when and why the
supervisor will visit your clients’ homes.
• Provide proper equipment and supplies for
you to safely do your work. For example,
your agency should provide the gloves you
must sometimes wear to protect you and
your client from infection.

Fig. 24-6. Your employer should provide you with a job 9. Identify the client’s rights in home
description.
health care

• Provide testing and skills evaluation before Clients in home care have legal rights, just as
you are sent to care for clients. residents in long-term care do. These rights re-
late to how clients must be treated. They provide
• Provide initial training and continuing in-
an ethical code of conduct for healthcare work-
service training. Initial training includes an
ers. Home health agencies give clients a list of
explanation of the policies and procedures of
these rights and review each right with them.
the agency. You should also be trained in the
Review Chapter 3 for more on legal rights.
agency’s documentation system. In-service
training is a federal requirement. It keeps The first right listed in the box below states
your skills fresh and helps you do an even that clients have the right to receive considerate,
better job. OSHA regulations require em- dignified, and respectful care. Remember that
ployers to offer AIDS and Hepatitis B educa- reporting abuse or suspected abuse is not an op-
tion as well. tion—it is the law. Two other basic clients’ rights
are the right to be fully informed of the goals of
• Provide appropriate preparation for each as- care and of the care itself, and the right to par-
signment. The agency should teach you to ticipate in care planning. Your employer should
properly care for each client’s special needs develop an agreement with each client about the
and conditions. You should be told why goals of care before service is provided. Your em-
the client needs service and what the goals ployer should also make every effort to involve
of care are. If other team members are in- clients and their families in care planning (Fig.
volved, their responsibilities should also be 24-7). Each of us knows how our bodies work
explained to you. best and what makes us comfortable. People who
• Provide supervision. Supervisors support feel in control of their bodies, lives, and health
and teach you how to do new tasks. They have greater self-esteem. They are more likely
help you find solutions to problems and to continue a treatment plan and to cooperate
adjust to new situations. Supervisors check with caregivers. Clients also have a right to know
 415 24

what the agency expects to happen as a result of

Clients have the right:
their care. These expected outcomes are some-
times called the goals of the care plan. Clients • to be notified in advance about the care that is
to be furnished, the disciplines of the caregivers
should be informed of barriers to their care. For

Introduction to Home Care

who will furnish the care, and the frequency of
example, a client’s failure to eat enough healthy the proposed visits;
food can be an obstacle to getting well. • to be advised of any change in the plan of care
before the change is made;
• to participate in planning care and planning
changes in care, and to be advised that they have
the right to do so;
• to be informed in writing of rights under state
law to make decisions concerning medical care,
including the right to accept or refuse treatment
and the right to formulate advance directives;
• to be notified of the expected outcomes of care
and any obstacles or barriers to treatment;*
• to be informed in writing of policies and pro-
Fig. 24-7. Clients and their families should be involved in
cedures for implementing advance directives,
care planning.
including any limitations if the provider cannot
implement an advance directive on the basis of
Client’s Bill of Rights conscience;
• to have healthcare providers comply with advance
Home health clients and their formal caregivers directives in accordance with state law;
have a right to not be discriminated against based
on race, color, religion, national origin, age, gender, • to receive care without condition or discrimina-
sexual orientation, or disability. Furthermore, clients tion based on the execution of advance directives;
and caregivers have a right to mutual respect and and
dignity, including respect for property. Caregivers are
• to refuse services without fear of reprisal or
prohibited from accepting personal gifts and borrow-
discrimination.
ing from clients.
* The home health provider or the client’s physician
Clients have the right:
may be forced to refer the client to another source of
• to have relationships with home health providers care if the client’s refusal to comply with the plan of
that are based on honesty and ethical standards care threatens to compromise the provider’s com-
of conduct; mitment to quality care.
• to be informed of the procedure they can fol- Clients have the right:
low to lodge complaints with the home health
provider about the care that is, or fails to be, fur- • to confidentiality of their medical record as well
nished and about a lack of respect for property; as information about their health, social, and
financial circumstances and about what takes
• to know about the disposition of such place in the home; and
complaints;
• to expect the home health provider to release
• to voice their grievances without fear of discrimi-
information only as required by law or authorized
nation or reprisal for having done so; and
by the client, and to be informed of procedures
• to be advised of the telephone number and hours for disclosure.
of operation of the state’s home care hotline,
which receives questions and complaints about Clients have the right:
local home health agencies, including complaints • to be informed of the extent to which payment
about implementation of advance directive may be expected from Medicare, Medicaid, or any
requirements. other payer known to the home health provider;
24 416

• to be informed of the charges that will not be • to provide a safe environment for care to be pro-
covered by Medicare; vided; and
• to be informed of the charges for which the client • to carry out mutually-agreed-upon
Introduction to Home Care

may be liable; responsibilities.

• to receive this information orally and in writing To satisfy Medicare certification requirements, the
before care is initiated and within 30 calendar Centers for Medicare & Medicaid Services (CMS) re-
days of the date the home health provider be- quires that agencies:
comes aware of any changes; and
1. Give a copy of the Bill of Rights to each client
• to have access, upon request, to all bills for ser- during the admission process.
vice the client has received regardless of whether
the bills are paid out-of-pocket or by another 2. Explain the Bill of Rights to the client and docu-
party. ment that this has been done.

Clients have the right: Agencies may have clients sign a copy of the Client’s
Bill of Rights to acknowledge receipt.
• to receive care of the highest quality;
• in general, to be admitted by a home health
provider only if it has the resources needed to Chapter Review
provide the care safely and at the required level of
intensity, as determined by a professional assess- 1. Name three reasons for the increase in de-
ment; a provider with less than optimal resources
mand for home health care.
may nevertheless admit the client if a more ap-
propriate provider is not available, but only after 2. List ten common services provided by a typi-
fully informing the client of the provider’s limita-
cal home health agency.
tions and the lack of suitable alternative arrange-
ments; and 3. Which one of the many differences between
• to be told what to do in the case of an emergency. working as an aide for a home health agency
and working for a facility is most important
The home health provider shall assure that:
to you?
• all medically-related home care is provided in ac-
cordance with physicians’ orders and that a plan 4. What are the factors considered when form-
of care specifies the services and their frequency ing a client care plan?
and duration; and
5. How can home health aides be good role
• all medically-related personal care is provided by
models for clients and their families?
an appropriately trained home health aide who
is supervised by a nurse or other qualified home 6. What does the phrase “home health aides
health care professional.
teach by example” mean?
Clients have the responsibility:
7. List five tasks said to be outside the scope of
• to notify the provider of changes in their condi- practice for a home health aide.
tion (e.g., hospitalization, changes in the plan of
care, symptoms to be reported); 8. List five common policies home health agen-
• to follow the plan of care; cies have.

• to notify the provider if the visit schedule needs 9. Create a sample schedule for a two-hour
to be changed; morning visit to Mrs. Smith. Use tasks dif-
• to inform providers of the existence of any ferent from those listed in Figure 24-5.
changes made to advance directives; 10. What type of preparation should an em-
• to advise the provider of any problems or dissat- ployer provide before sending HHAs to care
isfaction with the services provided; for clients?
 417 24

11. How do supervisors help HHAs and clients?

12. If a home health aide sees or suspects
that a client is being abused, what is her

Introduction to Home Care

responsibility?
13. What is one important reason that clients
should be involved in their care planning?
14. Pick five rights from the Client’s Bill of
Rights that are most important to you and
explain why you chose those particular
rights.
25 418

25
Infection Prevention and Safety in the Home

Infection Prevention and

Safety in the Home
Chapter 5 contains most of the important infec- • Body wastes, such as stool (feces) and urine;
tion prevention and control material. It includes this includes anything that comes into con-
information on standard precautions, isolation tact with these wastes, such as toilet paper,
precautions, hand hygiene, PPE, infectious dis- underwear, bed linens, and toilets
eases, handling spills, equipment and linen, and • Drainage from wounds; this includes objects
much more. This chapter contains information that come in contact with drainage, such as
on how infection prevention may need to be dressings, tissues, cloths, clothing, and bed
modified in the home. linens
Chapter 6 contains most of the information on • Spoiled food; this includes objects that come
general safety guidelines. In this chapter you into contact with this food, such as other
will find additional safety information for the food, dishes, cooking utensils, kitchen work-
home. ing areas, and surfaces
If possible, review both Chapters 5 and 6 before Sterilization is a measure that destroys all micro-
reading this chapter. organisms, including pathogens. Disinfection is
a process that kills some pathogens, but not all
1. Discuss disinfection in the home microorganisms. Disinfection does not destroy
all pathogens.
Measures like sterilization and disinfection are
In home care, you may disinfect items used by
used to decrease the spread of pathogens and
the client. You will also disinfect some areas
disease. An object can only be called “clean” if it
while doing housekeeping tasks. The care plan
has not been contaminated with pathogens. An
and your assignments will specify what disinfec-
object that is “dirty” has been contaminated with
tion you need to do.
pathogens. Here is a list of just some of the ob-
jects that are considered “dirty” in the home: General methods of disinfection are by wet and
dry heat and by chemicals. Wet heat disinfection
• The floor
uses boiling water to disinfect. Dry heat disin-
• Saliva and other discharges from the mouth fection means baking in the oven. See Chapter
and nose; this includes any objects that 29 for information on household chemical dis-
come into contact with these discharges, infecting solutions. The method used depends
such as hands, toothbrushes, sinks, napkins, on the type of item that needs to be disinfected.
pillowcases, cigarettes, eating utensils, hand- Your agency will have policies and procedures
kerchiefs, etc. for disinfection in the home.
 419 25

6. After items have cooled, remove with the

Disinfecting using wet heat
potholders.
Equipment: items to be disinfected, clean pot with
enough room to hold items, clean lid for pot, cold 7. Store the items.

Infection Prevention and Safety in the Home

water, timer or clock, stove, potholders
8. Wash and dry the disinfecting equipment. Re-
1. Wash your hands. turn to proper storage.

2. Place items in the pot and fill it with water. 9. Wash your hands.
Make sure water covers all items, leaving
10. Document the procedure.
enough room at the top for steam to escape.

3. Place lid on pot and place covered pot on

burner on stove. 2. Describe guidelines for assisting a
4. Turn on heat and bring water to a boil. Do client when isolation precautions have
not open the lid at any time during boiling. been ordered
5. Boil for 20 minutes. You should see steam Transmission-based, or isolation precautions are
escaping from the sides of the pot. used when caring for persons who are infected
or suspected of being infected with a disease.
6. Turn off heat. Allow items and water to cool.
When ordered, these precautions are used in
7. After items have cooled, remove the cover addition to standard precautions. Follow these
with the potholders. guidelines for assisting with isolation procedures
in the home:
8. Remove the items. Place on a rack or a clean
towel to air dry.
Guidelines
9. Wash and dry the disinfecting equipment. Re-
Isolation Procedures
turn to proper storage.

10. Wash your hands. G Serve food using disposable dishes and uten-
sils that are discarded in specially marked
11. Document the procedure.
bags and stored in covered garbage contain-
ers. When items cannot be discarded, they
must be washed thoroughly in very hot water
Disinfecting using dry heat
with detergent and bleach. Family members
Equipment: items to be disinfected, clean metal pan should use separate dishes and utensils.
(cookie sheet, cake pan, etc.), timer or clock, oven,
potholders G Wear disposable gloves when handling soiled
laundry. Bag laundry in the client’s room and
1. Wash your hands. carry it to the laundry area in the bag. Wash
2. Place items in the pan. the client’s laundry separately. Use hot water
and detergent.
3. Place sheet or cake pan in the oven.
G A solution of bleach and water (one part
4. Turn on oven to 350° F. Bake for one hour. bleach to nine parts water) should be mixed
Keep oven door closed while items are in a clearly labeled, plastic spray bottle and
baking. stored in a safe place. The bleach solution
5. Turn off heat. Allow items to cool. can be used to clean up spills of blood or
25 420

body fluids and to disinfect surfaces that may 3. List ways to adapt the home to
have been contaminated. principles of good body mechanics
G A client in contact or airborne isolation Chapters 6 and 10 contain more in-depth infor-
Infection Prevention and Safety in the Home

should use a separate bathroom if possible. mation on body mechanics. Following are sev-
If the client uses the same bathroom as oth- eral strategies that can help you apply good body
ers, disinfect it after each use by the client. mechanics in the home:
Remember that clients in isolation may be fear- Have the right tools for a job. For example, if
ful or concerned about what is happening. Listen you cannot reach an object on a high shelf, use
to what the client is telling you and allow time a step stool rather than climbing on a counter or
to talk with your client about his concerns. Reas- straining to reach.
sure clients that it is the disease, not the person,
that is being isolated. Explain why these steps Have footrests and pillows available. You can
are being taken. Relay any requests outside your make any position safer and more comfortable
scope of practice to your supervisor. Review by using footrests and pillows to keep the body
Chapter 5 for more on standard and isolation in alignment. For example, tasks that require
precautions. standing for long periods can be more comfort-
able if you rest one foot on a footrest. This posi-
Spills tion flexes the muscles in the lower back and
keeps the spine in alignment. When sitting,
In addition to guidelines for cleaning spills found in
using a footrest allows for a more comfortable
Chapter 5, follow these tips:
leg position. Crossing the legs disrupts align-
• When blood or body fluids are spilled, put on
gloves before starting to clean up the spill. In ment. It should be avoided. Using pillows can
some cases, industrial-strength gloves are best. make any chair more comfortable. Use pillows
• If blood or body fluids are spilled on a hard behind the back to keep the back straight.
surface such as a linoleum floor or countertop,
Keep tools, supplies, and clutter off the floor.
remove the spill first. First put on gloves, then
wipe up the spill with rags or paper towels. Then Keep frequently-used items on shelves or coun-
clean immediately using a solution of one part ters where they can be easily reached without
household bleach to nine parts water. You can lifting. Keeping things organized will also help
mix the solution in a bucket and wipe the area
you find what you need without straining.
with rags or paper towels dipped in the solution.
Or, mix the solution in a plastic spray bottle and Sit when you can. Whenever you can sit to do a
spray the area before wiping. Be careful not to
job, do so. Chopping vegetables, folding clothes,
spill bleach or bleach solution on clothes, car-
pets, or bedding. It can discolor and damage and other tasks can be done easily while sitting.
fabrics. Your employer may provide commercial For jobs like scouring the bathtub, kneel or use
sprays for cleaning spills. a low stool. Avoid bending at the waist.
• If blood or body fluids are spilled on fabrics
such as carpets, bedding, or clothes, do not use
Use gait or transfer belts when assisting clients
bleach to clean the spill. Commercial disinfec- with ambulation or transfers. In Chapter 10 you
tants that do not contain bleach are available. If learned correct procedures for safely assisting
you have no disinfectant, wear gloves and wipe clients with ambulation and transfers.
up spills. Then use soap and water to clean the
area. Clean carpet with regular carpet cleaner. Make sure the homes you work in are safe for
Use gloves to load soiled bedding or clothes into your clients, their family members, and yourself.
the washing machine and add color-safe bleach
Working in a home that is neglected puts you at
to the washer with the laundry detergent.
risk of injury. Do remember, however, that you
 421 25

are a visitor in the client’s home. Unless an im- • Keep frequently-used personal items close to
mediate danger exists, check with your supervi- the client.
sor and the client before making any significant • Immediately clean up spills on the floor.
changes.

Infection Prevention and Safety in the Home

• Mark uneven flooring or stairs with colored
A nurse or case manager will assess the safety of tape to indicate a hazard.
the homes in which you work. However, you will
• Improve lighting where necessary.
spend more time in the home than any other
member of the care team. Look for safety haz- • Lock wheels before helping a client into or
ards. Immediately report to your supervisor any out of a wheelchair.
hazards you observe. • Return adjustable beds to their lowest posi-
tions when you have finished with care.
4. Identify common types of accidents • Offer trips to the bathroom often. Respond
in the home and describe prevention to clients’ requests for bathroom assistance
guidelines promptly.
• Leave furniture in the same place as you
You learned about these common types of acci-
found it.
dents—falls, burns/scalds, poisoning, cuts, and
choking—in Chapter 6. The HHA needs to be Space
able to identify hazards and take action to remove Electric heater near
them. This will include working with the client, cord curtians
the client’s family, and/or other members of the
care team. Prevention is the key to safety. As you
work, watch for safety hazards, and report un-
safe conditions to your supervisor promptly.
Below you will find guidelines for how to pre- Stack of
vent common types of accidents in the home: books Loose rug
Shoes left out
Falls: Falls can be caused by an unsafe environ-
Fig. 25-1. Be aware of unsafe conditions in your clients’
ment or by loss of abilities. Falls are particularly homes. This living room contains many tripping and fire
common among the elderly. Older people are hazards.
often more seriously injured by falls because
their bones are more fragile. Be especially alert Electrical cord
to the risk of falls with your elderly clients. out of the way

Follow these tips to guard against falls in the

home: Additional lighting

• Clear all walkways of clutter, throw rugs, and

cords (Figs. 25-1 and 25-2).
• Avoid waxing floors, and use non-skid mats Space heater
or carpeting where appropriate. Books picked up Shoes put away removed
• Have clients wear non-skid shoes. Make sure Fig. 25-2. You can help prevent accidents. The hazards
shoelaces are tied. shown in Figure 25-1 have been removed. Talk with your
client about changes that need to be made to avoid
• Have clients wear clothing that fits properly, hazards.
e.g. is not too long.
25 422

Burns/Scalds: Burns can be caused by dry heat fee, tea, and other hot drinks are usually served
(e.g. hot iron, stove, other electrical appliances), at 160°F to 180°F. These temperatures can cause
wet heat (e.g. hot water or other liquids, steam), almost instant burns that require surgery.
or chemicals (e.g. lye, acids). Small children,
Infection Prevention and Safety in the Home

Follow these tips to guard against burns and

older adults, or people with loss of sensation
scalds:
due to paralysis are at the greatest risk of burns.
Scalds are burns caused by hot liquids. It takes • Roll up sleeves and avoid loose clothing
five seconds or less for a serious burn to occur when working at or near the stove (Figs. 25-3
when the temperature of a liquid is 140°F. Cof- and 25-4).

Too many items

plugged in

Cookie jar Fire extinguisher in

near stove cabinet above stove
Spoiled
food in
refrig-
erator

Loose
sleeves

Pan handle
facing out
Cleaning fluids
accessible to children
Wet floor

Fig. 25-3. Unsafe working conditions in the kitchen can lead to burns and other injuries.

Fewer appliances plugged in

and no cords draped over cabinets

Pan handle
facing
inward
Food
check-
list
Fire extinguisher Child lock on Medium pot
moved to far left cleaning cabinet with no flames
of cabinet around the side

Clean floor
Fig. 25-4. Prevent burns, other injuries, and fires by following safe practices in the kitchen.
 423 25

• Check that the stove and appliances are off board, and keep your fingers out of the way.
when you leave. Know proper first aid for cuts (see Chapter 7).
• Suggest that the hot water heater be set Choking: Choking can occur when eating,

Infection Prevention and Safety in the Home

lower than normal. It should be set at 120°F drinking, or swallowing medication. Babies
to 130°F to avoid burns from scalding tap and young children who put objects in their
water. mouths are at great risk of choking. People who
are weak, ill, or unconscious may choke on
• Always check water temperature with a ther-
their own saliva. A person’s tongue can also be-
mometer or your wrist before using.
come swollen and obstruct the airway. To guard
• Keep space heaters away from clients’ beds, against choking, keep small objects out of the
chairs, and draperies. Never allow space reach of babies and small children. Cut food into
heaters to be used in the bathroom. bite-sized pieces for clients who have trouble
• Report frayed electrical cords or unsafe- with utensils and for children.
looking appliances immediately. Do not use Position infants on their backs for sleeping after
these appliances. feeding. Infants should sleep on their backs to
prevent sudden infant death syndrome (SIDS).
• Let clients know when you are about to pour
Never put pillows, small toys, or other objects
or set down a hot liquid.
in a crib. Clients should eat in as upright a posi-
• Pour hot drinks away from clients. Keep tion as possible to avoid choking. Elderly clients
hot drinks and liquids away from edges of with swallowing difficulties may have a special
tables. Put a lid on them. diet with liquids thickened to the consistency of
• Make sure clients are sitting down before honey or syrup.
serving hot drinks.
Household Tips for Preventing Accidents
Poisoning: Homes contain many harmful sub-
stances that should not be swallowed. These Bathroom
include cleaning products, paints, medicines,
Falls: Use non-skid bathmats in tubs and show-
toiletries, and glues. Lock these products away
ers. Request grab bars for the tub, shower, and
from confused clients, clients with limited vi-
toilet if the client is weak and unsteady (Figs.
sion, and children. Clients who have a dimin-
25-5 and 25-6).
ished sense of taste or smell due to stroke or
head injury might eat spoiled food. Check the re-
frigerator and cabinets frequently for foods that No handrails Open medicine cabinet
are moldy, sour, or spoiled. Investigate any odors No hot water
you notice. Have the number for the Poison Con- protection
trol Center posted by the telephone.
Cuts: Cuts typically occur in the kitchen or
bathroom. Keep any sharp objects, including
knives, peelers, graters, food processor blades, Wet floor
scissors, nail clippers, or razors out of the reach Electrical appliance left
plugged in near sink
of children. Lock sharp objects away if there is a
confused client in the home. If you are prepar- Fig. 25-5. The bathroom is full of safety hazards if it is
ing food, cut away from yourself, use a cutting not properly maintained.
25 424

uniformly warm and not too hot before serving.

Electrical appliance stored
Handrails away from water source Cool hot liquids with an ice cube before serving,
installed when not in use as appropriate.
Hot water Lockmedicine
installed
Infection Prevention and Safety in the Home

Poisoning: Keep emergency numbers, including

protection oncabinet
device the Poison Control Center, near the phone. Sug-
gest that all household cleaning products and
other chemicals be locked away.
Cuts: Keep cutlery put away. If you are using
a knife and put it down for a moment, place it
away from the edge of the counter or table. Make
sure the blade is pointed away from the counter
or table edge. Keep other sharp kitchen tools in
Fig. 25-6. This bathroom has been made safer by using
special devices and by cleaning and straightening. safe places, out of the reach of children.
Choking: Do not give infants and toddlers pop-
Burns: Check water temperature with a bath corn, peanuts, hard candy, gum, or foods such
thermometer or on your wrist. Put away electri- as hot dogs or grapes. These items are easily in-
cal appliances when they are not in use. Do not haled, causing choking. Cut all foods into small,
use electrical appliances near a water source. bite-size pieces suitable for the age of the child.
Drowning: Do not leave young children unat- For elderly clients who have difficulty swallow-
tended near any water. This includes bathtubs, ing, serve softer foods and foods cut into small
swimming pools, buckets or basins of water, pieces. Encourage clients to take small bites of
puddles, ponds, drainage ditches, toilets, or food, chew thoroughly, and eat slowly. Keep plas-
sinks. Do not leave anyone who is ill and weak tic storage bags out of reach. Discard plastic bags
alone in a tub. Do not leave clients who are dizzy from dry cleaners or other vendors.
or confused alone in the tub or shower.
Bedroom
Poisoning: Suggest that all medications be
stored in containers with childproof caps and in Falls: If available, keep a nightlight on to illumi-
locked cabinets. Never tell children that medica- nate pathways. Do not leave children unattended
tion is candy. Be sure all medicines are labeled on high surfaces. This includes cribs, beds,
and your client reads medicine labels with his or changing tables, high chairs, and playpens. Do
her eyeglasses if reading glasses are necessary. not turn your back when you are changing a
Store client’s medications separately from medi- child on a high surface. Be sure crib side rails
cations taken by other members of the family. are raised before you leave the room.
Cuts: Put away razors and other sharp objects Burns: Do not allow clients to smoke in bed
(such as nail scissors) when they are not in use. or when unattended. Be especially not to allow
smoking around oxygen equipment. When a cli-
Kitchen ent is unattended, place a call signal nearby.
Falls: Fasten high chair safety belt. Cuts: Be sure sharp objects are put away.
Burns: Turn pot handles out of sight and toward Choking: Report any cribs that have wide spaces
the back of the stove. Stir food, especially if between the slats. The infant’s head could be-
cooked in a microwave. This ensures that it is come wedged between them. Keep crib away
 425 25

from drapes and blinds. Infants and toddlers can 5. List home fire hazards and describe fire
strangle on the cords. Do not prop up bottles for safety guidelines
infants and toddlers. Keep pillows out of cribs to
avoid suffocation. Examine all toys for loose or Recognize and report fire hazards. Any of the

Infection Prevention and Safety in the Home

removable parts. following can be a fire hazard:
• Wood stoves and kerosene, gas, or electric
Living Area heaters that appear old, damaged, or faulty
Falls: Request walkers or canes for clients who • Unvented heaters used in small, enclosed
need support when walking. Talk to your super- areas or sleeping areas
visor about having handrails installed where nec- • Space heaters used near fabrics such as
essary. Keep the floors clear. Keep electrical and draperies, bedspreads, or towels, or used to
extension cords out of the way. Be sure shoes dry clothing or towels
are sturdy and shoelaces are tied. For small chil-
• Flammable materials such as gasoline, kero-
dren, place safety gates, if available, at the tops
sene, or paint thinner stored near stoves,
and bottoms of stairs. Be certain the gates are
heaters, furnaces, hot water heaters, or other
secure and closed. Use hardware-mounted gates
appliances
at the top of stairs.
• Frayed or exposed electrical wires
Burns: Suggest that electrical outlets be cov-
ered with baby-proof plugs. Keep lighters and • Matches or lighters left within reach of chil-
matches out of reach and out of sight. Never dren or incapacitated adults
smoke around children. • Careless smoking, smoking in bed, ciga-
Poisoning: Keep plants out of children’s reach. rettes left burning, or confused clients
Many common plants are poisonous. smoking

Cuts: Keep sharp objects out of children’s reach.

Guidelines:
Do not allow children to run, jump, or play
Reducing Fire Hazards
roughly with any toy or object that could stab.
Choking: Do not permit young children to play G Never work wearing loose or flowing cloth-
with balloons or rubber bands. These objects are ing, especially around the stove. Roll up cli-
easily inhaled. Do not allow children to run and ents’ sleeves and avoid loose clothing when
jump with food in their mouths. client may be cooking or around the stove.
G Store potholders, dish towels, and other
Garage and Outdoors flammable kitchen items away from the
Never leave children at home alone or alone in a stove.
vehicle. Make sure all children are fastened into G Never store cookies, candy, or other items
an approved car seat. Child car seats should be that may attract children above or near the
placed in the back seat of the automobile. Chil- stove.
dren should never sit in the front seat of a car
G Discourage careless smoking and smoking
equipped with dual airbags. Supervise children
in bed. If clients must smoke, check to be
at play. Keep walkways clear of toys and other
sure that cigarettes are extinguished. Empty
obstructions, as well as snow and ice.
ashtrays frequently. Before emptying ashtrays,
For more information on safety in the home for make sure there are no hot ashes or hot
clients with dementia, see Chapter 19. matches in them.
25 426

G Stay in or near the kitchen when anything is Use caution when backing up. Many accidents
cooking or baking. occur when drivers back up. When you back up,
look around carefully. Turn your head to both
G Do not leave the clothes dryer on when you
sides and look behind your car. It is safest to
Infection Prevention and Safety in the Home

leave the house. Lint can catch fire.

turn your head and look behind you while back-
G Turn off space heaters when no one is home ing up rather than relying on your rear view
or everyone is asleep. mirror.
G Be sure there are working smoke alarms in Drive at a safe speed. Follow speed limits to be
the home. Check monthly to see that alarms sure you are not driving too fast. Road condi-
are working. Replace batteries when needed. tions such as ice or heavy rain may mean you
have to drive at a slower speed.
G Have fire extinguishers on hand. Every home
should have a fire extinguisher in the kitchen. Always wear your seat belt. Although it may not
Do not store the kitchen fire extinguisher help you avoid an accident, it will certainly help
near or above the stove, because you need protect you if an accident occurs. Always buckle
to be able to get to it if the stove is on fire. up, no matter how short the distance you must
Check that the homes you work in have fire drive. Require your passengers to wear their seat
extinguishers that have not expired. Know belts as well.
where the extinguisher is stored and how to
operate it. 7. Identify guidelines for using your car
See Chapter 6 for more information on fire on the job
safety.
Keep the following in mind when using your car
on the job:
6. Identify ways to reduce the risk of • Park in safe, well-lit areas.
automobile accidents
• Lock doors, both when driving and when
Since you may be driving to and from clients’ you leave your car.
homes, you will need to protect your safety on
• Do not leave valuables in the car. If you
the road.
must leave something in the car, put it out of
Plan your route. Trying to read a map or direc- sight.
tions while driving can be very dangerous. • Have valid car insurance and carry the insur-
When you must drive to a new location, study ance card with you.
the map or directions before you start your car.
Plan the route you will take. • Keep your proof of registration or registra-
tion card with you, not in the car. If your car
Minimize distractions. Paying attention to the is stolen, you do not want the thief to have
road can help you avoid accidents. Keep your this important document.
eyes on the road and your hands on the wheel. If
music is distracting, do not listen in the car. Do • Keep track of the miles you drive for work.
not talk on your cell phone while driving. Document them accurately. Lying about your
mileage is the same as stealing from your
Use turn signals. Using your turn signals lets employer.
other drivers know what you are planning to do.
• Keep your car in good working order. Get
Always use turn signals when preparing to turn
your car serviced at the appropriate times.
or change lanes.
 427 25

• Make sure you have good tires. Keep the gas • Try to avoid unsafe areas after dark.
tank full.
• If you are concerned about your safety in a
particular area, leave the area immediately.

Infection Prevention and Safety in the Home

8. Identify guidelines for working in high- Contact your supervisor.
crime areas • Do not approach a home where strangers are
hanging around. Go to your car and drive
If an assignment takes you to an area where
to a safe area. Use your cell phone or the
crime is a problem, use caution. If you are using
nearest phone in a safe area, and call your
public transportation, be alert at all times. The
supervisor.
following tips can help you avoid trouble:
• Call your client before you visit so they know
• Park in well-lit areas as close as possible to
approximately when to expect you.
the home you are visiting.
• Never enter a vacant home.
• Try to leave valuables at home when you
must work in a dangerous area. • If necessary, ask your supervisor to arrange
for an escort or another care provider to go
• If possible, do not take your purse with you.
with you.
If you must take it, hold your purse or bag
tightly, close to your body. • Be sure someone knows your schedule. Call
the office at the end of your work day.
• Lock your car and do not leave any valuables
in it.
• Walk confidently. Look as though you know Chapter Review
where you are going (Fig. 25-7). 1. How would an HHA disinfect using wet
heat? How would an HHA disinfect using
dry heat?
2. List two items that are considered “dirty” in
the home. Can you think of two examples
of dirty items that are not listed in Learning
Objective 1?
3. When serving food to an infectious client
using dishes and utensils that cannot be dis-
carded, what should the HHA do?
Fig. 25-7. Be cautious but look confident if you enter a 4. List five strategies of applying good body me-
high-crime area. chanics in the home.

• Carry a whistle so you can make a loud noise 5. List eight tips to guard against falls in the
to startle an attacker and get help. home.

• Carry your keys in your hand to unlock your 6. List eight tips to guard against burns in the
car as soon as you arrive. If necessary, you home.
can also use them as a weapon. 7. For each of the following rooms in a house,
• Do not sit in your car, even with the doors list one way to prevent accidents: bathroom,
locked. Drive away as soon as you reach your kitchen, bedroom, living area, garage, and
car. outdoors.
25 428

8. List seven guidelines for reducing fire

hazards.
9. Why is it a good idea not to use a cell phone
Infection Prevention and Safety in the Home

when driving?
10. Why is it a bad idea to leave car registration
or insurance documents in the car?
11. Is it okay for an HHA to guess the number
of miles he drove to a client’s house and
back? Why or why not?
12. If an HHA approaches a house where
strangers are hanging around, what should
he do?
13. Why is it a good idea for an HHA to carry
his keys in his hand before reaching his car?
 429 26

26

Medications in Home Care

Medications in Home Care

1. List four guidelines for safe and proper G Know the difference between prescription
use of medications drugs and over-the-counter drugs. Antibiotics
(such as penicillin), heart drugs (such as
People who need home care often need medica- nitroglycerin), and potent pain medications
tions. Clients who have problems such as coro- (such as codeine) are examples of prescrip-
nary artery disease, high blood pressure, and tion drugs. Aspirin or cold medications, such
diabetes may take many drugs, all with different as decongestants, are over-the-counter drugs
effects. Home health aides do not usually handle (Fig. 26-1).
or give medications. However, you need to un-
derstand the kinds of medicine your clients may
be taking. You also need to know what to do if a
client experiences side effects or refuses to take
medication.

Guidelines:
Safe and Proper Use of Medications

G Never handle or give medications unless you

are specifically trained and assigned to do
so. Do not touch the inside of a medicine
bottle or the pills or other medicines them-
selves. Do not put any medication in a cli- Fig. 26-1. Be aware of all medications a client is taking.
ent’s mouth. Handling or giving medication Know the difference between prescription and over-the-
can have serious consequences. You are not counter medications.
trained to give medications.
G Be aware of all medications a client is tak-
G Observe clients taking their medication. ing. There are many possible side effects
Although you cannot handle or give medi- and interactions among medications. Watch
cation, you can remind clients to take their for symptoms such as itching, trembling or
medications. You can also bring medication shaking, anxiety, stomachache, diarrhea, con-
containers to clients, and provide water or fusion, vomiting, rash, hives, or headache.
food as needed to take with the medication. Any of these symptoms could indicate a side
Always observe, report, and document as effect or interaction. Report any of these
appropriate. symptoms to your supervisor.
26 430

2. Identify the five “rights” of medications

Knowing and remembering the five “rights” of
medications will help prevent mistakes.
Medications in Home Care

1. The Right Client: Always check the label on

the medication container to make sure the
client’s name is on it.
2. The Right Medication: Check the expiration
date and the name of the medication before
giving the container to the client. Make
sure the medication name on the container
matches the name listed in the care plan.
3. The Right Time: Make sure the instructions
on the container label for what time or how Fig. 26-2. Medications come with instructions from
the pharmacist. Instructions include the dosage and
often to take the medication match the in-
when and how to take the medication.
structions in the care plan.
4. The Right Route: Check the label for instruc- The label will state how the medication should be
taken (the right route). For example, the Zolpidem
tions on how the medication is to be taken.
should be “taken by mouth at bedtime.” Sometimes
Make sure the instructions on the label the prescription states to “take as needed.” This
match those in the care plan. means it is not required to take the drug; it should
be taken when the client has symptoms. The Zolpi-
5. The Right Amount: Make sure the instruc- dem is to be taken as needed for sleep.
tions on the container label for how much
Liquid oral medications may be ordered in tea-
medication to take match the instructions in spoons, tablespoons, or portions of either. For ex-
the care plan. ample, the dose may be one-fourth of a teaspoon or
one-half tablespoon. Provide the client a measuring
If the medication label and the care plan do not
spoon—not a spoon used at the table—to measure
agree on any of the five “rights,” call your super- the dose. Medications which are to be put into the
visor. Also, if there is not enough information, eyes or ears will be labeled with the number of drops
or if you have noticed another problem with the per dose. A nasal spray label will state how many
sprays are in one dose. Medications for inhalers may
medication (for example, the client’s name is not
be pre-measured into dose-size packages.
on the container), call your supervisor.
Learn the abbreviations that are approved by your
agency. If abbreviations are unclear or confusing, call
Dosages your supervisor. Always call your supervisor if you
have a concern or question.
Medications come from the pharmacy with the in-
structions printed on the label (Fig. 26-2). When
assisting a client to self-administer medication, read
the directions on the bottle before handing the bottle 3. Explain how to assist a client with
to the client. Dosage means how much medica- self-administered medications
tion should be taken each time it is taken (the right
amount). A capsule, tablet or pill will be ordered with Some elderly people have a hard time remem-
both the strength of one pill, and how many are to bering to take all their medications. In addition,
be taken each time. For example, the bottle may read
there may be instructions to remember. Ex-
“Zolpidem 10 mg tablets, take one tablet.”
amples of instructions include taking pills with
 431 26

food or on an empty stomach, or drinking plenty • Read the medication label for the client.
of fluids. Pay close attention to the medication • Identify the container and bring the bottle or
schedule. The nurse usually sets this schedule. container of medication to the client.
Become familiar with all doctors’ instructions

Medications in Home Care

on how and when to take medications. Use • Bring client equipment needed to prepare
forms as ordered to assist (Fig. 26-3). If the spec- and self-administer medication.
ified time for a dose passes, remind the client • Provide food or water to take with the medi-
to take the medicine. Report to your supervisor cation, as directed.
if the client does not take a medication that has
• Shake liquid medications if ordered by the
been ordered.
care plan.
• Open and close containers.
• Position client for taking medication.
• Observe the client taking the medication.
• Document that the client took the medica-
tion, the time, and any other medications or
food taken at the same time.
• Report any possible reactions to your super-
visor. Call your supervisor if there are any
problems or questions.
• Clean and store or dispose of special medica-
tion equipment after use.
• Return medication to storage.

Home health aides are NOT allowed to do any of

the following:
• Break apart or crush capsules or tablets
• Mix medication with food or drink
• Pour or mix medication from one bottle
into another, even if both contain the same
Fig. 26-3. Many home health agencies use medication medicine
forms to help the client or aide document the client’s self-
• Touch medication directly with your hands
medication. (reprinted with permission of briggs corporation,
800-247-2343, www.briggscorp.com)
• Assist with self-administration of medicine
if the client’s name is different from that on
If specified, you may be instructed to help the the label
client with self-medication by doing any of the
following: • Assist with medication whose label has been
removed or changed
• Remind the client when it is time for
medication. • Assist with medicine if medication name
does not match the name on the care plan
• Check for right person, medication, time,
• Use appearance alone to identify a
expiration date, route, and amount.
medication
26 432

• Assist client in taking more or less of a med- tions with symptoms like hives, fever, rash, or
ication than is ordered difficulty breathing can be life-threatening. They
• Remove or change a medication label may require emergency help.
Medications in Home Care

• Assist client with medicine at a time when it Medication Nebulizer

is not ordered
A medication nebulizer is a small device that turns
• Provide the wrong liquid for swallowing liquid medication into a fine mist so that it can be
medications inhaled. It is also known as an atomizer. This device
helps clients who have lung problems to bring medi-
• Put medication into the client’s mouth cation deep into the lungs. The medication loosens
• Draw up solution for injections mucus in the lungs and helps the client cough it up.

• Give the client an injection Depending on your agency’s and state’s rules, you
may be allowed to assist the client with the use
• Dispose of used injection needles/syringes of the medication nebulizer. You should not per-
form any activity that is not listed in the care plan.
• Insert suppositories or other medication into
If allowed to assist, your duties may include the
the rectum following:
• Insert or apply vaginal medication • Gathering the necessary equipment and supplies
• Do special cleaning of the client’s eyelids or • Properly positioning the client
eyelashes to prepare for eye medications • Putting normal saline in the nebulizer
• Put drops into the eye, ear, or nose • Turning on the equipment
• Apply prescription medications to the skin • Timing the treatment
• Checking to make sure the client is using the
Some clients have reactions to certain medica-
equipment properly
tions, or some medications will interact with
• Turning off the equipment
others, causing problems. To avoid these prob-
lems, document all medication that is taken. • Cleaning and storing the equipment properly
Report drugs, prescription or nonprescription, • Documenting your observations and reporting to
that the client takes that are not part of the care your supervisor
plan. Even a pill as innocent as aspirin should You must be very careful to prevent infection when
be noted. It is very important to report to your assisting with a nebulizer. If microorganisms get
into the medicine or on the mouthpiece, they can go
supervisor and document any reactions the cli- deep into the client’s lungs when he uses the nebu-
ent may have to medications. lizer. Always wash your hands before and after touch-
ing the air hose, medication container, or medication
Avoiding certain foods or substances can be
bottle.
important when taking certain medications. For
If your client is using oxygen, it should be left on
example, drugs that have sedative or calming ef-
while using the medication nebulizer. Observe all
fects should never be mixed with alcohol. If the oxygen safety precautions. Do not try to repair the
client does not follow these restrictions, notify equipment if it is not working properly. Contact your
your supervisor immediately. The doctor and supervisor.
pharmacist will inform the client and the family If you notice any of the following signs, it may mean
of any possible side effects from the medication. that the client is not getting enough oxygen while
Be aware of what side effects to watch for. Com- using the nebulizer:
mon side effects include dizziness, drowsiness, • Rapid pulse and respirations
headache, nausea and vomiting, or confusion. • Difficulty breathing
More serious side effects occur when there is an • Cold, clammy skin
allergic reaction to the medication. Allergic reac-
 433 26

• Blue or darkened lips, fingernails, or eyelids

5. Describe what to do in an emergency
involving medications
• Inability to sit still
• Lack of response when you call his name If a client has a severe allergic reaction to a

Medications in Home Care

medication, takes the wrong dose, or takes
If your client shows any of these signs, stop the pro-
cedure and immediately notify your supervisor.
medications together that cause complications,
emergency medical treatment is necessary.
Treat an overdose, whether it was accidental or
intentional, as a poisoning. Call the local poison
4. Identify observations about
control number immediately. Follow their in-
medications that should be reported right
structions. Poison control will send paramedics
away or an ambulance if needed.
If a client shows signs of a reaction to a medica- For severe drug reactions or interactions, call
tion, or complains of side effects, report it right 911 or 0 for emergency help. Stay with the client.
away. Your supervisor can assess whether the Do not give any liquids, food, or other medica-
symptom is caused by the medication. Your re- tions unless instructed to do so by emergency
sponsibility is to report your observations. personnel. Notify your supervisor as soon as
possible.
Observing and Reporting:
Medications 6. Identify methods of medication storage
Dizziness, fainting You may be required to assist with the proper
storage of medications. Keep the following in
Nausea, vomiting
mind:
Rash, hives, itching
• Keep the client’s medications in one place,
Difficulty breathing, swelling of the throat or separate from medicine used by other mem-
eyes bers of the household.
Drowsiness • If there are young children or a disoriented
Headache, blurred vision elderly person in the home, recommend to
the family that medications be locked away.
Abdominal pain
• All medications should be kept in childproof
Diarrhea
containers if children are in the home. To
Any other unusual sign avoid an accidental overdose, keep medica-
In addition, report any of the following problems tions out of the reach of children.
immediately: • If medicine requires refrigeration, make
Client refuses to take medication as directed. sure the bottle is toward the back on an
upper shelf, out of a child’s reach (Fig. 26-4).
Client takes the wrong dose (amount) of
medication. • All medications should be stored away from
heat and light, as appropriate.
Client takes medication at the wrong time.
• The client or a family member should dis-
Client takes the wrong medication. card medications that have expired, are not
A medication container is missing or empty. labeled, or are discolored. Make sure these
26 434

medications are not discarded in the trash. Getting the client to express uncertainties may
Children or animals may have access to help you get information to the care team. A
them. Ask your supervisor for specific dis- doctor or nurse can then persuade the client to
posal instructions. If the client or family will take the medication or adjust the treatment.
Medications in Home Care

not dispose of expired medications, inform

People may avoid taking prescribed medication
your supervisor. Do not dispose of them
because they cannot afford it or because they
yourself.
have difficulty getting it. Sometimes the client
is confused about which drugs to take, at what
hour, and in what quantities. You can help. If
the client wants to know why he needs to be tak-
ing certain medications, ask the nurse or doctor
to provide an explanation. People who have con-
ditions that affect mental function, such as Al-
zheimer’s disease, will greatly benefit from your
friendly reminders. Other reasons people do not
take medicine are the dislike of side effects and
difficulty swallowing the pills. These problems
can be overcome once you have informed your
supervisor.
Be alert to the signs of misuse or abuse and re-
Fig. 26-4. Store medication properly. Keep medications
out of the reach of children. port them to your supervisor immediately.

Observing and Reporting

7. Identify signs of drug misuse and Drug Misuse and Abuse
abuse and know how to report these
Depression
Drug misuse and abuse may be accidental or de-
liberate. It includes the following: Anorexia
• Refusing to take medications Change in sleep patterns
• Taking the wrong dose or taking it at the Withdrawn behavior or moodiness
wrong time
Secrecy
• Mixing medication with alcohol
Verbal abusiveness
• Taking drugs that have not been prescribed
Poor relationships with family members
• Taking illegal drugs
The drugs that pose the highest risk for causing
Misuse and abuse of drugs is extremely danger- drug dependency are pain medications, tranquil-
ous. It can even be fatal. izers, muscle relaxers, and sleeping pills.
If your client refuses to take certain medications,
explain that recovery often depends on taking
Chapter Review
the right medication. If the client still refuses,
notify your supervisor. Do not push the client 1. What are the four guidelines for promoting
to take the medication. However, try to find out safe and proper use of medications? Briefly
what is making him or her reluctant to take it. describe why each guideline is important.
 435 26

2. List the five “rights” of medications and ex-

plain what they mean.
3. What should an HHA do if she has noticed

Medications in Home Care

any problem with a client’s medication?
4. List ten tasks an HHA may perform if
she is instructed to help a client with
self-medication.
5. List 18 tasks an HHA may NOT do with re-
gard to medications.
6. What are four signs of an allergic reaction to
a medication?
7. Name five side effects of medications.
8. List seven signs an HHA should report im-
mediately to her supervisor that might indi-
cate a reaction to medication.
9. How should an HHA treat an overdose?
Whom should she call?
10. What is the best place to keep medications if
there are young children in the home?
11. List five signs of drug abuse and misuse.
12. What are two common reasons people avoid
taking prescribed medications?
27 436

27
New Mothers, Infants, and Children

New Mothers, Infants, and

Children
1. Explain the growth of home care for diseases or disorders that require special care.
new mothers and infants Babies born prematurely or at low birth weight,
or who are injured during birth, will also need
New mothers and their babies used to stay in special care.
the hospital for several days after delivery. Today,
The most common neonatal disorders include
new restrictions by insurers and the popularity
the following:
of natural childbirth techniques have changed
that. Many new mothers and their babies are • Prematurity (birth more than three weeks
sent home as early as 24 hours after an uncom- before due date)
plicated delivery. Thus, new mothers today re- • Low birth weight
turn home more tired and uncomfortable. They
• Cerebral palsy
are less confident feeding and handling their
babies than women were in the past. • Cystic fibrosis

Home care helps ease the transition from hos- • Down syndrome
pital to home. It allows the mother to rest and • Viral or bacterial infections
recover. Home health aides also assist with • Susceptibility to sudden infant death syn-
household management when an expectant drome (SIDS)
mother is put on bed rest by her doctor. Bed
rest is ordered if a woman shows signs of early
labor, has a history of miscarriage or premature 3. Explain how to provide postpartum
deliveries, or is extremely ill. Stopping all activ- care
ity and staying in bed helps prevent labor from
Care for a new mother will be spelled out in the
starting before the baby is ready to be born. An
care plan. Each situation will be different. The
expectant mother may have to stay mostly in bed
care needed will depend on the mother’s condi-
for a period of a few weeks up to a few months.
tion, the baby’s condition, and the situation in
the home. Care will depend on how much sup-
2. Identify common neonatal disorders port the mother has from her husband or part-
ner, family, friends, or others.
Neonatal is the medical term for newborn. Doc-
tors who specialize in caring for newborn babies A new mother may need the following types of
are called neonatologists. A newborn baby is assistance:
sometimes called a neonate. While most babies • Basic care for the baby, such as feeding, dia-
are born healthy, some babies are born with pering, bathing
 437 27

• Basic care for herself, such as rest, meal incision or an episiotomy. A Cesarean section,
preparation, monitoring vital signs, and or C-section, is a surgical procedure in which
comfort measures such as heat, ice, or sitz the baby is delivered through an incision in
baths the mother’s abdomen. An episiotomy is an

New Mothers, Infants, and Children

incision made in the perineal area during vagi-
• Light housekeeping and laundry
nal delivery that enlarges the vaginal opening
• Care of older children for the baby’s head. Generally self-dissolving
• Meal planning and shopping for the family stitches are used to repair this incision. Your job
duties regarding an episiotomy include careful
The birth of a baby is a tremendous physical
observation and reporting. Observe for signs of
feat. Monitoring vital signs is important for
infection, including swelling at the site, redness,
checking the stability of a mother during her
radiating heat, increased pain and any wound
initial recovery period. Temperature, pulse, res-
changes such as discharge that is foul-smelling,
pirations, blood pressure and changes in pain
or yellow or green in color. You may also assist
level, if any, are vital measurements that track
with complete cleansing of the perineal area
the successful physical transition from preg-
after voiding and bowel movements. It is com-
nancy to motherhood. After a woman has given
mon to use a squeeze bottle of warmed water
birth, vital signs are usually taken often. You
to rinse the perineum followed by drying from
may be asked to monitor vital signs every 15
front to back. Other comfort measures you may
minutes, every 30 minutes, or every hour. Follow
assist with are sitz baths and frequent sanitary
the care plan’s instructions. Check with your su-
pad changes. Follow all care guidelines.
pervisor if you have any questions.
If the baby is on a monitor (for pulse and respi-
You may be required to monitor the amount and ration) or receiving oxygen, you may be asked
color of the new mother’s lochia. The lochia is to monitor the equipment. Sometimes a new
the vaginal flow that occurs after giving birth. mother needs help with breastfeeding. Report
This flow comes from the uterine wall where to your supervisor if she is having difficulties.
the placenta was attached. Similar to a monthly She may need the assistance of a breastfeeding
menses, the discharge is at first bright red in expert, called a lactation consultant.
color. Over the next number of days the flow
changes color to a duller red and then to pink.
Observing and Reporting:
During the second week, the flow continues
Postpartum Care
to change color from pink to a yellowish white
and then finally disappears. The lochia may be
Fever
quite heavy for a couple of days after birthing.
It usually lessens gradually over the next 7 to Change in amount of vaginal flow
10 days. However, it can also last much longer, Odor in vaginal flow
depending upon the person. Report the number
Changes in color of vaginal flow (e.g. bright
of sanitary pads a new mother uses, and report
red after it had been pink)
any changes in flow or color to your supervisor.
Increased amounts of lochia or a brightening in Pain in the pelvic region
color are signs that should not be ignored. Swelling, redness or pain in the legs
In some cases, special care for the mother or Changes in vital signs
baby may be needed. You may be asked to as-
Swelling, redness, heat, pain, or discharge at
sist the mother in caring for a cesarean section
surgical site or site of episiotomy
27 438

4. List important observations to report hold their heads up without assistance. Leaving
and document the head unsupported can cause injury. Be sure
all visitors and family members hold the baby
Your supervisor should instruct you about obser- safely.
New Mothers, Infants, and Children

vations to make. You may be documenting the

baby’s or the mother’s vital signs regularly. You Never leave a baby in an unsafe location or posi-
may also be documenting how much and how tion. The only safe place to leave a baby is in a
often the baby eats, how long the baby nurses, crib with the side rails up or in an adult’s arms.
the baby’s sleeping patterns, and how many dia- Do not leave babies in swings, carriers, seats,
pers are changed. Document and/or report any or on blankets on the floor unless you can see
observations that seem important to you. In ad- them at all times. Never put seats, swings, or
dition, pay attention to the following: carriers on tables, chairs, or countertops. Even
when changing a baby’s diaper, never leave the
The home: Is it clean, healthy, and safe? baby on a table or countertop without keeping
The family: Are older children maintaining their at least one hand on the baby at all times. Let-
regular routines? Do the husband or partner and ting go, even for one second, can be dangerous.
other family members know how they can help? Never leave a baby or any child alone in a bath.
The mother: Is she able to rest? Does she seem Never put a baby down on his or her abdomen.
to be handling everything? Is she depressed, cry- Babies should be placed on their backs. Crib
ing, or moody? Watch for signs of postpartum mattresses should be firm. Infants should not be
(after birth) depression, similar to signs of de- placed on a blanket, comforter, pillow, or sheep-
pression described in Chapter 20. skin to sleep. These items can cause suffocation
and may contribute to SIDS, which occurs when
The baby: Is the baby eating regularly, wetting
a baby stops breathing and dies.
and soiling diapers, and sleeping well? Does the
baby have good color? Supervise older children and pets around babies.
The baby’s room or space: Is there a safe place Jealousy can cause even well-behaved children
for the baby to sleep? Is the crib, bassinet, or bed and pets to harm babies. Older children may not
free of pillows, toys, or excess bedding that could mean to hurt a baby, but may not know how to
cause suffocation? Is the room temperature com- touch or handle a baby.
fortably warm?
Picking up and holding a baby
5. Explain guidelines for safely handling a
1. Wash your hands.
baby
2. Reach one hand under the baby and behind
Wash your hands thoroughly before touching his head and neck. Cradle the head and neck
a baby or any baby supplies. Preventing the in your hand. Support the head at all times
spread of germs is extremely important around when lifting or holding a newborn.
a newborn baby. See that all visitors and family
members wash their hands frequently, especially 3. With the other hand, support the baby’s back
before touching or holding the baby. People with and bottom.
colds or signs of illness should stay away from 4. There are several ways to hold a baby safely:
a newborn, or wear a mask to prevent transmis- the cradle hold; the football hold; and upright
sion of disease. against your chest (Figs. 27-1 through 27-3).
Always lift and hold a baby safely, according to Always be sure the baby’s head and neck are
the procedure below. Newborn babies cannot supported.
 439 27

Keep in mind that most infants love to be held.

They are very sensitive to touch. You should also
talk to them while performing personal care;
they respond well to stimulation. Although ba-

New Mothers, Infants, and Children

bies are helpless, they are sensitive to their envi-
ronment. They can see, taste, hear, and smell.

6. Describe guidelines for assisting with

feeding a baby
Fig. 27-1. The cradle hold has the baby’s head and neck
resting in the crook of one elbow and the legs in the other Assisting with Breastfeeding
arm. You must support the back with one or both hands.
Many pediatricians encourage mothers to
breastfeed, or nurse, their babies. Breastfeeding
provides the perfect nutrition for infants. The
decision to breast- or bottle-feed is a personal
one that each mother must make for herself. If
a mother chooses breastfeeding, she may need
support while learning how to breastfeed. Many
professionals recommend that women try breast-
feeding for at least two weeks before deciding
Fig. 27-2. The football hold is accomplished by holding
the baby’s head in one hand and supporting the baby’s
whether to continue. The first two weeks may
back with the arm on the same side of your body. The be challenging for the mother. Your support can
baby’s body will lie along the side of your body. help her get off to a good start.
Discuss with the mother how much help she
wants or needs. Ask her questions to determine
her experience with and knowledge of breast-
feeding: Did you breastfeed your other children?
If yes, for how long? If no, what made you decide
to do so now? Did the nurses in the hospital
teach you about breastfeeding? Did you take any
newborn classes before delivery? The mother
may only want you to help her get into position.
Or, she may need your coaching throughout the
process. Make sure she knows that lactation con-
sultants can help solve breastfeeding problems.
Report any problems you observe or the client
shares with you.
Mothers nursing for the first time may experi-
ence embarrassment, fear of pain, and/or lack
of self-confidence. You can help the new mother
by remaining calm, being supportive and con-
Fig. 27-3. When holding a baby upright against your
chest, you must support the baby’s head, neck, and back fident in her ability to nurse, and creating an
with one hand while keeping the other arm under the atmosphere in which she can comfortably nurse
baby’s bottom to support his or her weight. without interruption. Help for nursing mothers
27 440

is available from the La Leche League Interna- G Provide privacy. Close the door and occupy
tional, listed in the phone book and also found older children if necessary.
online at lalecheleague.net. G Change the baby’s diaper if necessary before
New Mothers, Infants, and Children

Women have different breastfeeding styles. bringing him to the mother. If desired, use a
Some are very comfortable and will nurse any- towel or blanket to cover the mother’s breast
time, including in the presence of others. Others and baby’s head after baby has latched on.
may want more privacy while nursing. Be sensi- G If necessary, remind the mother how to hold
tive to individual preferences. A calm setting the nipple and areola between thumb and
where the mother can relax will help her body forefinger to allow baby to latch on. If baby
provide the most milk for the baby. does not latch on right away, have the mother
stroke his cheek with her nipple.
Guidelines: G Good nutrition and plenty of fluids are
Helping a Mother with Breastfeeding important for nursing mothers. Offer snacks
and frequent drinks of water, juice, or milk.
G Remind the mother to wash her hands. Help
her get in position for breastfeeding, usually G Observe the baby nursing to be sure he stays
sitting upright in a comfortable chair or in latched on properly (Fig. 27-5). If needed, the
bed supported by pillows. Provide a low foot- mother can use one hand to hold the breast
rest if possible and a pillow for the mother’s tissue away from the baby’s nose.
lap (Fig. 27-4). Some mothers are able to There is no need to move the baby from one
breastfeed while lying down. Others, how- breast to the other until the baby stops nurs-
ever, find this more difficult, especially with a ing on his own. The longer the baby nurses
newborn baby. on one side, the more of the denser, fattier
“hindmilk” he receives.

Fig. 27-5. When the baby is properly latched on to the

mother’s nipple, his mouth covers much of the areola.
The nipple is sucked straight out rather than at an angle.
This ensures the best milk flow and prevents the nipples
from becoming sore.

G If the mother needs to reposition the baby or

wishes to try for a better latch, she can break
the suction by pressing down on the breast
above the nipple or by gently putting her fin-
ger in the baby’s mouth.
Fig. 27-4. A new mother usually prefers to nurse in an
upright sitting position. Provide support with pillows and G Help the mother burp the baby when switch-
a footrest. ing breasts and when finishing the feeding.
 441 27

G Change the baby’s diaper after the feeding. than two days. Ready-to-feed formula is the most
Help the mother lay the baby down safely. convenient to use. It is also the most expensive.
G Many women find it helpful to tie a ribbon or Concentrated formula is sold in small cans. It

New Mothers, Infants, and Children

place a pin on the side the baby last fed on. must be mixed with sterile water before using.
This helps them remember to start the baby’s Shake the can and open it with a sterile can
feeding on that side next time, so the breasts opener. Measure an amount into a marked bottle
will be emptied more evenly. and add an equal amount of sterile water. Screw
on the nipple and ring, and shake to mix. Ster-
Assisting with Bottle Feeding ile water can be purchased in small bottles or
Many women choose to bottle feed their babies in gallon jugs. You can also make sterile water
some or all of the time. Bottle-fed newborns by bringing water to a boil and then cooling.
require special formula. Infant formula is com- Store unused concentrate in a sterile container,
mercially prepared and provides the nutrition covered and refrigerated, for no more than two
babies need. Regular whole milk does not supply days.
the proper nourishment for babies and would Powdered formula is sold in one- or two-pound
upset their digestive systems. cans. It is carefully measured and mixed with
There are many brands and types of formula. If sterile water. A scoop is included in the can for
you are doing the shopping, know exactly which measuring. Mix the powder and sterile water in
type you need to buy. The three most common sterile bottles or a sterilized pitcher or covered
types are ready-to-feed formula, concentrated liq- container. Follow the directions on the package
uid formula, and powdered formula (Fig. 27-6). carefully. Once mixed, the formula can be stored
for two days in the refrigerator. Shake before
feeding. Powdered formula is the most difficult
to use, but is usually the cheapest to buy.
Before feeding, bottles should be warmed. To
heat, immerse the bottle in warm tap water for
several minutes. Bottles of formula just out of
the refrigerator will take longer to warm. Never
use the microwave to warm bottles. This can
create hot spots in the liquid that can burn the
baby (Fig. 27-7). Always shake the bottle after
Fig. 27-6. Baby formula is available ready-to-feed in cans warming and shake a few drops of formula onto
or bottles, concentrated in cans, or powdered in cans. the inside of your wrist. It should feel warm, not
hot or cold.
Ready-to-feed or prepared formula is sold in
bottles or cans. This formula is ready to use. Do
not dilute it or mix it with water. If the formula
comes in a bottle, simply shake, unscrew the
cap, and screw on a standard nipple and ring.
Discard any formula remaining in the bottle
after feeding. If the ready-to-feed formula comes
in a can, shake the can before opening it with a
sterilized can opener. Pour into sterile bottles.
Store remaining formula in a sterile container, Fig. 27-7. Warm bottles in warm tap water—not in the
microwave!
and keep covered and refrigerated, for no more
27 442

6. Talk or sing to the baby while feeding. Feed-

Sterilizing bottles
ings are the high points of his days and
Equipment: clean bottles, nipples, and rings to be should be special times.
sterilized (these should be washed in hot, soapy
New Mothers, Infants, and Children

water using a bottle brush, and allowed to drain), 7. When the baby is through or has stopped
large kettle filled halfway with water, tongs, clean sucking, burp him (see procedure below).
dish or paper towels to set sterile bottles on Resume feeding or, if finished, change the
1. Wash your hands. diaper (see procedure later in chapter). Put
the baby down safely.
2. Bring water to a boil and put bottles, nipples,
and rings in. Use tongs to push bottles under 8. Wash your hands and document the feeding,
water. how much was consumed, and any other
3. Bring water to a boil again and boil for five observations.
minutes. 9. Throw out unused formula left in bottle.
4. Using tongs, remove bottles, nipples, and Wash the bottle, nipple, and ring in hot soapy
rings, draining the water into the pot. Set ev- water with a bottle brush, and allow to dry.
erything on the clean towels. When dry, store Sterilize before using again.
in a clean, dry cabinet.
5. Discard water.
Babies must be burped after each feeding to
release air swallowed during feeding. Burping
Assisting with bottle feeding prevents babies from developing gas. Gas can
be very uncomfortable for them. Burping in
1. Wash your hands. the middle of a feeding may allow a baby to eat
2. Prepare bottle and formula as directed. more.
3. Sit in a comfortable chair and hold the baby
safely in either the cradle hold or football Burping a baby
hold.
1. Wash your hands.
4. Stroke the baby’s lips with the bottle nipple
until he opens his mouth. Put the bottle 2. Assemble equipment: a clean towel, cloth
nipple in the baby’s mouth. diaper, or burp pad.
5. Be sure the baby’s head is higher than his 3. Pick up the baby safely. There are two differ-
body during feeding. Also make sure the ent positions to use for burping. Most people
nipple stays full of milk so the baby does not like to hold the baby against the shoulder to
swallow air (Fig. 27-8). burp (Fig. 27-9). However, babies who are
very small, who have breathing problems, or
who tend to choke or spit up should be held
on the lap with the head supported by hold-
ing the baby’s chin with the thumb and fore-
finger (Fig. 27-10). This position allows you
to watch the baby for signs of respiratory dis-
tress, especially color changes, and spit-up.
Whichever position you use, put the burp pad
Fig. 27-8. The baby’s head should be higher than his under the baby’s chin to catch any spit-up.
body during feeding.
 443 27

Clients’ Rights
Schedule and Feeding
The mother has the right to determine how to

New Mothers, Infants, and Children

handle her new baby’s schedule. For example, if a
mother wants her baby to be fed whenever he cries,
whether she is present or not, the HHA should re-
spect her wishes. It is also the mother’s decision
what to feed her baby. Do not make judgments or
express your opinion on whether the mother should
be breastfeeding or using formula to feed her baby.
If any behavior causes you to be concerned, report it
Fig. 27-9. Holding a baby against the shoulder to burp is to your supervisor.
common.

7. Explain guidelines for bathing and

changing a baby
Keeping a baby clean is important to his health.
Follow the guidelines for safely handling a baby.
In addition, remember the following guidelines:

Guidelines:
Bathing and Changing a Baby

G Because you could come into contact with

body fluids, wear disposable gloves when
bathing or changing a baby. Remember, how-
ever, that gloves can make a wet baby slip-
pery! Be very careful when handling a baby
during a bath.
Fig. 27-10. Babies who have breathing problems or who G Whether bathing or changing a baby, keep
choke or spit up will be held on the lap with the head one hand on the infant at all times. Have all
supported to burp.
supplies ready so you never have to take both
hands off the baby.
4. With the baby in a safe and comfortable po-
sition, pat the baby’s back gently with your G Give baths in a warm place. Close doors and
flat hand. Concentrate on the area between windows to prevent drafts. Dry the baby’s
the shoulder blades. Some people like to pat head immediately after washing hair.
up and down the baby’s back. Others like to G Be very careful about bath temperature.
massage the back using an upward motion Always test the temperature of the water
with the flat hand. Use any technique that (either on the inside of your wrist or with a
works for you. The more relaxed and com- bath thermometer).
fortable the baby is, the sooner the burp will
G Keep the baby’s bottom dry. Be sure the area
come.
is thoroughly dried after a bath. Moisture
5. After the baby has burped, return him or her contributes to diaper rash. Dry the bottom
to a safe position or resume feeding. after changing a diaper. Leaving the diaper off
for a few moments when changing the baby
27 444

allows air to circulate and helps prevent dia- 6. To wash hair, hold the baby in the football
per rash. hold with the head over the basin. Use the
washcloth to wet the hair. Using a small
G Do not use powder unless directed to do so.
amount of shampoo, lather the baby’s hair
New Mothers, Infants, and Children

Babies who are very small, premature, or who

(Fig. 27-12). Rinse with the washcloth. Pat
have breathing problems can be harmed by
the head dry immediately with the towel. Put
inhaling baby powder.
a cotton hat over the baby’s head. Much heat
is lost through the head. Be careful to keep
Giving an infant sponge bath
the head warm.
Equipment: disposable gloves, clean basin, blanket
or towel to pad surface, washcloth and towel, baby
cleanser or mild soap, baby shampoo or mild sham-
poo, cotton hat, lotion or oil, cotton ball or cotton-
tipped swabs and alcohol, diaper ointment if used,
clean diaper, clean clothes or sleeper, clean receiving
blanket
1. Wash your hands.
2. Put on gloves. Be careful—gloves make the
baby slippery!
3. Give the bath in a warm place. Use a blanket
or towel to pad the surface the baby will lie
Fig. 27-12. Lather the hair with a small amount of
on. Have all your supplies within reach. You shampoo and, after rinsing, immediately dry the head.
will need to keep one hand on the baby dur-
ing the entire bath. Remove caps from sham- 7. Lay the baby down on the padded surface.
poo and cleanser to make it easier. Always keep at least one hand on the baby.
4. Fill the basin with warm water. Test the tem- 8. Undress the upper body. Wash the neck,
perature on the inside of your wrist. Put the chest, back, arms, and hands using the
bottle of lotion or oil in the warm water to washcloth and small amounts of soap. Rinse
warm it. using the washcloth and water from the
5. With the baby still dressed, hold him or her basin (Fig. 27-13). Pat dry. Cover the upper
in the football hold. Wet the washcloth and body with a towel.
gently wipe the eyes, from the inner corner to
the outer (Fig. 27-11). Then clean the rest of
the face. Use only warm water—no soap.

Fig. 27-11. Wipe with eyes from the inner area to the Fig. 27-13. Uncover only the area that you are washing.
outer area only using warm water. Keep one hand on the baby at all times.
 445 27

9. Undress the lower body, removing the diaper.

Wash the baby’s abdomen and legs. Rinse.
Pat dry.

New Mothers, Infants, and Children

10. Wash the perineal area last. For a girl, wipe
the perineal area from front to back. For
a boy who has recently been circumcised,
do not wash the area of the circumcision.
Follow special instructions to care for the
circumcision.

11. Wash the baby’s bottom thoroughly and dry Fig. 27-14. The baby’s head and neck must be supported
the entire area completely with the towel. at all times.
Moisture can contribute to diaper rash.
2. Using the washcloth and small amounts of
12. As gently and quickly as possible, rub lotion soap, wash the baby from the neck down.
over the baby’s body. Avoid the umbilical
cord stump if it has not yet healed. Use lo- 3. Remove the baby from the bath and lay him
tion on the face only if skin is very dry. Be ex- or her down on the padded surface. Keep one
tremely careful not to get any lotion near the hand on the baby at all times. Cover baby
eyes. Keep the baby covered except for the with a towel and pat dry (Fig. 27-15).
part you are rubbing.

13. Diaper and dress the baby. Wrap baby in

blanket and put him or her down safely.

14. Put used towels and washcloth in the laun-

dry. Discard water. Clean basin and store.
Store other supplies. Discard gloves.

15. Wash your hands.

16. Document the bath, including any

observations.
Fig. 27-15. Immediately dry and cover the baby after the
bath.

Giving an infant tub bath 4. Apply lotion, keeping the baby covered as
much as possible.
In addition to the supplies listed in the procedure
above for a sponge bath, you will need a large 5. Diaper, dress, and wrap the baby in a receiv-
basin or baby bath tub. You may also bathe a ing blanket. Put him or her down safely.
baby in a clean sink. Follow the first six steps in
6. Put used linens in the laundry. Discard bath
the procedure for a sponge bath for preparing the
water. Clean and store basin. Store all sup-
bath and washing the baby’s face and hair.
plies. Discard gloves.
1. Lay the baby down on the padded surface
7. Wash your hands.
and undress him or her completely. Immerse
baby in the basin. Support the head and neck 8. Document the bath, including any
above water with one hand at all times observations.
(Fig. 27-14).
27 446

Diapers catch the baby’s urine and feces. Chil- 7. For disposable diapers: Unfold the diaper and
dren wear diapers until they are toilet trained— expose tapes. Place the diaper flat under the
generally between two and three years of age. baby’s bottom with the tapes in back. Bring
Diapers are either cloth or disposable, made of the front of the diaper up between the baby’s
New Mothers, Infants, and Children

paper and plastic. Cloth diapers are used with legs and bring the back sides around and
special waterproof diaper covers or with diaper over the front (Fig. 27-16). Peel tapes open
pins or other fasteners and waterproof pants. and tape the side of the diaper securely to
the front.
A newborn will need between eight and twelve
diaper changes in 24 hours. As babies get older,
they use fewer diapers each day. The appear-
ance, consistency, and smell of a baby’s feces will
depend on what he or she is fed. Some newborn
babies have loose bowel movements with every
feeding, as many as eight a day. Others have
different schedules. Babies must be changed fre-
quently to avoid diaper rash or irritation.

Changing cloth or disposable diapers

Equipment: clean disposable diaper or clean cloth Fig. 27-16. A disposable diaper is fastened with adhesive
or Velcro tape attached to the back sides of the diaper.
diaper, diaper cover or pins or other fasteners and
waterproof pants, wipes or a washcloth wet with
warm water, diaper ointment or oil if used, clean For cloth diapers with a diaper cover: Fold
clothes if clothes are soiled or wet the diaper in thirds lengthwise. Then open
out the back corners about three inches (Fig.
1. Wash your hands.
27-17). Lay the back of the diaper inside the
2. Put on gloves. back of the diaper cover (the back of the
diaper cover has the tabs extending from it).
3. Change the diaper in a warm place. You need
Place the diaper and cover underneath the
a padded surface, which may be a special
baby’s bottom. Bring the front of the diaper
changing table or a countertop. Never turn
and cover up through the baby’s legs. Bring
your back on the baby. Keep one hand on
the tabs around from the sides to the front
baby at all times, and stand so as to leave no
of the diaper cover and use them to close the
space between your body and the changing
cover securely over the diaper. Check that all
surface. Have supplies within reach.
the edges of the diaper are tucked under the
4. Undress the baby to remove wet or soiled cover.
diaper. Set it aside for handling later.

5. Clean the perineal area with wipes or wash-

cloth. Remove all traces of feces. Spread the
legs to clean thoroughly. For girls, wipe from
front to back and spread the labia to clean as
needed.

6. Let air circulate on the bottom for a moment.

Exposure to air prevents diaper rash. Apply Fig. 27-17. After folding the diaper in thirds, open out the
ointment or oil as directed. back corners about three inches.
 447 27

For cloth diapers with pins or other fasten- 11. Wash your hands.
ers and waterproof pants: Fold the diaper
12. Clean changing area and store supplies.
lengthwise in thirds, then open out the back
corners about three inches. Place the diaper 13. Wash hands again as needed.

New Mothers, Infants, and Children

under the baby’s bottom and bring the front
14. Document any observations, including un-
of the diaper up between the baby’s legs.
usual color, consistency, or odor.
Fold down the front of the diaper to the in-
side (next to baby’s skin) so that the diaper
covers the genitals and lower abdomen. 8. Identify how to measure weight and
Bring the corners of the diaper around the length of a baby
baby’s sides and pin or fasten them to the
front of the diaper. Hold your fingers inside As part of your duties, you may be asked to mea-
the diaper next to baby’s skin when pinning sure a new baby’s weight and length. Measure-
to avoid sticking the baby (Fig. 27-18). You ment of a newborn is not normally difficult, but
do not need to pin through all layers. Just pin they do tend to squirm and wiggle when naked
enough to fasten the back of the diaper to and on a hard, flat surface. Always keep one
the front. When diaper is securely fastened, hand on the baby at all times.
put waterproof pants over the diaper to keep The infant may need to be naked for an accurate
urine from leaking. weight. Follow instructions. Use an infant scale
when measuring the baby’s weight.

Measuring a baby’s weight

Equipment: infant scale, clean paper or pad, pen

1. Wash your hands.
2. Place an infant scale on a firm surface.
3. Place a clean paper or pad on the scale.
4. Start with scale balanced at zero before
weighing baby.
Fig. 27-18. Keep your fingers between the baby’s skin and
the diaper to avoid sticking the baby. 5. Undress the baby.
6. Place the baby on the scale protecting the
8. Dress the baby in clean clothes and put him
sides so he or she does not roll. Keep at least
down safely.
one hand on the baby at all times.
9. Dispose of diaper properly. Disposable dia-
7. Read and remember the weight. If possible,
pers can be rolled into a ball (dirty side in),
lock the weight into place.
sealed with tapes, and disposed of in a spe-
cial trash bag in a sealed container to prevent 8. Remove the baby and dress him or her. Put
odors. Cloth diapers may need to be soaked baby in crib.
before washing or removal by a diaper ser-
9. Wash your hands.
vice. Check with the baby’s mother or your
supervisor for instructions. 10. Document the weight, including any
observations.
10. Remove gloves.
27 448

A baby’s length measurement can be obtained 8. With the tape measure, measure the distance
with the baby dressed. between the marks. Remember length.
9. Wash your hands.
New Mothers, Infants, and Children

Measuring a baby’s length

10. Document the length, including any
Equipment: paper with inch markings on it or plain observations.
paper, tape measure, pencil

1. Wash your hands.

9. Explain guidelines for special care
2. Prepare a firm surface with a clean sheet of
paper that has inch markings on it. At birth the umbilical cord that connected the
baby to the placenta inside the mother’s uterus is
3. Place the baby on the firm surface. Keep at cut. The stump of the cord remains attached to
least one hand on the baby at all times. a newborn’s navel for up to three weeks. Proper
4. Place the baby’s head at the beginning of the care of the cord stump is necessary to prevent
measured markings. infection and allow healing.
• With every diaper change, moisten the cord
5. Straighten the baby’s knee.
with rubbing alcohol. Use a cotton ball or
6. Make a pencil mark on the paper at the ba- cotton-tipped swabs soaked in rubbing alco-
by’s heel. hol to swab the area around the navel and
cord. This helps the stump dry up and fall
7. Determine and remember length.
off.
8. Remove the baby and put him in his crib.
• Never pull on or handle the cord. It will fall
9. Wash your hands. off by itself. The baby will feel no pain when
the cord falls off.
10. Document the length, including any
observations. • Keep diapers folded down away from the
cord to allow air to circulate and prevent ir-
When a paper with inch markings is not avail- ritation (Fig. 27-19).
able, follow these steps:

1. Wash your hands.

2. Prepare a firm clean surface with a plain

sheet of paper on it. The paper must be lon-
ger than the baby.

3. Place the baby on the firm surface. Keep at

least one hand on the baby at all times.

4. Make a pencil mark on the paper at the top

of the baby’s head.
Fig. 27-19. Keep diapers folded down, away from the
5. Straighten the baby’s knee. cord, to allow air to circulate and to prevent irritation.
6. Make another mark at the baby’s heel.
• Do not give an infant a tub bath until the
7. Remove the baby and put him in his crib. cord has fallen off.
 449 27

opposite eye (Fig. 27-21). Be sure the ear is

Taking an infant’s axillary or tympanic
sealed by the thermometer. Press the button
temperature
and hold for one second.

New Mothers, Infants, and Children

An infant’s temperature is typically taken by the
axillary or tympanic methods. Rectal tempera-
tures are no longer recommended due to the
chance of damaging rectal tissue. Oral tempera-
tures are never taken for infants because the
method is too difficult and dangerous.
Equipment: mercury-free thermometer, digital ther-
mometer, or tympanic thermometer, disposable
probe cover, if needed

1. Wash your hands.

2. Be sure thermometer is clean. Put on dispos-

Fig. 27-21. After gently pulling the outside of the ear
able probe cover, if used. For mercury-free back, insert the thermometer tip into the ear.
thermometer, shake thermometer down to
below the lowest number. 4. For all methods, remove the thermometer
3. For axillary temperature: Undress the upper and read the temperature. Keep one hand on
body on one side. Lay the baby on a padded the baby at all times.
surface. Place the tip of the thermometer 5. Dress the baby and put him down safely.
under the arm and hold the baby’s arm close
6. Clean and store thermometer and supplies.
to his body, so the thermometer tip touches
skin on all sides (Fig. 27-20). Keep thermom- 7. Wash your hands.
eter in place for 3 to 5 minutes for a mercury-
8. Document temperature.
free glass thermometer, or until the signal
sounds for a digital thermometer.
Circumcision is the removal of part of the fore-
skin of the penis. It is commonly performed on
male babies. Some religions require circumci-
sion. Other parents choose to have their baby
circumcised for hygienic or social reasons.
The circumcision is usually performed in the
hospital or at the doctor’s office when the baby is
only days old. Afterwards, the circumcision site
needs special care to heal. This usually includes
covering the tip of the penis with a gauze pad
rubbed with petroleum jelly to prevent the dia-
Fig. 27-20. Leave the thermometer in place for three to
per from irritating the site. However, some types
five minutes or until it beeps.
of circumcision require different care. Follow
your supervisor’s instructions and the care plan
For tympanic temperature: Lay the baby on
carefully.
his side. Pull the outside of the ear gently
toward the back of the head. Insert the ther- Some babies who need special care will have
mometer tip into the ear, pointing toward the medical equipment in the home. You will prob-
27 450

ably not be responsible for operating or handling appropriate activities, opportunities for learn-
the equipment. However, it is helpful to be fa- ing, and chances for increasing independence.
miliar with various items. Always follow your Emotionally, children need love and affection,
supervisor’s instructions before touching any reassurance, encouragement, security and guid-
New Mothers, Infants, and Children

medical equipment. ance. They also need consistent and constructive

Apnea monitor: Apnea is the state of not breath- discipline. In addition, children need protection
ing. Some babies may stop breathing for periods from injury and illness. Chapter 8 describes
of time due to immaturity of the lungs or other child development in more detail.
reasons. The apnea monitor alerts parents or Children with disabilities have the same physi-
caregivers if breathing has stopped. Many apnea cal and emotional needs as other children (Fig.
monitors also monitor heart rate. 27-22). Remember to treat these children as chil-
Ventilator or oxygen equipment: Some babies dren first. Disabilities may make normal social
with breathing problems need to be given oxy- contact with other children difficult. However,
gen. Oxygen is considered a medication. In most it is important for children with disabilities to
states it cannot be given by a home health aide. interact with others their own age.
In addition, HHAs are not allowed to change
the amount of oxygen being given. As always,
be careful when working around oxygen, as it
is flammable. Follow your supervisor’s instruc-
tions carefully when working in a home where
oxygen is in use. See Chapter 14 for more infor-
mation on oxygen and related care.

10. Identify special needs of children and

Fig. 27-22. Children with disabilities have the same
describe how children respond to stress emotional needs as other children. They need love and
acceptance, reassurance, encouragement, security and
You may have contact with children in several
guidance, and consistent and constructive discipline.
ways. You may be assigned to care for a client’s
children when the client is unable to care for Children may experience stress due to a variety
them. The client may be absent, or unable to of reasons, including unmet needs, problems at
care for them due to illness, injury, or disability. school or at home, unstable families, disability,
In this case you are a substitute for the parent. illness, and unfamiliar caregivers in the home.
In other cases, the child may be the client and Many factors influence how children respond to
is suffering from a disease or disability that re- stress, such as how old the child is, what is caus-
quires home care. In either case, it is important ing the stress, how severe the stress is, how long
to understand some basic principles of caring for it lasts, and how often it occurs.
and working with children.
School-age children may react to stress by re-
Children have the same basic physical and belling, skipping school, daydreaming, lying,
emotional needs as adults (see Chapter 8). They cheating, or stealing. They may also feel guilty
also have some special physical, mental, and and feel that they are to blame for the family’s
emotional needs. Children’s growing bodies problems. Adolescents may also react to stress
need adequate and nutritious food and fluids, in negative ways, such as staying out all night,
exercise, fresh air, and plenty of sleep. Their dropping out of school, and abusing drugs or
developing minds need to be stimulated by age- alcohol.
 451 27

11. List symptoms of common childhood Vomiting: The treatment for vomiting is similar
illnesses and the required care to the treatment for diarrhea, including rest and
clear liquids, and later the BRAT diet. Always
Most childhood illnesses are caused by bacterial call your supervisor if symptoms continue. Fol-

New Mothers, Infants, and Children

or viral infections. These include colds, flu, and low instructions in the care plan or your assign-
various infections causing fever, diarrhea, vomit- ment sheet carefully.
ing, or coughs. You can help prevent illness by
preventing the spread of infection in the home.
12. Identify guidelines for working with
Handwashing, cleaning, and disinfection are the
best ways to control infection (see Chapter 5).
children
Treatment for some of the most common symp- The following suggestions may help you estab-
toms of childhood illnesses is described below. lish a trusting and honest relationship with the
Fever: Fever may indicate serious illness. It children in your care.
should always be reported to your supervisor. Introduce yourself. Treat children as important
Rest and fluids are recommended for fevers. members of the family, and worthy of your no-
Treatment for a fever may also include acetamin- tice. Be friendly, tell the children your name,
ophen, or a lukewarm bath or sponging. Home and explain why you are there.
health aides never give any medication, includ- Maintain routine. As much as possible, stick
ing over-the-counter medications. You can assist with the family’s regular schedule. The comfort
by making sure the family caregiver follows a of a routine can help ease the stress children
doctor’s dosage instructions for all medications. may feel if someone in their household needs
The strength of over-the-counter drugs varies in home care.
infant, children, and adult formulas. It is espe-
cially important to follow dosage instructions. Give comfort. Children who are hurt, angry, or
Giving too much acetaminophen, for example, sad may need a hug, a pat, or soothing words to
can cause liver damage or failure. In general, make them feel more secure (Fig. 27-23).
children should not be given aspirin, as it has
been associated with some serious disorders.
Diarrhea: Diarrhea, or frequent loose or watery
bowel movements, can have many causes. In
children, it is often caused by a virus. Cramps
and abdominal pain may accompany diarrhea.
Children with diarrhea should rest and drink
plenty of clear liquids, including water, broth,
and diluted juices. Doctors may recommend
electrolyte-replacement drinks to prevent dehy-
dration. Usually, children with diarrhea should
avoid solid foods until the problem subsides.
Then they may follow the BRAT diet: bananas, Fig. 27-23. Comforting children can make them feel
more secure.
rice, applesauce, and toast. Other starchy foods,
such as pasta or crackers, are also allowed. Milk Offer encouragement and praise. Praise and en-
products, fruits, vegetables, and fatty foods couragement contribute to the child’s sense of
should be avoided until the bowels return to self-worth and self-confidence. Word your praise
normal. so that it does not belittle other children.
27 452

Do not make comparisons. Children should not Encourage children to play. Children need to ex-
be compared to each other. ercise and socialize with other children (Fig. 27-
25). Playing helps children express themselves
Use positive phrases. Children often respond
and be creative. Exercise is important for their
New Mothers, Infants, and Children

better to guidance such as, “Let’s try it this

growth and health. Socialization is especially
way...” rather than “no” or “don’t.”
important for children who are learning social
Listen. Pay attention when children attempt to skills.
communicate. Do not interrupt them or deny
their feelings. Help them to express what they
are feeling by using your communication skills.
Answer. Respond to children’s questions imme-
diately, willingly, and clearly. If you do not know
the answer or are not sure you are the right per-
son to answer it, tell the child. Take the child’s
question to the appropriate person.
Do not force children to eat. Like adults, children
do not always feel like eating. Do not allow a
meal to become a power struggle. Children are
usually motivated to eat when meals are simple Fig. 27-25. Encourage children to play with others.
but attractive and contain their favorite foods.
Recognize individual needs. Not all children are
Involve children in household activities. Children the same. They have different needs for sleep,
feel capable and responsible when they are given food, and exercise. They grow and develop at dif-
household tasks to perform (Fig. 27-24). Like all ferent paces.
people, they like to feel they are making a contri-
Be nonjudgmental. As with any client, you
bution to the family.
must accept a child regardless of disabilities or
problems.

13. List the signs of child abuse and

neglect and know how to report them
Child abuse is the physical, sexual, or psycho-
logical mistreatment of a child. Children who
are abused can range in age from infant to
adolescent. Sexual abuse of children includes
inappropriate touching of a child’s body, sexual
contact, penetration, or sharing sexual stories
or material with children. Psychological abuse
includes verbal abuse, such as name-calling,
social isolation, and seclusion. Child neglect is
the purposeful or unintentional failure to pro-
vide for the needs of a child. Children who are
neglected may not receive adequate food, water,
Fig. 27-24. Help children contribute. medications, supervision, or shelter.
 453 27

Children should never be harmed, threatened, Chapter Review

or teased. They must be treated with respect and
concern. Adults must talk to children calmly and 1. Why are new mothers often more tired and
quietly and give them positive comments, praise, uncomfortable when they get home than

New Mothers, Infants, and Children

and encouragement. women were in the past?

Child abuse or neglect can come from any- 2. What kind of doctor specializes in working
one who is responsible for a child’s care. This with newborns?
includes parents, guardians, paid caregivers, 3. List five tasks an HHA may do to assist a
teachers, friends, or relatives. The law requires new mother.
that health professionals must report suspected
4. What might an HHA be asked to routinely
child abuse. If you observe or suspect abuse or
document in caring for a newborn and
neglect, or if a child reports that someone has
mother?
abused or neglected him or her, you must imme-
diately report this to your supervisor. It not only 5. What should an HHA always do before
is the right thing to do, but you and your agency touching or picking up a baby?
can get into trouble for not reporting suspected 6. Where are the only safe places to leave a
abuse or neglect. Follow your employer’s proce- baby?
dures for reporting abuse or suspected abuse.
7. Why must a baby’s head be supported when
he is being held?
Observing and Reporting:
8. Why should a baby NOT be put to sleep on
Child Abuse
his stomach or on a blanket or comforter?
If you observe any of these signs of child abuse 9. Why are women encouraged to breastfeed?
or neglect, or if you suspect abuse or neglect,
10. How should a bottle be warmed?
speak to your supervisor immediately.
11. How is concentrated formula mixed?
G Child has burns, cuts, bruises, abrasions, or
fractured bones. 12. For what length of time can ready-to-feed
formula be refrigerated?
G Child stares vacantly or watches intently.
13. How does burping help a baby?
G Child is extremely quiet.
14. Why should an HHA have all supplies ready
G Child avoids eye contact. In some cultures,
before bathing or changing a baby?
however, it is the norm to avoid eye contact.
15. How can an HHA test the temperature of a
G Child is afraid of adults.
baby’s bath water?
G Child behaves aggressively.
16. How many diaper changes will a newborn
G Child exhibits excessive activity or hyperac- typically need in 24 hours?
tivity. Some hyperactive children, however,
17. What should an HHA do to care for the um-
have a chemical imbalance that produces this
bilical cord stump every time a baby’s diaper
behavior.
is changed?
G Child tells you that someone is abusing him
18. What does circumcision care generally
or her.
require?
27 454

19. What is important to report about a new

mother’s lochia?
20. Why may an HHA be assigned to care for a
New Mothers, Infants, and Children

client’s children?
21. Why is it important to treat children with
disabilities as children first?
22. List five factors that influence how children
respond to stress.
23. Name each of the three symptoms of illness
outlined in Learning Objective 11 and de-
scribe one common treatment for each.
24. If a child asks an HHA a question and she
does not know the answer, what should she
do?
25. Why is maintaining routine important for
children?
26. List six common signs of child abuse.
 455 28

28

Meal Planning, Shopping, Preparation, and Storage

Meal Planning, Shopping,
Preparation, and Storage
1. Explain how to prepare a basic food ning for each day, you will plan the right num-
plan and list food shopping guidelines ber of meals and buy the right amount of food
(Fig. 28-1).
It is very important to plan meals for a week
or at least several days before shopping. When Fill in breakfasts, lunches, dinners, and snacks
planning, take into account the client’s dietary for each day. Ask the client or family for ideas
restrictions and food preferences, the number or look in cookbooks. Plan to have leftovers that
of family members present at meals, and the cli- can be easily reheated on days you will not be
ent’s budget. in the home. Plan plenty of nutritious snacks;
clients may need as many as three snacks a day.
On a large sheet of paper, write out the days for Remember to list beverages as well.
which you will shop. Leave space under each day
for meals and snacks. You may end up serving When your meal plan is completed, make your
the meals in a different order. However, by plan- shopping list. On another large sheet of paper,

Fig. 28-1. A meal plan will help you know what kinds and quantities of food to buy for a week.
28 456

write down categories including produce, meats,

Meals that Make Good Leftovers
canned goods, frozen foods, dairy, and other.
Leave space under each category to list the foods • Beef stew
you need to buy. Listing items by category will
Meal Planning, Shopping, Preparation, and Storage

• Chili
save you time in the grocery store. Go through
• Spaghetti with sauce
your plan meal by meal. Write down all of
the ingredients you will need for each meal. • Casseroles
Remember to include beverages. Check the re- • Red beans and rice
frigerator, cabinets, and pantry for ingredients. • Split pea soup
Many ingredients you need may already be in
• Lentil soup
the home.
• Chicken soup
Keep a shopping list going all the time so fam-
ily members, clients, and you can write down • Macaroni and cheese
things you run out of during the week. • Lasagna
• Meat loaf
Nutritious Snacks
• Pot roast
Take into account the client’s dietary needs when
planning snacks.
Guidelines:
• Low-salt pretzels and tomato juice or vegetable
juice Shopping for Clients

• Celery with peanut butter or cream cheese and

G Use coupons. If your client receives a news-
milk
paper, scan it for coupons from stores or
• Graham crackers and milk manufacturers. Clip and use only those cou-
• Rice cakes with peanut butter and milk pons for items you have already planned to
• Cereal and milk buy.

• Yogurt G Check store circulars for advertised specials.

Compare foods by reading the unit price
• Baked tortilla chips with salsa
tags that are on the shelves in front of the
• Carrot or celery sticks with salsa products (Fig. 28-2). Store brands are usually
• Crackers and cheese cheaper than advertised brands.
• Gelatin with fruit
• Bran muffin and milk
• Raisins, dates, figs, prunes, or dried apricots
• Trail mix
• Smoothies made with yogurt, milk, and fruit
blended together
• Fresh fruit
• Apple with peanut butter
• Apple with cheese
Fig. 28-2. Compare foods by reading the unit price tags.
 457 28

G Buy fresh foods that are in season, when they cuts of less expensive meats yield only half of
are at peak flavor and inexpensive. You may what leaner cuts yield per pound. For clients
also want to buy seasonal foods for canning, on low-fat/low-cholesterol diets, pick lean
freezing, or preserving. Newspaper ads usu- meats and take the skin off chicken and tur-

Meal Planning, Shopping, Preparation, and Storage

ally tell you which foods are plentiful. Follow key parts. The skin holds much of the fat.
your client’s preferences when buying in-sea-
son foods. Inexpensive Meals

G Buy in quantity. Large amounts or larger sizes • Pasta dishes

are usually more economical, but do not buy • Baked stuffed potatoes
more than you can store. • Rice and beans

G Shop from your list. Do not be tempted by • Tuna casserole

items that are not on your list. • Chicken thighs or legs
• Hamburger casserole
G Avoid processed, already-mixed, or ready-
• Pot roast
made foods. They are usually more expensive
and less nutritious. When time allows, buy • Stews
staples, or basic items. • Lentil soup
• Split pea soup
G Loaves of bread are generally a better buy
than rolls or crackers. Day-old bread is usu-
When deciding what to buy, keep these four fac-
ally sold at reduced prices. Buy enriched and
tors in mind:
whole-grain breads, if the client agrees. Get
different varieties from time to time. 1. Nutritional value: Does this food contain es-
sential nutrients, vitamins, and minerals? Is
G Milk can be bought in many forms. Choose it unprocessed, without added salt or sugar?
the type that the client prefers. Skim, one
percent, or two percent milk contains lower 2. Quality: Is this food fresh and in good condi-
fat and is usually cheaper than whole milk. tion? Fruits, vegetables, and meats should
Evaporated milk is usually cheaper than look fresh. Canned goods should not be
whole milk; it is useful in cooking. dented, rusted, or bulging (bulging cans may
be a sign of bacterial growth). Milk and dairy
G Buy a cheaper brand when appearance is not products should not have passed their expi-
important. For example, store-brand mush- ration dates.
room bits are fine to use in a casserole and
3. Price: Is this the most economical choice? If
cheaper than name-brand mushroom pieces.
it costs more, is it worth it?
G Read labels to be sure you are getting the
4. Preference: Will my client like this food?
kind of product and the quantity you want.
Can I make an appealing meal using this
Read labels for ingredients that may be harm-
food?
ful to your client, such as excessive salt or
sodium or sugar.
2. List and define common health claims
G Estimate the cost per serving before buying.
Divide the total cost by the number of serv-
on food labels
ings to determine the cost per serving. Food packages often make claims about the
G Consider the amount of waste in bones and health benefits of the food they contain. Remem-
fat when buying cheaper cuts of meat. Some ber that food labels are advertising designed to
28 458

convince you to buy a product. Although some Sugar-free or no sugar added: Clients who must
regulations exist about what labels can claim, restrict their weight or who are diabetic must be
read health claims carefully before making a de- very careful about consuming any sugar. Sugar-
cision to buy. free products can be helpful, but you must read
Meal Planning, Shopping, Preparation, and Storage

the labels carefully. Sugar-free products may con-

Key Claims in Food Label Advertising tain artificial sweeteners, such as saccharin or
Low-fat, nonfat, fat-free, reduced fat, or light: If aspartame. These have no food value and should
a product is labeled low-fat or nonfat, it usually be used sparingly. Foods sweetened with fruit
does not contain much fat. Always read the label juice may still contain a lot of calories. Diabetics
anyway to determine the fat content of the food. may need to avoid fruit-juice-sweetened products
as well as sugar-sweetened ones.
Products labeled “reduced fat” or “light” contain
less fat than other versions of the same product. Organic: Organic food is produced without using
For example, salad dressing labeled “reduced fat” most conventional pesticides, fertilizers made
should contain 25 percent less fat than regular with synthetic ingredients or sewage sludge,
salad dressing. But it may still be high in fat. bioengineering, or ionizing radiation. Organic
Salad dressing labeled “light” should contain 50 meat, poultry, eggs, and dairy products come
percent less fat than regular. Read the label to from animals that are given no antibiotics or
determine fat content. Some foods labeled low- growth hormones. Before a product can be la-
fat, nonfat, or reduced fat may contain fat substi- beled “organic,” a government-approved certifier
tutes. In general, the best food and dollar value inspects the farm where the food is grown to
is found in products that do not contain these make sure the farmer is following all the rules
substitutes. to meet USDA organic standards. Companies
that handle or process organic food before it
Cookies, cakes, and other treats labeled “fat-free”
gets to the supermarket or restaurant must be
or “reduced fat” usually contain a lot of sugar
certified, too. Organic food differs from conven-
and calories. Remember that all sweets should
tionally produced food in the way it is grown,
be used sparingly, as they provide little or no
handled, and processed (Fig. 28-3).
food value. Also remember that extra calories,
especially sugars, are quickly converted to fat by
the body.
Low-sodium, sodium-free, or no salt added: For
clients who must reduce their sodium or salt
intake, foods labeled “low-sodium” or “sodium-
free” are important. Most foods naturally con-
tain some sodium. Avoid foods that list salt or
sodium as added ingredients. In general, canned
foods and prepared foods like soups and frozen
dinners usually have a lot of added salt and
should be avoided.
Fig. 28-3. Organic fruit spreads are one type of organic
Cholesterol-free: Cholesterol-free foods may be food.
useful for those clients who must restrict their
cholesterol intake. However, the best way to limit Natural, healthy, or good for you: These claims
cholesterol is to avoid foods containing animal may have little or no meaning. Buy whole, un-
fats, such as butter, cheese, whole milk, eggs, processed grains, fresh fruits and vegetables,
red meats, and organ meats. and lean meats, poultry, and fish, and you will
 459 28

know you are buying food that is healthful and Serving size and number of servings per con-
nutritious. Do not be swayed by the advertising tainer: Check the size of the serving. Remember
you see on labels; check the facts before you buy. that a serving may be a different amount than
what a client actually eats.

Meal Planning, Shopping, Preparation, and Storage

3. Explain the information on the Calories per serving and calories from fat per
FDA-required Nutrition Facts label serving: The number of calories per serving tells
you how much food energy a serving contains. It
The Food and Drug Administration (FDA) re- does not tell you how much nutritional value the
quires that all packaged foods contain a stan- food has. A candy bar is high in calories, provid-
dardized nutrition label, called “Nutrition Facts.” ing quick energy, but has very few nutrients and
This label contains information about the nutri- lots of fat and sugar.
tional content of food. Because the label is in the
The number of calories from fat tells you a lot
same format on all foods, it is easy to compare
about the fat content of a food. In general, no
different products (Fig. 28-4).
more than one-third, or roughly 30 percent, of
the total calories should come from fat. Thus,
potato chips containing 110 calories per ounce
and 80 calories from fat per ounce are not a
good food choice. With more than two-thirds of
their calories from fat, they are a high-fat food.
Amounts and percent daily values: For each
of the following items, the label tells you two
things. First, how much a serving contains, and
second, what percent of the recommended daily
total a serving contains. For example, crackers
that contain three grams of fat per serving con-
tain 5 percent of the recommended daily total of
fat. These recommended daily totals are based
on a 2,000-calorie diet. Someone who eats fewer
than 2,000 calories per day should have less fat
each day. Someone who eats more than 2,000
calories per day can have more fat. The label pro-
vides information on total fat and saturated fat,
cholesterol, sodium, total carbohydrates, dietary
fiber, sugars, and protein. The FDA-required
label gives amounts and daily totals for the per-
centage of the daily recommended amount one
serving of the food provides.
Fig. 28-4. The FDA-required Nutrition Facts label con-
tains standard nutritional information that makes it
Vitamins and minerals: The label lists the per-
easier to compare different products. centages of the recommended daily total for
certain vitamins and minerals. If the label says
The Nutrition Facts label gives you the following one serving contains 50 percent of the vitamin
information: C needed each day, you know this food is a good
source of vitamin C.
28 460

4. List guidelines for safe food air dry. Cutting boards made of plastic, glass,
preparation nonporous acrylic, and solid wood can also
be washed in the dishwasher. Use one cut-
Food-borne illnesses affect up to 100 million ting board for fresh produce and bread, and a
Meal Planning, Shopping, Preparation, and Storage

people each year. Elderly people are at increased separate cutting board for raw meat, poultry,
risk partly because they may not see, smell, or and seafood (Fig. 28-5). This helps prevent
taste that food is spoiled. They also may not have contamination of food.
the energy to prepare and store food safely. For
people who have weakened immune systems
because of AIDS or cancer, a food-borne illness
can be deadly.

Guidelines:
Safe Food Preparation

G Wash hands frequently. Wash your hands

thoroughly before beginning any food
preparation.
G Wash your hands after touching nonfood
Fig. 28-5. Carefully wash areas used to cut raw meat.
items, and after handling raw meat, poultry,
or fish.
G Use hot, soapy water to wash utensils.
G Keep your hair tied back or covered.
G Use clean dishcloths, sponges, and towels.
G Wear clean clothes or a clean apron. Change them frequently. Sponges may be
G Wear gloves when you have a cut on your washed in the dishwasher to disinfect them.
hands. G Defrost frozen foods in the refrigerator, not
G Avoid coughing or sneezing around food. on the countertop. Do not remove meats or
If you cough or sneeze, wash your hands dairy products from the refrigerator until just
immediately. before use.
G Wash fruits and vegetables thoroughly in run-
G Keep everything clean. Clean and disinfect
ning water to remove pesticides and bacteria.
countertops and other surfaces before, dur-
ing (as necessary), and after food G Cook meats, poultry, and fish thoroughly to
preparation. kill any harmful microorganisms they may
contain. Heat leftovers thoroughly. Never
G Handle raw meat, poultry, and fish carefully.
leave food out for more than two hours. Put
Use an antibacterial kitchen cleaner or a
warm foods in the refrigerator before they are
dilute bleach solution to clean any counter-
cool, so that bacteria does not have a chance
tops on which meat juices were spilled. Wrap
to grow. Keep cold foods cold and hot foods
paper or packaging containing meat juices in
hot. Use cooked meat, poultry, fish, and
plastic and discard immediately.
baked dishes within three to four days.
G Once you have used a knife or cutting board
G Do not use cracked eggs. Do not consume or
to cut fresh meat, do not use it for anything
serve raw eggs.
else until it has been washed in hot soapy
water, rinsed in clear water, and allowed to G Never taste and stir with the same utensil.
 461 28

5. Identify methods of food preparation

The following basic methods of food prepara-
tion will allow you to prepare a variety of healthy

Meal Planning, Shopping, Preparation, and Storage

meals:
Boiling: Food is cooked in boiling water until
tender or done. This is the best method for cook-
ing pasta, noodles, rice, and hard- or soft-boiled
eggs (Fig. 28-6).
Fig. 28-8. Fish and eggs can both be poached.

Roasting: Used for meats and poultry or some

vegetables, roasting is a simple way to cook. Dry
heat roasting means food is roasted in an open
pan in the oven (Fig. 28-9). Meats and poultry
are basted, or coated with juices or other liquid,
during roasting.

Fig. 28-6. Boiling works well for pasta and other grains.

Steaming: Steaming is a healthy way to prepare

vegetables. A small amount of water is boiled in
the bottom of a saucepan and food is set over it
on a rack (Fig. 28-7). The pan is tightly covered
to keep the steam in.

Fig. 28-9. Meats roast well at high temperatures (450°)

but may need to be basted. Vegetables can also be
roasted.

Braising: Braising is a slow-cooking method that

uses moist heat. Liquid such as broth, wine, or
tomato sauce is poured over and around meat or
vegetables, and the pot is covered. The meat or
vegetables are then slowly cooked at a tempera-
ture just below boiling. Braising is a good way to
Fig. 28-7. Steaming allows vegetables to retain their vita- tenderize tough meats and vegetables, since the
mins and flavor.
long cooking breaks down their fibers. Braising
may be done in the oven or on the stove top.
Poaching: Fish or eggs may be cooked by poach-
ing in barely boiling water or other liquid. Eggs Baking: Baking is used for many foods, includ-
are cracked and shells discarded before poach- ing breads, poultry, fish, and vegetables. Baking
ing. Fish may be poached in milk or broth, on is done at moderate heat, 350°F to 400°F. Foods
top of the stove or in the oven in a baking dish such as potatoes and winter squash bake very
(Fig. 28-8). well (Fig. 28-10).
28 462

Microwaving: Microwave ovens are safe to use

for defrosting, reheating, and cooking. However
“cold spots” can occur in microwaved foods be-
cause of the irregular way the microwaves enter
Meal Planning, Shopping, Preparation, and Storage

the oven and are absorbed by the food. If food

does not cook evenly, bacteria may survive and
cause food-borne illness.
Fig. 28-10. Many vegetables and meats can be baked To minimize cold spots, stir and rotate the food
together. once or twice during cooking. Arranging foods
uniformly in a covered dish and turning large
Broiling: Used primarily for meats, broiling in- foods upside down during cooking also help.
volves cooking food close to the source of heat When defrosting food in the microwave, remove
at a high temperature for a short time (Fig. 28- food from store wrap first. Foam trays and plastic
11). Meat must be tender to be broiled success- wraps may melt and cause chemicals to migrate
fully; inexpensive and lean cuts are often better into the food. Place food in a microwave-safe
cooked using moist heat. The “broil” setting bowl instead. Foods being reheated in the micro-
on the oven can also be used to melt cheese or wave should be steaming and hot to the touch, or
brown the top of a casserole. Leave the oven door at least 165°F. Cover foods. Stir them from the
ajar when broiling and never leave the kitchen; outside in to encourage safe, even heating.
things can burn very fast.
To insure that meat is properly cooked, use a
meat thermometer or the oven’s temperature
probe. This verifies that the food has reached a
safe temperature. Check in several places to be
sure red meat is 160°F and poultry 180°F. Check
for visual signs of doneness. Juices should run
clear and meat should not be pink.
Fig. 28-11. Broiling involves cooking at a very high Never place metal thermometers or any metal
temperature. object in the microwave oven. Be aware that
some clients cannot be near a microwave during
Sautéing or stir-frying: These are quick cooking
operation.
methods for vegetables and meats. Use a small
amount of oil in a frying pan or wok over high Frying: Frying uses a lot of fat and is the least
heat (Fig. 28-12). healthy way to cook. Avoid frying foods for cli-
ents (Fig. 28-13).

Fig. 28-12. Stir frying is quick and uses very little fat.
Food must be stirred constantly to prevent it from Fig. 28-13. Avoid frying foods because it is one of the least
sticking. healthy ways to cook.
 463 28

Fresh, uncooked foods: Many fruits and vegeta-

to make it more appealing. Talk about the food being
bles have the most nutrients when eaten fresh, served using positive words. Pureeing also causes
as in salads (Fig. 28-14). However, fresh fruits nutrients to be lost, so vitamin supplements may be
and vegetables may be difficult for some clients ordered. Constipation and dehydration are complica-

Meal Planning, Shopping, Preparation, and Storage

tions of a pureed diet. It is very important to follow
to chew or digest. Wash fruits and vegetables
directions exactly.
well to remove any chemicals or pesticides.

Preparing Nutritional Supplements

Illness and injury may call for nutritional supple-

ments to be added into the client’s diet. Certain
medications also change the need for nutrients. For
example, some medication prescribed for high blood
pressure increases the need for potassium.
Nutritional supplements may come in a powdered
form or liquid form. Powdered supplements need to
be mixed with a liquid before being taken; the care
Fig. 28-14. Many fruits and vegetables have the most nu- plan will include instructions on how much liquid to
trients when eaten uncooked and fresh. add.
When preparing supplements, make sure the supple-
Preparing Mechanically Altered Diets ment is mixed thoroughly. Make sure the client takes
it at the ordered time. Clients who are ill, tired, or in
You learned about special diets in Chapter 15. If a cli- pain may not have much of an appetite. It may take a
ent has chewing or swallowing difficulties, weakness, long time for him to drink a large glass of a thick liq-
paralysis, dental problems, or is recovering from sur- uid. Be patient and encouraging. If a client does not
gery, the doctor may order a liquid, soft or mechani- want to drink the supplement, do not insist that he
cal soft, or pureed diet for a short time. do so. However, do report this to your supervisor.
For soft, mechanical soft, or pureed diets, foods are
prepared with blenders, food processors, or cutting
utensils. Chopped foods are foods that have been 6. Identify four methods of low-fat food
cut up into very small pieces. When chopping food,
use a sharp knife and a clean cutting board (sepa- preparation
rate boards for raw meat and for vegetables and
other foods). Grinding breaks the foods up into even 1. Cook lean. Boiling, steaming, broiling, roast-
smaller pieces. Pureed foods are cooked and then ing, and braising are all methods of cooking
ground very fine or strained. A little liquid is added that require little or no added fat. Broiling
to give them the consistency of baby food. Grinding also allows fats in meat to drip out before
and pureeing can be done in a blender or food pro-
cessor. However, fruits and vegetables can be also be food is consumed. This lowers the fat con-
pureed by pushing them through a colander with the tent even more.
back of a spoon.
2. Drain fat. When using ground meat, brown
All equipment used must be kept very clean to help it first. Then drain it on paper towels to re-
prevent infection and illness. Take the blender or
food processor apart after every use. Wash each move excess fat.
piece that has come in contact with food in warm 3. Plan lean. Choosing foods with lower fat
soapy water, and rinse thoroughly. Wash the cutting
board after each use. This is especially important content to begin with will make low-fat cook-
after chopping raw meat, poultry, and fish. Wash ing easier. Planning meals around grains
it with soap, or in the dishwasher, before using it will help cut the fat content. Low-fat meals
again. Allow cutting board to air dry. based on grains include pasta dishes, rice
Changing the texture of food may make it lose its ap- and beans, baked or stuffed potatoes, and
peal. Season it according to the client’s preferences soups.
28 464

4. Substitute or cut down. Sometimes high-fat out for more than two hours. Tightly cover
ingredients can be left out or replaced to all foods. To prevent dry foods, such as corn-
lower the fat content of a recipe. Leave out meal and flour, from becoming infested with
or cut down the amount of cheese used on insects, store these items in tightly-sealed
Meal Planning, Shopping, Preparation, and Storage

sandwiches or to top casseroles. Substitute containers. If you find items that are already
plain nonfat yogurt for mayonnaise or sour infested, discard them. Use a clean container
cream. Nonfat cottage cheese can also be to store a fresh supply. Check dry storage
used. Try it on a baked potato instead of sour areas periodically for signs of insects and
cream. rodents.
4. When in doubt, throw it out! If you are not
Food Appearance, Texture, and Portion Size
sure whether food is spoiled, do not take any
Keep the color and texture of foods in mind when chances. Discard it. Check the expiration
planning meals. For example, do not serve two types dates on foods, especially perishables.
of green vegetables at the same meal. Rather than
green beans and spinach, try green beans and car-
rots instead. Serving food that is similar in texture
may make the meal less interesting. For example,
mashed potatoes and mashed rutabagas are similar.
Try a boiled or baked potato instead. To promote ap-
petites, make sure that food is attractively arranged
on the plate. It should look appealing. Avoid putting
large portions on the plate, unless the client nor-
mally eats larger amounts of food. Plan on smaller
portions, but have enough food available in case the Fig. 28-15. Look for refrigeration guidelines on food
client requests seconds. Small, frequent meals may labels.
be ordered for some clients. For more information
on how to make mealtime appealing, see Chapter 15. Check the refrigerator often for spoiled foods.
Discard any you find. Throw out foods that have
become moldy (mold cannot just be scraped off).
7. List four guidelines for safe food
storage Chapter Review
1. Buy cold food last; get it home fast. After 1. When planning a meal for a client, what
shopping, put away refrigerated foods first. are factors that the HHA should take into
2. Keep it safe; refrigerate. Maintain refrigera- account?
tor temperature between 36°F and 40°F. 2. List ten examples of nutritious snacks.
Maintain freezer temperature at 0°F. Refrig-
3. What are two reasons that an HHA should
erated items that spoil easily should be kept
buy fresh foods that are in season?
in the rear of the refrigerator, not the door.
Look on the jar or package to determine if 4. Why is more expensive meat sometimes a
food requires refrigeration once it has been better deal?
opened (Fig. 28-15). Do not refreeze items 5. Why are processed or ready-made foods not
after they have been thawed. as desirable as food made from scratch?
3. Use small containers that seal tightly. Foods 6. What does it mean if a food is labeled
cool more quickly when stored in smaller “organic?”
containers. Store with enough room around
7. What information can be learned by looking
them for air circulation. Never leave foods
at the number of calories from fat in a food?
 465 28

8. What is the longest period of time that it is Emergency Substitutions

safe to leave cooked food unrefrigerated?
Emergency substitutions can sometimes be
9. What needs to happen after an HHA has made, although it is best to use the ingredients

Meal Planning, Shopping, Preparation, and Storage

used a cutting board to cut fresh meat? called for in recipes.
10. How can pesticides be removed from fresh Vegetables
fruits and vegetables? Ingredient Substitute
11. How can a sponge be disinfected? 1 cup canned tomatoes 1 1/3 cups cut-up fresh
tomatoes, simmered 10
12. Briefly describe each of the following food minutes
preparation methods: boiling; steaming; 1/2 lb. fresh mushrooms 4-oz can mushrooms
poaching; roasting; braising; baking; broil-
Legumes With the exception of
ing; sauteing; microwaving; and frying. lentils, dry beans can be
13. What equipment is used to prepare soft, me- used interchangeably to
suit personal preference.
chanical soft, or pureed diets?
14. An HHA has browned ground beef to make Herbs, Spices, Seasonings
soft tacos for her client. What should be Ingredient Substitute
done before adding the seasoning to make it 1 tbsp snipped fresh 1 tsp. same herb, dried,
lower in fat? herbs or 1/4 tsp powdered or
ground
15. Give an example of one low-fat substitution
1 tsp dry mustard 2 tsp prepared mustard
in addition to those listed in the text.
1 tsp pumpkin pie spice 1/2 tsp cinnamon,
16. When is it acceptable to refreeze an item? 1/2 tsp ginger, 1/8 tsp
ground allspice, 1/8 tsp
17. What does the phrase, “When in doubt,
nutmeg
throw it out” mean?
18. If an HHA finds insects in the flour, what Baking
should he do? Ingredient Substitute
1 tsp baking powder 1/4 tsp baking soda plus
Conversion Tables 1/2 tsp cream of tartar

Liquid Measures 1 pkg active dry yeast 1 tbsp dry yeast

1 gal= 4 qt= 8 pt= 16 cups= 128 fl oz 1 cup oil 1/2 lb. butter or
margarine
1/2 gal= 2 qt= 4 pt= 8 cups= 64 fl oz
1 cup brown sugar 1 cup granulated sugar
1/4 gal= 1 qt= 2 pt= 4 cups= 32 fl oz
1/2 qt= 1 pt= 2 cups= 16 fl oz
Thickeners
1/4 qt= 1/2 pt= 1 cup= 8 fl oz
Ingredient Substitute
Dry Measures 1 tbsp cornstarch 2 tbsp flour, or 1 1/3
tbsp quick-cooking
1 cup= 8 fl oz= 16 tbsp= 48 tsp
tapioca
3/4 cup= 6 fl oz= 12 tbsp= 36 tsp
1 tbsp flour 1/2 tbsp cornstarch, or
2/3 cup= 5 1/3 fl oz= 10 2/3 tbsp= 32 tsp 2 tsp quick-cooking tapi-
1/2 cup= 4 fl oz= 8 tbsp= 24 tsp oca, or two egg yolks
1/3 cup= 2 2/3 fl oz= 5 1/3 tbsp= 16 tsp 1 tbsp tapioca 1 1/2 tbsp flour
1/4 cup= 2 fl oz= 4 tbsp= 12 tsp
1/8 cup= 1 fl oz= 2 tbsp= 6 tsp
1 tbsp= 3 tsp
29 466

29
The Clean, Safe, and Healthy Home Environment

The Clean, Safe, and Healthy

Home Environment
1. Describe how housekeeping affects ents and their families. How would you feel if a
physical and psychological well-being stranger were handling your personal items and
possessions? How would you feel if you could no
Providing a safe, clean, and orderly environment longer care for your home yourself?
has always been an essential part of home health
care. Illness and disability cause great stress. Be sensitive when you ask members of the
Clients feel better physically and psychologically household for help with housekeeping as well.
and recover more quickly when their homes Know when it is appropriate to ask for assistance
and families receive care and support. Infec- and how to ask for it in an appropriate way.
tion and accidents are prevented. In addition, Some family members may be experiencing
families who lack some knowledge to manage such stress that they are unable to help at all.
their homes can be taught valuable household Your assignments will vary. They may include
management skills. These skills include sanita- simple cleaning and organizing of the client’s
tion, safety, personal hygiene, nutrition, meal room or general cleaning throughout the house.
planning, shopping, child care, food preparation, Some clients require management of all house-
communication skills, and specific healthcare hold functions, including finances. You may be
techniques. You can be a role model for your required to dust, straighten, vacuum, sweep,
clients and their families by performing tasks wash dishes, clean the bathroom and kitchen,
efficiently and cheerfully. and do laundry. Your assignments will outline
the specific duties to be performed (Fig. 29-1).

2. List qualities needed to manage a

home and describe general housekeeping
guidelines
It takes efficiency, planning, knowledge, and
skills to manage a household. You will need to
know how to use your time and energy well.
This is so that you do not neglect your primary
responsibility—the personal care of the client.
Sensitivity is another important quality when
caring for your clients’ homes. You must respect Fig. 29-1. Your assignments will outline home mainte-
the customs, beliefs, and feelings of your cli- nance tasks you need to perform.
 467 29

Your assignments may list specific days on G Organize cleaning materials and equipment
which tasks should be performed or you may be by placing them in one closet. Place cleaning
allowed to make your own schedule. Flexibility materials in a pail, a carrying bin that has a
is important and allows you to meet the client’s handle, a laundry basket, or a shopping bag

The Clean, Safe, and Healthy Home Environment

and family’s needs. If you receive requests for (Fig. 29-2). Do not leave cleaning equipment
services not listed in your assignments or com- around the home.
plaints about how tasks are done, contact your
supervisor.
Most agencies require that aides perform light
housekeeping. This usually involves dusting,
straightening, vacuuming or sweeping floors
and floor coverings, cleaning bathrooms and
the kitchen, and disposing of trash. Light house-
keeping does not involve moving heavy furni-
ture, washing windows, taking down drapes,
cleaning the attic and basement, or mowing the
lawn. Fig. 29-2. Keep cleaning materials and equipment
organized.

Guidelines: G Familiarize yourself with the cleaning mate-

Housekeeping rials and equipment. Read the labels and
instruction booklets. Ask the client, family
G Invite family participation. Depending on members, or your supervisor how the equip-
their abilities and availability, clients and fam- ment works if you are unfamiliar with it.
ily members may be asked to participate in
housekeeping tasks. G Maintain a safe environment as well as a
clean and healthy one. Do not wax floors if
G Invite family and client input when you deter- your client is unsteady. Mop up spills imme-
mine the tasks that need to be done and the diately.
methods used.
G Use housekeeping procedures and methods
G Use cleaning materials and methods that are that promote good health. Many diseases
acceptable to and approved by clients and may be transmitted through improper food
their families. Any efforts you make toward handling, dishwashing, handwashing, and
improving the home environment should unclean bathrooms and kitchens.
coincide with the client’s choices, lifestyle,
G Observe the home environment for signs of
and values.
infestation by roaches, rats, mice, lice, and
G Be organized when performing tasks. Write fleas. These insects and animals are common
out detailed daily and weekly schedules. Seek carriers of disease. Controlling them is vital
feedback from your supervisor and the client to family health and cleanliness.
and family.
G Use good body mechanics in performing
G Build some flexibility into the schedule to home maintenance activities to prevent
allow for changes in the client’s condition, injury. Housecleaning can require a great deal
needs, appointments, or social activities. of bending, standing, stooping, and lifting.
29 468

Watch your posture. Kneel instead of stoop- Guidelines:

ing for long periods. Using Household Cleaning Products
G Clean up and straighten up after every activ-
The Clean, Safe, and Healthy Home Environment

ity. Spills that have dried are difficult to G Read and follow the directions on the label of
remove later. every product you use. Cleaning products can
harm the materials you are trying to clean.
G Carry paper and a small pencil to make note
of items that must be purchased or replaced. G Do not mix cleaning products. This can cause
Maintain a shopping list on a bulletin board, a dangerous chemical reaction that may
refrigerator door, or other convenient loca- harm you or others. In particular, never mix
tion, and encourage family members to use bleach or products containing bleach with
the list. ammonia. The fumes are toxic and can be
fatal.
G Use your time wisely and efficiently. For
example, prepare food while a load of wash is G Open windows when cleaning to provide
being done. fresh air. Some cleaning products have fumes
that are unpleasant or even harmful if you are
exposed to them for a long time.
3. Describe cleaning products and
G Do not leave cleaning products on surfaces
equipment
longer than the recommended time. Do not
Five basic types of home cleaning products are scrub too hard on soft surfaces.
available in the market: A basic set of cleaning tools generally includes
1. All-purpose cleaning agents can be used two types:
for many purposes and on several types of 1. Wet mops, pails, toilet brushes, and sponges
surfaces. These include countertops, walls, are tools for softening and removing soil
floors, and baseboards. that has dried and hardened on washable
surfaces.
2. Soaps and detergents are used for bathing,
laundering, and dishwashing. 2. A vacuum cleaner and attachments, carpet
sweeper, dust mop, dust cloths, broom, and
3. Abrasive cleansers are used mostly to scour
brush and dustpan are tools for removing
hard-to-clean surfaces.
dry dirt and dust.
4. Specialty cleaners are used to clean special Remember to be careful with equipment. Re-
surfaces, such as glass, metal, or ovens. placements can be expensive. Be familiar with
5. Non-toxic, environmentally safe cleaning the purpose and use of each piece of equipment.
products are made without toxic chemicals. Keep it clean and in its proper place. Check the
They may be vegetable-based. Some of these brushes and bags of vacuum cleaners frequently.
products are even made at home with basic
ingredients, such as baking soda, vinegar, 4. Describe proper cleaning methods for
castile soap, and water. living areas, kitchens, bathrooms, and
storage areas
All cleaning products must be used properly.
Many cleaning products are chemicals which Not all housekeeping tasks must be performed
can be irritating and can even cause burns. daily. Some tasks may be done weekly. Others
Some chemicals are poisonous when swallowed. only need to be done once a month or seasonally.
 469 29

Space out the special tasks. Do each cleaning job G Vacuum floors and rugs once a week or more
properly and efficiently. Do not take a lot of steps often if indicated. When vacuuming rugs, use
and do not reach, bend, and stoop unnecessarily. long strokes and go over each area repeated-
Experiment a little to find the most comfortable ly. If the home does not have a vacuum, use

The Clean, Safe, and Healthy Home Environment

and effective way to do a job. Cleaning can be a broom to sweep the floors and rugs. Take
done when your client is resting, sleeping, or care not to raise much dust.
doing another activity. Care of the client is your G Floors covered with vinyl, ceramic tile, and
primary responsibility. However, do not neglect linoleum may be washed. Some wood floors
housekeeping. may not. Some floor coverings should be
cleaned with water only. Check with the cli-
Guidelines: ent or family before you begin. After remov-
Straightening and Cleaning Living Areas ing loose dirt or crumbs with a vacuum or
broom, wash floors with a cloth or mop
G Clear up clutter and put objects in their cor- dipped in warm, sudsy water. Dry the floor
rect places. after you have washed it or close off the area
G Pick up newspapers, magazines, and toys as for the time it takes for the floor to dry (Fig.
needed. 29-4). Wet or waxed floors are slippery and
are frequent causes of falls in the home.
G Empty wastebaskets and ashtrays daily.
G Make the beds each day.
G Keep essential and frequently-used items,
such as eyeglasses, tissues, a wastebas-
ket, telephone, newspaper, magazines, and
books, within reach. Organize them on an
accessible table, magazine rack, or hanging
organizer (Fig. 29-3).

Fig. 29-4. Close off the area for the time it takes the floor
to dry.

Handling food on contaminated surfaces, im-

proper dishwashing, and contaminated food
Fig. 29-3. A hanging organizer can help reduce clutter storage areas may transmit many diseases.
while keeping important items handy. Roaches, rats, and mice may cause disease and
allergy by contaminating food with their saliva
G Dust once a week or when necessary. If your or through their droppings. Pest control is vital
client has allergies, you may need to dust to health and cleanliness. Always report pest
daily. control problems to your supervisor.
29 470

Guidelines: washer detergent. Fill the well with only the

Cleaning the Kitchen amount recommended on the label.

G Clean the outside of the stove, the trays,

The Clean, Safe, and Healthy Home Environment

G Clean the kitchen after every use. Ask family and burners with hot, sudsy water or an all-
members to do the same. Do not wait until purpose cleaner, and rinse. Ovens should be
the end of the day to clean up. Daily kitchen cleaned according to manufacturer’s recom-
cleaning tasks include washing dishes, wip- mendations. Be sure to follow the directions.
ing surfaces, taking out garbage, and storing Do not spray the light bulb inside the oven
leftover food. Weekly tasks include clean- with cleanser, or it may break. Soak the broil-
ing the refrigerator and washing the floor. er pan immediately after use.
Cleaning cabinets, drawers, and other storage
areas is usually done a few times a year. G The refrigerator should be totally cleaned
once a week. However, you should wipe it out
G Wash dishes in hot, soapy water using liq- more frequently (Fig. 29-5). If the refrigera-
uid dish detergent. Rinse them in hot water. tor is not a self-defrosting one, the freezer
When working with clients who have an infec- should be defrosted whenever necessary.
tious disease or a cold, use boiling water One-half inch of frost usually means it should
for rinsing and add a tablespoon of chlorine be defrosted. To defrost a freezer, turn the
bleach to the soapy water. The combination dial to the “off” position. Remove all food.
of heat and chlorine will kill pathogens, or Wrap frozen foods in a cooler or newspapers
harmful microorganisms. to keep them from defrosting. Defrosting the
G Wash glasses and cups first, then silverware, freezer may take less time if you place pans
plates, and bowls. Pots and pans are washed of hot water in it. Do not use a knife to chip
last. Rinse with hot water and dry on a rack. off the frost. This could damage the cooling
Air drying dishes is more sanitary than drying unit.
with a dish towel.

G If the house has a dishwasher, learn how to

correctly load and start it. Dishwashers save
time. They may also sterilize dishes because
of the high temperature used in washing and
drying. Ask the client if you should scrape
food from plates before placing in the dish-
washer. Empty cups and glasses. Do not
place dishes, cups, and flatware too close
together. This keeps them from being washed
thoroughly. Place dishes, cups, and glasses
so that their eating or drinking surfaces are
Fig. 29-5. The refrigerator should be totally cleaned once
facing the water source. a week, but you should wipe it out more frequently.
G Do not wash the following items in the dish-
washer: electrical appliances, certain plastic G Mix two tablespoons of baking soda in one
materials, wooden pieces or utensils, hand- quart of warm water. Wipe the inside walls of
painted or antique dishes, delicate china, the refrigerator and freezer. Baking soda will
crystal, cast iron, most pots and pans, and remove odors. Wash the shelves and trays
sharp or carbon steel knives. Use only a dish- with warm, soapy water.
 471 29

G Clean countertops, tables, and the stove each

Guidelines:
time they are used. Clean cabinet and drawer
Cleaning the Bathroom
fronts and the refrigerator once a week. If a
cutting board or other surface has been used

The Clean, Safe, and Healthy Home Environment

G Involve the entire family in keeping the bath-
to cut fresh meat, scrub the surface thor- room clean (Fig. 29-6). Always wash from
oughly with soapy water. Rinse well. clean areas to dirty areas, so you do not
G An all-purpose cleaner may be needed to spread dirt into areas that have already been
remove grease and cooked foods that have washed.
spilled or splashed on surfaces. Clean the G Flush the toilet each time it is used.
sink with a cleanser such as scouring powder
G Clean toothbrushes and toothbrush holders.
or cream.
G Scrub the tub and shower after use.
G Never place food on soiled work or storage
G Remove hair from drain strainers.
areas or in unclean containers. Keep food
covered. Close lids of cartons and cover food G Hang up all used towels to dry.
storage containers to prevent contamination G Put away toiletries.
or infestation by insects and rodents. Place
leftovers in covered containers and store G Rinse the sink after brushing teeth, shaving,
them in the refrigerator immediately. Use and washing.
them in two to three days. G Place soiled towels in the laundry hamper
after they are dry.
G Vacuum, sweep, or dry mop the floor daily.
Damp mop uncarpeted floors at least once
a week, using hot water and a floor cleaner.
Rinse the floor if the label recommends
doing so. Dry the floor or close off the area
until the floor dries to prevent accidents.

G Dispose of garbage daily. To prevent odor

and discourage insects and rodents, rinse out
tin cans and bottles before placing them in
the garbage pail or recycling bin. Follow the
recycling procedures for your client’s com-
munity. Periodically wash wastebaskets and
trash cans with hot, soapy water.

G Store all cleaning materials away from food,

Fig. 29-6. Clients and family members can help by doing
food preparation utensils, and food prepara-
such things as wiping out the shower after each use.
tion areas. Keep them out of reach of chil-
dren and confused clients. The bathroom is the location of many home ac-
A clean, organized, and odor-free bathroom is an cidents. Make sure that all bathroom rugs are
important part of improving a family’s hygiene nonskid. Wipe up puddles of water immediately.
and safety. Because it is moist and warm, the If grab bars are not present and your client has
bathroom is a reservoir for the growth of micro- difficulty moving about in the bathroom safely,
organisms, mold, and mildew. report this to your supervisor.
29 472

6. Clean the mirror and any glass or chrome

Cleaning a bathroom
surfaces using glass cleaner and paper towels
Equipment: approved disinfectant (a cleaning or clean rags.
product that kills germs), scouring powder or scour-
The Clean, Safe, and Healthy Home Environment

ing cream with bleach, sponge, toilet brush, glass 7. Place dry, soiled towels in the laundry ham-
cleaner, paper towels, disposable or rubber gloves per. Empty the waste can into a plastic or
paper garbage bag and dispose of it. Replace
1. Put on gloves. toilet tissue and facial tissue when needed.
2. Using the disinfectant and sponge, wipe all Open the bathroom window for a short time,
surfaces and rinse as needed. Be sure to if possible, to air the room out. Once a week,
clean the sides, walls, and curtain or door of wash out the waste can and laundry hamper,
the shower or tub; the towel racks; holders and launder the bath mats and rugs.
for toilet paper, toothbrushes, and soap; and 8. Store supplies.
window sills. 9. Remove and discard gloves.
3. Rinse sponge well or use a different sponge 10. Wash your hands.
to wipe the outside of the toilet bowl, seat, 11. Document the cleaning.
and lid. As a general cleaning rule, start with
the cleanest surface first, then move to dirtier
Cleaning and organizing storage areas will
areas.
contribute to the order and organization of the
4. Use a different sponge to clean the bathtub, home.
shower stall, and sink. Use scouring powder
or cream for tile and porcelain, and disinfec- Guidelines:
tant or all-purpose cleaner on other surfaces. Cleaning and Organizing Storage Areas
Remember that scouring powder can scratch.
Check with the client or a family member G Every item in the home should have a storage
before using it. Be sure to scrub the sides, place that is convenient for use. That means
edges, and bottoms of all these areas. Clean storage places should be as close as pos-
faucets and scrub around their bases. Scrub sible to where they are used (Fig. 29-7). For
the inside of the toilet bowl with a brush and example, bath towels should be stored in or
scouring powder containing bleach. Be sure near the bathroom. Frequently used pots and
to scrub under the rim. If you use a second, pans and cooking utensils should be near
stronger toilet cleaner, flush the first cleaning the stove. Less frequently used items, such
product down the drain first to avoid possible as popcorn poppers, should be stored in the
chemical reactions. Wash the toilet brush less accessible storage places.
with a disinfectant solution. Store it in a plas-
tic bag or holder after letting it air dry.

5. Vacuum or dry mop the floor first, then wash

if the floor is tile or linoleum. Use an all-
purpose floor cleaner in hot water. Wash the
floor with a cloth or mop, taking special care
to clean the areas at the base of the toilet
and sink. Do not leave the floor wet. Dry it
carefully to avoid accidents. Fig. 29-7. Store items near where they will be used.
 473 29

G Items that are frequently used should be eas- 5. Describe how to prepare a cleaning
ily seen and reached. When they are used, schedule
they should be immediately replaced. Items
that are used together should be stored near Most house-cleaning tasks should be done ei-

The Clean, Safe, and Healthy Home Environment

each other. Arrange food on shelves accord- ther immediately, daily, weekly, monthly, or
ing to category to save time in searching for less often. Take into account the care plan, your
items. Dangerous materials such as cleaning assignments, how much help is needed, and
products should be stored out of reach of how much time you have in a particular home
children and confused adults. to prepare a cleaning schedule. You may not
always stick to the schedule exactly. However, it
G Some storage areas only need to be cleaned
will guide your work and help you get essential
occasionally. Remove the stored items and
cleaning done. Establishing a schedule for clean-
any shelf or drawer liners. Wipe the shelves
ing can also help the family keep a housekeep-
and drawers with a damp cloth and all-
ing routine after your care has ended. Below is
purpose cleaner. Replace the liners or wipe
a sample cleaning schedule. The client can do
them if they can be cleaned. Food storage
almost nothing around the house. Her daughter
areas and other storage areas that are used
comes in several times a week, but no family
frequently should be cleaned more often.
members live with the client.
G Do not change the client’s or the family’s
storage arrangements without talking to
Cleaning Schedule for Mrs. Hedman
them. If you think changes are needed, dis-
cuss your ideas with the family. Immediately: Wipe counters, wash dishes, store
food, clean spills, put away supplies.
Cleaning Solution Ideas Daily: Straighten up: make bed, sort mail, remove
clutter, empty trash, etc. Clean bathroom. (One
Several types of cleaning solutions can be prepared hour)
from common household items when supplies
are not available or when the family budget is re- Weekly: Wash kitchen floors, wipe refrigerator, scrub
stricted. Some of these are environmentally safe and sink, vacuum other floors, dust all surfaces, scrub
non-toxic. bathtub. (Two to three hours)

• Baking soda can be used instead of scouring Monthly: Clean out refrigerator, defrost freezer. (One
powder. Baking soda can also be diluted with hour)
warm water to make a solution that will elimi-
Less often: Clean oven when needed. (One hour)
nate odors when used to clean surfaces.
Cleaning schedules will be different for each client.
• White vinegar can be used to remove lime or
Be flexible. You will need to adapt your schedule
other mineral deposits on sinks, toilets, or
after you make it. Remember that client care is your
chrome fixtures. White vinegar diluted with water
first priority.
can be used instead of glass cleaner and as a
general cleaner. Mix solution using one part
white vinegar to three parts water (1:3).
6. List special housekeeping procedures
• Household bleach, diluted with four parts water,
makes a strong disinfectant solution to clean to use when infection is present
bathroom surfaces. Diluted with nine parts water
and stored in a spray bottle, bleach makes a You must follow standard precautions with
milder disinfectant to use on kitchen counters. every client. This is true because you cannot
Do not spill or splash undiluted bleach or bleach know when infection is present (see Chapter
solutions on carpets, clothing, or other surfaces
5). However, when a client has a known infec-
that might be discolored.
tious disease such as influenza, or one that
29 474

weakens the immune system, such as AIDS or clothes. Bleach, color brighteners, stain remov-
cancer, you need to take special precautions in ers, and fabric softeners may also be used. Ask
housecleaning: the client and family about their preferences for
laundry products.
The Clean, Safe, and Healthy Home Environment

• Use disinfectant when cleaning countertops

and surfaces in the kitchen and bathroom. Pretreating: Pretreating means giving special
treatment to items that have heavy soil, spots,
• Clean the client’s bathroom daily. Have other
and stains before washing them. Spots and
family members use a different bathroom if
stains should be treated immediately. The
possible.
sooner they are treated, the easier they are to re-
• Use separate dishes and utensils for the move. Some oily stains harden with age and can-
infected client. In some cases, disposable not be removed. Washing and ironing may set
dishes and utensils will be ordered. some stains, making them difficult or impos-
• Wash dishes and utensils in the dishwasher sible to remove. If you can, identify the source of
or wash dishes in hot soapy water with the stain and treat it according to a stain guide
bleach. Rinse in boiling water, and allow to on the pretreating solution.
air dry. Bleach: Bleach is used with detergent. However,
• Disinfect any surfaces that contact body flu- bleach cannot be used on all fabrics. Be famil-
ids, such as bedpans, urinals, and toilets. iar with the type of bleach and the fabric that is
being washed. Three types of bleach are used in
• Frequently remove trash containing used
laundry: liquid chlorine, powdered chlorine, and
tissues.
oxygen or all-fabric bleach. Each type of bleach
• Keep any specimens of urine, stool, or spu- should be used with caution. Read the instruc-
tum in double bags and away from food or tions on the container carefully.
food preparation areas.
Liquid chlorine bleaches are excellent stain re-
movers. They whiten clothing. However, they
7. Explain how to do laundry and care for can be very damaging. Bleach should always be
clothes diluted in water. Fill the washer, then add liquid
bleach and stir the water before adding clothing.
You may be expected to do hand or machine Never use liquid chlorine bleach on silk, span-
washing as part of an assignment. Clean clothes, dex, wool, or any item that contains these fibers.
bed linens, and towels are important for hygiene Be careful not to spray or splash liquid chlorine
and comfort. bleach. It will remove color or damage fabric.
Laundry Products and Equipment: To do the Powdered chlorine bleach is more gentle than
laundry you will need laundry detergent, a liquid, but it can also damage clothing. Either
washing machine or a basin for hand washing type of chlorine bleach is also an excellent dis-
clothes, and a dryer or a clothesline and pins. infectant. Oxygen or all-fabric bleach is used on
The instructions for using washing machines washable fabrics, but it is most effective in hot
are usually located on the inside of the machine water.
lid. Water Temperature: Read the washing instruc-
In general, you will use all-purpose detergent. tions for all materials and garments (Fig. 29-8).
Some delicate fabrics, underwear, or stockings Warm water is safest for most garments. How-
may require a special detergent. Some clients ever, some must be washed in cold to prevent
may prefer a non-detergent soap for use on baby shrinking or colors fading. Hot water is gener-
 475 29

ally used for towels, bed linens, and white or ture. If the label does not recommend a particu-
colorfast cottons. Warm is usually used for lar setting or the fabric is a blend, use the lowest
permanent press, knit, synthetic, sheer, lace, ac- temperature on the iron. Take special care with
etate, fabric blends, washable rayons, and plastic. pile fabrics, such as velvets and corduroy. They

The Clean, Safe, and Healthy Home Environment

Cold water is used for brightly-colored fabrics or will keep their texture better if ironed on the
fabrics that are not colorfast. wrong side over a towel. Dark fabrics, silks, ac-
etates, rayons, linens, and some wools must be
pressed on the wrong side to prevent them from
becoming shiny. Use a pressing cloth to protect
the fabric.
To prevent stretching, iron all fabrics length-
wise. Iron collars, cuffs, and garment facings
first. Next, iron the sleeves, then the front and
back. Hang or fold clothes immediately. Fasten
all hooks and buttons and close zippers. Be sure
clothes are completely dry before putting them
away.
Fig. 29-8. A care tag gives washing and drying instruc-
tions. It can be found on most clothing. Maintaining Clothing: You may need to do basic
mending or sewing occasionally. This is espe-
Washing Action or Cycle: Use the normal setting cially true if you are taking care of a family, an
on the washer for cottons, linens, rayons, sturdy older person with impaired vision, or people
permanent press, knits, synthetics, blends, and who may not have the time or the ability to keep
most other items. Set the washer on the slow or clothing and linens repaired. Some clients who
gentle setting for washable woolens, old quilts, can do their own mending may just need you to
curtains, and delicate or fragile items. thread the needle.
Drying Clothes: Settings on the dryer vary ac-
cording to the model. Most dryers have a per- Doing the laundry
manent press setting and a delicate setting. The
1. Sort clothes carefully. Make separate piles of
more delicate a fabric, the lower the drying tem-
whites, colors, and bright colors. Check cloth-
perature and the shorter the time in the dryer.
ing labels for special washing instructions.
Heavy items such as towels need higher tem-
Do not wash anything labeled “Dry Clean
perature settings and a longer time in the dryer.
Only.” If hand washing is recommended, do
Clean the lint filter each time you use the dryer.
not wash in the machine.
If your client does not have a clothes dryer, hang
clothes on a clothesline using clothespins. 2. As you sort laundry, check pockets and re-
move tissues, money, pens, and other items.
Folding: To reduce the amount of wrinkling,
Remove belts with buckles, trims, and non-
remove all clothes from the dryer immediately.
washable ornaments. Close zippers, buttons,
Fold them neatly or place them on hangers. Set
and other fasteners. Check garments for
aside those that need to be ironed. Return other
stains and areas of heavy soil. If appropriate,
items to their drawers or closet.
mend or repair any holes, snags, rips, tears,
Ironing: Before you begin to iron, check the pulled seams, and weak spots in garments
label of the item for the recommended tempera- and other items.
29 476

3. Pretreat spots and stains before washing. A 8. List special laundry precautions to use
small amount of liquid detergent or dry de- when infection is present
tergent dissolved in water can be worked in
with an old toothbrush (Fig. 29-9). Pretreat When a client has a known infectious disease,
The Clean, Safe, and Healthy Home Environment

or soak clothing as soon as possible for best you must take special precautions when han-
results. If you know something is spotted, do dling laundry:
not let it sit in the laundry hamper all week • Keep client’s laundry separate from other
until you do the laundry. family members’.
• Handle dirty laundry as little as possible. Do
not shake it. Sort it and put it in plastic bags
in the client’s room or bathroom. Take it im-
mediately to the laundry area.
• Wear gloves and hold laundry away from
your clothes and body when you are han-
dling it.
• Use liquid bleach when fabrics allow.
Fig. 29-9. Pretreating helps remove spots, stains, and
• Use agency-approved disinfectants in all
areas that are heavily soiled.
loads.
4. Use the correct water temperature: hot for • Use hot water.
whites, warm for colors, cold for bright
colors.
9. List guidelines for teaching
5. Use the appropriate laundry product(s).
housekeeping skills to clients’ family
Follow the washing instructions on the
members
container.
6. Follow written instructions or client or fam- In some assignments, you will be asked to teach
ily instructions for using the washer. Use the housekeeping skills to family members. This
correct washing cycle for the load you are prepares them to take over housekeeping and
laundering. care when home care is discontinued. By teach-
ing household management skills, you help fam-
7. Dry clothes completely either in a dryer or on
ilies meet their daily needs and become more
a clothesline. If using an automatic dryer, fol-
self-reliant.
low the drying instructions on clothing labels
or the client’s preferences. Some fabrics re-
quire cooler temperatures. Guidelines:
8. Hand-wash items in warm or cool water, de- Teaching Family Members
pending on the fabric and instructions. Use
G Get to know the family before starting to
a mild detergent or special hand-washing
teach them. Understand their needs or prob-
liquid. Line dry or lay items flat on towels to
lems before beginning.
preserve the shape of the garment.
G Be patient. Give people time to learn new
9. Fold or hang clean laundry and sort into cat-
skills. Praise their efforts.
egories. Store in drawers or closets.
G Keep teaching sessions brief.
 477 29

G Break down tasks into simple steps. Explain

• Avoid lifting heavy objects from the floor. For
each step and demonstrate it. example, put the clothes basket on a chair before
G Answer all questions. filling it (Fig. 29-11).

The Clean, Safe, and Healthy Home Environment

G Assist the person as necessary. Do not do the
task for him or her.
G Remember that each person is an individual
and will learn in different ways. Customize
your teaching to allow for these differences.

Using Good Body Mechanics in the Home

Review the principles of body mechanics you

learned in Chapters 6 and 10. Remember the follow-
ing additional tips when working in a home:
• Bend the knees, not the back, when lifting things
from the floor or when kneeling to pick up
objects.
• Carry heavy objects close to the body and dis-
tribute the weight evenly. For example, when
carrying a basket of clothes, hold it directly in
front of the body (Fig. 29-10). Stand close to the
work area. When possible, raise the work area to
a comfortable level so you do not have to bend
your back and neck to do the work.

Fig. 29-11. By placing the basket on a chair close to

her, this HHA avoids excessive bending and reaching.

10. Identify hazardous household

materials
Any of the following household materials can
have harmful effects:

• Household bleach

• Cleaning products

• Aerosol or spray cans

Fig. 29-10. Holding objects close to your body helps • Paint
prevent back strain and injury.
• Chemicals such as turpentine or paint
• Try not to lift heavy objects. If you must move thinner
heavy objects such as furniture, try pushing, pull-
ing, or rolling, using the entire body. • Medicines, both prescription and
• Stand erect when doing tasks like washing over-the-counter
dishes. Your knees may be slightly bent.
• Hair spray
29 478

• Nail polish remover 16. How frequently should an HHA clean the
bathroom of a client who has an infectious
These products should be kept in separate cabi-
disease?
nets with childproof latches or locks, or up out
The Clean, Safe, and Healthy Home Environment

of the reach of children. If a client is confused, 17. List two guidelines for dealing with the
mark these cabinets with signs that indicate dishes and utensils of a client with an infec-
danger. tious disease.

18. What is pretreating?

Chapter Review
19. List three types of bleach.
1. What skills are important in household 20. List the safest temperature for most
management? garments.
2. What housekeeping assignments might an 21. How can an HHA reduce the amount of
HHA be asked to do? wrinkling after clothes have been dried in
3. What are some housekeeping tasks an HHA the dryer?
should NOT be asked to perform? 22. List six guidelines that an HHA should fol-
4. List ten housekeeping guidelines. low when handling laundry of a client with
an infectious disease.
5. Why is it important to read the instructions
23. List five guidelines to follow when teaching
for cleaning products?
family members housekeeping skills.
6. Why should cleaning products not be mixed?
24. Where should hazardous household materi-
7. What two parts of a vacuum cleaner should als be kept?
an HHA check often?

8. How often should wastebaskets and ashtrays

be emptied?

9. How should an HHA clean the floors if the

home does not have a vacuum?

10. What should an HHA do when washing

dishes for clients who have an infectious dis-
ease or cold?

11. How frequently should the refrigerator be

cleaned?

12. In what time frame should leftover food be

eaten?

13. What items should not be washed in the

dishwasher?

14. Ideally, where should storage places be

located?

15. Describe why it is helpful to make a cleaning

schedule.
 479 30

30

Managing Time, Energy, and Money in the Home

Managing Time, Energy, and
Money in the Home
1. Explain three ways to work more doing a task. Try to eliminate a few steps but
efficiently still get the same result. For example, when bak-
ing a cake, can you mix everything in one bowl?
Taking care of the client and other family mem- When you clean up, can you stack everything on
bers who need assistance and support is your a tray and take it all to the sink at one time?
most important responsibility. For this to be ac-
complished, you must maintain an orderly and Be realistic. You may not be able to get every-
clean environment. To balance these responsibil- thing done even if you plan carefully. Reassess
ities, you must manage your time and energy ef- your schedule during the day. Have you finished
ficiently. The following are ways to be sure your what you planned or are you behind? When
work schedule is as efficient as possible: tasks take longer than you expected, or unex-
pected tasks need to be done, be realistic about
Distribute tasks. Look at the client care plan and what you can do. Do not be afraid to change
your assignments. Note the assigned housekeep- your plan. It is better to accomplish the highest-
ing tasks. Divide the tasks and schedule them priority tasks and let others go unfinished than
for the week and the month. Make sure all your to do everything half-way. The key to success is
assignments can be completed in the time you to be flexible.
have. Some tasks are best accomplished together.
For example, it is most efficient to do all the Simple Ways to Conserve Time and Energy
laundry on one day. Then you are able to do
Energize. Use good body mechanics. Take oc-
larger loads and fold and iron all at once. Plan
casional breaks to restore your energy. Alternate
one morning or afternoon to do the laundry.
longer tasks with shorter tasks, and high-energy
For more efficiency, plan other tasks to do while
tasks with low-energy ones. Take care of your-
loads are in the washer or dryer.
self—eat right, exercise, and get plenty of rest.
Prioritize tasks. Prioritizing your tasks is an
Organize. At the beginning of the day, do a men-
important time and energy management skill.
tal rundown of the tasks that must be done and
Think about the jobs you want to complete
rearrange your schedule if necessary. Plan what
throughout the day. Which ones must be done
must be done and do it. Store frequently-used
immediately? Which ones must be done at a
items in convenient places near the work area.
certain time? Which activities are not absolutely
Assemble your equipment and materials before
essential and could be put off? Spend time on
you begin a task. Keep clutter in control and
activities that are most important first.
work in good light. Think about how to organize
Simplify tasks. Learn to simplify your tasks. activities and equipment to avoid unnecessary
Take time to think about how you will go about work. Make and use shopping lists.
30 480

Economize. Save time and energy by doing a appreciate knowing what will be happening in
little extra ahead of time. Use trays, baskets, or their homes at any given time.
carts to carry several things at once. Prepare
often-used food items ahead of time and freeze
Managing Time, Energy, and Money in the Home

3. Discuss ways to handle inappropriate

them. Cook in quantity and freeze meal-size requests
portions. Cook more than one item in the oven
at a time. Occasionally, you may be asked to do something
that is not in the care plan or your assignments.
Minimize. Look for ways to make tasks shorter
Because each client’s situation is unique, you
and easier. Modify your workspace to make your
will not be assigned to the same tasks for every
work more comfortable and easier.
client. For example, the care plan may specify
Specialize. Use the right tool for each task. For grocery shopping for Mrs. Singer, who lives
example, a vegetable peeler is more efficient alone and cannot drive. But if another client who
than a knife for peeling carrots. Take pride in lives with family members asks you to run to the
what you are doing. Finally, be sure to thank store, you have to say no if it is not in the care
family members who have picked up, cleaned plan or your assignments.
up, or participated in household chores.
Several things will help you handle requests that
you must refuse. First, explain that you are only
2. Describe how to follow an established allowed to do tasks assigned in the care plan. Ex-
work plan with the client and family plain that nurses familiar with the client’s condi-
tion give you your assignments. Emphasize that
The client care plan and your assignments will you would like to help, but that you are limited
tell you what tasks are required. You can develop to the tasks outlined in the care plan and your
your own work plan. This will allow you to fin- assignments. After explaining this to the client,
ish all your assigned tasks as quickly and effi- contact your supervisor and discuss the request.
ciently as possible. For each day or block of time Your supervisor may add the task requested by
you will spend in a home, list all the tasks you the client to your assignments. It is possible it
must complete. Then, prioritize them. Mark the was left out of your assignments by mistake. Be
most important as “1,” the next most important sure to document the client’s request and the ac-
as “2,” and so on. Finally, write out a schedule tions you took to address it.
for the day, filling in the highest priority tasks
Establishing a work schedule will also help you
first. If there are tasks that must be done at a
handle inappropriate requests. If a client and
certain time, put those tasks on the schedule at
family know what to expect of you, they may not
the appropriate time.
be tempted to ask you to do other tasks.
Remember to distribute tasks so that you are not
Sharing a schedule of everything you must
trying to do all the house cleaning on one after-
accomplish in a visit may help the client un-
noon and end up with no time to bathe or care
derstand your job. If inappropriate requests con-
for a client. Simplify tasks whenever possible to
tinue, refer clients or family members to your
allow you to accomplish more.
supervisor.
Following an established work plan will allow
you to get more done in less time. It will also
4. List five money-saving homemaking
allow your clients and families to know what to
tips
expect of you. You may even want to discuss the
plan with a client or family member as you are 1. Check store circulars for advertised specials.
making it up or when it is finished. Some people Plan your menus around foods that are a good
 481 30

value; for example, raw foods are less expensive If your state and your employer permit you to
than prepared ones. Chapter 28 discusses more handle clients’ money, there are several guide-
ways to plan economical meals. lines you must follow in doing so.

Managing Time, Energy, and Money in the Home

2. Use coupons. If your client receives a newspa-
per, scan it for coupons from stores or manufac- Guidelines:
turers (Fig. 30-1). Handling a Client’s Money

G Never use a client’s money for your own

needs, even if you plan to pay it back. This is
considered stealing. You could lose your job
and/or be arrested.
G Estimate the amount of money you will need
before requesting it. If you are making a trip
to the grocery store, show the client your
list and ask how much he or she is willing
to spend on groceries, or how much is bud-
geted. You may need to take things off your
list or estimate the total bill as you go along
Fig. 30-1. Clipping coupons can save your client money.
in the store to stay within the money allotted
Some clients may enjoy doing this task themselves. (Fig. 30-2).

3. Shop from your list. Do not be tempted by

items that are not on your list, even if they are
on sale.
4. Avoid convenience stores. Shopping at large
supermarkets or discount stores usually guaran-
tees you will get the best prices.
5. Plan ahead. Knowing what you need before
you run out will save money. Planning will also
save time and energy. For example, you will not
have to make a special trip when you discover
you are out of laundry detergent.
Fig. 30-2. Taking a calculator to the grocery store helps
you to stay within the client’s budget.
5. List guidelines for handling a client’s
money G Take checks rather than cash, when possible.
Have the client or family member fill out the
Different states and employers have different
name of the store. A signed check that is not
regulations and policies regarding healthcare
made out is as good as cash. If you lose cash
employees handling clients’ money. Find out
or a signed bank check, you may be respon-
from your employer whether you will be ex-
sible for paying back the amount.
pected to handle clients’ money. If you are not
allowed to handle money, never agree to do so, G Get a receipt for every purchase. This proves
even occasionally. You could get yourself and how much you spent and provides a record
your employer into serious trouble. for you and the client.
30 482

G Return receipts and change to the client or 8. How can taking a calculator to the store
family member immediately. Do not wait when shopping for clients be useful?
until the end of the day or week to settle up.
Do it right away while everything is fresh in
Managing Time, Energy, and Money in the Home

your mind. Forgetting to return change could

be viewed by the client or a family member as
stealing.
G Keep a record of money you have spent.
Follow your agency’s policies and procedures
for documenting money issues. Write down
how much you spent and where. Note any
change returned to the client. The better
record you have, the smaller the chance of
any misunderstanding.
G Keep a client’s cash separate from yours. If
you must use the client’s cash, do not put it
in your own wallet. Keep it in a separate, safe
place. Do the same with change. This will
prevent confusion.
G Never offer money advice to clients. You
should not even refer clients to others regard-
ing their financial matters.
G Remember, your clients’ financial matters are
private. Never discuss your clients’ money
matters with anyone.

Chapter Review
1. List three ways to work more efficiently.
2. What does it mean to “prioritize” tasks?
3. How should the HHA handle requests that
she must refuse?
4. How might an HHA help a client and his/
her family understand her job? How could
this help reduce inappropriate requests?
5. List five money-saving homemaking tips.
6. List six guidelines for handling a client’s
money.
7. Why is it important to get a receipt for any-
thing purchased with a client’s money?
 483 31

31

Caring for Your Career and Yourself

Caring for Your Career and
Yourself
1. Discuss different types of careers in tive and support staff, including directors or
the healthcare field other executive staff, medical records personnel,
receptionists, office managers, and billing staff
There are many different types of careers in the are part of the healthcare field.
healthcare field. Some of these are considered
direct service. These are the positions that serve Career opportunities in health care also include
the resident, client, or patient directly. Nursing the fields of dentistry, nutrition, and pharmacy.
assistants, home health aides, patient care tech- Complementary or alternative healthcare fields
nicians, nurses, physician assistants and doctors include chiropracty, massage therapy and ho-
all provide direct service. Professionals in thera- meopathic medicine (Fig. 31-2).
peutic services, such as occupational, speech,
and physical therapists, also offer direct care.
Some specialized technicians work in diagnostic
services, such as x-ray technicians, lab techni-
cians, and ultrasound technicians (Fig. 31-1).
Diagnostic services are procedures performed to
determine a condition and/or its cause.

Fig. 31-1. Lab technicians may conduct tests to help di- Fig. 31-2. Chiropractors perform hands-on manipula-
agnose a condition. tions, or adjustments, of the spine or other joints.

Medical social workers and substance abuse There are many opportunities for teachers
counselors are part of psychology, counseling, within health care. Most of the career paths re-
and social work fields. Activities directors and quire classes before working in the field, as well
assistants also work in health care. Administra- as continuing education. Health educators and
31 484

prevention professionals teach the general popu- • Check the Internet (Fig. 31-3). One good web
lation or specific populations, such as diabetics site is carecareers.net. Other good ones are
or pregnant women. jobbankinfo.org and monster.com. You can
also visit a search engine, such as
Caring for Your Career and Yourself

There are many opportunities available to you in

google.com or yahoo.com. Type in “nursing
the healthcare field, depending upon your inter-
assistant” or “home health aide” and your
est, education, and abilities. The careers listed
city. See what employment opportunities are
above are only a fraction of jobs offered in health
there.
care. You are reading this textbook most likely
because you want to become a nursing assistant
and/or home health aide. Those positions may
be the best fit for you, or at some point, you may
want to try something different. Speak with your
supervisor, instructor, or a career counselor if
you want more information about other careers
in the healthcare field. Review Chapters 1 and
2 for information on the different healthcare Fig. 31-3. Searching the Internet is one good way to find
settings and educational requirements for care a job.
team members.
Once you have a list of potential employers, you
2. Explain how to find a job and how to need to contact them about job opportunities.
write a résumé Phoning first, unless they mention not to do so,
is a good way to find out what opportunities are
You may soon be looking for a job. Nursing as- available. Ask how to apply for a job with each
sistants may be able to work in long-term care potential employer.
facilities, in assisted living facilities, in hospitals,
When making an appointment, ask what infor-
in the home, and in other places. Home health
mation to bring with you. Make sure you have it
aides usually look for jobs with home health
when you go. Some of these documents include
agencies. To find a job, you must first find po-
the following:
tential employers. Then you must contact them
to find out about job opportunities. To find em- • Identification, including driver’s license, so-
ployers, use the Internet, newspaper, telephone cial security card, birth certificate, passport,
book, or personal contacts. Try these resources: or other official form of identification
• Classified or employment sections of the • Proof of your legal status in this country and
newspaper list jobs currently available. Circle proof that you are legally able to work, even
ads for the positions for which you are quali- if you are a U.S citizen. Employers must
fied. Make a list of names and phone num- have files showing that employees are legally
bers to contact. allowed to work in this country. Do not be
offended by this request.
• Call the state or local Department of Social
Services or Department of Aging. Many • High school diploma or equivalency, school
states hire or place nursing assistants or transcripts, and diploma or certificate from
home health aides. your nursing assistant or home health aide
training course. Take the name and phone
• Ask your instructor for potential employers.
number of your instructor with you as well.
Some schools maintain a list of employers
seeking nursing assistants or home health • References are people who can be called
aides. to recommend you as an employee. They
 485 31

can include former employers or former • Date

teachers. Do not use relatives or friends • Sender’s name, address, and other contact
as references. You can ask your references information
beforehand to write letters of recommenda-

Caring for Your Career and Yourself

• Recipient’s name and address
tion for you, addressed “To whom it may
concern,” explaining how they know you and • Salutation (e.g. “Dear Human Resources
describing your skills, qualities, and habits. Director”)
Take copies of these with you. • Introduction (position you are seeking)
Some potential employers will ask you for a • Body (skills/experience that fit job being
résumé and a cover letter. A résumé is a sum- offered)
mary or listing of relevant job experience and • Closing and signature (e.g. “I look for-
education. It is also called also “curriculum ward to hearing from you. Sincerely, Josie
vitae” or “CV.” When creating your résumé, in- Hartman”)
clude the following:
• Your contact details: name, address, tele- 3. Identify information that may be
phone number, e-mail address required when filling out a job application
• A list of your educational experience, start- On one sheet of paper, write down the general
ing with the most current first (for example, information you will need. Take it with you,
nursing assistant training course, college de- along with your résumé, if you have one. This
gree, high school diploma or G.E.D. courses) will save time and avoid mistakes.
• A list of your work experience, starting with
Include the following general information:
the most current first (include name of
• Your address and phone number
company or organization, your title, dates
worked, and a brief summary of duties) • Your birth date
• Any special skills, such as knowledge of • Your social security number
computer software, typing skills, or speaking • Name and address of the school or program
other languages where you were trained and the date you
• Any memberships in professional completed it, as well as certification num-
organizations bers and expiration dates from a certification
card, if you have one
• Volunteer work
• Names, titles, addresses, and phone num-
State at the end of your résumé that references bers of former employers, and the dates you
are available upon request. Try to keep your ré- worked there
sumé brief (one page is best) and clear. Use nice
• Salary information from your former jobs
white or cream-colored paper for printing your
résumé. • Reasons why you left each of your former
jobs
The cover letter is a letter included with your
résumé. It should be no longer than one page in • Names, addresses, and phone numbers of
length. This letter briefly states the position you your references
are seeking and why you would be the best per- • Days and hours you can work
son for the job. Emphasize skills you have that • A brief statement of why you are changing
would be a good match. Include the following in jobs or why you want to work as a nursing
a cover letter: assistant or home health aide
31 486

Fill out the application carefully and neatly (Fig. being asked, find out before filling in that space.
31-4). Never lie on a job application. Before you Fill in all of the blanks. Write “N/A” (not appli-
write anything, read the application all the way cable) if the question does not apply to you.
through once. If you do not understand what is
Caring for Your Career and Yourself

Fig. 31-4. A sample job application.

 487 31

By law, your employer must perform a criminal

background check on all new aides hired. You
may be asked to sign a form granting permis-
sion to do this. Do not take it personally; it is

Caring for Your Career and Yourself

a law intended to protect patients, clients, and
residents.

4. Discuss proper job interview

techniques
Fig. 31-6. Be polite and make eye contact while
Use these tips to make the best impression at a interviewing.
job interview:
• Avoid slang words or expressions.
• Shower or bathe, and use deodorant.
• Never eat, drink, chew gum, or smoke in an
• Brush your teeth. interview.
• Apply makeup lightly.
• Sit up or stand up straight. Look happy to be
• Trim and clean your nails. there.
• Style clean hair simply. • Do not bring friends or children with you.
• Shave or trim facial hair before the interview • Relax. You have worked hard to get this far.
(men). You understand the work and what is ex-
• Dress neatly and appropriately. Make sure pected of you. Be confident!
clothing is clean, ironed, and has no holes
Be positive when answering questions. Empha-
in it. Avoid wearing jeans, shorts, or short
size what you enjoy or think you will enjoy about
dresses or skirts. Shoes should be clean and
the job. Do not complain about previous jobs.
polished.
Make it clear that you are hardworking and will-
• Wear little or no jewelry. ing to work with all kinds of residents, clients,
• Arrive 10 or 15 minutes early. and patients.
• Introduce yourself. Smile and shake hands The following are some questions you can ex-
(Fig. 31-5). Your handshake should be firm pect to be asked:
and confident.
• Why did you become a nursing assistant?
• What do you like about working as an aide?
• What do you not like? (If this is your first
job, you may be asked what you expect to
like or dislike.)
• What are your best qualities? What are your
weaknesses?
• Why did you leave your last job?
Fig. 31-5. Smile and shake hands confidently when you
• What kinds of residents or clients do you
arrive at a job interview.
prefer to work with?
• Answer questions clearly and completely. Usually interviewers will ask if you have any
• Make eye contact to show you are sincere questions. Have some prepared. Write them
(Fig. 31-6). down so you do not forget things you really want
31 488

to know. Questions you may want to ask include know certain duties were part of the job. The job
the following: description reduces misunderstandings and can
• What hours would I work? be used to document what was agreed upon if
misunderstandings or legal issues arise.
Caring for Your Career and Yourself

• What benefits does the job include? Is health

insurance available? Would I get paid sick Tip
days or holidays?
TB and Hepatitis
• What orientation or training will be Each year facilities must test all employees for ex-
provided? posure to diseases like tuberculosis. You will get a
notice when it is time to have an annual TB skin test.
• Will my supervisor be available when It is your responsibility to get the test. Once this is
needed? done, you will be asked to return within a certain
• How soon will you be making a decision time, usually 48 to 72 hours, for the test results.
about this position? As you learned in Chapter 5, hepatitis B and C are
bloodborne diseases that can cause death. Many
Later in the interview, you may want to ask people have hepatitis B (HBV). It is a serious threat
to healthcare workers. Your employer must offer you
about salary or wages if you have not already a free vaccine to protect you from hepatitis B. You
been given this information. will usually get the vaccine when you begin your new
job. There is no vaccine for hepatitis C.
Listen carefully to the answers to your questions.
Take notes if needed. You will probably be told
when you can expect to hear from the employer. 6. Discuss how to manage and resolve
Do not expect to be offered a job at the inter- conflict
view. When the interview is over, stand up and Everyone experiences conflict at some point in
shake hands again. Say something like, “Thank their lives. Families may argue at home; co-work-
you for taking the time to meet with me today. I ers may disagree on the job, and so on. When
look forward to hearing from you.” conflict at work is not managed or resolved, it
Send a thank-you letter after every job interview. may affect the ability to function well. Productiv-
This states your continued interest in a job. If ity and the workplace environment may suffer.
you have not heard from the employer within the When conflict occurs, there is a proper time
time frame you discussed with your interviewer, and place to address it. You may need to talk to
call and ask if the job was filled. your supervisor for assistance. In general, follow
these guidelines for managing conflict:
5. Describe a standard job description
Guidelines:
A job description is an agreement between the Resolving Conflict
employer and the employee. It states the respon-
sibilities and tasks of the job. It also includes the G Plan to discuss the issue at the right time.
skill required for the job, to whom the employee Do not start a conversation while you are
must report, and the salary range. helping residents or patients. Wait until the
The job description is protection for both par- supervisor has decided on an appropriate
ties. It protects the employee from the facility or time and place. Privacy is important. Shut the
agency changing duties without notifying the door. Limit distractions, such as TV, conver-
employee. It protects the employee from being sations, radio, etc.
fired based on something not related to his or G Agree not to interrupt the person. Do not be
her job description. The employer is protected rude or sarcastic, or name-call. Use active lis-
from the employee saying he or she did not tening. Take turns speaking.
 489 31

G Do not get emotional. Some situations may • Hostile criticism and constructive criticism
be very upsetting. However, you will be more are not the same. Hostile criticism is angry
effective in communicating and problem- and negative. Examples are, “You are use-
solving if you can keep your emotions out less!” or “You are lazy and slow.” Hostile

Caring for Your Career and Yourself

of it. criticism should not come from your em-
G Check your body language to make sure it ployer or supervisor. You may hear hostile
is not tense, unwelcoming, or threatening. criticism from residents, family members,
Maintain eye contact and use a posture that or others. The best response is something
says you are listening and interested. Lean like, “I’m sorry you are so disappointed,”
forward slightly and do not slouch. and nothing more. Give the person a chance
to calm down before trying to discuss their
G Keep the focus on the issue at hand. When
comments.
discussing conflict, state how you feel when
a behavior occurs. Use “I” statements. First • Constructive criticism may come from your
describe the actual behavior. Then use “feel- employer, supervisor, or others. Construc-
ing” words to describe how you feel. Let the tive criticism is meant to help you improve.
person know how the problem has affected Examples are, “You really need to be more
you. For example, “When you are late to accurate in your charting,” or “You are late
work, I feel upset because I end up doing too often. You’ll have to make more of an ef-
your work along with my own.” fort to be on time.” Listening and acting on
constructive criticism can help you be more
G People involved in the conflict may need to
successful in your job. Pay attention to it
brainstorm possible solutions. Think of ways
(Fig. 31-7).
that the conflict can be resolved. A solution
may be chosen by a supervisor or mediator
I think you are
that does not satisfy everyone. In order to having a problem or-
resolve conflict, you may have to compro- ganizing your time.
mise. Be prepared to do this.
For more assistance with conflict resolution,
speak to your supervisor.

7. Describe employee evaluations

and discuss appropriate responses to
criticism
Handling criticism is hard for most people.
Yes, I have felt
Being able to accept and learn from criticism is rushed lately. Do you have
important in all relationships, including employ- any suggestions on how I
ment. From time to time you will receive evalu- can prioritize my time?
ations from your employer. They contain ideas
to help you improve your job performance. Here
are some tips for handling criticism and using it
to your benefit:
• Listen to the message that is being sent. Do
not get so upset that you cannot understand Fig. 31-7. Ask for suggestions when receiving constructive
the message. criticism.
31 490

• If you are not sure how to avoid a mistake 9. Discuss certification and explain the
you have made, always ask for suggestions. state’s registry
Avoiding making mistakes will help you im-
prove your performance. To satisfy the requirements set forth in the Om-
Caring for Your Career and Yourself

nibus Budget Reconciliation Act (OBRA), states

• Apologize and move on. If you have made
must regulate nursing assistant training, evalua-
a mistake, apologize as needed (Fig. 31-8).
tion, and certification. OBRA mandates 75 hours
This may be to your supervisor, a resident,
as the minimum level of initial training and a
or others. Learn from the incident and put
12-hour minimum for annual continuing educa-
it behind you. Do not dwell on it or hold a
tion (called “in-services”). Many states’ require-
grudge. Responding professionally to criti-
ments exceed the minimum hours for the basic
cism is important for success in any job.
training programs and annual in-services. It is a
good idea to know your state’s rules.
I’m sorry I’ve been
After a nursing assistant has completed an ap-
late several times this month.
I know it’s inconvenient for you. proved training program in his or her state, he
I am making more of an effort to or she is given a competency evaluation (a certi-
be on time, and I expect not to
be late again. fication exam or test) in order to be certified to
work in that state. This exam usually consists of
both a written evaluation and a skills evaluation.
You must pass both parts in order to be certified
to work as a nursing assistant.
Fig. 31-8. Be willing to apologize if you have made a OBRA also requires that each state keep a
mistake.
registry of nursing assistants. This registry is
maintained by a state department, often by the
Your evaluation will also cover overall knowl-
state’s Department of Health. The registry con-
edge, conflict resolution, and team effort.
tains nursing assistants’ training information,
Flexibility, friendliness, trustworthiness, and
results of certification exams, and any findings
customer service are other things considered.
of abuse, neglect or theft by nursing assistants.
Evaluations are often the basis for salary in-
Employers are able to access this list to verify
creases. A good evaluation can help you advance
that you have passed the certification exam, as
within the facility. Being open to criticism and
well as to check if your certification is current.
suggestions for improvement will help you be
They are also able to see if you have been inves-
more successful.
tigated or found guilty of any abuse or neglect.
Nursing assistant registries are also a good
8. Explain how to make job changes
source of information for nursing assistants. By
If you decide to change jobs, be responsible. contacting the department that oversees the reg-
Always give your employer at least two weeks’ istry, you can find out how you may be able to
written notice that you will be leaving. Other- move your certification from one state to another
wise, your facility may be understaffed. Both the state. This is called reciprocity.
residents and other staff will suffer. In addition, Each state has different requirements for main-
future employers may talk with past supervisors. taining certification. Learn your state’s require-
People who change jobs too often or who do not ments. Follow them exactly or you will not be
give notice before leaving are less likely to be able to keep working. Once you are certified, you
hired.
 491 31

can lose your certification if you fail to follow • Sign up for the course or find out where it is
your state’s rules. Usually this occurs if you do offered (Fig. 31-9).
not work in long-term care for a period of time
or fail to get the required number of continuing

Caring for Your Career and Yourself

education hours. You can also lose certification
due to criminal activities, including abuse and
neglect.
For your state, make sure you know the
following:
• How quickly after completing a training pro-
gram you must take and pass the certifica-
tion exam
• How many days per year you must work in
long-term care to maintain your certification
Fig. 31-9. You may want to go outside the in-service pro-
• How many hours of continuing education
grams offered by your employer to take some continuing
you must take each year education courses.
Some states do not have a registry for home
health aides like the ones they maintain for • Attend all class sessions.
nursing assistants. If you are a home health • Pay attention and complete all the class
aide, ask your employer how best to maintain requirements.
your certification. Know who is responsible for • Make the most of your in-service programs.
reporting your work hours and in-service hours Participate! (Fig. 31-10)
to the state.

10. Describe continuing education

The federal government requires that nursing
assistants and home health aides have 12 hours
of continuing education each year. Some states
may require more. “In-service” continuing edu-
cation courses help you keep your knowledge
and skills fresh. Classes also give new informa-
tion about conditions, challenges you face in Fig. 31-10. Pay attention and participate during continu-
ing education courses.
working with residents/clients, or regulation
changes. You need to be up-to-date on the latest
• Keep original copies of all certificates and
that is expected of you.
records of your successful attendance so you
If you need more instruction in a particular can prove you took the class.
area, speak to your supervisor. Perhaps he or
she can arrange for an in-service continuing 11. Define “stress” and “stressors”
education class to be offered on that topic. Your
employer may be responsible for offering con- Stress is the state of being frightened, excited,
tinuing education courses. However, you are confused, in danger, or irritated. We may think
responsible for attending and completing them. only bad things cause stress. However, positive
Specifically, you must do the following: situations cause stress, too. For example, getting
31 492

married or having a baby are usually positive • Losing a job

situations. But both can bring enormous stress • New responsibilities at work
from the changes they bring to our lives
(Fig. 31-11). • Problems at work
Caring for Your Career and Yourself

• Supervisors
• Co-workers
• Residents/clients
• Illness
• Finances

12. Explain ways to manage stress

Stress is not only an emotional response. It is
also a physical response. When we experience
stress, changes occur in our bodies. The endo-
crine system may make more of the hormone
adrenaline. This can increase nervous system
Fig. 31-11. Although having a new baby is usually a
happy time, it can also cause stress. response, heart rate, respiratory rate, and blood
pressure. This is why, in stressful situations,
You may be thrilled when you get your new job. your heart beats fast, you breathe hard, and you
But starting work may also cause you stress. You feel warm or perspire.
may be afraid of making mistakes, excited about Each of us has a different tolerance level for
earning money or helping people, or confused stress. What one person would find overwhelm-
about your new duties. Learning how to recog- ing may not bother another person. Your toler-
nize stress and its causes is helpful. Then you ance for stress depends on your personality, life
can master a few simple methods for relaxing experiences, and physical health.
and learn to manage stress.
Defense mechanisms are unconscious behav- Guidelines:
iors used to cope with stress. See Chapter 20 for Managing Stress
more information on defense mechanisms.
To manage the stress in your life, develop healthy
A stressor is something that causes stress. Any-
habits of diet, exercise, and lifestyle:
thing can be a stressor if it causes you stress.
Some examples include the following: G Eat nutritious foods.
• Divorce G Exercise regularly (Fig. 31-12). You can exer-
cise alone or with a partner.
• Marriage
G Get enough sleep.
• New baby
G Drink only in moderation.
• Children growing up
G Do not smoke.
• Children leaving home
G Find time at least a few times a week to do
• Feeling unprepared for a task
something relaxing, such as taking a walk,
• Starting a new job reading a book, or sewing.
 493 31

• Your family
• Your friends
• Your place of worship

Caring for Your Career and Yourself

• Your doctor
• A local mental health agency
• Any phone hotline that deals with related
problems (check your local yellow pages or
the Internet)

Fig. 31-12. Exercising regularly is one healthy way to de-

crease stress.

Not managing stress can cause many problems.

Some of these problems affect how well you do
your job. Signs that you are not managing stress
include the following:
• Showing anger or being abusive to
residents/clients
• Arguing with your supervisor about Fig. 31-13. Support groups can help you deal with differ-
assignments ent types of stress.

• Having poor relationships with co-workers

It is not appropriate to talk to your residents/
and residents/clients
clients or their family members about your per-
• Complaining about your job and your sonal or job-related stress.
responsibilities
One of the best ways of managing stress is to de-
• Feeling work-related burnout (burnout is velop a plan for managing stress. The plan can
a state of mental or physical exhaustion include nice things you will do for yourself every
caused by stress) day and things to do in stressful situations.
• Feeling tired even when you are rested When you think about a plan, you first need to
answer the following questions:
• Having a difficult time focusing on resi-
dents/clients and procedures • What are the sources of stress in my life?

Stress can seem overwhelming when you try to • When do I most often feel stress?
handle it yourself. Often just talking about stress • What effects of stress do I see in my life?
can help you manage it better. Sometimes an-
• What can I change to decrease my stress?
other person can offer helpful suggestions. You
may think of new ways to handle stress just by • What do I have to learn to cope with because
talking it through. Get help from one or more I cannot change it?
of these resources when managing stress (Fig. When you have answered these questions, you
31-13): will have a clearer picture of the challenges you
• Your supervisor or another member of the face. Then you can come up with strategies for
care team for work-related stress managing stress.
31 494

13. Describe a relaxation technique

Sometimes a relaxation exercise can help you
feel refreshed and relaxed in only a short time.
Caring for Your Career and Yourself

Below is a simple relaxation exercise. Try it out.

See if it helps you feel more relaxed.
The body scan. Close your eyes. Focus on your
breathing and posture. Be sure you are comfort-
able. Starting at the balls of your feet, concen-
trate on your feet. Find any tension hidden in
the feet. Try to relax and release the tension.
Continue very slowly. Take a breath between Fig. 31-14. Be proud of the work you have chosen to do.
each body part. Move up from the feet, focusing It is important.
on and relaxing the legs, knees, thighs, hips,
stomach, back, shoulders, neck, jaw, eyes, fore- An important life skill is reflecting on how you
head, and scalp. Take a few very deep breaths. spend your time. Learn ways to fully appreciate
Open your eyes. that what you do has great meaning. Few jobs
have the challenges and rewards of working with
This exercise takes only about two minutes. If it
the elderly, ill, or disabled. Congratulate yourself
is helpful for you, try it the next time you need a
for choosing a path that includes helping others
break, at work or at home.
along the way.

14. List ways to remind yourself of the

Chapter Review
importance of the work you have chosen
to do 1. What are direct service positions?

Look back over all you have learned in this 2. What are two good ways to find out about
program. Your work as a caregiver is very im- job opportunities with potential employers?
portant. Every day may be different and chal- 3. List three documents you may need to take
lenging. In a hundred ways every week you will with you when applying for a job.
offer help that only a caring person like you can
give. 4. What should be done before writing any-
thing on a job application?
Do not forget to value the work you have chosen
to do. It is important. Your work can mean the 5. List 10 things that show potential employers
difference between living with independence professionalism during an interview.
and dignity and living without. The difference 6. How can you follow up on a job interview?
you make is sometimes life versus death. Look
7. What is contained in a job description?
in the face of each of your residents and clients.
Know that you are doing important work. Look 8. List four guidelines to follow while working
in a mirror when you get home and be proud of on resolving conflicts.
how you make your living (Fig. 31-14). 9. What is the difference between hostile and
constructive criticism?
10. Why might an employer not hire a person
who has changed jobs often?
 495 31

11. What information does a registry for certi-

fied nursing assistants keep?
12. How many hours of continuing education

Caring for Your Career and Yourself

does the federal government require for NAs
and HHAs each year?
13. What is stress? Give three examples of
stressors you have experienced in the last
year. How did you respond to them?
14. List five guidelines for managing stress.
15. What are five resources that are appropriate
for an NA or HHA to turn to when trying to
manage stress?
16. Before developing a stress management
plan, what are four questions that a person
should ask herself?
17. What do you think you will like best about
being a nursing assistant or home health
aide?
Abbreviations 496

Abbreviations CBC complete blood

count
DOA
DOB
dead on arrival
date of birth
CBR complete bedrest
DON director of nursing
ABCD airway, breath- CCU cardiac care unit,
ing, circulation, Dr., DR doctor
cardiovascular care
defibrillation unit drsg dressing
abd abdomen CDC Centers for Disease DVT deep vein
ABR absolute bedrest Control thrombosis

ac, a.c. before meals C. diff clostridium difficile Dx, dx diagnosis

ad lib as desired CHF congestive heart ECG, EKG electrocardiogram

failure EMS emergency medical
adm. admission
ck  check services
ADLs activities of daily
living cl liq clear liquid ER emergency room

AIDS acquired immune CMS Centers for Medi- exam examination

deficiency syndrome care and Medicaid F Fahrenheit
Services
amb ambulate, FBS fasting blood sugar
ambulatory c/o complains of, in
care of FF force fluids
amt amount
CNA certified nursing ft foot
ap apical
assistant F/U, f/u follow-up
AROM active range of
CNS central nervous FWB full weight bearing
motion
system
FYI for your information
ASAP as soon as possible
COPD chronic obstructive
as tol as tolerated geri chair geriatric chair
pulmonary disease
ax. axillary (armpit) GI gastrointestinal
CPR cardiopulmonary
BID, b.i.d. two times a day resuscitation h, hr, hr. hour

BM bowel movement CS Central Supply H20 water

BP, B/P blood pressure CVA cerebrovascular H/A, HA headache

accident, stroke HBV hepatitis B virus
BPM beats per minute
CVP central venous
BR bedrest HHA home health aide
pressure
BRP bathroom privileges HIPAA Health Insurance
CVS cardiovascular
Portability and
BSC bedside commode system
Accountability Act
c with CXR chest X-ray
HIV human immunodefi-
C Centigrade DAT diet as tolerated ciency virus
CA cancer DM diabetes mellitus HOB head of bed
cath. catheter DNR do not resuscitate HS/hs hours of sleep
 497

Abbreviations
ht height MSDS material safety data post-op after surgery
HTN hypertension sheet
PPE personal protective
hyper above normal, too NA nursing assistant equipment
fast, rapid N/A not applicable pre-op before surgery
hypo low, less than N/C no complaints, no p.r.n., prn when necessary
normal call
PROM passive range of
ICU intensive care unit NG, ng nasogastric motion
inc incontinent PT physical therapist/
NKA no known allergies
I&O intake and output therapy
NPO nothing by mouth
IV, I.V. intravenous (within PVD peripheral vascular
NVD nausea, vomiting
a vein) disease
and diarrhea
isol isolation PWB partial weight
NWB non-weight bearing
L, lt left bearing
OBRA Omnibus Budget
lab laboratory q every
Reconciliation Act
lb. pound qh, qhr every hour
OOB out of bed
lg large q2h every two hours
OR operating room
LOC level of q3h every three hours
OSHA Occupational q4h every four hours
consciousness
Safety and Health
LPN licensed practical R, rt. right
Administration
nurse R respirations, rectal
OT occupational
LTC long-term care therapist/therapy RBC red blood cell/count
LTCF long-term care oz ounce rehab rehabilitation
facility
p after res. resident
LVN licensed vocational
nurse pc, p.c. after meals resp. respiration
M.D. medical doctor PCA patient-controlled RF restrict fluids
anesthesia
MDS minimum data set R.I.C.E. rest, ice, compres-
meds medications PEG percutaneous sion, elevation
endoscopic
MI myocardial RN registered nurse
gastrostomy
infarction R/O rule out
per os by mouth
min minute
ROM range of motion
peri care perineal care
mm Hg millimeters of
RR respiratory rate
mercury PHI Protected Health
Information s without
mL milliliter
PNS peripheral nervous SNF skilled nursing
mod moderate
system facility
MRSA methicillin-resistant
staphylococcus PO by mouth SOB shortness of breath
aureus
Abbreviations 498

SP standard w/c, W/C wheelchair

precautions
WNL within normal limits
spec. specimen
wt. weight
S&S, S/S signs and symptoms
SSE soapsuds enema
staph staphylococcus
Symbols
stat, STAT immediately
STD sexually transmitted © copyright
disease
biohazard
std. prec. standard
change, heat
precautions
° degree
STI sexually transmitted
infection female

strep streptococcus male

T., temp temperature % percent

TB tuberculosis radiation

TIA transient ischemic

attack
t.i.d., tid three times a day
TLC tender loving care
TPN total parenteral
nutrition
TPR temperature, pulse
and respiration
TWE tap water enema
U/A, u/a urinalysis
URI upper respiratory
infection
UTI urinary tract
infection
VRE vancomycin resis-
tant enterococcus
VS, vs vital signs
WBC white blood cell/
count
 499

Appendix
Appendix Here are common values shown in decimal,
fraction, and percentage forms:
Decimal Fraction Percentage
Basic Math Skills 0.01 1/100 1%

Nursing assistants need math skills when doing 0.1 1/10 10%
certain tasks, such as calculating intake and out- 0.2 1/5 20%
put. A basic math review is listed below: 0.25 1/4 25%

Addition 0.333 1/3 33 1/3%

0.5 1/2 50%
2,905 53,138
+ 174 + 3,008 0.75 3/4 75%

3,079 56,146 1 1/1 100%

Subtraction Follow these rules for converting decimals, frac-

32,542 549,233 tions, and percentages:
– 8,710 – 26,903
23,832 522,330 To convert from decimal to a percentage, you
will multiply by 100, and add a percent sign (%).
Multiplication .25 x 100 = 25%
4,962 79
x 13 x 41 To convert from a percentage to decimal,
14,886 79 you will divide by 100, and delete the percent
sign (%).
+ 49,620 + 3,160
64,506 3,239 80% ÷ 100 = 0.8

Division To convert a fraction to a decimal, you will divide

the top number by the bottom number.
34 39
22 748 14 546 2
= 2 ÷ 3 = 0.67
– 660 – 420 3
88 126
– 88 – 126
To convert a decimal to a fraction, write the deci-
mal over the number 1.
0 0
Step 1 0.5
Converting Decimals, Fractions, 1
and Percentages Then multiply top and bottom by 10 for every
number after the decimal point (10 for 1 num-
Decimals, fractions and percentages are differ-
ber, 100 for 2 numbers, and so on.)
ent ways of showing the same value. For exam-
ple, a half can be written in the following ways: Step 2 0.5 x 10 5
=
As a decimal: 0.5 1 x 10 10
As a fraction: 1/2 The resulting fraction is 5/10 (or 1/2 if you sim-
As a percentage: 50% plify the fraction).
Appendix 500

To convert a fraction to a percentage, you will Conversions: Volume

divide the top number by the bottom number.
1 milliliter (mL) = 1 cubic centimeter (cc)
Then you multiply the result by 100, and add a
percent sign (%). 1 ounce (oz.) = 30 mL (cc)

Step 1 3 ¼ cup = 2 oz. = 60 mL (cc)

= 3 ÷ 5 = 0.6
5 ½ cup = 4 oz. = 120 mL (cc)
1 cup = 8 oz. = 240 mL (cc)
Step 2 0.6 x 100 = 60%
1 Liter = 1000 mL (cc)

To convert a percentage to a fraction, first con-

vert to a decimal by dividing by 100. Then use Conversions: Weight
the steps for converting decimal to fractions. 2 pints = 1 quart (qt.) = 960 mL (cc)
Step 1 15% ÷ 100 = 0.15 2 quarts = ½ gallon (gal.) = 1920 cc = 2 liters (L)

Step 2 0.15 4 quarts = 1 gallon (gal.)

1 2.2 pounds (lbs.) = 1 kilogram (kg)

Step 3 0.15 x 100 15 1 gram (g) = 1000 milligrams (mg)

=
1 x 100 100
The resulting fraction is 15/100 (or 3/20 if you Conversions: Length
simplify the fraction). 1 inch (in) = 2.54 centimeters (cm)
(or round off to 2.5)
Other Useful Information 12 inches = 1 foot

Multiplication Table 3 feet = 1 yard

1 2 3 4 5 6 7 8 9 10 11 12 10 millimeters (mm) = 1 centimeter (cm)

2 4 6 8 10 12 14 16 18 20 22 24 100 centimeters (cm) = 1 meter

3 6 9 12 15 18 21 24 27 30 33 36

4 8 12 16 20 24 28 32 36 40 44 48

5 10 15 20 25 30 35 40 45 50 55 60

6 12 18 24 30 36 42 48 54 60 66 72

7 14 21 28 35 42 49 56 63 70 77 84

8 16 24 32 40 48 56 64 72 80 88 96

9 18 27 36 45 54 63 72 81 90 99 108

10 20 30 40 50 60 70 80 90 100 110 120

11 22 33 44 55 66 77 88 99 110 121 132

12 24 36 48 60 72 84 96 108 120 132 144

 501

Glossary
Glossary additive: a substance added to another sub-
stance, changing its effect.
adduction: moving a body part toward the mid-
24-hour urine specimen: a urine specimen line of the body.
consisting of all urine voided in a 24-hour adult daycare: care given at a facility during
period. daytime working hours for people who need
abdominal thrusts: method of attempting to re- some help but are not seriously ill or disabled.
move an object from the airway of someone who
advance directives: legal documents that allow
is choking.
people to choose what medical care they wish
abduction: moving a body part away from the to have if they cannot make those decisions
midline of the body. themselves.
abrasion: an injury which rubs off the surface affected side: a weakened side from a stroke or
of the skin. injury; also called the weaker or involved side.
abuse: purposely causing physical, mental, or ageism: prejudice toward, stereotyping of,
emotional pain or injury to someone. and/or discrimination against older persons or
acquired immune deficiency syndrome the elderly.
(AIDS): disease caused by the human immu- agitated: the state of being excited, restless, or
nodeficiency virus (HIV) in which the body’s troubled.
immune system is weakened and unable to fight
infection. agnostics: persons who claim that they do not
know or cannot know if God exists.
active assisted range of motion (AAROM)
exercises: range of motion exercises performed alternative medicine: practices and treat-
by a person with some assistance and support. ments used instead of conventional healthcare
methods.
active neglect: purposely harming a person by
failing to provide needed care. ambulation: walking.

active range of motion (AROM) exercises: ambulatory: capable of walking.

range of motion exercises performed by a person amputation: the removal of some or all of a
by himself. body part, usually a foot, hand, arm or leg; may
active TB: type of tuberculosis in which the be the result of an injury or disease.
person shows symptoms of the disease and can
anal incontinence: the inability to control the
spread TB to others; also known as TB disease.
bowels, leading to involuntary passage of stool;
activities of daily living (ADLs): personal daily also called fecal incontinence.
care tasks, such as bathing, dressing, caring for
anesthesia: the use of medication to block pain
teeth and hair, toileting, eating and drinking,
during surgery and other medical procedures.
walking, and transferring.
angina pectoris: the medical term for chest
acute care: care given in hospitals and ambula-
pain, pressure, or discomfort due to coronary
tory surgical centers for people who have an im-
artery disease.
mediate illness.
anorexia: an eating disorder in which a per-
adaptive devices: special equipment that helps
son does not eat or exercises excessively to lose
a person who is ill or disabled to perform ADLs;
weight.
also called assistive devices.
Glossary 502

antimicrobial: destroying or resisting axillae: underarms.

pathogens. baseline: initial values that can then be com-
anxiety: uneasiness or fear, often about a situa- pared to future measurements.
tion or condition. battery: touching a person without his or her
apical pulse: the pulse located on the left side permission.
of the chest, just below the nipple. bed rest: stopping all activity and staying in bed
apnea: the state of not breathing. in order to prevent labor from starting before a
baby is ready to be born.
arm lock: position in which the caregiver places
his arm under the resident’s armpit, grasping benign prostatic hypertrophy: a disorder that
the resident’s shoulder, while the resident grasps occurs in men as they age, in which the prostate
the caregiver’s shoulder; also called lock arm. becomes enlarged and causes pressure on the
urethra, leading to frequent urination, dribbling
arthritis: a general term that refers to inflam-
of urine, difficulty in starting the flow of urine,
mation of the joints; causes stiffness, pain, and
and urinary retention.
decreased mobility.
benign tumors: tumors that are considered
artificial airway: any plastic, metal, or rubber
non-cancerous.
device inserted into the respiratory tract to main-
tain or promote breathing. bias: prejudice.
aspiration: the inhalation of food or drink into bloodborne pathogens: microorganisms found
the lungs. in human blood, body fluid, draining wounds,
and mucous membranes that can cause infec-
assault: the act of threatening to touch a person
tion and disease in humans.
without his or her permission.
Bloodborne Pathogens Standard: federal law
assisted living : living facilities for people who
that requires that healthcare facilities protect
do not need skilled, 24-hour care, although they
employees from bloodborne health hazards.
do require some help with daily care.
body mechanics: the way the parts of the body
assistive devices: special equipment that helps
work together whenever a person moves.
a person who is ill or disabled to perform ADLs;
also called adaptive devices. bone: rigid tissue that protects organs and
works together to allow the body to move.
asthma: a chronic inflammatory disease that
causes difficulty with breathing and coughing bony prominences: areas of the body where
and wheezing. bone is close to the skin.
atheist: person who claims there is no God and brachial pulse: the pulse inside the elbow,
actively denies God’s existence. about 1-1 1/2 inches above the elbow.
atherosclerosis: a hardening and narrowing of bronchiectasis: condition in which the bron-
the blood vessels. chial tubes are permanently enlarged, causing
chronic coughing and thick sputum; may be re-
atrophy: the wasting away, decreasing in size,
sult of chronic infections and inflammation.
and weakening of muscles from lack of use.
bronchitis: an irritation and inflammation of
autoimmune illness: an illness in which the
the lining of the bronchi.
body’s immune system attacks normal tissue in
the body.
 503

Glossary
bulimia: an eating disorder in which a person Cesarean section: a surgical procedure in
binges, eating huge amounts of foods or very fat- which a baby is delivered through an incision in
tening foods, and then purges, or eliminates the the mother’s abdomen.
food by vomiting, using laxatives, or exercising
chain of infection: a way of describing how
excessively.
disease is transmitted from one living being to
calculi: kidney stones that form when urine another.
crystallizes in the kidneys. chancres: open sores.
cardiopulmonary resuscitation (CPR): medi- charting: writing down important information
cal procedures used when a person’s heart or and observations about residents.
lungs have stopped working.
chest tubes: hollow drainage tubes that are in-
cataracts: a condition in which milky or cloudy serted into the chest to drain air, blood, or fluid
spots develop in the eye, causing vision loss. that has collected inside the pleural cavity or
catastrophic reaction: overreacting to some- space.
thing in an unreasonable way. Cheyne-Stokes: slow, irregular respirations or
catheter: a thin tube inserted into the body that rapid, shallow respirations.
is used to drain or inject fluids. chickenpox: a highly contagious viral illness
causative agent: a pathogen or microorganism that strikes nearly all children.
that causes disease. child abuse: physical, emotional, and sexual
C cane: a straight cane with a curved handle at mistreatment of children, as well as neglect and
the top. maltreatment.

cells: basic units of the body that divide, de- child neglect: the purposeful or unintentional
velop, and die, renewing tissues and organs. failure to provide for the needs of a child.
chlamydia: sexually transmitted disease that
Centers for Disease Control and Prevention
causes yellow or white discharge from the penis
(CDC): a government agency under the Depart-
or vagina and burning with urination.
ment of Health and Human Services (HHS) that
issues information to protect the health of indi- chronic illness: a disease or condition that is
viduals and communities. long-term or long-lasting.
Centers for Medicare & Medicaid Services chronic kidney failure: condition that occurs
(CMS): a federal agency within the U.S. Depart- when the kidneys cannot eliminate certain waste
ment of Health and Human Services that is products from the body; also called chronic renal
responsible for Medicare and Medicaid, among failure.
many other responsibilities. chronic obstructive pulmonary disease
central nervous system: part of the nervous (COPD): a chronic lung disease that cannot be
system that is composed of the brain and spinal cured; causes difficulty breathing.
cord. chronic renal failure: condition that occurs
cerebrovascular accident (CVA): a condition when the kidneys cannot eliminate certain waste
that occurs when blood supply to a part of the products from the body; also called chronic kid-
brain is cut off suddenly by a clot or a ruptured ney failure.
blood vessel; also called a stroke. circadian rhythm: the 24-hour day-night cycle.
Glossary 504

circumcision: the removal of part of the fore- compassionate: caring, concerned, considerate,
skin of the penis. empathetic, and understanding.
cite: in a long-term care facility, to find a prob- complementary medicine: treatments that are
lem through a survey. used in addition to the conventional treatments
prescribed by a doctor.
claustrophobia: the fear of being in a confined
space. complex carbohydrates: carbohydrates that are
broken down by the body into simple sugars for
clean: in health care, a condition in which ob-
energy; found in foods such as bread, cereal, po-
jects are not contaminated with pathogens.
tatoes, rice, pasta, vegetables, and fruits.
clean catch specimen: a urine specimen that
concentrated formula: a type of formula for
does not have the first and last urine included.
infants that is sold in small cans and must be
clichés: phrases that are used over and over mixed with sterile water before using.
again and do not really mean anything. condom catheter: catheter that has an attach-
closed bed: a bed completely made with the ment on the end that fits onto the penis; also
bedspread and blankets in place. called an external or “Texas” catheter.

closed fracture: a broken bone that does not confidentiality: the legal and ethical principle
break the skin. of keeping information private.

Clostridium difficile (C-diff, C. difficile): bac- confusion: the inability to think clearly.
terial illness that causes diarrhea and can cause congestive heart failure (CHF): a condition
colitis. in which the heart is no longer able to pump ef-
cognition: the ability to think logically and fectively; blood backs up into the heart instead of
quickly. circulating.
conscientious: guided by a sense of right and
cognitive: related to thinking and learning.
wrong; having principles.
cognitive impairment: loss of ability to
conscious: the state of being mentally alert and
think logically; concentration and memory are
having awareness of surroundings, sensations,
affected.
and thoughts.
colitis: inflammation of the large intestine that
constipation: the inability to eliminate stool, or
causes diarrhea and abdominal pain; also called
the difficult and painful elimination of a hard,
irritable bowel syndrome.
dry stool.
colorectal cancer: cancer of the gastrointestinal
constrict: to narrow.
tract; also known as colon cancer.
contracture: the permanent and often very
colostomy: surgically-created diversion of stool painful stiffening of a joint and muscle.
or feces to an artificial opening through the ab-
domen; stool will generally be semi-solid. cultural diversity: the variety of people with
varied backgrounds and experiences who live
combative: violent or hostile behavior. and work together in the world.
combustion: the process of burning. culture: a system of learned behaviors by a
communication: the process of exchanging in- group of people that are considered to be the tra-
formation with others by sending and receiving dition of that people and are passed on from one
messages. generation to the next.
 505

Glossary
culture change: a term given to the process of diabetes: a condition in which the pancreas
transforming services for elders so that they are does not produce enough or does not properly
based on the values and practices of the person use insulin.
receiving care; core values include choice, dig-
diabetic ketoacidosis (DKA): complication of
nity, respect, self-determination, and purposeful
diabetes that is caused by having too little insu-
living.
lin; also called hyperglycemia or diabetic coma.
cyanotic: skin that is pale, blue, or gray.
diagnosis: physician’s determination of an
cystitis: inflammation of the bladder that may illness.
be caused by bacterial infection.
diarrhea: frequent elimination of liquid or semi-
dandruff: a skin condition that results from an liquid feces.
excessive shedding of dead skin cells from the
diastole: phase when the heart relaxes or rests.
scalp.
diastolic: second measurement of blood pres-
dangle: to sit up with the feet over the side of
sure; phase when the heart relaxes or rests.
the bed in order to regain balance.
dietary restrictions: rules about what and
defecation: the act of passing feces from the
when individuals can eat.
large intestine out of the body through the anus.
diet cards: cards that list the resident’s name
defense mechanisms: unconscious behaviors
and information about special diets, allergies,
used to release tension or cope with stress.
likes and dislikes, and other instructions.
degenerative: something that continually gets
digestion: the process of preparing food physi-
worse.
cally and chemically so that it can be absorbed
dehydration: a condition that results from inad- into the cells.
equate fluid in the body.
dilate: to widen.
delegation: the act of transferring authority to a
direct contact: touching an infected person or
person to for a specific task.
his secretions.
delirium: a state of severe confusion that occurs
dirty: in health care, a condition in which ob-
suddenly and is usually temporary.
jects have been contaminated with pathogens.
delusions: persistent false beliefs.
disinfection: process that kills pathogens, but
dementia: a general term that refers to a seri- not all microorganisms; it reduces the organism
ous loss of mental abilities, such as thinking, count to a level that is generally not considered
remembering, reasoning, and communicating. infectious.
dental floss: a special kind of string used to disorientation: confusion about person, place,
clean between teeth. or time.
dentures: artificial teeth. disposable: only to be used once and then
discarded.
dermatitis: general term that refers to inflam-
mation of the skin; usually involves swollen, red- disposable razor: type of razor, usually plastic,
dened, irritated, and itchy skin. that is discarded after one use; requires the use
of shaving cream or soap.
developmental disabilities: disabilities that are
present at birth or emerge during childhood that diuretics: medications that reduce fluid volume
restrict physical or mental ability. in the body.
Glossary 506

domestic violence: physical, sexual, or emo- empathy: entering into the feelings of others.
tional abuse by spouses, intimate partners, or
emphysema: a chronic disease of the lungs that
family members.
usually develops as a result of chronic bronchitis
do-not-resuscitate (DNR): an order that tells and smoking.
medical professionals not to perform CPR.
enema: a specific amount of water, with or with-
dorsal recumbent: position in which a person out an additive, that is introduced into the colon
is flat on her back with her knees flexed and her to eliminate stool.
feet flat on the bed.
epilepsy: an illness of the brain that produces
dorsiflexion: bending backward. seizures.
douche: putting a solution into the vagina in episiotomy: an incision made in the perineal
order to cleanse the vagina, introduce medica- area during vaginal delivery of a baby that en-
tion to treat an infection or condition, or to re- larges the vaginal opening for the baby’s head.
lieve discomfort.
ergonomics: the science of designing equip-
draw sheet: an extra sheet placed on top of the ment and work tasks to suit the worker’s
bottom sheet when the bed is made; also called a abilities.
turning sheet.
ethics: the knowledge of right and wrong.
durable power of attorney for health care: a
exchange lists: lists of similar foods that can be
signed, dated, and witnessed paper that appoints
substituted for each other on a meal plan.
someone else to make the medical decisions for
a person in the event he or she becomes unable expiration: exhaling air out of the lungs.
to do so.
exposure control plan: plan designed to elimi-
dysphagia: difficulty swallowing. nate or reduce employee exposure to infectious
material.
dyspnea: difficulty breathing.
expressive aphasia: inability to speak or speak
edema: swelling caused by excess fluid in body
clearly.
tissues.
edentulous: having no teeth; toothless. extension: straightening a body part.

electric razor: type of razor that runs on elec- facilities: in medicine, places where health care
tricity; does not require the use of soap or shav- is delivered or administered, including hospitals,
ing cream. long-term care facilities or nursing homes, and
treatment centers.
elimination: the process of expelling solid
wastes made up of the waste products of food fallacy: a false belief.
that are not absorbed into the cells. farsightedness: the ability to see objects in the
elope: in medicine, when a person with Al- distance better than objects nearby.
zheimer’s disease wanders away from the pro- fasting: not eating food or eating very little
tected area and does not return. food.
emesis: the act of vomiting, or ejecting stomach fecal impaction: a hard stool that is stuck in
contents through the mouth. the rectum and cannot be expelled; results from
emotional lability: laughing or crying without unrelieved constipation.
any reason, or when it is inappropriate.
 507

Glossary
financial abuse: the act of stealing, taking ad- geriatrics: the study of health, wellness, and
vantage of, or improperly using the money, prop- disease later in life.
erty, or other assets of another person.
gerontology: the study of the aging process in
first aid: emergency care given immediately to people from mid-life through old age.
an injured person.
gestational diabetes: type of diabetes that ap-
flammable: easily ignited and capable of burn- pears in pregnant women who have never had
ing quickly. diabetes before but who have high glucose levels
flatulence: air in the intestine that is passed during pregnancy.
through the rectum, which can result in cramp- glands: structures that secrete hormones.
ing or abdominal pain; also called flatus or gas.
glaucoma: a condition in which the fluid inside
flexion: bending a body part. the eyeball is unable to drain; increased pressure
fluid balance: taking in and eliminating equal inside the eye causes damage that often leads to
amounts of fluid. blindness.

fluid overload: a condition that occurs when glucose: natural sugar.

the body is unable to handle the amount of fluid gonads: sex glands.
consumed.
gonorrhea: sexually transmitted disease that
foot drop: a weakness of muscles in the feet
causes greenish or yellowish discharge from the
and ankles that impairs the ability to flex the
penis and burning with urination in men.
ankles and walk normally.
groin: the area from the pubis (area around the
force fluids: a medical order for a person to
penis and scrotum) to the upper thighs.
drink more fluids.
grooming: practices to care for oneself, such as
Fowler’s: position in which a person is in a
caring for fingernails and hair.
semi-sitting position (45 to 60 degrees).
halitosis: bad breath.
fracture: a broken bone.
hallucinations: illusions a person sees or hears.
fracture pan: a bedpan that is flatter than the
regular bedpan. hand antisepsis: washing hands with water
and soap or other detergents that contain an an-
full weight bearing: able to bear 100 percent of
tiseptic agent.
the body weight on one or both legs on a step.
functional grip cane: cane that has a straight hand hygiene: washing hands with either plain
grip handle. or antiseptic soap and water and using alcohol-
based hand rubs.
gait belt: a belt made of canvas or other heavy
material used to assist people who are who are hat: in health care, a collection container that
weak, unsteady, or uncoordinated; also called a is sometimes inserted into a toilet to collect and
transfer belt. measure urine or stool.

gastroesophageal reflux disease (GERD): a healthcare-associated infections (HAIs): in-

chronic condition in which the liquid contents of fections that patients acquire within healthcare
the stomach back up into the esophagus. settings that result from treatment for other
conditions.
gastrostomy: an opening in the stomach and
abdomen.
Glossary 508

health maintenance organizations (HMOs): hypertension: high blood pressure.

a method of health insurance in which a person hyperthyroidism: condition in which the thy-
has to use a particular doctor or group of doctors roid produces too much thyroid hormone, caus-
except in case of emergency. ing the cells to burn too much food.
heartburn: a condition that results from a weak- hypotension: abnormally low blood pressure.
ening of the sphincter muscle which joins the
esophagus and the stomach; causes a burning hypothyroidism: condition in which the thyroid
sensation in the esophagus. produces too little thyroid hormone, causing the
body processes to slow down; weight gain and
hemiparesis: weakness on one side of the body. physical and mental sluggishness result.
hemiplegia: paralysis on one side of the body. ileostomy: surgically-created opening into the
hemorrhoids: enlarged veins in the rectum or end of the small intestine to allow feces to be ex-
outside the anus that can cause rectal itching, pelled; causes stool to be liquid.
burning, pain, and bleeding. impairment: a loss of function or ability.
hepatitis: inflammation of the liver caused by incident: an accident or unexpected event dur-
infection. ing the course of care that is not part of the nor-
Herpes simplex 2: a sexually-transmitted, in- mal routine in a healthcare facility.
curable disease caused by a virus; repeated out- incontinence: the inability to control the blad-
breaks of the disease may occur for the rest of der or bowels.
the person’s life.
indirect contact: touching something contami-
HIV: stands for human immunodeficiency nated by an infected person.
virus, the virus that can cause AIDS.
indwelling catheter: a type of catheter that
hoarding: collecting and putting things away in remains inside the bladder for a period of time;
a guarded manner. urine drains into a bag.
holistic: a type of care that involves considering infection: the state resulting from pathogens
a whole system, such as a whole person, rather invading the body and multiplying.
than dividing the system into parts.
infection control: the measures practiced in
home health agencies: businesses that provide healthcare facilities to prevent and control the
health care and personal services in the home. spread of disease.
home health care: care that takes place in a infectious: contagious.
person’s home.
inflammation: swelling.
homeostasis: the condition in which all of the
body’s systems are working their best. informed consent: the process in which a per-
son, with the help of a doctor, makes informed
hormones: chemical substances created by the decisions about his or her health care.
body that control numerous body functions.
input: the fluid a person consumes; also called
hospice care: holistic, compassionate care given intake.
in facilities or homes for people who have six
months or less to live. insomnia: the lack of ability to fall asleep or stay
asleep.
hygiene: practices used to keep bodies clean
and healthy. inspiration: breathing in.
 509

Glossary
insulin: a hormone that converts glucose into knee-chest: position in which the person is
energy for the body. lying on her abdomen with her knees pulled to-
insulin reaction: complication of diabetes that wards the abdomen and her legs separated; arms
can result from either too much insulin or too are pulled up and flexed, and the head is turned
little food; also known as hypoglycemia. to one side.

intake: the fluid a person consumes; also called lactose intolerance: the inability to digest lac-
input. tose, a type of sugar found in milk and some
other dairy products.
integument: a natural protective covering, such
as the skin. latent TB: type of tuberculosis in which the per-
son carries the disease but does not show symp-
intervention: a way to change an action or
toms and cannot infect others; also known as TB
development.
infection.
intravenous (IV): into a vein.
lateral: position in which a person is lying on
intubation: the passage of a plastic tube either side.
through the mouth, nose, or opening in the
neck and into the trachea. laws: rules set by the government to help people
live peacefully together and to ensure order and
involuntary seclusion: separating a person
safety.
from others against the person’s will.
length of stay: the number of days a person
involved: term used to refer to the weaker, or af-
stays in a healthcare facility.
fected, side of the body after a stroke or injury.
leukemia: form of cancer in which the body’s
irreversible: incurable.
white blood cells are unable to fight disease.
isolate: to keep something separate, or by itself.
lever: something that moves an object by rest-
isolation precautions: method of infection
ing on a base of support.
control used when caring for persons who
are infected or suspected of being infected liability: a legal term that means someone can
with a disease; also called transmission-based be held responsible for harming someone else.
precautions. lithotomy: position in which a person lies on
jaundice: a condition in which the skin, whites her back with her hips at the end of an exam
of the eyes, and mucous membranes appear table; legs are flexed, and feet are in padded
yellow. stirrups.
joint: the place at which two bones meet. living will: a document that states the medical
Joint Commission: an independent, not-for- care a person wants, or does not want, in case he
profit organization that evaluates and accredits or she becomes unable to make those decisions
healthcare organizations. for him- or herself.

Kaposi’s sarcoma: a rare form of skin cancer localized infection: an infection that is con-
that appears as purple or red skin lesions. fined to a specific location in the body and has
local symptoms.
karma: the belief that all past and present deeds
affect one’s future and future lives. lock arm: position in which the caregiver places
his arm under the person’s armpit, grasping the
kidney dialysis: an artificial means of remov-
person’s shoulder, while the person grasps the
ing the body’s waste products.
caregiver’s shoulder; also called arm lock.
Glossary 510

logrolling: method of moving a person as a Medicare: a federal health insurance program

unit, without disturbing the alignment of the for people who are 65 or older, are disabled, or
body. are ill and cannot work.
long-term care (LTC): care given in long-term menopause: the end of menstruation.
care facilities (LTCF) for people who need 24-
mental health: a general term that refers to the
hour, supervised nursing care.
normal functioning of emotional and intellec-
lung cancer: the development of abnormal cells tual abilities.
or tumors in the lungs.
mental illness: a disease that affects a person’s
lymph: a clear yellowish fluid that carries dis- ability to function at a normal level in the family,
ease-fighting cells called lymphocytes. home, or community; often produces inappropri-
malabsorption: inability to absorb or digest a ate behavior.
particular nutrient properly. metabolism: physical and chemical processes
malignant tumors: tumors that are considered by which substances are produced or broken
to be cancerous. down into energy or products for use by the
body.
malnutrition: poor nutrition due to improper
diet. microbe: a living thing or organism that is so
malpractice: injury to a person due to profes- small that it can be seen only through a micro-
sional misconduct through negligence, careless- scope; also called microorganism.
ness, or lack of skill. microorganism: a living thing or organism that
managed care: a system or strategy of manag- is so small that it can be seen only through a mi-
ing health care in a way that controls costs. croscope; also called microbe.

mandated reporters: people who are legally re- Minimum Data Set (MDS): a detailed form
quired to report suspected or observed abuse or with guidelines for assessing residents in long-
neglect because they have regular contact with term care facilities; also details what to do if resi-
vulnerable populations, such as the elderly in dent problems are identified.
facilities. mode of transmission: method of describing
mastectomy: the surgical removal of all or part how a pathogen travels from one person to the
of the breast and sometimes other surrounding next person.
tissue. modified diets: diets for people who have cer-
masturbation: to touch or rub sexual organs in tain illnesses; also called special or therapeutic
order to give oneself or another person sexual diets.
pleasure.
MRSA: stands for methicillin-resistant Staphy-
mechanical ventilation: the use of a machine lococcus aureus, an antibiotic-resistant infection
to assist with or replace breathing (inflate and often acquired by people in hospitals and other
deflate the lungs) when a person is unable to do healthcare facilities who have weakened immune
this on his own. systems.
Medicaid: a medical assistance program for low- mucous membranes: the membranes that line
income people. body cavities, such as the mouth, nose, eyes, rec-
medical asepsis: the process of remov- tum, or genitals.
ing pathogens, or the state of being free of
pathogens.
 511

Glossary
multidrug-resistant organisms (MDROs): mi- nephritis: an inflammation of the kidneys.
croorganisms, mostly bacteria, that are resistant
neuropathy: numbness, tingling, and pain in
to one or more antimicrobial agents.
the feet and legs.
multidrug-resistant TB (MDR-TB): type of TB
nitroglycerin: medication that helps to relax the
that can develop when a person with active TB
walls of the coronary arteries, allowing them to
does not take all the prescribed medication.
open and get more blood to the heart; comes in
multiple sclerosis (MS): a progressive disease tablet, patch or spray form.
of the nervous system in which the protective
non-intact skin: skin that is broken by abra-
covering for the nerves, spinal cord, and white
sions, cuts, rashes, acne, pimples, or boils.
matter of the brain breaks down over time; with-
out this covering, nerves cannot send messages nonspecific immunity: a type of immunity that
to and from the brain in a normal way. protects the body from disease in general.
muscles: groups of tissues that provide move- nonverbal communication: communicating
ment of body parts, protection of organs, and without using words.
creation of body heat. non-weight bearing: unable to support any
muscular dystrophy: an inherited, progressive weight on one or both legs.
disease that causes a gradual wasting of muscle,
nutrient: something found in food that provides
weakness, and deformity.
energy, promotes growth and health, and helps
myocardial infarction (MI): a condition that regulate metabolism.
occurs when the heart muscle does not re-
nutrition: how the body uses food to maintain
ceive enough oxygen because blood vessels are
health.
blocked; also called a heart attack.
objective information: information based on
nasal cannula: a device used to deliver oxygen,
what a person sees, hears, touches, or smells.
which consists of a piece of plastic tubing that
fits around the face and is secured by a strap obsessive compulsive disorder: a disorder in
that goes over the ears and around the back of which a person uses obsessive behavior to cope
the head. with anxiety.
nasogastric tube: a feeding tube that is in- obstructed airway: a condition in which the
serted into the nose and goes to the stomach. tube through which air enters the lungs is
blocked.
nearsightedness: the ability to see things near
but not far. occult: hidden; difficult to see or observe.
neglect: harming a person physically, mentally, Occupational Safety and Health Administra-
or emotionally by failing to provide needed care. tion (OSHA): a federal government agency that
negligence: actions, or the failure to act or pro- makes rules to protect workers from hazards on
vide the proper care, that result in unintended the job.
injury to a person. occupied bed: a bed made while a person is in
neonatal: pertaining to a newborn infant. the bed. An unoccupied bed is a bed made while
no resident is in the bed.
neonate: a newborn baby.
ombudsman: the legal advocate for residents;
neonatologists: doctors who specialize in car-
helps resolve disputes and settle conflicts.
ing for newborn babies.
Glossary 512

Omnibus Budget Reconciliation Act (OBRA): palliative care: care that focuses on the comfort
law passed by the federal government that in- and dignity of the person rather than on curing
cludes minimum standards for nursing assistant him or her.
training, staffing requirements, resident assess-
panic disorder: a disorder in which a person is
ment instructions, and information on rights for
terrified for no apparent reason.
residents.
paralysis: the loss of ability to move all or part
onset: in medicine, the first appearance of the
of the body, and often includes loss of feeling in
signs or symptoms of an illness.
the affected area.
open bed: a bed made with linen fanfolded
paranoid schizophrenia: a brain disorder that
down to the foot of the bed.
centers mainly on hallucinations and delusions.
open fracture: a broken bone that penetrates
paraplegia: loss of function of the lower body
the skin; also known as a compound fracture.
and legs.
opportunistic infections: infections that in-
Parkinson’s disease: a progressive disease that
vade the body when the immune system is weak
causes the brain to degenerate; causes stooped
and unable to defend itself.
posture, shuffling gait, pill-rolling, and tremors.
oral care: care of the mouth, teeth, and gums.
partial bath: a bath that includes washing the
organ: a structural unit in the human body that face, hands, underarms, and perineum; is given
performs a specific function. on days when a complete bed bath, tub bath, or
shower is not done.
orthotic device: a device that helps support and
align a limb and improve its functioning and partial weight bearing: able to support some
helps prevent or correct deformities. weight on one or both legs.
osteoarthritis: a common type of arthritis that passive neglect: unintentionally harming a
usually affects the hips, knees, fingers, thumbs, person physically, mentally, or emotionally by
and spine. failing to provide needed care.
osteoporosis: a disease that causes bones to be- passive range of motion (PROM) exercises:
come porous and brittle. range of motion exercises performed by another
person, without the affected person’s help.
ostomy: a surgically-created opening from an
area inside the body to the outside. pathogens: harmful microorganisms.
outpatient care: care given for less than 24 payers: people or organizations paying for
hours for people who have had treatments or healthcare services.
surgery and need short-term skilled care.
pediculosis: an infestation of lice.
output: all fluid that is eliminated from the
peptic ulcers: raw sores in the stomach or the
body; includes fluid in urine, feces, vomitus,
small intestine that cause pain, belching, and
perspiration, and moisture in the air that is
vomiting.
exhaled.
percutaneous endoscopic gastrostomy (PEG)
oxygen concentrator: a box-like device that
tube: a tube placed through the skin directly
changes air in the room into air with more
into the stomach to assist with eating.
oxygen.
perineal care: care of the genitals and anal area.
oxygen therapy: the administration of oxygen
to increase the supply of oxygen to the lungs. perineum: the genital and anal area.
 513

Glossary
peripheral nervous system: part of the ner- portal of exit: any body opening on an infected
vous system made up of the nerves that extend person that allows pathogens to leave.
throughout the body.
positioning: the act of helping people into posi-
peripheral vascular disease (PVD): a disease tions that will be comfortable and healthy for
in which the legs, feet, arms, or hands do not them.
have enough blood circulation due to fatty de-
postmortem care: care of the body after death.
posits in the blood vessels that harden over time.
postoperative: after surgery.
peristalsis: involuntary contractions that move
food through the gastrointestinal system. postpartum depression: a type of depression
that occurs after giving birth.
perseveration: repeating words, phrases, ques-
tions, or actions. post traumatic stress disorder: an anxiety-
related disorder brought on by a traumatic
personal: relating to life outside one’s job, such
experience.
as family, friends, and home life.
posture: the way a person holds and positions
personal protective equipment (PPE): equip-
his body.
ment that helps protect employees from serious
workplace injuries or illnesses resulting from powdered formula: a type of formula for in-
contact with workplace hazards. fants that is sold in cans and is measured and
mixed with sterile water.
phantom sensation: pain or feeling from a
body part that has been amputated; caused by pre-diabetes: a condition that occurs when a
remaining nerve endings. person’s blood glucose levels are above normal
but not high enough for a diagnosis of Type 2
phlegm: thick mucus from the respiratory
diabetes.
passage.
preferred provider organizations (PPOs):
phobia: an intense form of anxiety.
a network of providers that contract to provide
physical abuse: any treatment, intentional health services to a group of people.
or not, that causes harm to a person’s body;
prehypertension: a condition in which a per-
includes slapping, bruising, cutting, burning,
son has a systolic measurement of 120–139 mm
physically restraining, pushing, shoving, or even
Hg and a diastolic measurement of 80–89 mm
rough handling.
Hg; indicator that the person does not have high
pillaging: taking things that belong to someone blood pressure now but is likely to have it in the
else. future.
pneumonia: a bacterial, viral, or fungal infec- premature: term for babies who are born before
tion that causes acute inflammation in a portion 37 weeks gestation (more than three weeks be-
of lung tissue. fore the due date).
policy: a course of action that should be taken preoperative: before surgery.
every time a certain situation occurs.
prepared formula: a type of formula for infants
portable commode: a chair with a toilet seat that is sold in bottles or cans and is ready to use.
and a removable container underneath; used for
elimination. pressure points: areas of the body that bear
much of its weight.
portal of entry: any body opening on an unin-
fected person that allows pathogens to enter.
Glossary 514

pressure sore: a serious wound resulting from quadriplegia: loss of function of the legs,
skin breakdown; also called bed sore or decubi- trunk, and arms.
tus ulcer. rabbi: religious leader of the Jewish faith.
procedure: a method, or way, of doing radial pulse: the pulse located on the inside of
something. the wrist, where the radial artery runs just be-
professional: having to do with work or a job. neath the skin.
professionalism: how a person behaves when range of motion (ROM) exercises: exercises
on the job; it includes how a person dresses, the that put a joint through its full arc of motion.
words he uses, and the things he talks about. ready-to-feed: a type of formula for infants that
progressive: term used to mean that a disease is sold in bottles or cans and is ready to use.
gets worse, causing greater and greater loss of receptive aphasia: inability to understand spo-
health and abilities. ken or written words.
pronation: turning downward. rehabilitation: care given in facilities or homes
prone: position in which a person is lying on his by a specialist to restore or improve function
stomach. after an illness or injury.
prosthesis: a device that replaces a body part reincarnation: a belief that some part of a living
that is missing or deformed because of an ac- being survives death to be reborn in a new body.
cident, injury, illness, or birth defect; used to renovascular hypertension: a condition in
improve a person’s ability to function and/or his which a blockage of arteries in the kidneys
appearance. causes high blood pressure.
protected health information (PHI): a per- repetitive phrasing: repeating words, phrases,
son’s private health information, which includes or questions.
name, address, telephone number, social secu-
rity number, e-mail address, and medical record reproduce: to create new life.
number. reservoir: a place where a pathogen lives and
providers: people or organizations that provide grows.
health care, including doctors, nurses, clinics, residents’ rights: numerous rights identified
and agencies. in the OBRA law that relate to how residents
psychosocial: having to do with social interac- must be treated while living in a facility; they
tion, emotions, intellect, and spirituality. provide an ethical code of conduct for healthcare
workers.
psychological abuse: any behavior that causes
a person to feel threatened, fearful, intimidated, resistant: state in which drugs no longer work
or humiliated in any way; includes verbal abuse, to kill specific bacteria.
social isolation, and seclusion. respiration: the process of breathing air into the
pulse oximeter: a device that measures a per- lungs and exhaling air out of the lungs.
son’s blood oxygen level and pulse rate. restraint: a physical or chemical way to restrict
puree: to chop, blend, or grind food into a thick voluntary movement or behavior.
paste of baby food consistency. restraint alternatives: any intervention used in
quad cane: cane that has four rubber-tipped feet place of a restraint or that reduces the need for a
and a rectangular base. restraint.
 515

Glossary
restraint-free: the state of being free of re- sexually transmitted diseases (STDs): dis-
straints and not using restraints for any reason. eases caused by sexual contact with an infected
restrict fluids: a medical order that limits the person; also called venereal diseases.
amount of fluids a person takes in. sexually transmitted infections (STIs): infec-
tions caused by sexual contact with an infected
résumé: a summary or listing of relevant job
person; a person may be infected, and may po-
experience and education; also called also “cur-
tentially infect others, without showing signs of
riculum vitae” or “CV.”
the disease.
rheumatoid arthritis: a type of arthritis in
sharps: needles or other sharp objects.
which joints become red, swollen, and very pain-
ful, and movement is restricted. shearing: rubbing or friction that results from
the skin moving one way and the bone under-
rigor mortis: the Latin term for the temporary
neath it remaining fixed or moving in the oppo-
condition after death in which the muscles in
site direction.
the body become stiff and rigid.
shingles: non-contagious skin rash caused by
rotation: turning a joint.
the varicella-zoster virus (VZV), which is the
routine urine specimen: a urine specimen that same virus that causes chickenpox; causes pain,
can be collected any time a person voids. tingling, or itching in an area, which later devel-
ops into a rash of fluid-filled blisters.
safety razor: a type of razor that has a sharp
blade with a special safety casing to help prevent shock: a condition that occurs when organs and
cuts; requires the use of shaving cream or soap. tissues in the body do not receive an adequate
blood supply.
scabies: contagious skin condition caused by a
tiny mite burrowing into the skin, where it lays shower chair: a sturdy, water- and slip-resistant
eggs; causes intense itching and a skin rash that chair designed to be placed in a tub or shower.
may look like thin burrow tracks. simple carbohydrates: carbohydrates that are
scalds: burns caused by hot liquids. found in foods such as sugars, sweets, syrups,
and jellies and have little nutritional value.
scope of practice: defines the things that
healthcare providers are legally allowed to do Sims’: position in which a person is in a left
and how to do them correctly. side-lying position; lower arm is behind the back
and the upper knee is flexed and raised toward
sedative: an agent or drug that helps calm and
the chest.
soothe a person and may cause sleep.
situation response: a temporary condition that
sexual abuse: forcing a person to perform or
may be caused by a crisis, temporary changes in
participate in sexual acts against his or her will;
the brain, side effects from medications, interac-
includes unwanted touching, exposing oneself,
tions among medications, or severe change in
and sharing pornographic material.
the environment.
sexual harassment: any unwelcome sexual sitz bath: a warm soak of the perineal area
advance or behavior that creates an intimidat- given to clean perineal wounds and reduce in-
ing, hostile, or offensive working environment; flammation and pain.
includes requests for sexual favors, unwanted
touching, and other acts of a sexual nature. skilled care: medically necessary care given by
a skilled nurse or therapist; is available 24 hours
a day.
Glossary 516

slide board: a wooden board that helps transfer substance abuse: the use of legal or illegal
people who are unable to bear weight on their drugs, cigarettes, or alcohol in a way that is
legs; also called a transfer board. harmful to the abuser or to others.
special diets: diets for people who have certain sudden infant death syndrome (SIDS): the
illnesses; also called therapeutic or modified sudden and unexpected death of a baby for no
diets. known reason, usually during sleep.
specific immunity: a type of immunity that suffocation: death from a lack of air or oxygen.
protects against a particular disease that is in- sundowning: becoming restless and agitated in
vading the body at a given time. the late afternoon, evening, or night.
specimen: a sample that is used for analysis in supination: turning upward.
order to try to make a diagnosis.
supine: position in which a person lies flat on
sphygmomanometer: a blood pressure cuff. his back.
spiritual: of, or relating to, the spirit or soul. suppository: a medication given rectally to
sputum: the fluid a person coughs up from the cause a bowel movement.
lungs. surgical asepsis: the state of being free of all
standard precautions: a method of infection microorganisms, not just pathogens; also called
control in which all blood, body fluids, non-in- sterile technique.
tact skin, and mucous membranes are treated as surgical bed: a bed made to easily accept resi-
if they were infected with an infectious disease. dents who must return to bed on stretchers.
sterilization: a measure that destroys all micro- susceptible host: an uninfected person who
organisms, including pathogens. could get sick.
stethoscope: an instrument designed to listen sympathy: sharing in the feelings and difficul-
to sounds within the body. ties of others.

stoma: an artificial opening in the body. syphilis: sexually transmitted disease that can
cause chancres on the penis and, if untreated,
straight catheter: a catheter that does not re-
rash, sore throat, or fever.
main inside the person; it is removed immedi-
ately after urine is drained. systemic infection: an infection that is in the
bloodstream and is spread throughout the body,
stress: the state of being frightened, excited,
causing general symptoms.
confused, in danger, or irritated.
systole: phase where the heart is at work,
stressor: something that causes stress.
contracting and pushing blood out of the left
subacute care: care given in a hospital or in a ventricle.
long-term care facility for people who have had systolic: first measurement of blood pressure;
an acute injury or illness or problem resulting phase when the heart is at work, contracting and
from a disease. pushing the blood from the left ventricle of the
subjective information: information that a heart.
person cannot or did not observe, but is based tact: the ability to understand what is proper
on something reported to the person that may or and appropriate when dealing with others; being
may not be true. able to speak and act without offending others.
 517

Glossary
telemetry: the application of a cardiac moni- Type 1 diabetes: type of diabetes in which the
toring device that sends information about the body does not produce enough insulin; is usu-
heart’s rhythm and rate to a monitoring station. ally diagnosed in children and young adults and
will continue throughout a person’s life.
terminal illness: a disease or condition that will
eventually cause death. Type 2 diabetes: common form of diabetes in
which either the body does not produce enough
therapeutic diets: diets for people who have
insulin or the body fails to properly use insulin;
certain illnesses; also called special or modified
typically develops after age 35 and is the milder
diets.
form of diabetes.
tissues: groups of cells that perform similar
ulceration: scarring.
tasks.
ulcerative colitis: a chronic inflammatory
total parenteral nutrition (TPN): the intrave-
disease of the large intestine; causes cramp-
nous infusion of nutrients administered directly
ing, diarrhea, pain, rectal bleeding, and loss of
into the bloodstream, bypassing the digestive
appetite.
tract.
umbilical cord: the cord that connects a baby to
tracheostomy: a surgically-created opening
the placenta inside the mother’s uterus.
through the neck into the trachea.
unoccupied bed: a bed made while nobody is
transfer belt: a belt made of canvas or other
in the bed.
heavy material used to assist people who are who
are weak, unsteady, or uncoordinated; also called upper respiratory infection (URI): a bacte-
a gait belt. rial or viral infection of the nose, sinuses, and
throat; commonly called a cold.
transfer board: a wooden board that helps
transfer people who are unable to bear weight on ureterostomy: surgically created opening
their legs; also called a slide board. from an ureter to the abdomen for urine to be
eliminated.
transient ischemic attack: a warning sign of a
CVA/stroke resulting from a temporary lack of urinary incontinence: the inability to control
oxygen in the brain; symptoms may last up to 24 the bladder, which leads to an involuntary loss of
hours. urine.

transmission: passage or transfer. urinary tract infection (UTI): inflammation

of the bladder and the ureters that results in a
transmission-based precautions: method of painful burning during urination and the fre-
infection control used when caring for persons quent feeling of needing to urinate; also called
who are infected or suspected of being infected cystitis.
with a disease; also called isolation precautions.
urination: the act of passing urine from the
trauma: severe injury. bladder through the urethra to the outside of the
triggers: situations that lead to agitation. body; also known as micturition or voiding.

tuberculosis: an airborne disease carried on vaginitis: an infection of the vagina that may
very small mucous droplets suspended in the be caused by a bacteria, protozoa (one-celled ani-
air. mals), or fungus (yeast).

tumor: a group of abnormally growing cells. validating: giving value to or approving.

Glossary 518

vegans: people who do not eat or wear any ani-

mals or animal products.
vegetarians: people who do not eat meat, fish,
or poultry and who may or may not eat eggs and
dairy products.
verbal abuse: the use of language—spoken or
written—that threatens, embarrasses, or insults
a person.
verbal communication: communicating using
words or sounds, spoken or written.
vital signs: measurements that show how well
the vital organs of the body are working; consist
of body temperature, pulse, respirations, blood
pressure, and level of pain.
VRE: vancomycin-resistant enterococcus, a geneti-
cally changed strain of enterococcus that origi-
nally developed in people who were exposed to
the antibiotic vancomycin.
walker: adaptive equipment used for people who
are unsteady or who lack balance; usually has
four rubber-tipped feet and/or wheels.
workplace violence: verbal, physical, or
sexual abuse of staff by residents or other staff
members.
wound: a type of injury to the skin.
yarmulke: a small skullcap worn by Jewish men
as a sign of their faith.
 519

Index
Index active neglect
active range of motion (AROM)
25 for sense organs
for urinary system
134
138
exercises 381 agitated 356
active TB 73 agnostic 115
24-hour urine specimen 291 activities director 11 AIDS, see acquired immune deficiency
procedure for collecting 291-292 syndrome (AIDS)
activities of daily living (ADLs) 4, 10
abbreviations 41, 496-498 and Alzheimer’s disease 353-356 AIDS dementia complex 337
abdominal pads 244 NA’s role 193-195 airborne infection isolation room
abdominal thrusts activity (AIIR) 73
defined 95 and bowel elimination 297 airborne precautions 67-68
procedure for 95 and MyPyramid 254 alcohol
abduction 381 benefits of 115-116 and residents’ rights 373
abrasion 59, 80, 311 need for 115-116 alignment 86
abuse activity therapy and body mechanics 87
defined 25 and Alzheimer’s disease 362-363 guidelines for proper 379
observing and reporting 26-27 acute care 2 alternative medicine 318
reporting of 26, 27 acute conditions 310 Alzheimer’s Association 348, 364
sexual 25
adaptive devices, see also assistive Alzheimer’s disease
signs of 26-27 devices 10, 167, 215, 262, 378 defined 348
suspected abuse by NA 28-29
additive 199 and ADLs 353-356
types of 25-26
adduction 381 and independence 349
abuse registry 28 and nutritional problems 355-356
admitting a resident
acceptance and personal care 353
guidelines for 172-174
as a stage of grief 397 and Residents’ Rights 355
NA’s role in 172-174
accidents and safety in the home 360-361
procedure for 174
common types 77-80 caregiver attitudes 350-351
adolescence 120-121 common difficult behaviors 356-360
guidelines for preventing 78-80
common disorders of 121
in the home, guidelines for 421-425 communication strategies 351-353
adult daycare 2 community resources 364
accommodations 24
Adult Protective Service (APS) 27 effects on family 363-364
ACE bandages, see also elastic
adulthood 121-122 nonverbal communication 353
bandages 245
stages of 349-350
acquired immune deficiency advance directives 31-32
symptoms 348
syndrome (AIDS) and CPR 94
therapies for 361-363
defined 337 and the dying resident 399
ambulation
and dementia 337 AED (automated external
defined 166
and infection control 338, 340 defibrillator) 94
procedure for assisting with 167-168
and opportunistic infections 338 affected side 214
and residents’ rights 338 ambulatory 166
ageism 122
confidentiality 339 a.m. care, see also personal care 193
aging, normal changes of 123, 346
diet 339 Americans with Disabilities Act 24
and bowel elimination 296
emotional support 339 amputation
and urination 275-276
guidelines for care 338-339 defined 318
for cardiovascular system 136
high-risk behaviors 338 guidelines for care 380
for endocrine system 141
signs and symptoms 337-338
for gastrointestinal system 139 anal incontinence 140
testing 340
for immune system 145 anatomical terms
transmission of 337
for integumentary system 128-129 of location 127-128
ways to protect against spread 338
for musculoskeletal system 130
active assisted range of motion anesthesia
for nervous system 132
(AAROM) exercises 381 defined 386-387
for reproductive system 143
types of 387
active listening 37 for respiratory system 137
Index 520

anger atrophy battery 25

as stage of grief 396 and inactivity 130 bed
guidelines for communication 53 as result of restraint use 84 types of 184
angina pectoris attitude bed bath
defined 325 and Alzheimer’s disease 350-351 procedure for giving 200-203
guidelines for care 325 of the NA 12, 209, 319
bed cradle 198
angry behavior autoimmune illness 312
bedmaking
guidelines for handling 53 automobile closed bed 191
anorexia 121 guidelines for using on the job 426 guidelines for bedmaking 187-188
anti-embolic stockings procedure for transferring open bed 191
resident into 165-166
procedure for putting on 327-328 procedure for occupied bed 188-190
reducing risk of accidents 426
antimicrobial 61 procedure for surgical bed 191-192
axillae 199 procedure for unoccupied
anxiety 368
axillary bed 190-191
anxiety-related disorders 368-369
procedure for measuring and bedpan 276
apathy 369 recording temperature 229-230 procedure for assisting with 278-279
apical pulse 231 baby bed rest 436
procedure for measuring and feeding: see “breastfeeding” or
“bottle feeding”
bed sore, see pressure sore
recording 231-232
guidelines for bathing 443-444 benign prostatic hypertrophy 336
apnea 450
guidelines for safe handling 438 benign tumor 340
appetite
procedure for burping 442-443 bias 34
guidelines for promoting 262
procedure for changing cloth or
Aquamatic K-Pad ® disposable diapers 446-447 binders 244
procedure for applying 240 procedure for holding 438-439 biohazard container 60, 72
arthritis procedure for measuring length 448 bipolar disorder 370
defined 312 procedure for measuring weight 447 bisexual 112
guidelines for care 313 procedure for sponge bath 444-445
blackouts
types of 312-313 procedure for sterilizing bottles 442
guidelines for responding to 105-106
artificial airway procedure for taking axillary or
tympanic temperature 449 bladder retraining
defined 390
procedure for tub bath 445 guidelines for assisting 294-295
guidelines for care 390-391
back rub bland diet 259
artificial eye
procedure for 203-204 bleeding
care of 380
bandages procedure for controlling 98
aspiration
cotton 244 blood cells 134-135
defined 217
elastic 245
guidelines for preventing 268-269 blood glucose monitoring 333
bargaining blood oxygen level 389
assault 25
as stage of grief 396
assertive 53 blood pressure
barriers diastolic 233
assessment PPE 62-65
factors affecting 233
as part of nursing process 16-17 to communication 35-36
normal range 223, 233
assisted living 2 base of support 86 procedure for one-step
assistive devices, see also adaptive baseline 174 method 234-235
devices procedure for two-step
bathing method 235-236
defined 10
additives 199-200 systolic 233
and arthritis 313
and Alzheimer’s disease 354
for ADLs 378 bloodborne pathogens 70
guidelines 200
for ambulation 167-170 Bloodborne Pathogens Standard 71
guidelines for safety 207
for eating 267 guidelines for employers 72
procedure for bed bath 200-203
asthma 329 procedure for shower or tub 207-208 body fluids 59
atheist 115 bathroom body language 34
procedure for cleaning 472
 521

Index
body mechanics C cane 168 center of gravity 87
defined 86 calculi 284 Centers for Disease Control and
applied to daily activities 87-88 Prevention (CDC) 59
call lights 48
guidelines for proper 146-147
and residents’ rights 376 Centers for Medicare & Medicaid
in the home 420-421
as a part of standard unit Services (CMS) 6
body positions equipment 185
central nervous system (CNS) 131
five basic 148-149 placement of 147
cerebellum 132
body system, see individual systems cancer
cerebral palsy
body temperature, see also guidelines for care 341-342
guidelines for care 125
temperature 223-230 observing and reporting 342
risk factors 340 cerebrovascular accident (CVA)
bones 129
treatments 341 defined 51
bony prominences 195 communication and 51-52
warning signs 340-341
bottle feeding effects of 51
car, see automobile
procedure for assisting 442 guidelines for care 319-320
carbohydrates
procedure for sterilizing bottles 442 signs and symptoms of 103
sources of 250
types of formula 441 cerebrum 131-132
types of 250
bowel elimination certification
cardiopulmonary resuscitation
defined 296 general guidelines 490-491
(CPR) 92
factors affecting 296-298
certified nursing assistant, see also
guidelines for retraining 308-309 cardiovascular system
nursing assistant
privacy and 297 common disorders 324-328
educational requirements 490-491
NA’s role in assisting with 136
bowel retraining Cesarean section 437
normal changes of aging 136
and residents’ rights 308
observing and reporting 136 chain of command 14
guidelines for 308-309
structure and function 134-136 chain of infection
brachial pulse 231
care plan defined 57
Braille 324 breaking 58
formulation of 16-17
brain in home health setting 409-410 chancres 335
normal changes of aging 346 NA’s role in 16
chart
parts of 131-132 purpose of 16
information found in 43
brainstem 132 care procedures
charting
BRAT diet beginning steps 147
defined 12
and diarrhea 299 ending steps 147-148
guidelines for careful 44
and HIV/AIDS 339 care team 9-11 reasons for careful 44
breastfeeding careers chemical restraint 83
guidelines for assisting 439-441 in healthcare field 483-484
chest tubes
bronchiectasis 330 cast defined 393
bronchitis 328 guidelines for care 314-315 guidelines for care 394
Buddhism 114 cataract 323-324 Cheyne-Stokes respiration 403
bulimia 121 catastrophic reaction 357 chickenpox 120
burnout 493 catheter child abuse
burns defined 4 defined 452
as a sign of abuse and neglect 26 guidelines for care 286 observing and reporting 453
guidelines for preventing 79 observing and reporting 286
child neglect 452
in the home 99 procedure for applying condom
catheter 288-289 childhood
procedure for treating 100
procedure for care 286-287 common disorders of 120
types of 99
procedure for emptying bag 287-288 children
canes types of 285 and stress 450
guidelines for use 168
causative agent 57 common illnesses 451
procedure for assisting
guidelines for working with 451-452
resident 168-170 cells 127
special needs of 450
types of 168
Index 522

chlamydia 335 closed bed 191 competency evaluation

choking closed fracture 314 for the NA 490
preventing 80 NATCEP 28
Clostridium difficile (C-diff or
procedure for clearing C. difficile) 74-75 complementary medicine 318
obstructed airway 95
code of ethics 21 complex carbohydrates 250
Christianity 114
cognition 346 computers
chronic 1 and HIPAA 31
cognitive impairment 346
chronic conditions 310 guidelines for using 48
cold applications
chronic kidney failure 285 concentrated formula 441
benefits of 237
chronic obstructive pulmonary procedures for 242-243 condom catheter
disease (COPD) risks of 237 defined 285
defined 328 types of 238 procedure for applying 288-289
guidelines for care 329 confidentiality
cold compress
observing and reporting 329 and HIPAA 29-30
procedure for applying 242-243
signs and symptoms 328-329 and HIV/AIDS 339-340
colitis 299
chronic renal failure 285 and residents’ rights 23
colorectal cancer 300
cigarettes NA’s role 30-31
colostomy 300, 306
and fire prevention 81, 89 conflict
combative 52 guidelines for resolving 488-489
circadian rhythm 186
combative behavior confusion
circulatory system, see cardiovascular
guidelines for handling 52-53 defined 346
system
circumcision 449 combustion 81 common causes 346
comfort guidelines for care 346-347
cite 6
guidelines for promoting 183-184 congestive heart failure
claustrophobia 369
commercial enema 300 defined 326
clean 56 guidelines for care 326-327
procedure for giving 303-304
clean catch specimen signs and symptoms 326
communication
defined 290 conscientious 13
defined 33
procedure for collecting 290-291
active listening 37 conscious 91
cleaning and cultural considerations 34-35 constipation
guidelines for bathroom 471 and CVA 51-52 defined 298
guidelines for kitchen 470-471 and documentation 42-44 and diet 260, 297
guidelines for living areas 469 and incident reporting 45 signs of 298
guidelines for storage areas 472-473 and mechanical ventilator 392
preparing a schedule 473 constrict 128
and tracheostomy 391
procedure for bathroom 472 contact lenses 323
barriers to 35-36
see also “laundry” body language 34 contact precautions 68-69
cleaning products by telephone 45, 47 continuing education 491
guidelines for use in home 468 medical terminology 40-41 contracture 130
types of 468 nonverbal 34
conversion tables 269-270, 500
cleaning tools 468 techniques for accurate 37-39
for liquid and dry measures 465, 500
types of 34
cleansing enema converting units of measure 269
verbal 34
procedure for giving 301-303
with residents’ families 39 COPD, see chronic obstructive
cliché 36 pulmonary disease
with residents with special
client needs 48-54 core values 7
and infection control 418-420 with team members 40, 42
coronary artery disease (CAD) 325
and money management 481-482 community resources
as part of the care team 410
cough etiquette 68
for people who are ill 343
rights 414-416 for people with Alzheimer’s 364
cover letter 485
safety 421-426 for the elderly 126 crime
Client Bill of Rights 415-416 guidelines for high-crime areas 427
compassionate 13
in the healthcare setting 21
 523

Index
critical thinking delirium 347 diarrhea
and the NA 42 delusion defined 298
criticism and Alzheimer’s disease 358 and BRAT diet 299
tips for handling 489-490 dementia diastole 135
types of 489 defined 347 diastolic pressure 233
crutches common causes of 348 normal range 223
procedure for assisting with 168-170 denial dietary department
cues as stage of grief 396 and diet cards 257
and assisting with eating 266-267 see also defense mechanisms role of 257
and promoting independence 266 dental floss 218 dietary restriction 115
cultural diversity 34 dentures diet cards 257
culture defined 220 diets, see special diets
defined 34 procedure for cleaning 220
digestion 138
accommodating differences 113-114 removing and reinserting 221
digestive system, see gastrointestinal
and communication 34-35, 37 depression
system
and diet 115, 256-257 and Alzheimer’s disease 359
and eye contact 35 dignity
and loss 110, 111
and language 36, 37 and dying resident 400-401
as stage of grief 396
and touch 35 and personal care 194
guidelines for communication 368
and residents’ rights 23, 111
culture change 7 symptoms of 369
and sexual needs 112
CVA, see cerebrovascular accident types of 370
dilate 128
cyanotic 40 dermatitis
defined 311 direct contact 57
cystitis 283
atopic 311-312 dirty
dandruff 213
stasis 312 defined 56
dangle items in the home 418
dermis 128
defined 155
development, human disaster
procedure for assisting with 155-157
and common disorders 118-122 general guidelines 104-106
death and dying guidelines for home care 106
stages of 118-122
and hospice care 401-403 types of 104-106
developmental disabilities
feelings and attitudes about 397-398
defined 123 discharging a resident
guidelines for caring for dying
common types of 123-125 NA’s role in 178
resident 398-399
guidelines for care 123-125 procedure for 179
legal rights and 400-401
physical changes after 403 diabetes disinfection
postmortem care 403-404 defined 331 defined 66
signs of impending 403 and diet 259-260 in the home 418
complications of 102, 332 procedure using dry heat 419
decubitus ulcer, see pressure sore
gestational 332 procedure using wet heat 419
deep breathing exercises
guidelines for care 332-333 disorientation 78
benefits of 385
observing and reporting 333 disposable 66
defecation
pre-diabetes 332
defined 296 disposable razor 211
procedure for foot care 334
factors affecting 296-298 disruptive behavior
signs and symptoms 332
see also bowel elimination and Alzheimer’s disease 359-360
type 1 331
defense mechanisms 368 type 2 331-332 diuretics 258
degenerative 347 diabetes mellitus, see diabetes DNR (do not resuscitate) 31
dehydration diabetic coma, see diabetic doctor, see physician
defined 58 ketoacidosis documentation
guidelines for preventing 272 and computers 48
diabetic ketoacidosis (DKA) 102
observing and reporting 272 guidelines for 44
diagnosis
warning signs of 272 see also charting
as part of nursing process 17
delegation 11
Index 524

domestic violence 25 edentulous 217 ethics

do-not-resuscitate (DNR) order 31 elastic bandages defined 20
guidelines for use 245 guidelines for ethical behavior 20-21
dorsal recumbent position 180
elastic stockings evaluation
dorsiflexion 381
procedure for applying 327-328 as part of nursing process 17
douche
elderly exchange lists 258
defined 336
guidelines for 336-337 resources available for 126 exercise
electric razor 211 basic principles 377-378
Down syndrome 124-125
procedure for assisting with 211-213 benefits of 377
guidelines for care 125
elimination expiration 136
draw sheet
defined 150 defined 138 exposure control plan 72
procedure for assisting resident to rights with 278 expressive aphasia 51
move up in bed 150-152 see also bowel elimination and
extension 381
procedure for moving resident to side urination
of bed 152-153 eyeglasses 323, 380
elope 358
dressing face shield 65
emergencies, medical, see also
and Alzheimer’s disease 354-355 specific emergency facility
and assistive devices 378 defined 1
emesis
guidelines for assisting with 214-215 assisted living 2
defined 104
procedure for resident with affected extended care 1
procedure for assisting a resident who
right arm 215-216 long-term care 1
has vomited 104
procedure for resident who rehabilitation 1
see also vomiting
has an IV 246-247
emotional lability 51 residential 1
with one-sided weakness 320
skilled nursing 1
dressings emotional needs
responding to 117-118 fact
non-sterile 243
vs. opinion 39
procedure for non-sterile 243-244 empathy 13
sterile 244-245 fainting 100
emphysema 328
procedure for responding to 101
droplet precautions 68 employee evaluation 489-490
fallacy 367
drug misuse and abuse endocrine system
observing and reporting 434 falls
common disorders 331-335
signs of 434 assisting resident 159
NA’s role in assisting with 141
guidelines for preventing 77-79
durable power of attorney for health normal changes of aging 141
care 31 observing and reporting 141 family
structure and function 140-141 as members of care team 11
dying resident
communicating with 39
guidelines for care 398-399 enema
emotional needs of 117-118
legal rights 400-401 defined 298
NA’s role 117-118
see also death and dying guidelines for 301
role of 116-117
dysphagia procedures for 301-304
significance in health care 116-117
defined 51 types of 300
types of 116-117
signs and symptoms 268 environmental issues
farsightedness 50
dyspnea 97 and Alzheimer’s disease 360-361
fasting 115
eating epilepsy 103
fats
and residents’ rights 264, 268 episiotomy 437
examples of 251
assistive devices for 262 epistaxis, see nosebleed
guidelines for assisting 262-264 fecal impaction 298
equipment
guidelines for residents with special fecal incontinence, see anal
needs 266-268 cleaning 186
incontinence
independence with 263 guidelines for handling 66
federal tags (F-tags) 6
procedure for assisting with 265-266 ergonomics 157
feeding
edema 273 estrogen 142
a resident, procedure for 265-266
Eden Alternative 7-8 see also eating
 525

Index
financial abuse 25 Fowler’s position 149 gurney 161
fingernail care fracture 77, 314 hair
procedure for providing 209-210 fracture pan 276 dandruff 213
fire pediculosis 213
functional grip cane 168
guidelines for safety 89-90, 425-426 procedure for combing or
fungal infections 312 brushing 213-214
potential hazards 88
gait procedure for shampooing hair
fire safety 89-90 and Parkinson’s disease 321 in bed 205-206
in the home, guidelines 425-426 shampooing hair at sink 205-206
gait belt, see also transfer belt 157
first aid halitosis 216
gastroesophageal reflux disease
defined 92 hallucination
(GERD) 299
procedures for responding to 96-104 and Alzheimer’s disease 358
gastrointestinal system
Five Rights of Delegation 17-18 hand and fingernail care
common disorders 298-300
flammable 81 NA’s role in assisting with 140 procedure for giving 209-210
flatulence 299 normal changes of aging 139 hand antisepsis 60
flexion 381 observing and reporting 140 hand hygiene 60
floods structure and function 138-139
handrolls 198
guidelines for responding to 105 gastrostomy 256 handwashing
flossing teeth gauze procedure for 61-62
procedure for 218-219 for sterile dressings 244 when to wash hands 61
flow sheet 43 gay 112 hat 289
fluid balance geriatric chair (geri-chair) 262 hazardous materials
defined 258 geriatrics 122 in the home 477-478
assisting resident to maintain 271-272 gerontology 122 head or spinal cord injury 322
fluid overload gifts 5, 21 guidelines for care 322-323
defined 273 healthcare-associated infection 56
glands 128
signs and symptoms 273
glaucoma 324 Health Care Finance Administration
fluid-restricted diet 258 (HCFA) 6
gloves
food Health Insurance Portability and
procedure for applying 63
appearance, texture, and portion Accountability Act (HIPAA) 30
size 464 procedure for removing 63-64
when to wear 62-63 guidelines for protecting
guidelines for safe preparation 460 privacy 30-31
guidelines for safe storage 464 glucose penalties for violating 31
ingredient substitutions 465 defined 331
health maintenance organization
low-fat preparation 463-464 testing for 293
(HMO) 3
methods of preparation 461-463 goggles
healthcare system 1
planning and shopping 455-457 procedure for applying 65
preparing mechanically altered hearing aid
gonads 141
diets 463 guidelines for 49
gonorrhea 335
food guide pyramid, see MyPyramid hearing impairment
gown guidelines for communication 49-50
food labels
procedure for applying 64
health claims 457-459 heart 134
nutrition facts 459 graduate 270
heart attack, see myocardial
food preferences 256-257 grief process 397 infarction
footboard 198 grooming heartburn 299
defined 193
foot care height
and Alzheimer’s disease 356
observing and reporting 210 procedure for measuring and
and independence 194 recording 176-177
procedure for 210-211
and self-care 194
procedure for diabetic resident 334 hemiparesis 51
guidelines for assisting with 208-209
foot drop 198 hemiplegia 51
guidelines for a job interview 487
force fluids 271 habits of good NA 14
Index 526

Hemoccult® guidelines for teaching family inappropriate behavior

test 305 members 476-477 and Alzheimer’s disease 360
qualities needed for effective 466-467 guidelines for handling 360
hemorrhoids 298
when infection is present 473-474
hepatitis inappropriate requests
human immunodeficiency virus handling, in home health setting 480
defined 71
(HIV)
transmission of 71 incentive spirometer 385
defined 71
types of 71 incident
and residents’ rights 338
vaccine for 71 defined 45
confidentiality 339
herpes simplex 2 335-336 diet 339 guidelines for reporting 45
herpes zoster 310 emotional support 339 incontinence
heterosexual 112 guidelines for care 338-339 defined 40, 138
high-risk behaviors 338 anal/fecal 140
high blood pressure, see
signs and symptoms 337-338 causes of 281
hypertension
testing 340 guidelines for care 281-282
high-fiber diet 260
ways to protect against spread 338 procedure for perineal care 282-283
high-potassium diet 258 types of 281
hurricanes
Hinduism 114 guidelines for responding to 106 urinary 138
HIPAA (Health Insurance Portability hygiene 193 independence
and Accountability Act) after CVA 319
hyperalimentation, see total
and confidentiality 29-30 and Alzheimer’s disease 359, 360
parenteral nutrition
guidelines for protecting and assistive devices 378
privacy 30-31 hyperglycemia, see diabetic and personal care 193, 194
penalties for violating 31 ketoacidosis
and rehabilitation and restorative
hip replacement hypertension care 375-377
guidelines for care 315-316 defined 233 importance of promoting 109-111
observing and reporting 316 guidelines for care 324-325 with eating 266-267

hoarding range 223, 233 indirect contact 57

and Alzheimer’s disease 360 hyperthyroidism 335 indwelling catheter 285
holistic 109 hypoglycemia, see insulin reaction infancy 118
home health agencies hypotension 233 common disorders of 118-119
defined 407 hypothyroidism 335 infant, see baby
and working as an HHA 408-409 ice pack infection
common policies 412-413 procedure for applying 242 defined 56
common services 407 healthcare-acquired 56
ileostomy 306
employer responsibilities 413-414 localized 56
immobility
home health aide (HHA) nosocomial 56
complications of 116
and scope of practice 411-412 systemic 56
typical tasks performed 410-412 immune system
infection control
working efficiently 413 common disorders 337-343
defined 56
NA’s role in assisting with 145
home health care and PPE 62-65
normal changes of aging 145
defined 2 and standard precautions 59-60
observing and reporting 145
and client’s rights 414-416 employee responsibilities 75
structure and function 143-144
purpose of 406 employer responsibilities 75
weakened 58, 73, 74, 460
homeostasis 127 infection prevention, see also
impairment
homosexual 112 infection control 57
hearing 48-50
hormones 128 visual 50-51 infectious 58
hospice care implementation inflammation 311
defined 3 as part of nursing process 17 informed consent 23
goals of 401-402 inactivity injuries
housekeeping complications of 116 preventing 77-80
and well-being 466 suspicious 26
guidelines for 467-468
 527

Index
input 269 job interview logrolling
in-service education common questions 487-488 defined 154
and OBRA 490 tips for 487 procedure for 154-155

insomnia 186 job search long-term care 1

contacting employers 484-485 long-term care facility 1
inspiration 136
important documents 484-485
insulin 141, 293 low-fat foods
joint 129 preparing 463-464
insulin reaction
Joint Commission 6 low-fat/low-cholesterol diet 258
defined 102
signs and symptoms 102 Judaism 115 low-fiber diet 260
insurance 3 Kaposi’s sarcoma 338 low-protein diet 258
intake 269 karma 114 low-sodium diet 258
procedure for measuring 270-271 Kerlix bandages 244 lung cancer 330
intake and output (I&O) 269 kidney dialysis 285 lungs 136
procedure for measuring and kidney stones, see calculi lymph 144
recording 270-271
kidneys 137 lymphatic system
integument 128
Kling bandages 244 NA’s role in assisting with 145
integumentary system
knee replacement normal changes of aging 145
common disorders 310-312
guidelines for care 317 observing and reporting 145
NA’s role in assisting with 129
structure and function 144-145
normal changes of aging 128-129 knee-chest position 181
machines, office 47-48
observing and reporting 129 Kubler-Ross, Dr. Elisabeth 396
structure and function 128-129 major depression 370
lactose intolerance 299
intervention 353 malabsorption 299
latent TB 73
intravenous (IV) 245 malignant tumor 340
lateral position 148
intubation 390 malnutrition 58
laundry
involuntary seclusion 25 procedure for doing 475-476 malpractice 25
involved products and equipment 474-475 managed care 4
as term for weaker side 214 when infection is present 476 mandated reporters 27
irreversible 348 laws manic depression, see bipolar
defined 20 disorder
irritable bowel syndrome 299
guidelines for legal behavior 20-21
Islam 114-115 mask 64
length of stay 1 procedure for applying 65
isolate 59
lesbian 112 Maslow’s Hierarchy of Needs 108
isolation
leukemia 120 massage, see back rub
caring for residents in 67-69
guidelines for 69-70 lever 86 mastectomy 342-343
isolation precautions liability 14 masturbation 111
defined 67 licensed practical nurse (LPN) 9 Material Safety Data Sheet 81-83
in the home, guidelines 419-420 licensed vocational nurse (LVN) 9 meal planning
see also transmission-based
precautions
life support 401 and shopping for clients 456-457
lightning good meals for leftovers 456
IV
defined 245 guidelines for responding to 105 meal trays
linen how to serve 262-264
observing and reporting 246
procedure for changing guidelines for handling 65-66 mechanical lifts
clothes 246-247 liquid diet 260 guidelines for use 162-163
jaundice 71 procedure for transferring 163-164
lithotomy position 180
job application 485-486 mechanical soft diet 260-261
living will 31
job changes 490 mechanical ventilation
localized infection
job description 488 defined 392
defined 56
guidelines for care 392
observing and reporting 58
Index 528

mechanically altered diets money management neglect

preparing 463 in home health setting 480-482 defined 25
Medicaid 7 Montgomery straps 244 observing and reporting 26-27
types of 25
medical asepsis 56 mouth care, see oral care
negligence 25
medical emergency mucous membranes 57
recognizing and responding to 91-92 neonatal 436
multidrug-resistant organisms
see also individual emergencies (MDROs) 67 neonate
medical social worker (MSW) 11 defined 436
multidrug-resistant TB (MDR-TB) 73
common disorders 436
medical terminology 40-41 multiple sclerosis
neonatologist 436
Medicare 7 defined 321
guidelines for care 321-322 nephritis 284
medications
assisting with muscles 130 nervous system
self-administered 430-432 common disorders 318-324
muscular dystrophy 317-318
emergencies involving 433 NA’s role in assisting with 132, 134
musculoskeletal system
“five rights” of 430 normal changes of aging 132
common disorders 312-318
guidelines for safe and proper observing and reporting 132-133, 134
use 429 NA’s role in assisting with 130
sense organs 133-134
observing and reporting 433 normal changes of aging 130
structure and function 131-132
proper storage 433-434 observing and reporting 130-131
neuropathy 339
structure and function 129-130
menopause 122
nitroglycerin 325
mental health music therapy 363
noise
defined 366 myocardial infarction
controlling 183
and physical health 367 defined 97, 326
guidelines for care 326 non-intact skin 62
mental illness
defined 366
procedure for responding to 98 nonspecific immunity 143
signs and symptoms of 97 non-sterile bandage 245
and defense mechanisms 368
causes 366-367 MyPyramid 251-254 non-sterile dressing
guidelines for care 371-372 modified version for older adults 254 procedure for changing 243-244
guidelines for N-95 mask 68, 73 nonverbal communication 34
communication 367-368
nail care nosebleed
observing and reporting 372
procedure for providing 209-210 procedure for responding to 101-102
treatments 371
nasal cannula 248 nosocomial infection 56
mental retardation 123
degrees of 124
nasogastric tube 256 nothing by mouth (NPO) 271
as distinct from mental illness 367 National Citizens’ Coalition for nurse
guidelines for care 124 Nursing Home Reform 24 as a member of the care team 9
metabolism 127 National Council of State Boards of Nurse Aide Training Competency
Nursing Evaluation Program (NATCEP)
methicillin-resistant Staphylococcus
and Five Rights of Delegation 17 and abuse registry 28
aureus (MRSA) 74
microbe 56 National Hospice and Palliative Care nursing, see breastfeeding
Organization 32
microorganism 56 nursing assistant (NA, CNA)
nearsightedness 50 as member of care team 9
military time 44-45
nebulizer educational requirements 490-491
minerals
and oxygen use 432 professionalism 12-14
examples of 251
assisting with use 432-433 qualities of 13-14
Minimum Data Set (MDS) 21 role in rehabilitation 375-376
needs
mode of transmission 57 basic physical 108 role of 11-12
modified calorie diet 259 psychosocial 108 nursing process 16-17
modified diet 257-261 sexual 111-112 nutrient 250
spiritual 112-113
money
guidelines for handling
client’s 481-482
 529

Index
nutrition oral care passive neglect 25
defined 250 defined 216 passive range of motion (PROM)
and Alzheimer’s disease 355-356 and cancer 342 exercises
and cancer 341 and dying resident 398 defined 381
and HIV/AIDS 338-339 observing and reporting 216 procedure for assisting 381-385
and medications 254 procedure for 216-217
pathogens 56
cultural factors 256-257 procedure for flossing teeth 218-219
procedure for unconscious
patient-controlled analgesic (PCA)
problems of elderly and ill 251-256
resident 217-218 pump 399
nutrition facts
organization Patient Self-Determination Act
on food labels 459
and home care 413, 479-480 (PSDA) 31-32
nutritional supplements
organs 127 payer 1
preparing 463
orthostatic hypotension 236 pediculosis 213
objective information 39
orthotic devices 198 peptic ulcers 299
obsessive compulsive disorder 369
osteoarthritis 312 percutaneous endoscopic
obstructed airway
gastrostomy (PEG) tube 256
defined 94 osteoporosis 313
perineal care
procedure for clearing, in infant 96 ostomy
defined 62
occult 305 defined 306
procedure for providing 282-283
guidelines 307
occult blood testing
procedure for care 307-308 perineum 199
procedure 305-306
types of 306 peripheral nervous system (PNS) 131
Occupational Safety and Health
Administration (OSHA) outpatient care 3 peripheral vascular disease (PVD) 327
defined 71 output 269 peristalsis 139
and ergonomics 157 ova and parasites perseveration
and MSDS 81-82 test for 304 and Alzheimer’s disease 352, 359
Bloodborne Pathogen Standard 71-72 oxygen personal 12
occupational therapist (OT) 10 guidelines for delivery personal care
devices 247-249
occupied bed a.m. care 193
guidelines for safe use 80-81
defined 188 observing and reporting 195
procedure for making 188-190 oxygen concentrator 248 p.m. care 193
odors oxygen therapy 247 promoting independence
controlling 183 p.m. care 193 with 193-194

office machines pacing 358 personal protective equipment (PPE)

guidelines for using 47-48 defined 62
pain
order for applying and removing 65
oil retention enema 300 and cancer 341
and dying resident 398-399 phantom sensation 318
Older Americans Act (OAA) 29
as a vital sign 223 phobia 369
ombudsman
management of 236-237 physical abuse 25
defined 29
observing and reporting 237
tasks of 29 physical exams
questions to ask resident 236
Omnibus Budget Reconciliation Act guidelines for 181
palliative care 401 NA’s role in 179-181
(OBRA) 21
panic disorder 369 residents’ rights during 181
On Death and Dying 396
paralysis 77 physical therapist (PT) 10
onset 348
paranoid schizophrenia 370 physician 9
open bed 191
paraplegia 322 pillaging
open fracture 314
Parkinson’s disease and Alzheimer’s disease 360
opinion
defined 320 Pioneer Network 7
vs. fact 39
guidelines for 320-321 pituitary gland 140
opportunistic infections 338
partial bath 199 planning
PASS as part of nursing process 17
fire extinguisher use 89
Index 530

pneumonia 328 and residents’ rights 23 range of motion exercises 381

poisoning 80 and sexual needs 112, 143 razors
procedure for responding to 98-99 and urination 276 types of 211
as a beginning step in care
policy 5 procedures 147 ready-to-feed formula 441
portable commode during exams 181 reality orientation 361
defined 277 guidelines for protecting 30-31 receptive aphasia 51
procedure for assisting 280-281 privacy curtain 185 reciprocity 490
portal of entry 57 procedure 5 registered dietician (RD) 11
portal of exit 57 professional registered nurse (RN) 9
positioning, see also specific defined 12 registry of nursing assistants 490-491
position 148-157 relationship with employer 13
rehabilitation
positioning devices relationship with residents 12-13
defined 3
guidelines for 198-199 professionalism 12 goals of 375
postmortem care progesterone 142 NA’s role 375-376
defined 403
progressive 347 reincarnation 114
guidelines for 403-404
pronation 381 relaxation technique 494
postoperative care
prone position 148 religion
defined 388
prostate cancer 336 accommodating differences 112-115
guidelines 388-389
prosthetic devices and food preferences 115
observing and reporting 389
examples of 379-380 common types 114-115
postpartum care
guidelines for 380 reminscence therapy 362
how to provide 436-437
observing and reporting 437 prosthesis 317 renovascular hypertension 284-285
postpartum depression 438 protected health information (PHI) repetitive phrasing 359
post-traumatic stress disorder 369 examples of 30 reporting 12
posture 86 protein reproduce 141
sources of 250 reproductive system
powdered formula 441
provider 1 common disorders 335-337
pre-diabetes 332
psychological abuse 25 NA’s role in assisting with 143
preferred provider organization
psychosocial 108 normal changes of aging 143
(PPO) 3
observing and reporting 143
prefix 40 psychotherapy 371
structure and function 141-143
prehypertension 233 puberty 120
reservoir 57
premature 119 pulse
resident call system 48
common pulse sites 231
preoperative care resident identification 79
factors affecting rate 231
guidelines for 387-388
normal ranges 231 residents
prepared formula 441 as member of care team 11
procedure for taking apical 231-232
pressure points 195 procedure for taking radial 232-233 tips for communicating with 35-39
pressure sore see also individual pulse locations Residents’ Council 29
defined 195 pulse oximeter residents’ rights
and incontinence 281-282 defined 389 defined 23-24
areas at risk 195 guidelines for 389-390 guidelines for promoting 27-28
guidelines for skin care 196-198
puree 231 residents’ rights boxes
observing and reporting 196
quad cane 168 admission, rights during 174
preventing 196-198
quadriplegia 322 Alzheimer’s disease 355
stages of 195-196
alcohol consumption 373
privacy rabbi 115
bathing 207
and bowel elimination 297 RACE bowel retraining 308
and dying resident 400 and fire evacuation 89 call lights 376
and ostomy care 307 radial pulse clothing protectors 264
and personal care 193-194 procedure for 232-233
 531

Index
comforting family and friends after restorative care sexual abuse 25
resident’s death 404 guidelines for 376 sexual harassment 26
communicating during transfers 157 observing and reporting 376
CPR 94 sexual identity 112
restraints
culturally-sensitive care 35 sexual needs
defined 83
dignity and independence 111 accommodating residents’ 111-112
guidelines 85-86
discharges 179 sexually transmitted diseases 335
problems associated with 83-84
diseases and disorders 312 sexually transmitted infections 335
elimination 278 restraint alternatives
defined 84 shampooing hair
enemas 303
examples of 84-85 procedure for 205-206
exams 181
fluid intake 273 restraint-free 84 sharps 59
food choices 257 restrict fluids 258 shaving
HIV/AIDS 338 procedure for 211-213
résumé
IVs 247 types of razors 211
defined 485
keeping residents covered 238 preparation 485 shearing 150
life support measures 401 shingles 310-311
rheumatoid arthritis 313
mental illness 371
rigor mortis 403 shock
moving, lifting, transferring 157
defined 96
oral care 220 rotation 381
procedure for responding to 97
physical abuse 54 routine urine specimen
Residents’ Council 29 shopping
defined 289
residents in isolation 70 for clients, guidelines 456-457
procedure for collecting 289-290
residents’ names 38 shower
safety
residents who cannot speak 52 procedure for giving 207-208
during bathing 207
responsibility for all residents 12 general guidelines 77-81 shower chair 208
room or roommate change 177 in the home 421-426 signs and symptoms
safety 80 defined 39
safety razor 211
sexual abuse 112 to report immediately 42
sexual expression 143 scabies 310
simple carbohydrates 250
special needs 268 scalds
specimens 290 defined 79 Sims’ position 149
urinary catheters 287 guidelines for preventing 79 sit up
vital signs 223 schizophrenia 370 procedure for helping
voting 28 resident 149-150
scope of practice
vulnerable adults 27 situation response 366
defined 15
resident unit tasks outside home health sitz bath
cleaning of 186 aide’s 411-412 defined 240
guidelines 186 tasks outside nursing procedure for assisting 241
assistant’s 15
standard equipment in 184-185 skilled care 2
respiration sedative 392
skin care
defined 232 seizures guidelines for 196-197
procedure for taking 232-233 procedure for responding to 103 observing and reporting 196
respiratory distress self-care sleep
signs of 393 and Alzheimer’s disease 353 importance of 186-187
importance of 109-111 observing and reporting 187
respiratory hygiene 68
respiratory system sense organs slide board 158
NA’s role in assisting with 134
common disorders 328-331 soft diet 260
normal changes of aging 134
NA’s role in assisting with 137 special diets
observing and reporting 134
normal changes of aging 137 defined 257
structure and function 133
observing and reporting 137 types of 257-261
structure and function 136-137 senses
using to gather information 39-40
specific immunity 143
Index 532

specimen stretcher temperature

defined 289 guidelines for safe use 161 factors affecting 223-224
collecting 24-hour 291 procedure for transferring to normal range 223
collecting clean catch 290-291 and from 161-162 procedure for axillary 229-230
collecting routine urine 289-290 stroke procedure for oral 226-227
collecting sputum 331 guidelines for assisting procedure for rectal 228-229
collecting stool 304-305 resident 319-320 procedure for tympanic 229
see also cerebrovascular accident sites for measuring 224
speech-language pathologist 10-11 (CVA)
sphygmomanometer 233 terminal illness 1
subacute care 386
spills testosterone 142
subjective information 39
guidelines for cleaning 66-67 Texas catheter, see condom catheter
substance abuse
spina bifida defined 26, 372 therapeutic diet, see special diet
guidelines for care 125 observing and reporting 373 thermometer
spinal cord 131 suctioning types of 224
injuries of 322 guidelines for 393 thickening consistencies 261
spiritual 112 sudden infant death syndrome time
spiritual needs (SIDS) 119 changing regular to military 44-45
accommodating residents’ 112-113 suffix 40 time management
sputum suffocation 84 in home health setting 479-480
defined 137 tissues 127
sundowning
procedure for collecting
and Alzheimer’s disease 357 tornado
specimen 331
supination 381 guidelines for responding to 105
standard precautions
supine position 148 total parenteral nutrition (TPN) 256
defined 59
guidelines for 59-60 suppository 298 tracheostomy
importance of 59 defined 390
surgery
observing and reporting 391
stereotypes reasons for 386
reasons for 391
of the elderly 122 types of 386
transfer belt
sterile dressing surgical asepsis 56
defined 157
observing and reporting 245 surgical bed procedure for applying 157-158
sterile technique, see surgical asepsis defined 191
see also gait belt
sterilization 66 procedure for making 191-192
transfer board 158
stethoscope 231 survey 6
transferring a resident
stoma 300 susceptible host 57 bed to wheelchair 159-161
stomach 139 swallowing problems, see dysphagia bed to stretcher 161-162
stool sympathy 13 into a car 165-166
observing and reporting 296 syncope, see fainting NA’s role in 157-159
procedure for collecting onto and off of a toilet 164-165
syphilis 335
specimen 304-305 using mechanical lift 163-164
systemic infection
straight catheter 285 transfers, in-house
defined 56
stress procedure for 177-178
observing and reporting 58
defined 491 transient ischemic attack (TIA) 103
systole 135
consequences of not managing 493 transmission 58
guidelines for managing 492 systolic pressure
normal range 223 transmission-based precautions
plan for managing 493
defined 67
resources for managing 493 tact 13
categories 67-69
stressor telemetry guidelines for 69-70
defined 492 defined 390 see also isolation precautions
list of common 492 guidelines for 390
transsexual 112
trapeze 378
 533

Index
trauma 121 urine warm compress
triggers common tests performed 292-293 procedure for applying 238-239
and Alzheimer’s disease 356 normal qualities of 275 warm soak
procedure for testing with reagent procedure for administering 239-240
trochanter rolls 199
strips 293-294
tub bath washing hands
urine straining 284
procedure for giving 207-208 procedure for 61-62
U.S. Department of Agriculture when to wash 61
tube feedings (USDA) see also hand hygiene and hand
observing and reporting 256
and MyPyramid 251-254 antisepsis
tuberculosis (TB) U.S. Department of Health and water
defined 72 Human Services as a nutrient 251
guidelines for 73-74 Medicare and Medicaid 6-7 procedure for serving 272-273
signs and symptoms 73
U.S. Living Will Registry 32 weight
tumor
vaginitis 336 procedure for measuring and
types of 340 recording 175
validating 361
Type 1 diabetes 331 weight loss, unintended
validation therapy 361
Type 2 diabetes 331-332 guidelines for preventing 255
vancomycin-resistant enterococcus observing and reporting 255
ulceration 299
(VRE) 74
ulcerative colitis 300 wheelchair
vegan 115, 261 guidelines for assisting with 158-159
umbilical cord 448
vegetarians 115, 261 withdrawal
unconscious resident
verbal abuse 25 as a sign of depression 369, 372
procedure for oral care 217-218
verbal communication 34 as a sign of abuse 26
unit, resident
violent behavior workplace violence 25
guidelines 186
standard equipment 184-186
and Alzheimer’s disease 357 wounds
vision impairment types of 311
unoccupied bed
defined 188
guidelines for communication 50-51 yarmulke 115
procedure for making 190-191 vital signs
defined 223
upper respiratory infection (URI) 330
measuring and recording 223-237
ureterostomy 306
normal ranges 223
urinal observing and reporting 223-237
procedure for assisting 280
vitamins 251
urinary incontinence
voiding 275
defined 138
causes of 281
vomiting
procedure for responding to 104
guidelines for care 281-282
see also emesis
procedure for perineal care 282-283
types of 281 Vulnerable Adults Acts 27
urinary system walker
common disorders 281-285 defined 168
NA’s role in assisting with 138 guidelines for use 168
normal changes of aging 138 procedure for assisting
resident 168-170
observing and reporting 138
structure and function 137-138 wandering 358
urinary tract infection warm applications
defined 283 benefits of 237
guidelines for preventing 283-284 observing and reporting 238
procedures for 238-241
urination
risks of 237
defined 275
types of 238
factors affecting 275-276
observing and reporting 275