Hartman’s Nursing Assistant Care

The Basics
Hartman Publishing, Inc.
with Jetta Fuzy, RN, MS
third edition
ii

Credits Special Thanks

Managing Editor A heartfelt thank you goes to our insightful and wonderful
Susan Alvare Hedman reviewers, listed in alphabetical order:
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Page Layout Sally Lyle, RN, BSN
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Austin, TX
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Jean P. Stanhagen, RN, BSN
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Virginia Vollmer, PhD, RN
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Notice to Readers
• Motion Control, Inc.
Though the guidelines and procedures contained in this
text are based on consultations with healthcare profession- • North Coast Medical, Inc.
als, they should not be considered absolute recommenda- • Dr. Frederick Miller
tions. The instructor and readers should follow employer,
local, state, and federal guidelines concerning healthcare • Nova Ortho Med, Inc.
practices. These guidelines change, and it is the reader’s re- • Lee Penner of Penner Tubs
sponsibility to be aware of these changes and of the policies
and procedures of her or his healthcare facility. • RG Medical Diagnostics of Southfield, MI

The publisher, author, editors, and reviewers cannot accept • Vancare, Inc.
any responsibility for errors or omissions or for any conse-
quences from application of the information in this book
Gender Usage
and make no warranty, expressed or implied, with respect
to the contents of the book. The Publisher does not war- This textbook utilizes the pronouns “he,” “his,” “she,” and
rant or guarantee any of the products described herein or “hers” interchangeably to denote healthcare team members
perform any analysis in connection with any of the product and residents.
information contained herein.
 iii

Contents Page Learning Objective Page

1 The Nursing Assistant in 7. Describe the stages of human development 62

Long-Term Care 8. Discuss the needs of people with

developmental disabilities 65
1. Compare long-term care to other healthcare
settings 1 9. Describe mental illness, depression and
related care 66
2. Describe a typical long-term care facility 2
10. Explain how to care for dying residents 67
3. Explain Medicare and Medicaid 3
11. Define the goals of a hospice program 72
4. Describe the role of the nursing assistant 3
5. Describe the care team and the chain of
command 5
4 Body Systems and Related
6. Define policies, procedures, and professionalism 8
Conditions
1. Describe the integumentary system 73
7. List examples of legal and ethical behavior and
explain Residents’ Rights 10 2. Describe the musculoskeletal system
and related conditions 75
8. Explain legal aspects of the resident’s medical
record 17 3. Describe the nervous system and
related conditions 78
9. Explain the Minimum Data Set (MDS) 18
4. Describe the circulatory system and
10. Discuss incident reports 19
related conditions 84
5. Describe the respiratory system and
2 Foundations of Resident Care related conditions 87
1. Understand the importance of verbal and 6. Describe the urinary system and
written communications 20 related conditions 89
2. Describe barriers to communication 23 7. Describe the gastrointestinal system
3. List guidelines for communicating with and related conditions 91
residents with special needs 25 8. Describe the endocrine system and
4. Identify ways to promote safety and handle related conditions 94
non-medical emergencies 29 9. Describe the reproductive system and
5. Demonstrate how to recognize and respond related conditions 97
to medical emergencies 35 10. Describe the immune and lymphatic
6. Describe and demonstrate infection prevention systems and related conditions 99
practices 43

5 Confusion, Dementia, and

3 Understanding Your Residents Alzheimer’s Disease
1. Identify basic human needs 56
1. Discuss confusion and delirium 104
2. Define “holistic care” 58
2. Describe dementia and discuss
3. Explain why promoting independence and Alzheimer’s disease 105
self-care is important 58
3. List strategies for better communication
4. Identify ways to accommodate cultural with residents with Alzheimer’s disease 106
differences 59
4. List and describe interventions for problems
5. Describe the need for activity 61 with common activities of daily living (ADLs) 108

6. Discuss family roles and their significance in 5. List and describe interventions for common
health care 61 difficult behaviors related to Alzheimer’s disease 111
iv

Learning Objective Page Learning Objective Page

6. Describe creative therapies for residents 6. Identify ways to promote appetites at mealtime 206
with Alzheimer’s disease 115
7. Demonstrate how to assist with eating 207
8. Identify signs and symptoms of
6 Personal Care Skills swallowing problems 210
1. Explain personal care of residents 117 9. Describe how to assist residents with
2. Identify guidelines for providing skin care special needs 212
and preventing pressure sores 118
3. Describe guidelines for assisting with bathing 121 9 Rehabilitation and Restorative
4. Describe guidelines for assisting with grooming 130 Care
5. List guidelines for assisting with dressing 135 1. Discuss rehabilitation and restorative care 214

6. Identify guidelines for proper oral hygiene 138 2. Describe the importance of promoting
independence and list ways exercise improves
7. Explain guidelines for assisting with toileting 143
health 215
8. Explain the guidelines for safely positioning
3. Discuss ambulation and describe assistive
and moving residents 147
devices and equipment 215
4. Explain guidelines for maintaining proper
7 Basic Nursing Skills body alignment 219
1. Explain admission, transfer, and discharge 5. Describe care guidelines for prosthetic devices 220
of a resident 160
6. Describe how to assist with range of motion
2. Explain the importance of monitoring vital signs 164 exercises 221
3. Explain how to measure weight and height 177 7. List guidelines for assisting with bowel and
4. Explain restraints and how to promote a bladder retraining 225
restraint-free environment 179
5. Define fluid balance and explain intake and 10 Caring for Yourself
output (I&O) 182
1. Describe how to find a job 227
6. Explain care guidelines for different types
2. Describe a standard job description 229
of tubing 186
3. Discuss how to manage and resolve conflict 229
7. Discuss a resident’s unit and related care 190
4. Describe employee evaluations and
8. Explain the importance of sleep and
discuss appropriate responses to criticism 230
perform proper bedmaking 191
5. Discuss certification and explain the
9. Discuss dressings and bandages 195
state’s registry 231
6. Describe continuing education 232
8 Nutrition and Hydration
7. Explain ways to manage stress 232
1. Identify the six basic nutrients and
explain MyPyramid 197
2. Describe factors that influence food preferences 200 Abbreviations 235

3. Explain special diets 201 Glossary 236

4. Describe how to assist residents in Index 247

maintaining fluid balance 203
5. List ways to identify and prevent
unintended weight loss 205
 v

Procedure Page Procedure Page

Procedures Moving a resident to the side of the bed

Turning a resident
149
150

Performing abdominal thrusts for the conscious Logrolling a resident with one assistant 152
person 36 Assisting resident to sit up on side of bed:
Responding to shock 37 dangling 153

Responding to a heart attack 38 Transferring a resident from bed to wheelchair 156

Controlling bleeding 39 Transferring a resident using a mechanical lift 158

Treating burns 39 Admitting a resident 161

Responding to fainting 40 Transferring a resident 162

Responding to seizures 41 Discharging a resident 163

Responding to vomiting 42 Measuring and recording oral temperature 166

Washing hands 46 Measuring and recording rectal temperature 168

Putting on (donning) gown 48 Measuring and recording tympanic temperature 169

Putting on (donning) mask and goggles 48 Measuring and recording axillary temperature 170

Putting on (donning) gloves 49 Measuring and recording radial pulse and

counting and recording respirations 171
Removing (doffing) gloves 49
Measuring and recording blood pressure
Caring for an ostomy 94 (one-step method) 173
Giving a complete bed bath 122 Measuring and recording blood pressure
Giving a back rub 125 (two-step method) 174

Shampooing hair in bed 127 Measuring and recording weight of an

ambulatory resident 177
Giving a shower or a tub bath 128
Measuring and recording height of a resident 178
Providing fingernail care 130
Measuring and recording urinary output 183
Providing foot care 131
Collecting a routine urine specimen 184
Combing or brushing hair 133
Collecting a clean catch (mid-stream) urine
Shaving a resident 134 specimen 184
Dressing a resident with an affected (weak) Collecting a stool specimen 185
right arm 136
Providing catheter care 187
Putting a knee-high elastic stocking on resident 137
Making an occupied bed 192
Providing oral care 139
Making an unoccupied bed 195
Providing oral care for the unconscious resident 140
Changing a dry dressing using non-sterile
Flossing teeth 141
technique 195
Cleaning and storing dentures 142
Serving fresh water 205
Assisting resident with use of bedpan 144
Feeding a resident who cannot feed self 208
Assisting a male resident with a urinal 145
Assisting a resident to ambulate 215
Assisting a resident to use a portable commode or
Assisting with ambulation for a resident using a
toilet 147
cane, walker, or crutches 217
Moving a resident up in bed 148
Assisting with passive range of motion exercises 221
18 vi

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!
 vii 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

Making an occupied bed
bar for easy recognition.

Guidelines and Observing and Reporting are colored

Guidelines: Preventing Falls
green for easy reference.

Residents’ Rights These boxes teach important information on how to

support and promote Residents’ Rights, as well as
Abuse and Alzheimer’s Disease
provide other types of important information.
People with Alzheimer’s disease may be at a higher
risk for abuse.
 1 1

The Nursing Assistant in Long-Term Care

The Nursing Assistant in
Long-Term Care
1. Compare long-term care to other physical disabilities, heart disease, stroke, and
healthcare settings dementia. (You will learn more about these dis-
orders and diseases in Chapters 4 and 5.)
Welcome to the world of health care. Health
People who live in long-term care facilities are
care happens in many places. Nursing assistants
usually called “residents” because the facility is
work in many of these settings. In each setting
where they reside or live. These places are their
similar tasks will be performed. However, each
homes for the duration of their stay.
setting is also unique.
People who need long-term care will have dif-
This textbook will focus on long-term care.
ferent diagnoses, or medical conditions de-
Long-term care (LTC) is given in long-term care
termined by a doctor. The stages of illnesses
facilities (LTCF) for persons who need 24-hour
or diseases affect how sick people are and how
supervised nursing care. This type of care is
much care they will need. The job of nursing
given to people who need a high level of care for
assistants will also vary. This is due to each per-
ongoing conditions. The term “nursing homes”
son’s different symptoms, abilities, and needs.
was once widely used to refer to these facilities.
Now, however, they are often called long-term Other types of healthcare settings include:
care facilities, skilled nursing facilities, residen- Home health care is provided in a person’s
tial facilities, rehabilitation centers, or extended home (Fig. 1-1). This type of care is also gener-
care facilities. ally given to people who are older and are chron-
People who live in long-term care facilities may ically ill but who are able to and wish to remain
be disabled and/or elderly. They may arrive from at home. Home care may also be needed when a
hospitals or other healthcare settings. Their person is weak after a recent hospital stay. Home
length of stay (the number of days a person care includes many of the services offered in
stays in a care facility) may be short, such as other settings.
a few days or a few months, or longer than six
months. Some of these people will have a ter-
minal illness. This means that the person is ex-
pected to die from the illness. Other people may
recover and return to their homes or to other
facilities or situations.
Most conditions seen in long-term care are
chronic. This means they last a long period of
time, even a lifetime. Chronic conditions include Fig. 1-1. Home care is performed in a person’s home.
 1 2

Assisted living facilities provide some help Subacute care can be given in a hospital or in
with daily care, such as showers, meals, and a long-term care facility. Subacute care is given
dressing. Help with medications may also be to people who have had an acute injury or ill-
given. People who live in these facilities do not ness or problem resulting from a disease. These
The Nursing Assistant in Long-Term Care

need skilled, 24-hour care. Assisted living facili- patients need treatment that requires more care
ties allow more independent living in a home- than some long-term care facilities can give and
like environment. An assisted living facility may less care than acute illnesses require. The cost is
be attached to a long-term care facility, or it may usually less than a hospital but more than long-
stand alone. term care.
Adult daycare is care given at a facility during Outpatient care is usually given for less than
daytime working hours. Generally, adult daycare 24 hours. It is for people who have had treat-
is for people who need some help but are not se- ments or surgery and need short-term skilled
riously ill or disabled. Adult daycare centers give care.
different levels of care. Adult daycare can also Rehabilitation is care given in facilities or
provide a break for spouses, family members, homes by a specialist. Physical, occupational,
and friends. and speech therapists restore or improve func-
Acute care is given in hospitals and ambula- tion after an illness or injury. You will learn
tory surgical centers. It is for people who have more about rehabilitation and related care in
an immediate illness. People are admitted for Chapter 9.
short stays for surgery or diseases. Acute care is Hospice care is given in facilities or homes for
24-hour skilled care for temporary, but serious, people who have six months or less to live. Hos-
illnesses or injuries (Fig. 1-2). Skilled care is pice workers give physical and emotional care
medically necessary care given by a skilled nurse and comfort. They also support families. You
or therapist. This care is available 24 hours a will learn more about hospice care in Chapter 3.
day. It is ordered by a doctor, and involves a
treatment plan.
2. Describe a typical long-term care
facility
Long-term care facilities (LTCF) are businesses
that provide skilled nursing care 24 hours a
day. These facilities may offer assisted living
housing, dementia care, or subacute care. Some
facilities offer specialized care. Others care for
all types of residents. The typical long-term care
facility offers personal care for all residents and
focused care for residents with special needs.
Personal care includes bathing, skin, nail and
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 include the following:

Fig. 1-2. Acute care is performed in hospitals for illnesses • Physical, occupational, and speech therapy
or injuries that require immediate care.
• Wound care
 3 1

• Care of different types of tubes and catheters

(a thin tube inserted into the body that is
used to drain fluids or inject fluids)

The Nursing Assistant in Long-Term Care

• Nutrition therapy
• Management of chronic diseases, such as
AIDS, diabetes, chronic obstructive pulmo-
nary disease (COPD), cancer, and congestive
heart failure (CHF)

When specialized care is offered at long-term

care facilities, the employees must have special
training. Residents with similar needs may be
placed in units together. Non-profit companies Fig. 1-3. The CMS website’s address is cms.hhs.gov.
or for-profit companies can own long-term care
facilities. Medicare is a health insurance program that
was established in 1965 for people aged 65 or
Residents’ Rights older. It also covers people of any age with per-
Culture Change manent kidney failure or certain disabilities.
Some long-term care facilities are adopting newer Medicare has four parts. Part A helps pay for
models of care. These models promote meaning- care in a hospital or skilled nursing facility or for
ful environments with individualized approaches to care from a home health agency or hospice. Part
care. Culture change is a term given to the process
of transforming services for elders so that they are B helps pay for doctor services and other medi-
based on the values and practices of the person cal services and equipment. Part C allows private
receiving care. Culture change involves respecting health insurance companies to provide Medicare
both elders and those working with them. Core val- benefits. Part D helps pay for medications pre-
ues are choice, dignity, respect, self-determination,
and purposeful living. To honor culture change, care scribed for treatment. Medicare will only pay for
facilities may need to change organization prac- care it determines to be medically necessary.
tices, physical environments, and relationships at all
levels. For more information, visit the Pioneer Net- Medicaid is a medical assistance program for
work’s website at pioneernetwork.net. and The Eden low-income people. It is funded by both the fed-
Alternative’s website at edenalt.org. eral government and each state. Eligibility is de-
termined by income and special circumstances.
People must qualify for this program.
3. Explain Medicare and Medicaid
Medicare and Medicaid pay long-term care facili-
The Centers for Medicare & Medicaid Services ties a fixed amount for services. This amount is
(CMS), formerly the Health Care Finance Ad- based on the resident’s needs upon admission.
ministration (HCFA), is a federal agency within
the U.S. Department of Health and Human Ser- 4. Describe the role of the nursing
vices (Fig. 1-3). CMS runs two national health-
assistant
care programs, Medicare and Medicaid. They
both help pay for health care and health insur- Nursing assistants can have many different ti-
ance for millions of Americans. CMS has many tles. “Nurse aide,” “certified nurse aide,” “patient
other responsibilities as well. care technician” and “certified nursing assis-
tant” are some examples. This textbook will use
the term “nursing assistant.”
 1 4

Nursing assistants (NAs) perform assigned nurs- Nursing assistants spend more time with resi-
ing tasks, such as taking a resident’s tempera- dents than any other care team member. They
ture. Nursing assistants also provide personal act as the “eyes and ears” of the team. Observing
care, such as bathing residents, helping them eat changes in a resident’s condition and reporting
The Nursing Assistant in Long-Term Care

and drink, and helping with hair care (Fig. 1-4). these changes is a very important role of the
Promoting independence and self-care are other NA. Residents’ care can be revised or updated
very important tasks that nursing assistants as conditions change. Another role of the NA is
do. Other nursing assistant duties include the writing down important information about the
following: resident (Fig. 1-5). This is called charting.

Fig. 1-4. Encouraging residents to drink often will be an

important part of your job.

• Helping residents with toileting needs

Fig. 1-5. Observing carefully and reporting accurately are
• Assisting residents to move around safely some of the most important duties you will have.
• Keeping residents’ living areas neat and
Nursing assistants are part of a team of health
clean
professionals. The team includes doctors,
• Caring for supplies and equipment nurses, social workers, therapists, dietitians,
• Helping residents dress and specialists. The resident and resident’s
family are part of the team. Everyone, includ-
• Making beds
ing the resident, works closely together to meet
• Giving backrubs goals. Goals include helping residents to recover
• Helping residents with mouth care from illnesses or to do as much as possible for
themselves.
Nursing assistants are generally not allowed to
give medications; nurses are responsible for giv- Residents’ Rights
ing medications. Some states allow nursing as-
Responsibility for Residents
sistants to work with medications after receiving
All residents are the responsibility of each nursing
special training. Examples of other tasks that assistant. You will receive assignments to complete
nursing assistants are not allowed to do are in- tasks, care, and paperwork for specific residents. If
serting/removing tubes, changing sterile dress- you see a resident who needs help, even if he or she
is not on your assignment sheet, provide the needed
ings, and giving tube feedings.
care.
 5 1

5. Describe the care team and the chain The RN also writes and develops care plans. A
of command care plan is created for each resident. It helps
the resident achieve his or her goals. The resi-
Residents will have different needs and prob- dent assists with developing the care plan. The

The Nursing Assistant in Long-Term Care

lems. Healthcare professionals with different care plan outlines the steps and tasks the care
kinds of education and experience will help care team must perform. It states how often these
for them (Fig. 1-6). This group is known as the tasks should be performed and specifies how
“care team.” Members of the care team include they should be carried out.
the following:
Licensed Practical Nurse (LPN) or Licensed Vo-
cational Nurse (LVN). A licensed practical nurse
or licensed vocational nurse is a licensed profes-
sional who has completed one to two years of
education. An LPN/LVN gives medications and
treatments. LPNs may also supervise nursing as-
sistants’ daily care of residents.
Physician or Doctor (MD or DO). A doctor’s job
is to diagnose disease or disability and prescribe
treatment. Doctors have graduated from four-
year medical schools after receiving bachelor’s
degrees. Many doctors also take specialized
training programs after medical school (Fig.
Fig. 1-6. The care team is made up of many different
healthcare professionals.
1-7). (“DO” stands for “doctor of osteopathic
medicine.”)
Nursing Assistant (NA) or Certified Nursing As-
sistant (CNA). The nursing assistant (NA) per-
forms assigned tasks, such as taking vital signs.
NAs also provide routine personal care, such
as bathing residents and helping with toileting.
Nursing assistants must have at least 75 hours of
training, and, in many states, training exceeds
100 hours.
Registered Nurse (RN). A registered nurse is a
licensed professional who has completed two to
four years of education. RNs have diplomas or
college degrees. They have passed a licensing
exam given by the state board of nursing. Reg-
istered nurses may have additional academic de-
grees or education in special areas. In long-term
care, an RN coordinates, manages, and provides
skilled nursing care. This includes giving spe-
cial treatments and medication as prescribed by
a doctor. A registered nurse also assigns tasks
and supervises daily care of residents by nursing Fig. 1-7. Doctors diagnose disease and prescribe
assistants. treatment.
 1 6

Physical Therapist (PT). A physical therapist Occupational Therapist (OT). An occupational

evaluates a person and develops a treatment therapist helps residents learn to compensate for
plan. Goals are to increase movement, improve disabilities. An OT helps residents perform ac-
circulation, promote healing, reduce pain, pre- tivities of daily living (ADLs). This often involves
The Nursing Assistant in Long-Term Care

vent disability, and regain or maintain mobility. equipment called assistive or adaptive devices.
A PT gives therapy in the form of heat, cold, For example, an OT can teach a person to use
massage, ultrasound, electricity, and exercise to a special fork to feed himself. The occupational
muscles, bones, and joints. For example, a PT therapist observes a resident’s needs and plans
helps a person to safely use a walker, cane, or a treatment program. OTs generally have an un-
wheelchair (Fig. 1-8). Physical therapist educa- dergraduate degree before being admitted to a
tion programs are offered at two degree levels: doctoral or master’s program. OTs have to pass
doctoral and master’s. Entrance into these pro- a national certification examination and most
grams usually requires an undergraduate de- must be licensed within their state.
gree. Master’s degree programs usually last two
Speech-Language Pathologist (SLP). A speech-
years. Doctoral degree programs last three years.
language pathologist helps with speech and
PTs have to pass national and state licensure
swallowing problems. An SLP identifies com-
exams before they can practice.
munication disorders, addresses factors involved
in recovery, and develops a plan of care to meet
recovery goals. An SLP teaches exercises to
help the resident improve or overcome speech
problems. For example, after a stroke, a person
may not be able to speak or speak clearly. An
SLP may use a picture board to help the person
communicate thirst or pain. An SLP also evalu-
ates a person’s ability to swallow food and drink.
Speech-language pathologists are generally re-
quired to have a master’s degree in speech-lan-
guage pathology. Most states require that SLPs
be licensed or certified to work.
Registered Dietitian (RD). A registered dietitian
creates diets for residents with special needs.
Special diets can improve health and help man-
age illness. RDs may supervise the prepara-
tion and service of food and educate others on
healthy nutritional habits. Registered dietitians
have completed a bachelor’s degree and may also
have a master’s degree. They may also have com-
pleted postgraduate work. Most states require
that RDs be licensed or certified.
Medical Social Worker (MSW). A medical social
Fig. 1-8. A physical therapist will help restore specific
abilities. worker determines residents’ needs and helps
get them support services, such as counseling.
 7 1

He or she may help residents obtain clothing what you did was in the care plan and was done
and personal items if the family is not involved according to policy and procedure. Then you
or does not visit often. A medical social worker may not be liable, or responsible, for hurting the
may book appointments and transportation. resident. However, if you do something not in

The Nursing Assistant in Long-Term Care

Generally, MSWs hold a master’s degree in so- the care plan that harms a resident, you could
cial work. be held responsible. That is why it is important
to follow instructions in the care plan and know
Activities Director. The activities director plans
the chain of command (Fig. 1-9).
activities for residents to help them socialize
and stay active. These activities are meant to
improve and maintain residents’ well-being and
to prevent further complications from illness or
disability. An activities director may have a bach-
elor’s degree, associate’s degree, or qualifying
work experience. An activities director may be
called a “recreational therapist” depending upon
education and experience.
Resident and Resident’s Family. The resident
is an important member of the care team. The
resident has the right to make decisions about
his or her own care. The resident helps plan care
and makes choices. The resident’s family may
also be involved in these decisions. The family Fig. 1-9. The chain of command describes the line of au-
is a great source of information. They know the thority and helps ensure that the resident receives proper
resident’s personal preferences, history, diet, care.
rituals, and routines.
Nursing assistants must understand what they
Residents’ Rights can and cannot do. This is so that you do not
Resident as Member of Care Team harm a resident or involve yourself or your em-
All members of the care team should focus on the ployer in a lawsuit. Some states certify that a
resident. The team revolves around the resident and nursing assistant is qualified to work. However,
his or her condition, treatment, and progress. With- nursing assistants are not licensed healthcare
out the resident, there is no team.
providers. Everything in your job is assigned to
you by a licensed healthcare professional. You
As a nursing assistant, you will be carrying
work under the authority of another person’s li-
out instructions given to you by a nurse. The
cense. That is why these professionals will show
nurse is acting on the instructions of a doctor
great interest in what you do and how you do it.
or other member of the care team. This is called
the chain of command. It describes the line of Every state grants the right to practice various
authority and helps to make sure that your resi- jobs in health care through licensure. Examples
dents get proper health care. The chain of com- include a license to practice nursing, medicine,
mand also protects you and your employer from or physical therapy. All members of the care
liability. Liability is a legal term. It means that team work under each professional’s “scope
someone can be held responsible for harming of practice.” A scope of practice defines the
someone else. For example, imagine that some- things you are allowed to do and how to do them
thing you do for a resident harms him. However, correctly. Laws and regulations on what NAs can
 1 8

and cannot do vary from state to state. It is im- Your employer will have policies and procedures
portant to know which tasks are said to be out- for every resident care situation. Written proce-
side a nursing assistant’s scope of practice. dures may seem long and complicated, but each
step is important. Become familiar with your
The Nursing Assistant in Long-Term Care

facility’s policies and procedures.

6. Define policies, procedures, and
professionalism Professional means having to do with work or a
job. The opposite of professional is personal. It
All facilities must have manuals outlining refers to your life outside your job, such as your
policies and procedures. A policy is a course family, friends, and home life. Professional-
of action that should be taken every time a ism is how you behave when you are on the job.
certain situation occurs. A very basic policy is It includes how you dress, the words you use,
that healthcare information must remain con- and the things you talk about. It also includes
fidential. A procedure is a method, or way, of being on time, completing tasks, and reporting
doing something. A facility will have a proce- to the nurse. For an NA, professionalism means
dure for reporting information about residents. following the care plan, making careful obser-
The procedure explains what form to complete, vations, and reporting accurately. Following
when and how often to fill it out, and to whom policies and procedures is an important part of
it is given. You will be told where to locate a list professionalism.
of policies and procedures that all staff are ex-
Residents, coworkers, and supervisors respect
pected to follow.
employees who behave in a professional way.
Common policies at long-term care facilities in- Professionalism helps you keep your job. It may
clude the following: also help you earn promotions and raises.
• All resident information must remain con- A professional relationship with a resident
fidential. This is not only a facility rule, it includes:
is also the law. See later in the chapter for
• Keeping a positive attitude
more information on confidentiality, includ-
ing the Health Insurance Portability and Ac- • Doing only the assigned tasks you are
countability Act (HIPAA). trained to do and that are listed in the care
plan
• The plan of care must always be followed.
Activities not listed in the care plan should • Keeping all residents’ information
not be performed. confidential

• Nursing assistants should not do tasks not • Being polite and cheerful, even if you are not
included in the job description. in a good mood (Fig. 1-10)

• Nursing assistants must report important • Not discussing your personal problems
events or changes in residents to a nurse. • Not using profanity, even if a resident does
• Personal problems must not be discussed • Listening to the resident
with the resident or the resident’s family. • Calling a resident “Mr.,” “Mrs.,” “Ms.,” or
• Nursing assistants should not take money or “Miss,” or by the name he or she prefers
gifts from residents or their families. • Never giving or accepting gifts
• Nursing assistants must be on time for work • Always explaining the care you will provide
and must be dependable. before providing it
 9 1

• Following practices, such as handwashing, to

protect yourself and residents

The Nursing Assistant in Long-Term Care

Fig. 1-10. Being polite and cheerful is something that will
be expected of you.

A professional relationship with an employer

includes:
• Completing tasks efficiently
• Always following all policies and procedures Fig. 1-11. Keeping your hair neatly tied back and wearing
a clean uniform are examples of professional behavior.
• Always documenting and reporting carefully
and correctly
Nursing assistants must be:
• Communicating problems with residents or
• Compassionate: Being compassionate is
tasks
being caring, concerned, empathetic, and
• Reporting anything that keeps you from understanding. Demonstrating empathy
completing duties means entering into the feelings of others.
Compassionate people understand others’
• Asking questions when you do not know or
problems. They care about them. Compas-
understand something
sionate people are also sympathetic. Show-
• Taking directions or criticism without get- ing sympathy means sharing in the feelings
ting upset and difficulties of others.
• Being clean and neatly dressed and groomed • Honest: An honest person tells the truth
(Fig. 1-11) and can be trusted. Residents need to feel
• Always being on time that they can trust those who care for them.
The care team depends on your honesty in
• Telling your employer if you cannot report
planning care. Employers count on truthful
for work
records of your care and observations.
• Following the chain of command
• Tactful: Tact is the ability to understand
• Participating in education programs what is proper and appropriate when dealing
with others. It is the ability to speak and act
• Being a positive role model for your facility
without offending others.
 1 10

• Conscientious: People who are conscien-

Guidelines: Legal and Ethical Behavior
tious always try to do their best. They are
guided by a sense of right and wrong and G Be honest at all times.
have principles. They are alert, observant,
The Nursing Assistant in Long-Term Care

accurate, and responsible. Giving conscien- G Protect residents’ privacy. Do not discuss
tious care means making accurate observa- their cases except with other members of the
tions and reports, following assignments, care team.
and taking responsibility for actions. G Keep staff information confidential.
• Dependable: Nursing assistants must make G Report abuse or suspected abuse of resi-
and keep commitments. You must get to dents, and assist residents in reporting abuse
work on time. You must skillfully do tasks, if they wish to make a complaint of abuse.
avoid too many absences, and help your
G Follow the care plan and your assignments. If
peers when they need it.
you make a mistake, report it promptly.
• Respectful: Being respectful means valuing
G Do not perform any tasks outside your scope
other people’s individuality. This includes
of practice.
their age, religion, culture, feelings, prac-
tices, and beliefs. G Report all resident observations and inci-
• Unprejudiced: You will work with people dents to the nurse.
from many different backgrounds. Give each G Document accurately and promptly.
resident the same quality care regardless
G Follow rules on safety and infection control
of age, gender, sexual orientation, religion,
(see Chapter 2).
race, ethnicity, or condition.
G Do not accept gifts or tips.
• Tolerant: You may not like or agree with
things that your residents or their families G Do not get personally or sexually involved
do or have done. However, your job is to care with residents or their family members or
for each resident as assigned, not to judge friends.
him or her. Put aside your opinions. See Due to reports of poor care and abuse in long-
each resident as an individual who needs term care facilities, the U.S. government passed
your care. the Omnibus Budget Reconciliation Act
(OBRA) in 1987. It has been updated several
7. List examples of legal and ethical times since. OBRA set minimum standards for
behavior and explain Residents’ Rights nursing assistant training. NAs must complete
at least 75 hours of training. NAs must also
Ethics and laws guide behavior. Ethics are the
pass a competency evaluation (testing program)
knowledge of right and wrong. An ethical per-
before they can be employed. They must at-
son has a sense of duty toward others. He always
tend regular in-service education to keep skills
tries to do what is right. Laws are rules set by
updated.
the government to help people live peacefully
together and to ensure order and safety. Ethics OBRA also requires that states keep a current
and laws are very important in health care. They list of nursing assistants in a state registry.
protect people receiving care. They guide those OBRA sets guidelines for minimum staff re-
giving care. NAs and all care team members quirements. It specifies the minimum services
should be guided by a code of ethics. They must that long-term care facilities must provide. An-
know the laws that apply to their jobs. other important part of OBRA is the resident
 11 1

assessment requirements. OBRA requires com- to assistance for any sensory impairment. Blind-
plete assessments on every resident. The assess- ness is one type of sensory impairment.
ment forms are the same for every facility.
The right to participate in their own care: Resi-

The Nursing Assistant in Long-Term Care

OBRA made major changes in the survey pro- dents have the right to participate in planning
cess. Surveys are inspections done to make sure their treatment, care, and discharge. Residents
long-term care facilities follow state and federal have the right to refuse medication, treatment,
regulations. Surveys are done every 9 to 15 care, and restraints. They have the right to be
months by the state agency that licenses facili- told of changes in their condition. They have the
ties. They may be done more often if a facility right to review their medical record. Informed
has been cited. To cite means to find a problem consent is a concept that is part of participating
through a survey. Inspections may be done less in one’s own care. A person has the legal and
often if the facility has a good record. Inspection ethical right to direct what happens to his or her
teams include a variety of trained healthcare pro- body. Doctors also have an ethical duty to involve
fessionals. The results from surveys are available the person in his or her health care. Informed
to the public and posted in the facility. consent is the process in which a person, with
the help of a doctor, makes informed decisions
OBRA also identifies important rights for resi-
about his or her health care.
dents in long-term care facilities. Residents’
Rights relate to how residents must be treated The right to make independent choices: Resi-
while living in a facility. They are an ethical code dents can make choices about their doctors, care,
of conduct for healthcare workers. Facilities give and treatments. They can make personal deci-
residents a list of these rights and review each sions, such as what to wear and how to spend
right with them. You need to be familiar with their time. They can join in community activi-
Residents’ Rights, which are very detailed. They ties, both inside and outside the care facility.
include the following: The right to privacy and confidentiality: Resi-
Quality of life: Residents have the right to the dents can expect privacy with care given. Their
best care available. Dignity, choice, and indepen- medical and personal information cannot be
dence are important parts of quality of life. shared with anyone but the care team. Residents
have the right to private, unrestricted communi-
Services and activities to maintain a high level
cation with anyone.
of wellness: Residents must receive the correct
care. Their care should keep them as healthy as The right to dignity, respect, and freedom: Resi-
possible every day. Health should not decline as dents must be respected and treated with dignity
a direct result of the facility’s care. by caregivers. Residents cannot be abused, mis-
treated, or neglected in any way.
The right to be fully informed regarding rights
and services: Residents must be told what care The right to security of possessions: Residents’
and services are available. They must be told the personal possessions must be safe at all times.
fees for each service. They must be made aware They cannot be taken or used by anyone without
of all their legal rights. Legal rights must be a resident’s permission. Residents have the right
explained in a language they can understand. to manage their own finances or choose some-
This includes being given a written copy of their one to do it for them. Residents can ask the care
rights. They have the right to be notified in ad- facility to handle their money and in this case,
vance of any change of room or roommate. They the resident must sign a written statement. If
have the right to communicate with someone the facility handles residents’ financial affairs,
who speaks their language. They have the right residents must have access to their accounts and
 1 12

financial records. They must receive quarterly sible about when, where, and how care is
statements, among other things. performed.
Rights during transfers and discharges: Location • Always explain a procedure to a resident be-
The Nursing Assistant in Long-Term Care

changes must be made safely and with the resi- fore performing it.
dent’s knowledge and consent. Residents have
• Do not unnecessarily expose a resident while
the right to stay in a facility unless a transfer or
giving care.
discharge is needed.
• Respect a resident’s refusal of care. Resi-
The right to complain: Residents have the right
dents have a legal right to refuse treatment
to make complaints without fear of punishment.
and care. However, report the refusal to the
Facilities must work quickly to try to resolve
nurse immediately.
complaints.
• Tell the nurse if a resident has questions
The right to visits: Residents have the right to
or concerns about treatment or the goals of
have visits from family, friends, doctors, clergy
care.
members, groups and others (Fig. 1-12).
• Be truthful when documenting care.
• Do not talk or gossip about residents. Keep
all resident information confidential.
• Knock and ask for permission before enter-
ing a resident’s room.
• Do not accept gifts or money (Fig. 1-13).
• Do not open a resident’s mail or look
through his belongings.
• Respect residents’ personal possessions.
Handle them gently and carefully.
Fig. 1-12. Residents have the right to visitors.
• Report observations about a resident’s condi-
Rights with regard to social services: The facil- tion or care.
ity must provide residents with access to social • Help resolve disputes by reporting them to
services. This includes counseling, assistance in the nurse.
solving problems with others, and help contact-
ing legal and financial professionals.
Protect your residents’ rights in these ways:
• Never abuse a resident physically, emotion-
ally, verbally, or sexually.
• Watch for and report any signs of abuse or
neglect immediately.
• Call the resident by the name he or she
prefers.
• Involve residents in your planning. Allow Fig. 1-13. Nursing assistants should not accept money or
gifts because it is unprofessional and may lead to conflict.
residents to make as many choices as pos-
 13 1

Residents’ Rights • Physical abuse is any treatment, intentional

or not, that causes harm to a person’s body.
Maintaining Boundaries
This includes slapping, bruising, cutting,
In professional relationships, boundaries must be
burning, physically restraining, pushing,

The Nursing Assistant in Long-Term Care

set. Boundaries are the limits to or within the rela-
tionships. Nursing assistants are guided by ethics shoving, or even rough handling.
and laws that set limits for their relationships with
residents. These boundaries help support a healthy • Psychological abuse is emotionally harm-
resident-caregiver relationship. Working closely with ing a person by threatening, scaring, humili-
residents on a regular basis may make it more dif- ating, intimidating, isolating, insulting, or
ficult to honor the boundaries. Residents may feel
treating him or her as a child.
that you are their friend. If the worker and resident
become personally involved with each other, it be- • Verbal abuse involves the use of lan-
comes more difficult to enforce rules. The resident guage—spoken or written—that threatens,
may expect you to break the rules because she thinks
you are friends. Emotional attachments to residents embarrasses, or insults a person.
weaken your judgment and are unprofessional. Be • Assault is threatening to touch a person
friendly, warm, and caring with residents. But be-
have professionally and stay within the limits of set
without his or her permission. The person
boundaries. Follow your facility’s rules and the care feels fearful that he or she will be harmed.
plan’s instructions. They are in place for everyone’s Telling a resident that she will be slapped if
protection. she does not stop yelling is an example of
assault.
A very important part of protecting your resi-
dents’ rights is preventing abuse and neglect. In • Battery means a person is actually touched
order to do this, it helps if you understand more without his or her permission. An example
about the different types of each. is an NA hitting or pushing a resident. This
is also considered physical abuse. Forcing a
Neglect means harming a person physically, resident to eat a meal is another example of
mentally, or emotionally by failing to provide battery.
needed care. Neglect can be purposeful (active
neglect) or unintentional (passive neglect). Ex- • Sexual abuse is forcing a person to perform
amples of active neglect are leaving a bedridden or participate in sexual acts against his or
resident alone for a long time or denying a resi- her will. This includes unwanted touching
dent food, dentures, or eyeglasses. With passive and exposing oneself to a person. It also in-
neglect the caregiver may not know how to prop- cludes sharing pornographic material.
erly care for the resident, or may not understand • Financial abuse is stealing, taking advan-
the resident’s needs. tage of, or improperly using the money,
Negligence means actions, or the failure to act property, or other assets of another.
or provide the proper care for a resident, that • Domestic violence is abuse by spouses,
result in unintended injury. An example of neg- intimate partners, or family members. It can
ligence is an NA forgetting to lock a resident’s be physical, sexual, or emotional. The vic-
wheelchair before transferring her. The resident tim can be a woman or man of any age or a
falls and is injured. Malpractice occurs when a child.
person is injured due to professional misconduct • Workplace violence is abuse of staff by
through negligence, carelessness, or lack of skill. residents or other staff members. It can be
Abuse is purposely causing physical, mental, or verbal, physical, or sexual. This includes im-
emotional pain or injury to someone. There are proper touching and discussion about sexual
many forms of abuse, including the following: subjects.
 1 14

• False imprisonment is the unlawful Burns of unusual shape and in unusual loca-
restraint of someone which affects the tions; cigarette burns
person’s freedom of movement. Both the
Scalding burns
threat of being physically restrained and
The Nursing Assistant in Long-Term Care

actually being physically restrained are false Scratches and puncture wounds
imprisonment. Not allowing a resident to Scalp tenderness and patches of missing hair
leave the building is also considered false
Swelling in the face, broken teeth, nasal
imprisonment.
discharge
• Involuntary seclusion is separating a per-
Bruises, bleeding, or discharge from the
son from others against the person’s will.
vaginal area
For example, an NA confines a resident to
his room without his consent. Signs that could indicate abuse include:

• Sexual harassment is any unwelcome Yelling obscenities

sexual advance or behavior that creates an Fear, apprehension, fear of being alone
intimidating, hostile or offensive working
Poor self-control
environment. Requests for sexual favors, un-
wanted touching, and other acts of a sexual Constant pain
nature are examples of sexual harassment. Threatening to hurt others
• Substance abuse is the use of legal or ille- Withdrawal or apathy (Fig. 1-14)
gal drugs, cigarettes, or alcohol in a way that
harms oneself or others. Alcohol or drug abuse

Nursing assistants must never abuse residents Agitation or anxiety, signs of stress
in any way. They must also try to protect resi- Low self-esteem
dents from others who abuse them. If you ever
Mood changes, confusion, disorientation
see or suspect that another caregiver, family
member, or resident is abusing a resident, report Private conversations are not allowed, or the
this immediately to the nurse in charge. Report- family member/caregiver must be present
ing abuse is not an option—it is the law. during all conversations
Resident or family reports of questionable
Observing and Reporting: Abuse and Neglect care
Signs that could indicate neglect include:
These are “suspicious injuries.” They should be
Pressure sores
reported:
Body not clean
Poisoning or traumatic injury
Body lice
Teeth marks
Unanswered call lights
Belt buckle or strap marks
Soiled bedding or incontinence briefs not
Old and new bruises, contusions and welts being changed
Scars Poorly-fitting clothing
Fractures, dislocation Refusal of care
 15 1

Unmet needs relating to hearing aids, eye- If abuse is suspected or observed, give the nurse
glasses, etc. as much information as possible. If residents
Weight loss, poor appetite want to make a complaint of abuse, you must
help them in every possible way. This includes

The Nursing Assistant in Long-Term Care

Uneaten food telling them of the process and their rights.
Dehydration Never retaliate against (punish) residents com-
Fresh water or beverages not being given plaining of abuse. If you see someone being
each shift cruel or abusive to a resident who made a com-
plaint, you must report it.
An ombudsman can assist residents, too. An
ombudsman is assigned by law as the legal ad-
vocate for residents. The Older Americans Act
(OAA) is a federal law that requires all states to
have an ombudsman program. The ombudsman
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-
tle disputes concerning residents’ health, safety,
welfare, and rights. The ombudsman will gather
information and try to resolve the problem on
the resident’s behalf, and may suggest ways to
solve the problem. Ombudsmen provide an on-
going presence in long-term care facilities. They
monitor care and conditions (Fig. 1-15).

Fig. 1-14. Withdrawing from others is an important

change to report.

You will be in an excellent position to observe

and report abuse or neglect. As mentioned
earlier NAs have an ethical and legal responsi-
bility to observe for signs of abuse and report
suspected cases to the nurse. Nursing assistants
must follow the chain of command when report-
ing abuse. If action is not taken, keep reporting
up the chain of command, and do this until ac-
tion is taken. If no appropriate action is taken
at the facility level, call the state abuse hotline,
which is an anonymous call. If a life-or-death
situation is witnessed, remove the resident to a
safe place, if possible. Get help immediately or Fig. 1-15. An ombudsman is a legal advocate for resi-
have someone go for help. Do not leave the resi- dents. He or she may work with other agencies to resolve
dent alone. complaints.
 1 16

Residents’ Rights NAs cannot give out any resident information

to anyone not directly involved in the resident’s
Residents’ Council
care, unless the resident gives official consent
A Residents’ Council is a group of residents who
or unless the law requires it. For example, if a
The Nursing Assistant in Long-Term Care

meet regularly to discuss issues related to the care

facility. This Council gives residents a voice in facility neighbor asks you how a resident is doing, reply,
operations. Topics of discussion may include facil- “I’m sorry, but I cannot share that information.
ity policies, decisions regarding activities, concerns,
It’s confidential.” That is the correct response to
and problems. The Residents’ Council offers resi-
dents a chance to provide suggestions on improving anyone who does not have a legal reason to know
the quality of care. Council executives are elected about the resident. Other ways to protect resi-
by residents. Family members are invited to attend dents’ privacy include the following guidelines:
meetings with or on behalf of residents. Staff may
participate in this process when invited by Council
members. Guidelines: Protecting Privacy

To respect confidentiality means to keep pri- G Make sure you are in a private area when you
vate things private. You will learn confidential listen to or read your messages.
(private) information about your residents. You
G Know with whom you are speaking on the
may learn about health, finances, and relation-
phone. If you are not sure, get a name and
ships. Ethically and legally, you must protect this
number. Call back after you get approval.
information. You should not tell anyone except
members of the care team anything about your G Do not talk about residents in public (Fig.
residents. 1-16). Public areas include elevators, gro-
cery stores, lounges, waiting rooms, parking
Congress passed the Health Insurance Por-
garages, schools, restaurants, etc.
tability and Accountability Act (HIPAA) in
1996. It was refined and revised in 2001 and G Use confidential rooms for reports to other
again in 2002. One reason for this law is to care team members.
keep health information private and secure. All G If you see a resident’s family member or a
healthcare organizations must take special steps former resident in public, be careful with your
to protect health information. They and their greeting. He or she may not want others to
employees can be fined and/or imprisoned if know about the family member or that he or
they break rules that protect patient privacy. This she has been a resident.
applies to all healthcare providers, including
doctors, nurses, nursing assistants, and all team G Do not bring family or friends to the facility
members. to meet residents.

Under this law, health information must be kept G Make sure nobody can see health informa-
private. It is called protected health information tion on your computer screen.
(PHI). PHI includes the patient’s name, address, G Log off when not using your computer.
telephone number, social security number, e-
G Do not send confidential information in
mail address, and medical record number. Only
e-mails. You do not know who has access to
those who must have information for care or to
your messages.
process records should know this information.
They must protect the information. It must not G Make sure fax numbers are correct before
become known or used by anyone else. It must faxing information. Use a cover sheet with a
be kept confidential. confidentiality statement.
 17 1

G Do not leave documents where others may • It is the only way to guarantee clear and
see them. complete communication among all the
members of the care team.
G Store, file, or shred documents according

The Nursing Assistant in Long-Term Care

to facility policy. If you find documents with • It is a legal record of every resident’s treat-
a resident’s information, give them to the ment. Medical charts can be used in court as
nurse. legal evidence.
• Documentation protects you and your em-
ployer from liability by proving what you did.
• Documentation gives an up-to-date record
of the status and care of each resident
(Fig. 1-17).

Fig. 1-16. Do not discuss residents in public places.

All healthcare workers must follow HIPAA regu-

lations no matter where they are or what they are
doing. There are serious penalties for violating
these rules, including:
• Fines ranging from $100 to $250,000
• Prison sentences of up to ten years
Fig. 1-17. Documentation provides important, up-to-date
Maintaining confidentiality is a legal and ethical
information about the resident.
obligation. It is part of respecting your residents
and their rights. Discussing a resident’s care or
personal affairs with anyone other than mem- Guidelines: Careful Documentation
bers of the care team violates the law.
G Write your notes immediately after the care is
given. This helps you to remember important
8. Explain legal aspects of the resident’s details. Do not record any care before it has
medical record been done.

The resident’s medical record or chart is a legal G Think about what you want to say before writ-
document. What is written in the record is con- ing. Be as brief and as clear as possible.
sidered in court to be what actually happened. G Write facts, not opinions.
In general, if something does not appear in a
G Write neatly. Use black ink.
resident’s chart, it did not legally happen. Failing
to document your care could cause very serious G If you make a mistake, draw one line through
legal problems for you and your employer. It it. Write the correct word or words. Put your
could also cause harm to your resident. Remem- initials and the date. Never erase what you
ber: if you did not document it, you did not do it. have written. Do not use correction fluid
Careful charting is important for these reasons: (Fig. 1-18).
 1 18

and seconds do not change when converting

from regular to military time. For example,
to change 4:22 p.m. to military time, add 4 +
12. The minutes do not change. The time is
The Nursing Assistant in Long-Term Care

expressed as 1622 hours.

Fig. 1-18. Corrected notes.
Midnight is the only time that differs.
G Sign your full name and title. Write the cor- Midnight can be written as 0000, and it can
rect date. also be written as 2400. This follows the rule
of adding 12 to the regular time. Follow your
G Document as specified in the care plan. facility’s policy on whether to use 0000 or
Some facilities have a “check-off” sheet for 2400 to express midnight.
documenting care. It is also called an ADL
(activities of daily living) or flow sheet. G Some facilities use computers to document
information. Computers record and store
G You may need to document using the information. It can be retrieved when it is
24-hour clock, or military time (Fig. 1-19). needed. This is faster and more accurate than
To change regular hours between 1:00 p.m. writing information by hand. If your facil-
to 11:59 p.m. to military time, add 12 to the ity uses computers for documentation, you
regular time. For example, to change 4:00 will be trained to use them. HIPAA privacy
p.m. to military time, add 4 + 12. The time is guidelines apply to computer use. Make sure
expressed as 1600 (sixteen hundred) hours. nobody can see private and protected health
or personal information on your computer
1200
PM screen. Do not share confidential information
2300 1300
12 with anyone except the care team.
11 1
0000
2200 1100 or 0100 1400
10
2400
2
9. Explain the Minimum Data Set (MDS)
1000 0200
AM A resident assessment system was developed
2100 9 0900 0300 3 1500 in 1990. It is revised periodically. It is called
the Minimum Data Set (MDS). The MDS is
0800 0400 a detailed form with guidelines for assessing
8 4 residents. It also lists what to do if resident prob-
2000 0700 0500 1600 lems are identified. Facilities must complete the
0600
7 5 MDS for each resident within 14 days of admis-
6
1900 1700 sion and again each year. In addition, the MDS
1800 for each resident must be reviewed every three
months. A new MDS must be done when there
Fig. 1-19. Divisions in the 24-hour clock.
is any major change in the resident’s condition.
To change from military time to regular time, The reporting you do on changes in your resi-
subtract 12. For example, to change 2200 dents may “trigger” a needed assessment. Al-
hours to standard time, subtract 12 from 22. ways report changes you notice to the nurse.
The answer is 10:00 p.m. They may be a sign of an illness or problem. By
reporting them promptly, a new MDS assess-
Both regular and military time list minutes
ment can be done if needed.
and seconds the same way. The minutes
 19 1

10. Discuss incident reports your protection, write a brief and accurate de-
scription of the events as they happened. Never
An incident is an accident or unexpected event place any blame or liability within the incident
during the course of care. It is not part of the report. Incident reports help demonstrate areas

The Nursing Assistant in Long-Term Care

normal routine in a facility. An error in care, where changes can be made to avoid repeating
such as feeding a resident from the wrong meal the same incident. When completing an incident
tray, is an incident. A fall or injury to a resident, report, follow these guidelines:
employee, or visitor is another type of incident.
An accusation from a resident or family member
against staff is another example of an incident. Guidelines: Incident Reporting
Employee injuries also require reporting. A
sentinel event is an accident or incident that re- G Tell what happened. State the time, and the
sults in grave physical or psychological injury or mental and physical condition of the person.
death. In general, file a report when any of the G Tell how the person tolerated the incident
following incidents occur: (his reaction).
• A resident falls (all falls must be reported, G State the facts; do not give opinions.
even if the resident says he or she is fine)
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
advances or remarks
• Anything happens that makes you feel un-
comfortable, threatened, or unsafe
• You get injured on the job
• You are exposed to blood or body fluids
Reporting and documenting incidents is done to
protect everyone involved. This includes the resi-
dent, your employer, and you. Always complete
an incident report when an incident occurs.
Complete the report as soon as possible and give
it to the charge nurse. This is important so that
you do not forget any details.
State and federal guidelines require incidents to
be recorded in an incident report. The informa-
tion in an incident report is confidential.
If a resident falls, and you did not see it, do not
write “Mr. G fell.” Instead write “found Mr. G
on the floor,” or “Mr. G states that he fell.” For
 2 20

2
Foundations of Resident Care

Foundations of Resident Care

1. Understand the importance of verbal

and written communications
Effective communication is a critical part of your
job. Nursing assistants must communicate with
supervisors, the care team, residents, and family
members. A resident’s health depends on how
well you communicate your observations and
concerns to the nurse.
Communication is the process of exchanging
information with others. It includes sending and Fig. 2-1. Body language often speaks as plainly as words.
receiving messages. People communicate with Which of these people seems more interested in the con-
signs and symbols, such as words, drawings, versation they are having?
and pictures. They also communicate by their
behavior. Nursing assistants must be able to make brief,
accurate oral and written reports to residents
Verbal communication uses words or sounds,
and staff. Good communication skills are
spoken or written. Oral reports are an example
needed to collect information about residents.
of verbal communication. Nonverbal com-
These skills will help you get information from
munication is communicating without using
residents and their families to report to the care
words. Examples include shaking your head
team. This information may be written or given
or shrugging your shoulders. Body language
in oral reports from shift to shift. Remember
is another form of nonverbal communication.
that all resident information is confidential; only
Movements, facial expressions, and posture can
share information with members of the care
express different attitudes or emotions. Be aware
team.
of your body language when you speak (Fig. 2-1).
Your careful observations are important to the
Residents’ Rights health and well-being of all residents. Signs
Different Languages and symptoms that should be reported will be
Residents may speak a different language than you discussed throughout this textbook. Some of
do. When caring for residents, always use a language your observations will need to be reported im-
they can understand or find an interpreter (someone
who speaks their language). You may need to use mediately to the nurse. Deciding what to report
pictures or gestures to communicate. Do not use a immediately involves critical thinking. Anything
different language when speaking with staff in front that endangers residents should be reported at
of residents. once, including:
 21 2

• Falls
• Encourage the resident to interact with you and
• Chest pain others.

• Severe headache • Be courteous.

Foundations of Resident Care

• Trouble breathing • Tell the resident when you are leaving the room.

• Abnormal pulse, respiration, or blood

pressure Residents’ Rights
• Change in mental status Names
Call residents by the names that they prefer you to
• Sudden weakness or loss of mobility
use. Do not refer to them by their first names unless
• High fever they have told you that it is OK to do so. Do not use
disrespectful terms such as “sweetie,” “honey,” or
• Loss of consciousness “dearie.”
• Change in level of consciousness
• Bleeding When making any report, you must collect the
right information before documenting it. Facts,
• Change in resident’s condition not opinions, are most useful to the nurse and
• Bruises, abrasions, or other signs of possible the care team. Two kinds of factual information
abuse are needed in your reporting. Objective infor-
mation is based on what you see, hear, touch,
When residents report symptoms, events, or
or smell. Objective information is collected by
feelings, have them repeat what they have said.
using the senses. Subjective information is
Ask for more information. Avoid asking ques-
something you cannot or did not observe. It is
tions that can be answered with a simple “yes”
based on something that the resident reported to
or “no.” Instead, ask questions that ask for more
you that may or may not be true. An example of
detailed information. For example, asking, “Did
objective information is, “Mr. McClain is hold-
you sleep well last night?” could easily be an-
ing his head and rubbing his temples.” A subjec-
swered “yes” or “no.” However, “Tell me about
tive report of the same situation might be, “Mr.
your night and how you slept” will encourage
McClain says he has a headache.” The nurse
the resident to offer facts and details.
needs factual information in order to make deci-
Proper Communication sions about care and treatment. Both objective
and subjective reports are valuable.
When communicating with residents, remember to
In any report, make sure what you observe
• Always greet the resident by his or her preferred
name. (signs) and what the resident reports to you
(symptoms) are clearly noted. “Ms. Scott reports
• Identify yourself.
pain in left shoulder” is an example of clear re-
• Focus on the proper topic to be discussed. porting. You are not expected to make diagnoses
• Face the resident while speaking. Avoid talking based on signs and symptoms you observe. Your
into space. observations, however, can alert staff to possible
• Talk with the resident while giving care. problems. In order to report accurately, observe
your residents accurately. To observe accurately,
• Listen and respond when the resident speaks.
use as many senses as possible to gather infor-
• Praise the resident and smile often. mation (Fig. 2-2). Some examples follow.
 2 22

Sight: Sometimes the nurse or another member of the

Smell:
resident’s body or changes in care team will give you a brief oral report on a
breath odor resident’s resident. Listen carefully and take notes (Fig.
appearnce 2-3). Ask about anything you do not understand.
Foundations of Resident Care

At the end of the report, restate what you have

Hearing: been told to make sure you understand.
resident’s words,
tone and breathing

Touch:
resident’s skin
and pulse

Fig. 2-2. Reporting what you observe means using more

than one sense.

Sight. Look for changes in resident’s appearance.

These include rashes, redness, paleness, swell- Fig. 2-3. Take notes so you can remember facts and re-
port accurately.
ing, discharge, weakness, sunken eyes, and pos-
ture or gait (walking) changes. In your training, you will learn medical terms
Hearing. Listen to what the resident tells you for specific conditions. Medical terms are made
about his condition, family, or needs. Is he up of roots, prefixes, and suffixes. A root is a
speaking clearly and making sense? Does he part of a word that contains its basic meaning.
show emotions, such as anger, frustration, or The prefix is the word part that comes before
sadness? Is breathing normal? Does the resident the root to help form a new word. The suffix
wheeze, gasp, or cough? Is the area calm and is the word part added to the end of a root that
quiet enough for him to rest as needed? helps form a new word. Prefixes and suffixes are
called “affixes” because they are attached to a
Touch. Does your resident’s skin feel hot or cool,
root. Here are some examples:
moist or dry? Is the pulse rate regular?
• The root “derm” or “derma” means skin. The
Smell. Do you notice odor from the resident’s
suffix “itis” means inflammation. Dermatitis
body? Odors could suggest poor bathing, infec-
is an inflammation of the skin.
tions, or incontinence. Incontinence is the in-
ability to control the bladder or bowels. Breath • The prefix “brady” means slow. The root
odor could suggest use of alcohol or tobacco, “cardia” means heart. “Bradycardia” is slow
indigestion, or poor oral care. heartbeat or pulse.
Using all your senses will help you make the • The suffix “pathy” means disease. The root
most complete report of a resident’s situation. “neuro” means of the nerve or nervous sys-
tem. Neuropathy is a nerve disease or dis-
For an oral report, write notes so you do not for-
ease of the nervous system.
get any important details. Do not rely on your
memory alone. Following an oral report, docu- When speaking with residents and their fami-
ment when, why, about what, and to whom an lies, use simple, non-medical terms. Do not use
oral report was given. medical terms, because they may not under-
 23 2

stand these terms. But when you speak with

room and a sound and can be heard in the nurses’
the care team, medical terms will help you give station. This is the primary way a resident can call for
more complete information. help. Always respond immediately when you see the
light or hear the sound. Respond in a courteous and

Foundations of Resident Care

Abbreviations are a way to communicate more respectful manner. Check each time before you leave
efficiently with the care team. For example, the a room to make sure that the call light is within the
abbreviation “prn” means “as necessary.” Learn resident’s reach. Make sure that the resident knows
how to use it.
the standard medical abbreviations your facility
uses. Use them to report information briefly and
accurately. You may need to know these abbrevi- 2. Describe barriers to communication
ations to read assignments or care plans. A brief
list of abbreviations is located at the end of this Communication can be blocked or disrupted in
textbook. Check with your facility to see if there many ways (Fig. 2-4). These are some barriers
are terms you must know. and ways to avoid them:
Resident does not hear you, does not hear cor-
Telephone Communication
rectly, or does not understand. Face the resident.
You may be asked to answer the telephone at Speak more slowly than you do with family and
your facility. When answering calls, follow these friends. Speak clearly. Use a low, pleasant voice.
steps: Do not whisper or mumble. If the resident says
• Always identify your facility’s name and he cannot hear you, speak more loudly. However,
your name. Be friendly and professional. For use a pleasant, professional tone. If the resident
example, “Hartman Manor, this is Isabelle wears a hearing aid, check that it is on and is
Hedman. How may I help you?” working properly.

• If you need to find the person the caller Resident is difficult to understand. Be patient.
wishes to speak with, place the caller on hold Take time to listen. Ask resident to repeat or
after asking if it is OK to do so. explain. State the message in your own words to
make sure you have understood. Use a pen and
• If the caller has to leave a message, write it
paper or communication board to communicate.
down and repeat it to make sure you have
the correct message. Ask for proper spellings Message uses words receiver does not under-
of names. Do not ask for more information stand. Do not use medical terms with residents.
than the person needs to return the call: a Speak in simple, everyday words. Ask what a
name, short message, and phone number word means if you are not sure.
is enough. Do not give out any information Do not use slang words. Do not curse. Using
about staff or residents. slang can confuse the message. Avoid slang; it is
• Thank the person for calling and say unprofessional and may not be understood. Do
goodbye. not curse or use profanity, even if the resident
does.
Call Lights Avoid clichés. Clichés are phrases that are used
Long-term care facilities are required to have call sys- over and over again and do not really mean any-
tems—often called “call lights”—so that residents thing. For example, “Everything will be fine” is
can ask for help whenever they need it. They are in a cliché. Instead of using a cliché, listen to what
resident rooms and bathrooms. Some have strings
for residents to pull and others have buttons to
your resident is really saying. Respond with a
push. The signal is usually both a light outside the meaningful message.
 2
Foundations of Resident Care
24

Fig. 2-4. Barriers to communication.

Giving advice is inappropriate. Do not offer sages from residents. Clarify them. For example,
your opinion or advice. Giving medical advice “Mr. Feldman, you say you’re feeling fine but
is not within your scope of practice. It could be you seem to be in pain. Can I help?”
dangerous.
Defense mechanisms may be considered barri-
Asking “why” makes the resident defensive. ers to communication. Defense mechanisms
Avoid asking “why” when a resident makes a are unconscious behaviors used to release ten-
statement. “Why” questions make people feel sion or cope with stress. They help to block un-
defensive. comfortable or threatening feelings. Common
Yes/no answers end a conversation. Ask open- defense mechanisms include:
ended questions. They require more than a “yes” • Denial: Completely rejecting the thought or
or “no” answer. Yes and no answers bring con- feeling—”I’m not upset with you!”
versation to an end. For example, if you want to • Projection: Seeing feelings in others that are
know what your resident likes to eat, do not ask really one’s own—”My teacher hates me.”
“Do you like vegetables?” Instead, try, “Which
vegetables do you like best?” • Displacement: Transferring a strong nega-
tive feeling to a safer place—for example, an
Resident speaks a different language. If a resi- unhappy employee cannot yell at his boss
dent speaks a different language than you do, for fear of losing his job. He later yells at his
speak slowly and clearly. Keep your messages wife.
short and simple. Be alert for words the resident
understands. Also be alert for signs the resident • Rationalization: Making excuses to justify a
is only pretending to understand you. You may situation—for example, after stealing some-
need to use pictures or gestures to communi- thing, saying, “Everybody does it.”
cate. Ask the resident’s family or other staff • Repression: Blocking painful thoughts or
members who speak the resident’s language for feelings from the mind—for example, forget-
help. Be patient and calm. ting sexual abuse.
Nonverbal communication changes the message. • Regression: Going back to an old, usually
Be aware of your body language and gestures immature behavior—for example, throwing
when you are speaking. Look for nonverbal mes- a temper tantrum as an adult.
 25 2

Culture can affect communication. A culture ing impairment may use a hearing aid, may read
is a system of learned behaviors, practiced by a lips, or use sign language. People with impaired
group of people, that are considered to be the hearing also closely observe the facial expres-
tradition of that people and are passed on from sions and body language of others to add to their

Foundations of Resident Care

one generation to the next. Each culture may knowledge of what is being said. Hearing loss
have different knowledge, behaviors, beliefs, may affect how well residents can express their
values, attitudes, religions, and customs. When needs.
you communicate with residents from different
cultures, ask yourself:
Guidelines: Hearing Impairment
• What information do I need to communicate
to this person? G If the person has a hearing aid, make sure
he or she is wearing it and that it is working
• Does this person speak English as a first or
properly (Fig. 2-5). There are many types of
second language?
hearing aids. Follow manufacturer’s direc-
• Do I speak this person’s language, or do I tions for cleaning. In general, the hearing aid
need an interpreter? needs to be cleaned daily. Wipe it with alco-
• Does this person have any cultural practices hol using a tissue or soft cloth. Do not put
about touch or gestures I should adapt to? it in water. Handle the hearing aid carefully.
Do not drop it. Always store it inside its case
Learning each resident’s behavior can be a
when it is not worn. Turn it off when it is not
challenge. However, it is an important part of
in use. Remove it before showers or when
communication. It is especially vital in a multi-
bathing resident and during the night. When
cultural society (a society made up of many cul-
storing it for an extended period of time,
tures), such as the United States. Be aware of all
remove the battery.
the messages you send and receive. Listen and
observe carefully. You will learn to better under-
stand your residents’ needs and feelings.

3. List guidelines for communicating with

residents with special needs
Due to illness or impairments, some residents
will need special techniques to aid communica-
tion. An impairment is a loss of function or
Fig. 2-5. This is one type of hearing aid. Make sure hear-
ability; it can be a partial or complete loss. Spe- ing aids are turned on.
cial techniques for different conditions are listed
below. G Reduce or remove noise, such as TVs, radios,
Information on communicating with residents and loud speech. Close doors if needed.
who have Alzheimer’s disease is in Chapter 5. G Get residents’ attention before speaking. Do
not startle them by approaching from behind.
Hearing Impairment or Deafness Walk in front or touch them lightly on the
Persons who have impaired hearing or are deaf arm to show you are near.
may have lost their hearing gradually, or they G Speak clearly and slowly. Directly face the
may have been born deaf. People who have hear- person (Fig. 2-6). Make sure there is enough
 2 26

light in the room. The light should be on your occur in one eye or in both. It can also be the
face, rather than on the resident’s. Ask if he result of injury, illness, or aging. Some vision
can hear what you are saying. impairment causes people to wear corrective
lenses. These can be contact lenses or eye-
Foundations of Resident Care

glasses. Some people need to wear eyeglasses all

the time. Others only need them to read or for
activities, such as driving, that require seeing
distant objects.

Guidelines: Vision Impairment

G If the resident has glasses, make sure they

Fig. 2-6. Speak face-to-face in good light. are clean and that they are worn. Clean glass
lenses with water and soft tissue. Clean plas-
G Do not shout. Do not mouth the words in an tic lenses with cleaning fluid and a lens cloth.
exaggerated way. Also, make sure that glasses are in good
condition and fit well. If they do not, tell the
G Keep the pitch of your voice low.
nurse.
G Residents may read lips, so keep hands away
from your face while talking. Do not chew G Knock on the door and identify yourself when
gum or eat while speaking. you enter the room. Do this before touching
the resident. Explain why you are there and
G Know which ear hears better. Try to speak to what you would like to do. Let the resident
and stand on that side. know when you are leaving the room.
G Use short sentences and simple words. Avoid G Always tell the resident what you are doing
sudden topic changes. while caring for him. Give specific directions,
G Repeat what you have said using different such as, “On your right” or, “In front of you.”
words, when needed. Some hearing-impaired Talk directly to the resident whom you are
people want you to repeat exactly what you assisting. Do not talk to other residents or
said. This is because they miss only a few staff members.
words.
G Make sure there is proper lighting in the
G Use picture cards or a notepad as needed. room. Face the resident when speaking.
G Hearing impaired residents may hear less G When you enter a new room with the resi-
when they are tired or ill. This is true of every- dent, orient him or her to the area. Describe
one. Be patient and empathetic. the things you see around you. Do not use
G Hearing decline can be a normal aspect of words such as “see,” “look,” and “watch.”
aging. Be matter-of-fact about this. Be under- G Tell the resident where the call light is.
standing and supportive.
G Use the face of an imaginary clock as a guide
Vision Impairment to explain the position of objects that are
around the resident (Fig. 2-7). For example,
Vision impairment can affect people of all ages.
“There is a sofa at 7 o’clock.”
It can exist at birth or develop gradually. It can
 27 2

• Adapt to change
• Care for self and others
• Give and accept love

Foundations of Resident Care

• Deal with situations that cause stress, disap-
pointment, and frustration
• Take responsibility for decisions, feelings,
and actions
• Control and fulfill desires and impulses
appropriately

Fig. 2-7. The face of a clock can explain the position of

objects.

G Do not move personal items or furniture

without the resident’s permission.
G Put everything back where it was found.
G Leave the door completely open or complete-
Fig. 2-8. The ability to interact well with other people is a
ly closed.
characteristic of mental health.
G Encourage the use of the other senses, such
as hearing, touch, and smell. Encourage the While it involves emotions and mental func-
resident to feel and touch things, such as tions, mental illness is a disease. It is like any
clothing, furniture, or items in the room. physical disease. It produces signs and symp-
G Offer large-print newspapers, magazines, and toms and affects the body’s ability to function. It
books. responds to proper treatment and care. Mental
illness disrupts a person’s ability to function at a
G Use large clocks, clocks that chime, and radi-
normal level in the family, home, or community.
os to help keep track of time.
It often causes inappropriate behavior.
G Get books on tape and other aids from the
Mentally healthy people are able to control their
library or support organizations.
emotions and actions. Mentally ill people may
G If the resident has a guide dog, do not play not have this control. Mentally ill people cannot
with or distract it or feed it. simply choose to be well. Knowing that mental
illness is a disease helps you work with mentally
Mental Illness ill residents.
Mental health is the normal functioning of emo- Different types of mental illness will affect how
tional and intellectual abilities. Traits of a person well residents communicate. Treat each resident
who is mentally healthy include the abilities to as an individual. Tailor your approach to the
• Get along with others (Fig. 2-8) situation.
 2 28

Guidelines: Mental Illness Guidelines: Combative Behavior

G Do not talk to adults as if they were children. G Block physical blows or step out of the way,
Foundations of Resident Care

but never hit back (Fig. 2-10). No matter

G Use simple, clear statements. Use a normal
how much a resident hurts you, or how angry
tone of voice.
or afraid you are, never hit or threaten a
G Be sure that what you say and how you say it resident.
show respect and concern.
G Sit or stand at a normal distance from the
resident. Be aware of your body language.
G Be honest and direct, as with any resident.
G Avoid arguments.
G Maintain eye contact.
G Listen carefully (Fig. 2-9).

Fig. 2-10. Step out of the way but never hit back.

G Remain calm. Lower the tone of your voice.

G Be flexible and patient.
G Do not respond to verbal attacks. Do not
argue. Do not accuse the resident of
Fig. 2-9. Practice good communication skills with men-
wrongdoing.
tally ill residents.
G Do not use gestures that could frighten or
See Learning Objective 9 in Chapter 3 for more startle the resident.
information on mental illness.
G Be reassuring and supportive.

Combative Behavior G Consider what provoked the resident.

Sometimes something as simple as a change
Residents may display combative, meaning vio- in caregiver or routine can be very upsetting.
lent or hostile, behavior. Such behavior includes Get help to take the resident to a quieter
hitting, pushing, kicking, or verbal attacks. It place.
may result from disease affecting the brain. It
may also be due to frustration. Or it may just be G Report inappropriate behavior to the nurse.
part of someone’s personality. In general, com-
bative behavior is not a reaction to you. Try not Anger
to take it personally. Anger is a natural emotion that has many
Always report and document combative behav- causes. Some are disease, fear, pain, loneliness,
ior. Even if you are not upset by the behavior, the and loss of independence. Anger may also just
care team needs to be aware of it. be a part of someone’s personality. Some people
get angry more easily than others.
 29 2

People express anger in different ways. Some of-fact. Do not over-react. This may actually
may shout, yell, threaten, throw things, or pace. reinforce the behavior. Try to distract the person.
Others express their anger by withdrawing, If that does not work, gently direct the resident
being silent, or sulking. Always report angry be- to a private area. Notify the nurse.

Foundations of Resident Care

havior to the nurse. Confused residents may have problems that
mimic inappropriate sexual behavior. They may
Guidelines: Angry Behavior have an uncomfortable rash, clothes that are too
tight, too hot, or too scratchy, or they may need
G Stay calm. to go to the bathroom. Consider and watch for
these problems. When residents act inappropri-
G Do not argue or respond to verbal attacks.
ately, report it, even if you think it was harmless.
G Empathize with the resident. Try to under-
stand what he or she is feeling. Residents’ Rights
G Try to find out what caused the resident’s Communicating with Residents
Your interactions with residents are important. Resi-
anger. Using silence may help the resident
dents’ emotional, social, and physical health can
explain. Listen attentively as the resident depend a great deal on how you communicate. This
speaks. is especially true for residents who are cognitively
impaired, lonely, helpless, or bored. Be comforting
G Treat the resident with dignity and respect. and kind with residents. Listen if they want to talk.
Explain what you are going to do and when Just the presence of a caring person can communi-
you will do it. cate, “I am here for you” and can reassure residents
that they are not alone.
G Answer call lights promptly.
G Stay at a safe distance if the resident 4. Identify ways to promote safety and
becomes combative. handle non-medical emergencies

Inappropriate Behavior Safety

Some residents will behave inappropriately. In- All staff members, including you, are responsi-
appropriate behavior from a resident includes ble for safety in a facility. It is very important to
trying to establish a personal, rather than a pro- try to prevent accidents before they occur. Preven-
fessional, relationship. Examples include asking tion is the key to safety. As you work, watch for
personal questions, requesting visits on personal safety hazards. Report unsafe conditions to your
time, asking for or doing favors, giving tips or supervisor promptly. Before leaving a resident’s
gifts, and loaning or borrowing money. room, look around and do a final check. Ask
yourself:
Inappropriate behavior includes making sexual
advances and comments. Sexual advances in- • Is the call light within reach?
clude any sexual words, comments, or behavior • Is the room tidy? Are the resident’s items in
that make you feel uncomfortable. Report this their proper places?
behavior to the nurse immediately.
• Are the side rails up if they are ordered?
Inappropriate behavior also includes residents
• Is the furniture in the same place as you
removing their clothes or touching themselves
found it? Is the bed in its lowest position?
in public. Illness, dementia, confusion, and
medication may cause this behavior. If you en- • Does the resident have a clear walkway
counter any embarrassing situation, be matter- around the room and into the bathroom?
 2 30

Principles of Body Mechanics Center of gravity. The center of gravity in your

Back strain or injury is one of the greatest risks body is the point where the most weight is con-
that nursing assistants face. Using proper body centrated. This point will depend on the position
of the body. When you stand, your weight is cen-
Foundations of Resident Care

mechanics is an important step in preventing

back strain and injury. Body mechanics is the tered in your pelvis. A low center of gravity gives
way the parts of the body work together when a more stable base of support. Bending your
you move. Understanding some basic principles knees when lifting an object lowers your pelvis
of body mechanics will help keep you and resi- and, therefore, lowers your center of gravity. This
dents safe. gives you more stability. It makes you less likely
to fall or strain the working muscles.
Alignment. When standing, sitting, or lying
down, try to have your body in alignment and Some examples of using good body mechanics
to have good posture. This means that the two include:
sides of the body are mirror images of each When lifting a heavy object from the floor,
other, with body parts lined up naturally. Pos- spread your feet shoulder-width apart. Bend
ture is the way a person holds and positions his your knees. Using the strong, large muscles in
body. Maintain correct body alignment when your thighs, upper arms, and shoulders, lift the
lifting or carrying an object by keeping it close object. Pull it close to your body, level with your
to your body. Point your feet and body in the pelvis. By doing this, you keep the object close to
direction you are moving. Avoid twisting at the your center of gravity and base of support. When
waist (Fig. 2-11). you stand up, push with your strong hip and
Alignment thigh muscles. Raise your body and the object
together (Fig. 2-12).

Back muscles must lift Legs and thighs do the

the object and half of lifting
the body

Center
of gravity

Base of
support
Fig. 2-12. In this illustration, which person is lifting
correctly?
Fig. 2-11. Proper body alignment is important when
standing and when sitting.
Do not twist when you are moving an object.
Base of support. The base of support is the foun- Always face the object or person you are moving.
dation that supports an object. The feet are the Pivot your feet instead of twisting at the waist.
body’s base of support. The wider your support, To help a resident sit up, stand up, or walk, pro-
the more stable you are. Standing with your legs tect yourself by assuming a good stance. Place
shoulder-width apart allows for a greater base of your feet 12 inches, or shoulder-width, apart. Put
support. You will be more stable than someone one foot in front of the other, with your knees
standing with his feet together. bent. Your upper body should stay upright and
 31 2

in alignment. Do this whenever you have to sup- • Avoid bending and reaching as much as pos-
port a resident’s weight. If the resident starts to sible. Move or position furniture so that you
fall, you will be in a good position to help sup- do not have to bend or reach.
port her. Never try to “catch” a falling resident.

Foundations of Resident Care

• Avoid twisting at the waist. Instead, turn
If the resident falls, assist her to the floor. If you your whole body. Your feet should point to-
try to reverse a fall in progress, you could injure ward what you are lifting.
yourself and/or the resident.
• When moving a resident, let him know what
Bend your knees to lower yourself, rather than you will do so he can help if possible. Count
bending from the waist. When a task requires to three. Lift or move on three so everyone
bending, use a good stance. This lets you use moves together.
the big muscles in your legs and hips rather
Report to the nurse any task that you feel you
than the smaller muscles in your back.
cannot safely do. Never try to lift an object or a
If you are making a bed, adjust the height to resident that you feel you cannot handle.
a safe working level, usually waist high. Avoid
bending at the waist. Accident Prevention

Keep the following tips in mind to avoid strain Falls

and injury: Most accidents that occur in a facility are falls.
• Assess the situation first. Clear the path. Re- Falls can be caused by an unsafe environment,
move any obstacles. loss of abilities, diseases and medications. Prob-
lems resulting from falls range from minor
• Get help when possible for lifting or helping bruises to fractures and life-threatening injuries.
residents. A fracture is a broken bone. Falls are particu-
• Use both arms and hands to lift, push, or larly common among the elderly. Older people
carry objects. are often more seriously injured by falls, as their
bones are more fragile. Be especially alert to the
• Hold objects close to you when you are lift- risk of falls.
ing or carrying them (Fig. 2-13).
These factors raise the risk of falls:
• Push objects and equipment rather than lift-
• Clutter
ing them.
• Throw rugs
• 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 in-
clude medications, loss of vision, gait or balance
Fig. 2-13. Holding things close to you moves weight problems, weakness, paralysis, and disorienta-
toward your center of gravity. In this illustration, who is tion. Disorientation means confusion about
more likely to strain his back muscles?
person, place or time.
 2 32

falling resident. Use your body to slide her to

Guidelines: Preventing Falls
the floor. If you try to reverse a fall, you may
G Keep all walkways free of clutter, trash, throw hurt yourself and/or the resident.
Foundations of Resident Care

rugs, and cords.

G Use rugs with a non-slip backing. Tip
Reporting Falls
G Have residents wear non-slip, sturdy shoes.
Whenever a resident falls, it must be reported to the
Make sure shoelaces are tied. nurse. Always complete an incident report, even if
the resident says he or she feels fine.
G Residents should avoid wearing clothing that
is too long or drags on the floor.
Burns/Scalds
G Keep frequently-used items close to resi-
dents, including call lights. Burns can be caused by dry heat (e.g. hot iron,
stove, other electrical appliances), wet heat (e.g.
G Answer call lights right away.
hot water or other liquids, steam), or chemicals
G Immediately clean up spills on the floor. (e.g. lye, acids). Small children, older adults, or
G Report loose hand rails immediately. people with loss of sensation due to paralysis
are at greatest risk of burns. Scalds are burns
G If used, check placement of body or bed
caused by hot liquids. It takes five seconds or
alarms and see if they are working.
less for a serious burn to occur when the tem-
G Mark uneven flooring or stairs with colored perature of liquid is 140°F. Coffee, tea, and other
tape to indicate a hazard. hot drinks are usually served at 160°F to 180°F.
G Improve lighting where needed. These temperatures can cause almost instant
burns that require surgery. Preventing burns is
G Lock wheelchairs before helping residents very important.
into or out of them.
G Lock bed wheels before helping a resident Guidelines: Preventing Burns and Scalds
into and out of bed or when giving care.
G Return beds to their lowest position when G Always check water temperature with a bath
you have finished with care. thermometer or on wrist before using.

G Get help when moving residents. Do not G Report frayed electrical cords or unsafe-
assume you can do it alone. looking appliances immediately. Do not use
them. Remove them from the room.
G Offer trips to the bathroom often. Respond
to requests for help immediately. Think about G Let residents know you are about to pour or
how you might feel if you had to wait for help set down a hot liquid.
to go to the bathroom. G Pour hot drinks away from residents.
G Leave furniture in the same place. G Keep hot drinks and liquids away from edges
G Know residents who are at risk for falls. Pay of tables. Put a lid on them.
close attention so that you can give help G Make sure residents are sitting down before
often. serving hot drinks.
G If a resident starts to fall, be in a good posi- G If plate warmers are used, monitor them
tion to help support her. Never try to catch a carefully.
 33 2

Resident Identification sharp objects, including scissors, nail clippers,

or razors, away after use. Take care when trans-
Residents must always be identified before giv-
ferring residents into and out of beds, chairs,
ing care or serving food. Failure to identify
and wheelchairs. When moving a resident in a

Foundations of Resident Care

residents can cause serious problems, and even
wheelchair, push the wheelchair forward. Do not
death. Facilities have different methods of iden-
pull it behind you. If using an elevator to get to
tification. Some have ID bracelets. Some have
another floor, turn the wheelchair around before
pictures to identify residents. Identify each resi-
entering the elevator, so the resident is facing
dent before beginning any procedure or giving
forward.
any care. Always identify residents before plac-
ing meal trays or helping with feeding. Check
the diet card against the resident’s identification. Material Safety Data Sheet (MSDS)
Call the resident by name. The Occupational Safety and Health Ad-
ministration (OSHA) is a federal government
Choking agency that makes rules to protect workers from
Choking can occur when eating, drinking or hazards on the job. OSHA requires that all dan-
taking medication. People who are weak, ill, or gerous chemicals have a Material Safety Data
unconscious may choke on their own saliva. A Sheet (MSDS). This sheet details the chemical
person’s tongue can also become swollen and ingredients, chemical dangers, emergency re-
obstruct the airway. To guard against choking, sponse actions to be taken, and safe handling
residents should eat sitting as upright as pos- procedures for the product. Some facilities use
sible. Residents with swallowing problems may a toll-free number to access MSDS information.
have a special diet with liquids thickened to the MSDSs must be accessible in work areas for all
consistency of honey or syrup. Thickened liquids employees. Important information about the
are easier to swallow. You will learn more about MSDS includes:
thickened liquids in Chapter 8. • Your employer must have a MSDS for every
chemical used.
Poisoning
• Your employer must provide easy access to
Facilities have many harmful substances that the MSDS.
should not be swallowed. These include clean-
• You must know where your MSDSs are kept
ers, paints, medicines, toiletries, and glues.
and how to read them. If you do not know
These products should be stored or locked away
how, ask for help.
from confused residents or those with limited
vision. Do not leave cleaning products in resi- The list of hazardous chemicals that have to
dents’ rooms. Residents with dementia may hide have an MSDS will be updated as new chemicals
food and let it spoil in closets, drawers, or other are purchased.
places. Investigate any odors you notice. The
number for the Poison Control Center should be Fire
posted by all telephones. All facilities have a fire safety plan, and all work-
ers need to know this plan. Your facility’s guide-
Cuts/Abrasions
lines regarding fires and evacuations will be
Cuts or abrasions typically occur in the bath- explained to you. Evacuation routes are posted
room at a facility. An abrasion is an injury in facilities. Read and review them often. Attend
that rubs off the surface of the skin. Put any fire and disaster in-services when they are of-
 2 34

fered. They will help you learn what to do in an G In case of fire, the RACE acronym is a good
emergency. Get residents to safety first. A fast, rule to follow:
calm and confident response by the staff saves Remove residents from danger.
lives.
Foundations of Resident Care

Activate 911.

Guidelines: Reducing Fire Hazards and Contain fire if possible.

Responding to Fires Extinguish, or fire department will extinguish.
Follow these guidelines for helping residents exit
G Never leave smokers unattended. If residents
the building safely:
smoke, make sure they are in the proper
area for smoking. Be sure that cigarettes are G Know the facility’s fire evacuation plan.
extinguished. Empty ashtrays often. Before G Stay calm.
emptying ashtrays, make sure there are no
G Follow the directions of the fire department.
hot ashes or hot matches in the ashtray.
G Know which residents need one-on-one help
G Report frayed or damaged electrical cords
or assistive devices. Immobile residents can
immediately. Report electrical equipment in
be moved in several ways. If they have a
need of repair immediately.
wheelchair, help them into it. You can also
G Fire alarms and exit doors should not be use other wheeled transporters, such as
blocked. If they are, report this to the nurse. carts, bath chairs, stretchers, or beds. A blan-
G Every facility will have a fire extinguisher (Fig. ket can be used as a stretcher or even pulled
2-14). The PASS acronym will help you under- across the floor with someone on it.
stand how to use it: G Residents who can walk will also need help
Pull the pin. getting out of the building. Those who are
hard of hearing or deaf may not hear the
Aim at the base of fire when spraying.
warnings and instructions. Staff will need to
Squeeze the handle. tell them directly what to do while guiding
Sweep back and forth at the base of the fire. them to a safe exit. People with vision prob-
lems should be moved out of the way of the
wheelchairs, carts, etc. and helped to the exit.
Confused and disoriented residents will also
need guidance.
G Remove anything blocking a window or door
that could be used as a fire exit.
G Do not use elevators.
G If a door is closed, check for heat coming
from it before opening it. If the door or door-
knob feels hot, stay in the room if there is no
safe exit. Plug the doorway (use wet towels
or clothing) to prevent smoke from entering.
Stay in the room until help arrives.
Fig. 2-14. Know where the extinguisher is stored in your G Use the “stop, drop, and roll” fire safety
facility and how to use it.
technique to extinguish a fire on clothing or
 35 2

hair. Stop running or stay still. Drop to the what to do in a medical emergency. Heart at-
ground, lying down if possible. Roll on the tacks, stroke, diabetic emergencies, choking,
ground to try to extinguish the flames. automobile accidents, and gunshot wounds are
all medical emergencies. Falls, burns, and cuts

Foundations of Resident Care

G Use a damp covering over the mouth and
nose to reduce smoke inhalation. can also be emergencies. In an emergency, try
to remain calm, act quickly, and communicate
G After leaving the building, move away from it. clearly. Knowing these steps will help:

Disaster Guidelines • Assess the situation. Try to find out what has
happened. Make sure you are not in danger.
Disasters can include fire, flood, earthquake,
Notice the time.
hurricane, tornado, and severe weather. Acts of
terrorism may also be considered disasters. The • Assess the victim. Ask the injured or ill
disasters you may experience will depend on person what has happened. If the person is
where you live. Nursing assistants need to be unable to respond, he may be unconscious.
skilled and professional when a disaster occurs. Being conscious means being mentally alert
Facilities have disaster plans and you will be and having awareness of surroundings, sen-
trained on these plans. Annual in-services and sations, and thoughts. Determine whether
disaster drills are often held at facilities. Take ad- the person is conscious. Tap the person and
vantage of these sessions when offered. Pay close ask if he is all right. Speak loudly. Use the
attention to instructions. person’s name if you know it. If there is no
response, assume that the person is uncon-
During natural disasters, a nurse or the admin-
scious. This is an emergency. Call for help
istrator will give directions. Listen carefully and
right away, or send someone else to call.
follow instructions. Facilities may rely on local
or state groups and the American Red Cross to If a person is conscious and able to speak, then
assume responsibility for the ill and disabled. he is breathing and has a pulse. Talk with the
The following guidelines apply in any disaster person about what happened. Get the person’s
situation: permission to touch him or her. (Anyone who
• Remain calm. is unable to give consent for treatment, e.g. a
child with no parent near or an unconscious or
• Know the locations of all exits and stairways.
seriously injured person, may be treated with
• Know where the fire alarms and extinguish- “implied consent.” This means that if the person
ers are located. was able or the parent was present, they would
• Know the appropriate action to take in any have given consent). Check the person for injury.
situation. Look for these things:
In addition, you will be required to know spe- • Severe bleeding
cific guidelines for the area in which you work.
• Changes in consciousness
Your instructor will have information on disas-
ters that commonly occur in your area. • Irregular breathing
• Unusual color or feel to the skin
5. Demonstrate how to recognize and • Swollen places on the body
respond to medical emergencies
• Medical alert tags
Medical emergencies may be the result of acci-
• Anything the person says is painful
dents or sudden illnesses. This section discusses
 2 36

If any of these exist, you may need professional cough (Fig. 2-15). As long as the person can
medical help. Always get help. Call the nurse be- speak, breathe, or cough, do nothing. Encour-
fore doing anything else. age her to cough as forcefully as possible to get
the object out. Stay with the person until she
Foundations of Resident Care

If the injured or ill person is conscious, he may

stops choking or can no longer speak, breathe,
be frightened. Listen to the person. Tell him
or cough.
what is being done to help him. Be calm and
confident. Reassure him that you are taking care
of him.
Once the emergency is over, you will need to
document it in your notes. Complete an incident
report. Try to remember as many details as pos-
sible. Only report the facts, not opinions.
First aid is emergency care given immedi-
ately to an injured person. Cardiopulmonary
Fig. 2-15. People who are choking usually put their hands
resuscitation (CPR) refers to medical proce-
to their throats and cough.
dures used when a person’s heart or lungs have
stopped working. CPR is used until medical help If a person can no longer speak, cough, or
arrives. breathe, have someone call 911. Use the call
Quick action is necessary. CPR must be started light or emergency cord to notify someone that
immediately after calling for help or sending you need help. Do not leave a choking victim to
someone to call for help. Brain damage may call for help.
occur within four to six minutes after the heart Abdominal thrusts are a method of attempting
stops beating and the lungs stop breathing. The to remove an object from the airway of someone
person can die within 10 minutes. who is choking. These thrusts work to remove
Only properly trained people should perform the blockage upward, out of the throat. Make
CPR. Your employer will probably arrange for sure the person needs help before starting to
you to be trained in CPR. If not, ask about give abdominal thrusts. Ask, “Can you cough?
American Heart Association or Red Cross CPR Can you speak? Can you breathe? Are you chok-
training. CPR is an important skill to learn. If ing?” Say, “I know what to do. Can I help you?”
you are not trained, do not attempt to perform This is obtaining consent. If the person cannot
CPR. Performing CPR incorrectly can further speak or cough, or if his response is weak, start
injure a person. giving abdominal thrusts.

Know your facility’s policies on whether you can Performing abdominal thrusts for the conscious
initiate CPR if you have been trained. Some fa- person
cilities do not allow NAs to begin CPR without
direction of the nurse. 1. Stand behind the person and bring your arms
under his arms. Wrap your arms around the
Choking person’s waist.
When something is blocking the tube through 2. Make a fist with one hand. Place the flat,
which air enters the lungs, the person has an thumb side of the fist against the person’s
obstructed airway. When people are choking, abdomen, above the navel but below the
they usually put their hands to their throats and breastbone.
 37 2

3. Grasp the fist with your other hand. Pull

Responding to shock
both hands toward you and up, quickly and
forcefully (Fig. 2-16). 1. Have the person lie down on her back. If
the person is bleeding from the mouth or

Foundations of Resident Care

vomiting, place her on her side (unless you
suspect that the neck, back, or spinal cord is
injured).
2. Control bleeding. This procedure is described
later in the chapter.
3. Check pulse and respirations if possible (see
Chapter 7).
4. Keep the person as calm and comfortable as
Fig. 2-16. When giving abdominal thrusts, pull both possible.
hands toward you and up (inward and upward), quickly
5. Maintain normal body temperature. If the
and forcefully.
weather is cold, place a blanket around the
person. If the weather is hot, provide shade.
4. Repeat until the object is pushed out or the
person loses consciousness. 6. Elevate the feet unless the person has a head
5. Report and document the incident properly. or abdominal injury, breathing difficulties, or
a fractured bone or back (Fig. 2-17). Elevate
the head and shoulders if a head wound or
If the person becomes unconscious while chok-
breathing difficulties are present. Never el-
ing, help her to the floor gently. Lie her on her
evate a body part if the person has a broken
back with her face up. Make sure help is on the
bone.
way. She may have a completely blocked airway.
She needs professional medical help immedi-
ately. Do not practice this procedure on a live
person. This risks injury to the ribs or internal
organs.

Shock
Shock occurs when organs and tissues in the
body do not receive an adequate blood supply.
Bleeding, heart attack, severe infection, and fall- Fig. 2-17. If a person is in shock, elevate the feet unless
he or she has head or abdominal injuries, breathing dif-
ing blood pressure can lead to shock. Shock can
ficulties, or fractured bones or back.
become worse when the person is frightened or
in severe pain. 7. Do not give the person anything to eat or
Shock is a dangerous, life-threatening situation. drink.
Signs of shock include pale or bluish (cyanotic)
8. Call for help immediately. Victims of shock
skin, staring, increased pulse and respiration
should always receive medical care quickly.
rates, low blood pressure, and extreme thirst.
Always call for help if you suspect a person is in 9. Report and document the incident properly.
shock. To treat shock, do the following:
 2 38

Myocardial Infarction or Heart Attack seem more flu-like, and women are more likely
to deny that they are having a heart attack.
Myocardial infarction (MI), or heart attack,
occurs when the heart muscle itself does not You must take immediate action if a resident has
Foundations of Resident Care

receive enough oxygen because blood vessels any of these symptoms. Follow these steps:
are blocked. A myocardial infarction is an emer-
gency that can result in serious heart damage or Responding to a heart attack
death. The following are signs and symptoms of
MI: 1. Call or have someone call the nurse.

• Sudden, severe pain in the chest, usually 2. Place the person in a comfortable position.
on the left side or in the center, behind the Encourage him to rest. Reassure him that
breastbone you will not leave him alone.
• Pain or discomfort in other areas of the 3. Loosen the clothing around the person’s
body, such as one or both arms, the back, neck (Fig. 2-18).
neck, jaw, or stomach
• Indigestion or heartburn
• Nausea and vomiting
• Dyspnea, or difficulty breathing
• Dizziness
• Pale, gray, or bluish skin color, indicating
lack of oxygen
• Perspiration
• Cold and clammy skin
Fig. 2-18. Loosen clothing around the person’s neck if you
• Weak and irregular pulse rate suspect he is having an MI.
• Low blood pressure
4. Do not give the person liquids or food.
• Anxiety and a sense of doom
5. Monitor the person’s breathing and pulse. If
• Denial of a heart problem
the person stops breathing or has no pulse,
The pain of a heart attack is commonly de- perform CPR only if you are trained and if
scribed as a crushing, pressing, squeezing, stab- your facility allows you to do so.
bing, piercing pain, or, “like someone is sitting
on my chest.” The pain may go down the inside 6. Stay with the person until help arrives.
of the left arm. A person may also feel it in the 7. Report and document the incident properly.
neck and/or in the jaw. The pain usually does
not go away.
As with men, women’s most common symp- Some states allow nursing assistants to offer
tom is chest pain or discomfort. But women heart medication, such as nitroglycerin, to a
are somewhat more likely than men to have person having a heart attack. If you are allowed
shortness of breath, nausea/vomiting, and back, to do this, offer the medication only. Never place
shoulder, or jaw pain. Some women’s symptoms medication in someone’s mouth.
 39 2

Bleeding Burns
Severe bleeding can cause death quickly. It must Care of a burn depends on its depth, size, and
be controlled. Call the nurse immediately. Then location. Always notify the nurse when a resi-

Foundations of Resident Care

follow these steps to control bleeding: dent is burned. Burns may require emergency
help.
Controlling bleeding
Treating burns
1. Put on gloves. Take time to do this. If the
resident is able, he can hold his bare hand To treat a minor burn:
over the wound until you can put on gloves.
1. Use cool, clean water (not ice) to decrease
2. Hold a thick sterile pad, a clean pad, or a the skin temperature and prevent further
clean cloth, handkerchief, or towel against injury. Ice will cause further skin damage.
the wound. Dampen a clean cloth. Place it over the burn.
3. Press down hard directly on the bleeding
2. Once the pain has eased, you may cover the
wound until help arrives. Do not decrease
area with dry, sterile gauze.
pressure (Fig. 2-19). Put additional pads over
the first pad if blood seeps through. Do not 3. Never use any kind of ointment, salve, or
remove the first pad. grease on a burn.

For more serious burns:

1. Remove the person from the source of the

burn. If clothing has caught fire, smother it
with a blanket or towel to put out flames.
Protect yourself from the source of the burn.

2. Call for emergency help.

Fig. 2-19. Press down hard directly on the bleeding

3. Check for breathing, pulse, and severe
wound; do not decrease pressure. bleeding.

4. Do not apply water. It may cause infection.

4. If you can, raise the wound above the level of
the heart to slow the bleeding. If the wound 5. Do not try to pull away any clothing from
is on an arm, leg, hand, or foot, and there are burned areas. Cover the burn with thick, dry,
no broken bones, prop up the limb. Use tow- sterile gauze if available, or a clean cloth.
els, blankets, or other absorbent materials. Apply the gauze or cloth lightly. A dry, insu-
lated cool pack may be used over the dress-
5. When bleeding is under control, secure the
ing. Again, never use any kind of ointment,
dressing to keep it in place. Check the person
salve, or grease on a burn.
for symptoms of shock (pale skin, increased
pulse and respiration rates, low blood pres- 6. Ask the person to lie down and elevate the
sure, and extreme thirst). Stay with the per- affected part if this does not cause greater
son until help arrives. pain.
6. Remove gloves and wash hands thoroughly. 7. If the burn covers a larger area, wrap the
7. Report and document the incident properly. person or the limb in a dry, clean sheet. Take
care not to rub the skin.
 2 40

8. Wait for emergency medical help. 5. Help the person get up slowly. Continue to
observe her for symptoms of fainting. Stay
9. Report and document the incident properly.
with her until she feels better. If you need
help but cannot leave the person, use the call
Foundations of Resident Care

light.
Fainting
6. Report and document the incident properly.
Fainting occurs as a result of decreased blood
flow to the brain, causing a loss of conscious-
ness. Fainting may be the result of hunger, fear, If a person does faint, lower her to the floor
pain, fatigue, standing for a long time, poor or other flat surface. Position her on her back.
ventilation, or overheating. Signs and symp- Elevate her legs eight to 12 inches. Loosen any
toms of fainting include dizziness, perspiration, tight clothing. Check to make sure the person is
pale skin, weak pulse, shallow respirations, and breathing. She should recover quickly, but keep
blackness in the visual field. If someone appears her lying down for several minutes. Report the
likely to faint, follow these steps: incident to the nurse immediately. Fainting may
be a sign of a more serious medical condition.
Responding to fainting

1. Have the person lie down or sit down before Insulin Reaction and Diabetic Ketoacidosis
fainting occurs. Insulin reaction and diabetic ketoacidosis are
2. If the person is in a sitting position, have her problems of diabetes that can be life-threatening.
bend forward and place her head between her Insulin reaction (also called hypoglycemia) can
knees (Fig. 2-20). If the person is lying flat on result from either too much insulin or too little
her back, elevate the legs. food. It occurs when insulin is given and the
person skips a meal or does not eat all the food
required. Even when a regular amount of food
is eaten, physical activity may rapidly absorb the
food. This causes too much insulin to be in the
body. Vomiting and diarrhea may also lead to in-
sulin shock in people with diabetes.
The first signs of insulin reaction include feel-
ing weak or different, nervousness, dizziness,
and perspiration. These signal that the resident
needs food in a form that can be rapidly ab-
sorbed. A lump of sugar, a hard candy, or a glass
of orange juice should be consumed right away.
A diabetic should always have a quick source
of sugar handy. Call the nurse if the resident
has shown signs of insulin reaction. Signs and
symptoms of insulin reaction include:
Fig. 2-20. Have the person bend forward and place her
head between her knees if she is sitting. • Hunger
• Weakness
3. Loosen any tight clothing.
• Rapid pulse
4. Have the person stay in position for at least
five minutes after symptoms disappear. • Headache
 41 2

• Low blood pressure Seizures

• Perspiration Seizures are involuntary, often violent, contrac-
tions of muscles. They can involve a small area
• Cold, clammy skin

Foundations of Resident Care

or the entire body. Seizures are caused by an ab-
• Confusion normality in the brain. They can occur in young
• Trembling children who have a high fever. Older children
and adults who have a serious illness, fever, head
• Nervousness
injury, or a seizure disorder such as epilepsy
• Blurred vision may also have seizures.
• Numbness of the lips and tongue The main goal of a caregiver during a seizure
is to make sure the resident is safe. During a
• Unconsciousness
seizure, a person may shake severely and thrust
Diabetic ketoacidosis (DKA) (also called arms and legs uncontrollably. He may clench his
hyperglycemia or diabetic coma) is caused by jaw, drool, and be unable to swallow. Take the
having too little insulin. It can result from un- following measures if a resident has a seizure:
diagnosed diabetes, going without insulin or
not taking enough, eating too much, not getting Responding to seizures
enough exercise, or physical or emotional stress.
The signs of the onset of diabetic ketoacidosis 1. Lower the person to the floor. Lay him on his
include increased thirst or urination, abdominal side.
pain, deep or labored breathing, and breath that 2. Have someone call the nurse immediately or
smells sweet or fruity. Call the nurse if the resi- use the call light. Do not leave the person un-
dent has shown signs of DKA. Other signs and less you must do so to get medical help.
symptoms include:
3. Move furniture away to prevent injury. If a
• Hunger pillow or blanket is nearby, place it under his
• Weakness head.

• Rapid, weak pulse 4. Do not try to restrain the person.

• Headache 5. Do not force anything between the person’s

teeth. Do not place your hands in the per-
• Low blood pressure son’s mouth for any reason. You could be
• Dry skin bitten.

• Flushed cheeks 6. Do not give liquids or food.

• Drowsiness 7. When the seizure is over, check breathing.

• Slow, deep, and difficult breathing 8. Report and document the incident properly,
including how long the seizure lasted.
• Nausea and vomiting
• Air hunger, or resident gasping for air and
CVA or Stroke
being unable to catch his breath
The medical term for a stroke is a cerebrovas-
• Unconsciousness
cular accident (CVA). CVA, or stroke, is caused
This condition has a high risk of coma and even when the blood supply to the brain is cut off
death unless treated immediately. See Chapter 4 suddenly by a clot or a ruptured blood vessel.
for more information on diabetes. A quick response to a suspected stroke is criti-
 2 42

cal. Tests and treatment need to be given within sign of a serious illness or injury. If a resident
a short time of the stroke’s onset. Early treat- has vomited, talk to him kindly as you help him
ment may be able to reduce the severity of the clean up. Tell him what you are doing to help
stroke. him. Notify the nurse and take these steps:
Foundations of Resident Care

A transient ischemic attack, or TIA, is a warn-

Responding to vomiting
ing sign of a CVA. It is the result of a temporary
lack of oxygen in the brain. Symptoms may last 1. Put on gloves.
up to 24 hours. They include difficulty speaking,
2. Make sure the head is up or turned to one
weakness on one side of the body, temporary
side. Place an emesis basin under the chin.
loss of vision, and numbness or tingling. These
Remove it when vomiting has stopped.
symptoms should not be ignored. Report them
to the nurse immediately. These are also signs 3. Remove soiled linens or clothes and set
that a CVA is occurring: aside. Replace with fresh linens or clothes.

• Facial numbness or weakness, especially on 4. If resident’s intake and output (I&O) are
one side being monitored (Chapter 7), measure and
note amount of vomitus.
• Arm numbness or weakness, especially on
one side 5. Flush vomit down the toilet unless vomit is
• Slurred speech or difficulty speaking red, has blood in it, or looks like wet coffee
grounds. If these symptoms are observed,
• Use of inappropriate words
show this to the nurse before discarding the
• Inability to understand spoken or written vomit. After disposing of vomit, wash and
words store basin.
• Redness in the face 6. Remove and discard gloves.
• Noisy breathing 7. Wash your hands.
• Dizziness 8. Put on fresh gloves.
• Blurred vision
9. Provide comfort to resident (Fig. 2-21). Wipe
• Ringing in the ears face and mouth. Position comfortably. Offer a
• Headache drink of water. Provide oral care. It helps get
rid of the taste of vomit in the mouth.
• Nausea/vomiting
• Seizures
• Loss of bowel and bladder control
• Paralysis on one side of the body
• Elevated blood pressure
• Slow pulse rate
• Loss of consciousness
See Chapter 4 for more information.

Vomiting
Vomiting, or emesis, is the act of ejecting stom- Fig. 2-21. Be calm and comforting when helping a resi-
dent who has vomited.
ach contents through the mouth. It can be a
 43 2

10. Put soiled linen in proper containers. to create in your facility and is used in all health-
11. Remove and discard gloves. care settings. In healthcare settings, the term
“clean” means objects are not contaminated
12. Wash your hands again. with pathogens. The term “dirty” means that

Foundations of Resident Care

13. Report and document the incident properly. objects have been contaminated with pathogens.
Document time, amount, color, odor, and Surgical asepsis (or “sterile technique”) is the
consistency of vomitus. state of being free of all microorganisms, not
just pathogens. Surgical asepsis is used for many
types of procedures, such as changing catheters.
6. Describe and demonstrate infection Preventing the spread of infection is important.
prevention practices To understand how to prevent disease you must
Infection control is the term for measures first know how it is spread. The chain of infec-
practiced in healthcare facilities to prevent and tion is a way of describing how disease is trans-
control the spread of disease. Working to prevent mitted from one living being to another (Fig.
the spread of disease is the responsibility of all 2-22). Definitions and examples of each of the
care team members. Know your facility’s infec- six links in the chain of infection are:
tion control policies. They are there to help pro-
tect you, residents, and others from disease.
A microorganism is a living thing or organism
that is so small that it can be seen only through
a microscope. A microbe is another name for
a microorganism. Microorganisms are always
present in the environment. Infections occur
when harmful microorganisms, called patho-
gens, invade the body and multiply.
There are two main types of infections, systemic
and localized. A systemic infection is in the
bloodstream and is spread throughout the body. Fig. 2-22. The chain of infection.
It causes general symptoms, such as fever, chills,
or mental confusion. A localized infection is Link 1: The causative agent is a pathogen or
confined to a specific location in the body and microorganism that causes disease. Normal
has local symptoms, near the site of infection. flora are the microorganisms that live in and on
For example, if a wound becomes infected, the the body. They do not cause harm. When they
area around it may become red, hot, and painful. enter a different part of the body, they may cause
Another type of infection is a healthcare- an infection. Causative agents include bacteria,
associated infection, or nosocomial infection. viruses, fungi, and protozoa.
Healthcare-associated infections (HAIs) are Link 2: A reservoir is where the pathogen lives
infections that patients acquire within health- and grows. It can be a person, animal, plant,
care settings that result from treatment for other soil, or substance. Microorganisms grow best in
conditions. warm, dark, and moist places where food is pres-
Medical asepsis is the process of removing ent. Some microorganisms need oxygen to sur-
pathogens, or the state of being free of patho- vive; others do not. Reservoirs within humans
gens. It refers to the clean conditions you want include the lungs, blood, and large intestine.
 2 44

Link 3: The portal of exit is any body opening Link 6: A susceptible host is an uninfected per-
on an infected person that allows pathogens to son who could get sick. This includes all health-
leave. These include the nose, mouth, eyes, or a care workers and anyone in their care who is not
cut in skin (Fig. 2-23). already infected with that particular disease.
Foundations of Resident Care

Link 4: The mode of transmission describes If one of the links in the chain of infection is
how the pathogen travels from one person to an- broken, then the spread of infection is stopped.
other. Transmission can happen through the air Infection prevention practices help stop patho-
or by direct or indirect contact. Direct contact gens from traveling (Link 4), and getting on
happens by touching the infected person’s secre- your hands, nose, eyes, mouth, skin, etc. (Link
tions. Indirect contact results from touching 5). You can also reduce your own chances of get-
something contaminated by the infected person, ting sick (Link 6) by having immunizations for
such as a tissue or clothes. diseases such as hepatitis B and influenza.

Standard Precautions and Transmission-Based

Precautions
State and federal government agencies have
guidelines and laws concerning infection pre-
vention. The Centers for Disease Control
and Prevention (CDC) is a government agency
under the Department of Health and Human
Services (HHS). It issues information to protect
the health of individuals and communities. In
1996, the CDC recommended a new infection
Fig. 2-23. Portals of exit. control system to reduce the risk of contracting
infectious diseases in healthcare settings. In
Link 5: The portal of entry is any body opening 2007 some additions and changes were made to
on an uninfected person that allows pathogens this system. There are two tiers of precautions
to enter. This includes the nose, mouth, other within the infection control system: Standard
mucous membranes, a cut in the skin, or dry/ Precautions and Transmission-Based, or Isola-
cracked skin (Fig. 2-24). Mucous membranes tion, Precautions.
are the membranes that line body cavities, such Following Standard Precautions means treat-
as the mouth, nose, eyes, rectum, and genitals. ing all blood, body fluids, non-intact skin (like
abrasions, pimples, or open sores), and mucous
membranes (lining of mouth, nose, eyes, rec-
tum, or genitals) as if they were infected. This is
the only safe way of doing your job. You cannot
tell by looking at your residents or by reading
their medical charts if they have a contagious
disease such as HIV, hepatitis, or influenza.
Under Standard Precautions, “body fluids”
include saliva, sputum (mucus coughed up),
urine, feces, semen, vaginal secretions, and pus
or other wound drainage. They do not include
Fig. 2-24. Portals of entry. sweat.
 45 2

Standard Precautions and Transmission-Based G Wear gloves and use caution when handling
Precautions are a way to stop the spread of infec- razor blades, needles, and other sharps.
tion. They interrupt the mode of transmission. Sharps are needles or other sharp objects.
In other words, these guidelines do not stop an Discard these objects carefully in a puncture-

Foundations of Resident Care

infected person from giving off pathogens. How- resistant biohazard container.
ever, by following these guidelines you help stop
G Never attempt to put a cap on a needle or
those pathogens from infecting you or those in
syringe. Dispose of them in a biohazardous
your care:
waste container.
• Practice Standard Precautions with every
G Avoid nicks and cuts when shaving residents.
single person in your care.
G Carefully bag all contaminated supplies.
• Transmission-Based Precautions vary based
Dispose of them according to your facility’s
on how an infection is transmitted. When
policy.
indicated, they are used in addition to the
Standard Precautions. You will learn about G Clearly label body fluids that are being saved
these precautions in greater detail later. for a specimen with the resident’s name and
a biohazard label. Keep them in a container
Guidelines: Standard Precautions with a lid. Put in a biohazardous specimen
bag for transportation, if required.
G Wash your hands before putting on gloves.
Wash your hands immediately after removing G Dispose of contaminated wastes according to
gloves. Be careful not to touch clean objects your facility’s policy. Waste containing blood
with your used gloves. or body fluids is considered biohazardous
waste. Liquid waste can usually be disposed
G Wear gloves if you may come into contact of through the regular sewer system as long
with: blood, body fluids or secretions, broken as there is no splashing, spraying, or aero-
skin, such as abrasions, acne, cuts, stitches, solizing of the waste as it is being disposed.
or staples, or mucous membranes. Such con- Appropriate PPE needs to be worn, followed
tacts occur during mouth care, toilet assis- by proper removal and handwashing. Follow
tance, perineal care, helping with a bedpan or instructions at your facility.
urinal, cleaning up spills, cleaning basins, uri-
nals, bedpans, and other containers that have Standard Precautions should ALWAYS be prac-
held body fluids, and disposing of wastes. ticed on persons in your care regardless of their
infection status. Remember, you cannot tell if
G Remove gloves immediately when finished
someone carries a bloodborne disease by how a
with procedure.
person looks or acts, or even by reading his or
G Immediately wash all skin surfaces that have her chart. If you practice Standard Precautions
been contaminated with blood and body you greatly reduce the risk of transmitting infec-
fluids. tion to yourself and others.
G Wear a disposable gown that is resistant to In your work you will use your hands constantly.
body fluids if you may come into contact with Microorganisms are on everything you touch.
blood or body fluids. Washing your hands is the single most impor-
G Wear a mask and protective goggles if you tant thing you can do to prevent the spread of
may come into contact with splashing or disease. The CDC has defined hand hygiene as
spraying blood or body fluids (for example, handwashing with either plain or antiseptic soap
emptying a bedpan). and water and using alcohol-based hand rubs.
 2 46

Alcohol-based hand rubs include gels, rinses, • After picking up anything from the floor
and foams. They do not require the use of water.
• Before and after using the toilet
Hand antisepsis refers to washing hands with
water and soap or other detergents that contain • After blowing your nose or coughing or
Foundations of Resident Care

an antiseptic agent. sneezing into your hand

Alcohol-based hand rubs—often just called • Before and after you eat
“hand rubs”—have proven effective in reducing • After smoking
bacteria on the skin. However, they are not a
• After touching areas on your body, such as
substitute for proper handwashing. Always use
your mouth, face, eyes, hair, ears, or nose
soap and water for visibly soiled hands. Once
hands are clean, hand rubs can be used in ad- • Before and after applying makeup
dition to handwashing any time your hands are • After any contact with pets and after contact
not visibly soiled. When using a hand rub, the with pet care items
hands must be rubbed together until the prod-
uct has completely dried. Use hand lotion to pre- • Before leaving the facility
vent dry, cracked skin.
Washing hands
If you wear rings, consider removing them while
working. Rings may increase the risk of contam- Equipment: soap, paper towels
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. You should wash your
lower than your elbows. This prevents water
hands:
from running up your arm. Wet hands and
• When you get to work wrists thoroughly (Fig. 2-25).
• Whenever they are visibly soiled The hands are more likely to be contaminated.
Water should run from cleanest to dirtiest.
• 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
• After handling contaminated items
• After contact with objects in the resident’s
room (care environment)
• Before and after touching meal trays and/or
handling food
• Before and after feeding residents
• Before getting clean linen Fig. 2-25.

• After touching garbage or trash 3. Apply skin cleanser or soap to hands.

 47 2

4. Rub hands together and fingers between each

other to create a lather. Lather all surfaces
of your fingers and hands, including your
wrists (Fig. 2-26). Use friction for at least 20

Foundations of Resident Care

seconds.
Lather and friction loosen skin oils and allow patho-
gens to be rinsed away.

Fig. 2-27.

9. Dispose of used paper towel(s) in wastebas-

ket after turning off faucet.

Personal Protective Equipment

Personal protective equipment (PPE) is
equipment that helps protect employees from se-
rious injuries or illnesses resulting from contact
with workplace hazards. In care facilities, PPE
Fig. 2-26. helps protect you from contact with potentially
infectious material. Your employer is responsible
5. Clean nails by rubbing them in palm of other for giving you the appropriate PPE to wear.
hand.
Personal protective equipment includes gowns,
Most pathogens on hands come from under nails.
masks, goggles, face shields, and gloves. Gowns
6. Being careful not to touch the sink, rinse protect the skin and/or clothing. Masks protect
thoroughly under running water. Rinse all the mouth and nose. Goggles protect the eyes.
surfaces of your hands and wrists. Run water Face shields protect the entire face—the mouth,
down from wrists to fingertips. Do not run nose, and eyes. Gloves protect the hands. Gloves
water over unwashed arms down to clean are used the most often by all caregivers.
hands.
You should wear PPE if there is a chance you
Wrists are cleanest, fingertips dirtiest.
could come into contact with body fluids, mu-
7. Use clean, dry paper towel to dry all surfaces cous membranes, or open wounds. Wear, or
of hands, wrists, and fingers. Do not wipe don, gowns, masks, goggles, and face shields
towel on unwashed forearms and then wipe when splashing or spraying of body fluids or
clean hands. Dispose of towel without touch- blood could occur. Clean, non-sterile gowns pro-
ing wastebasket. If your hands touch the sink tect your exposed skin. They also prevent soil-
or wastebasket, start over. ing of your clothing. Gowns should fully cover
your torso. They should fit comfortably over your
8. Use clean, dry paper towel to turn off faucet
body, and have long sleeves that fit snugly at the
(Fig. 2-27). Do not contaminate your hands
wrist. When finished with a procedure, remove,
by touching the surface of the sink or faucet.
Hands will be recontaminated if you touch the dirty or doff, the gown as soon as possible and wash
faucet or sink with clean hands. your hands.
 2 48

Masks should be worn when caring for residents

Putting on (donning) gown
with respiratory illnesses. Sometimes special
1. Wash your hands. masks are required for certain diseases, such
as tuberculosis (TB). Masks should fully cover
Foundations of Resident Care

2. Open gown. Hold out in front of you and

allow gown to open/unfold (Fig. 2-28). Do your nose and mouth and prevent fluid pen-
not shake it. Slip your arms into the sleeves. etration. Masks should fit snugly over the nose
Pull gown on. and mouth. Always change your mask between
residents; do not wear the same mask from one
resident to another. Goggles provide protection
for your eyes. Eyeglasses alone do not provide
proper eye protection. Goggles should fit snugly
over and around your eyes or eyeglasses.

Putting on (donning) mask and goggles

1. Wash your hands.

Fig. 2-28.
2. Pick up mask by top strings or elastic strap.
3. Fasten the neck opening. Do not touch mask where it touches your
face.
4. Reach behind you. Pull gown until it com-
pletely covers your clothing. Secure gown at 3. Adjust mask over your nose and mouth. Tie
waist (Fig. 2-29). top strings first, then bottom strings. Masks
must always be dry or they must be replaced.
Never wear a mask hanging from only the
bottom ties (Fig. 2-30).

Fig. 2-29.

5. Use a gown only once and then remove and

discard it. If gown becomes wet or soiled Fig. 2-30.
during care, remove it. Check clothing. Put
on a new gown. OSHA requires non-perme- 4. Put on the goggles.
able gowns—gowns that liquids cannot pen- 5. Put on gloves after putting on mask and
etrate—when working in a bloody situation. goggles.
6. Put on your gloves after putting on gown.
When additional skin protection is needed, a
When removing a gown, unfasten gown at neck face shield can be used as a substitute for wear-
and waist. Remove without touching outside of ing a mask or goggles. The face shield should
gown. Roll the dirty side in and away from the cover your forehead and go below the chin. It
body. wraps around the sides of your face.
 49 2

Your facility will have specific policies and 5. Carefully look for tears, holes, or spots. Re-
procedures on when to wear gloves. Learn and place the glove if needed.
follow these rules. Always wear gloves for the
6. If wearing a gown, pull the cuff of the gloves
following tasks:

Foundations of Resident Care

over the sleeves of the gown (Fig. 2-31).
• Any time you might touch blood or any body
fluid, including vomitus, urine, feces, or
saliva
• When performing or helping with mouth
care or care of any mucous membrane
• When performing or helping with perineal Fig. 2-31.
care (care of the genitals and anal area)
• When performing personal care on non-in-
Remove gloves promptly after use. Remove
tact skin—skin that is broken by abrasions,
gloves before touching non-contaminated items
cuts, rashes, acne, pimples, or boils
or surfaces. Remove gloves before exiting the
• When assisting with personal care when you room. Always wash your hands directly after re-
have open sores or cuts on your hands moving gloves. You are wearing gloves to protect
• When shaving a resident your skin from becoming contaminated. After
• When disposing of soiled bed linens, gowns, giving care, your gloves are contaminated. If you
dressings, and pads open a door with a gloved hand, the doorknob
becomes contaminated. Later, when you open
Clean, non-sterile gloves are generally adequate.
the door with an ungloved hand, you will be
They may be vinyl, nitrile, or latex. Some people
touching a contaminated surface. Before touch-
are allergic to latex. If you are, let the nurse
ing surfaces or leaving the room, remove your
know. Alternative gloves will be provided. Tell
gloves. Wash your hands. Afterward, put on new
the nurse if you have dry, cracked, or broken
gloves if needed.
skin. Gloves should fit your hands comfortably.
They should not be too loose or too tight.
Removing (doffing) gloves
Disposable gloves are to be worn only once.
They may not be washed or disinfected for 1. Touch only the outside of one glove. With
reuse. Change gloves right before contact with one gloved hand, grasp the other glove at the
mucous membranes or broken skin, or if gloves palm, and pull the glove off (Fig. 2-32).
are soiled, torn, or damaged. Wash your hands
before putting on fresh gloves.

Putting on (donning) gloves

1. Wash hands.
2. If right-handed, slide one glove on your left
hand (reverse if left-handed).
3. With gloved hand, slide other hand into the
second glove.
4. Interlace fingers. Smooth out folds and cre-
ate a comfortable fit. Fig. 2-32.
 2 50

2. As the glove comes off the hand it should be Equipment and Linen Handling
turned inside out. Facilities will have separate areas for clean and
3. With the fingertips of your gloved hand, hold dirty items, such as equipment, linen, and sup-
Foundations of Resident Care

the glove you just removed. With your un- plies. There are separate rooms for supplies that
gloved hand, reach two fingers underneath are considered “clean” and for supplies that are
cuff of the remaining glove at wrist. Be care- considered “dirty” or contaminated. You will
ful not to touch any part of the outside of be told where these rooms are located and what
glove (Fig. 2-33). types of equipment and supplies are found in
each room. Perform hand hygiene before enter-
ing clean utility rooms and before leaving dirty
utility rooms. This helps prevent the spread of
pathogens.

Guidelines: Handling Equipment, Linen, and

Clothing

G Handle all equipment in a manner that

prevents:
• Skin/mucous membrane contact
Fig. 2-33.
• Contamination of your clothing
4. Pull down, turning this glove inside out and • Transfer of disease to other residents or
over the first glove as you remove it. areas
G Do not use “re-usable” equipment again
5. You should now be holding one glove from
until it has been properly cleaned and repro-
its clean inner side. The other glove should
cessed. Sterilization is a cleaning measure
be inside it.
that destroys all microorganisms, including
6. Drop both gloves into the proper container. pathogens. It uses steam under pressure,
7. Wash your hands. dry heat, or liquid or gas chemicals to steril-
ize. Items that need to be sterilized are ones
that go directly into the bloodstream or into
When applying PPE, remember this order: other normally sterile areas of the body (for
1. Apply gown. example, surgical instruments). Disinfection
is a process that kills pathogens, but not all
2. Apply mask.
microorganisms; it reduces the organism
3. Apply goggles or face shield. count to a level that is generally not consid-
4. Apply gloves last. ered infectious. Disinfection is carried out
with pasteurization or chemical germicides.
When removing PPE, remember this order:
Examples of items that are usually disinfect-
1. Remove gloves. ed are reusable oxygen tanks, wall mounted
2. Remove goggles or face shield. blood pressure cuffs, and any reusable resi-
dent care equipment.
3. Remove gown.
G Dispose of all “single-use,” or disposable,
4. Remove mask.
equipment properly. Disposable means it is
Performing hand hygiene is always the final discarded after one use. Disposable razors
step after removing and disposing of PPE. are an example of disposable equipment.
 51 2

G Clean and disinfect

Guidelines: Cleaning Spills Involving Blood,
• All environmental surfaces Body Fluids, or Glass
• Beds, bedrails, all bedside equipment

Foundations of Resident Care

G Apply gloves before starting. In some cases,
• All frequently touched surfaces (such as industrial-strength gloves are best.
doorknobs and call lights)
G First, absorb the spill with whatever product
G Handle, transport, and process soiled linens is used by the facility. It may be an absorbing
in a way that prevents powder.
• Skin and mucous membrane exposure G Scoop up the absorbed spill, and dispose of
• Contamination of clothing (hold linen in a designated container.
and clothing away from your uniform) G Apply the proper disinfectant to the spill area
(Fig. 2-34) and allow it stand wet for a minimum of 10
minutes.
G Clean up spills immediately with the proper
cleaning solution.
G Do not pick up any pieces of broken glass,
no matter how large, with your hands. Use a
dustpan and broom or other tools.
G Waste containing broken glass, blood, or
body fluids should be properly bagged. Waste
containing blood or body fluids may need to
be placed in a special biohazard container.
Follow facility policy.
Fig. 2-34. Hold and carry dirty linen away from your
uniform.
Transmission-Based Precautions
• Transfer of disease to other residents and These precautions are used when caring for
areas (do not shake linen or clothes; fold persons who are infected or suspected of being
or roll linen so that dirtiest area is inside) infected with a disease. These precautions are
G Bag soiled linen at point of origin. called Transmission-Based, or Isolation, Pre-
cautions. When ordered, these precautions are
G Sort soiled linen away from resident care
used in addition to Standard Precautions. These
areas.
precautions will always be listed in the care plan
G Place wet linen in leak-proof bags. and on your assignment sheet. It is for your
You will learn more about cleaning equipment safety and the safety of others that these precau-
and supplies in Chapter 7. tions must be followed.
There are three categories of Transmission-
Spills Based Precautions:
Spills can pose a serious risk of infection. Long- • Airborne Precautions
term care facilities will have cleaning solutions
• Droplet Precautions
for spills. Clean spills using proper equipment
and procedure. • Contact Precautions
 2 52

The category used depends on the disease and

how it spreads to other people. They may also be
used in combination for diseases that have mul-
tiple routes of transmission.
Foundations of Resident Care

Airborne Precautions are used for diseases that

can be transmitted through the air after being
expelled (Fig. 2-35). The pathogens are so small
that they can attach to moisture in the air. They
remain floating for some time. For certain care
you may be required to wear a special mask, Fig. 2-36. Droplet Precautions are followed when the dis-
ease-causing microorganism does not remain in the air.
such as N-95 or HEPA masks, to avoid being
infected. Airborne diseases include tuberculosis,
Contact Precautions are used when there is a
measles, and chickenpox.
risk of transmitting or contracting a microorgan-
ism from touching an infected object or person
(Fig. 2-37). 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 wear-
ing PPE and resident isolation. They require
washing hands with antimicrobial soap. An an-
timicrobial agent destroys or resists pathogens.
Contact Precautions also require not touching
infected surfaces with ungloved hands or unin-
fected surfaces with contaminated gloves.
Fig. 2-35. Airborne Precautions are used for diseases that
can be transmitted through the air.

Droplet Precautions are used when the disease-

causing microorganism does not remain in the
air and usually only travels short distances after
being expelled. Droplets normally do not travel
more than three feet. Droplets can be created by
coughing, sneezing, talking, laughing, or suc-
tioning (Fig. 2-36). Droplet Precautions include
wearing a face mask during care and restricting Fig. 2-37. Contact Precautions are followed when the per-
visits from uninfected people. Residents should son is at risk of transmitting a microorganism by touching
wear masks when being moved from room to an infected object or person.
room. Cover your nose and mouth with a tis-
sue when you sneeze or cough. Ask residents, Staff often refer to residents who need Transmis-
family, and others to do the same. Dispose of sion-Based Precautions as being in “isolation.” A
the tissue in the nearest waste container. If you sign should be on the door indicating “isolation”
sneeze on your hands, wash them promptly. An or “Contact Precautions” and alerting people to
example of a droplet disease is the mumps. see the nurse before entering the room.
 53 2

Common Infectious Diseases

Guidelines: Isolation
Bloodborne pathogens are microorganisms
G When they are indicated, Transmission-Based
found in human blood. They can cause infec-

Foundations of Resident Care

Precautions are always used in addition to
tion and disease in humans. They may also
Standard Precautions.
be in body fluids, draining wounds, and mu-
G You will be told the proper PPE to wear for cous membranes. Bloodborne diseases can be
care of each resident in isolation. Make sure transmitted by infected blood entering your
to put on the PPE properly and remove it bloodstream, or if infected semen or vaginal
safely. PPE cannot be worn outside the resi- secretions contact your mucous membranes.
dent’s room. Remove PPE and perform hand Using a needle to inject drugs and sharing nee-
hygiene before exiting the room. dles can also transmit bloodborne diseases. In
G Do not share equipment between residents. addition, infected mothers may transmit blood-
Use disposable supplies that can be discard- borne diseases to their babies in the womb or at
ed after use whenever possible. Discard them birth.
in the room before leaving. Use dedicated In health care, contact with infected blood or
(only for use by one resident) equipment certain other body fluids is the most common
when disposable is not an option. Do not way to get a bloodborne disease. Infections can
contaminate reusable equipment by setting it be spread through contact with contaminated
on furniture in the resident’s room. blood or body fluids, needles or other sharp ob-
G Wear the proper PPE, if indicated, when serv- jects, or contaminated supplies or equipment.
ing food and drink. Do not leave uneaten Employers are required by law to help prevent
food uncovered in the resident’s room. When exposure to bloodborne pathogens. Follow Stan-
the meal is completed, remove the meal tray. dard Precautions and other procedures to protect
Take it to the proper area. yourself from bloodborne diseases.

G Follow Standard Precautions when dealing The major bloodborne diseases in the United
with body waste removal. Wear gloves when States are acquired immune deficiency syn-
touching or handling waste. Wear gowns and drome (AIDS) and hepatitis. You will learn more
goggles when indicated. about AIDS in Chapter 4.

G If required to take a specimen from a Hepatitis is inflammation of the liver caused

resident in isolation, wear the proper PPE. by infection. Liver function can be perma-
Collect the specimen. Place it in the appro- nently damaged by hepatitis. It can lead to other
priate container without the outside of the chronic, life-long illnesses. Several different
container coming into contact with the speci- viruses can cause hepatitis. The most common
men. Properly remove your PPE and dispose types of hepatitis are A, B, and C. Hepatitis B
of it in the room. Perform hand hygiene (HBV) is contracted through blood or needles
before leaving the room. Take the specimen that are contaminated with the virus, or by
to the nurse. sexual contact with an infected person. Hepatitis
C is also transmitted through blood and possi-
G Reassure residents that it is the disease, not
bly by sexual intercourse. Hepatitis B and C can
the person, that is being isolated. Explain
lead to cirrhosis and liver cancer; they can even
why these steps are being taken. Allow time
cause death.
to talk with your resident about his concerns.
 2 54

HBV is a serious threat to healthcare workers. recently hospitalized. They are sometimes
Your employer must offer you a free vaccine to acquired in fitness centers when equipment
protect you from hepatitis B. The HBV vaccine has not been disinfected during use. These
can prevent hepatitis B. Prevention is the best infections are known as community-associ-
Foundations of Resident Care

option for dealing with this disease. Take the ated MRSA infections (CA-MRSA) and are
vaccine when it is offered. There is no vaccine usually skin infections, such as pimples or
for hepatitis C. boils.
Other serious infections include: MRSA can spread among those having close
contact with infected people. It is almost
• Tuberculosis, or TB, is an airborne disease.
always spread by direct physical contact, and
It is carried on mucous droplets suspended
not through the air. If a person has MRSA
in the air. When a person infected with TB
on his skin, especially on the hands, and
talks, coughs, breathes, or sings, he may re-
touches someone, he may spread MRSA.
lease mucous droplets carrying the disease.
Spread also occurs through indirect con-
TB usually infects the lungs, causing cough-
tact by touching objects, such as sheets or
ing, trouble breathing, fever, weight loss,
clothes, contaminated by the infected skin of
and fatigue. It can be cured. However, if left
a person with MRSA.
untreated, TB may cause death.
To help prevent MRSA practice good hy-
Symptoms of TB include fatigue, loss of ap-
giene. Handwashing, using soap and warm
petite, weight loss, slight fever and chills,
water, is the single most important measure
night sweats, prolonged coughing, coughing
to control MRSA. Keep cuts and abrasions
up blood, chest pain, shortness of breath,
clean and covered with a proper dressing
and trouble breathing.
(e.g. bandage) until healed. Avoid contact
When caring for residents who have TB, with other people’s wounds or material that
follow Standard Precautions and Airborne is contaminated from wounds.
Precautions. Wear a mask and gown dur-
• VRE stands for vancomycin-resistant entero-
ing resident care. Use special care when
coccus. Enterococci are bacteria that live in the
handling sputum. When entering a special
digestive and genital tracts. They normally
airborne infection isolation room (AIIR), do
do not cause problems in healthy people.
not open or close the door quickly. This pulls
Vancomycin is a powerful antibiotic. It is
contaminated room air into the hallway. The
often the antibiotic of last resort. It is gener-
door should remain closed. Follow isolation
ally limited to use against bacteria that are
procedures if directed. Help the resident
resistant to other antibiotics. Vancomycin-
remember to take all medication prescribed.
resistant enterococcus is a genetically changed
Failure to do so is a major factor in the
strain of enterococcus. It originally developed
spread of TB.
in people who were exposed to the antibiotic
• MRSA stands for methicillin-resistant vancomycin.
Staphylococcus aureus. Staphylococcus aureus
VRE is dangerous. It is very difficult to treat.
is a common type of bacteria that can cause
Multiple medications may be required. It
illness. Methicillin is a powerful antibiotic
causes life-threatening infections in those
drug. MRSA is an antibiotic-resistant infec-
with weak immune systems—the very
tion often acquired in hospitals and other
young, the very old, and the very ill. VRE is
facilities. MRSA infections also occur in
spread through direct and indirect contact.
otherwise healthy people who have not been
 55 2

Once it establishes itself, it is very difficult • Provide continuing in-service education on

to eliminate. Preventing VRE is much easier. infection prevention, including bloodborne
You can help prevent its spread by washing and airborne pathogens.
your hands often. Wear PPE as directed. Dis-

Foundations of Resident Care

• Have written procedures to follow should an
infect items according to facility policy.
exposure occur, including medical treatment
• Clostridium difficile (C-diff, C. difficile) is and plans to prevent similar exposures.
a spore-forming bacteria which can be part
• Provide PPE for employees to use and teach
of the normal intestinal flora. When the nor-
them when and how to properly use it.
mal intestinal flora are altered, C. difficile can
flourish in the intestinal tract. It produces • Provide free hepatitis B vaccinations for all
a toxin that causes frequent, foul-smelling, employees.
watery stools. Other symptoms include di- Employees’ responsibilities for infection preven-
arrhea that contains blood and mucus and tion include the following:
abdominal cramps. Enemas, nasogastric
• Follow Standard Precautions.
tube insertion, and GI tract surgery increase
a person’s risk of developing the disease. The • Follow all of the facility’s policies and
overuse of antibiotics may also alter the nor- procedures.
mal intestinal flora and increase the risk of • Follow care plans and assignments.
developing C. difficile diarrhea. C. difficile can
also cause colitis, a more serious intestinal • Use provided PPE as indicated or as
condition. appropriate.

C. difficile is spread by spores in feces that • Take advantage of the free hepatitis B
are difficult to kill. These spores can be car- vaccination.
ried on the hands of people who have direct • Immediately report any exposure you have to
contact with infected residents or with envi- infection.
ronmental surfaces (floors, bedpans, toilets,
• Participate in annual education programs
etc.) contaminated with C. difficile.
covering the control of infection.
Proper handwashing and handling of con-
taminated wastes can help prevent the dis-
Tip
ease. Using hand rubs alone is not effective.
Infection Prevention
Use a hand rub only after performing proper
The term “infection prevention,” rather than “infec-
handwashing. Limiting the use of antibiotics tion control,” is now used in many facilities. The rea-
also helps lower the risk of developing son for this is that infections should not be allowed
C. difficile diarrhea. to develop and then need to be controlled. Instead,
they should be prevented.

Employer-Employee Responsibilities
Employers’ responsibilities for infection preven-
tion include the following:
• Establish infection prevention procedures
and an exposure control plan to protect
workers.
 3 56

3
Understanding Your Residents

Understanding Your Residents

1. Identify basic human needs fear, anxiety, anger, aggression, withdrawal, in-
difference, and depression. Stress can also cause
People have different genes, physical appear- physical problems that may eventually lead to
ances, cultural backgrounds, ages, and social or illness.
financial positions. But all human beings have
the same basic physical needs:
• Food and water
• Protection and shelter
• Activity
• Sleep and rest
• Safety
• Comfort, especially freedom from pain
People also have psychosocial needs, which in-
volve social interaction, emotions, intellect, and
spirituality. Psychosocial needs are not as easy
to define as physical needs. However, all human
beings have the following psychosocial needs:
• Love and affection
• Acceptance by others Fig. 3-1. Interaction with other people is a basic psycho-
social need. Take time to talk with residents. Encourage
• Security them to be with friends or relatives, too. Social contact is
important.
• Self-reliance and independence in daily
living Abraham Maslow was a researcher of human
• Contact with other people (Fig. 3-1) behavior. He wrote about human physical and
psychosocial needs. He arranged these needs
• Success and self-esteem
into an order of importance. He thought that
Health and well-being affect how well psychoso- physical needs must be met before psychosocial
cial needs are met. Stress and frustration occur needs can be met. His theory is called “Maslow’s
when basic needs are not met. This can lead to Hierarchy of Needs” (Fig 3-2).
 57 3

Always knock or announce yourself before en-

tering residents’ rooms. Listen and wait for a
response before entering. If you encounter a sex-
ual situation between consenting adults, provide

Understanding Your Residents

privacy and leave the room. Be open and non-
judgmental about residents’ sexual attitudes. Do
not judge residents’ sexual orientation. Do not
judge any sexual behavior you see. Honor “Do
Not Disturb” signs if your facility uses them.
Sexual needs may also be affected by residents’
living environments. A lack of privacy and no
available partner are often reasons for a lack of
sexual expression in long-term care facilities. Be
sensitive to privacy needs.
Fig. 3-2. Maslow’s Hierarchy of Needs.
Residents’ Rights
Humans are sexual beings. They continue to Sexual Abuse
have sexual needs throughout their lives (Fig. Residents must be protected from unwanted sexual
advances. If you see sexual abuse happening, re-
3-3). Sexual urges do not end due to age or ad-
move the resident from the situation. Take him or
mission to a care facility. The ability to engage her to a safe place. Report to the nurse immediately
in sexual activity, such as intercourse and mas- after making sure the resident is safe and secure.
turbation, continues unless a disease or injury
occurs. Masturbation means to touch or rub Helping residents meet their spiritual needs can
sexual organs in order to give oneself or another help them cope with illness or disability. Spiritu-
person sexual pleasure. ality is a sensitive area. Do not make judgments
about any spiritual beliefs or lack of beliefs. Do
not try to push your beliefs on residents. Ways
you can help residents with their spiritual needs
include:
• Learn about residents’ religions or beliefs.
Listen carefully to what residents say.
• Respect residents’ decisions to participate in,
or refrain from, food-related rituals.
• If residents are religious, encourage partici-
Fig. 3-3. Human beings continue to have sexual needs pation in religious services.
throughout their lives.
• Respect all religious items.
Residents have the right to choose how they ex- • Report to the nurse (or social worker) if a
press their sexuality. In all age groups, there is resident expresses the desire to see clergy.
a variety of sexual behavior. This is true of your
residents also. An attitude that any expression of • Allow privacy for clergy visits (Fig. 3-4).
sexuality by the elderly is “disgusting” or “cute” • If asked, read religious materials aloud. If
is inappropriate. It deprives residents of their you are uncomfortable doing this, find an-
right to dignity and respect. other staff member who is not.
 3 58

• If a resident asks you, help find spiritual the body. This is the approach you should use
resources available in the area. The yellow when caring for residents. A simple example
pages usually list churches, synagogues, and of holistic care is taking time to talk with your
other houses of worship. You can also refer residents while helping them bathe. You are
Understanding Your Residents

this request to the nurse or social worker. meeting the physical need with the bath while
meeting the psychosocial need for interaction
with others at the same time.

3. Explain why promoting independence

and self-care is important
Any big change in lifestyle, such as moving
into a long-term care facility, requires a huge
emotional adjustment. Residents may be expe-
riencing fear, loss, and uncertainty with their
Fig. 3-4. Be open to your residents’ spiritual needs. Be decline in health and independence. Other com-
welcoming when residents receive a visit from a spiritual mon reactions to illness are denial and with-
leader. drawal. All of these feelings may cause them
to behave differently than they have before. Be
You should never do any of the following:
aware that dramatic changes in a resident’s life
• Try to change someone’s religion may cause anger, hostility, or depression. People
• Tell residents their belief or religion is wrong handle feelings differently. Each person adjusts
to illness and change in his or her own way
• Express judgments about a religious group
and in his or her own time. Be supportive and
• Insist residents join religious activities encouraging. Be patient, understanding, and
• Interfere with religious practices empathetic.

There are many community resources available To best understand feelings residents may be
to help residents meet different needs: having, you must first understand how difficult
it is to lose one’s independence. Somebody else
• Area Agency on Aging
must now do what residents did for themselves
• Ombudsman program all of their lives. It is also difficult for friends
• Alzheimer’s Association and family members. For example, a resident
• Local hospice organization may have been the main provider for his or her
family. A resident may have been the person
• Social workers
who did all of the cooking for the family. Other
• Resident advocacy organizations losses residents may be experiencing include the
• Meal or transportation services following:
• Loss of spouse, family members, or friends
2. Define “holistic care” due to death
• Loss of workplace and its relationships due
Holistic means considering a whole system,
to retirement
such as a whole person, rather than dividing the
system up into parts. Holistic care means car- • Loss of ability to go to favorite places
ing for the whole person—the mind as well as
 59 3

• Loss of ability to attend services and meet- To prevent these feelings, encourage residents to
ings at their faith communities do as much as possible for themselves. Even if it
seems easier for you to do things for residents,
• Loss of home and personal possessions
allow them to do tasks independently. Encourage

Understanding Your Residents

(Fig. 3-5)
self-care, regardless of how long it takes or how
poorly they are able to do it. Be patient (Fig. 3-6).

Fig. 3-6. Even if tasks take a long time, encourage resi-

Fig. 3-5. Understand and be sympathetic to the fact that dents to do what they can for themselves.
many residents had to leave familiar places.
Allowing residents to make choices is another
• Loss of health and the ability to care for way to promote independence. For example,
themselves residents can choose where to sit while they
eat. They can choose what they eat and in what
• Loss of ability to move freely
order. Respect a resident’s right to make choices.
• Loss of pets
Residents’ Rights
Independence often means not having to rely on
others for money, daily routine care, or participa- Dignity and Independence
tion in social activities. Activities of daily living Residents are adults; do not treat them like children.
Encourage them to do self-care without rushing
(ADLs) are the personal care tasks you do every them. Remember that they have the right to refuse
day to care for yourself. People may take these care and to make their own choices. Maintaining
activities for granted until they can no longer do dignity and independence is your residents’ legal
them for themselves. ADLs include bathing or right. It is also the proper and ethical way for you to
work.
showering, dressing, caring for teeth and hair,
toileting, eating and drinking, and moving from
place to place. 4. Identify ways to accommodate cultural
A loss of independence can cause these differences
problems:
Cultural diversity has to do with the different
• Poor self-image groups of people with varied backgrounds and
• Anger toward caregivers, others, and self experiences living together in the world. Positive
responses to cultural diversity include accep-
• Feelings of helplessness, sadness, and tance and knowledge, not prejudice. Each cul-
hopelessness ture may have different knowledge, behaviors,
• Feelings of being useless beliefs, values, attitudes, religions, and customs.

• Increased dependence You will take care of residents with different

backgrounds and traditions than your own. It is
• Depression
 3 60

important to respect and value each person as A resident’s first language may be different from
an individual. Respond to differences and new yours. If he or she speaks a different language,
experiences with acceptance. an interpreter may be necessary. Take time to
learn a few common phrases in a resident’s na-
Understanding Your Residents

There are so many different cultures that they

cannot all be listed here. One might talk about tive language. Picture cards and flash cards can
American culture being different from Japanese assist with communication.
culture. But within American culture there are Religious differences also influence the way
thousands of different groups with their own people behave. Religion can be very important
cultures. Japanese-Americans, African-Ameri- in people’s lives, particularly when they are ill or
cans, and Native Americans are just a few. Even dying. You must respect the religious beliefs and
people from a particular region, state, or city can practices of your residents, even if they are dif-
be said to have a different culture (Fig. 3-7). The ferent from your own. Never question your resi-
culture of the South is not the same as the cul- dents’ beliefs. Do not discuss your own beliefs
ture of New York City. with them.

Be aware of and respect practices that affect your

work. Many religious beliefs include dietary re-
strictions. These are rules about what and when
followers can eat and drink. For example, Jewish
people may not eat any pork. Be aware of any di-
etary restrictions and honor them. (Food differ-
ences will be discussed more in Chapter 8.)

Some people’s backgrounds may make them

less comfortable being touched. Ask permission
before touching residents. Be sensitive to their
feelings. You must touch residents in order to do
your job. However, recognize that some residents
feel more comfortable when there is little physi-
cal contact. If in doubt, ask residents or family
members. Tell other staff members what you
discover. Adjust care to your residents’ needs.
Fig. 3-7. There are many different cultures in the United
States.
Residents’ Rights
Cultural background affects how friendly people Ask, acknowledge, and accept.
Focus on compassionate, respectful, and culturally-
are to strangers. It can affect how close they
sensitive care. Treat your residents as they wish to be
want you to stand to them when talking. It can treated, not how you want to treat them. Your culture
affect how they feel about you performing care and experiences have shaped your thinking. Others
for them or discussing their health with them. may come from different cultures and have had dif-
ferent experiences, which have shaped the way they
Be sensitive to your residents’ backgrounds and
think. Something you may want from others may be
preferences. You cannot expect to be treated the different from what your resident wants. Ask ques-
same way by all your residents. You may have tions to find out what is appropriate. Acknowledge
to adjust your behavior around some residents. and accept differences without judgment. Never try
to make residents change their beliefs in any way.
Treat all residents with respect and profession-
alism. Expect them to treat you respectfully as
well.
 61 3

5. Describe the need for activity grooming beforehand, as needed and requested.
Assist with any personal care that the resident
Activity is an essential part of a person’s life; it requires. Help residents with walking and
improves and maintains physical and mental wheelchairs, as necessary.

Understanding Your Residents

health. Meaningful activities help promote in-
dependence, memory, self-esteem, and quality
of life. In addition, physical activity can help 6. Discuss family roles and their
manage illnesses, such as diabetes, high blood significance in health care
pressure, or high cholesterol. Regular physical
Families are the most important unit within our
activity can also help by:
social system. Families play a huge role in many
• Lessening the risk of heart disease, colon people’s lives (Fig. 3-8). Some examples of family
cancer, diabetes, and obesity types are listed below:
• Relieving symptoms of depression
• Improving mood and concentration
• Improving body function
• Lowering risk of falls
• Improving sleep quality
• Improving ability to cope with stress
• Increasing energy
• Increasing appetite and promoting better
eating habits
Inactivity and immobility can result in physical
and mental problems, such as:
• Loss of self-esteem
• Depression
• Boredom
• Pneumonia Fig. 3-8. Families come in all shapes and sizes.
• Urinary tract infection
• Single-parent families include one parent
• Constipation
with a child or children.
• Blood clots
• Nuclear families include two parents with a
• Dulling of the senses child or children.
Many facilities have an activity department. The • Blended families include widowed or di-
activities are designed to help residents socialize vorced parents who have remarried. There
and keep them physically and mentally active. may be children from previous marriages as
Daily schedules are normally posted with activi- well as from this marriage.
ties for that particular day. Activities include ex-
• Multigenerational families include parents,
ercise, arts and crafts, board games, newspapers,
children, and grandparents.
magazines, books, TV and radio, pet therapy,
gardening, and group religious events. When • Extended families may include aunts, un-
activities are scheduled, help residents with cles, cousins, or even friends.
 3 62

• Families may also be made up of unmarried two people will follow the exact same pattern
couples of the same sex or opposite sexes, or rate of development. Each resident must be
with or without children. treated as an individual and a whole person who
is growing and developing. He or she should
Understanding Your Residents

Today a family is defined more by supporting

not be treated as someone who is merely ill or
each other than by the particular people in-
disabled.
volved. Whatever kinds of families your residents
have, recognize the important part they can play.
Infancy, Birth to 12 Months
Family members help in many ways:
Infants grow and develop very quickly. In one
• Helping residents make care decisions
year a baby moves from total dependence to the
• Communicating with the care team relative independence of moving around, com-
• Giving support and encouragement municating basic needs, and feeding himself.
Physical development in infancy moves from the
• Connecting the resident to the outside world head down. For example, infants gain control
• Offering assurance to dying residents that over the muscles of the neck before the muscles
family memories and traditions will be val- in their shoulders. Control over muscles in the
ued and carried on trunk area, such as the shoulders, develops be-
fore control of arms and legs (Fig. 3-9).
Be respectful and nice to friends and family
members. Allow privacy for visits. After any
visitor leaves, observe the effect the visit had on
the resident. Report any noticeable effects to the
nurse. Some residents have good relationships
with their families. Others do not. If you notice
any abusive behavior from a visitor towards a
resident, report it immediately to the charge
nurse.
Families are great sources of information for the
resident’s personal preferences, history, diet, rit- Fig. 3-9. An infant’s physical development moves from
uals, and routines. Take time to ask them ques- the head down.
tions. Families often seek out nursing assistants
because they are closest to the residents. This is
Childhood
an important responsibility. Show families that
you have time for them, too. Communicate with The Toddler Period, Ages 1 to 3
them, but do not discuss a resident’s care with During the toddler years, children gain inde-
friends or family members. Listen if they want pendence. One part of this independence is
to talk. Refer questions regarding care to the new control over their bodies. Toddlers learn
nurse. to speak, gain coordination of their limbs, and
learn to control their bladders and bowels (Fig.
7. Describe the stages of human 3-10). Toddlers assert their new independence by
development exploring. Poisons and other hazards, such as
sharp objects, must be locked away. Psychologi-
Throughout their lives, people change physically cally, toddlers learn that they are individuals,
and psychologically. Everyone will go through separate from their parents. Children of this age
the same stages of development. However, no may try to control their parents. They may try to
 63 3

get what they want by throwing tantrums, whin- School-Age Children, Ages 6 to 12
ing, or refusing to cooperate. This is a key time
From ages 6 to about 12 years, children’s de-
for parents to set rules and standards.
velopment is centered on cognitive (related to

Understanding Your Residents

thinking and learning) and social development.
As children enter school, they also explore the
world around them. They relate to other children
through games, peer groups, and classroom
activities. In these years, children learn to get
along with each other. They also begin to behave
in ways common to their sex. They begin to de-
velop a conscience, morals, and self-esteem.

Adolescence
Puberty
During puberty, secondary sex characteristics,
such as body hair, appear. Reproductive organs
begin to function. The body begins to secrete
reproductive hormones. The start of puberty oc-
curs between the ages of 10 and 16 for girls and
Fig. 3-10. Toddlers gain coordination of their limbs.
12 and 14 for boys.

The Preschool Years, Ages 3 to 6 Adolescence, Ages 12 to 18

Children in their preschool years develop new Many teenagers have a hard time adapting to
skills. These will help them become more in- the changes that occur in their bodies after
dependent and have social relationships (Fig. puberty. Peer acceptance is important to them.
3-11). They learn new words and language skills. Adolescents may be afraid that they are ugly or
They learn to play in groups. They become more even abnormal. This concern for body image and
physically coordinated and learn to care for acceptance, combined with changing hormones
themselves. Preschoolers also develop ways of that influence moods, can cause rapid mood
relating to family members. They begin to learn swings. Adolescents need to express themselves
right from wrong. socially and sexually. Social interaction between
members of the opposite sex becomes very im-
portant (Fig. 3-12).

Fig. 3-11. Children in preschool years develop social

relationships. Fig. 3-12. Adolescence is a time of adapting to change.
 3 64

Adulthood ones, retirement, and preparation for death.

Young Adulthood, Ages 18 to 40 The developmental tasks of this age may seem
to deal entirely with loss. But solutions to these
By the age of eighteen, most young adults have
problems often involve new relationships, friend-
Understanding Your Residents

stopped growing. Adopting a healthy lifestyle in

ships, and interests.
these years can make life better now and prevent
health problems in later adulthood. Psychologi- Later adulthood covers an age range of as many
cal and social development continues, however. as 25 to 35 years. People in this age category can
The tasks of these years include: have very different abilities, depending on their
health (Fig. 3-14). Some 70-year-old people enjoy
• Selecting an appropriate education
active sports, while others are not active. Many
• Selecting an occupation or career 85-year-old people can still live alone. Others
may live with family members or in long-term
• Selecting a mate (Fig. 3-13)
care facilities.

Fig. 3-13. Young adulthood often involves finding long-

term mates.

• Learning to live with a mate or others

• Raising children
Fig. 3-14. Most older adults remain involved and
• Developing a satisfying sex life engaged.

Middle Adulthood, Ages 40 to 65

Ideas about older people are often false. They
In general, people in middle adulthood are more create prejudices against the elderly. These are
comfortable and stable than they were before. as unfair as prejudices against racial, ethnic, or
Many of their major life decisions have already religious groups. On television or in the movies
been made. In the early years of middle adult- older people are often shown as helpless, lonely,
hood people sometimes experience a “mid-life disabled, slow, forgetful, dependent, or inactive.
crisis.” This is a period of unrest centered on a However, research shows that most older people
subconscious desire for change and fulfillment are active and engaged in work, volunteer activi-
of unmet goals. ties, and learning and exercise programs. Aging
is a normal process, not a disease. Most older
Late Adulthood, Ages 65 and Older
people live independent lives and do not need
Persons in late adulthood must adjust to the ef- assistance (Fig. 3-15). Prejudice toward, stereo-
fects of aging. These changes can include the typing of, and/or discrimination against older
loss of strength and health, the death of loved persons or the elderly is called ageism.
 65 3

There are also changes that are NOT considered

normal changes of aging and should be reported
to the nurse. These include:

Understanding Your Residents

• 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.
Your job includes reporting any change, normal
or not.

Fig. 3-15. Most older people lead active lives.

8. Discuss the needs of people with
You are likely to spend much of your time work- developmental disabilities
ing with elderly residents. You must know what
is true about aging and what is not true. Aging Some of the people you will care for will be
causes many changes. However, normal changes developmentally disabled. Developmental dis-
of aging do not mean an older person must be- abilities are disabilities that are present at birth
come dependent, ill, or inactive. Knowing how or emerge during childhood. A developmental
to tell normal changes of aging from signs of disability is a chronic condition. It restricts
illness or disability will allow you to better help physical or mental ability. These disabilities pre-
residents. Normal changes of aging include: vent a child from developing at a “normal” rate.
Residents’ care will depend on the type and the
• Skin is thinner, drier, more fragile and less
extent of the disability. A person may not be able
elastic.
to perform certain activities, including activities
• Muscles weaken and lose tone. of daily living (ADLs). A person’s ability to com-
• Bones become more brittle. municate may be affected. His or her ability to
• Sensitivity of nerve endings in the skin learn may be limited as well. Many persons with
decreases. developmental disabilities require special care,
treatment or other services for long periods of
• Responses and reflexes slow.
time or throughout their lives.
• Short-term memory loss occurs.
According to the CDC, mental retardation is the
• Senses of vision, hearing, taste, and smell
most common developmental disorder. Approxi-
weaken.
mately 1% of the population has mental retar-
• Heart works less efficiently. dation. It is neither a disease nor a psychiatric
• Oxygen in the blood decreases. illness. People with mental retardation develop
• Appetite decreases. at a below-average rate. They have below-average
mental functioning. They have difficulty learn-
• Urinary elimination is more frequent.
ing, communicating, moving, and may have
• Digestion takes longer and is less efficient. problems adjusting socially. The ability to care
• Levels of hormones decrease. for themselves may be affected.
• Immunity weakens. Despite their special needs, people who are men-
• Lifestyle changes occur. tally retarded have the same emotional and phys-
 3 66

ical needs as others. They experience the same • Anxiety

emotions, such as anger, sadness, love, and joy, • Loss of appetite or overeating
as others do. • Problems with sexual functioning and desire
Understanding Your Residents

• Sleeplessness, trouble sleeping, or excessive

Guidelines: Developmental Disabilities sleeping

G Treat adult residents as adults, regardless of • Lack of attention to basic personal care
their behavior. tasks (e.g. bathing, combing hair, changing
clothes)
G Praise and encourage often, especially posi-
• Intense feelings of despair
tive behavior.
• Guilt
G Help teach ADLs by dividing a task into
• Trouble concentrating
smaller units.
• Withdrawal and isolation
G Promote independence. Assist residents
with activities and motor functions that are • Repeated thoughts of suicide and death
difficult. There are different types and degrees of depres-
G Encourage social interaction. sion. Major depression may cause a person to
lose interest in everything he once cared about.
G Repeat words you use to make sure they
Manic depression, or bipolar disorder, causes
understand.
a person to swing from deep depression to ex-
G Be patient. treme activity. These episodes can include high
energy, little sleep, big speeches, rapidly chang-
9. Describe mental illness, depression ing moods, high self-esteem, overspending, and
and related care poor judgment.

You first learned about mental health and men- People cannot overcome depression through
tal illness in Chapter 2. You can review the com- sheer will. It is an illness like any other illness.
munication guidelines for mentally ill residents It can be treated successfully. People who suffer
in that chapter. There are many degrees of men- from depression need compassion and support.
tal illness. It ranges from mild to severe. Know the symptoms. Recognize the beginning
or worsening of depression. Any suicide threat
Depression: Clinical depression is a serious
should be taken seriously. Report it immediately.
mental illness. It may cause intense mental,
It should not be regarded as an attempt to get
emotional, and physical pain, and disability. It
attention.
also makes other illnesses worse. If untreated, it
may result in suicide. Clinical depression is not Anxiety-related Disorders: Anxiety is uneasi-
a normal reaction to stress. Sadness is only one ness or fear, often about a situation or condition.
symptom of this illness. Not all people who have When a mentally healthy person feels anxiety,
depression complain of sadness or appear sad. he or she usually knows the cause. The anxiety
Other common symptoms of clinical depression fades once the cause is removed. A mentally ill
include: person may feel anxiety all the time. He or she
may not know the reason why. Physical signs
• Pain, including headaches, stomach pain,
and symptoms of anxiety-related disorders in-
and other body aches
clude shakiness, muscle aches, sweating, cold
• Low energy or fatigue
and clammy hands, dizziness, fatigue, racing
• Apathy, or lack of interest in activities heart, cold or hot flashes, a choking or smother-
• Irritability ing sensation, and a dry mouth.
 67 3

Phobias are an intense form of anxiety. Many

people are very afraid of some things or situa-
tions. Examples are a fear of dogs or of flying.
For a mentally ill person, a phobia is a disabling

Understanding Your Residents

terror. It keeps the person from doing normal
things. For example, the fear of being in a con-
fined space, claustrophobia, may make using
an elevator a terrifying task. Other anxiety-
related disorders include panic disorder, in
which a person is terrified for no known reason.
Fig. 3-16. Withdrawal is an important change to report.
Obsessive compulsive disorder is obsessive
behavior a person uses to cope with anxiety. For Behavior changes, including changes in per-
example, a person may wash his hands over and sonality, extreme behavior, and behavior that
over as a way of dealing with anxiety. Anxiety- does not seem to fit the situation
related disorders may also be caused by a
Comments, even jokes, about hurting self or
traumatic experience. This is known as
others
post-traumatic stress disorder.
Failure to take medicine or improper use of
medicine
Guidelines: Mentally Ill Residents
Real or imagined physical symptoms
G Observe residents carefully for changes in Events, situations, or people that seem to
condition or abilities. Document and report upset or excite residents
your observations.
Tip
G Support the resident and his family and
friends. Your positive, professional attitude Mental Retardation and Mental Illness
Sometimes people confuse the terms “mental retar-
encourages them.
dation” and “mental illness.” They are not the same.
G Encourage residents to do as much for them- Mental retardation is not a type of mental illness.
selves as possible. Progress may be very Mental retardation is a developmental disability
that is present at birth or emerges in childhood. It
slow. Be patient, supportive, and positive.
causes below-average mental functioning. Mental ill-
G Mental illness can be treated. Medication ness may develop at any time during a person’s life.
and psychotherapy are common meth- It may or may not affect mental ability. There is no
cure for mental retardation, although persons with
ods. Medication must be taken properly to
this disability can be helped. Many mental illnesses
promote benefits and reduce side effects. can be cured with treatment, such as medications
Psychotherapy is a method of treating men- and therapy. Mental retardation and mental illness
tal illness that involves talking about one’s are different conditions; however, persons who have
either condition need emotional support, as well as
problems with mental health professionals.
care and treatment.

Observing and Reporting: Mentally Ill

Residents 10. Explain how to care for dying
residents
Changes in ability
Death can occur suddenly without warning, or
Positive or negative mood changes, especially it can be expected. Older people, or those with
withdrawal (Fig. 3-16) terminal illnesses, may have time to prepare for
 3 68

death. A terminal illness is a disease or condi- comes unable to make those decisions him- or
tion that will eventually cause death. Preparing herself. It is called a “living will” because it takes
for death is a process. It affects the dying per- effect while the person is still living. It may also
son’s emotions and behavior. be called a “directive to physicians,” “health care
Understanding Your Residents

Dr. Elisabeth Kubler-Ross studied and wrote declaration,” or “medical directive.” A living will
about the grief process. Her book, On Death and is not the same thing as a will. A will is a legal
Dying, describes five stages that dying people declaration of how a person wishes his or her
and their loved ones may reach before death. possessions to be disposed of after death.
These five stages are listed below. Not all resi- A durable power of attorney for health care
dents go through all the stages. Some may stay is a signed, dated, and witnessed paper that
in one stage until death. They may move back appoints someone else to make the medical
and forth between stages during the process. decisions for a person in the event he or she be-
Denial. People in the denial stage may refuse comes unable to do so. This can include instruc-
to believe they are dying. They often believe a tions about medical treatment the person wants
mistake has been made. They may avoid discus- to avoid.
sion of their illnesses and simply act like it is not A do-not-resuscitate (DNR) order is another
happening. tool that helps medical providers honor wishes
Anger. Once they start to face the possibility of about care. A DNR order tells medical profes-
their death, people may become angry that they sionals not to perform CPR. A DNR order means
are dying. that medical personnel will not attempt emer-
gency CPR if breathing or the heartbeat stops. In
Bargaining. Once people have begun to believe general, DNR orders are appropriate for those in
that they are dying, they may make promises to the final stages of a terminal illness or who suf-
God. They may somehow try to bargain for their fer from a serious condition.
recovery.
Residents’ Rights
Depression. As dying people get weaker and
Advance Directives
symptoms get worse, they may become deeply
By law, advance directives and DNR orders must be
sad or depressed. They may cry or withdraw or honored. Respect each resident’s decisions about
be unable to do even simple things. advance directives. This is a very personal and pri-
vate matter. Do not make comments about his or
Acceptance. Many people who are dying are
her choices to anyone, including family members,
eventually able to accept death and prepare for other residents, or staff.
it. They may make plans for their last days or for
the ceremonies to follow. Death is a very sensitive topic. Many people find
Some residents will have advance directives. Ad- it hard to discuss. Feelings and attitudes about
vance directives are legal documents that allow death can be formed by many factors:
people to choose what medical care they wish to • Experiences with death
have if they cannot make those decisions them- • Personality type
selves. Advance directives can also name some-
• Religious beliefs
one to make decisions for a person if that person
• Cultural background
becomes ill or disabled. Living wills and durable
power of attorney for health care are examples of Common signs of approaching death include the
advance directives. following:
A living will states the medical care a person • Blurred and failing vision
wants, or does not want, in case he or she be- • Unfocused eyes
 69 3

• Impaired speech G Care of the Mouth and Nose. Give mouth

• Diminished sense of touch care often. If the resident is unconscious,
give mouth care every two hours. Apply lubri-
• Loss of movement, muscle tone, and feeling
cant, such as lip balm, to lips and nose.

Understanding Your Residents

• A rising or below-normal body temperature
G Skin Care. Give bed baths and incontinence
• Decreasing blood pressure
care as needed. Bathe perspiring residents
• Weak pulse that is abnormally slow or rapid often. Skin should be kept clean and dry.
• Slow, irregular respirations or rapid, shal- Change sheets and clothes for comfort. Keep
low respirations, called Cheyne-Stokes sheets wrinkle-free. Reposition residents
respirations often. Skin care to prevent pressure sores
• A “rattling” or “gurgling” sound as the per- is important. (More on pressure sores is in
son breathes Chapter 6.)

• Cold, pale skin G Comfort. Pain relief is critical. Residents may

not be able to tell you that they are in pain.
• Mottling (bruised appearance), spotting, or
Observe for signs of pain. Report them.
blotching of skin caused by poor circulation
Frequent changes of position, back massage,
• Perspiration skin care, mouth care and proper body align-
• Incontinence (both urine and stool) ment may help.
• Disorientation or confusion G Environment. Put favorite objects and pho-
tographs where the resident can easily see
Guidelines: Dying Resident them. Make sure the room is comfortable,
appropriately lit and well-ventilated. When
G Diminished Senses. Reduce glare and keep leaving the room, place the call light within
room lighting low (Fig. 3-17). Hearing is usu- reach. Do this even if the resident is unaware
ally the last sense to leave the body. Speak of his or her surroundings.
in a normal tone. Tell person about any pro- G Emotional and Spiritual Support. Listening
cedures that are being done. Describe what may be one of the most important things
is happening in the room. Do not expect an you can do for a dying resident. Touch can
answer. Observe body language to anticipate be very important. Pay attention to these
a resident’s needs. conversations. Do not avoid the dying per-
son or his or her family. Do not deny that
death is approaching. Do not tell the resident
that anyone knows how or when it will hap-
pen. Report any comments about fear to the
nurse. Some residents may seek spiritual
comfort from clergy. Give privacy for visits
from clergy, family, and friends. Do not dis-
cuss your religious or spiritual beliefs with
residents or their families or make
recommendations.
You can treat residents with dignity when they
Fig. 3-17. Keep a dying resident’s room softly lit without are approaching death by respecting their
glare.
rights and their preferences. Some legal rights
 3 70

to remember when caring for the terminally ill • Have my questions answered honestly.
include: • Not be deceived.
The right to refuse treatment. Remember that • Have help from and for my family in accept-
Understanding Your Residents

whether you agree or disagree with a resident’s ing my death.

decisions, the choice is not yours. It belongs to
• Die in peace and dignity.
the person involved. Be supportive of family
members. Do not judge them. They are most • Retain my individuality and not be judged
likely following the resident’s wishes. for my decisions, which may be contrary to
the beliefs of others.
The right to have visitors. When death is close,
it is an emotional time for all those involved. • Discuss and enlarge my religious and/or
Saying goodbye can be a very important part of spiritual experiences, whatever these may
dealing with a loved one’s death. It may also be mean to others.
reassuring to the dying person to have some- • Expect that the sanctity of the human body
one in the room, even if they do not seem to be will be respected after death.
aware of their surroundings. • Be cared for by caring, sensitive, knowledge-
The right to privacy. Privacy is a basic right, but able people who will attempt to understand
privacy for visiting, or even when the person is my needs and will be able to gain some sat-
alone, may be even more important now. isfaction in helping me face my death.
Other rights of a dying person are listed below Ways to treat dying residents and their families
in “The Dying Person’s Bill of Rights.” This was with dignity include the following:
created at a workshop on “The Terminally Ill • Respect their wishes in all possible ways.
Patient and the Helping Person,” sponsored by Communication between staff is extremely
Southwestern Michigan In-Service Education important at this time so that everyone un-
Council, and appeared in the American Journal derstands what the resident’s wishes are.
of Nursing, Vol. 75, January 1975, p. 99. Listen carefully for ideas on how to provide
I have the right to: simple gestures that may be special and
appreciated.
• Be treated as a living human being until I
die. • Do not isolate or avoid a resident who is
dying. Enter his or her room regularly.
• Maintain a sense of hopefulness, however
changing its focus may be. • Be careful not to make promises that cannot
or should not be kept.
• Be cared for by those who can maintain a
sense of hopefulness, however changing this • Continue to involve the dying person in fa-
might be. cility activities. Be resident-centered. Do not
talk with other staff members about your
• Express my feelings and emotions about my
personal life when caring for a resident.
approaching death in my own way.
• Listen if a dying resident wants to talk but
• Participate in decisions concerning my care.
do not offer advice. Do not make judgmental
• Expect continuing medical and nursing at- comments.
tentions even though “cure” goals must be
• Do not babble or be especially cheerful or
changed to “comfort” goals.
sad. Be professional.
• Not die alone.
• Keep the resident as comfortable as possible.
• Be free from pain. The nurse needs to know immediately if
 71 3

pain medication is requested. Keep the resi- G Put dentures back in the mouth if instructed
dent clean and dry. by the nurse. Close the mouth. If not possi-
• Assure privacy when it is desired. ble, place dentures in denture cup near head.

Understanding Your Residents

• Respect the privacy of the family and other G Close the eyes carefully.
visitors. They may be upset and not want to G Position the body on the back with legs
be bothered with others now. They may wel- straight. Fold arms across the abdomen. Put
come a friendly smile, however, and should a small pillow under the head.
not be isolated, either. G Follow facility policy on personal items.
• Help with the family’s physical comfort. If Check to see if you should remove jewelry.
requested, get them coffee, water, chairs, Always have a witness if personal items
blankets, etc. are removed or given to a family member.
Document what was given to whom.
When death occurs, the body will not have
heartbeat, pulse, respiration, or blood pres- G Strip the bed after the body has been
sure. The muscles in the body become stiff and removed. Open windows to air the room, as
rigid. This is a temporary condition called “rigor needed. Straighten up.
mortis” which is Latin for “stiffness of death.” G Document according to your facility’s policy.
The eyelids may remain open or partially open
Dealing with grief after the death of a loved one
with the eyes in a fixed stare. The mouth may
is a process. Grieving is an individual process.
remain open. The body may be incontinent of
No two people will grieve in exactly the same
both urine and stool. Though these things are
way. Clergy, counselors, or social workers can
a normal part of death, they can be frightening.
help people who are grieving (Fig. 3-18). Family
Inform the nurse immediately to help confirm
members or friends may have any of these reac-
the death.
tions to the death of a loved one:
Postmortem care is care of the body after
• Shock
death. Be sensitive to the needs of the family
and friends after death. They may wish to sit by • Denial
the bed to say goodbye. They may wish to stay • Anger
with the body for a while. Allow them to do so. • Guilt
Be aware of religious and cultural practices that
• Regret
the family wants to observe. Follow your facil-
ity’s policies and procedures. Perform assigned • Sadness
tasks. • Loneliness

Guidelines: Postmortem Care

G Bathe the body. Be gentle to avoid bruising.

G Place drainage pads where needed. This is
most often under the head and/or under the
perineum. Follow Standard Precautions.
G Do not remove any tubes or other equip-
ment. A nurse or the funeral home will do
Fig. 3-18. Some people will speak with clergy to help
this. them deal with their grief.
 3 72

11. Define the goals of a hospice program • Be sensitive to individual needs. Ask family
members or friends how you can be of help.
Hospice is the term for the special care that a
dying person needs. It is a compassionate way to • Recognize that some persons wish to be
Understanding Your Residents

care for dying people and their families. Hospice alone with their dying loved ones.
care uses a holistic approach. It treats the per- • Be aware of your own feelings. Know your
son’s physical, emotional, spiritual, and social limits and respect them.
needs.
• Recognize the stress. Talking with a coun-
Hospice care can be given seven days a week, selor or a support group may help. Remem-
24 hours a day. Hospice care may be given in a ber, however, that you must keep specific
hospital, at a care facility, or in the home. A hos- information confidential.
pice can be any location where a person who is
• Take good care of yourself. Eating right, ex-
dying is treated with dignity by caregivers. Hos-
ercising, and getting enough rest are ways
pice care is available with a doctor’s order. Any
of taking care of yourself. Take a break when
caregiver may give hospice care. Often specially-
you need to.
trained people provide hospice care.
• Allow yourself to grieve. You will develop
Hospice care helps to meet all needs of the
close relationships with some residents.
dying resident. Family and friends, as well as the
Know that it is normal to feel sad, angry, or
resident, are directly involved in care decisions.
lonely when residents die.
The resident is encouraged to participate in fam-
ily life and decision-making as long as possible. Tip
In long-term care, goals focus on recovery, or on Transitions
the resident’s ability to care for him- or herself Some hospice programs also have “Transitions”
programs. Transitions programs provide help for
as much as possible. However, in hospice care,
people who are not yet ready for hospice. This in-
the goals are the comfort and dignity of the resi- cludes people with life-limiting diagnoses, such as
dent. This type of care is called palliative care. cancer, Alzheimer’s disease, and some heart and
This is an important difference. You will need lung diseases. These patients may still be receiving
curative treatment for their illnesses. In a Transitions
to change your mindset when caring for hospice
program, a coordinator and a volunteer may be pro-
residents. Focus on pain relief and comfort, vided to assist the person with general needs and
rather than on teaching them to care for them- support. Medical services are not usually provided
selves. Report complaints or signs of pain to the until the person’s condition advances and he or she
needs hospice care.
nurse immediately. Residents who are dying also
need to feel independent for as long as possible.
Caregivers should allow residents to have as
much control over their lives as possible. Eventu-
ally, caregivers may have to meet all basic needs.
Certain attitudes and skills are useful in hospice
care:
• Be a good listener. Some people, however,
will not want to confide in you. Never push
someone to talk.
• Respect privacy and independence.
 73 4

Body Systems and Related Conditions

Body Systems and Related
Conditions
Bodies are organized into body systems. Each Body systems are made up of organs. An organ
system has conditions under which it works has a specific function. Organs are made up of
best. Homeostasis is the condition in which tissues. Tissues are made up of groups of cells
all of the body’s systems are working their best. that perform a similar task. For example, in the
To be in homeostasis, the body’s metabolism, circulatory system, the heart is one of the or-
or physical and chemical processes, must be gans. It is made up of tissues and cells. Cells are
working at a steady level. When disease or injury the building blocks of our bodies. Living cells di-
occur, the body’s metabolism is disturbed. Ho- vide, develop, and die, renewing the tissues and
meostasis is lost. organs of our body.
Each system in the body has its own unique This chapter discusses the structure and func-
structure and function. There are also normal, tion, age-related changes, and common diseases
age-related changes for each body system. You of each body system. Dementia and Alzheimer’s
need to know normal changes of aging for each disease, common diseases of the nervous sys-
body system. This will help you better recognize tem, will be discussed in Chapter 5.
any abnormal changes in your residents. This
chapter also includes tips on how you can help
residents with their normal changes of aging. 1. Describe the integumentary system
Body systems can be broken down in different The largest organ and system in the body is the
ways. In this book we divide the human body skin. Skin is a natural protective covering, or
into ten systems: integument. It prevents injury to internal or-
1. Integumentary, or skin gans. It also protects the body against entry of
2. Musculoskeletal bacteria or germs. Skin also prevents the loss of
too much water, which is essential to life. Skin
3. Nervous
is made up of layers of tissue. Within these lay-
4. Circulatory or Cardiovascular ers are sweat glands, which secrete sweat to
5. Respiratory help cool the body when needed, and sebaceous
6. Urinary glands, which secrete oil (sebum) to keep the
skin lubricated. There are also hair follicles,
7. Gastrointestinal
many tiny blood vessels (capillaries), and tiny
8. Endocrine nerve endings (Fig. 4-1).
9. Reproductive
10. Immune and Lymphatic
 4 74

How You Can Help: NA’s Role

Older adults perspire less and do not need to bathe

as often. Most elderly people generally need a com-
Body Systems and Related Conditions

plete bath only twice a week, with sponge baths every

day. Use lotions as ordered for moisture to relieve
dry skin. Be gentle; elderly residents’ skin can be
fragile and tear easily. Hair also becomes drier and
needs to be shampooed less often. Gently brush dry
hair to stimulate and distribute the natural oils. Layer
clothing and bed covers for additional warmth. Keep
bed linens wrinkle-free. Be careful if directed to give
nail care. Do not cut toenails. Encourage fluids.

Observing and Reporting: Integumentary

System

During daily care, a resident’s skin should be

Fig. 4-1. Cross-section showing details of the integumen- observed for changes that may indicate injury
tary system. or disease. Observe and report these signs and
symptoms:
The skin is also a sense organ. It feels heat, cold,
Pale, white or reddened, or purple areas, blis-
pain, touch, and pressure. It then tells the brain
ters or bruises on the skin
what it is feeling. Body temperature is regulated
in the skin. Blood vessels dilate, or widen, when Dry or flaking skin
the outside temperature is too high. This brings Rashes or any skin discoloration
more blood to the body surface to cool it off. The
Cuts, boils, sores, wounds, abrasions
same blood vessels constrict, or narrow, when
the outside temperature is too cold. By restrict- Fluid or blood draining from the skin
ing the amount of blood reaching the skin, the Changes in moistness/dryness
blood vessels help the body retain heat. Swelling
Normal changes of aging include: Blisters
• Skin is thinner, drier, and more fragile. It is Changes in wound or ulcer (size, depth,
more easily damaged. drainage, color, odor)
• Skin is less elastic. Redness or broken skin between toes or
• Protective fatty tissue is lost, so person feels around toenails
colder. Scalp or hair changes
• Hair thins and may turn gray. Skin that appears different from normal or
• Wrinkles and brown spots, or “liver spots,” that has changed
appear. In ebony complexions, also look for any
• Nails are harder and more brittle. change in the feel of the tissue, any change
• Dry, itchy skin may result from lack of oil in the appearance of the skin, such as an
from the sebaceous glands. “orange-peel” look, a purplish hue, and
extremely dry, crust-like areas that might be
covering a tissue break.
 75 4

Pressure sores are a common disorder of the exercises can help prevent these conditions.
integumentary system and will be covered in With ROM exercises, the joints are extended and
Chapter 6. flexed. Exercise increases circulation of blood,
oxygen, and nutrients and improves muscle

Body Systems and Related Conditions

2. Describe the musculoskeletal system tone. See Chapter 9 for more information on
and related conditions ROM exercises.
Muscles, bones, ligaments, tendons, and car- Normal changes of aging include:
tilage give the body shape and structure. They • Muscles weaken and lose tone.
work together to move the body. The skeleton, or
• Body movement slows.
framework, of the human body has 206 bones
(Fig. 4-2). Besides allowing the body to move, • Bones lose density. They become more brit-
bones also protect organs. Two bones meet at a tle, making them more susceptible to breaks.
joint. Muscles are connected to bone by tendons. • Joints may stiffen and become painful.
Muscles provide movement of body parts to • Height is gradually lost.
maintain posture and to produce heat.
How You Can Help: NA’s Role

Falls can cause life-threatening complications, in-

cluding fractures. Prevent falls by keeping items out
of residents’ paths. Keep furniture in the same place.
Keep walkers or canes where residents can easily
reach them. Be sure the resident is wearing non-skid
shoes and that the laces are tied. Immediately clean
up spills. Encourage regular movement and self-care.
Encourage residents to perform as many ADLs as
possible. Help with range of motion (ROM) exer-
cises as needed.

Observing and Reporting: Musculoskeletal

System

Observe and report the following:

Fig. 4-2. The skeleton is composed of 206 bones that aid Changes in ability to perform routine move-
movement and protect organs. ments and activities
Any changes in residents’ ability to perform
Exercise is important for improving and main- ROM exercises
taining physical and mental health. Inactivity
Pain during movement
and immobility can result in a loss of self-es-
teem, depression, pneumonia, and urinary tract Any new or increased swelling of joints
infections. They can also lead to constipation, White, shiny, red, or warm areas over a joint
blood clots, dulling of the senses, and muscle Bruising
atrophy or contractures. When atrophy occurs,
Aches and pains reported to you
the muscle wastes away, decreases in size, and
becomes weak. When a contracture develops,
the muscle shortens, becomes inflexible, and Arthritis
“freezes” in position. This causes permanent Arthritis is a general term. It refers to inflam-
disability of the limb. Range of motion (ROM) mation, or swelling, of the joints. It causes
 4 76

stiffness, pain, and decreased mobility. Arthritis G Encourage activity. Gentle activity can help
may be the result of aging, injury, or an autoim- reduce the effects of arthritis. Follow care
mune illness. Autoimmune illness causes the plan instructions carefully. Use canes or other
body’s immune system to attack normal tissue aids as needed.
Body Systems and Related Conditions

in the body. There are several types of arthritis. G Adapt activities of daily living (ADLs) to allow
Osteoarthritis is a common type of arthritis independence. Many devices are available
that affects the elderly. It may occur with aging to help residents to bathe, dress, and feed
or as the result of joint injury. Hips and knees, themselves even when they have arthritis.
which are weight-bearing joints, are usually af- G Choose clothing that is easy to put on and
fected. Joints of the fingers, thumbs, and spine fasten. Encourage use of hand rails and safe-
can also be affected. Pain and stiffness seem to ty bars in the bathroom.
increase in cold or damp weather.
G Treat each resident as an individual. Arthritis
Rheumatoid arthritis can affect people of all is very common among elderly residents. Do
ages. Joints become red, swollen, and very pain- not assume that each resident has the same
ful. Movement is restricted. Fever, fatigue, and symptoms and needs the same care.
weight loss are also symptoms (Fig. 4-3).
G Help resident’s self-esteem. Encourage self-
care. Have a positive attitude. Listen to the
resident’s feelings. You can help him be inde-
pendent as long as possible.

Osteoporosis
Osteoporosis causes bones to become porous
and brittle. Brittle bones can break easily. Weak-
ness in the bones may be due to age, lack of
hormones, lack of calcium in bones, alcohol,
Fig. 4-3. Rheumatoid arthritis. (photo courtesy of frederick
miller, md) or lack of exercise. Osteoporosis is more com-
mon in women after menopause (the end of
Treatment for arthritis includes: menstruation). Extra calcium and regular exer-
• Anti-inflammatory medications such as aspi- cise can help prevent osteoporosis. Signs and
rin or ibuprofen symptoms of osteoporosis include low back pain,
stooped posture, and becoming shorter over
• Local applications of heat to reduce swelling
time (Fig. 4-4).
and pain
• Range of motion exercises (Chapter 9)
• Regular exercise and/or activity routines
• Diet to reduce weight or maintain strength

Guidelines: Caring for Residents with Arthritis

G Watch for stomach irritation or heartburn

caused by aspirin or ibuprofen. Some resi-
dents cannot take these medications. Report
Fig. 4-4. Stooped posture, or “dowager’s hump,” is a
signs of stomach irritation or heartburn
common sign of osteoporosis. (Photos courtesy of Jeffrey T. Behr,
immediately. MD.)
 77 4

To prevent or slow osteoporosis, encourage

Guidelines: Caring for Residents Recovering
residents to walk and do other light exercise, as
from Hip Replacements
ordered. Nursing assistants must move residents
with osteoporosis very carefully. Medication, cal-

Body Systems and Related Conditions

G Keep often-used items, such as telephone,
cium, and fluoride supplements are used to treat tissues, call light, and water, within easy
osteoporosis. reach. Avoid placing items in high places.

Fractures and Hip/Knee Replacement G Dress the affected (weaker) side first.

Fractures are broken bones. They are caused by G Never rush the resident. Use praise and
accidents or by osteoporosis. Preventing falls, encouragement often. Do this even for small
which can lead to fractures, is very important. tasks.
Fractures of arms, elbows, legs, and hips are G Ask the nurse to give pain medication prior
the most common. Signs and symptoms of a to moving if needed.
fracture are pain, swelling, bruising, changes in G Have the resident sit to do tasks if allowed.
skin color at the site, and limited movement. This saves energy.
Weakened bones make hip fractures more com- G Follow the care plan exactly, even if the resi-
mon. A sudden fall can result in a fractured hip. dent wants to do more. Follow orders for
Hip fractures can also occur when weakened weight bearing. An order may be written as
bones fracture and cause a fall. A hip fracture is partial weight bearing (PWB) or non-weight
a serious condition. The elderly heal slowly. They bearing (NWB). Partial weight bearing
are also at risk for secondary illnesses and dis- means the resident is able to support some
abilities. Many fractured hips need surgery. Total weight on one or both legs. Non-weight
hip replacement is surgery that replaces the head bearing means the resident is unable to
of the long bone of the leg (femur) where it joins support any weight on one or both legs. Full
the hip. This is done for these reasons: weight bearing (FWB) means that one or
• Fractured hip due to an injury or fall which both legs can bear 100 percent of the body
does not heal properly weight on a step. Assist resident as needed
• Weakened hip due to aging with cane, walker, or crutches.

• Hip causes extreme pain and disability be- G Never perform ROM exercises on a leg on
cause the joint is badly damaged from osteo- the side of a hip replacement unless directed
arthritic changes. The bones are no longer by the nurse.
strong enough to bear the person’s weight. G Caution the resident not to sit with his or her
After the surgery, the person cannot stand on legs crossed or turn toes inward. The hip can-
that leg while the hip heals. A physical therapist not be bent or flexed more than 90 degrees.
will play an important role after surgery. The It cannot be turned inward or outward.
goals of care include strengthening the hip mus- G When transferring from the bed, stand on the
cles and getting the resident walking on that leg. side of the unaffected hip so that the strong
side leads in standing, pivoting, and sitting.
Be familiar with the resident’s care plan. It
With chair or toilet transfers, the stronger leg
will state when the resident may begin putting
should stand first.
weight on the hip. It will also tell how much the
resident is able to do. Help with personal care G Report any of these to the nurse:
and using assistive devices, such as walkers or • Redness, drainage, bleeding, or warmth
canes. in incision area
 4 78

• An increase in pain G Assist with deep breathing exercises as

• Numbness or tingling ordered.

• Abnormal vital signs, especially change in G Ask the nurse to give pain medication prior
Body Systems and Related Conditions

temperature to moving and positioning if needed.

G Report to the nurse if you notice redness,
• Resident cannot use equipment properly
swelling, heat, or deep tenderness in one or
and safely
both calves.
• Resident is not following doctor’s orders
for activity and exercise 3. Describe the nervous system and
• Any problems with appetite related conditions
• Any improvements, such as increased The nervous system is the control and message
strength and improved ability to walk center of the body. It controls and coordinates all
Knee replacement is the surgical insertion of body functions. The nervous system also senses
a prosthetic knee. This is performed to relieve and interprets information from the environ-
pain. It also restores motion to a knee damaged ment outside the human body (Fig. 4-5).
by injury or arthritis. It can help stabilize a knee
that buckles or gives out repeatedly. Care is simi-
lar to that for the hip replacement, but the recov-
ery time is much shorter. These residents have
more ability to care for themselves.

Guidelines: Knee Replacement

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
deflates on its own. It acts in the same way
that the muscles usually do during normal
activity. The sleeves are normally applied after
surgery while the resident is in bed. Anti-
embolic stockings are another type of special
Fig. 4-5. The nervous system includes the brain, spinal
stocking. They aid circulation. See Chapter 6 cord, and nerves throughout the body.
for more information on this type of stocking.
G Perform ankle pumps as ordered. These are Normal changes of aging include:
simple exercises that promote circulation to • Responses and reflexes slow.
the legs. Ankle pumps are done by raising the • Sensitivity of nerve endings in skin
toes and feet toward the ceiling and lowering decreases.
them again.
• Person may show some memory loss, more
G Encourage fluids, especially cranberry and often with short-term memory. Long-term
orange juice, which contain Vitamin C, to memory, or memory for past events, usually
prevent urinary tract infections (UTIs). remains sharp.
 79 4

4-6). Without blood, part of the brain gets no

How You Can Help: NA’s Role
oxygen. Brain cells die. Brain tissue is further
Help with memory loss by suggesting residents damaged by leaking blood, clots, and swelling.
make lists or write notes about things they want to These cause pressure on surrounding areas of

Body Systems and Related Conditions

remember. Placing a calendar nearby may help. If
your residents enjoy reminiscing, take an interest in healthy tissue. See Chapter 2 for more informa-
their past by asking to see photos or hear stories. tion on the warning signs of a CVA.
Allow time for decision-making and avoid sudden
changes in schedule. Allow plenty of time for move-
ment. Never rush the person. Encourage reading,
thinking, and other mental activities.

Observing and Reporting: Central Nervous

System

Observe and report these signs and symptoms:

Fatigue or any pain with movement or
exercise
Shaking or trembling Fig. 4-6. A stroke is caused when the blood supply to
Inability to speak clearly the brain is cut off suddenly by a clot or ruptured blood
vessel.
Inability to move one side of body
Disturbance or changes in vision or hearing Strokes can be mild or severe. Afterward, a per-
son may experience any of these problems:
Changes in eating patterns and/or fluid intake
• Paralysis on one side of the body, called
Difficulty swallowing hemiplegia
Bowel and bladder changes • Weakness on one side of the body, called
Depression or mood changes hemiparesis

Memory loss or confusion • Inability to speak or speak clearly, called ex-

pressive aphasia
Violent behavior
• Inability to understand spoken or written
Any unusual or unexplained change in
words, called receptive aphasia
behavior
• Loss of sensations such as temperature or
Decreased ability to perform ADLs
touch
Dementia and Alzheimer’s disease are common
• Loss of bowel or bladder control
disorders of the nervous system. Chapter 5 has
information on these diseases. • Confusion
• Poor judgment
CVA or Stroke
• Memory loss
The medical term for a stroke is a cerebrovas-
• Loss of cognitive abilities
cular accident (CVA). CVA, or stroke, is caused
when blood supply to the brain is cut off sud- • Tendency to ignore one side of the body,
denly by a clot or a ruptured blood vessel (Fig. called one-sided neglect
 4 80

• Laughing or crying without any reason, or G Encourage independence and self-esteem.

when it is inappropriate, called emotional Let the resident do things for him- or herself
lability whenever possible, even if you could do a
better or faster job. Make tasks less difficult
Body Systems and Related Conditions

• Difficulty swallowing, called dysphagia

for residents. Notice and praise residents’
The two sides of the brain control different func- efforts to do things for themselves even when
tions. Symptoms depend on which side of the they are unsuccessful. Praise even the small-
brain the CVA affected. Weaknesses on the right est successes to build confidence.
side of the body show that the left side of the
G Always check on the resident’s body align-
brain was affected. Weaknesses on the left side
ment. Sometimes an arm or leg can be
of the body show that the right side of the brain
caught and the resident is unaware.
was affected.
G Pay special attention to skin care and observe
If the stroke was mild, the resident may experi-
for changes in the skin if a resident is unable
ence few, if any, of these complications. Physi-
to move.
cal therapy may help restore physical abilities.
Speech and occupational therapy can also help G If residents have a loss of touch or sensation,
with communication and performing ADLs. check for potentially harmful situations (for
example, heat and sharp objects). If residents
Guidelines: Residents Recovering from Stroke are unable to sense or move part of the body,
check and change positioning to prevent
G Residents with paralysis, weakness, or loss pressure sores.
of movement will usually have physical or G Adapt procedures when caring for resi-
occupational therapy. Residents may also per- dents with one-sided paralysis or weakness.
form leg exercises to aid circulation. Safety is Carefully assist with shaving, grooming, and
very important when residents are exercising. bathing.
Assist carefully with exercises as ordered.
G When helping with transfers or walking,
G Never refer to the weaker side as the “bad always use a gait belt for safety. Stand on the
side.” Do not talk about the “bad” leg or weaker side. Support the weaker side. Lead
arm. Use the terms “weaker” or “involved” to with the stronger side (Fig. 4-7).
refer to the side with paralysis.
G Residents with speech loss or communica-
tion problems may receive speech therapy.
You may be asked to help. This may include
helping residents recognize written words
or spoken words. Speech therapists will also
evaluate a resident’s swallowing ability. They
will decide if swallowing therapy or thickened
liquids are needed.
G Confusion and memory loss are upsetting.
People often cry for no apparent reason after
suffering a stroke. Be very patient and under-
standing. Your positive attitude will be impor-
tant. Keep a routine of care. This may help Fig. 4-7. When helping a resident transfer, support the
residents feel more secure. weak side while leading with the stronger side.
 81 4

When assisting with dressing, remember to:

G Dress the weaker side first. Place the weaker
arm or leg into the clothing. This prevents

Body Systems and Related Conditions

unnecessary bending and stretching of the
limb. Undress the stronger side first. Then
remove the weaker arm or leg from clothing
to prevent the limb from being stretched and
twisted.
G Use assistive equipment to help the resident
dress himself. Encourage self-care.
When assisting with communication, remember
to:
G Keep questions and directions simple.
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
the head or raising a hand or finger for “yes”
or “no.”
G Give residents time to respond. Listen
attentively.
G Use a pencil and paper if the resident can
write. A thick handle or tape around the pen-
cil may help the resident hold it more easily.
G Use verbal and nonverbal communication to
express your positive attitude. Let the resident
know you have confidence in his or her abili-
ties through smiles, touches, and gestures.
G Use pictures, gestures, or pointing. Use com-
munication boards or special cards to aid
communication (Fig. 4-8).
G Keep the call signal within reach of residents.
They can let you know when you are needed.
Guidelines for helping with eating for a person Fig. 4-8. A sample communication board.
recovering from stroke are in Chapter 8.
Parkinson’s Disease
Residents’ Rights Parkinson’s disease is a prog­ressive disease. It
Residents Who Cannot Speak causes a section of the brain to degenerate. It af-
Never talk about residents as if they were not there. fects the muscles, causing them to become stiff.
Just because they cannot speak does not mean they
It causes stooped posture and a shuffling gait,
cannot hear. Treat all residents with respect.
or walk. It can also cause pill-rolling. This is a
 4 82

circular movement of the tips of the thumb and G Prevent falls, which may be due to a lack of
the index finger when brought together, which coordination, fatigue, or vision problems.
looks like rolling a pill. Tremors or shaking G Stress can worsen the effects of MS. Be calm.
make it hard for a person to perform ADLs such
Body Systems and Related Conditions

Listen to residents when they want to talk.

as eating and bathing. A person with Parkin-
son’s may have a mask-like facial expression. G Encourage a healthy diet with plenty of fluids.
G Give regular skin care to prevent pressure
Guidelines: Parkinson’s Disease sores.

G Residents are at a high risk for falls. Protect G Assist with range of motion exercises to pre-
residents from any unsafe areas and vent contractures and to strengthen muscles.
conditions.
Head and Spinal Cord Injuries
G Help with ADLs as needed.
Diving, sports injuries, falls, car and motorcycle
G Assist with range of motion exercises to pre-
accidents, industrial accidents, war, and criminal
vent contractures and to strengthen muscles.
violence are some causes of these injuries. Head
G Encourage self-care. Be patient with self-care injuries can cause permanent brain damage.
and communication. Allow the resident time Residents who have had a head injury may have
to do and say things. Listen. the following problems: mental retardation; per-
Multiple Sclerosis (MS) sonality changes; breathing problems; seizures;
coma; memory loss; loss of consciousness; pare-
Multiple sclerosis (MS) is a progressive disease.
sis; and paralysis. The effects of spinal cord in-
It affects the central nervous system. When a
juries depend on the force of impact and where
person has MS, the protective covering for the
the spine is injured. The higher the injury, the
nerves, spinal cord, and white matter of the
greater the loss of function is. People with head
brain breaks down over time. Without this cov-
and spinal cord injuries may have paraplegia.
ering, or sheath, nerves cannot send messages
This is a loss of function of the lower body and
to and from the brain in a normal way. People
legs. These injuries may also cause quadriple-
with MS have varying abilities. Multiple sclerosis
gia. The person is then unable to use his legs,
is usually diagnosed when a person is in his or
trunk, and arms (Fig. 4-9).
her early twenties to thirties. It progresses slowly
and unpredictably. Symptoms include blurred vi-
sion, fatigue, tremors, poor balance, and trouble
walking. Weakness, numbness, tingling, inconti-
nence, and behavior changes are also symptoms.
MS can cause blindness, contractures, and loss
of function in the arms and legs.

Guidelines: Multiple Sclerosis

G Assist with ADLs as needed. Be patient with

self-care and movement. Allow enough time
for tasks. Offer rest periods as necessary.
Fig. 4-9. Loss of function depends on where the spine is
G Give resident plenty of time to communicate.
injured.
People with MS may have trouble forming
their thoughts. Be patient. Do not rush them.
 83 4

Guidelines: Head or Spinal Cord Injury

G Give emotional support, as well as physical

Body Systems and Related Conditions

help.
G Be patient with all care.
G Safety is very important. Be very careful that
residents do not fall or burn themselves.
Because these residents have no sensation,
they cannot feel a burn.
G Be patient with self-care. Allow as much inde-
pendence as possible with ADLs.
G Give good skin care to prevent pressure sores. Fig. 4-10. The parts of the eye.
G Assist residents to change positions at least
every two hours to prevent pressure sores. Be
gentle when repositioning.
G Perform passive range of motion exercises
as ordered to prevent contractures and to
strengthen muscles.
G Immobility leads to constipation. Encourage
fluids and a high-fiber diet, if ordered.
G Loss of control of urination may lead to the
need for a urinary catheter. Urinary tract infec-
tions are common. Encourage a high intake of Fig. 4-11. The outer ear, middle ear, and inner ear are
fluids and give extra catheter care as needed. the three main divisions of the ear.
G Lack of activity leads to poor circulation and
fatigue. Offer rest periods as necessary. You Normal changes of aging include:
may be directed to use special stockings to • Vision and hearing decreases. Sense of bal-
increase circulation. ance may be affected.
G Difficulty coughing and shallow breathing can • Senses of taste and smell decrease.
lead to pneumonia. Encourage deep breath-
• Sensitivity to heat and cold decreases.
ing exercises as ordered.
G Male residents may have involuntary erec-
How You Can Help: NA’s Role
tions. These are not deliberate. Provide for
privacy and be sensitive to this. Encourage the use of eyeglasses and keep them
clean. Bright colors and good lighting will also help.
G Assist with bowel and bladder training if Encourage the use of hearing aids and keep them
needed. clean. Speak slowly and clearly; do not shout. Loss
of senses of taste and smell may lead to decreased
The Nervous System: Sense Organs appetite. Encourage good oral care. Foods with a va-
riety of tastes and textures should be provided. Loss
The eyes, ears, nose, tongue, and skin are the
of smell may make resident unaware of increased
body’s major sense organs (Fig. 4-10 and Fig. body odor. Assist as needed with regular bathing.
4-11). They are part of the central nervous system Due to decreased sense of touch, be careful with hot
because they receive impulses from the environ- drinks and hot bath water. Residents may not be able
to tell if something is too hot for them.
ment. They relay these impulses to the nerves.
 4 84

Observing and Reporting: Eyes and Ears

Observe and report these signs and symptoms:

Body Systems and Related Conditions

Changes in vision or hearing

Signs of infection
Dizziness
Complaints of pain in eyes or ears

Vision Impairment
You first learned about vision impairment in
Chapter 2. People over the age of 40 are at risk
for developing certain serious vision problems.
These include cataracts, glaucoma, and blind-
ness. When a cataract develops, the lens of the
eye becomes cloudy. This prevents light from
entering the eye. Vision blurs and dims initially.
All vision is eventually lost. This disease can
occur in one or both eyes. It is corrected with
surgery, in which a permanent lens is usually
implanted. Fig. 4-12. The heart, blood vessels, and blood are the
main parts of the circulatory system.
Glaucoma is a disease that causes the pressure
in the eye to increase. This eventually damages Normal changes of aging include:
the retina and the optic nerve. It causes blind-
• Heart pumps less efficiently.
ness. Glaucoma can occur suddenly or gradually.
Symptoms include blurred vision, tunnel vision, • Blood flow decreases.
and blue-green halos around lights. Glaucoma is • Blood vessels narrow.
treated with medication and sometimes surgery.
How You Can Help: NA’s Role
4. Describe the circulatory system and Encourage movement and exercise. Allow enough
related conditions time to complete activities. Prevent residents from
tiring. Layer clothing to keep residents warm. Use
The circulatory system is made up of the heart, socks, slippers, or shoes to keep the feet warm.
blood vessels, and blood (Fig. 4-12). The heart
pumps blood through the blood vessels to the
Observing and Reporting: Circulatory System
cells. The blood carries food, oxygen, and other
substances cells need to function properly. Observe and report these signs and symptoms:
The circulatory system supplies food, oxygen, Changes in pulse rate
and hormones to cells. It supplies the body with
Weakness, fatigue
infection-fighting blood cells. It removes waste
products from cells. The circulatory system also Loss of ability to perform activities of daily
controls body temperature. living (ADLs)
Swelling of hands and feet
 85 4

Pale or bluish hands, feet, or lips

Guidelines: Hypertension
Chest pain
G High blood pressure can lead to serious
Weight gain

Body Systems and Related Conditions

problems such as CVA, heart attack, kidney
Shortness of breath, changes in breathing disease, or blindness. Treatment to control it
patterns, inability to catch breath is vital. Residents may take diuretics or medi-
Severe headache cation that lowers cholesterol. Diuretics are
drugs that reduce fluid in the body.
Inactivity (which can lead to circulatory
problems) G Residents may also have a prescribed exer-
cise program or be on a special low-fat, low-
Hypertension (HTN) or High Blood Pressure sodium diet. Encourage residents to follow
their diet and exercise programs.
When blood pressure is consistently 140/90 or
higher, a person is diagnosed as having hyper- Coronary Artery Disease (CAD)
tension, or high blood pressure. If blood pres-
Coronary artery disease occurs when the blood
sure is between 120/80 and 139/89 mmHg, it
vessels in the coronary arteries narrow. This
is called prehypertension. The person does not
reduces the supply of blood to the heart muscle
have high blood pressure now but is likely to de-
and deprives it of oxygen and nutrients. Over
velop it in the future.
time, as fatty deposits block the artery, the mus-
Hypertension may be caused by a hardening and cle that was supplied by the blood vessel dies.
narrowing of the blood vessels (Fig. 4-13). It can CAD can lead to heart attack or stroke.
also result from kidney disease, tumors of the
The heart muscle that is not getting enough oxy-
adrenal gland, and pregnancy. Hypertension can
gen causes chest pain, pressure, or discomfort,
develop in persons of any age.
called angina pectoris. The heart needs more
Signs and symptoms of high blood pressure are oxygen during exercise, stress, excitement, or a
not always obvious. This is especially true in the heavy meal. In CAD, narrow blood vessels keep
early stages. Often it is only discovered when the extra blood with oxygen from getting to the
blood pressure is taken. Persons may complain heart (Fig. 4-14).
of headache, blurred vision, and dizziness.

Fig. 4-13. Arteries may become hardened or narrower be-

cause of a build-up of plaque. Hardened arteries are one
cause of high blood pressure.
Fig. 4-14. Angina pectoris results from the heart not get-
ting enough oxygen.
 4 86

The pain of angina pectoris is usually described result in serious heart damage or death. See
as pressure or tightness. It occurs in the left side Chapter 2 for warning signs of an MI.
or the center of the chest behind the sternum
or breastbone. Some people have pain moving
Body Systems and Related Conditions

down the inside of the left arm or to the neck

and left side of the jaw. A person suffering from
angina pectoris may sweat or look pale. The per-
son may feel dizzy and have trouble breathing.

Guidelines: Angina Pectoris

G Rest is extremely important. Rest reduces

the heart’s need for extra oxygen. It helps
the blood flow return to normal, often within
three to 15 minutes.
G Medication is also needed to relax the walls
of the coronary arteries. This allows them to
open and get more blood to the heart. This Fig. 4-15. A heart attack occurs when blood flow to the
heart or a portion of the heart is cut off.
medication, nitroglycerin, is a small tablet
that the resident places under the tongue.
There it dissolves and is rapidly absorbed. Guidelines: Myocardial Infarction
Residents who have angina pectoris may
keep nitroglycerin on hand to use as symp- G Most residents who have had an MI will be
toms arise. Nursing assistants are not placed on a regular exercise program.
allowed to give any medication unless they
G Residents may be on a diet that is low in fat
have had special training. Tell the nurse if a
and cholesterol and/or a low-sodium diet.
resident needs help taking the medication.
Nitroglycerin is also available as a patch. Do G Medications may be used to regulate heart
not remove the patch. Tell the nurse imme- rate and blood pressure.
diately if the patch comes off. Nitroglycerin G Quitting smoking will be encouraged.
may also come in the form of a spray that the
G A stress management program may be start-
resident sprays onto or under the tongue.
ed to help reduce stress levels.
G Residents may also need to avoid heavy
G Residents recovering from a heart attack may
meals, overeating, intense exercise, and cold
need to avoid cold temperatures.
or hot and humid weather.
Congestive Heart Failure (CHF)
Myocardial Infarction (MI) or Heart Attack
Coronary artery disease, heart attack, high blood
When blood flow to the heart muscle is blocked, pressure, or other disorders may damage the
oxygen and nutrients fail to reach the cells in heart. When the heart muscle has been severely
that region (Fig. 4-15). Waste products are not damaged, it fails to pump effectively. Blood
removed. The muscle cells die. This is called backs up into the heart instead of circulating.
a myocardial infarction (MI) or heart attack. A This is called congestive heart failure, or CHF. It
myocardial infarction is an emergency that can can occur on one or both sides of the heart.
 87 4

Guidelines: Congestive Heart Failure Peripheral Vascular Disease (PVD)

Peripheral vascular disease (PVD) is a disease in
G Although CHF is a serious illness, it can which the legs, feet, arms or hands do not have

Body Systems and Related Conditions

be treated and controlled. Medications can enough blood circulation. This is due to fatty de-
strengthen the heart muscle and improve its posits in the blood vessels that harden over time.
pumping. The legs, feet, arms, and hands feel cool or cold.
G Medications help remove excess fluids. This Nail beds and/or feet become ashen or blue.
means more trips to the bathroom. Answer Swelling occurs in the hands and feet. Ulcers of
call lights promptly. the legs and feet may develop and can become
infected. Pain may be very severe when walking,
G A low-sodium diet or a fluid restriction may
but it is usually relieved with rest.
be prescribed.
Some changes in health may lead to inactivity.
G A weakened heart may make it hard for resi-
A lack of mobility may contribute to PVD. For
dents to walk, carry items, or climb stairs.
some cases of poor circulation to legs and feet,
Limited activity or bedrest may be prescribed.
elastic stockings are ordered. These stockings
Allow for a period of rest after an activity.
help prevent swelling and blood clots. They aid
G Intake and output of fluids may need to be circulation. See Chapter 6 for more information.
measured.
G Resident may be weighed daily at the same 5. Describe the respiratory system and
time of day to note weight gain from fluid related conditions
retention.
Respiration, the body taking in oxygen and
G Elastic leg stockings may be applied to
removing carbon dioxide, involves breathing in,
reduce swelling in feet and ankles.
inspiration, and breathing out, expiration. The
G Range of motion exercises improve muscle lungs accomplish this process (Fig. 4-16). The
tone when activity and exercise are limited. functions of the respiratory system are to bring
oxygen into the body and to eliminate carbon di-
G Extra pillows may help residents who have
oxide produced as the body uses oxygen.
trouble breathing. Keeping the head of the
bed elevated may also help with breathing.
G Help with personal care and ADLs as needed.
G Report any of these to the nurse:
• 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 Fig. 4-16. The respiratory process begins with inspiration
through the nose or mouth. The air travels through the
• Weight gain trachea and into the lungs via the bronchi, which then
branch into bronchioles.
 4 88

Normal changes of aging include: Bronchitis is an irritation and inflammation of

• Lung strength decreases. the lining of the bronchi. Chronic bronchitis is
a form of bronchitis that is usually caused by
• Lung capacity decreases.
cigarette smoking. Symptoms include coughing
Body Systems and Related Conditions

• Oxygen in the blood decreases. that brings up sputum (phlegm) and mucus.
• Voice weakens. Breathlessness and wheezing may be present.
Treatment includes stopping smoking and pos-
How You Can Help: NA’s Role sibly medications.
Provide rest periods as needed. Encourage exercise Emphysema is a chronic disease of the lungs
and regular movement. Encourage and assist with that usually results from chronic bronchitis and
deep breathing exercises, as ordered. Make sure resi-
cigarette smoking. People with emphysema have
dents with acute or chronic upper respiratory condi-
tions are not exposed to cigarette smoke or polluted trouble breathing. Other symptoms are cough-
air. People who have trouble breathing will usually be ing, breathlessness, and a fast heartbeat. There
more comfortable sitting up than lying down. is no cure for emphysema. Treatment includes
managing symptoms and pain. Oxygen therapy
may be ordered, as well as medications. Quitting
Observing and Reporting: Respiratory System
smoking is very important.
Observe and report these signs and symptoms: Over time, a person with either of these lung
disorders becomes chronically ill and weakened.
Change in respiratory rate
There is a high risk for acute lung infections,
Shallow breathing or breathing through such as pneumonia. Pneumonia is an illness
pursed lips that can be caused by a bacterial, viral, or fungal
Coughing or wheezing infection. Acute inflammation occurs in lung
tissue. The affected person develops a high fever,
Nasal congestion or discharge
chills, cough, greenish or yellow sputum, chest
Sore throat, difficulty swallowing, or swollen pains, and rapid pulse. Treatment includes an-
tonsils tibiotics, along with plenty of fluids. Recovery
The need to sit after mild exertion from pneumonia may take longer for older adults
and persons with chronic illnesses.
Pale or bluish color of the lips and arms and
legs When the lungs and brain do not get enough
oxygen, all body systems are affected. Residents
Pain in the chest area may have a constant fear of not being able to
Discolored sputum (green, yellow, blood- breathe. This can cause them to sit upright to
tinged, or gray), the fluid a person coughs up improve their ability to expand the lungs. These
from the lungs residents can have poor appetites. They usu-
ally do not get enough sleep. All of this can add
Chronic Obstructive Pulmonary Disease (COPD) to feelings of weakness and poor health. They
may feel they have lost control of their bodies,
Chronic obstructive pulmonary disease, or and particularly their breathing. They may fear
COPD, is a chronic disease. This means a per- suffocation.
son may live for years with it but never be cured.
COPD causes trouble with breathing, especially Residents with COPD may have these symptoms:
in getting air out of the lungs. There are two • Chronic cough or wheeze
chronic lung diseases that are grouped under • Trouble breathing, especially with inhaling
COPD: chronic bronchitis and emphysema. and exhaling deeply
 89 4

• Shortness of breath, especially during physi- G Ensure that residents always have help avail-
cal effort able, especially in case of a breathing crisis.
• Pale or blue skin (cyanosis) or reddish-pur- G Encourage pursed-lip breathing. Pursed-lip

Body Systems and Related Conditions

ple skin breathing is placing the lips as if kissing and
• Confusion taking controlled breaths. A nurse should
teach residents how to do this type of
• General state of weakness
breathing.
• Trouble completing meals due to shortness
of breath G Encourage residents to save energy for
important tasks. Encourage residents to rest.
• Fear and anxiety
G Report any of these to the nurse:
Guidelines: COPD • Temperature over 101°F
• Changes in breathing patterns, including
G Colds or viruses can make residents very ill
shortness of breath
quickly. Always observe and report signs of
symptoms getting worse. • Changes in color or consistency of lung
secretions
G Help residents sit upright or lean forward.
Offer pillows for support (Fig. 4-17). • Changes in mental state or personality
• Refusal to take medications as ordered
• Excessive weight loss
• Increasing dependence upon caregivers
and family

6. Describe the urinary system and

related conditions
The urinary system is composed of two kid-
neys, two ureters, one urinary bladder, and a
Fig. 4-17. It helps people with COPD to sit upright and
single urethra (Figs. 4-18 and 4-19). The urinary
lean forward slightly.
system has two important functions. Through
G Offer plenty of fluids and small, frequent urine, the urinary system eliminates waste prod-
meals. ucts created by the cells. The urinary system
also maintains the water balance in the body.
G Encourage a well-balanced diet.
G Keep oxygen supply available as ordered.
G Be calm and supportive. Being unable to
breathe or fearing suffocation is very
frightening.
G Use good infection control. Encourage hand-
washing and proper disposal of used tissues.
G Encourage as much independence with ADLs
as possible.
G Remind residents to avoid exposure to infec-
Fig. 4-18. The male urinary system.
tions, especially colds and the flu.
 4 90

Complaints that bladder feels full or painful

Urinary incontinence/dribbling
Pain in the kidney or back/flank region
Body Systems and Related Conditions

Inadequate fluid intake

Urinary Incontinence
Some people cannot control the muscles of the
bowels or bladder. They are said to be inconti-
nent. Incontinence can occur in residents who
Fig. 4-19. The female urethra is shorter than the male
urethra. Because of this, the female bladder is more likely are confined to bed, ill, elderly, paralyzed, or
to become infected by bacteria traveling up the urethra. who have circulatory or nervous system diseases
Encourage female residents to wipe from front to back or injuries. Incontinence is not a normal part of
after elimination. aging. Follow these guidelines for dealing with
urinary incontinence:
Normal changes of aging include:
• The ability of kidneys to filter blood
decreases. Guidelines: Urinary Incontinence
• Bladder muscle tone weakens.
G Offer a bedpan, urinal, commode or trip
• Bladder holds less urine, which causes more
to the bathroom often. Follow toileting
frequent urination.
schedules.
• Bladder may not empty completely, causing
greater chance of infection. G Answer call lights and requests for help
immediately.
How You Can Help: NA’s Role G Urinary incontinence is a major risk factor for
Encourage residents to drink plenty of fluids. Offer pressure sores. You must document all epi-
frequent trips to the bathroom. If residents are in- sodes of incontinence. The Minimum Data
continent, do not show frustration or anger. Urinary Set (MDS) counts any time a resident’s skin
incontinence is the inability to control the bladder, or anything touching a resident’s skin (pad,
which leads to an involuntary loss of urine. Keep
residents clean and dry. brief, or underwear) is wet from urine as an
episode of incontinence. This is true even if it
is a small amount of urine. This is important
Observing and Reporting: Urinary System to help prevent pressure sores. Document
carefully and accurately.
Observe and report these symptoms:
G Cleanliness and good skin care are impor-
Weight loss or gain tant for residents who are incontinent. Urine
Swelling in upper or lower extremities and feces are very irritating to the skin. They
should be washed off immediately and com-
Pain or burning during urination
pletely. Keep residents clean, dry, and free
Changes in urine, such as cloudiness, odor, from odor. Observe the skin carefully when
or color bathing and giving perineal care.
Changes in frequency and amount of G Incontinent residents who are bedbound
urination should have a plastic, latex, or disposable
Swelling in the abdominal/bladder area sheet placed under them to protect the bed.
 91 4

G Some residents will wear disposable inconti- G Offer bedpan or a trip to the toilet at least
nence pads or briefs for adults. Change wet every two hours. Answer call lights promptly.
briefs immediately. Do not refer to an incon- G Taking showers, rather than baths, helps pre-
tinence brief or pad as a “diaper.” Residents

Body Systems and Related Conditions

vent UTIs.
are not children. This is disrespectful.
G Report cloudy, dark, or foul-smelling urine,
G Residents who are incontinent need reassur- or if a resident urinates often and in small
ance and understanding. Be professional and amounts.
kind when dealing with incontinence.
7. Describe the gastrointestinal system
Urinary Tract Infection (UTI)
and related conditions
Urinary tract infection (UTI) causes inflamma-
The gastrointestinal (GI) system, also called the
tion of the bladder and the ureters. This causes
digestive system, is made up of the gastrointes-
burning during urination. It also causes a feel-
tinal tract and the accessory digestive organs
ing of needing to urinate frequently. UTI, or cys-
(Fig. 4-21). The gastrointestinal system has two
titis, may be caused by bacterial infection. Being
functions: digestion and elimination. Digestion
bedbound can cause urine to stay in the bladder
is the process of preparing food physically and
too long. This helps bacteria to grow.
chemically so that it can be absorbed into the
UTIs are more common in women. The ure- cells. Elimination is the process of expelling
thra is much shorter in women (three to four solid wastes made up of the waste products of
inches) than in men (seven to eight inches). Bac- food that are not absorbed into the cells.
teria can reach a woman’s bladder more easily.

Guidelines: Preventing UTIs

G Encourage residents to wipe from front to

back after elimination (Fig. 4-20). When you
give perineal care, make sure you do this too.
G Give careful perineal care when changing
incontinence briefs.

Fig. 4-21. The GI system consists of all the organs needed

Fig. 4-20. After elimination, wipe from front to back to
to digest food and process waste.
prevent infection.

Normal changes of aging include:

G Encourage plenty of fluids. Drinking plenty of
fluids helps prevent UTIs. Drinking cranberry • Decreased saliva production affects the abil-
and blueberry juice acidifies urine. This helps ity to chew and swallow.
to prevent infection. Vitamin C also has this • Absorption of vitamins and minerals
effect. decreases.
 4 92

• Process of digestion takes longer and is less painful elimination of a hard, dry stool. Consti-
efficient. pation occurs when the feces move too slowly
• Body waste moves more slowly through through the intestine. This can result from de-
creased fluid intake, poor diet, inactivity, medi-
Body Systems and Related Conditions

the intestines, causing more frequent

constipation. cations, aging, disease, or ignoring the urge to
eliminate. Signs of constipation include abdomi-
How You Can Help: NA’s Role nal swelling, gas, irritability, and record of no
recent bowel movement.
Encourage fluids and nutritious, appealing meals.
Allow time to eat. Make mealtime enjoyable. Provide Treatment often includes increasing fiber and
good oral care. Make sure dentures fit properly and
fluid intake, increasing activity level, and possi-
are cleaned regularly. Residents who have trouble
chewing and swallowing are at risk of choking. Pro- bly medication. An enema or suppository may be
vide plenty of fluids with meals. Residents should eat ordered to help. An enema is a specific amount
a diet that contains fiber and drink plenty of fluids of water introduced into the colon to eliminate
to help prevent constipation. Encourage daily bowel
stool. A suppository is a medication given rec-
movements. Give residents the opportunity to have a
bowel movement around the same time each day. tally to cause a bowel movement. If allowed and
trained to do so, follow facility policy on assist-
Observing and Reporting: Gastrointestinal ing with these treatments.
System
Fecal Impaction
Observe and report these symptoms: A fecal impaction is a hard stool that is stuck
Difficulty swallowing or chewing (includ- in the rectum and cannot be expelled. It results
ing denture problems, tooth pain, or mouth from unrelieved constipation. Symptoms include
sores) no stool for several days, oozing of liquid stool,
cramping, abdominal swelling, and rectal pain.
Fecal incontinence (inability to control the
When an impaction occurs, a nurse or doctor
bowels, leading to involuntary passage of
will insert one or two gloved fingers into the rec-
stool)
tum and break the mass into fragments so that
Weight gain/weight loss it can be passed. Prevention of fecal impactions
Anorexia (loss of appetite) includes a high-fiber diet, plenty of fluids, an in-
Abdominal pain and cramping crease in activity level, and possibly medication.
Diarrhea
Hemorrhoids
Nausea and vomiting (especially vomitus
Hemorrhoids are enlarged veins in the rec-
that looks like coffee grounds)
tum. They may also be visible outside the anus.
Constipation
Hemorrhoids can develop from an increase in
Flatulence/gas pressure in the lower rectum due to straining
Hiccups, belching during bowel movements. Chronic constipation,
Bloody, black, or hard stools obesity, pregnancy, and sitting for long periods
of time on the toilet are other causes. Signs and
Heartburn
symptoms include rectal itching, burning, pain,
Poor nutritional intake and bleeding. Treatment may include medica-
tions, compresses, and sitz baths. Surgery may
Constipation be necessary. When cleaning the anal area, be
Constipation is the inability to eliminate stool careful to avoid causing pain and bleeding from
(have a bowel movement), or the difficult and hemorrhoids.
 93 4

Diarrhea is brought out of the body through an artificial

opening in the abdomen. This opening is called
Diarrhea is frequent elimination of liquid or
a stoma. Stool, or feces, are eliminated through
semi-liquid feces. Abdominal cramps, urgency,
the ostomy rather than through the anus.

Body Systems and Related Conditions

nausea, and vomiting can accompany diarrhea,
depending on the cause. Infections, microor- The terms “colostomy” and “ileostomy” tell what
ganisms, irritating foods, and medications can part of the intestine was removed and the type of
cause diarrhea. Treatment is usually medication stool that will be eliminated. In a colostomy, stool
and a change of diet. A diet of bananas, rice, will generally be semi-solid. With an ileostomy,
apples, and tea/toast (BRAT diet) is often used. stool may be liquid. It may be irritating to the
skin. Residents who have had an ostomy wear a
Gastroesophageal Reflux Disease (GERD) disposable bag that fits over the stoma to collect
the feces (Fig. 4-22). The bag is attached to the
Gastroesophageal reflux disease, commonly
skin by adhesive. A belt may also be used to se-
referred to as GERD, is a chronic condition in
cure it.
which the liquid contents of the stomach back
up into the esophagus. The liquid can inflame Many people manage the ostomy appliance by
and damage the lining of the esophagus. It can themselves. If you are providing ostomy care,
cause bleeding or ulcers. In addition, scars from give careful skin care. Empty and clean or replace
tissue damage can narrow the esophagus and the ostomy bag whenever a stool is eliminated.
make swallowing difficult. Always wear gloves and wash hands carefully.
Teach proper handwashing to residents with
Heartburn is the most common symptom of
ostomies.
GERD. Heartburn and GERD must be reported.
These conditions are usually treated with medi-
cations. Serving the evening meal three to four
hours before bedtime may help. The resident
should not lie down until at least two to three
hours after eating. Give residents an extra pil-
low so the body is more upright during sleep.
Serving the largest meal of the day at lunchtime,
serving several small meals throughout the day,
and reducing fast foods, fatty foods, and spicy
foods may help. Stopping smoking, not drinking
alcohol, and wearing loose-fitting clothes may
also help. Fig. 4-22. The top of this photo shows the front and back
of one type of drainage pouch for an ostomy. An example
of a skin barrier is at the bottom of the photo. (photos cour-
Ostomies tesy of hollister incorporated, libertyville, illinois)

An ostomy is an operation to create an open-

ing from an area inside the body to the outside. Residents’ Rights
The terms “colostomy” and “ileostomy” refer to Ostomies
the surgical removal of a portion of the intes- Many residents with ostomies feel they have lost
tines. It may be necessary due to bowel disease, control of a basic bodily function. They may be em-
cancer, or trauma. (More information on cancer barrassed or angry about the ostomy. Be sensitive
and supportive. Always provide privacy for ostomy
is listed later in the chapter.) In a resident with care.
one of these ostomies, the end of the intestine
 4 94

Caring for an ostomy

Equipment: disposable bed protector, bath blan-

ket, clean ostomy bag and belt/appliance, toilet
Body Systems and Related Conditions

paper or gauze squares, basin of warm water,

soap or cleanser, washcloth, skin cream as or-
dered, 2 towels, plastic disposable bag, gloves
Fig. 4-23.­Wash away from the stoma.
1. Wash your hands.
Provides for infection control.
11. Place the clean ostomy appliance on resident.
2. Identify yourself by name. Identify the resi- Make sure the bottom of the bag is clamped.
dent by name.
Resident has right to know identity of his or her care- 12. Remove disposable bed protector and dis-
giver. Identifying resident by name shows respect and card. Place soiled linens in proper container.
establishes correct identification.
13. Remove bag. Discard the bag in the proper
3. Explain procedure to the resident. Speak
container.
clearly, slowly, and directly. Maintain face-to-
face contact whenever possible. 14. Remove and discard gloves.
Promotes understanding and independence.
15. Wash your hands.
4. Provide for resident’s privacy with curtain,
Provides for infection control.
screen, or door.
Maintains resident’s right to privacy and dignity. 16. Return bed to lowest position. Remove pri-
5. Adjust bed to a safe level, usually waist high. vacy measures.
Lowering the bed provides for safety.
Lock bed wheels. Raise head of bed.
Prevents injury to you and to resident.
17. Place call light within resident’s reach.
6. Place bed protector under resident. Cover Signaling device allows resident to communicate
resident with a bath blanket. Pull down the with staff as necessary.
top sheet and blankets. Only expose ostomy 18. Report any changes in resident to the nurse.
site. Offer resident a towel to keep clothing Report if stoma is very red or blue, or if swell-
dry. ing or bleeding is present.
Maintains resident’s right to privacy and dignity. Provides nurse with information to assess resident.
7. Put on gloves.
Provides for infection control.
19. Document procedure using facility
guidelines.
8. Remove ostomy bag carefully. Place it in plas- What you write is a legal record of what you did. If
tic bag. Note the color, odor, consistency, and you don’t document it, legally it didn’t happen.
amount of stool in the bag.
Changes in stool can indicate a problem.

9. Wipe area around stoma with toilet paper or

8. Describe the endocrine system and
gauze squares. Discard paper/gauze in plas- related conditions
tic bag. The endocrine system is made up of glands that
10. Using a washcloth and warm soapy water, secrete hormones. Glands are structures in the
wash the area in one direction, away from the body that produce substances. Each substance
stoma (Fig. 4-23). Pat dry with another towel. has a specific purpose in the overall functioning
Apply cream as ordered. of the body. Hormones are chemical substances
Keeping skin clean and dry prevents skin breakdown. created by the body that regulate essential body
 95 4

processes (Fig. 4-24). They are carried in the Observing and Reporting: Endocrine System
blood to the organs, where they perform these
functions: Observe and report these symptoms:

Body Systems and Related Conditions

• Maintaining homeostasis Headache*
• Influencing growth and development Weakness*
• Regulating levels of sugar in the blood Blurred vision*
• Regulating levels of calcium in the bones Dizziness*
• Regulating the body’s ability to reproduce Hunger*
• Determining how fast cells burn food for
Irritability*
energy
Sweating/excessive perspiration*
Change in “normal” behavior*
Confusion*
Change in mobility*
Change in sensation*
Numbness or tingling in arms or legs*
Weight gain/weight loss
Loss of appetite/increased appetite
Increased thirst
Frequent urination or any change in urine
output
Dry skin
Skin breakdown
Sweet or fruity breath
Fig. 4-24. The endocrine system includes organs that pro-
duce hormones that regulate body processes. Sluggishness or fatigue
Hyperactivity
Normal changes of aging include:
* indicates signs and symptoms that should be
• Levels of hormones, such as estrogen and
reported immediately
progesterone, decrease.
• Insulin production lessens. Diabetes
• Body is less able to handle stress. Diabetes mellitus is commonly called diabetes.
Diabetes is a disease in which the pancreas
How You Can Help: NA’s Role
does not produce enough or properly use in-
Encourage proper nutrition. Try to eliminate or re- sulin. Insulin is a hormone that converts glu-
duce stressors. Stressors are anything that causes cose, or natural sugar, into energy for the body.
stress. Offer encouragement and listen to residents.
Without insulin to process glucose, these sugars
 4 96

collect in the blood. This causes problems with • Frequent urination

circulation and can damage vital organs. Diabe-
• Weight loss
tes is common in people with a family history of
the illness, in the elderly, and in people who are • High levels of blood sugar
Body Systems and Related Conditions

obese. There are two major types of diabetes: • Sugar in the urine
Type 1 diabetes is usually diagnosed in children • Sudden vision changes
and young adults. It was formerly known as ju-
• Tingling or numbness in hands or feet
venile diabetes. It most often appears before age
20. However, a person can develop type 1 dia- • Feeling very tired much of the time
betes up to age 40. In type 1 diabetes, the body • Very dry skin
does not produce enough insulin. The condition
will continue throughout a person’s life. Type • Sores that are slow to heal
1 diabetes is treated with insulin and a special • More infections than usual
diet.
Diabetes can lead to further complications:
Type 2 diabetes, also called adult-onset diabetes, • Changes in the circulatory system can cause
is the most common form of diabetes. In type heart attack and stroke, reduced circulation,
2 diabetes, either the body does not produce poor wound healing, and kidney and nerve
enough insulin or the body fails to properly use damage.
insulin. This is known as “insulin resistance.”
Type 2 diabetes usually develops slowly. It is the • Damage to the eyes can cause vision loss
milder form of diabetes. It typically develops and blindness.
after age 35. The risk of getting it increases with • Poor circulation and impaired wound heal-
age. However, the number of children with type ing may cause leg and foot ulcers, infected
2 diabetes is growing rapidly. Type 2 diabetes wounds, and gangrene. Gangrene can lead
often occurs in obese people or those with a to amputation.
family history of the disease. It can usually be
• Insulin reaction and diabetic ketoacidosis
controlled with diet and/or oral medications.
can be serious complications of diabetes. See
Pre-diabetes occurs when a person’s blood Chapter 2 for signs and symptoms of each.
glucose levels are above normal but not high
Diabetes must be carefully controlled to prevent
enough for a diagnosis of type 2 diabetes. Re-
complications and severe illness. When working
search indicates that some damage to the body,
with people with diabetes, follow care plan in-
especially the heart and circulatory system, may
structions carefully.
already be occurring during pre-diabetes.
Pregnant women who have never had diabetes Guidelines: Diabetes
before but who have high blood sugar (glucose)
levels during pregnancy are said to have gesta- G Follow diet instructions exactly. The intake of
tional diabetes. carbohydrates, including breads, potatoes,
grains, pasta, and sugars, must be regulated.
People with diabetes may have these signs and Meals must be eaten at the same time each
symptoms: day. The resident must eat all that is served.
• Excessive thirst If a resident will not eat what is served, or if
you suspect that he or she is not following
• Extreme hunger
the diet, tell the nurse.
 97 4

G Encourage the person to exercise. A regu-

lar exercise program is important. Exercise
affects how quickly bodies use food. Exercise
also improves circulation. Exercises may

Body Systems and Related Conditions

include walking or other active exercise (Fig.
4-25). It may also include passive range of
motion exercises. Help with exercise as nec-
essary. Be positive. Try to make it fun. A walk
can be a chore or it can be the highlight of
the day.

Fig. 4-26. There are different types of equipment to mea-

sure glucose levels in the blood. (reprinted with permission of
briggs corporation, 800-247-2343, www.briggscorp.com)

G Give foot care as directed. Diabetics have

poor circulation. Even a small sore on the leg
or foot can grow into a large wound. It can
require amputation. Careful foot care, includ-
ing regular, daily inspection, is vital. The
Fig. 4-25. Exercise is very important for diabetic residents.
It helps to increase circulation and maintain a healthy goals of diabetic foot care are to check for
weight. irritation or sores, to promote blood circula-
tion, and to prevent infection.
G Observe the resident’s management of insu-
G Encourage diabetics to wear comfortable,
lin. Doses are calculated exactly. They are
well-fitting leather shoes that do not hurt
given at the same time each day. Nursing
their feet. Leather shoes breathe and help
assistants should know when residents take
prevent buildup of moisture. To avoid injuries
insulin and when their meals should be
to the feet, diabetics should never go bare-
served. There must be a balance between
foot. Cotton socks are best to absorb sweat.
the insulin level and food intake. Unless you
You should never trim or clip any resident’s
have had special training, you will not inject
toenails, but especially not a diabetic’s toe-
insulin.
nails. Only a nurse or doctor should do this.
G Perform urine and blood tests only as direct-
ed (Fig. 4-26). A fingerstick blood glucose 9. Describe the reproductive system and
test is one type of blood test that may be related conditions
used to check blood sugar. This is a simple
test that is performed by quickly piercing The reproductive system is made up of the re-
the fingertip, then placing the blood on a productive organs. They are different in men
chemically active disposable strip. The strip and women (Figs. 4-27 and 4-28). The reproduc-
will indicate the result. Sometimes the care tive system allows human beings to reproduce,
plan will specify a daily blood or urine test or create new human life. Reproduction begins
for insulin levels. Not all states allow you to when a male’s and female’s sex cells (sperm and
do this. Know your state’s rules. Your facility ovum) join. These sex cells are formed in the
will train you if you need to do these tests. male and female sex glands. These sex glands
Perform tests only as directed and allowed. are called the gonads.
 4 98

Normal changes of aging include: Observing and Reporting: Reproductive

Female: System

• Menstruation ends. Menopause is when a

Observe and report these symptoms:
Body Systems and Related Conditions

female stops having menstrual periods.

Discomfort or difficulty with urination
• Decrease in estrogen may lead to a loss of
calcium. This can cause brittle bones and, Discharge from the penis or vagina
potentially, osteoporosis. Swelling of the genitals
• Vaginal walls become drier and thinner.
Blood in urine or stool
Male:
Breast changes, including size, shape, lumps,
• Sperm production decreases. or discharge from the nipple
• Prostate gland enlarges, which can interfere
Sores on the genitals
with urination.
Resident reports of impotence, or inability of
male to have sexual intercourse
Resident reports painful intercourse

Vaginitis
Vaginitis is an infection of the vagina. It may
be caused by a bacteria, protozoa (one-celled
animals), or fungus (yeast). It may also be
caused by hormonal changes after menopause.
Women who have vaginitis have a white vaginal
discharge. This is accompanied by itching and
Fig. 4-27. The male reproductive system. burning. Report these symptoms to the nurse.
Treatment of vaginitis includes oral medications,
as well as vaginal gels or creams.

Benign Prostatic Hypertrophy (BPH)

Benign prostatic hypertrophy is a disorder that
occurs in men as they age. The prostate becomes
enlarged. This causes pressure on the urethra.
The pressure leads to frequent urination, drib-
bling of urine, and difficulty in starting the flow
Fig. 4-28. The female reproductive system. of urine. Urinary retention (urine remaining
in the bladder) may also occur, causing urinary
tract infection. Urine can also back up into the
How You Can Help: NA’s Role
ureters and kidneys, causing damage to these
Sexual needs and desires continue as people age. organs. Benign prostatic hypertrophy can be
Provide privacy when necessary for sexual activity. treated with medications or surgery. A test is
Respect your residents’ sexual needs. Never make
fun of or judge any sexual behavior. Do report any also available to screen for cancer of the prostate.
behavior that makes you uncomfortable or seems in- As men age, they are at increased risk for pros-
appropriate. Inappropriate behavior is not a normal tate cancer. Prostate cancer is usually slow-grow-
sign of aging, and could be a sign of illness. ing and responsive to treatment if detected early.
 99 4

Residents’ Rights How You Can Help: NA’s Role

Sexual Expression and Privacy
Factors that weaken the immune system include not
Residents have the right to sexual freedom and ex- enough sleep, poor nutrition, chronic illness, and

Body Systems and Related Conditions

pression. Residents have the right to privacy and to stress. Follow rules for preventing infection. Wash
meet their sexual needs. hands often. Keep the resident’s environment clean
to prevent infection. Encourage and help with good
personal hygiene. Encourage proper nutrition and
10. Describe the immune and lymphatic fluid intake. Promote a comfortable environment that
systems and related conditions allows for enough rest. A slight temperature increase
may indicate that a person is fighting an infection.
The immune system protects the body from Take accurate vital sign measurements.
disease-causing bacteria, viruses, and organisms
in two ways. Nonspecific immunity protects the
Observing and Reporting: Immune and
body from disease in general. Specific immunity
Lymphatic Systems
protects against a particular disease that is in-
vading the body at a given time.
Observe and report these symptoms:
The lymphatic system removes excess fluids Recurring infections (such as fevers and
and waste products from the body’s tissues. It diarrhea)
also helps the immune system fight infection.
Swelling of the lymph nodes
It is closely related to both the immune and the
circulatory systems (Fig. 4-29). The lymphatic Increased fatigue
system consists of lymph vessels and lymph cap- HIV and AIDS
illaries in which a fluid called lymph circulates.
Acquired immune deficiency syndrome, or
Lymph is a clear, yellowish fluid that carries
AIDS, is an illness caused by the human im-
disease-fighting cells called lymphocytes.
munodeficiency virus, or HIV. HIV attacks the
Normal changes of aging include: body’s immune system. It gradually disables it.
• Immune system weakens, increasing the Eventually the person has less resistance to other
risk of all types of infections infections. Death may be the result of these in-
• Decreased response to vaccines fections. However, medications help people live
longer. HIV is a sexually-transmitted disease. It
is also spread through infected blood, infected
needles, or to a fetus from an infected mother.
In general, HIV affects the body in stages. The
first stage shows symptoms like the flu, with
fever, muscle aches, cough, and fatigue. These
are signs of the immune system fighting the
infection. As the infection worsens, the immune
system overreacts. It attacks not only the virus,
but also normal tissue.
When the virus weakens the immune system
in later stages, a group of problems may ap-
pear. These include infections, tumors, and
central nervous system symptoms. These would
Fig. 4-29. Lymph nodes work to fight infection and are not occur if the immune system were healthy.
located throughout the body. This stage of the disease is known as AIDS. In
 4 100

the late stages of AIDS, damage to the central Infections, such as pneumonia, tuberculosis,
nervous system may cause memory loss, poor or hepatitis, invade the body when the immune
coordination, paralysis, and confusion. These system is weak and cannot defend itself. These
symptoms together are known as AIDS demen- illnesses worsen AIDS. They further weaken the
Body Systems and Related Conditions

tia complex. immune system. It is hard to treat these infec-

Signs and symptoms of HIV/AIDS include: tions. Over time, a person may develop a resis-
tance to some antibiotics. These infections often
• Appetite loss
cause death in people with AIDS.
• Involuntary weight loss of ten pounds or
more Persons with HIV are treated with drugs that
slow the progress of the disease. They do not
• Vague, flu-like symptoms, including fever,
cure it. The medicines must be taken at precise
cough, weakness, and severe fatigue
times. They have many unpleasant side effects.
• Night sweats For some people, the medications work less well
• Swollen lymph nodes in the neck, under- than for others. Other aspects of HIV treatment
arms, or groin are relief of symptoms and prevention and treat-
• Severe diarrhea ment of infection. Follow Standard Precautions
to help prevent the spread of HIV/AIDS.
• Dry cough
• Skin rashes
Guidelines: HIV/AIDS
• Painful white spots in the mouth or on the
tongue G People with poor immune systems are more
• Cold sores or fever blisters on the lips and sensitive to infections. Wash your hands
flat, white ulcers in the mouth often. Follow Standard Precautions. Keep
• Cauliflower-like warts on the skin and in the everything clean.
mouth G Involuntary weight loss occurs in almost
• Inflamed and bleeding gums all people who develop AIDS. High-protein,
high-calorie, and high-nutrient meals can
• Low resistance to infection, particularly
help maintain a healthy weight.
pneumonia, but also tuberculosis, herpes,
bacterial infections, and hepatitis G Some people with HIV/AIDS lose their appe-
• Bruising that does not go away tites and have trouble eating. Encourage
these residents to relax before meals and to
• Kaposi’s sarcoma, a form of skin cancer that
eat in a pleasant setting. Familiar and favorite
appears as purple or red skin lesions
foods should be served. Report appetite loss
(Fig. 4-30)
or trouble eating to the nurse. If appetite loss
• AIDS dementia complex continues, the doctor may prescribe an appe-
tite stimulant.
G Residents with infections of the mouth may
need food that is low in acid and neither
cold nor hot. Spicy seasonings should not
be used. Soft or pureed foods may be easier
to swallow. Liquid meals and fortified drinks
may help ease the pain of chewing. Warm
Fig. 4-30.­A purple or red skin lesion called Kaposi’s sar- salt water or other rinses may ease the pain
coma can be a sign of AIDS.
of mouth sores. Good mouth care is vital.
 101 4

G A person who has nausea or vomiting should disease need support from others. This may
eat small, frequent meals, if possible. The come from family, friends, religious and com-
person should eat slowly. Encourage fluids in munity groups, and support groups, as well
between meals. These residents must main- as the care team. Treat all your residents with

Body Systems and Related Conditions

tain intake of fluids to balance lost fluids. respect. Help give the emotional support
they need.
G Residents with mild diarrhea may need fre-
quent small meals that are low in fat, fiber, G Withdrawal, avoidance of tasks, and mental
and milk products. If diarrhea is severe, the slowness are early symptoms of HIV infec-
doctor may order a “BRAT” diet (a diet of tion. Medications may also cause side effects
bananas, rice, apples, and toast). This is of this type. AIDS dementia complex may
helpful for short-term use. Diarrhea rapidly cause further mental symptoms. There may
depletes the body of fluids. Fluid replacement also be muscle weakness and loss of muscle
is necessary. Good rehydration fluids include control, making falls a risk. Residents will
water, juice, soda, and broth. Caffeinated need a safe environment and close supervi-
drinks should be avoided. sion in their ADLs.
G Numbness, tingling, and pain in the feet
Residents’ Rights
and legs is usually treated with medications.
Handshakes and Hugs
Going barefoot or wearing loose, soft slip-
Understanding the facts about HIV/AIDS is impor-
pers may be helpful. If blankets cause pain, a tant. This will help you not to feel afraid of a person
bed cradle can keep sheets and blankets from with this disease. A handshake or a hug cannot
resting on legs and feet (Fig. 4-31). spread HIV or AIDS. The disease cannot be trans-
mitted by telephones, doorknobs, tables, chairs, toi-
lets, mosquitoes, or by breathing the same air as an
infected person. Spend time with residents who have
HIV/AIDS. They need the same thoughtful, personal
attention you give to all your residents.

Cancer
Cancer is a general term used to describe many
types of malignant tumors. A tumor is a group
of abnormally growing cells. Benign tumors are
considered non-cancerous. They usually grow
slowly in local areas. Malignant tumors are can-
Fig. 4-31. A bed cradle helps to keep covers from resting cerous. They grow rapidly and invade surround-
on the feet.
ing tissues.
G Residents with HIV/AIDS may have anxiety Cancer invades local tissue. It can spread to
and depression. They often suffer the judg- other parts of the body. When it spreads from
ments of family, friends, and society. Some the site where it first appeared, it can affect
people blame them for their illness. People other body systems. In general, treatment is
with HIV/AIDS may have tremendous stress. harder and cancer is more deadly after this
They may feel uncertainty about their illness, has occurred. Cancer often appears first in the
health care, and finances. They may also have breast, colon, rectum, uterus, prostate, lungs,
lost people in their social support network or skin. There is no known cure for cancer, but
of friends and family. Residents with this some treatments are effective.
 4 102

These risk factors may contribute to cancer:

• Tobacco use
• Exposure to sunlight
Body Systems and Related Conditions

• Excessive alcohol use

• Some food additives
• Exposure to some chemicals and industrial
agents
• Radiation
• Poor nutrition
• Lack of physical activity

When diagnosed early, cancer can often be

treated and controlled. The American Cancer Fig. 4-32. Radiation is targeted at cancer cells, but it also
Society has identified some warning signs of destroys some healthy cells in its path.
cancer:
• Unexplained weight loss Guidelines: Cancer

• Fever G Each case is different. Cancer is a general

• Fatigue term. It refers to many separate situations.
Residents may live many years or only several
• Pain
months. Treatment affects each person dif-
• Skin changes ferently. Do not make assumptions about a
• Change in bowel or bladder habits resident’s condition.

• Sores that do not heal G Residents may want to talk or may avoid talk-
ing. Respect their needs. Be honest. Never
• Unusual bleeding or discharge say, “Everything will be okay.” Be sensitive.
• Thickening or lump in the breast or other Remember that cancer is a disease. Its cause
part of the body is unknown. Have a positive attitude.

• Indigestion or difficulty swallowing G Good nutrition is important for residents

with cancer. Follow the care plan carefully.
• Recent change in a wart or mole
Residents frequently have poor appetites.
• Nagging cough or hoarseness Encourage a variety of food and small por-
tions. Liquid nutrition supplements may be
People with cancer can live longer and some-
used in addition to, not in place of, meals.
times recover if they are treated early. Often
If nausea or swallowing is a problem, foods
these treatments are combined:
such as soups, gelatin, or starches may
• Surgery appeal to the resident. Use plastic utensils
• Chemotherapy for a resident receiving chemotherapy. It
makes food taste better. Silver utensils cause
• Radiation (Fig. 4-32) a bitter taste.
 103 4

G Cancer can cause great pain, especially in G Having a family member with cancer can be
the late stages. Watch for signs of pain (see very difficult. Be alert to needs that are not
Chapter 7). Report them to the nurse. Help being met or stresses created by the illness.
with comfort measures, such as reposition-

Body Systems and Related Conditions

G Report any of these to the nurse:
ing and providing conversation, music, or
• Increased weakness or fatigue
reading materials. Report if pain seems to be
uncontrolled. • Weight loss

G Give back rubs for comfort and to increase • Nausea, vomiting, or diarrhea
circulation. For residents who spend many • Changes in appetite
hours in bed, moving to a chair for a peri- • Fainting
od of time may improve comfort as well.
• Signs of depression
Residents who are weak or immobile need to
be repositioned every two hours. • Confusion
• Blood in stool or urine
G Use lotion on dry or delicate skin. Do not
apply lotion to areas receiving radiation ther- • Change in mental status
apy. Do not remove markings that are used in • Changes in skin
radiation therapy. Follow any special skin care • New lumps, sores, or rashes
orders (for example: no hot or cold packs, no
• Increase in pain, or unrelieved pain
soap or cosmetics, no tight stockings).
G Help residents brush and floss teeth regular- Tip
ly. Medications, nausea, vomiting, or mouth Community Resources
infections may cause a bad taste in the Many services and support groups exist for people
mouth. You can help by using a soft-bristled with cancer and their families or caregivers. Hospi-
tals, hospice programs, and religious organizations
toothbrush, rinsing with baking soda and
have many resources. These include meal services,
water, or using a prescribed rinse. Do not use transportation to doctors’ offices, counseling, and
a commercial mouthwash. Use oral swabs, support groups. For cancer, visit the American Can-
rather than toothbrushes, for residents with cer Society online at cancer.org, or call the local
or state chapter. The National Association of Area
mouth sores. Be very gentle when giving oral
Agencies on Aging, n4a.org, operates the Eldercare
care. Locator, which is a free national service that links
G People with cancer may have a low self-image older adults and caregivers to aging information and
resources in their own communities.
because they are weak and their appearance
has changed. For example, hair loss is a com-
mon side effect of chemotherapy. Be sensi-
tive. Help with grooming if it is desired.
G If visitors help cheer your resident, encour-
age them. Do not intrude. If some times of
day are better than others, suggest this. It
may help a person with cancer to think of
something else for a while. Pursue other top-
ics. Get to know what interests your residents
have.
 5 104

5
Confusion, Dementia, and Alzheimer’s Disease

Confusion, Dementia, and

Alzheimer’s Disease
1. Discuss confusion and delirium Guidelines: Confusion
Confusion is the inability to think clearly. A
G Do not leave a confused resident alone.
confused person has trouble focusing his at-
tention and may feel disoriented. Confusion G Stay calm. Provide a quiet environment.
interferes with the ability to make decisions. Per- G Speak in a lower tone of voice. Speak clearly
sonality may change. The person may not know and slowly.
his name, the date, other people, or where he is.
G Introduce yourself each time you see the
A confused person may be angry, depressed, or
resident.
irritable.
G Remind the resident of his or her location,
Confusion may come on suddenly or gradually.
name, and the date. A calendar can help.
It can be temporary or permanent. Confusion is
more common in the elderly. It may occur when G Explain what you are going to do, using sim-
a person is in the hospital. Some causes of con- ple instructions.
fusion include: G Do not rush the resident.
• Low blood sugar G Talk to confused residents about plans for
• Head trauma or head injury the day. Keeping a routine may help.

• Dehydration G Encourage the use of glasses and hearing

aids. Make sure they are clean and are not
• Nutritional problems
damaged.
• Fever
G Promote self-care and independence.
• Sudden drop in body temperature
G Report observations to the nurse.
• Lack of oxygen
Delirium is a state of severe confusion that oc-
• Medications curs suddenly; it is usually temporary. Possible
• Infections causes include infections, disease, fluid imbal-
ances, and poor nutrition. Drugs and alcohol
• Brain tumor may also cause delirium. Symptoms include:
• Illness • Agitation
• Loss of sleep • Anger
• Seizures • Depression
 105 5

• Irritability and toileting. Dementia is not a normal part of

aging (Fig. 5-1).
• Disorientation
• Trouble focusing

Confusion, Dementia, and Alzheimer’s Disease

• Problems with speech
• Changes in sensation and perception
• Changes in consciousness
• Decrease in short-term memory
Report these signs to the nurse. The goal of
treatment is to control or reverse the cause.
Emergency care may be needed, as well as a stay
in a hospital.

Tip
Confusion and Delirium
When communicating with a person who is con-
fused or disoriented, keep your voice low. Do not
raise your voice or shout. Use the person’s name,
and speak clearly in simple sentences. Use facial Fig. 5-1. Some loss of cognitive ability is normal; how-
expressions and body language to aid in understand- ever, dementia is not a normal part of aging.
ing. Reduce distractions by taking action, such as
turning down the TV. Be gentle and try to decrease
fears. These are some common causes of dementia:
• Alzheimer’s disease
2. Describe dementia and discuss • Multi-infarct or vascular dementia (a series
Alzheimer’s disease of strokes causing damage to the brain)

As we age, we may lose some of our ability to • Lewy body dementia

think logically and quickly. This ability is called • Parkinson’s disease
cognition. Loss of some of this ability is called
• Huntington’s disease
cognitive impairment. How much ability is
lost depends on the individual. Cognitive im- Alzheimer’s disease (AD) is the most common
pairment affects concentration and memory. cause of dementia in the elderly. The Alzheim-
Elderly residents may lose their memories of er’s Association (alzheimers.org) estimates that
recent events. This can be frustrating for them. as many as 5.2 million people in the U.S. are
You can help. Encourage them to make lists of living with Alzheimer’s disease, and one in eight
things to remember. Write down names, events, persons age 65 and over has Alzheimer’s dis-
and phone numbers. Other normal changes of ease. Women are more likely than men to have
aging in the brain are slower reaction time, trou- Alzheimer’s disease and dementia. The risk of
ble finding or using words, and sleeping less. getting AD increases with age, but it is not a
normal part of aging.
Dementia is a general term that refers to a seri-
ous loss of mental abilities such as thinking, re- Alzheimer’s disease causes tangled nerve fi-
membering, reasoning, and communicating. As bers and protein deposits to form in the brain.
dementia advances, these losses make it hard to They eventually cause dementia. The disease
perform ADLs such as eating, bathing, dressing, gets worse, causing greater and greater loss of
 5 106

health and abilities. There is no known cause of possible. Working, socializing, reading, problem
AD, and there is no cure. Residents with AD will solving, and exercising should all be encouraged
never recover. They will need more care as the (Fig. 5-3). Having them do as much as possible
disease progresses. for themselves may even help slow the disease.
Confusion, Dementia, and Alzheimer’s Disease

Look for tasks that are challenging but not frus-

Diagnosis of Alzheimer’s disease is difficult. It
trating. Help residents succeed in doing them.
involves many physical and mental tests to rule
out other causes. The only sure way to deter-
mine AD at this time is by autopsy. The length
time it takes AD to progress from onset to death
varies greatly. It may take anywhere from three
to 20 years.
Symptoms of AD appear gradually. It begins
with memory loss. As AD progresses, the symp-
toms get worse. People with AD may get disori-
ented. They may be confused about time and
place. Communication problems are common.
They may lose their ability to read, write, speak, Fig. 5-3. Encourage reading and thinking activities for
residents with AD.
or understand. Mood and behavior changes. Ag-
gressiveness, wandering, and withdrawal are all These attitudes will help you give the best pos-
part of AD. AD progresses to complete loss of all sible care to your residents with AD:
ability to care for oneself. The person eventually
requires constant care. • Do not take their behavior personally.

Each person with AD will show different symp- • Treat residents with AD with dignity and re-
toms at different times. For example, one resi- spect, as you would want to be treated.
dent with Alzheimer’s may be able to read, but • Work with the symptoms and behaviors you
not use the phone or recall her address. Another see.
may have lost the ability to read, but is still able
• Work as a team.
to do simple math. Skills a person has used over
a lifetime are usually kept longer (Fig. 5-2). • Encourage communication.
• Take care of yourself.
• Work with family members.
• Follow the goals of the care plan.

3. List strategies for better

communication with residents with
Alzheimer’s disease
Some general communication guidelines for
residents with AD include the following:
Fig. 5-2. Even when a person loses much of her memory,
she may still keep skills she has used her whole life. • Always approach from the front. Do not
startle the resident.
Encourage residents with AD to do ADLs. Help • Determine how close the resident wants you
them keep their minds and bodies as active as to be.
 107 5

• Speak in a low, calm voice. Find a room try to stop him. Answer his questions, using
that has very little background noise and the same words each time, until he stops.
distraction. • Keep messages simple. Break complex tasks

Confusion, Dementia, and Alzheimer’s Disease

• Always identify yourself. Use the resident’s into smaller, simpler ones.
name. Continue to use the resident’s name
If the resident has trouble finding words or
during the conversation.
names:
• Speak slowly. Use a lower tone of voice
• Suggest a word that sounds correct. If this
than normal. This is calming and easier to
upsets the resident, learn from it. Try not
understand.
to correct a resident who uses an incorrect
• Repeat yourself, using the same words and word. As words become more difficult, use
phrases, as often as needed. smiles, touches, and hugs. They can help
• Use signs, pictures, gestures, or written show care and concern (Fig. 5-4). Know,
words to help communicate. though, that some people find touch fright-
ening or unwelcome.
• Break complex tasks into smaller, simpler
ones. Give simple, step-by-step instructions
as necessary.
In addition, residents with AD can be helped by
using these techniques for specific situations:
If the resident is frightened or anxious:
• Try to keep him calm. Speak slowly in a low,
calm voice. Find a room with little back-
ground noise and distraction. Get rid of
noise and distractions, such as televisions or
Fig. 5-4. Touch, smiles, hugs, and laughter will be under-
radios. stood even after speaking ability declines.
• Try to see and hear yourself as they might.
Always describe what you are going to do. If the resident seems not to understand basic in-
structions or questions:
• Use simple words and short sentences. If
helping with care, list steps one at a time. • Ask the resident to repeat your words.
• Check your body language. Make sure you • Use short words and sentences. Allow time
are not tense or hurried. to answer.
If the resident forgets or shows memory loss: • Note the communication methods that are
• Repeat yourself. Use the same words if you effective. Use them.
need to repeat an instruction or question. • Watch for nonverbal cues as the ability to
However, you may be using a word the resi- talk declines. Observe body language—eyes,
dent does not understand, such as “tired.” hands, and face.
Try other words like “nap,” “lie down,”
• Use signs, pictures, gestures, or written
“rest,” etc.
words. Use pictures, such as a drawing of a
• Repetition can also be soothing. Many resi- toilet on the bathroom door. Combine verbal
dents with AD will repeat words, phrases, and nonverbal communication. For example,
questions, or actions. This is called persever- say “Let’s get dressed now,” as you hold up
ation. If your resident perseverates, do not clothes.
 5 108

If the resident wants to say something but touch, smiles, and laughter for much longer.
cannot: Remember that some people do not like to
• Ask him or her to point, gesture, or act it be touched. Approach touching slowly. Be
gentle. Softly touch the hand or place your
Confusion, Dementia, and Alzheimer’s Disease

out.
arm around the resident. A hug can show af-
• If the resident is upset but cannot explain
fection and caring. A smile can say you want
why, offer comfort. Try a hug or a smile, or
to help.
try to distract. Verbal communication may be
frustrating. • Even after verbal skills are lost, signs, la-
bels, and gestures can reach people with
If the resident does not remember how to per-
dementia.
form basic tasks:
• Assume people with AD can understand
• Break each activity into simple steps. For ex-
more than they can express. Never talk about
ample, “Let’s go for a walk. Stand up. Put on
them as though they were not there.
your sweater. First the right arm...” Always
encourage the person to do what he can.
If the resident insists on doing something that is
4. List and describe interventions for
unsafe or not allowed: problems with common activities of daily
living (ADLs)
• Try to limit the times you say “don’t.” In-
stead, redirect activities toward something Use the same procedures for personal care and
else. activities of daily living (ADLs) for residents with
Alzheimer’s disease as with other residents.
If the resident hallucinates (sees or hears things
There are some guidelines to keep in mind
that are not really happening), is paranoid or
when helping residents with AD. These general
accusing:
principles will help you give the best care:
• Do not take it personally.
1. Develop a routine. Stick to it. Being consis-
• Try to redirect behavior or ignore it. Atten- tent is important for residents who are con-
tion span is limited. This behavior often fused and easily upset.
passes quickly.
2. Promote self-care. Help your residents to
If the resident is depressed or lonely: care for themselves as much as possible.
• Take time, one-on-one, to ask how she is This will help them cope with this difficult
feeling. Really listen. disease.
• Try to involve the resident in activities. 3. Take good care of yourself, both mentally
• Always report signs of depression to the and physically. This will help you give the
nurse. best care.

If the resident is verbally abusive, or uses bad As Alzheimer’s disease worsens, residents will
language: have trouble doing their ADLs. Below are tech-
niques that can help with these problems.
• Remember it is the dementia speaking and
not the person. Try to ignore the language.
Problems with Urinary Incontinence
Redirect attention to something else.
• Encourage fluids. Never withhold or discour-
If the resident has lost most verbal skills: age fluids because a resident is incontinent.
• Use nonverbal skills. As speaking abilities If you notice the resident is not drinking flu-
decline, people with AD will still understand ids, tell the nurse.
 109 5

• Note when the resident is incontinent over • Use a friendly, calm voice when speaking.
two to three days. Check him or her every • Praise and encourage the resident at each
30 minutes. This can help determine “bath- step.
room times.” Take the resident to the bath-

Confusion, Dementia, and Alzheimer’s Disease

room just before his or her “bathroom time.” Underwear
• Take the resident to the bathroom before and
after meals and just before bed. T-shirt
• Make sure the resident actually urinates be-
fore getting off the toilet.
Socks
• Mark the bathroom with a sign or a picture.
This is a reminder of where it is and to use
the toilet. Elastic-Waist
Pants
• Family or friends may be upset by their
loved one’s incontinence. Be matter-of-fact
Pullover
about cleaning after episodes of inconti-
Shirt
nence. Do not show any disgust or irritation.
• For incontinence during the night, observe
toilet patterns for two to three nights to try
to determine nighttime bathroom times.
• Make sure there is enough light in the bath-
room and on the way there.
• Put lids on trash cans, waste baskets, or
other containers if the resident has a habit of
Fig. 5-5. Lay out clothes in the order in which they should
urinating in them. be put on.

Problems with Dressing

• Show the resident clothing to put on. This Problems with Bathing
brings up the idea of dressing. • Schedule bathing when the resident is least
• Avoid delays or interruptions while dressing. agitated. Be organized so the bath can be
quick. Give sponge baths if the resident re-
• Provide privacy. Close doors and curtains. sists a shower or tub bath.
Dress the resident in the resident’s room.
• Prepare the resident before bathing. Hand
• Encourage the resident to pick clothes to him the supplies (washcloth, soap, shampoo,
wear. Give just a few choices. Make sure the towels). This serves as a visual aid.
clothing is clean and appropriate. Lay out
clothes in the order in which they are put on • Take a walk with the resident down the hall.
(Fig. 5-5). Choose clothes that are simple to Stop at the tub or shower room, rather than
put on. Some people with AD layer clothing asking directly about the bath.
regardless of the weather. • Make sure the bathroom is well-lit and is at a
• Break the task down into simple steps. In- comfortable temperature.
troduce one step at a time. Do not rush the • Provide privacy during the bath.
resident.
 5 110

• Be calm and quiet when bathing. Keep the They allow residents to choose the food they
process simple. want to eat. Examples of finger foods that
• Be sensitive when talking to the resident may be good to serve are sandwiches cut
into fourths, chicken nuggets or small pieces
Confusion, Dementia, and Alzheimer’s Disease

about bathing.
of cooked boneless chicken, fish sticks,
• Give the resident a washcloth to hold. This cheese cubes, halved hard-boiled eggs, and
can distract him while you finish the bath. fresh fruit and soft vegetables cut into bite-
• Be safe. Always follow safety precautions. sized pieces.
Ensure safety by using non-slip mats, tub • Do not serve steaming or very hot foods or
seats, and hand-holds. drinks.
• Be flexible about when you bathe. Your • Use dishes without a pattern. White usually
resident may not always be in the mood. works best. Use a simple place setting with
Also, not everyone bathes with the same fre- a single eating utensil. Remove other items
quency. Understand if your resident does not from the table (Fig. 5-6).
want to bathe.
• Be relaxed. Allow the resident to enjoy the
bath. Offer encouragement and praise.
• Let the resident do as much as possible dur-
ing the bath.
• While bathing the resident, check the skin
regularly for signs of irritation.
Fig. 5-6. Simple place settings with white plates on a
Problems with Eating solid-colored placemat may help avoid confusion and dis-
Food may not interest a resident with Alzheim- traction during eating.
er’s disease at all. It may be of great interest,
but he or she may only want to eat a few types • Put only one item of food on the plate at a
of food. In either case, a resident with AD is at time. Multiple kinds of food on a plate or a
risk for malnutrition. Nutritious food should be tray may be overwhelming.
encouraged. Here are some ideas for improving • Residents with AD may not understand how
eating habits: to eat or use utensils. Give simple, clear in-
• Have meals at regular times each day. You structions. Help the resident taste a sample
may need to remind the resident that it first. To get him to eat, place a spoon to the
is mealtime. Serve familiar foods. Foods lips. This will encourage him to open his
should look and smell appetizing. mouth. Ask him to open his mouth.

• Make sure there is proper lighting. • Guide the resident through the meal. Pro-
vide simple instructions. Offer regular
• Keep noise and distractions low during
drinks of water, juice, and other fluids to
meals.
avoid dehydration.
• Keep the task of eating simple. If the resi-
• Use adaptive equipment, such as special
dent is restless, try smaller, more frequent
spoons and bowls, as needed.
meals. Finger foods (foods that are easy to
pick up with the fingers) may be easier to eat • If a resident needs to be fed, do so slowly.
and can allow eating while moving around. Give small pieces of food.
 111 5

• Make mealtimes simple and relaxed. Allow Agitation: A resident who is excited, restless,
time for eating. Give the resident time to or troubled is said to be agitated. Situations
swallow before each bite or drink. that lead to agitation are triggers. Triggers may
include a change of routine or caregiver, new

Confusion, Dementia, and Alzheimer’s Disease

• Seat residents with AD with others at small
tables. This encourages socializing. or frustrating experiences, or even television.
These responses may help calm a person who is
• Observe for eating or swallowing prob- agitated:
lems. Report them to the nurse as soon as
possible. • Try to remove triggers. Keep routine con-
stant. Avoid frustration.
• Observe and report changes or problems in
eating habits. • Focus on a soothing, familiar activity. Try
sorting things or looking at pictures.
See Chapter 8 for more information on eating
and drinking. • Stay calm. Use a low, soothing voice. Reas-
sure the resident.
In addition, use the following tips when caring
for residents with AD: • An arm around the shoulder, patting, or
stroking may soothe some residents.
• Help with grooming. Help the people in
your care feel attractive and dignified. Sundowning: When a person gets restless and
agitated in the late afternoon, evening, or night,
• Prevent infections. Follow Standard
it is called sundowning. Sundowning may be
Precautions.
caused by hunger or fatigue, a change in routine
• Observe the resident’s physical health. Re- or caregiver, or any new or frustrating situation.
port any potential problems. People with Some effective responses to sundowning are:
dementia may not notice their own health
• Remove triggers. Give snacks or encourage
problems.
rest.
• Maintain a daily exercise routine.
• Avoid stressful situations during this time.
• Maintain self-esteem. Encourage indepen- Limit activities, appointments, and visits.
dence in ADLs.
• Play soft music.
• Share in fun activities, looking at pictures,
talking, and reminiscing. • Set a bedtime routine. Keep it.

• Reward positive and independent behav- • Recognize when sundowning occurs. Plan a
ior with smiles, hugs, warm touches, and calming activity just before.
thanks. • Remove caffeine from the diet.
• Give a soothing back massage.
5. List and describe interventions for
common difficult behaviors related to • Distract the resident with a simple, calm ac-
tivity like looking at a magazine.
Alzheimer’s disease
• Maintain a daily exercise routine.
Below are some common difficult behaviors that
you may face with Alzheimer’s residents. Each Catastrophic Reactions: When a person with
resident is different. Work with each person as AD overreacts to something, it is called a cata-
an individual. Report behavior in detail to the strophic reaction. It may be triggered by any of
nurse. the following:
 5 112

• Fatigue is wandering. Pacing and wandering may have

some of these causes:
• Change of routine, environment, or
caregiver • Restlessness
Confusion, Dementia, and Alzheimer’s Disease

• Overstimulation (too much noise or activity) • Hunger

• Difficult choices or tasks • Disorientation
• Physical pain • Need for toileting
• Hunger • Constipation
• Need for toileting • Pain
You can respond to catastrophic reactions as you • Forgetting how or where to sit down
would to agitation or sundowning. For example,
• Too much daytime napping
remove triggers. Help the resident focus on a
soothing activity. • Need for exercise

Violent Behavior: A resident who attacks, hits, Remove causes when you can. For example, give
or threatens someone is violent. Frustration or nutritious snacks, encourage an exercise routine,
overstimulation may trigger violence. It can also and maintain a toileting schedule. Let residents
be triggered by a change in routine, environ- pace or wander in a safe and secure (locked)
ment, or caregiver. These are appropriate re- area. Keep an eye on them (Fig. 5-8). Suggest an-
sponses to violent residents: other activity, such as going for a walk together.

• Block blows but never hit back (Fig. 5-7).

• Step out of reach.
• Call for help if needed.
• Do not leave resident alone.
• Try to remove triggers.
• Use techniques to calm residents as you
would for agitation or sundowning.

Fig. 5-8. Make sure residents are in a safe, secured area if

they pace or wander.

Mark rooms with signs or pictures. This may

prevent residents from wandering into areas
where they should not go (Fig. 5-9). Bed, body,
or door alarms can be used in beds or on wheel-
chairs, chairs, or doors. They help by sounding
an alarm when confused or demented residents
Fig. 5-7. Block blows but do not hit back. attempt to leave the bed or chair or open a door.
They also help prevent falls and decrease the
Pacing and Wandering: A resident who walks need for side rails. If a resident is ordered to
back and forth in the same area is pacing. A have a body alarm (bed or chair), make sure it is
resident who walks aimlessly around the facility on the resident and turned on.
 113 5

• Reality of facing a progressive, incurable

illness
• Chemical imbalance

Confusion, Dementia, and Alzheimer’s Disease

You can respond to depression in these ways:
• Report signs of depression to the nurse im-
mediately. It is an illness that can be treated
with medication.
• Encourage independence, self-care, and
activity.
Fig. 5-9. This Posey Door Guard helps remind residents
with dementia not to exit or enter a restricted area. • Talk about moods and feelings if the resident
(reprinted with permission of briggs corporation, 800-247-2343,
www.briggscorp.com) wishes. Be a good listener.
• Encourage social interaction.
If a resident wanders away from the protected
area, or elopes, notify the nurse immediately. Perseveration or Repetitive Phrasing: A resident
Follow the facility’s policies and procedures for who repeats a word, phrase, question, or activ-
missing residents. ity over and over is perseverating. Repeating
a word or phrase is also called repetitive phras-
Hallucinations or Delusions: A resident who
ing. This may be caused by disorientation or
sees, hears, smells, tastes, or feels things that
confusion. Respond to this with patience. Do not
are not there is having hallucinations. A resi-
try to silence or stop the resident. Answer ques-
dent who believes things that are not true is
tions each time they are asked. Use the same
having delusions. You can respond to hallucina-
words each time.
tions and delusions in these ways:
Disruptiveness: Disruptive behavior is anything
• Ignore harmless hallucinations and
that disturbs others, such as yelling, banging
delusions.
on furniture, slamming doors, etc. Often this
• Reassure a resident who seems agitated or behavior is triggered by a wish for attention, by
worried. pain or constipation, or by frustration. When
• Do not argue with a resident who is imagin- this behavior happens, gain the resident’s at-
ing things. The feelings are real to him or tention. Be calm and friendly. Gently direct the
her. Do not tell the resident that you can see resident to a more private area, if possible. Find
or hear his or her hallucinations. Redirect out why the behavior is occurring. There may be
resident to other activities or thoughts. a physical reason, such as pain or discomfort.

• Be calm. Reassure resident that you are You can help prevent or respond to disruptive
there to help. behavior in these ways:

Depression: When residents become withdrawn, • Notice and praise improvements in the
lack energy, or do not eat or do things they used resident’s behavior. Be tactful and sensitive
to enjoy, they may be depressed. Depression may when you do this. Do not treat the resident
have many causes, including: like a child.

• Loss of independence • Tell the resident about any changes in

schedules, routines, or the environment in
• Inability to cope
advance. Involve the resident in developing
• Feelings of failure, fear routine activities and schedules.
 5 114

• Encourage the resident to join in indepen- belongs to him, even when it clearly does not.
dent activities that are safe (for example, Hoarding is collecting and putting things away
folding towels). This helps the resident feel in a guarded way. Pillaging and hoarding should
in charge. It can prevent feelings of power- not be considered stealing. A person with Al-
Confusion, Dementia, and Alzheimer’s Disease

lessness. Independence is power. zheimer’s disease cannot and does not steal.
Stealing is planned. It requires a conscious ef-
• Help the resident find ways to cope. Focus
fort. In most cases, the person with AD is only
on positive activities he or she may still be
collecting something that catches his attention.
able to do, such as knitting, crocheting,
crafts, etc. This can provide a diversion. It is common for those with AD to wander in
and out of rooms collecting things. They may
Inappropriate Social Behavior: Inappropriate
carry these objects around for a while, and then
social behavior may be cursing, name calling,
leave them in other places. This is not inten-
or other behavior. As with violent or disruptive
tional. People with AD will often take their own
behavior, there may be many reasons why a
things and leave them in another room, not
resident is behaving this way. Try not to take it
knowing what they are doing. Ways you can help
personally. The resident may only be reacting to
lessen problems include:
frustration or other stress, not to you. Stay calm.
Be reassuring. Try to find out what caused the • Label all personal belongings with the resi-
behavior (for example, too much noise, too many dent’s name and room number. This way
people, too much stress, pain, or discomfort). If there is no confusion about what belongs to
possible, gently direct the resident to a private whom.
area if he or she is disturbing others. Respond • Place a label, symbol, or object on the resi-
positively to any appropriate behavior. Report dent’s door. This helps the resident find his
any physical abuse or serious verbal abuse to the or her own room.
nurse.
• Do not tell family that their loved one is
Inappropriate Sexual Behavior: Inappropri- “stealing” from others.
ate sexual behavior, such as removing clothes,
• Prepare the family so they are not upset
touching one’s own genitals, or trying to touch
when they find items that do not belong to
others can embarrass those who see it. Be mat-
their family member.
ter-of-fact when dealing with such behavior. Do
not overreact. This may reinforce the behavior. • Ask the family to tell staff if they notice
Be sensitive to the nature of the problem. Is the strange items in the room.
behavior actually intentional? Is it consistent? • Regularly check areas where residents store
Try to distract the resident. If this does not work, items. They may store uneaten food in
gently direct him or her to a private area. Tell these places. Provide a rummage drawer—a
the nurse. A resident may be reacting to a need drawer with items that are safe for the resi-
for physical stimulation or affection. Consider dent to take with him or her.
other ways to provide physical stimulation. Try
backrubs, a soft doll or stuffed animal to cuddle, Residents’ Rights
comforting blankets, pieces of cloth, or physical Abuse and Alzheimer’s Disease
touch that is appropriate. People with Alzheimer’s disease may be at a higher
risk for abuse. One reason for this is that caring for
Pillaging and Hoarding: Pillaging is taking someone with Alzheimer’s disease is very difficult.
things that belong to someone else. A person There are many psychological and physical demands
with dementia may honestly think something placed on caregivers.
 115 5

Example: Mr. Baldwin tells you he does not want

To help manage the stress of caring for people with
AD, take good care of yourself, both mentally and to eat lunch today because he is going out to a
physically. This will help you give the best care. If you restaurant with his wife. You know his wife has
feel that you need more resources to help you cope, been dead for many years and that Mr. Baldwin

Confusion, Dementia, and Alzheimer’s Disease

talk to the nurse. can no longer eat out. Instead of telling him that
Remember that you must never abuse your residents he is not going out to eat, you ask what restau-
in any way. And if you notice someone else abusing
a resident, you are legally required to report it. Take rant he is going to and what he will have. You
this responsibility seriously. Help end abuse of the suggest that he eat a good lunch now because
elderly and ill. sometimes the service is slow in restaurants
(Fig. 5-10).
6. Describe creative therapies for
residents with Alzheimer’s disease
Although Alzheimer’s disease cannot be cured,
there are many ways to improve life for residents
with AD.
Reality orientation is using calendars, clocks,
signs, and lists to help residents remember who
and where they are. It is useful in early stages of
AD when residents are confused but not totally
disoriented. In later stages, reality orientation
may frustrate residents.
Fig. 5-10. Validation therapy accepts a resident’s fanta-
Example: Each day when you go into Mrs. El- sies without attempting to reorient him to reality.
kin’s room, you show her the calendar and point
out what day of the week it is. On the calendar Reminiscence therapy is encouraging residents
or another piece of paper, list all the things you to remember and talk about the past. Explore
will do today, for example, take a shower, eat memories. Ask about details. Focus on a time
lunch, and go for a walk. When you speak to her, of life that was pleasant. Work through feelings
call her by her name: Mrs. Elkin. When helping about a hard time in the past. It is useful in
with tasks, explain why you do things as you many stages of AD, but especially with moderate
do. For example, “We use a shower chair in the to severe confusion.
shower so you don’t have to stand up for so long, Example: Mr. Benton, an 82-year-old man with
Mrs. Elkin.” Alzheimer’s disease, fought in World War II. In
Validation therapy is letting residents believe his room are many mementos of the war. He
they live in the past or in imaginary circum- has pictures of his war buddies, a medal he was
stances. Validating means giving value to or given, and more. You ask him to tell you where
approving. When using validation therapy, make he was sent in the war. He tells you about being
no attempt to reorient the resident to actual cir- in the Pacific. You ask him more detailed ques-
cumstances. Explore the resident’s beliefs. Do tions. Eventually he tells you a lot: the friends
not argue with or correct him or her. Validating he made in the service, why he was given the
can give comfort and reduce agitation. It is use- medal, times he was scared, and how much he
ful in cases of moderate to severe disorientation. missed his wife and daughter (Fig. 5-11).
 5
Confusion, Dementia, and Alzheimer’s Disease
116

Fig. 5-11. Reminiscence therapy encourages a resident to

remember and talk about his past.

Activity therapy uses things residents enjoy to

prevent boredom and frustration. These activi-
ties also promote self-esteem. Help the resident
take walks, do puzzles, listen to music, or do
other things she enjoys (Fig. 5-12). Activities
may be done in groups or one-on-one. Activity
therapy is useful in most stages of AD.

Fig. 5-12. Activities that are not frustrating can be helpful

for residents with AD. They promote mental exercise.

Example: Mrs. Hoebel, a 70-year-old woman

with AD, was a librarian for almost 45 years.
She loves books and reading, but she cannot
read much anymore. You bring in books that
are filled with pictures. She sits with the books,
sorting them and turning pages and looking at
pictures.
 117 6

Personal Care Skills

Personal Care Skills

1. Explain personal care of residents • Assisting with mouth care

• Giving a back rub
Personal care is different from taking vital signs
or tidying a resident’s unit, which are other tasks The way you help residents with personal care
that NAs may perform for residents. The term plays a large part in promoting their indepen-
“personal” refers to tasks that are concerned dence and dignity. The tasks you help with and
with the person’s body, appearance, and hygiene. how much help you give will be different for
It suggests privacy may be important. Hygiene each resident. It will depend on each resident’s
is the term used to describe ways to keep bodies ability to do self-care and/or his or her physical
clean and healthy. Bathing and brushing teeth or mental limitations. For example, a resident
are two examples. Grooming refers to practices who has recently had a stroke will need more
like caring for fingernails and hair. Hygiene and help than one who has a broken foot that is al-
grooming activities, as well as dressing, eating, most healed. Promoting independence is an im-
transferring, and toileting are called activities of portant part of the care you give.
daily living (ADLs). You will help residents every Many people have been doing personal care
day with these tasks. These activities are often tasks for themselves their entire lives. They may
called “a.m. care” or “p.m. care.” This refers to feel embarrassed about having anyone do or
the time of day when they are done. help them do these tasks. Be sensitive to this.
Assisting with a.m. care includes: Be professional when helping with these tasks.
Before you begin, explain to the resident exactly
• Offering a bedpan or urinal or helping the
what you will be doing. Explaining care to a
resident to the bathroom
resident is his legal right. It may also help lessen
• Helping the resident to wash face and hands anxiety. Ask if he or she would like to use the
bathroom or bedpan first. Provide the resident
• Assisting with mouth care before or after
with privacy. Let him or her make as many deci-
breakfast, as the resident prefers
sions as possible about when, where, and how
Assisting with p.m. care includes: a procedure is done (Fig. 6-1). This promotes
dignity and independence. Encourage residents
• Offering a bedpan or urinal or helping the
to do as much as they are able to do while giving
resident to the bathroom
care. Other ways to promote respect, dignity, and
• Helping the resident to wash face and hands privacy include:
• Giving a snack • Knocking before entering the resident’s
room
 6 118

• Not interrupting residents while they are in Make sure the call light is within reach. Check
the bathroom to see that the room has good lighting and is
a comfortable temperature. Make sure that the
• Leaving the room when residents receive or
walkways are clear. Leave the bed in its lowest
Personal Care Skills

make personal phone calls

position unless instructed otherwise.
• Respecting residents’ private time and per-
sonal things Observing and Reporting: Personal Care
• Not interrupting residents while they are
dressing Skin color, temperature, redness

• Encouraging residents to do things for them- Mobility

selves and being patient Flexibility
• Keeping residents covered whenever possible Comfort level, or complaints of pain or
when you help with dressing discomfort
Strength and the ability to perform self-care
and ADLs
Mental and emotional state
Resident complaints

2. Identify guidelines for providing skin

care and preventing pressure sores
Immobility reduces the amount of blood that
Fig 6-1. Let the resident make as many decisions as pos- circulates to the skin. Residents who have less
sible about the personal care you will perform. mobility have greater risk of skin deterioration
at pressure points. Pressure points are areas of
During personal care, look for any problems the body that bear much of its weight. Pressure
or changes that have occurred. Personal care points are mainly located at bony prominences.
gives you a chance to talk with residents. Some Bony prominences are areas of the body where
residents will share symptoms, feelings and the bone lies close to the skin. These areas
concerns with you. Keep a small notepad to include elbows, shoulder blades, tailbone, hip
write down exactly what the resident says. Make bones, ankles, heels, and the back of the neck
notes right after the procedure. Report these and head. The skin here is at a much higher risk
comments to the nurse. Document them prop- for skin breakdown.
erly. Also look for physical and mental changes.
Other areas at risk are the ears, the area under
Observe the resident’s environment. Look for
the breasts, and the scrotum (Fig. 6-2). The
unsafe or unhealthy surroundings. Report these
pressure on these areas reduces circulation, de-
to the nurse as well.
creasing the amount of oxygen the cells receive.
If the resident seems tired, stop and take a Warmth and moisture also add to skin break-
short rest. Never rush him or her. After care, down. Once the surface of the skin is weakened,
always ask if the resident would like anything pathogens can invade and cause infection. When
else. Leave the resident’s area clean and tidy. infection occurs, the healing process slows.
 119 6

• Stage 3: There is full skin loss involving

damage or death of tissue that may extend
down to but not through the tissue that
covers muscle. The ulcer looks like a deep

Personal Care Skills

crater.
• Stage 4: There is full skin loss with major
destruction, tissue death, and damage to
muscle, bone, or supporting structures.

Stage 1 Stage 2

Stage 3 Stage 4

Fig. 6-2. Pressure sore danger zones.

Fig. 6-3. Pressure sores are categorized by four stages.
(photos courtesy of dr. tamara d. fishman and the wound care institute, inc.)
When skin begins to break down, it becomes
pale, white, or a reddened color. Darker skin may
look purple. The resident may also feel tingling Observing and Reporting: Resident’s Skin
or burning in the area. This discoloration does
Report any of these to the nurse:
not go away, even when the resident’s position
is changed. If pressure is allowed to continue, Pale, white or reddened, or purple areas, blis-
the area will further break down. The resulting ters or bruises on the skin
wound is called a pressure sore, bed sore, or Complaints of tingling, warmth, or burning of
decubitus ulcer. Once a pressure sore forms, it the skin
can get bigger, deeper, and infected. Pressure
Dry or flaking skin
sores are painful and difficult to heal. They can
lead to life-threatening infections. Prevention is Itching or scratching
the key to skin health. Rash or any skin discoloration
There are four accepted stages of pressure sores Swelling
(Fig. 6-3): Fluid or blood draining from skin
• Stage 1: Skin is intact but there is redness Broken skin
that is not relieved within 15 to 30 minutes
Wounds or ulcers on the skin
after removing pressure.
Changes in wound or ulcer (size, depth,
• Stage 2: There is partial skin loss involving
drainage, color, odor)
the outer and/or inner layer of skin. The
ulcer is superficial. It looks like a blister or a Redness or broken skin between toes or
shallow crater. around toenails
 6 120

In darker complexions, also look for G Encourage well-balanced meals. Proper nutri-
tion is important for keeping skin healthy.
Any change in the feel of the tissue, any
change in the appearance of the skin, such as G Keep plastic or rubber materials from coming
Personal Care Skills

the “orange-peel” look or a purplish hue, and into contact with the resident’s skin. These
extremely dry, crust-like areas that might be materials prevent air from circulating, which
covering a tissue break causes the skin to sweat.

Breaks in the skin can cause serious, even life- G Follow the care plan. It may include instruc-
threatening, problems. It is better to prevent tions on giving special skin care. The skin
skin problems and keep the skin healthy than it may have to be washed with a special soap,
is to treat skin problems. Here are guidelines for or a brush may have to be used on the skin.
basic skin care: For residents who are not mobile or cannot
change positions easily, remember:

Guidelines: Basic Skin Care G Keep the bottom sheet tight and free from
wrinkles. Keep the bed free from crumbs.
G Report changes in a resident’s skin. Keep clothing or gowns free of wrinkles, too.

G Provide regular, daily care for skin to keep it G Do not pull the resident across sheets during
clean and dry. Always check the resident’s transfers or repositioning. This causes shear-
skin when bathing. Apply lotion as directed. ing, or rubbing, which can lead to skin
breakdown.
G Reposition immobile residents often (at least
every two hours). G Place a bed pad under the back and buttocks
to absorb moisture that may build up. It can
G Give frequent and thorough skin care as
also protect the skin from irritating bed
often as needed for incontinent residents.
linens.
Change clothing and linens often as well.
Check on them every two hours or as needed. G Relieve pressure under bony prominences.
Place foam rubber or sheepskin pads under
G Do not scratch or irritate the skin in any way. them. Heel and elbow protectors made of
Keep rough, scratchy fabrics away from the foam and sheepskin are available (Fig. 6-4).
resident’s skin. Report to the nurse if a resi-
dent wears shoes or slippers that cause blis-
ters or sores.
G Massage the skin often. Use light, circular
strokes to increase circulation. Use little or
no pressure on bony areas. Do not massage
a white, red, or purple area or put any pres-
sure on it. Massage the healthy skin and tis-
sue around the area.
Fig. 6-4. Padded heel protectors help keep feet properly
G Be careful during transfers. Avoid pulling or aligned and prevent pressure sores. (reprinted with permission of
briggs corporation, 800-247-2343, www.briggscorp.com)
tearing fragile skin.
G Residents who are overweight may have poor G A bed or chair can be made softer with flota-
circulation and extra folds of skin. Pay careful tion pads.
attention to the skin under the folds. Keep it G Use a bed cradle to keep top sheets from
clean and dry. Report signs of skin irritation. rubbing the resident’s skin.
 121 6

G Residents in chairs or wheelchairs need to be

repositioned often, too. Reposition residents
every 15 minutes if they are in a wheelchair
or chair and cannot change positions easily.

Personal Care Skills

Many positioning devices are available to help
make residents safer and more comfortable.

Guidelines: Positioning Devices Fig. 6-6. Handrolls help keep fingers from curling too
tightly. (reprinted with permission of briggs corporation, 800-247-2343, www.
briggscorp.com)

G Backrests provide support. They can be regu-

lar pillows or special wedge-shaped foam G Splints may be prescribed to keep a resi-
pillows. dent’s joints in the correct position. Splints
G Bed cradles are used to keep the bed covers are a type of orthotic device. An orthotic
from pushing down on a resident’s feet. device is a device, such as a splint or brace,
that helps support and align a limb and
G Use draw sheets, or turning sheets, under improve its functioning. Orthotics also help
residents who cannot help with turning prevent or correct deformities.
in bed, lifting, or moving up in bed. Draw
sheets help prevent skin damage from shear- G Trochanter rolls keep a resident’s hips from
ing. A regular bed sheet folded in half can be turning outward. A rolled towel works well,
used as a draw sheet. too.

G Footboards are padded boards placed against G Knee pillows can help keep spine, hips, and
the resident’s feet to keep them properly knees in the proper position and ease pain in
aligned and to prevent foot drop (Fig. 6-5). the back, leg, hip and knee areas (Fig. 6-7).
Foot drop is a weakness of muscles in the
feet and ankles that causes problems with
the ability to flex the ankles and walk normal-
ly. Rolled blankets or pillows can also be used
as footboards.

Fig. 6-7. Knee pillows help keep the knees, hip, and spine
in the proper alignment. (reprinted with permission of briggs corpo-
ration, 800-247-2343, www.briggscorp.com)

3. Describe guidelines for assisting with

bathing
Bathing promotes good health and well-being.
Fig. 6-5. Footboards help prevent foot drop. (reprinted with
permission of briggs corporation, 800-247-2343, www.briggscorp.com) It removes perspiration, dirt, oil, and dead skin
cells from the skin. It helps to prevent skin ir-
G Handrolls keep the fingers from curling ritation and body odor. Bathing can also be
tightly. A rolled washcloth, gauze bandage, or relaxing. The bed bath is an excellent time for
a rubber ball placed inside the palm may be moving arms and legs. This increases circula-
used to keep the hand in a natural position tion. Bathing gives you an opportunity to ob-
(Fig. 6-6). serve residents’ skin carefully.
 6 122

A partial bath is done on days when a complete 2. Identify yourself by name. Identify the resi-
bed bath, tub bath, or shower is not done. It dent by name.
includes washing the face, hands, axillae (un- Resident has right to know identity of his or her care-
derarms), and perineum. The perineum is the giver. Identifying resident by name shows respect and
Personal Care Skills

establishes correct identification.

genital and anal area.
3. Explain procedure to the resident. Speak
Guidelines: Bathing clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.
G The face, hands, underarms, and perineum Promotes understanding and independence.
should be washed every day. A complete bath 4. Provide for resident’s privacy with curtain,
or shower can be taken every other day or screen, or door. Be sure the room is at a
even less often. comfortable temperature and there are no
G Older skin produces less perspiration and drafts.
oil. Elderly people with dry and fragile skin Maintains resident’s right to privacy and dignity.
should bathe only once or twice a week. This 5. Adjust bed to a safe level, usually waist high.
prevents further dryness. Be gentle with the Lock bed wheels.
skin when bathing residents. Prevents injury to you and to resident.
G Use only products approved by the facility or 6. Place a bath blanket or towel over resident
that the resident prefers. (Fig. 6-8). Ask him to hold onto it as you
G Before bathing a resident, make sure the remove or fold back top bedding. Remove
room is warm enough. gown, while keeping resident covered with
bath blanket (or top sheet).
G Be familiar with available safety and assistive
devices.
G Before bathing, make sure the water tempera-
ture is safe and comfortable. Test the water
temperature to make sure it is not too hot.
Fig. 6-8. Cover the resident with a cotton blanket before
Then have the resident test the water tem- removing top bedding.
perature. The resident is best able to choose
a comfortable water temperature. 7. Fill the basin with warm water. Test water
G Gather supplies before giving a bath so the temperature with thermometer or your wrist
resident is not left alone. and ensure it is safe. Water temperature
should be 105° to 110° F. It cools quickly.
G Make sure all soap is removed from the skin
Have resident check water temperature on
before completing the bath.
his or her wrist. Adjust if necessary. Change
G Keep a record of the bathing schedule for the water when it becomes too cool, soapy,
each resident. Follow the care plan. or dirty.
Resident’s sense of touch may be different than
Giving a complete bed bath yours; therefore, resident is best able to identify a
comfortable water temperature.
Equipment: bath blanket, bath basin, soap, bath
thermometer, 2-4 washcloths, 2-4 bath towels, clean 8. Put on gloves.
gown or clothes, gloves, orangewood stick or emery Protects you from contact with body fluids.
board, lotion, deodorant
9. Ask and help resident to participate in
1. Wash your hands. washing.
Provides for infection control. Promotes independence.
 123 6

10. Uncover only one part of the body at a time. Wash the hand in a basin. Clean under the
Place a towel under the body part being nails with an orangewood stick or nail brush
washed. (Fig. 6-11). Rinse and pat dry. Give nail care
Promotes resident’s dignity and right to privacy. Also if it has been assigned (see procedure later in

Personal Care Skills

helps keep resident warm. this chapter). Repeat for the other arm. Put
11. Wash, rinse, and dry one part of the body at lotion on the resident’s elbows and hands if
a time. Start at the head. Work down, and ordered.
complete the front first. When washing, use a
clean area of the washcloth for each stroke.
Eyes and Face: Wash face with wet washcloth
(no soap). Begin with the eye farther away
from you. Wash inner aspect to outer aspect
(Fig. 6-9). Use a different area of the wash-
cloth for each eye. Wash the face from the Fig. 6-11. Wash the hand in a basin. Thoroughly clean
middle outward. Use firm but gentle strokes. under the nails with a nail brush.
Wash the neck and ears and behind the ears.
Rinse and pat dry. Chest: Place the towel across the resident’s
chest. Pull the blanket down to the waist.
Lift the towel only enough to wash the chest.
Rinse it and pat dry. For a female resident,
wash, rinse, and dry breasts and under
breasts. Check the skin in this area for signs
of irritation.
Abdomen: Keep towel across chest. Fold the
blanket down so that it still covers the pubic
area. Wash the abdomen, rinse, and pat dry.
Fig. 6-9. Wash the eye from the inner part to the outer If the resident has an ostomy, give skin care
part.
around the opening (see Chapter 4). Cover
Arms: Remove one arm from under the towel. with the towel. Pull the cotton blanket up to
With a soapy washcloth, wash the upper arm the resident’s chin. Remove the towel.
and underarm. Use long strokes from the Legs and Feet: Expose one leg. Place a towel
shoulder to the wrist (Fig. 6-10). Rinse and under it. Wash the thigh. Use long downward
pat dry. Repeat for the other arm. strokes. Rinse and pat dry. Do the same from
the knee to the ankle (Fig. 6-12).

Fig. 6-10. Support the wrist while washing the shoulder, Fig. 6-12. Use long downward strokes when washing the
arm, underarm, and elbow. legs.
 6 124

Place another towel under the foot. Move and a washcloth and towel within reach.
the basin to the towel. Place the foot into the Hand items to the resident as needed. If the
basin. Wash the foot and between the toes resident wants you to leave the room, leave
(Fig. 6-13). Rinse foot and pat dry. Make sure supplies and the call light within reach.
Personal Care Skills

area between toes is dry. Give nail care if it 13. If the resident cannot provide perineal care,
has been assigned. Do not give nail care to you must do so. Provide privacy at all times.
a diabetic resident. Never clip a resident’s
toenails. Apply lotion to the foot if ordered, Perineal area: Change bath water. Put on
especially at the heels. Do not apply lotion clean gloves. Wash, rinse, and dry perineal
between the toes. Repeat steps for the other area. Work from front to back.
leg and foot. For a female resident: Wash the perineum
with soap and water. Work from front to
back. Use single strokes (Fig. 6-15). Do not
wash from the back to the front. This may
cause infection. Use a clean area of wash-
cloth or clean washcloth for each stroke.
First wipe the center of the perineum, then
each side. Then spread the labia majora, the
outside folds of perineal skin that protect
Fig. 6-13. Washing the feet includes cleaning between the the urinary meatus and the vaginal opening.
toes.
Wipe from front to back on each side. Rinse
Back: Help resident move to the center of the area in the same way. Dry entire perineal
the bed. Ask resident to turn onto his side area. Move from front to back. Use a blotting
so his back is facing you. If the bed has rails, motion with towel. Ask resident to turn on
raise the rail on the far side for safety. Fold her side. Wash, rinse, and dry buttocks and
the blanket away from the back. Place a towel anal area. Clean the anal area without con-
lengthwise next to the back. Wash the back, taminating the perineal area.
neck, and buttocks with long, downward
strokes. Rinse and pat dry (Fig. 6-14). Apply
lotion if ordered.

Fig. 6-15. Always work from front to back when perform-

ing perineal care. This helps prevent infection.

For a male resident: If the resident is uncir-

Fig. 6-14. Wash the back with long downward strokes. cumcised, pull back the foreskin first. Gently
push skin towards the base of penis. Hold
12. Place the towel under the buttocks and upper the penis by the shaft. Wash in a circular mo-
thighs. Help the resident turn onto his back. tion from the tip down to the base. Use a
If the resident is able to wash his or her peri- clean area of washcloth or clean washcloth
neal area, place a basin of clean, warm water for each stroke (Fig. 6-16). Rinse the penis. If
 125 6

resident is uncircumcised, gently return fore- 23. Report any changes in resident to the nurse.
skin to normal position. Then wash the scro- Provides nurse with information to assess resident.
tum and groin. The groin is the area from the
24. Document procedure using facility
pubis (area around the penis and scrotum)

Personal Care Skills

guidelines.
to the upper thighs. Rinse and pat dry. Ask What you write is a legal record of what you did. If
the resident to turn on his side. Wash, rinse, you don’t document it, legally it didn’t happen.
and dry buttocks and anal area. Clean the
anal area without contaminating the perineal
A back rub can help residents relax. It can in-
area.
crease comfort and circulation. Back rubs are
often given after baths. After giving a back rub,
make sure to note any changes in a resident’s
skin.

Giving a back rub

Equipment: cotton blanket or towel, lotion

Fig. 6-16. 1. Wash your hands.

Provides for infection control.
14. Cover the resident with the blanket. 2. Identify yourself by name. Identify the resi-
15. Empty, rinse, and dry bath basin. Place basin dent by name.
Resident has right to know identity of his or her care-
in designated dirty supply area or return to
giver. Addressing resident by name shows respect and
storage, depending on facility policy. establishes correct identification.
16. Place soiled clothing and linens in proper 3. Explain procedure to resident. Speak clearly,
containers. slowly, and directly. Maintain face-to-face con-
17. Remove and discard gloves. Wash your tact whenever possible.
Promotes understanding and independence.
hands.
18. Put clean gown on resident. Provide de- 4. Provide for resident’s privacy with curtain,
odorant. Assist with brushing or combing screen, or door.
Maintains resident’s right to privacy and dignity.
resident’s hair (see procedure later in the
chapter). 5. Adjust bed to a safe level, usually waist high.
Lower the head of the bed. Lock bed wheels.
19. Make resident comfortable. Replace bedding.
Prevents injury to you and to resident.
Make sure sheets are free from wrinkles and
the bed free from crumbs. 6. Position resident lying on his stomach. If this
is uncomfortable, have him lie on his side.
20. Return bed to lowest position. Remove pri-
Cover with a cotton blanket or towel. Fold
vacy measures.
back bed covers. Expose the back to the top
Lowering the bed provides for safety.
of the buttocks. Back rubs can also be given
21. Place call light within resident’s reach. with the resident sitting up.
Allows resident to communicate with staff as
necessary. 7. Warm lotion by putting bottle in warm water
for five minutes. Run your hands under warm
22. Wash your hands. water. Pour lotion on your hands. Rub them
Provides for infection control.
 6 126

together. Always put lotion on your hands 10. Gently massage bony areas (spine, shoulder
rather than on the resident’s skin. blades, hip bones). Use circular motions of
Increases resident’s comfort. fingertips. If any of these areas are red, mas-
sage around them rather than on them.
Personal Care Skills

8. Place hands on each side of upper part of

Redness indicates that skin is already irritated and
the buttocks. Use the full palm of hand. fragile. Include this information in your report to the
Make long, smooth upward strokes with both nurse.
hands. Move along each side of the spine, up
11. Let the resident know when you are almost
to the shoulders (Figs. 6-17 and 6-18). Circle
through. Finish with some long, smooth
hands outward. Move back along outer edges
strokes.
of the back. At buttocks, make another circle.
Move hands back up to the shoulders. With- 12. Dry the back if extra lotion remains on it.
out taking hands from resident’s skin, repeat
13. Remove blanket or towel.
this motion for three to five minutes.
Long upward strokes release muscle tension; circular 14. Help the resident get dressed. Make resident
strokes increase circulation in muscle areas.
comfortable.

15. Store supplies. Place soiled clothing and lin-

ens in proper containers.

16. Return bed to lowest position. Remove pri-

vacy measures.
Provides for resident’s safety.

17. Place call light within resident’s reach.

Allows resident to communicate with staff as
Fig. 6-17. A resident on his side.
necessary.

18. Wash your hands.

Provides for infection control.

19. Report any changes in resident to the nurse.

Provides nurse with information to assess resident.

20. Document procedure using facility

guidelines.
What you write is a legal record of what you did. If
you don’t document it, legally it didn’t happen.

Hair care is an important part of cleanliness.

Fig. 6-18. A resident on his stomach. Shampooing the hair removes dirt, bacteria,
oils, and other materials from the hair. Resi-
9. Knead with the first two fingers and thumb of dents who can get out of bed may have their hair
each hand. Place them at base of the spine. shampooed in the sink, tub, or shower. For resi-
Move upward together along each side of the dents who cannot get out of bed, special troughs
spine. Apply gentle downward pressure with exist for shampooing hair in bed (Fig. 6-19).
fingers and thumbs. Follow same direction There are also special types of shampoo that do
as with the long smooth strokes, circling at not require the use of water. Follow the care plan
shoulders and buttocks. on what type of shampoo to use.
 127 6

8. Place the waterproof pad under the resident’s

head and shoulders. Cover the resident with
the bath blanket. Fold back the top sheet and
regular blankets.

Personal Care Skills

Protects bed linen.

9. Place the trough under resident’s head. Con-

nect trough to the catch basin. Place one
towel across the resident’s shoulders.
Fig. 6-19. An inflatable shampoo trough can be used to
shampoo hair while the person is in bed. (reprinted with permis- 10. Protect resident’s eyes with dry washcloth.
sion of briggs corporation, 800-247-2343, www.briggscorp.com)

11. Use pitcher or attachment to wet hair thor-

Shampooing hair in bed oughly. Apply a small amount of shampoo to
your hands and rub them together.
Equipment: shampoo, hair conditioner (if re-
quested), 2 bath towels, washcloth, bath thermome- 12. Lather and massage scalp with fingertips
ter, pitcher or hand-held shower or sink attachment, (Fig. 6-20). Use a circular motion from front
waterproof pad, bath blanket, trough and catch to back. Do not scratch the scalp.
basin, comb and brush, hair dryer
1. Wash your hands.
Provides for infection control.

2. Identify yourself by name. Identify the resi-

dent by name.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
establishes correct identification.

3. Explain procedure to resident. Speak clearly,

slowly, and directly. Maintain face-to-face con- Fig. 6-20. Use your fingertips to work shampoo into a
tact whenever possible. lather. Be gentle so that you do not scratch the scalp.
Promotes understanding and independence.
13. Rinse hair until water runs clear. Apply con-
4. Provide for resident’s privacy with curtain, ditioner if resident wants it. Rinse as directed
screen, or door. Be sure room is at a comfort- on container. Be sure to rinse the hair thor-
able temperature and there are no drafts. oughly to prevent the scalp from getting dry
Maintains resident’s right to privacy and dignity.
and itchy.
5. Adjust bed to a safe level, usually waist high.
14. Wrap resident’s hair in a clean towel. Dry his
Lock bed wheels.
face with washcloth used to protect eyes.
Prevents injury to you and to resident.
15. Remove trough and waterproof covering.
6. Lower head of bed. Remove pillows.
16. Raise head of bed.
7. Test water temperature with thermometer or
your wrist. Ensure it is safe. Water tempera- 17. Gently rub the scalp and hair with the towel.
ture should be 105° F. Have resident check 18. Dry and comb resident’s hair as he or she
water temperature on his or her wrist. Adjust prefers. See procedure later in the chapter.
if necessary.
Resident’s sense of touch may be different than 19. Return bed to lowest position. Remove pri-
yours; therefore, resident is best able to identify a vacy measures.
comfortable water temperature. Lowering the bed provides for safety.
 6 128

20. Place call light within resident’s reach. G Be familiar with available safety and assistive
Allows resident to communicate with staff as devices. Check that hand rails, grab bars, and
necessary. lifts are in working order.
Personal Care Skills

21. Empty, rinse, and wipe bath basin/pitcher. G Have resident use safety bars when getting
Take to proper area. into or out of the tub or shower.
22. Clean comb/brush. Return hair dryer and G Place all needed items within reach.
comb/brush to proper storage.
G Do not leave resident alone.
23. Place soiled linen in proper container.
G Do not use bath oils, lotions, or powders in
24. Wash your hands. showers or tubs. They make surfaces slippery.
Provides for infection control.
G Test water temperature with thermometer or
25. Report any changes in resident to nurse.
your wrist before resident gets into shower.
Provides nurse with information to assess resident.
Water temperature should be no more than
26. Document procedure using facility 105° F. Make sure temperature is comfort-
guidelines. able for resident.
What you write is a legal record of what you did. If
you don’t document it, legally it didn’t happen. Residents’ Rights
Privacy when Bathing
Privacy is very important when giving showers or tub
Many people prefer showers or tub baths to bed
baths. Keep doors closed. Keep residents covered
baths (Fig. 6-21). Check with the nurse first to when possible. Make sure their bodies are not un-
make sure a shower or tub bath is allowed. necessarily exposed.

Giving a shower or a tub bath

Equipment: bath blanket, soap, shampoo, bath

thermometer, 2-4 washcloths, 2-4 bath towels, clean
gown and robe or clothes, non-skid footwear, gloves,
lotion, deodorant
1. Wash your hands.
Provides for infection control.

2. Place equipment in shower or tub room.

Clean shower or tub area and shower chair.
Place bucket under shower chair (in case res-
ident has a bowel movement). Turn on heat
lamp to warm the room, if available.
Fig. 6-21. A common style of tub in long-term care Cleaning reduces pathogens and prevents the spread
facilities. (photo courtesy of lee penner of penner tubs) of infection.

3. Wash your hands.

Provides for infection control.
Guidelines: Safety for Showers and Tub Baths
4. Go to resident’s room. Identify self by name.
G Clean tub or shower before and after use. Identify resident by name.
Resident has right to know identity of his or her care-
G Make sure bathroom or shower room floor is giver. Addressing resident by name shows respect and
dry. establishes correct identification.
 129 6

5. Explain procedure to resident. Speak clearly, temperature should be no more than 105° F.
slowly, and directly. Maintain face-to-face con- Have resident check water temperature on
tact whenever possible. his or her wrist. Adjust if necessary.
Promotes understanding and independence.

Personal Care Skills

Remaining steps for either procedure:
6. Provide for resident’s privacy with curtain,
screen, or door. 10. Put on gloves.
Maintains resident’s right to privacy and dignity. Protects you from contact with body fluids.

7. Help resident to put on nonskid footwear. 11. Help resident remove clothing and shoes.
Transport resident to shower or tub room. 12. Help the resident into shower or tub. Put
Nonskid footwear helps lessen the risk of falls. shower chair into shower and lock wheels.
For a shower: 13. Stay with resident during procedure.
Provides for resident’s safety.
8. If using a shower chair, place it into position.
Lock wheels (Fig. 6-22). Safely transfer resi- 14. Let resident wash as much as possible. Help
dent into shower chair. to wash his or her face.
Chair may slide if resident attempts to get up. Encourages resident to be independent.

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-
dent with bath blanket until the tub drains.
Maintains resident’s dignity and right to privacy by
not exposing body. Keeps resident warm.

18. Unlock shower chair wheels if used. Roll resi-

dent out of shower, or help resident out of
tub and onto a chair.
19. Give resident towel(s) and help to pat dry.
Fig. 6-22. A shower chair must be locked before trans-
Remember to pat dry under the breasts, be-
ferring a resident into it. (photo courtesy of innovative products
unlimited) tween skin folds, in the perineal area, and
between toes.
9. Turn on water. Test water temperature with Patting dry prevents skin tears and reduces chafing.
thermometer. Water temperature should be
20. Apply lotion and deodorant as needed.
no more than 105° F. Have resident check
water temperature on his or her wrist. Adjust 21. Place soiled clothing and linens in proper
if necessary. Check water temperature fre- containers.
quently throughout the shower. 22. Remove and discard gloves.
Resident’s sense of touch may be different than
yours; therefore, resident is best able to identify a 23. Wash your hands.
comfortable water temperature. Provides for infection control.

For a tub bath: 24. Help resident dress and comb hair before
leaving shower or tub room. Put on non-skid
8. Safely transfer resident onto chair or tub lift.
footwear. Return resident to room.
9. Fill the tub halfway with warm water. Test Combing hair in shower room allows resident to
water temperature with thermometer. Water maintain dignity when returning to room.
 6 130

25. Make sure resident is comfortable. Never cut a resident’s toenails. Poor circulation
26. Place call light within resident’s reach. can lead to infection if skin is accidentally cut
Allows resident to communicate with staff as while caring for nails. In a diabetic resident,
such an infection can lead to a severe wound or
Personal Care Skills

necessary.
even amputation. If you are told to give nail care,
27. Report any changes in resident to nurse.
know what care you are to provide. Never use the
Provides nurse with information to assess resident.
same nail equipment on more than one resident.
28. Document procedure using facility
guidelines. Providing fingernail care
What you write is a legal record of what you did. If
you don’t document it, legally it didn’t happen. Equipment: orangewood stick, emery board, lotion,
basin, soap, washcloth, 2 towels, bath thermometer,
gloves
4. Describe guidelines for assisting with 1. Wash your hands.
grooming Provides for infection control.

Grooming affects the way people feel about 2. Identify yourself by name. Identify the resi-
themselves and how they look to others (Fig. dent by name.
Resident has right to know identity of his or her care-
6-23). When helping with grooming, always
giver. Addressing resident by name shows respect and
let residents do all they can for themselves. Let establishes correct identification.
them make as many choices as possible. Follow
3. Explain procedure to resident. Speak clearly,
the care plan’s instructions for what care to give.
slowly, and directly. Maintain face-to-face con-
Residents may have particular ways of groom-
tact whenever possible.
ing themselves. They may have routines. These
Promotes understanding and independence.
routines are important even when people are
elderly, sick, or disabled. Remember that some 4. Provide for resident’s privacy with curtain,
residents may be embarrassed or depressed be- screen, or door.
cause they need help with grooming tasks they Maintains resident’s right to privacy and dignity.
have done for themselves most of their lives. Be 5. If resident is in bed, adjust bed to a safe
sensitive to this. level, usually waist high. Lock bed wheels.
Prevents injury to you and to resident.

6. Fill the basin halfway with warm water. Test

water temperature with thermometer or your
wrist. Ensure it is safe. Water temperature
should be 105° F. Have resident check water
temperature on his or her wrist. Adjust if nec-
essary. Place basin at a comfortable level for
resident.
Resident’s sense of touch may be different than
yours; therefore, resident is best able to identify a
Fig. 6-23. A well-groomed appearance helps a person feel comfortable water temperature.
good about herself.
7. Put on gloves.
Fingernails can harbor bacteria. It is important 8. Soak the resident’s hands and nails in the
to keep hands and nails clean to help prevent in- basin of water. Soak all 10 fingertips for at
fection. Nail care should be given when assigned least five minutes.
and when nails are dirty or have jagged edges. Nail care is easier if nails are first softened.
 131 6

9. Remove hands. Wash hands with soapy 18. Place call light within resident’s reach.
washcloth. Rinse. Pat hands dry with towel, Allows resident to communicate with staff as
including between fingers. Remove the hand necessary.
basin.

Personal Care Skills

19. Report any changes in resident to the nurse.
Provides nurse with information to assess resident.
10. Place resident’s hands on the towel. Clean
under each fingernail with orangewood stick 20. Document procedure using facility
(Fig. 6-24). guidelines.
Most pathogens on hands come from beneath the What you write is a legal record of what you did. If
nails. you don’t document it, legally it didn’t happen.

Careful foot care is extremely important; it

should be a part of daily care of residents.

Observing and Reporting: Foot Care

Report any of these to the nurse:

Dry, flaking skin
Non-intact or broken skin
Fig. 6-24. Be gentle when removing dirt from under the Discoloration of the feet, such as reddened,
nails with an orangewood stick. gray, white, or black areas

11. Wipe orangewood stick on towel after each Blisters

nail. Wash resident’s hands again. Dry them Bruises
thoroughly, especially between fingers.
Blood or drainage
12. Shape nails with file or emery board. File in Long, ragged toenails
a curve. Finish with nails smooth and free of
rough edges. Ingrown toenails
Filing in a curve smoothes nails and eliminates Differences in temperature of the feet
edges, which may catch on clothes or tear skin.

13. Apply lotion from fingertips to wrists. Providing foot care

14. Empty, rinse, and dry basin. Place basin in Equipment: basin, bath mat, soap, lotion, wash-
cloth, 2 towels, bath thermometer, clean socks,
designated dirty supply area or return to stor-
gloves
age, depending on facility policy.
Support the foot and ankle throughout
15. Place soiled clothing and linens in proper
procedure.
containers.
1. Wash your hands.
16. Remove and discard gloves. Wash your Provides for infection control.
hands.
Provides for infection control. 2. Identify yourself by name. Identify the resi-
dent by name.
17. Return bed to lowest position. Remove pri- Resident has right to know identity of his or her care-
vacy measures. giver. Addressing resident by name shows respect and
Lowering the bed provides for safety. establishes correct identification.
 6 132

3. Explain procedure to resident. Speak clearly, 11. Rinse entire foot, including between the toes.
slowly, and directly. Maintain face-to-face con-
12. Dry entire foot, including between the toes.
tact whenever possible.
Promotes understanding and independence. 13. Repeat steps 10 through 12 for the other
Personal Care Skills

foot.
4. Provide for resident’s privacy with curtain,
screen, or door. 14. Put lotion in hand. Warm lotion by rubbing
Maintains resident’s right to privacy and dignity. hands together.
5. If the resident is in bed, adjust bed to a safe 15. Massage lotion into entire foot (top and bot-
level, usually waist high. Lock bed wheels. tom), except between the toes. Remove ex-
Prevents injury to you and to resident. cess, if any, with a towel.
6. Fill the basin halfway with warm water. Test 16. Assist resident to replace socks.
water temperature with thermometer or your
wrist. Ensure it is safe. Water temperature 17. Empty, rinse, and dry basin. Place basin in
should be 105° F. Have resident check water designated dirty supply area or return to stor-
temperature on his or her wrist. Adjust if age, depending on facility policy.
necessary. 18. Place soiled clothing and linens in proper
Resident’s sense of touch may be different than containers.
yours; therefore, resident is best able to identify a
comfortable water temperature. 19. Remove and discard gloves. Wash your
7. Place basin on the bath mat or bath towel on hands.
Provides for infection control.
the floor (if the resident is sitting in a chair)
or on a towel at the foot of the bed (if the 20. Return bed to lowest position. Remove pri-
resident is in bed). Make sure basin is in a vacy measures.
comfortable position for resident. Lowering the bed provides for safety.

8. Put on gloves. 21. Place call light within resident’s reach.

Allows resident to communicate with staff as
9. Remove resident’s socks. Completely sub- necessary.
merge resident’s feet in water. Soak the feet
22. Report any changes in resident to the nurse.
for five to ten minutes.
Provides nurse with information to assess resident.
10. Put soap on wet washcloth. Remove one
23. Document procedure using facility
foot from water. Wash entire foot, including
guidelines.
between the toes and around nail beds (Fig.
What you write is a legal record of what you did. If
6-25). you don’t document it, legally it didn’t happen.

Handle residents’ hair gently. Hair thins as

people age. Pieces of hair can be pulled out of
the head while combing or brushing it. Also, the
skin on residents’ heads is fragile. Handle hair
carefully.
Pediculosis is an infestation of lice. Lice are
tiny bugs that bite into the skin and suck blood
Fig. 6-25. Soak the resident’s feet before washing the en- to live and grow. Three types of lice are head
tire foot, including between the toes. lice, body lice, and crab or pubic lice. Head lice
 133 6

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.
the scalp, skin sores, and matted, bad-smelling Reduces hair breakage, scalp pain and irritation.
hair and scalp. If you notice any of these symp-

Personal Care Skills

9. After tangles are removed, brush two-inch
toms, tell the nurse immediately. Lice can spread
sections of hair at a time. Brush from roots
very quickly. Special lice cream, shampoo, or
to ends (Fig. 6-26).
lotion may be used to treat the lice. People who
have lice spread it to others. To help prevent the
spread of lice, do not share residents’ combs,
brushes, clothes, wigs, or hats.

Combing or brushing hair

Equipment: comb, brush, towel, mirror, hair care

items requested by resident

Use hair care products that the resident prefers

for his or her type of hair. Fig. 6-26. Gently brush hair from roots to ends.

1. Wash hands. 10. Each resident may prefer a different hairstyle.

Provides for infection control. Style hair in the way the resident prefers.
2. Identify yourself by name. Identify the resi- Avoid childish hairstyles. Offer a mirror to the
dent by name. resident.
Resident has right to know identity of his or her care- Each resident has the right to choose. Promotes resi-
giver. Addressing resident by name shows respect and dent’s independence.
establishes correct identification.
11. Return bed to lowest position. Remove pri-
3. Explain procedure to resident. Speak clearly, vacy measures.
slowly, and directly. Maintain face-to-face con- Provides for safety.
tact whenever possible.
12. Place call light within resident’s reach.
Promotes understanding and independence.
Allows resident to communicate with staff as
4. Provide for resident’s privacy with curtain, necessary.
screen, or door. 13. Return supplies to proper storage. Clean hair
Maintains resident’s right to privacy and dignity. from brush/comb.
5. If the bed is adjustable, adjust bed to safe 14. Dispose of soiled linen in the proper
level. Lock bed wheels. container.
Prevents injury to you and to resident.
15. Wash your hands.
6. Raise head of bed so resident is sitting up. Provides for infection control.
Place a towel under the head or around the
16. Report any changes in resident to nurse.
shoulders.
Provides nurse with information to assess resident.
Puts resident in more natural position.
17. Document procedure using facility
7. Remove any hair pins, hair ties or clips.
guidelines.
8. Remove tangles first by dividing hair into What you write is a legal record of what you did. If
small sections. Hold lock of hair just above you don’t document it, legally it didn’t happen.
 6 134

Make sure the resident wants you to shave him 7. Put on gloves.
or help him shave before you begin. Respect Shaving may cause bleeding. Wearing gloves pro-
personal preferences for shaving. Always wear motes infection control and follows Standard
Precautions.
gloves when shaving a resident. Do not share
Personal Care Skills

razors between residents. Ask the nurse to see Shaving using a safety or disposable razor:
which type of razor the resident uses: 8. Soften the beard with a warm, wet washcloth
• A safety razor has a sharp blade, but with on the face for a few minutes before shaving.
a special safety casing to help prevent cuts. Lather the face with shaving cream or soap
This type of razor requires shaving cream or and warm water.
soap. Warm water and lather soften skin and hair and
• A disposable razor requires shaving cream make shaving more comfortable.
or soap. It is discarded in a sharps container
9. Hold skin taut. Shave in the direction of hair
after use.
growth. Shave beard in downward strokes on
• An electric razor is the safest and easiest
face and upward strokes on neck (Fig. 6-27).
type of razor to use. It does not require soap
Rinse the blade often in warm water to keep
or shaving cream.
it clean and wet.
Maximizes hair removal by shaving in the direction
Shaving a resident
of hair growth.
Equipment: razor, basin filled halfway with warm
water (if using a safety or disposable razor), 2 tow-
els, washcloth, bath thermometer, mirror, shaving
cream or soap (if using a safety or disposable razor),
after-shave lotion, gloves
1. Wash your hands.
Provides for infection control.

2. Identify yourself by name. Identify the resi-

dent by name.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and Fig. 6-27. Holding the skin taut, shave in downward
establishes correct identification. strokes on face and upward strokes on neck.

3. Explain procedure to resident. Speak clearly,

10. When you have finished, wash, rinse, and dry
slowly, and directly. Maintain face-to-face con-
the resident’s face with a warm, wet wash-
tact whenever possible.
cloth. If he is able, let him use the washcloth
Promotes understanding and independence.
himself. Offer mirror to resident.
4. Provide for resident’s privacy with curtain, Removes soap, which may cause irritation. Promotes
screen, or door. independence.
Maintains resident’s right to privacy and dignity.
Shaving using an electric razor:
5. If bed is adjustable, adjust bed to a safe level,
8. Use a small brush to clean razor. Do not
usually waist high. Lock bed wheels.
use an electric razor near any water source,
Prevents injury to you and to resident.
when oxygen is in use, or if resident has a
6. Raise head of bed so resident is sitting up. pacemaker.
Place towel across the resident’s chest, under Electricity near water may cause electrocution.
his chin. Electricity near oxygen may cause an explosion.
Puts resident in more natural position. Towel protects Electricity near some pacemakers may cause an ir-
resident’s clothing and bed linen. regular heartbeat.
 135 6

9. Turn on the razor and hold skin taut. Shave 18. Report any changes in resident to the nurse.
with smooth, even movements (Fig. 6-28). Provides nurse with information to assess resident.
Shave beard in direction of beard growth with
19. Document procedure using facility
foil shaver. Shave beard in circular motion

Personal Care Skills

guidelines.
with three-head shaver. Shave the chin and What you write is a legal record of what you did. If
under the chin. you don’t document it, legally it didn’t happen.

10. Offer mirror to resident.

Promotes independence.
5. List guidelines for assisting with
dressing
When helping a resident with dressing, know
what limitations he or she has. If he has a
weakened side from a stroke or injury, that side
is called the affected side. It will be weaker.
Never refer to the weaker side as the “bad side,”
or talk about the “bad” leg or arm. Use the terms
“weaker” or “involved” to refer to the affected
Fig. 6-28. Shave, or have the resident shave, with side. The weaker arm is usually placed through
smooth, even movements. a sleeve first (Fig. 6-29). When a leg is weak, it is
easier if the resident sits down to pull the pants
Final steps: over both legs.
11. Apply after-shave lotion as resident wishes.
Improves resident’s self-esteem.

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 sharps container. For elec-
tric razor, clean head of razor. Remove whis-
kers from razor. Recap shaving head and
return razor to case.

14. Remove and discard gloves. Wash your

hands.
Fig. 6-29. When dressing, start with the affected (weaker)
Provides for infection control.
side first.
15. Make sure that resident and environment are
free of loose hairs. Guidelines: Dressing and Undressing
16. Return bed to lowest position. Remove pri-
vacy measures. G The resident’s wishes should be asked and
Provides for safety. followed.

17. Place call light within resident’s reach. G Let the resident choose clothing for the day.
Allows resident to communicate with staff as Check to see if it is clean, appropriate for the
necessary. weather, and in good condition.
 6 136

G Encourage the resident to dress in regular 4. Provide for resident’s privacy with curtain,
clothes rather than nightclothes. screen, or door.
Maintains resident’s right to privacy and dignity.
G The resident should do as much to dress or
Personal Care Skills

undress himself as possible. It may take lon- 5. Ask resident what she would like to wear.
ger, but it helps maintain independence. Dress her in outfit of choice (Fig. 6-30).
Promotes resident’s right to choose.
G Provide privacy.
G Roll or fold socks or stockings down when
putting them on. Slip over the toes and foot,
then unroll into place.
G For a female resident, make sure bra cups
fit over the breasts. Front-fastening bras are
easier for residents to work by themselves.
Bras that fasten in back can be put around
the waist and fastened first. Then rotate
around and move bra up. Put arms through Fig. 6-30. Residents have a legal right to choose the
the straps last. Reverse for undressing. clothing they want to wear for the day.

G Place the weaker arm or leg through the gar-

6. Remove resident’s gown. Remove from stron-
ment first. Then help with the stronger arm
ger side first when undressing. Then remove
or leg. When undressing, do the opposite—
from weaker side. Do not completely expose
start with the stronger, or unaffected side.
resident.
G Assistive devices for dressing are available. Maintains resident’s dignity and right to privacy.
They help maintain independence. Use them 7. Assist resident to put the right (affected/
as directed. weak) arm through the right sleeve of the
shirt, sweater, or slip before placing garment
Dressing a resident with an affected (weak)
on left (unaffected/strong) arm.
right arm
8. Help resident to put on skirt, pants, or dress.
Equipment: clean clothes of resident’s choice, non-
skid footwear 9. Place bed at the lowest position. Lock bed
When putting on items, move resident’s body wheels.
gently and naturally. Avoid force and over-exten- 10. Have resident sit down. Help to apply non-
sion of limbs and joints. skid footwear. Tie laces.
1. Wash your hands. Promotes resident’s safety.
Provides for infection control. 11. Finish with resident dressed appropriately.
2. Identify yourself by name. Identify the resi- Make sure clothing is right-side-out and zip-
dent by name. pers/buttons are fastened.
Resident has right to know identity of his or her care-
12. Place gown in soiled linen container.
giver. Addressing resident by name shows respect and
establishes correct identification. 13. Keep bed in lowest position. Remove privacy
3. Explain procedure to resident. Speak clearly, measures.
slowly, and directly. Maintain face-to-face con- 14. Place call light within resident’s reach.
tact whenever possible. Allows resident to communicate with staff as
Promotes understanding and independence. necessary.
 137 6

15. Wash your hands.

Putting a knee-high elastic stocking on resident
Provides for infection control.

16. Report any changes in resident to the nurse. Equipment: elastic stockings

Personal Care Skills

Provides nurse with information to assess resident. 1. Wash your hands.
17. Document procedure using facility Provides for infection control.
guidelines. 2. Identify yourself by name. Identify resident by
What you write is a legal record of what you did. If
name.
you don’t document it, legally it didn’t happen.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
establishes correct identification.
IV stands for intravenous, or into a vein. Medi-
cation, nutrition, or fluids drip from a bag sus- 3. Explain procedure to resident. Speak clearly,
pended on a pole or are pumped by a portable slowly, and directly. Maintain face-to-face con-
pump through a tube and into the vein. Chapter tact whenever possible.
7 has more information on IVs. Promotes understanding and independence.

4. Provide for resident’s privacy with curtain,

Guidelines: Dressing a Resident with an IV screen, or door.
Maintains resident’s right to privacy and dignity.
G Never disconnect IV lines or turn off the
pump. The nurse will be responsible for 5. If bed is adjustable, adjust bed to a safe level,
unhooking IV tubing from the pump. usually waist high. Lock bed wheels.
Prevents injury to you and to resident.
G Always keep the IV bag higher than the IV
site on the body. 6. The resident should be in the supine posi-
tion (on his back) in bed. With resident lying
G First remove clothing from the side without the
down, remove his or her socks, shoes, or
IV. Then gather the clothing on the side with the
slippers, and expose one leg.
IV. Lift clothing over the IV site. Move it up the
tubing toward the IV bag. Lift the IV bag off its 7. Turn stocking inside-out at least to heel area
pole. Carefully slide the clothing over the bag. (Fig. 6-31).
Place the bag back on the pole.
G Apply clean clothing first to side with the IV.
Slide the correct arm opening over the bag,
then over the tubing and the resident’s IV
arm. Place the IV bag back on the pole.
G Check that the IV is dripping properly. Make
sure none of the tubing is dislodged. Check
to see that the IV site dressing is in place.
When a resident has poor circulation to the legs
and feet, elastic stockings are ordered. These Fig. 6-31. Turning the stocking inside-out allows stocking
stockings help prevent swelling and blood clots to roll on gently.
and aid circulation. These stockings are called
“anti-embolic hose” or “elastic stockings.” They 8. Gently place foot of stocking over toes, foot,
need to be put on before the resident gets out of and heel (Fig. 6-32). Make sure the heel is
bed. Follow manufacturer’s instructions and il- in the right place (heel should be in heel of
lustrations on how to put on stockings. stocking).
 6 138

6. Identify guidelines for proper oral

hygiene
Oral care, or care of the mouth, teeth, and
Personal Care Skills

gums, is done at least twice each day. Oral care

should be done after breakfast and after the last
meal or snack of the day. It may also be done
before a resident eats. Oral care includes brush-
Fig. 6-32. Place the foot of the stocking over the toes, ing teeth, tongue, and gums, flossing teeth, and
foot, and heel. Promote the resident’s comfort and safety. caring for dentures (Fig. 6-34). When giving oral
Avoid force and over-extension of joints.
care, wear gloves. Follow Standard Precautions.
9. Gently pull top of stocking over foot, heel,
and leg.
10. Make sure there are no twists or wrinkles in
stocking after it is on (Fig. 6-33). It must fit
smoothly.

Fig. 6-34. Some supplies needed for oral care.

When you provide oral care, observe the resi-

dent’s mouth carefully.

Fig. 6-33. Make stocking smooth. Twists or wrinkles cause Observing and Reporting: Oral Care
the stocking to be too tight, which reduces circulation.
Report any of these to the nurse:
11. Repeat for other leg.
Irritation
12. Return bed to lowest position. Remove pri-
vacy measures. Infection
Provides for safety. Raised areas
13. Place call light within resident’s reach. Coated or swollen tongue
Allows resident to communicate with staff as
necessary. Ulcers, such as canker sores or small, pain-
ful, white sores
14. Wash your hands.
Provides for infection control. Flaky, white spots
15. Report any changes in resident to nurse. Dry, cracked, bleeding or chapped lips
Provides nurse with information to assess resident.
Loose, chipped, broken or decayed teeth
16. Document procedure using facility
Swollen, irritated, bleeding, or whitish gums
guidelines.
What you write is a legal record of what you did. If Breath that smells bad or fruity
you don’t document it, legally it didn’t happen.
Resident reports of mouth pain
 139 6

Providing oral care

Equipment: toothbrush, toothpaste, emesis basin,

gloves, towel, glass of water

Personal Care Skills

1. Wash your hands.
Provides for infection control.

2. Identify yourself by name. Identify the resi-

dent by name.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
establishes correct identification. Fig. 6-35. Rinsing and spitting removes food particles and
toothpaste.
3. Explain procedure to resident. Speak clearly,
slowly, and directly. Maintain face-to-face con-
11. Dispose of soiled linen in the proper
tact whenever possible.
Promotes understanding and independence. container.

4. Provide for resident’s privacy with curtain, 12. Clean and return supplies to proper storage.
screen, or door. 13. Remove and discard gloves. Wash your
Maintains resident’s right to privacy and dignity. hands.
5. Adjust bed to a safe level, usually waist high. Provides for infection control.
Lock bed wheels. Make sure resident is in an 14. Return bed to lowest position. Remove pri-
upright sitting position. vacy measures.
Prevents injury to you and to resident. Prevents fluids Provides for safety.
from running down resident’s throat, causing
choking. 15. Place call light within resident’s reach.
Allows resident to communicate with staff as
6. Put on gloves. necessary.
Brushing may cause gums to bleed.
16. Report any problems with teeth, mouth,
7. Place towel across resident’s chest. tongue, and lips to nurse. This includes
Protects resident’s clothing and bed linen.
odor, cracking, sores, bleeding, and any
8. Wet brush. Put on small amount of discoloration.
toothpaste. Provides nurse with information to assess resident.
Water helps distribute toothpaste.
17. Document procedure using facility
9. Clean entire mouth (including tongue and all guidelines.
surfaces of teeth). Use gentle strokes. First What you write is a legal record of what you did. If
brush upper teeth, then lower teeth. Use you don’t document it, legally it didn’t happen.
short strokes. Brush back and forth.
Brushing upper teeth first minimizes production of Although residents who are unconscious cannot
saliva in lower part of mouth.
eat, breathing through the mouth causes saliva
10. Give the resident water to rinse the mouth. to dry in the mouth. Good mouth care needs
Place emesis basin under the resident’s chin, to be performed more frequently to keep the
with the inward curve under the resident’s mouth clean and moist. Swabs with a mixture of
bottom lip. Have resident spit water into em- lemon juice and glycerine are sometimes used
esis basin (Fig. 6-35). Wipe resident’s mouth to soothe the gums. These may further dry the
and remove towel.
 6 140

gums if used too often. Follow the care plan re- Place an emesis basin next to the cheek and
garding the use of swabs. chin for excess fluid.
Protects resident’s clothing and bed linen.
With unconscious residents, use as little liquid
Personal Care Skills

as possible when giving oral care. Because the 8. Hold mouth open with padded tongue blade.
person’s swallowing reflex is weak, he or she Enables you to safely clean mouth.
is at risk for aspiration. Aspiration is the in-
9. Dip swab in cleaning solution. Squeeze ex-
halation of food, fluid, or foreign material into
cess solution to prevent aspiration. Wipe
the lungs. Aspiration can cause pneumonia
teeth, gums, tongue, and inside surfaces of
or death. Turning unconscious residents on
mouth. Change swab often. Repeat until the
their sides before giving oral care can also help
mouth is clean (Fig. 6-36).
prevent aspiration (see procedure later in this Stimulates gums and removes mucus.
chapter).

Providing oral care for the unconscious resident

Equipment: sponge swabs, padded tongue blade,

towel, emesis basin, gloves, lip moisturizer, cleaning
solution (check the care plan)

1. Wash your hands.

Provides for infection control.

2. Identify yourself by name. Identify the resi-

dent by name. Even residents who are uncon-
scious may be able to hear you. Always speak Fig. 6-36. Wipe all inside surfaces of the mouth to clean
to them as you would to any resident. the mouth, stimulate the gums, and remove mucus.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and 10. Rinse with clean swab dipped in water.
establishes correct identification. Squeeze swab first to remove excess water.
Removes solution from mouth.
3. Explain procedure to resident. Speak clearly,
slowly, and directly. Maintain face-to-face con- 11. Remove the towel and basin. Pat lips or face
tact whenever possible. dry if needed. Apply lip moisturizer.
Promotes understanding. The resident may be Prevents lips from drying and cracking. Improves resi-
able to hear and understand even though he is dent’s comfort.
unconscious.
12. Dispose of soiled linen in proper container.
4. Provide for resident’s privacy with curtain,
screen, or door. 13. Clean and return supplies to proper storage.
Maintains resident’s right to privacy and dignity.
14. Remove and discard gloves. Wash your
5. Adjust bed to a safe level, usually waist high. hands.
Lock bed wheels. Provides for infection control.
Prevents injury to you and to resident.
15. Return bed to lowest position. Remove pri-
6. Put on gloves. vacy measures.
Protects you from coming into contact with body Lowering the bed provides for safety.
fluids.
16. Place call light within resident’s reach.
7. Turn resident on his side or turn head to the Allows resident to communicate with staff as
side. Place a towel under his cheek and chin. necessary.
 141 6

17. Report any problems with teeth, mouth,

tongue, and lips to nurse. This includes
odor, cracking, sores, bleeding, and any
discoloration.

Personal Care Skills

Provides nurse with information to assess resident.
18. Document procedure using facility
guidelines.
What you write is a legal record of what you did. If
you don’t document it, legally it didn’t happen.

Flossing the teeth removes plaque and tartar Fig. 6-37. Before beginning, wrap floss securely around
buildup around the gum line and between the each index finger.
teeth. Teeth may be flossed immediately after or
before they are brushed, as the resident prefers. 8. Start with the back teeth. Place floss between
Flossing should not be done for certain resi- teeth. Move it down the surface of the tooth.
dents. Follow the care plan. Use a gentle sawing motion (Fig. 6-38).

Flossing teeth

Equipment: floss, cup with water, emesis basin,

gloves, towel
1. Wash your hands.
Provides for infection control.

2. Identify yourself by name. Identify the resi-

dent by name.
Resident has right to know identity of his or her care- Fig. 6-38. Floss teeth gently. Being gentle protects the
giver. Addressing resident by name shows respect and gums.
establishes correct identification.

3. Explain procedure to resident. Speak clearly, Continue to the gum line. At the gum line,
slowly, and directly. Maintain face-to-face con- curve the floss into a letter C. Slip it gently
tact whenever possible. into the space between the gum and tooth.
Promotes understanding and independence. Then go back up, scraping that side of the
tooth (Fig. 6-39). Repeat this on the side of
4. Provide for resident’s privacy with curtain,
the other tooth.
screen, or door.
Removes food and prevents tooth decay.
Maintains resident’s right to privacy and dignity.

5. Adjust the bed to a safe level. Lock bed

wheels. Make sure the resident is in an up-
right sitting position.
Prevents fluids from running down resident’s throat,
causing choking.

6. Put on gloves.
Flossing may cause gums to bleed.

7. Wrap the ends of floss securely around each Fig. 6-39. Floss gently in the space between the gum and
index finger (Fig. 6-37). tooth.
 6 142

9. After every two teeth, unwind floss from your Make sure you match the dentures to the correct
fingers. Move it so you are using a clean resident. Store in solution or cool water.
area. Floss all teeth.
Residents’ Rights
Personal Care Skills

10. Offer water to rinse the mouth. Ask the resi-

dent to spit it into the basin. Oral Care
Flossing loosens food. Rinsing removes it. Oral care is very personal. Always pull the privacy
curtain and close the door before beginning. Many
11. Offer resident a face towel when done floss- people who have dentures do not want to be seen
ing all teeth. without their teeth in place. When you remove the
teeth, clean and return them immediately.
Promotes dignity.

12. Discard floss. Empty basin into the toilet.

Clean and store basin and supplies. Cleaning and storing dentures

13. Dispose of soiled linen in the proper Equipment: denture brush or toothbrush, denture
cleanser or tablet, labeled denture cup, 2 towels,
container.
gloves
14. Remove and discard gloves. Wash your
1. Wash your hands.
hands. Provides for infection control.
Provides for infection control.
2. Put on gloves.
15. Return bed to lowest position. Remove pri- Prevents you from coming into contact with body
vacy measures. fluids.
Lowering the bed provides for safety.
3. Line sink/basin with a towel(s) and partially
16. Place call light within resident’s reach. fill sink with water.
Allows resident to communicate with staff as Prevents dentures from breaking if dropped.
necessary.
4. Rinse dentures in cool running water before
17. Report any problems with teeth, mouth,
brushing them. Do not use hot water.
tongue, and lips to nurse. This includes Hot water may damage dentures.
odor, cracking, sores, bleeding, and any
discoloration. 5. Apply toothpaste or cleanser to toothbrush.
Provides nurse with information to assess resident.
6. Brush the dentures on all surfaces
18. Document procedure using facility (Fig. 6-40).
guidelines.
What you write is a legal record of what you did. If
you don’t document it, legally it didn’t happen.

Dentures are artificial teeth. They are expen-

sive. 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 resident’s dentures do not
fit properly, are chipped, or are missing.

When storing dentures, place them in a denture Fig. 6-40. Brush dentures on all surfaces to properly clean
cup with the resident’s name and room number. them.
 143 6

7. Rinse all surfaces of dentures under cool run- 7. Explain guidelines for assisting with
ning water. Do not use hot water. toileting
Hot water may damage dentures.
Residents who cannot get out of bed to go to

Personal Care Skills

8. Rinse denture cup before placing clean den-
the bathroom may be given a bedpan, a fracture
tures in it.
Removes pathogens. pan, or a urinal. A fracture pan is a bedpan
that is flatter than the regular bedpan. It is used
9. Place dentures in clean, labeled denture cup for residents who cannot assist with raising their
with solution or cool water (Fig. 6-41). Place hips onto a regular bedpan (Fig. 6-42). Women
lid on cup. Return denture cup to storage. will generally use a bedpan for urination and
Some residents will want to wear dentures all bowel movements. Men will generally use a uri-
of the time. They will only remove them for nal for urination and a bedpan for a bowel move-
cleaning. If the resident wants to continue ments (Fig. 6-43).
wearing dentures, return them to him or her.
Do not place them in the denture cup. b)

a)

Fig. 6-42. a) Standard bedpan and b) fracture pan.

Fig. 6-41. Dentures should be stored in solution in a den-

ture cup that is properly labeled with the resident’s name
and room number.

10. Clean and return the equipment to proper

storage.

11. Drain sink. Dispose of towels in proper Fig. 6-43. Two types of urinals.
container.
Elimination equipment should be cleaned after
12. Remove and discard gloves. Wash your
each use. It may need to be put in a special area
hands.
for cleaning and is usually kept in the bathroom
Provides for infection control.
between uses. Residents who share bathrooms
13. Report any changes in appearance of den- may need to have urinals and bedpans labeled
tures to the nurse. with their names. Follow your facility’s policy for
Provides nurse with information to assess resident. storage. Never place this equipment on an over-
bed table or on top of a side table.
14. Document procedure using facility
guidelines. Wastes such as urine and feces can carry infec-
What you write is a legal record of what you did. If tion. Always dispose of wastes in the toilet. Be
you don’t document it, legally it didn’t happen. careful not to spill or splash the wastes. Wear
gloves when handling bedpans, urinals, or ba-
 6 144

sins that contain wastes. This includes dirty protective pad nearest the resident should be
bath water. Wash these containers thoroughly, fanfolded (folded several times into pleats).
rinse and dry them, or place them in the proper
Ask resident to roll onto his back, or roll him
area for cleaning.
Personal Care Skills

as you did before. Unfold rest of protective

Assisting resident with use of bedpan sheet so it completely covers area under and
around the resident’s hips. (Fig. 6-44)
Equipment: bedpan, bedpan cover, protective pad or Prevents linen from being soiled.
sheet, bath blanket, toilet paper, disposable wash-
cloths or wipes, soap, towel, 2 pairs of gloves 9. Ask resident to remove undergarments or
help him do so.
1. Wash your hands. Promotes independence.
Provides for infection control.

2. Identify yourself by name. Identify the resi-

dent by name.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
establishes correct identification.

3. Explain procedure to resident. Speak clearly,

slowly, and directly. Maintain face-to-face con-
tact whenever possible.
Promotes understanding and independence.
Fig. 6-44. Unfold the rest of the bed protector so it com-
4. Provide for resident’s privacy with curtain, pletely covers area under and around the resident’s hips.
screen, or door.
Maintains resident’s right to privacy and dignity. 10. Place bedpan near his hips in the correct po-
sition. Standard bedpan should be positioned
5. Adjust bed to a safe working level, usually
with the wider end aligned with the resident’s
waist high. Before placing bedpan, lower the
buttocks. Fracture pan should be positioned
head of the bed. Lock bed wheels.
When bed is flat, resident can be moved without with handle toward foot of bed.
working against gravity. 11. If resident is able, ask him to raise hips by
6. Put on gloves. pushing with feet and hands at the count of
Prevents contact with body fluids. three (Fig. 6-45). Slide the bedpan under his
hips.
7. Cover the resident with the bath blanket. Ask
him to hold it while you pull down the top
covers underneath. Do not expose more of
the resident than you have to.
Maintains resident’s right to privacy and dignity.
Wid
er E
8. Place a protective pad under the resident’s nd
buttocks and hips. To do this, have the resi-
dent roll toward you. If the resident cannot
do this, you must turn him toward you (see
later in this chapter). Be sure resident can-
not roll off the bed. Move to empty side of Fig. 6-45. On the count of three, slide the bedpan under
bed. Place protective pad on the area where the resident’s hips. The wider end of bedpan should be
the resident will lie on his back. The side of aligned with the resident’s buttocks.
 145 6

If a resident cannot help you in any way, keep or urine (for example, the presence of blood),
the bed flat and roll the resident onto the do not discard it. You will need to inform the
far side. Slip the bedpan under the hips and nurse.
gently roll the resident back onto the bedpan. Changes may be the first sign of a medical problem.

Personal Care Skills

Keep the bedpan centered underneath.
21. Turn the faucet on with a paper towel. Rinse
12. Remove and discard gloves. Wash your the bedpan with cold water first and empty
hands. it into the toilet. Place bedpan in proper area
Provides for infection control. for cleaning or clean it according to policy.

13. Raise the head of the bed. Prop the resident 22. Remove and discard gloves. Wash your
into a semi-sitting position using pillows. hands.
Puts resident in comfortable position for voiding. Provides for infection control.

14. Place toilet tissue and washcloths or wipes 23. Return bed to lowest position. Remove pri-
within resident’s reach. Ask resident to clean vacy measures.
his hands with the hand wipe when finished, Lowering the bed provides for resident’s safety.
if he is able. 24. Place call light within resident’s reach.
15. Place the call light within resident’s reach. Allows resident to communicate with staff as
necessary.
Ask resident to signal when done. Leave the
room. 25. Report any changes in resident to the nurse.
Ensures ability to communicate need for help. Provides nurse with information to assess resident.

16. When called by the resident, return and put 26. Document procedure using facility
on clean gloves. guidelines.
What you write is a legal record of what you did. If
17. Lower the head of the bed. Make sure resi- you don’t document it, legally it didn’t happen.
dent is still covered. Do not overexpose the
resident.
Places resident in proper position to remove pan. Assisting a male resident with a urinal
Promotes dignity.
Equipment: urinal, protective pad or sheet, dispos-
18. Remove bedpan carefully and cover bedpan.
able washcloths or wipes, 2 pairs of gloves
Promotes infection control and odor control. Provides
dignity for resident. 1. Wash your hands.
Provides for infection control.
19. Give perineal care if help is needed. Wipe
female residents from front to back. Dry the 2. Identify yourself by name. Identify the resi-
perineal area with a towel. Help the resident dent by name.
put on undergarment. Place the towel in Resident has right to know identity of his or her care-
a hamper or bag, and discard disposable giver. Addressing resident by name shows respect and
establishes correct identification.
supplies.
Wiping from front to back prevents spread of patho- 3. Explain procedure to resident. Speak clearly,
gens that may cause urinary tract infection. slowly, and directly. Maintain face-to-face con-
20. Take bedpan to the bathroom. Empty con- tact whenever possible.
tents of bedpan into the toilet unless a Promotes understanding and independence.
specimen is needed. Note color, odor, and 4. Provide for resident’s privacy with curtain,
consistency of contents before flushing. If screen, or door.
you notice anything unusual about the stool Maintains resident’s right to privacy and dignity.
 6 146

5. Adjust bed to a safe working level, usually 13. Turn the faucet on with a paper towel. Rinse
waist high. Lock bed wheels. the urinal with cold water first. Then empty
Prevents injury to you and to resident. rinse water into the toilet. Place urinal in
proper area for cleaning or clean it according
Personal Care Skills

6. Put on gloves.
Prevents you from coming into contact with body to facility policy.
fluids.
14. Remove and discard gloves. Wash your
7. Place a protective pad under the resident’s hands.
buttocks and hips, as in earlier procedure.
15. Return bed to lowest position. Remove pri-
Prevents linen from being soiled.
vacy measures.
8. Hand the urinal to the resident. If the resi- Lowering the bed provides for resident’s safety.
dent is not able to help himself, place urinal
16. Place call light within resident’s reach.
between his legs and position penis inside
Allows resident to communicate with staff as
the urinal (Fig. 6-46). Replace covers. necessary.
Promotes independence, dignity and privacy.
17. Report any changes in resident to the nurse.
Provides nurse with information to assess resident.

18. Document procedure using facility

guidelines.
What you write is a legal record of what you did. If
you don’t document it, legally it didn’t happen.

Fig. 6-46. Position the penis inside the urinal if the resi-
dent cannot do it himself. Some residents are able to get out of bed, but
may still need help walking to the bathroom and
9. Remove and discard gloves. Wash your using the toilet. Others who are able to get out of
hands. bed but cannot walk to the bathroom may use a
portable commode. A portable commode is a
10. Place wipes within resident’s reach. Ask the chair with a toilet seat and a removable container
resident to clean his hands with the hand underneath (Fig. 6-47).
wipe when finished, if he is able. Leave call
light within reach while resident is using uri-
nal. Ask resident to signal when done. Leave
the room.
Ensures ability to communicate need for help.

11. When called by the resident, return and put

on clean gloves.

12. Remove urinal or have resident hand it to

you. Empty contents into toilet unless speci-
men is needed or the urine is being mea-
sured for intake/output monitoring. Note
color, odor, and qualities (for example, cloud-
iness) of contents before flushing. Fig. 6-47. A portable commode. (photo courtesy of nova ortho
med, inc.)
Changes may be first sign of medical problem.
 147 6

10. Help resident back to bed.

Assisting a resident to use a portable commode
or toilet 11. Remove waste container. Empty into toilet
unless a specimen is needed. Note color,
Equipment: portable commode with basin, toilet

Personal Care Skills

paper, disposable washcloths or wipes, towel, gloves odor, and consistency of contents.
Changes may be first sign of medical problem.
1. Wash your hands.
Provides for infection control.
12. Rinse container. Pour rinse water into toilet.
Place container in proper area for cleaning or
2. Identify yourself by name. Identify the resi- clean it according to facility policy.
dent by name.
Resident has right to know identity of his or her care- 13. Remove and discard gloves. Wash your
giver. Addressing resident by name shows respect and hands.
establishes correct identification. Provides for infection control.
3. Explain procedure to resident. Speak clearly, 14. Remove privacy measures. Place call light
slowly, and directly. Maintain face-to-face con- within resident’s reach.
tact whenever possible. Allows resident to communicate with staff as
Promotes understanding and independence. necessary.

4. Provide for resident’s privacy with curtain, 15. Report any changes in resident to the nurse.
screen, or door. Provides nurse with information to assess resident.
Maintains resident’s right to privacy and dignity. 16. Document procedure using facility
5. Help resident out of bed and to the portable guidelines.
commode or bathroom. Make sure resident What you write is a legal record of what you did. If
you don’t document it, legally it didn’t happen.
is wearing non-skid shoes and that the laces
are tied.
6. If needed, help resident remove clothing and
sit comfortably on toilet seat. Place toilet tis-
8. Explain the guidelines for safely
sue and washcloths or wipes within resident’s positioning and moving residents
reach. Ask resident to clean his hands with Residents who spend a lot of time in bed often
the hand wipe when finished, if he is able. need help getting into comfortable positions.
7. Provide privacy. Leave call light within reach They also need to change positions periodically
while resident is using commode. Ask resi- to avoid muscle stiffness and skin breakdown or
dent to signal when done. Leave the room. pressure sores. Too much pressure on one area
Ensures ability to communicate need for help. for too long can cause a decrease in circulation.
8. When called by the resident, return and put This can lead to pressure sores. Positioning
on gloves. means helping residents into positions that will
Prevents you from coming into contact with body be comfortable and healthy for them. Bed-bound
fluids. residents should be repositioned at least every
two hours. Follow the care plan. Document the
9. Give perineal care if help is needed. Wipe
time and position with each change. Always
female residents from front to back. Dry the
check the skin for signs of irritation whenever
perineal area with a towel. Help the resident
you reposition a resident.
put on undergarment. Place the towel in a
hamper or bag. Discard disposable supplies. Following are the five basic body positions:
Wiping from front to back prevents spread of patho-
gens that may cause urinary tract infection. 1. Supine or lying flat on back (Fig. 6-48)
 6 148

Helping a resident move up in bed helps prevent

skin irritation that can lead to pressure sores.
You can use a helper if one is available. Get help
if you think it is not safe to move the resident by
Personal Care Skills

Fig. 6-48. A person in the supine position is lying flat on yourself.

his or her back.
Moving a resident up in bed
2. Lateral or side (Fig. 6-49)
1. Wash your hands.
Provides for infection control.

2. Identify yourself by name. Identify the resi-

dent by name.
Fig. 6-49. A person in the lateral position is lying on his Resident has right to know identity of his or her care-
or her side. giver. Addressing resident by name shows respect and
establishes correct identification.
3. Prone or lying on the stomach (Fig. 6-50)
3. Explain procedure to resident. Speak clearly,
slowly, and directly. Maintain face-to-face con-
tact whenever possible.
Promotes understanding and independence.

Fig. 6-50. A person in the prone position is lying on his or 4. Provide for resident’s privacy with curtain,
her stomach. screen, or door.
Maintains resident’s right to privacy and dignity.
4. Fowler’s or semi-sitting position (45 to 60
degrees) (Fig. 6-51) 5. Adjust bed to a safe level, usually waist high.
Lock bed wheels (Fig. 6-53).
Prevents injury to you and to resident.

Fig. 6-51. A person lying in the Fowler’s position is par-

tially reclined.

5. Sims’ or lying on the left side with one leg

Fig. 6-53. Always lock bed wheels if bed is movable before
drawn up (Fig. 6-52) positioning or transferring a resident.

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

pillow to head of the bed.
When bed is flat, resident can be moved without
working against gravity. Pillow prevents injury should
resident hit the head of bed.

Fig. 6-52. A person lying in the Sims’ position is lying on 7. If the bed has side rails, raise the rail on the
his or her left side with one leg drawn up. far side of the bed.
 149 6

8. Stand by bed with feet apart. Face the 16. Report any changes in resident to the nurse.
resident. Provides nurse with information to assess resident.

9. Place one arm under resident’s shoulder 17. Document procedure using facility

Personal Care Skills

blades. Place other arm under resident’s guidelines.
thighs. Use good body mechanics. What you write is a legal record of what you did. If
Putting your arm under resident’s neck could cause you don’t document it, legally it didn’t happen.
injury.

10. Ask resident to bend knees, brace feet on Moving a resident to the side of the bed
mattress, and push feet and hands on the
count of three (Fig. 6-54). Equipment: draw sheet
Enables resident to help as much as possible and re- 1. Wash your hands.
duces strain on you. Provides for infection control.

2. Identify yourself by name. Identify the resi-

dent by name.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
establishes correct identification.

3. Explain procedure to resident. Speak clearly,

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

4. Provide for resident’s privacy with curtain,

screen, or door.
Maintains resident’s right to privacy and dignity.

5. Adjust the bed to a safe level, usually waist

high. Lock bed wheels.
Prevents injury to you and to resident.

Fig. 6-54. Keep your back straight and your knees bent. 6. Lower the head of bed.
When bed is flat, resident can be moved without
11. On three, shift body weight. Help move resi- working against gravity.
dent while she pushes with her feet. 7. Stand on the same side of the bed to which
Communicating helps resident help you.
you are moving the resident.
12. Place pillow under resident’s head.
8. With a draw sheet: Roll the draw sheet up
Provides for resident’s comfort.
to the resident’s side, and grasp the sheet
13. Return bed to lowest position. Remove pri- with your palms up. One hand should be
vacy measures. at the resident’s shoulders, the other about
Lowering the bed provides for resident’s safety. level with the resident’s hips. Apply one knee
14. Place call light within resident’s reach. against the side of the bed, and lean back
Allows resident to communicate with staff as with your body. On the count of three, slowly
necessary. pull the draw sheet and resident toward you.

15. Wash your hands. Without a draw sheet: Gently slide your
Provides for infection control. hands under the head and shoulders and
 6 150

move them toward you (Fig. 6-55). Gently 12. Report any changes in resident to the nurse.
slide your hands under the midsection and Provides nurse with information to assess resident.
move it toward you. Gently slide your hands
13. Document procedure using facility
under the hips and legs and move them to-
Personal Care Skills

guidelines.
ward you (Fig. 6-56). What you write is a legal record of what you did. If
Being gentle while sliding helps protect resident’s you don’t document it, legally it didn’t happen.
skin.

Turning a resident

1. Wash your hands.

Provides for infection control.

2. Identify yourself by name. Identify the resi-

dent by name.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
establishes correct identification.

3. Explain procedure to resident. Speak clearly,

slowly, and directly. Maintain face-to-face con-
tact whenever possible.
Promotes understanding and independence.
Fig. 6-55.
4. Provide for resident’s privacy with curtain,
screen, or door.
Maintains resident’s right to privacy and dignity.

5. Adjust bed to a safe level, usually waist high.

Lock bed wheels.
Prevents injury to you and to resident.

6. Lower the head of bed.

When bed is flat, resident can be moved without
working against gravity.

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
Fig. 6-56. you if it is up.

9. Return bed to lowest position. Remove pri- 8. Move resident to side of bed nearest you
vacy measures. using previous procedure.
Lowering the bed provides for resident’s safety. Positions resident for turn.

10. Place call light within resident’s reach. 9. Turning resident away from you:
Allows resident to communicate with staff as a. Cross resident’s arm over his or her chest.
necessary.
Move arm on side resident is being turned to
11. Wash your hands. out of the way. Cross leg nearest you over the
Provides for infection control. far leg (Fig. 6-57).
 151 6

d. Gently roll the resident toward you (Fig.

6-59). Your body will block resident and pre-
vent her from rolling out of bed.

Personal Care Skills

Fig. 6-57. Cross leg nearest you over far leg.

b. Stand with feet about 12 inches apart. Bend

your knees.
Reduces your risk of injury. Promotes good body Fig. 6-59. Gently roll resident toward you.
mechanics.

c. Place one hand on the resident’s shoulder. 10. Position resident properly:
Place the other hand on the resident’s near- • Head supported by pillow
est hip. • Shoulder adjusted so resident is not lying
d. Gently push resident onto side as one unit, on arm
toward the other side of bed (toward raised • Top arm supported by pillow
side rail). Shift your weight from your back • Back supported by supportive device
leg to your front leg (Fig. 6-58).
• Top knee flexed
• Supportive device between legs with top
knee flexed; knee and ankle supported

11. Return bed to lowest position. Remove pri-

vacy measures.
Lowering the bed provides for resident’s safety.

12. Place call light within resident’s reach.

Allows resident to communicate with staff as
necessary.
Fig. 6-58. Push resident as you shift your weight from
your back leg to the front leg. 13. Wash your hands.
Provides for infection control.
Turning resident toward you:
14. Report any changes in resident to the nurse.
a. Cross resident’s arm over his or her chest. Provides nurse with information to assess resident.
Move arm on side resident is being turned
15. Document procedure using facility
to out of the way. Cross leg furthest from you
guidelines.
over the near leg.
What you write is a legal record of what you did. If
b. Stand with feet about 12 inches apart. Bend you don’t document it, legally it didn’t happen.
your knees.
Reduces your risk of injury. Promotes good body
Some residents’ spinal columns must be kept in
mechanics.
alignment. To turn these residents in bed, you
c. Place one hand on the resident’s far shoul- will logroll them. Logrolling means moving a
der. Place the other hand on the far hip. resident as a unit, without disturbing the align-
 6 152

ment of the body. The head, back and legs must 11. Grasp the draw sheet on the far side
be kept in a straight line. This is necessary in (Fig. 6-60).
cases of neck or back problems, spinal cord inju-
ries, or after back or hip surgeries. It is safer for
Personal Care Skills

two people to perform this procedure together. A

draw sheet assists with moving.

Logrolling a resident with one assistant

Equipment: draw sheet, co-worker

1. Wash your hands.

Provides for infection control.

2. Identify yourself by name. Identify the resi- Fig. 6-60. Both workers grasp the draw sheet on the far
dent by name. side.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and 12. On the count of three, gently roll the resident
establishes correct identification.
toward you. Turn the resident as a unit (Fig.
3. Explain procedure to resident. Speak clearly, 6-61). Your bodies will block resident and
slowly, and directly. Maintain face-to-face con- prevent him from rolling out of bed.
tact whenever possible. Work together for your safety and the resident’s.
Promotes understanding and independence.

4. Provide for resident’s privacy with curtain,

screen, or door.
Maintains resident’s right to privacy and dignity.

5. Adjust bed to a safe level, usually waist high.

Lock bed wheels.
Prevents injury to you and to resident.

6. Lower the head of bed.

When bed is flat, resident can be moved without
working against gravity.

7. If the bed has side rails and they are raised, Fig. 6-61. Be gentle when turning the resident. Turn the
lower the side rail on side closest to you. resident as a unit.

8. Both workers stand on the same side of the

13. Reposition resident comfortably.
bed. One person stands at the resident’s Maintains alignment.
head and shoulders. The other stands near
the resident’s midsection. 14. Return bed to lowest position.
Lowering the bed provides for resident’s safety.
9. Place the resident’s arms across his or her
chest. Place a pillow between the knees. 15. Place call light within resident’s reach.
Allows resident to communicate with staff as
10. Stand with feet about 12 inches apart. Bend necessary.
your knees.
16. Wash your hands.
Reduces your risk of injury. Promotes good body
Provides for infection control.
mechanics.
 153 6

17. Report any changes in resident to the nurse.

Provides nurse with information to assess resident.

18. Document procedure using facility

Personal Care Skills

guidelines.
What you write is a legal record of what you did. If
you don’t document it, legally it didn’t happen.

Before a resident who has been lying down

stands up, she should dangle. To dangle means Fig. 6-62. Place one hand under the shoulder blades and
to sit up with the feet over the side of the bed the other under the thighs.
to regain balance. It gives the resident time to
8. On the count of three, slowly turn resident
adjust to being in an upright position after lying
into sitting position with legs dangling over
down.
side of bed (Fig. 6-63).
Assisting resident to sit up on side of bed: Communicating helps resident help you.
dangling

1. Wash hands.
Provides for infection control.

2. Identify yourself by name. Identify the resi-

dent by name.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
establishes correct identification.

3. Explain procedure to resident. Speak clearly, Fig. 6-63. The weight of the resident’s legs hanging down
slowly, and directly. Maintain face-to-face con- from the bed helps the resident sit up.
tact whenever possible.
Promotes understanding and independence. 9. Ask resident to hold onto edge of mattress
with both hands. Assist resident to put on
4. Provide for resident’s privacy with curtain,
non-skid shoes or slippers.
screen, or door.
Prevents sliding on floor and protects resident’s feet
Maintains resident’s right to privacy and dignity.
from contamination.
5. Adjust bed height to lowest position. Lock 10. Have resident dangle as long as ordered. The
bed wheels. care plan may direct you to allow the resi-
Allows resident’s feet to touch floor when sitting.
dent to dangle for several minutes and then
Reduces chance of injury if resident falls.
return her to lying down, or it may direct you
6. Raise the head of bed to sitting position. to allow the resident to dangle in preparation
Resident can move without working against gravity. for walking or a transfer. Follow the care plan.
7. Place one arm under resident’s shoulder Do not leave the resident alone. If the resi-
blades. Place the other arm under resident’s dent is dizzy for more than a minute, have
thighs (Fig. 6-62). her lie down again and report to the nurse.
Placing your arm under the resident’s neck may Change of position may cause dizziness due to a
cause injury. drop in blood pressure.
 6 154

11. Take vital signs as ordered (Chapter 7). chance there is of injury. Carefully follow facil-
ity policies on lifting. Use equipment properly.
12. Remove slippers or shoes.
If you are unsure how to use equipment, ask for
13. Gently assist resident back into bed. Place help. Always get help when you need it.
Personal Care Skills

one arm around resident’s shoulders. Place

A transfer belt is a safety device used to trans-
the other arm under resident’s knees. Slowly
fer residents who are weak, unsteady, or uncoor-
swing resident’s legs onto bed.
dinated. It is called a gait belt when it is used to
14. Leave bed in lowest position. Remove privacy help residents walk. The belt is made of canvas
measures. or other heavy material. It sometimes has han-
15. Place call light within resident’s reach. dles. It fits around the resident’s waist outside
Allows resident to communicate with staff as the clothing. The belt gives you something firm
necessary. to hold on to. Transfer belts cannot be used if a
16. Wash your hands. resident has fragile bones or recent fractures.
Provides for infection control. A slide or transfer board may be used to help
17. Report any changes in resident to the nurse. transfer residents who are unable to bear weight
Provides nurse with information to assess resident. on their legs. Slide boards can be used for al-
most any transfer that involves moving from one
18. Document procedure using facility
sitting position to another. This includes trans-
guidelines.
What you write is a legal record of what you did. If fers from a bed to a wheelchair (Fig. 6-64).
you don’t document it, legally it didn’t happen.

Transferring a resident means that you are mov-

ing him from one place to another. Transfers
can move a resident from a wheelchair to a bed
or stretcher, from a bed to a chair, from a wheel-
chair to a shower or toilet, and so on. Safety is
one of the most important things to consider
during transfers. In 2002, OSHA announced
new ergonomic guidelines for transfers. Ergo-
nomics is the science of designing equipment
and work tasks to suit the worker’s abilities.
Fig. 6-64. A slide board can help with bed-to-chair
OSHA now says that manual lifting of residents
transfers.
should be reduced in all cases and eliminated
when possible. Manual lifting, transferring, and
Guidelines: Wheelchairs
repositioning of residents may increase risks of
pain and injury.
G Learn how a wheelchair works. Residents
To that end, many facilities have adopted “zero- may use manual (requiring human power to
lift” or “lift-free” policies. These policies set move) or electric wheelchairs. Know how to
strict guidelines for lifting and transferring of apply and release the brake and how to work
residents. Some facilities allow no lifting at all the armrests and footrests. Always lock a
and require that mechanical equipment be used wheelchair before helping a resident into or
on every resident who needs to be transferred. out of it (Fig. 6-65). After a transfer, unlock
The more restrictions placed on lifting, the less the wheelchair.
 155 6

G To transfer to or from a wheelchair, the resi-

dent must use the side of the body that can
bear weight to support and lift the side that
cannot bear weight. Residents who can bear

Personal Care Skills

no weight with their legs may use leg
braces or an overhead trapeze to support
themselves.
G Before any transfer, make sure the resident is
wearing non-skid footwear which is securely
fastened. This promotes residents’ safety and
reduces the risk of falls.
Fig. 6-65. You must always lock the wheelchair before a G During wheelchair transfers make sure the
resident gets into or out of it. resident is safe and comfortable. Ask the resi-
dent how you can help. Some may only want
G To unfold a standard wheelchair, tilt the chair you to bring the chair to the bedside. Others
slightly to raise the wheels on the opposite may want you to be more involved.
side. Press down on one or both seat rails
until the chair opens and the seat is flat. To G When a resident is in a wheelchair or any
fold a standard wheelchair, lift up under the chair, he or she should be repositioned every
center edge of the seat. two hours or as needed. The reasons for
doing this are as follows:
G To remove an armrest, release the arm lock
• It promotes comfort.
by the armrest, and lift the arm from the cen-
• It reduces pressure.
ter. To replace the armrest, simply reverse the
procedure. • It increases circulation.
• It exercises the joints.
G To move a footrest out of the way, press or
• It promotes muscle tone.
pull the release lever. Swing the footrest out
toward the side of the wheelchair. To remove G Keep the resident’s body in good alignment
the footrest, lift it off when it is toward the while in a wheelchair or chair. Special cush-
side of the wheelchair (Fig. 6-66). To replace ions and pillows can be used for support.
a footrest, simply put it back in the side posi- The hips should be positioned well back in
tion. Then swing it back to the front position. the chair. If the resident needs to be moved
It should lock into place. back in the wheelchair, go to the back of the
chair. Gently reach forward and down under
the resident’s arms. Ask the resident to place
his feet on the ground and push up. Gently
pull the resident up in the chair while the
resident pushes.

Tip
Falls
Remember the following tips if a resident starts to
fall during a transfer:
• Widen your stance. Bring the resident’s body
Fig. 6-66. To remove a footrest, swing the footrest toward
close to you to break the fall. Bend your knees
the side of the wheelchair and lift it off.
 6 156

4. Provide for resident’s privacy with curtain,

and support the resident as you lower her to the
floor (Fig. 6-67). You may need to drop to the screen, or door. Check the area to be certain
floor with the resident to avoid injury to you or it is uncluttered and safe.
the resident. Maintains resident’s right to privacy and dignity.
Personal Care Skills

• Do not try to reverse or stop a fall. You or the Keeping area free from clutter promotes safety.
resident can be injured if you try to stop rather
than break the fall. 5. Remove both wheelchair footrests close to
• Call for help. Do not try to get the resident up the bed.
after the fall. Report the fall to nurse so that the
incident report can be prepared. 6. Place wheelchair near the head of the bed
with arm of the wheelchair almost touching
the bed. Wheelchair should be facing the foot
of the bed. It should be placed on resident’s
stronger, or unaffected, side.
Unaffected side supports weight.

7. Lock wheelchair wheels.

Wheel locks prevent chair from moving.

8. Raise the head of the bed. Adjust bed level.

The height of the bed should be equal to
or slightly higher than the chair. Lock bed
wheels.
Prevents injury to you and to resident.

9. Assist resident to sitting position with feet

flat on the floor.

10. Put non-skid footwear on resident and se-

curely fasten.
Promotes resident’s safety. Reduces risk of falls.
Fig. 6-67. Do not try to reverse or stop a fall. Bend your
knees and support the resident as you lower her to the
11. With transfer (gait) belt:
floor.
a. Stand in front of resident.
Transferring a resident from bed to wheelchair
b. Stand with feet about 12 inches apart. Bend
Equipment: wheelchair, transfer belt, non-skid your knees.
footwear Reduces your risk of injury. Promotes good body
mechanics.
1. Wash your hands.
Provides for infection control. c. Place belt around resident’s waist over cloth-
ing (not on bare skin). Grasp belt securely on
2. Identify yourself by name. Identify the resi-
both sides.
dent by name.
Resident has right to know identity of his or her care- Without transfer belt:
giver. Addressing resident by name shows respect and
establishes correct identification. a. Stand in front of resident.
3. Explain procedure to resident. Speak clearly, b. Stand with feet about 12 inches apart. Bend
slowly, and directly. Maintain face-to-face con- your knees.
tact whenever possible. Reduces your risk of injury. Promotes good body
Promotes understanding and independence. mechanics.
 157 6

c. Place your arms around resident’s torso 16. Ask the resident to put hands on wheelchair
under the arms. Ask resident to use the bed arm rests if able. When the chair is touching
to push up (or your shoulders, if possible). the back of the resident’s legs, help her lower
herself into the chair.

Personal Care Skills

12. Provide instructions to allow resident to help
with transfer. Instructions may include: 17. Reposition resident with hips touching back
“When you start to stand, push with your of wheelchair. Remove transfer belt, if used.
hands against the bed.” Using full seat of chair is safest position.

“Once standing, if you’re able, you can take 18. Attach footrests. Place the resident’s feet on
small steps in the direction of the chair.” the footrests. Check that the resident is in
good alignment.
“Once standing, reach for the chair with your
Protects feet and ankles.
stronger hand.”
19. Remove privacy measures.
13. With your legs, brace resident’s lower legs to
prevent slipping. This can be done by placing 20. Place call light within resident’s reach.
both of your knees in front of the resident’s Allows resident to communicate with staff as
knees. It can also be done by placing both of necessary.
your knees on the outside of both of the resi- 21. Wash your hands.
dent’s legs. Follow facility policy. Provides for infection control.
14. Count to three to alert resident. On three, 22. Report any changes in resident to the nurse.
slowly help resident to stand. Provides nurse with information to assess resident.
Communicating helps resident help you.
23. Document procedure using facility
15. Tell the resident to take small steps in the guidelines.
direction of the chair while turning her back What you write is a legal record of what you did. If
toward the chair. If more help is needed, help you don’t document it, legally it didn’t happen.
the resident to pivot to front of wheelchair
with back of her legs against wheelchair
(Fig. 6-68). Mechanical Lifts
Pivoting is safer than twisting.
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.

If you are trained to do so, you may assist resi-

dents with many types of transfers using a me-
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.
There are many different types of mechanical
lifts (Fig. 6-69). You must be trained on the spe-
cific lift you will be using. Most facilities require
two staff members to assist when using a me-
chanical lift.
Fig. 6-68. Help her pivot to the front of the wheelchair.
The back of her legs should be against the chair.
 6 158

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. Fanfold if
necessary. Make the bottom of the sling even
Personal Care Skills

with the resident’s knees. Help the resident

roll back to the middle of the bed. Spread out
the fanfolded edge of the sling.

8. Roll the mechanical lift to bedside. Make sure

the base is opened to its widest point. Push
the base of the lift under the bed.

9. Place the overhead bar directly over the

resident.

10. With the resident lying on his back, attach

Fig. 6-69. There are different types of lifts that transfer one set of straps to each side of the sling.
completely dependent residents and residents who can Attach one set of straps to the overhead bar.
bear some weight. (photos courtesy of vancare inc., 800-694-4525) Have co-worker support the resident at the
head, shoulders, and knees while being lifted.
Transferring a resident using a mechanical lift The resident’s arms should be folded across
his chest (Fig. 6-70). If the device has “S”
This is a basic procedure for transferring using a hooks, they should face away from resident.
mechanical lift. Ask someone to help you before Make sure all straps are connected properly.
starting.
Equipment: wheelchair or chair, co-worker, mechan-
ical or hydraulic lift

1. Wash your hands.

Provides for infection control.

2. Identify yourself by name. Identify the resi-

dent by name.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
establishes correct identification.

3. Explain procedure to resident. Speak clearly,

slowly, and directly. Maintain face-to-face con-
tact whenever possible. Fig. 6-70. With the resident’s arms folded across his
chest, attach the straps to the sling.
Promotes understanding and independence.

4. Provide for resident’s privacy with curtain, 11. Following manufacturer’s instructions, raise
screen, or door. the resident two inches above the bed. Pause
Maintains resident’s right to privacy and dignity. a moment for the resident to gain balance.
5. Lock bed wheels. 12. Have co-worker help support and guide the
Wheel locks prevent bed from moving. resident’s body. You can then move the lift so
6. Position wheelchair next to bed. Lock brakes. that the resident is positioned over the chair
Wheel locks prevent chair from moving. or wheelchair.
 159 6

Having another person help promotes safety during

the transfer and lessens chance of injury.

13. Slowly lower the resident into the chair or

Personal Care Skills

wheelchair. Push down gently on the resi-
dent’s knees to help the resident into a sit-
ting position.

14. Undo the straps from the overhead bar.

Leave the sling in place for transfer back to
bed.

15. Be sure the resident is seated comfortably

and correctly in the chair or wheelchair. Re-
move privacy measures.

16. Place call light within resident’s reach.

Allows resident to communicate with staff as
necessary.

17. Wash your hands.

Provides for infection control.

18. Report any changes in resident to the nurse.

Provides nurse with information to assess resident.

19. Document procedure using facility

guidelines.
What you write is a legal record of what you did. If
you don’t document it, legally it didn’t happen.
 7 160

7
Basic Nursing Skills

Basic Nursing Skills

1. Explain admission, transfer, and cannot answer, find the nurse. Ask questions to
discharge of a resident find out a resident’s personal preferences and
routines. Your facility will have a procedure for
Nursing assistants play an important role in admitting residents to their new home. These
helping residents make a successful transition to guidelines will help make the experience pleas-
a long-term care facility. Giving emotional sup- ant and successful.
port is a big part of this. Moving always requires
an adjustment, but as a person ages, it can be Guidelines: Admission
even harder (Fig. 7-1). Listening and being kind,
compassionate, and helpful may make new resi- G Prepare the room before the resident arrives.
dents feel better about their new homes. This helps him or her to feel expected and
welcome. Make sure the bed is made and the
room is tidy. Restock supplies that are low.
Make sure there is an admission kit available,
if used. Admission kits often contain per-
sonal care items, such as bath basin, emesis
basin, water pitcher, drinking glass, tooth-
paste, soap, comb, lotion, and tissues (Fig.
7-2). They may also contain a urine specimen
cup, label, and transport bag.

Fig. 7-1. A new resident must leave familiar places and

things. He may have just lost someone very close to him.
He may be experiencing other losses as well. Be support-
ive and welcoming.

Admission is often the first time you meet a

new resident. This is a time of first impres-
sions. Make sure a resident has a good impres-
sion of you and your facility. Because change
is difficult, staff must communicate with new
residents. Explain what to expect during the pro- Fig. 7-2. An admission kit is usually placed in a resident’s
room before he or she is admitted. It contains personal
cess. Answer any questions that are within your
care items that the resident will need. (reprinted with permission
scope of practice. If residents have questions you of briggs corporation, 800-247-2343, www.briggscorp.com)
 161 7

G When a new resident arrives at the facility, G Handle personal items with care and respect.
note the time and her condition. Is she using A resident has a legal right to have his per-
a wheelchair, on a stretcher, or walking? Who sonal items treated carefully. These items are
is with her? Observe the new resident for special things he has chosen to bring with

Basic Nursing Skills

level of consciousness and if she seems con- him. When setting up the room, ask him
fused. Look for signs of nervousness. Note what he likes. Place personal items where the
any tubes she has, such as IVs or catheters. resident wants them.
G Introduce yourself. State your position. Smile G Admission is a stressful time. Observe the
and be friendly. Always call the person by his resident, as she could have a problem that is
formal name until he tells you what he wants missed. Report to the nurse if you notice any
to be called. of the following:
G Never rush the process or the new resident. • Tubes that need to be reconnected
He should not feel like he is an inconve- • Resident seems confused, combative,
nience. Make sure the new resident feels wel- and/or unaware of surroundings
come, comfortable, and wanted.
• Resident is having difficulty breathing or
G Explain day-to-day life in the facility. Offer to any other signs of distress
take the resident on a tour (Fig. 7-3).
• Resident has missed a meal during
admission process
G Follow facility policy on any other tasks that
are required during admission.
G New residents may have good days followed
by not-so-good days. Let residents adapt to
their new homes at their own pace.

Residents’ Rights
Fig. 7-3. Make sure you include the location of the din- Rights during Admission
ing room when taking a new resident on a tour. Go over Upon admission, residents must be told of their
posted dining schedules. 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
G Introduce the resident to other residents and
agency.
staff members you see (Fig. 7-4). Introduce
the roommate if there is one.
Admitting a resident

Equipment: may include admission paperwork

(checklist and inventory form), gloves and vital signs
equipment

1. Wash your hands.

Provides for infection control.

2. Identify yourself by name. Identify the resi-

dent by name.
Resident has right to know identity of his or her care-
Fig. 7-4. Introduce new residents to all other residents
giver. Addressing resident by name shows respect and
you see.
establishes correct identification.
 7 162

3. Explain procedure to resident. Speak clearly, 11. Document procedure using facility
slowly, and directly. Maintain face-to-face con- guidelines.
tact whenever possible. What you write is a legal record of what you did. If
Promotes understanding and independence. you don’t document it, legally it didn’t happen.
Basic Nursing Skills

4. Provide for resident’s privacy with curtain,

Residents may be transferred to a different area
screen, or door. If the family is present, ask
of the facility. In cases of acute illness, they may
them to step outside until the admission pro-
be transferred to a hospital. Change is difficult.
cess is over.
Maintains resident’s right to privacy and dignity.
This is especially true when a person has an ill-
ness or his condition gets worse. Make the trans-
5. If part of facility procedure, do these things: fer as smooth as possible for the resident. Try to
• Take the resident’s height and weight lessen the stress. Inform him of the transfer as
(see Learning Objective 3). soon as possible. He can then begin to adjust to
the idea. Explain how, where, when and why the
• Take the resident’s baseline vital signs
transfer will occur.
(Learning Objective 2). Baseline signs are
initial values that can then be compared For example, “Mr. Jones, you will be moving to
to future measurements. a private room. You will be transferred to your
• Obtain a urine specimen if required new room in a wheelchair. This will happen
(Learning Objective 5). on Wednesday around 10 a.m. The staff will
take good care of you and your things. We will
• Complete the paperwork. Take an inven- make sure you are comfortable. Do you have any
tory of all the personal items. questions?”
• Help the resident to put personal items
Help residents to pack their personal items.
away. Label personal items according to
Residents often worry about losing their belong-
facility policy.
ings. Involve them with the packing process if
• Provide fresh water. appropriate. For example, let them see the empty
6. Show the resident to his/her room and bath- closet, drawers, etc.
room. Explain how to work the bed (and tele-
Residents’ Rights
vision if there is one). Show the resident how
Changing Rooms or Roommates
to work the call light and explain its use.
Promotes resident’s safety. Residents have the right to receive advance notice of
any room or roommate change.
7. Introduce the resident to his roommate, if
there is one. Introduce other residents and Transferring a resident
staff.
Makes resident feel more comfortable. Equipment: may include a wheelchair, cart for be-
longings, the medical record, all of the resident’s
8. Make sure resident is comfortable. Remove personal care items and packed personal items
privacy measures. Bring the family back in-
side if they were outside. 1. Wash your hands.
Provides for infection control.
9. Place call light within resident’s reach.
Allows resident to communicate with staff as 2. Identify yourself by name. Identify the resi-
necessary. dent by name.
Resident has right to know identity of his or her care-
10. Wash your hands. giver. Addressing resident by name shows respect and
Provides for infection control. establishes correct identification.
 163 7

3. Explain procedure to resident. Speak clearly, The nurse may cover important information
slowly, and directly. Maintain face-to-face con- with the resident and family. Some of these
tact whenever possible. areas may be discussed:
Promotes understanding and independence.

Basic Nursing Skills

• Future doctor or physical, speech, and occu-
4. Collect items to be moved onto the cart. Take pational therapy appointments (Fig. 7-5)
them to the new location. If the resident is
going into the hospital, they may be placed in
temporary storage.

5. Help the resident into the wheelchair

(stretcher may be used). Take him or her to
proper area.

6. Introduce new residents and staff.

Makes resident feel more comfortable.

7. Help the resident to put personal items away.

8. Make sure the resident is comfortable.

Fig. 7-5. After a resident is discharged, he or she may
9. Place call light within resident’s reach. continue to receive physical therapy.
Allows resident to communicate with staff as
necessary. • Home care, skilled nursing care
10. Wash your hands. • Medications
Provides for infection control. • Ambulation instructions from the doctor
11. Report any changes in resident to the nurse. • Medical equipment needed
Provides nurse with information to assess resident.
• Medical transportation
12. Document procedure using facility • Any restrictions on activities
guidelines.
What you write is a legal record of what you did. If • Special exercises to keep the resident func-
you don’t document it, legally it didn’t happen. tioning at the highest level
• Special nutrition or dietary requirements

The day of discharge is usually a happy day for a • Community resources

resident who is going home. When a resident is
Discharging a resident
discharged, he is released from the facility’s care
by the doctor. You will collect the resident’s be- Equipment: may include a wheelchair, cart for
longings and pack them. Ask the resident which belongings, the discharge paperwork, including
personal care items to include. Pack those, too. the inventory list done on admission, all of the
Know the resident’s condition at the time of dis- resident’s personal care items
charge. Find out if he will be using a wheelchair 1. Wash your hands.
or stretcher. The resident may have doubts about Provides for infection control.
not being cared for at the facility anymore. Be
2. Identify yourself by name. Identify the resi-
positive. Assure the resident he is ready for this
dent by name.
important change. Remind him that his doctor
Resident has right to know identity of his or her care-
believes he is ready. However, if she has specific giver. Addressing resident by name shows respect and
questions about care, inform the nurse. establishes correct identification.
 7 164

3. Explain procedure to resident. Speak clearly, • Measuring the body temperature

slowly, and directly. Maintain face-to-face con-
• Counting the pulse
tact whenever possible.
Promotes understanding and independence. • Counting the rate of respirations
Basic Nursing Skills

4. Provide for resident’s privacy with curtain, • Measuring the blood pressure
screen, or door.
Maintains resident’s right to privacy and dignity.
• Observing and reporting level of pain

5. Compare the checklist to the items there. If Watching for changes in vital signs is very im-
all items are there, ask the resident to sign. portant. Changes can indicate a resident’s condi-
tion is worsening. Always notify the nurse if:
6. Put the items to be taken onto the cart and
take them to pick-up area. • The resident has a fever (temperature is
above average for the resident or outside the
7. Help the resident dress and then into the normal range)
wheelchair or stretcher, if used.
• The resident has a respiratory or pulse rate
8. Help the resident to say his goodbyes to the that is too rapid or too slow
staff and residents.
• The resident’s blood pressure changes
9. Take resident to the pick-up area. Help him
into vehicle. You are responsible for the resi- • The resident’s pain is worse or is not re-
dent until he is safely in the car and the door lieved by pain management
is closed.
Normal Ranges for Adult Vital Signs
10. Wash your hands.
Temperature Fahrenheit Celsius
Provides for infection control.
Oral 97.6°–99.6° 36.5°–37.5°
11. Document procedure using facility guide- Rectal 98.6°–100.6° 37.0°–38.1°
lines. Include the following:
Axillary 96.6°–98.6° 36.0°–37.0°
• Time of discharge
Pulse: 60–100 beats per minute
• Method of transport Respirations: 12–20 respirations per minute
• Who was with the resident
Blood Pressure
• The vital signs at discharge Normal: Systolic 100–139 Diastolic 60–89
• What items the resident took with her High: 140/90 or above
(inventory checklist)
Low: Below 100/60
What you write is a legal record of what you did. If
you don’t document it, legally it didn’t happen.
Temperature

Body temperature is normally very close to

2. Explain the importance of monitoring
98.6°F (Fahrenheit) or 37°C (Celsius). Body tem-
vital signs
perature is a balance between the heat created by
Nursing assistants monitor, document, and our bodies and the heat lost to the environment.
report residents’ vital signs. Vital signs are im- Many factors affect temperature: age, illness,
portant. They show how well the vital organs of stress, environment, exercise, and the circadian
the body, such as the heart and lungs, are work- rhythm can all cause changes in body tempera-
ing. They consist of the following: ture. The circadian rhythm is the 24-hour day-
 165 7

night cycle. Increases in body temperature may

indicate an infection or disease. There are four
sites for taking body temperature:

Basic Nursing Skills

1. The mouth (oral)
2. The rectum (rectal)
3. The armpit (axillary)
4. The ear (tympanic)
Fig. 7-6. A mercury-free oral thermometer and a mer-
The different sites require different thermom- cury-free rectal thermometer. Thermometers are usually
eters. Temperatures are most often taken orally. color-coded to show which is for oral and which is for
rectal use. Oral thermometers are usually green or blue;
Do not take an oral temperature on a person
rectal thermometers are usually red. (photos provided by rg medi-
who: cal diagnostics of southfield, mi.)

• Is unconscious
• Has recently had facial or oral surgery
• Is younger than 5 years old
• Is confused or disoriented
• Is heavily sedated
• Is likely to have a seizure
Fig. 7-7. A digital thermometer with a disposable sheath
• Is coughing underneath it.
• Is using oxygen
• Has facial paralysis
• Has a nasogastric tube (a feeding tube that is
inserted through the nose and goes into the
stomach)
• Has sores, redness, swelling, or pain in the
mouth
• Has an injury to the face or neck Fig. 7-8. An electronic thermometer.
Types of thermometers are as follows:
• Mercury-free glass (Fig. 7-6)
• Mercury glass (glass bulb)
• Battery-powered, digital, or electronic
(Figs. 7-7 and 7-8)
• Disposable
• Tympanic (Fig. 7-9)
Fig. 7-9. A tympanic thermometer.
• Temporal artery
 7 166

Using mercury glass or glass bulb thermom-

Measuring and recording oral temperature
eters to take oral or rectal temperatures used
to be common. However, because mercury is a Do not take an oral temperature on a resident
dangerous, toxic substance, many facilities now who has smoked, eaten or drank fluids, chewed
Basic Nursing Skills

do not use products containing mercury. In fact, gum, or exercised in the last 10–20 minutes.
many states have passed laws to ban the sale Equipment: clean mercury-free, digital, or electronic
of mercury thermometers. Today, mercury-free thermometer, gloves, disposable sheath/cover for
glass thermometers are more common. They thermometer, tissues, pen and paper
can be used to take an oral or rectal tempera-
1. Wash your hands.
ture. They are considered much safer.
Provides for infection control.
Some mercury-free thermometers are slightly
2. Identify yourself by name. Identify the resi-
larger than glass bulb thermometers. However,
dent by name.
they operate identically. Numbers on the ther-
Resident has right to know identity of his or her care-
mometer let you read the temperature after it giver. Addressing resident by name shows respect and
registers. Most thermometers show the tempera- establishes correct identification.
ture in degrees Fahrenheit (F). Each long line
represents one degree. Each short line represents 3. Explain procedure to resident. Speak clearly,
two-tenths of a degree. Some thermometers slowly, and directly. Maintain face-to-face con-
show the temperature in degrees Celsius (C). tact whenever possible.
Promotes understanding and independence.
The long lines represent one degree. The short
lines represent one-tenth of a degree. The small 4. Provide for resident’s privacy with curtain,
arrow points to the normal temperature: 98.6° F screen, or door.
and 37° C (Fig. 7-10). Maintains resident’s right to privacy and dignity.

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
Fig. 7-10. You read a mercury glass and a mercury-free
thermometer the same way. fingers. With a snapping motion of the wrist,
shake the thermometer (Fig. 7-11). Stand
There is a range of normal temperatures. Some away from furniture and walls while doing so.
people’s temperatures normally run low. Others Holding the stem end prevents contamination of the
bulb end. The thermometer reading must be below
in good health will run slightly higher. Normal the resident’s actual temperature.
temperature readings also vary by the method
used to take the temperature. A rectal tempera- Digital thermometer: Put on the disposable
ture is generally considered to be the most ac- sheath. Turn on thermometer and wait until
curate. However, taking a rectal temperature on “ready” sign appears.
an uncooperative person, such as a resident with
Electronic thermometer: Remove the probe
dementia, can be dangerous. An axillary tem-
from base unit. Put on probe cover.
perature is considered the least accurate.
 167 7

Electronic thermometer: Leave in place until

you hear a tone or see a flashing or steady
light.

Basic Nursing Skills

9. Mercury-free thermometer: Remove the ther-
mometer. Wipe with a tissue from stem to
bulb or remove sheath. Dispose of the tissue
or sheath. Hold the thermometer at eye level.
Rotate until line appears, rolling the ther-
mometer between your thumb and forefinger.
Fig. 7-11. Shake thermometer down to below the lowest Read the temperature. Remember the tem-
number before inserting in a resident’s mouth.
perature reading.

7. Mercury-free thermometer: Put on disposable Digital thermometer: Remove the thermom-

sheath, if available. Insert bulb end of the eter. Read temperature on display screen.
thermometer into resident’s mouth, under Remember the temperature reading.
tongue and to one side (Fig. 7-12). Electronic thermometer: Read the tempera-
The thermometer measures heat from blood vessels
under the tongue.
ture on the display screen. Remember the
temperature reading. Remove the probe.
10. Mercury-free thermometer: Rinse the ther-
mometer in lukewarm water and dry. Return
it to a plastic case or container.
Digital thermometer: Using a tissue, remove
and dispose of sheath. Replace the thermom-
eter in case.
Fig. 7-12. Insert thermometer under the resident’s tongue
and to one side.
Electronic thermometer: Press the eject but-
ton to discard the cover (Fig. 7-13). Return
Digital thermometer: Insert the end of digital the probe to the holder.
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 Fig. 7-13. Eject the probe cover and dispose of it properly
after use.
closed. Assist as necessary. Resident should
breathe through his nose. Ask the resident
11. Remove and discard gloves.
not to bite down or to talk. Leave the ther-
mometer in place for at least three minutes. 12. Wash your hands.
The lips hold the thermometer in position. If broken, Provides for infection control.
injury to the mouth may occur. More time may be
required if resident opens mouth to breathe or talk. 13. Immediately record the temperature, date,
time and method used (oral).
Digital thermometer: Leave in place until Record temperature immediately so you won’t for-
thermometer blinks or beeps. get. Care plans are made based on your report.
 7 168

14. Place call light within resident’s reach. 7. Fold back linens to expose only the rectal area.
Allows resident to communicate with staff as
necessary. 8. Put on gloves.
9. Mercury-free thermometer: Hold thermometer
Basic Nursing Skills

15. Report any changes in resident to the nurse.

Provides nurse with information to assess resident. by stem. Shake the thermometer down to
below the lowest number.

You need the resident’s cooperation to take a rec- Digital thermometer: Put on the disposable
tal temperature. Always explain what you will do sheath. Turn on thermometer and wait until
before beginning. Ask the resident to hold still. “ready” sign appears.
Reassure him that the task will only take a few 10. Apply a small amount of lubricant to tip of
minutes. Keep your hand on the thermometer bulb or probe cover (or apply pre-lubricated
the entire time you are taking the temperature. cover).

Measuring and recording rectal temperature 11. Separate the buttocks. Gently insert ther-
mometer one inch into rectum (Fig. 7-15).
Equipment: clean rectal mercury-free or digital Stop if you meet resistance. Do not force the
thermometer, lubricant, gloves, tissue, disposable
thermometer in the rectum.
sheath/cover, pen and paper
1. Wash your hands.
Provides for infection control.

2. Identify yourself by name. Identify resident by

name.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
establishes correct identification.

3. Explain procedure to resident. Speak clearly, Fig. 7-15. Gently insert a rectal thermometer one inch
slowly, and directly. Maintain face-to-face con- into the rectum. Do not force it into the rectum.
tact whenever possible.
Promotes understanding and independence. 12. Replace the sheet over buttocks while holding
on to the thermometer. Hold on to the ther-
4. Provide for resident’s privacy with curtain,
mometer at all times.
screen, or door.
Maintains resident’s right to privacy and dignity. 13. Mercury-free thermometer: Hold thermometer
in place for at least three minutes.
5. If the bed is adjustable, adjust to a safe level,
usually waist high. Lock bed wheels. Digital thermometer: Hold thermometer in
Promotes safety. place until thermometer blinks or beeps.
6. Help the resident to left-lying (Sims’) posi- 14. Gently remove the thermometer. Wipe with
tion (Fig. 7-14). tissue from stem to bulb or remove sheath.
Dispose of tissue or sheath.
15. Read the thermometer at eye level as you
would for an oral temperature. Remember the
temperature reading.
16. Mercury-free thermometer: Rinse the ther-
Fig. 7-14. The resident must be in the left-lying (Sims’) mometer in lukewarm water and dry. Return it
position.
to plastic case or container.
 169 7

Digital thermometer: Discard probe cover. 5. Put on gloves.

Replace the thermometer in case.
6. Put a disposable sheath over earpiece of the
17. Remove and discard gloves. thermometer.

Basic Nursing Skills

Protects equipment. Reduces risk of contamination.
18. Wash your hands.
Provides for infection control. 7. Position the resident’s head so that the ear
19. Assist the resident to a position of safety and is in front of you. Straighten the ear canal
comfort. by gently pulling up and back on the outside
edge of the ear (Fig. 7-16). Insert the covered
20. Immediately record the temperature, date, probe into the ear canal. Press the button.
time and method used (rectal).
Record temperature immediately so you won’t for-
get. Care plans are made based on your report.

21. Place call light within resident’s reach.

Allows resident to communicate with staff as
necessary.

22. Report any changes in resident to the nurse.

Provides nurse with information to assess resident.

Tympanic thermometers can take fast and accu- Fig. 7-16. Gently pull up and back on the outside edge of
the ear to straighten the ear canal.
rate temperature readings. Tell the resident that
you will be placing a thermometer in the ear 8. Hold thermometer in place either for one
canal. Reassure the resident that this is painless. second or until thermometer blinks or beeps
The short tip of the thermometer will only go (depends on model).
into the ear one-quarter to one-half inch. Follow
9. Read temperature. Remember temperature
the manufacturer’s instructions.
reading.
Measuring and recording tympanic temperature 10. Dispose of sheath. Return thermometer to
Equipment: tympanic thermometer, gloves, dispos- storage or to the battery charger if thermom-
able probe sheath/cover, pen and paper eter is rechargeable.

1. Wash your hands. 11. Remove and discard gloves.

Provides for infection control.
12. Wash your hands.
2. Identify yourself by name. Identify the resi- Provides for infection control.
dent by name.
13. Immediately record resident’s name, tem-
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and perature, date, time, and method used
establishes correct identification. (tympanic).
Record temperature immediately so you won’t for-
3. Explain procedure to resident. Speak clearly, get. Care plans are made based on your report.
slowly, and directly. Maintain face-to-face con-
14. Place call light within resident’s reach.
tact whenever possible.
Allows resident to communicate with staff as
Promotes understanding and independence.
necessary.
4. Provide for resident’s privacy with curtain,
15. Report any changes in resident to the nurse.
screen, or door. Provides nurse with information to assess resident.
Maintains resident’s right to privacy and dignity.
 7 170

Axillary temperatures are less reliable than tem- Digital thermometer: Leave in place until
peratures taken at other sites. However, they can thermometer blinks or beeps.
be safer if residents are confused, disoriented,
Electronic thermometer: Leave in place until
uncooperative, or have dementia.
Basic Nursing Skills

you hear a tone or see a flashing or steady

light.
Measuring and recording axillary temperature

Equipment: mercury-free, digital, or electronic ther-

mometer, gloves, tissues, disposable sheath/cover,
pen and paper

1. Wash your hands.

Provides for infection control.

2. Identify yourself by name. Identify resident by

name.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
establishes correct identification.

3. Explain procedure to resident. Speak clearly,

slowly, and directly. Maintain face-to-face con-
Fig. 7-17. After inserting the thermometer, fold the resi-
tact whenever possible.
dent’s arm over his chest and hold it in place for 8 to 10
Promotes understanding and independence.
minutes.
4. Provide for resident’s privacy with curtain,
screen, or door. 10. Mercury-free thermometer: Remove the ther-
Maintains resident’s right to privacy and dignity. mometer. Wipe with a tissue from stem to
bulb or remove sheath. Dispose of the tissue
5. Put on gloves.
or sheath. Read the thermometer at eye level
6. Remove resident’s arm from sleeve of gown. as you would for an oral temperature. Re-
Wipe axillary area with tissues. member the temperature reading.

7. Mercury-free thermometer: Hold the ther- Digital thermometer: Remove the thermom-
mometer by the stem. Shake the thermom- eter. Read temperature on display screen.
eter down to below the lowest number. Remember the temperature reading.

Digital thermometer: Put on the disposable Electronic thermometer: Read the tempera-
sheath. Turn on thermometer and wait until ture on the display screen. Remember the
“ready” sign appears. temperature reading. Remove the probe.

Electronic thermometer: Remove the probe 11. Mercury-free thermometer: Rinse the ther-
from base unit. Put on probe cover. mometer in lukewarm water and dry. Return
it to plastic case or container.
8. Position thermometer (bulb end for mercury-
free) in center of the armpit. Fold resident’s Digital thermometer: Using a tissue, remove
arm over her chest. and dispose of sheath. Replace the thermom-
eter in case.
9. Mercury-free thermometer: Hold the ther-
mometer in place, with the arm close against Electronic thermometer: Press the eject but-
the side, for 8 to 10 minutes (Fig. 7-17). ton to discard the cover. Return the probe to
the holder.
 171 7

12. Remove and discard gloves. For adults, the normal pulse rate is 60–100 beats
per minute. Small children have faster pulses, in
13. Wash your hands.
Provides for infection control. the range of 100–120 beats per minute. A new-
born baby’s pulse may be as high as 120–140

Basic Nursing Skills

14. Put resident’s arm back into sleeve of gown. beats per minute. Many things can affect the
15. Immediately record the temperature, date, pulse rate. Some are exercise, fear, anger, anxi-
time and method used (axillary). ety, heat, medications, and pain. An unusually
Record temperature immediately so you won’t for- high or low rate may not indicate disease, but
get. Care plans are made based on your report. sometimes the pulse rate can be a signal of seri-
16. Place call light within resident’s reach. ous illness. For example, a rapid pulse may re-
Allows resident to communicate with staff as sult from fever, infection, or heart failure. A slow
necessary. or weak pulse may indicate dehydration, infec-
17. Report any changes in resident to the nurse. tion, or shock.
Provides nurse with information to assess resident.
Respirations

Pulse Respiration is the process of breathing air into

the lungs, or inspiration, and exhaling air out of
The pulse is the number of heartbeats per min-
the lungs, or expiration. Each respiration con-
ute. The beat that you feel at certain pulse points
sists of an inspiration and an expiration. The
in the body represents the wave of blood mov-
chest rises during inspiration and falls during
ing. This is a result of the heart pumping. The
expiration.
most common site for checking the pulse is on
the inside of the wrist, where the radial artery The normal respiration rate for adults ranges
runs just beneath the skin. This is called the from 12 to 20 breaths per minute. Infants and
radial pulse. The brachial pulse is the pulse children have a faster respiratory rate. Infants
inside the elbow. It is about 1–1½ inches above normally breathe at a rate of 30 to 40 respira-
the elbow. The radial and brachial pulse are in- tions per minute. People may breathe more
volved in taking blood pressure. Blood pressure quickly if they know they are being observed.
is explained later in this chapter. Other common Because of this, count respirations immediately
pulse sites are shown in Fig. 7-18. after taking the pulse. Keep your fingers on the
resident’s wrist or the stethoscope over the heart.
Do not make it obvious that you are watching
the resident’s breathing.

Measuring and recording radial pulse and

counting and recording respirations

Equipment: watch with a second hand, pen and

paper

1. Wash your hands.

Provides for infection control.

2. Identify yourself by name. Identify the resi-

dent by name.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
Fig. 7-18. Common pulse sites.
establishes correct identification.
 7 172

3. Explain procedure to resident. Speak clearly, 60 beats per minute, over 100 beats per min-
slowly, and directly. Maintain face-to-face con- ute, if the rhythm is irregular, or if breathing
tact whenever possible. is irregular.
Promotes understanding and independence. Provides nurse with information to assess resident.
Basic Nursing Skills

4. Provide for resident’s privacy with curtain,

screen, or door.
Blood Pressure
Maintains resident’s right to privacy and dignity.
Blood pressure is an important measure of
5. Place fingertips on thumb side of resident’s
health. Blood pressure is measured in millime-
wrist. Locate radial pulse (Fig. 7-19).
ters of mercury (mmHg). The measurement
6. Count beats for one full minute. shows how well the heart is working. There are
two parts of blood pressure. They are the systolic
measurement and diastolic measurement.
In the systolic phase, the heart is at work. It
contracts and pushes blood from the left ven-
tricle of the heart. The reading shows the pres-
sure on the walls of arteries as blood is pumped
through the body. The normal range for systolic
blood pressure is 100–119 mmHg.
The second measurement reflects the diastolic
phase. This is when the heart relaxes. The dia-
Fig. 7-19. Measure the radial pulse by placing fingertips stolic measurement is always lower than the sys-
on the thumb side of the wrist. tolic measurement. It shows the pressure in the
arteries when the heart is at rest. The normal
7. Keep your fingertips on the resident’s wrist. range for adults is 60–79 mmHg.
Count respirations for one full minute. Ob-
serve for the pattern and character of the People with high blood pressure, or hyperten-
resident’s breathing. Normal breathing is sion, have elevated systolic and/or diastolic blood
smooth and quiet. pressures. A blood pressure level of 140/90
Count will be more accurate if resident does not mmHg or higher is considered high. However,
know you are counting his respirations. if blood pressure is between 120/80 mmHg
and 139/89 mmHg, it is called prehypertension.
8. Record pulse rate, date, time and method
This means that the person does not have high
used (radial). Record the respiratory rate and
blood pressure now but is likely to have it in the
the pattern or character of breathing.
Record pulse and respiration rate immediately so
future. Report to the nurse if a resident’s blood
you won’t forget. Care plans are made based on your pressure is 140/90 or above.
report.
Many factors can increase blood pressure. These
9. Place call light within resident’s reach. include aging, exercise, physical or emotional
Allows resident to communicate with staff as stress, pain, medications, and the volume of
necessary. blood in circulation.
10. Wash your hands. Blood pressure is taken with a stethoscope and
Provides for infection control. a blood pressure cuff, or sphygmomanometer
11. Report any changes in resident to the nurse. (Fig. 7-20). There may be an electronic sphygmo-
Report to the nurse if the pulse is less than manometer available. The systolic and diastolic
 173 7

pressure readings and pulse are displayed digi- 2. Identify yourself by name. Identify the resi-
tally. You do not need a stethoscope with an elec- dent by name.
tronic sphygmomanometer. Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and

Basic Nursing Skills

a) b) establishes correct identification.

3. Explain procedure to the resident. Speak

clearly, slowly, and directly. Maintain face-to-
face contact whenever possible.
Fig. 7-20. a) A sphygmomanometer and b) an electronic Promotes understanding and independence.
sphygmomanometer.
4. Provide for resident’s privacy with curtain,
screen, or door.
When taking blood pressure, the first clear
Maintains resident’s right to privacy and dignity.
sound you will hear is the systolic pressure (top
number). When the sound changes to a soft 5. Ask the resident to roll up his or her sleeve.
muffled thump or disappears, this is the dia- Do not measure blood pressure over
stolic pressure (bottom number). Blood pressure clothing.
is recorded as a fraction. The systolic reading is
6. Position resident’s arm with palm up. The
on top and the diastolic reading is on the bottom
arm should be level with the heart.
(for example: 120/80). A false low reading is possible if arm is above heart
Never measure blood pressure on an arm level.
that has an IV or any medical equipment. 7. With the valve open, squeeze the cuff. Make
Avoid a side that has a cast, recent trauma, pa- sure it is completely deflated.
ralysis from a stroke, burns, or breast surgery
(mastectomy). 8. Place blood pressure cuff snugly on resi-
dent’s upper arm. The center of the cuff with
This textbook includes two methods for taking sensor/arrow is placed over the brachial
blood pressure. They are the one-step method artery (1-1½ inches above the elbow toward
and the two-step method. In the two-step inside of elbow) (Fig. 7-21).
method, you will get an estimate of the systolic Cuff must be proper size and put on arm correctly so
blood pressure before you start. After getting an amount of pressure on artery is correct. If not, read-
estimated systolic reading, you will deflate the ing will be falsely high or low.
cuff and begin again. With the one-step method,
you will not get an estimated systolic reading
before getting the blood pressure reading. Your
state may require that you know one or both of
these methods. Some states do not allow NAs
to measure blood pressure. Know your scope of
practice. Follow your facility’s policies.

Measuring and recording blood pressure

(one-step method) Fig. 7-21. Place the center of the cuff over the brachial
artery.
Equipment: sphygmomanometer (blood pressure
cuff ), stethoscope, alcohol wipes, pen and paper 9. Before using stethoscope, wipe diaphragm
and earpieces with alcohol wipes.
1. Wash your hands. Reduces pathogens, prevents ear infections and pre-
Provides for infection control. vents spread of infection.
 7 174

10. Locate brachial pulse with fingertips. reading on the bottom (for example: 120/80).
11. Place diaphragm of stethoscope over brachial Note which arm was used. Write “RA” for
artery. right arm and “LA” for left arm.
Record readings immediately so you won’t forget.
Basic Nursing Skills

12. Place earpieces of stethoscope in ears. Care plans are made based on your report.

13. Close the valve (clockwise) until it stops. Do 21. Wipe diaphragm and earpieces of stetho-
not tighten it (Fig. 7-22). scope with alcohol wipes. Store equipment.
Tight valves are too hard to release.
22. Place call light within resident’s reach. Re-
move privacy measures.
Allows resident to communicate with staff as
necessary.

23. Wash your hands.

Provides for infection control.

24. Report any changes in resident to the nurse.

Provides nurse with information to assess resident.

Measuring and recording blood pressure

Fig. 7-22.
(two-step method)

14. Inflate cuff to 30 mmHg above the point at Equipment: sphygmomanometer (blood pressure
which the pulse is last heard or felt. cuff ), stethoscope, alcohol wipes, pen and paper

15. Open the valve slightly with thumb and index 1. Wash your hands.
Provides for infection control.
finger. Deflate cuff slowly.
Releasing the valve slowly allows you to hear beats 2. Identify yourself by name. Identify the resi-
accurately. dent by name.
16. Watch gauge. Listen for sound of pulse. Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
17. Remember the reading at which the first clear establishes correct identification.
pulse sound is heard. This is the systolic
3. Explain procedure to resident. Speak clearly,
pressure.
slowly, and directly. Maintain face-to-face con-
18. Continue listening for a change or muffling tact whenever possible.
of pulse sound. The point of a change or the Promotes understanding and independence.
point at which the sound disappears is the 4. Provide for resident’s privacy with curtain,
diastolic pressure. Remember this reading. screen, or door.
19. Open the valve. Deflate cuff completely. Re- Maintains resident’s right to privacy and dignity.
move cuff. 5. Ask the resident to roll up his or her sleeve.
An inflated cuff left on resident’s arm can cause Do not measure blood pressure over
numbness and tingling. If you must take blood pres-
sure again, completely deflate cuff and wait 30 sec- clothing.
onds. Never partially deflate a cuff and then pump it 6. Position resident’s arm with palm up. The
up again. Blood vessels will be damaged and reading
will be falsely high or low. arm should be level with the heart.
A false low reading is possible if arm is above heart
20. Record both the systolic and diastolic pres- level.
sures. Write the numbers like a fraction, with
7. With the valve open, squeeze the cuff. Make
the systolic reading on top and the diastolic
sure it is completely deflated.
 175 7

8. Place blood pressure cuff snugly on resi- 22. Remember the reading at which the first clear
dent’s upper arm. The center of the cuff with pulse sound is heard. This is the systolic
sensor/arrow is placed over the brachial pressure.
artery (1-1½ inches above the elbow toward

Basic Nursing Skills

23. Continue listening for a change or muffling
inside of elbow).
of pulse sound. The point of a change or the
Cuff must be proper size and put on arm correctly so
amount of pressure on artery is correct. If not, read- point at which the sound disappears is the
ing will be falsely high or low. diastolic pressure. Remember this reading.
9. Locate the radial (wrist) pulse with fingertips. 24. Open the valve. Deflate cuff completely. Re-
move cuff.
10. Close the valve (clockwise) until it stops. In-
An inflated cuff left on resident’s arm can cause
flate cuff slowly, watching gauge. numbness and tingling. If you must take blood pres-
If you inflate the cuff too quickly, you will not be able sure again, completely deflate cuff and wait 30 sec-
to identify the point where the pulse stops. onds. Never partially deflate a cuff and then pump it
up again. Blood vessels will be damaged and reading
11. Stop inflating when you can no longer feel
will be falsely high or low.
the pulse. Note the reading. The number is
an estimate of the systolic pressure. 25. Record systolic and diastolic pressures. Write
This estimate helps you to not inflate the cuff too the numbers like a fraction, with the systolic
high later in this procedure. Inflating cuff too high is reading on top and the diastolic reading
painful and may damage small blood vessels.
on the bottom (for example: 120/80). Note
12. Open the valve. Deflate cuff completely. which arm was used. Write “RA” for right arm
An inflated cuff left on resident’s arm can cause and “LA” for left arm.
numbness and tingling. Record readings immediately so you won’t forget.
13. Write down estimated systolic reading. Care plans are made based on your report.

14. Before using stethoscope, wipe diaphragm 26. Wipe diaphragm and earpieces of stetho-
and earpieces of stethoscope with alcohol scope with alcohol wipes. Store equipment.
wipes. 27. Place call light within resident’s reach. Re-
Reduces pathogens, prevents ear infections and pre- move privacy measures.
vents spread of infection. Allows resident to communicate with staff as
15. Locate brachial pulse with fingertips. necessary.

16. Place diaphragm of stethoscope over brachial 28. Wash your hands.
artery. Provides for infection control.

17. Place earpieces of stethoscope in ears. 29. Report any changes in resident to the nurse.
Provides nurse with information to assess resident.
18. Close the valve (clockwise) until it stops. Do
not tighten it.
Tight valves are too hard to release. Pain Management
19. Inflate cuff to 30 mmHg above your esti- Pain is often referred to as the “fifth vital sign”
mated systolic pressure. because it is so important to monitor. Pain is
Inflating cuff too high is painful and may damage uncomfortable. It is also a personal experience.
small blood vessels. This means it is different for each person. You
20. Open the valve slightly with thumb and index spend the most time with residents. You play an
finger. Deflate cuff slowly. important role in pain monitoring and preven-
Releasing the valve slowly allows you to hear beats tion. Care plans are made based on your reports.
accurately. It is important to observe and report carefully on
21. Watch gauge. Listen for sound of pulse. a resident’s pain.
 7 176

Pain is not a normal part of aging. Treat resi- Residents may have concerns about their pain.
dents’ complaints of pain seriously (Fig. 7-23). These concerns may make them hesitant to
Listen to what residents are saying about the way report their pain. Barriers to managing pain in-
they feel. Take action to help them. If a resident clude the following:
Basic Nursing Skills

complains of pain, ask these questions to get • Fear of addiction to pain medication
the most accurate information. Immediately
• Feeling that pain is a normal part of aging
report the information to the nurse. Sustained
pain may lead to withdrawal, depression, and • Worrying about constipation and fatigue
isolation. from pain medication
• Feeling that caregivers are too busy to deal
with their pain
• Feeling that too much pain medication will
cause death
Be patient and caring when helping residents
who are in pain. If they are worried about the
effects of pain medication or if they have ques-
Fig. 7-23. Believe residents when they say they are in
tions about it, tell the nurse. Understand that
pain. Take quick action to help them. Being in pain is un-
pleasant. Ask questions and report your observations. some people do not feel comfortable saying that
they are in pain. A person’s culture affects how
• Where is the pain? he or she responds to pain. Some cultures be-
• When did the pain start? lieve that it is best not to react to pain. Other cul-
tures believe in expressing pain freely. Watch for
• Is the pain mild, moderate, or severe? To body language or other messages that residents
help find out, ask the resident to rate the may be in pain.
pain on a scale of 0 to 5 or 0 to 10, with 5 or
10 being the worst (Fig. 7-24). Observing and Reporting: Pain

Report any of these to the nurse:

0 1 2 3 4 5
Increased pulse, respirations, blood pressure
NO HURT HURT HURTS HURTS HURTS HURTS
Alternate
LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORST Sweating
coding 0 2 4 6 8 10

Fig. 7-24. The Wong-Baker FACES Pain Rating Scale is Nausea

one type of pain scale. Point to each face. Ask the resi- Vomiting
dent to choose the face that best describes his or her pain.
(from hockenberry mj, wilson d, winkelstein ml: wong’s essentials of pediatric Tightening the jaw
nursing, ed. 7, st. louis, 2005, p. 1259. used with permission. copyright, mosby.)
Squeezing eyes shut
• Ask the resident to describe the pain. Make Holding a body part tightly
notes if you need to. Use the resident’s
Frowning
words when reporting to the nurse.
Grinding teeth
• Ask the resident what he or she was doing
Increased restlessness
before the pain started.
Agitation or tension
• Ask the resident how long the pain lasts and
how often it occurs. Change in behavior

• Ask the resident what makes the pain better Crying

and what makes it feel worse. Sighing
 177 7

Groaning 4. Provide for resident’s privacy with curtain,

Breathing heavily screen, or door.
Maintains resident’s right to privacy and dignity.
Difficulty moving or walking

Basic Nursing Skills

5. Make sure resident is wearing non-skid shoes
Measures that may reduce pain include:
before walking to scale.
• Report complaints of pain or unrelieved pain
6. Start with scale balanced at zero before
promptly to the nurse.
weighing resident.
• Gently position the body in good alignment. Scale must be balanced on zero for weight to be
Use pillows for support. Help in changes of accurate.
position if the resident wishes.
7. Help resident to step onto the center of the
• Give back rubs. scale. Be sure she is not holding, touching,
• See if resident would like to take a warm or leaning against anything.
bath or shower. This interferes with weight measurement.

• Help the resident to the bathroom or com- 8. Determine resident’s weight. This is done by
mode or offer the bedpan or urinal. balancing the scale. Make the balance bar
• Encourage slow, deep breathing. level. Move the small and large weight indica-
tors until the bar balances (Fig. 7-25). Add
• Provide a calm and quiet environment. Use
these two numbers together.
soft music to distract the resident.
• Be patient, caring, gentle, kind and
responsive.

3. Explain how to measure weight and

height
You will check residents’ weights and heights as
part of your care. Height is checked less often
than weight. Weight changes can be signs of ill- Fig. 7-25. Move the small and large weight indicators
ness. You must report any weight loss or gain, until the bar balances.
no matter how small.
9. Help resident to safely step off scale before
Measuring and recording weight of an recording weight.
ambulatory resident Protects against falls.

Equipment: standing scale, pen and paper 10. Record weight.

Record weight immediately so you won’t forget. Care
1. Wash your hands. plans are made based on your report.
Provides for infection control.
11. Remove privacy measures.
2. Identify yourself by name. Identify the resi-
dent by name. 12. Place call light within resident’s reach.
Allows resident to communicate with staff as
Resident has right to know identity of his or her care-
necessary.
giver. Addressing resident by name shows respect and
establishes correct identification. 13. Wash your hands.
3. Explain procedure to resident. Speak clearly, Provides for infection control.
slowly, and directly. Maintain face-to-face con- 14. Report any changes in resident to the nurse.
tact whenever possible. Provides nurse with information to assess resident.
Promotes understanding and independence.
 7 178

Some residents will not be able to get out of

a wheelchair easily. These residents may be
weighed on a wheelchair scale. Wheelchairs are
rolled onto this type of scale (Fig. 7-26). On some
Basic Nursing Skills

wheelchair scales, you will need to subtract

the weight of the wheelchair from a resident’s
Fig. 7-28. A tape measure.
weight. In this case, weigh the empty wheelchair
first. Then subtract the wheelchair’s weight Equipment: tape measure, pencil, pen and paper
from the total. Some wheelchairs are marked
1. Wash your hands.
with their weight.
Provides for infection control.

2. Identify yourself by name. Identify the resi-

dent by name.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
establishes correct identification.

3. Explain procedure to resident. Speak clearly,

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

4. Provide for resident’s privacy with curtain,

Fig. 7-26. Wheelchairs can be rolled directly onto wheel- screen, or door.
chair scales to determine the resident’s weight. Maintains resident’s right to privacy and dignity.

Some residents will not be able to get out of bed. 5. Position the resident lying straight in bed, flat
Weighing these residents requires a special scale on his back with arms and legs at his sides.
(Fig. 7-27). Before using a bed scale, know how Be sure the bed sheet is smooth underneath
to use it properly and safely. Follow your facility’s the resident.
Ensures accurate reading.
procedure and any manufacturer’s instructions.
6. Make a pencil mark on the sheet at the top of
the head.
7. Make another mark at the resident’s heel
(Fig. 7-29).

Fig. 7-27. A type of bed scale. (photo courtesy of detecto, detecto.

com, 800-641-2008)

Measuring and recording height of a resident

Some residents will be unable to get out of bed.
If this is the case, height can be measured using Fig. 7-29. Make marks on the sheet at the resident’s
a tape measure (Fig. 7-28). head and feet.
 179 7

8. With the tape measure, measure the distance

between the marks.
9. Record height.

Basic Nursing Skills

Record height immediately so you won’t forget. Care
plans are made based on your report.

10. Remove privacy measures. Store equipment.

11. Place call light within resident’s reach.
Allows resident to communicate with staff as
necessary.

12. Wash your hands.

Provides for infection control.

13. Report any changes in resident to the nurse.

Provides nurse with information to assess resident. Fig. 7-30. To determine height on a standing scale, gently
lower the measuring rod until it rests flat on the resident’s
For residents who can get out of bed, you will head.
measure height using a standing scale.
Equipment: standing scale, pencil, pen and paper 11. Remove privacy measures. Place call light
within resident’s reach.
1. Wash your hands.
Allows resident to communicate with staff as
2. Identify yourself by name. Identify the resi- necessary.
dent by name. 12. Wash your hands.
3. Explain procedure to the resident. Speak Provides for infection control.
clearly, slowly, and directly. Maintain face-to- 13. Report any changes in resident to the nurse.
face contact whenever possible. Provides nurse with information to assess resident.
4. Provide for resident’s privacy with curtain,
screen, or door. The rod measures height in inches and fractions
5. Help resident to step onto scale, facing away of inches. Record the total number of inches. If
from the scale. you have to change inches into feet, remember
that there are 12 inches in a foot.
6. Ask resident to stand straight. Help as
needed.
Ensures accurate reading. 4. Explain restraints and how to promote
a restraint-free environment
7. Pull up measuring rod from back of scale.
Gently lower measuring rod until it rests flat A restraint is a physical or chemical way to
on resident’s head (Fig. 7-30). restrict voluntary movement or behavior. Physi-
8. Determine resident’s height. cal restraints are also called postural supports
or protective devices. Examples of physical
9. Help resident off scale before recording restraints are vest and jacket restraints, belt
height. Make sure measuring rod does not restraints, wrist/ankle restraints, and mitt re-
hit resident in the head. straints. Side rails and special chairs, such as
10. Record height. geriatric chairs, are also physical restraints (Figs.
Record height immediately so you won’t forget. Care 7-31 and 7-32). Chemical restraints are medica-
plans are made based on your report. tions given to control behavior.
 7 180

trained in their use. It is against the law for staff

to use restraints for convenience or to discipline
a resident. Check with the nurse for laws and
policies on the use of restraints.
Basic Nursing Skills

There are many serious problems that occur

with restraints. Some negative effects of re-
straint use include:
• Reduced blood circulation
• Stress on the heart
Fig. 7-31. Side rails are considered restraints because they
restrict movement. Some facilities do not have side rails • Incontinence
on any of the beds.
• Constipation
• Weakened muscles and bones
• Loss of bone mass
• Muscle atrophy (weakening or wasting of the
muscle)
• Pressure sores
• Risk of suffocation (suffocation is death
from a lack of air or oxygen)
• Pneumonia

Fig. 7-32. When the tray table is attached or locked, a • Less activity, leading to poor appetite and
geriatric chair, or geri-chair, is considered a restraint. malnutrition
• Sleep disorders
In the past, restraints were commonly used for
these reasons: • Loss of dignity

• To keep a person with dementia or who is • Loss of independence

confused from wandering • Increased agitation
• To prevent falls • Increased depression and/or withdrawal
• To keep a person from injuring self or others • Poor self-esteem
• To keep a person from pulling out tubing Restraints have also caused severe injury and
that is needed for treatment even death.
Restraint use was abused by caregivers. Resi- Laws allow the use of restraints only when abso-
dents were injured. This led to new restrictions lutely necessary for the safety of the person, oth-
and laws on the use of restraints. In many states, ers around that person, and the staff. State and
restraints are illegal, and in general, the use of federal agencies encourage facilities to take steps
any type of restraint has greatly decreased. toward a restraint-free environment. Restraint-
If restraint use is legal, a doctor must prescribe free care means that restraints are not used for
it. Never use restraints unless a doctor has any reason. They are usually not kept in the fa-
ordered it in the care plan and you have been cility. To reach this goal, many care facilities use
 181 7

creative ideas called restraint alternatives. Re- be used with wheelchairs or chairs. They help
straint alternatives are any intervention used in prevent falls by alerting staff when residents at-
the place of a restraint or that reduces the need tempt to leave the bed or chair. Alarms can also
for a restraint. Examples of restraint alternatives be used for confused residents who wander. If

Basic Nursing Skills

include: a resident is ordered to have a body alarm (bed
or chair), make sure it is on the resident and
• Improve safety measures to prevent acci-
turned on.
dents and falls. Improve lighting.
• Make sure call light is within reach. Answer a.
call lights promptly.
• Ambulate the resident when he is restless.
The doctor or nurse may add exercise into
the care plan.
• Provide activities for those who wander at
night.
• Encourage activities and independence. Es-
cort the person to social activities. Increase b.
visits and social interaction.
• Give frequent help with toileting. Help with
cleaning immediately after an episode of
incontinence.
• Offer food or drink. Offer reading materials.
• Distract or redirect interest. Give the person c. d.
a repetitive task.
• Decrease the noise level. Listen to sooth-
ing music. Offer massage or use relaxation
techniques.
• Reduce pain levels through medication.
Monitor the resident closely and report com-
plaints of pain to the nurse. Fig. 7-33. a) A Posey Torso Support; b) A lap-top cush-
ion; c) A chair alarm warns caregiver of chair exits; d)
• Offer a few minutes of one-on-one time with An under-mattress alarm warns if person gets out of bed
a caregiver. Provide familiar caregivers. In- (photos a and b courtesy of north coast medical, inc., www.ncmedical.com,
800-821-9319. photos c and d reprinted with permission of briggs corporation,
crease the number of caregivers with family 800-247-2343, www.briggscorp.com)

and volunteers.
Remember that a restraint can never be applied
• Use a team approach to meeting needs. without a doctor’s order. If a restraint has been
Offer training to teach gentle approaches to ordered, place the call light where the resident
difficult people. can easily access it. Answer call lights immedi-
There are also several types of pads, belts, spe- ately. A restrained resident must be monitored
cial chairs, and alarms that can be used instead constantly. The resident must be checked at least
of restraints (Fig. 7-33). Bed or body alarms can every 15 minutes. At regular, ordered intervals,
be used in place of side rails. They can also the following must be done:
 7 182

• Release the restraint (or discontinue use).

• Offer help with toileting. Check for episodes
of incontinence. Provide incontinence care.
Basic Nursing Skills

• Offer fluids.
• Check the skin for signs of irritation. Report
any red, purple, blue-tinged, gray, or pale
skin or any discolored areas to the nurse
immediately.
• Check for swelling of the body part and re-
port swelling to the nurse immediately.
• Reposition the resident.
• Ambulate the resident if he is able.
If any problems occur with the restraint, espe-
cially resident injury, notify the nurse and com-
plete an incident report as soon as possible.

5. Define fluid balance and explain intake

and output (I&O)
To maintain health, the body must take in a cer- Fig. 7-34. A sample intake and output form.
tain amount of fluid each day. Fluid comes in
the form of liquids you drink. It is also found in
Conversions
semi-liquid foods like gelatin, soup, ice cream,
pudding, and yogurt. Generally, a healthy per- A milliliter (mL or ml) is a unit of measure equal to
son needs to take in from 64 to 96 ounces (oz.) one cubic centimeter (cc). Follow your facility’s poli-
of fluid each day. The fluid a person consumes cies on whether to document using “mL” or “cc.”
is called intake, or input. All fluid taken in 1 oz. = 30 mL or 30 cc
each day cannot stay in the body. It must be
2 oz. = 60 mL
eliminated as output. Output includes urine,
feces (including diarrhea), and vomitus. It also 3 oz. = 90 mL
includes perspiration and moisture in the air we 4 oz. = 120 mL
exhale.
5 oz. = 150 mL
Fluid balance is maintaining equal input and
output, or taking in and eliminating equal 6 oz. = 180 mL
amounts of fluids. Most people do this naturally. 7 oz. = 210 mL
But some residents must have their intake and
8 oz. = 240 mL
output, or I&O, monitored and recorded. To do
this, you will need to measure and document all ¼ cup = 2 oz. = 60 mL
fluids the resident takes by mouth. You will also ½ cup = 4 oz. = 120 mL
need to measure and record all urine and vomi-
tus. This is recorded on an Intake/Output (I&O) 1 cup = 8 oz. = 240 mL
sheet (Fig. 7-34).
 183 7

12. Report any changes in resident to the nurse.

Measuring and recording urinary output
Provides nurse with information to assess resident.
Equipment: I&O sheet, graduate (measuring con-
tainer), gloves, pen and paper

Basic Nursing Skills

1. Wash your hands. Collecting Specimens
Provides for infection control. You may be asked to collect a specimen from a
2. Put on gloves before handling bedpan/urinal. resident. A specimen is a sample that is used for
analysis in order to try to make a diagnosis. Dif-
3. Pour the contents of the bedpan or urinal
ferent types of specimens are used for different
into measuring container. Do not spill or
tests. You may be asked to collect these different
splash any of the urine.
types of specimens:
4. Measure the amount of urine at eye level on
• Urine (routine, clean catch/mid-stream, or
a flat surface. (Fig. 7-35).
24-hour)
Helps get accurate reading.
• Stool (feces)
• Sputum (mucus coughed up from the lungs)
A routine urine specimen is collected anytime
the resident voids. The resident will void into
a bedpan, urinal, commode, or “hat.” A “hat”
is a plastic collection container sometimes put
into a toilet to collect and measure urine or stool
(Fig. 7-36). Hats should be labeled. They must be
Fig. 7-35. Keep container level on a flat surface while
measuring output. cleaned after each use.

5. After measuring urine, empty contents of

measuring container into toilet. Do not
splash.
Reduces risk of contamination.

6. Rinse measuring container. Pour rinse water

into toilet.
7. Rinse bedpan/urinal. Pour rinse water into Fig. 7-36. A “hat” is a container that is placed under the
toilet. toilet seat to collect and measure urine or stool.

8. Place bedpan/urinal and container in proper Some residents will be able to collect their own
area for cleaning or clean it according to facil- specimens. Others will need your help. When
ity policy. getting a specimen container, be sure the seal is
9. Remove and discard gloves. intact. This helps avoid specimen contamination.
10. Wash hands before recording output.
Residents’ Rights
Provides for infection control.
Specimens
11. Record contents of container in output col-
Body wastes and elimination needs are very private
umn on sheet.
matters for most people. Having another person
Record amount immediately so you won’t forget.
handle body wastes may make residents embar-
Care plans are made based on your report. What you
rassed. Be sensitive to this, and be empathetic. Be-
write is a legal record of what you did. If you don’t
have professionally. If you feel that this is an
document it, legally it didn’t happen.
 7 184

10. Pour urine into the specimen container. Spec-

unpleasant task, do not make it known. Do not
make faces or frown. Do not use words that let the imen container should be at least half full.
resident know you are uncomfortable. Remain pro- 11. Cover the urine container with its lid. Do not
fessional when collecting specimens. This can help
Basic Nursing Skills

put residents at ease. touch the inside of container. Wipe off the
outside with a paper towel.
Prevents contamination.
Collecting a routine urine specimen 12. Place the container in a plastic bag.
Equipment: urine specimen container and lid, label Provides for safe transport.
(labeled with resident’s name, room number, date 13. If using a bedpan or urinal, discard extra
and time), gloves, bedpan or urinal (if resident can-
urine. Rinse equipment. Place in proper area
not use portable commode or toilet), “hat” for toilet
(if resident can get to the bathroom), 2 plastic bags, for cleaning or clean it according to facility
washcloth, towel, paper towel, supplies for perineal policy.
care, lab slip, if required
14. Remove and discard gloves.
1. Wash your hands.
15. Wash your hands.
Provides for infection control.
Provides for infection control.
2. Identify yourself by name. Identify the resi- 16. Place call light within resident’s reach.
dent by name. Allows resident to communicate with staff as
Resident has right to know identity of his or her care- necessary.
giver. Addressing resident by name shows respect and
establishes correct identification. 17. Report any changes in resident to the nurse.
Provides nurse with information to assess resident.
3. Explain procedure to the resident. Speak
clearly, slowly, and directly. Maintain face-to- 18. Take specimen and lab slip to proper area.
face contact whenever possible. Document procedure using facility guide-
Promotes understanding and independence. lines. Note amount and characteristics of
urine.
4. Provide for resident’s privacy with curtain,
What you write is a legal record of what you did. If
screen, or door. you don’t document it, legally it didn’t happen.
Maintains resident’s right to privacy and dignity.

5. Put on gloves.
The clean catch specimen is called “mid-
Prevents you from coming into contact with body
fluids. stream” because the first and last urine are not
included in the sample. Its purpose is to deter-
6. Help the resident to the bathroom or com- mine the presence of bacteria in the urine.
mode, or offer the bedpan or urinal.
Collecting a clean catch (mid-stream) urine
7. Have resident void into “hat,” urinal, or bed-
specimen
pan. Ask the resident not to put toilet paper
in with the sample. Provide a plastic bag to Equipment: specimen kit with container and lid,
discard toilet paper. label (labeled with resident’s name, room number,
Paper ruins the sample. date and time), cleaning solution, gauze or tow-
elettes, gloves, bedpan or urinal (if resident cannot
8. After urination, help as necessary with use portable commode or toilet), plastic bag, wash-
perineal care. Help resident wash his or her cloth, paper towel, towel, supplies for perineal care,
hands. Make the resident comfortable. lab slip, if required

9. Take bedpan, urinal, or commode pail to the 1. Wash your hands.

bathroom. Provides for infection control.
 185 7

2. Identify yourself to resident by name. Identify 14. Remove and discard gloves. Wash your
the resident by name. hands. Help resident wash his hands.
Resident has right to know identity of his or her care- Promotes infection control.
giver. Addressing resident by name shows respect and

Basic Nursing Skills

establishes correct identification. 15. Place call light within resident’s reach.
Allows resident to communicate with staff as
3. Explain procedure to resident. Speak clearly, necessary.
slowly, and directly. Maintain face-to-face con-
tact whenever possible. 16. Report any changes in resident to the nurse.
Provides nurse with information to assess resident.
Promotes understanding and independence.

4. Provide for resident’s privacy with curtain, 17. Take specimen and lab slip to proper area.
screen, or door. Document procedure using facility guide-
Maintains resident’s right to privacy and dignity. lines. Note amount and characteristics of
urine.
5. Put on gloves. What you write is a legal record of what you did. If
Prevents you from coming into contact with body you don’t document it, legally it didn’t happen.
fluids.

6. Open the specimen kit. Do not touch the in-

Ask the resident to let you know when he or she
side of the container or lid.
can have a bowel movement. Be ready to collect
Prevents contamination.
the specimen.
7. If the resident cannot clean his or her peri-
neal area, you will do it. See bed bath pro- Collecting a stool specimen
cedure in Chapter 6 for reminder on how to
give perineal care. Equipment: specimen container and lid, label (la-
Improper cleaning can infect urinary tract and con- beled with resident’s name, room number, date, and
taminate the sample. time), 2 tongue blades, 2 pairs of gloves, bedpan (if
resident cannot use portable commode or toilet),
8. Ask the resident to urinate into the bedpan, “hat” for toilet (if resident uses toilet or commode),
urinal, or toilet, and to stop before urination 2 plastic bags, toilet tissue, washcloth or towel, sup-
is complete. plies for perineal care, lab slip, if required

9. Place the container under the urine stream. 1. Wash your hands.
Have the resident start urinating again. Fill Provides for infection control.
the container at least half full. Have the resi- 2. Identify yourself to resident by name. Identify
dent finish urinating in bedpan, urinal, or the resident by name.
toilet. Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
10. Cover the urine container with its lid. Do not establishes correct identification.
touch the inside of the container. Wipe off
3. Explain procedure to resident. Speak clearly,
the outside with a paper towel.
slowly, and directly. Maintain face-to-face con-
11. Place the container in a plastic bag. tact whenever possible.
Provides for safe transport. Promotes understanding and independence.
12. After urination, assist as necessary with peri- 4. Provide for resident’s privacy with curtain,
neal care. screen, or door.
13. If using a bedpan or urinal, discard extra Maintains resident’s right to privacy and dignity.
urine. Rinse equipment. Place in proper area 5. Put on gloves.
for cleaning or clean it according to facility Prevents you from coming into contact with body
policy. fluids.
 7 186

6. When the resident is ready to move bowels, Sputum specimens are collected to check for
ask him not to urinate at the same time. Ask respiratory problems. Early morning is the best
him not to put toilet paper in with the sam- time to collect sputum. Your instructor will
ple. Provide a plastic bag for toilet paper. have more information on how to collect these
Basic Nursing Skills

Urine and paper ruin the sample. specimens.

7. Fit hat to toilet or commode, or provide resi-
dent with bedpan. Ask the resident to signal 6. Explain care guidelines for different
when he is finished with the bowel move- types of tubing
ment. Make sure call light is within reach.
A catheter is a thin tube inserted into the body
8. Remove and discard gloves. Wash your that is used to drain fluids or inject fluids. A
hands. Leave the room. urinary catheter is used to drain urine from the
Promotes infection control. Promotes resident’s pri- bladder. A straight catheter does not remain
vacy and dignity.
inside the person. It is removed immediately
9. When called, return to room. Put on clean after urine is drained. An indwelling catheter
gloves. remains inside the bladder for a period of time
(Fig. 7-37). The urine drains into a bag. Nursing
10. Help as necessary with perineal care. Help
assistants do not insert, remove, or irrigate cath-
resident wash his or her hands.
eters. You may be asked to provide daily care for
11. Using the two tongue blades, take about two the catheter, cleaning the area around the ure-
tablespoons of stool and put it in the con- thral opening and emptying the drainage bag.
tainer. Cover it tightly.
a) b)
12. Place the container in a clean plastic bag.

13. Wrap tongue blades in toilet paper. Put them

in plastic bag with used toilet paper. Discard
bag in proper container. Empty the bedpan
or container into the toilet. Rinse equipment.
Place in proper area for cleaning or clean it
according to facility policy.
Fig. 7-37. a) An indwelling catheter (female). b) An in-
14. Remove and discard gloves. dwelling catheter (male).

15. Wash your hands. An external, or condom catheter (also called

Provides for infection control. a Texas catheter), has an attachment on the
16. Place call light within resident’s reach. end that fits onto the penis. The attachment
Allows resident to communicate with staff as is fastened with tape. The external catheter is
necessary. changed daily or as needed.
17. Report any changes in resident to the nurse.
Provides nurse with information to assess resident. Guidelines: Catheters

18. Take specimen and lab slip to proper area. G The drainage bag must always be kept lower
Document procedure. Note amount and than the hips or bladder. Urine must never
characteristics of stool. flow from the bag or tubing back into the
What you write is a legal record of what you did. If bladder. This can cause infection.
you don’t document it, legally it didn’t happen.
 187 7

G Keep the drainage bag off the floor. 5. Adjust bed to a safe working level, usually
waist high. Lock bed wheels.
G Tubing should be kept as straight as possible.
Prevents injury to you and to resident.
It should not be kinked.

Basic Nursing Skills

6. Lower head of bed. Position resident lying flat
G The genital area must be kept clean to pre-
on her back.
vent infection. Because the catheter goes all
the way into the bladder, bacteria can enter 7. Remove or fold back top bedding. Keep resi-
the bladder more easily. Daily care of the dent covered with bath blanket.
genital area is especially important. Promotes resident’s privacy.

8. Test water temperature with thermometer

Observing and Reporting: Catheter Care or your wrist and ensure it is safe. Water
temperature should be 105°F. Have resident
Report any of these to the nurse: check water temperature. Adjust if necessary.
Resident’s sense of touch may be different than
Blood in the urine or any other unusual yours; therefore, resident is best able to identify a
appearance of the urine comfortable water temperature.

Catheter bag does not fill after several hours 9. Put on gloves.
Prevents you from coming into contact with body
Catheter bag fills suddenly fluids.
Catheter is not in place 10. Ask the resident to flex her knees and raise
Urine leaks from the catheter the buttocks off the bed by pushing against
the mattress with her feet. Place clean protec-
Resident reports pain or pressure
tive pad under her buttocks.
Odor Keeps linen from getting wet.

11. Expose only the area necessary to clean the

Providing catheter care catheter. Avoid overexposure of resident.
Promotes resident’s privacy.
Equipment: bath blanket, protective pad, bath basin
with warm water, soap, bath thermometer, 2-4 12. Place towel or pad under catheter tubing be-
washcloths or wipes, 1 towel, gloves fore washing.
1. Wash your hands. Helps keep linen from getting wet.
Provides for infection control. 13. Apply soap to wet washcloth. Clean area
2. Identify yourself by name. Identify the resi- around meatus. Use a clean area of the wash-
dent by name. cloth for each stroke.
Resident has right to know identity of his or her care- 14. Hold catheter near meatus. Avoid tugging the
giver. Addressing resident by name shows respect and
catheter.
establishes correct identification.
15. Clean at least four inches of catheter nearest
3. Explain procedure to resident. Speak clearly,
meatus. Move in only one direction, away
slowly, and directly. Maintain face-to-face con-
from meatus. Use a clean area of the cloth
tact whenever possible.
for each stroke.
Promotes understanding and independence.
Prevents infection.
4. Provide for resident’s privacy with curtain,
16. Dip a clean washcloth in the water. Rinse
screen, or door.
area around meatus, using a clean area of
Maintains resident’s right to privacy and dignity.
washcloth for each stroke.
 7 188

17. Dip a clean washcloth in the water. Rinse at 24. Return bed to lowest position. Remove pri-
least four inches of catheter nearest meatus. vacy measures.
Move in only one direction, away from me- Lowering the bed provides for safety.
atus (Fig. 7-38). Use a clean area of the cloth
Basic Nursing Skills

25. Place call light within resident’s reach.

for each stroke. Allows resident to communicate with staff as needed.

26. Report any changes in resident to the nurse.

Provides nurse with information to assess resident.

27. Document procedure using facility

guidelines.
What you write is a legal record of what you did. If
you don’t document it, legally it didn’t happen.

Residents with breathing difficulties may receive

oxygen. It is more concentrated than what is in
the air. Oxygen is prescribed by a doctor. Nurs-
ing assistants never stop, adjust, or administer
oxygen. Oxygen may be piped into a resident’s
room through a central system. It may be in
tanks or produced by an oxygen concentrator.
An oxygen concentrator is a box-like device that
changes air in the room into air with more
oxygen.
Oxygen is a very dangerous fire hazard be-
Fig. 7-38. Hold the catheter near the meatus, so that you cause it makes other things burn. Oxygen itself
do not tug it. Moving in only one direction, away from does not burn. It merely supports combustion.
meatus, helps prevent infection. Use a clean area of the
Combustion means the process of burning.
cloth for each stroke.
Working around oxygen requires special safety
precautions.
18. With towel, dry at least four inches of cath-
eter nearest meatus. Move in only one direc-
tion, away from meatus. Guidelines: Working Safely Around Oxygen
Equipment
19. Remove towel or pad from under catheter
tubing. Replace top covers. Remove bath G Remove all fire hazards from the room or
blanket. area. Fire hazards include electric razors, hair
dryers, or other electrical appliances. They
20. Dispose of linen in proper containers.
also include cigarettes, matches, and flam-
21. Empty, rinse, and wipe basin. Place in proper mable liquids (Fig. 7-39). Flammable means
area for cleaning or return to storage. easily ignited and capable of burning quickly.
22. Remove and discard gloves. Alcohol and gasoline are examples of flam-
mable liquids. Notify the nurse if a fire haz-
23. Wash your hands. ard is present and the resident does not want
Provides for infection control. it removed.
 189 7

tion, or fluids through a vein. When a doctor

prescribes an IV, a nurse inserts a needle or
tube into a vein. This gives direct access to the
bloodstream. Medication, nutrition, or fluids

Basic Nursing Skills

either drip from a bag suspended on a pole or
are pumped by a portable pump through a tube
and into the vein (Fig. 7-41). Some residents with
chronic conditions have a permanent opening
for IVs. It has been surgically created to allow
easy access for IV fluids. Nursing assistants
never insert or remove IV lines. You will not
be responsible for care of the IV site. Your only
responsibility for IV care is to report and docu-
Fig. 7-39. Examples of fire hazards. ment any observations of changes or problems
with the IV.
G Post “No Smoking” and “Oxygen in Use”
signs. Never allow smoking where oxygen is
used or stored.
G Do not burn candles, light matches, or use
lighters around oxygen. Any type of open
flame that is present around oxygen is a dan-
gerous fire hazard.
G Learn how to turn oxygen off in case of fire if
facility allows this. Never adjust the oxygen
level.
G Report if the nasal cannula or face mask
causes irritation. Check behind ears for irrita- Fig. 7-41. A resident receiving IV therapy.
tion from tubing (Fig. 7-40).
Observing and Reporting: IVs

Report any of the following to the nurse:

The tube/needle falls out or is removed.
The tubing disconnects.
The dressing around the IV site is loose or
not intact.
Blood is in the tubing or around the site of
the IV.
The site is swollen or discolored.
Fig. 7-40. A resident with a nasal cannula.
The resident complains of pain.
IV stands for intravenous, or into a vein. A The bag is broken, or the level of fluid does
resident with an IV receives medication, nutri- not seem to decrease.
 7 190

The IV fluid is not dripping. • Personal hygiene items

The IV fluid is nearly gone. • Overbed table

The pump beeps, indicating a problem. • Chair

Basic Nursing Skills

The pump is dropped. • Call light

• Privacy screen or curtain
As always, document your observations and the
care you give. Do not get the IV site wet or lower Small items are usually stored in bedside stands.
the bag below the IV site. Do not disconnect the The water pitcher and cup are often placed on
IV from the pump or turn off a beeping alarm. top of the bedside stand. A telephone and/or a
Do not take blood pressure on an arm that has radio, and other items, such as photos, may also
an IV. Having an IV in place makes some care be placed there.
procedures more difficult. Be careful not to pull
The overbed table may be used for meals or
or catch on IV tubing when giving care to resi-
personal care. It is a clean area. It must be kept
dents with IVs. Special gowns with sleeves that
clean and free of clutter. Bedpans, urinals, soiled
snap and unsnap are available to lessen the risk
linen, and other contaminated items should not
of pulling out IVs.
be placed on overbed tables.
The intercom system is the most common call
7. Discuss a resident’s unit and related system. When the resident presses the button, a
care light will be seen and/or a bell will be heard at
A resident’s unit is the room or area where the the nurses’ station. The call light allows the resi-
resident lives. It contains furniture and personal dent to contact staff anytime. Always place the
items. The unit is the resident’s home. It must call light within the resident’s reach. Answer all
be treated with respect. Always knock and wait call lights immediately.
for permission before entering. You will need
to keep a resident’s unit neat and clean. Provid- Residents’ Rights
ing a clean, safe, and orderly environment is an Privacy Curtains
essential part of your job. After giving care, tidy All residents in a facility have the legal right to per-
sonal privacy. This means that they must always be
the area. Clean and put equipment away. Do not
protected from public view when receiving care. Each
move personal items without permission. If a bed usually has a privacy curtain that extends all
safety hazard exists, inform the nurse. He or she the way around the bed. Curtains keep others from
will handle the situation. seeing a resident undressed or while having care
procedures done. Keep this curtain closed when you
Each unit may have slightly different equipment. are giving care. This helps to protect the resident’s
Standard unit equipment includes: privacy. Although curtains and screens block vision,
they do not block sound. Keep your voice low. Do
• Electric or manual bed not discuss a resident’s care near others. Close the
• Bedside stand door when possible to give more complete privacy.

• Urinal/bedpan and covers

• Wash basin You will be taught how to use many pieces of
equipment. Know how to use and care for equip-
• Emesis basin
ment properly. This prevents infection and in-
• Soap dish and soap jury. If you do not know how to use a piece of
• Bath blanket equipment, ask for help. Do not try to use equip-
• Toilet paper ment that you do not know how to use.
 191 7

nizing memory. Sleep is essential to a person’s

Guidelines: Resident’s Unit
health and well-being.
G Clean the overbed table after use. Place it Many elderly persons, especially those who are

Basic Nursing Skills

within the resident’s reach before leaving. living away from their homes, have sleep prob-
G Keep equipment clean and in good condition. lems. Many things can affect sleep. Fear, anxi-
If any equipment appears damaged, report it ety, noise, diet, medications, and illness all affect
to the nurse and/or file the proper paperwork sleep. Sharing a room with another person can
to get it repaired. Do not use broken or dam- disturb sleeping.
aged equipment.
G Keep the call light within the resident’s reach Observing and Reporting: Sleep Issues
at all times. Check to see that the resident
can reach the call light every time you leave When a resident complains that he or she is not
the room. sleeping well, observe and report the following:
G Remove meal trays right after meals. Check Sleeping too much in daytime
to make sure that there are no crumbs in the Eating or drinking items that contain too
bed. Straighten bed linens as needed. Change much caffeine late in the day
linens if they become wet, soiled, or wrinkled.
Wearing night clothes during the day
G Report signs of insects or pests right away.
G Restock supplies. Make sure the resident has Eating heavy meals late at night
fresh drinking water and a clean cup within Refusing to take medication ordered for sleep
reach. Check that the resident is able to lift
Taking new medications
the pitcher and the cup. Make sure that tis-
sues, paper towels, toilet paper, soap and TV, radio, or light on late at night
other supplies that are used daily are stocked Pain
before you leave.
Lack of sleep causes many problems. These in-
G If trash needs to be emptied or the bathroom clude decreased mental function, reduced reac-
needs to be cleaned, notify the housekeeping tion time, and irritability. Sleep deprivation also
department. Trash should be emptied at least decreases immune system function.
daily.
Some residents spend much or all of their time
G Do not move resident’s belongings. Do not in bed. Careful bedmaking is essential for
discard resident’s items. Respect the resi- comfort, cleanliness, and health. Linens should
dent’s things. always be changed after personal care, such as
G Clean equipment or take it to the proper area bed baths. Change them any time bedding or
for cleaning. Tidy the unit. sheets are damp, soiled, or in need of straight-
ening. Bed linens should be changed often for
8. Explain the importance of sleep and these reasons:
perform proper bedmaking • Sheets that are damp, wrinkled, or bunched
Sleep is a natural period of rest for the mind and up are uncomfortable. They may keep the
body. As a person sleeps, the mind and body’s resident from sleeping well.
energy is restored. During sleep, vital functions • Microorganisms live in moist, warm places.
are performed. These include repairing and re- Bedding that is damp or unclean may cause
newing cells, processing information, and orga- infection and disease.
 7 192

• Residents who spend long hours in bed are G Place wet linen in leak-proof bags.
at risk for pressure sores. Sheets that do
G Change disposable bed protectors whenever
not lie flat increase this risk by cutting off
they become soiled or wet. Dispose of them
circulation.
Basic Nursing Skills

properly.

Guidelines: Bedmaking If a resident cannot get out of bed, you must

change the linens with the resident in bed. An
G Keep linens wrinkle-free and tidy. Change occupied bed is made with the resident in bed.
linen whenever wet, damp, wrinkled, or dirty. When making the bed, use a wide stance. Bend
your knees. Avoid bending from the waist, espe-
G Wash your hands before handling clean linen.
cially when tucking sheets or blankets under the
G Hold soiled linens away from your body. mattress. Raise the height of the bed to make it
Place it in the proper container immediately. easier and safer.
If dirty linen touches your uniform, your uni-
form becomes contaminated (Fig. 7-42). Mattresses can be heavy. It is easier to make an
empty bed than one with a resident in it. An un-
occupied bed is a bed made while no resident
is in the bed. If the resident can be moved, your
job will be easier.

Making an occupied bed

Equipment: clean linen—mattress pad, fitted or flat

bottom sheet, waterproof bed protector if needed,
cotton draw sheet, flat top sheet, blanket(s), bath
blanket, pillowcase(s), gloves

1. Wash your hands.

Fig. 7-42. Carry dirty linen away from your uniform. Provides for infection control.

G Do not shake linen or clothes. It may spread 2. Identify yourself by name. Identify the resi-
airborne contaminants. dent by name.
Resident has right to know identity of his or her care-
G Put on gloves before removing bed linens giver. Addressing resident by name shows respect and
from beds. establishes correct identification.
G Look for personal items, such as dentures,
3. Explain procedure to resident. Speak clearly,
hearing aids, jewelry, and glasses, before
slowly, and directly. Maintain face-to-face con-
removing linens.
tact whenever possible.
G When removing linen, fold or roll linen so Promotes understanding and independence.
that the dirtiest area is inside. Rolling puts
4. Provide for resident’s privacy with curtain,
the dirtiest surface of the linen inward. This
screen, or door.
lessens contamination.
Maintains resident’s right to privacy and dignity.
G Bag soiled linen at the point of origin. Do not
5. Place clean linen on clean surface within
take it to other residents’ rooms.
reach (e.g. bedside stand, overbed table, or
G Sort soiled linen away from resident care chair).
areas. Prevents contamination of linen.
 193 7

6. Adjust bed to a safe working level, usually

waist high. Lower head of bed. Lock bed
wheels.
When bed is flat, resident can be moved without

Basic Nursing Skills

working against gravity. Adjusting bed level and lock-
ing wheels prevents injury to you and resident.

7. Put on gloves.
Prevents you from coming into contact with body
fluids.

8. Loosen top linen from the end of the bed

on working side. Unfold bath blanket over
the top sheet to cover resident. Remove top
sheet.

9. You will make the bed one side at a time. If

bed has side rails, raise side rail on far side
of bed. After raising side rail, go to other
side. Help resident to turn onto her side,
moving away from you toward raised side rail
(Fig. 7-43).

Fig. 7-44. Hospital corners help keep the flat sheet

smooth under the resident. They help prevent a resident’s
feet from being restricted by or tangled in linen when get-
ting in and out of bed.

13. Smooth the bottom sheet out toward the

resident. Be sure there are no wrinkles in the
mattress pad. Roll the extra material toward
the resident. Tuck it under the resident’s
Fig. 7-43. Turn resident onto her side, toward raised side body (Fig. 7-45).
rail.

10. Loosen bottom soiled linen, mattress pad

and protector, if present, on the working side.

11. Roll bottom soiled linen toward resident.

Tuck it snugly against resident’s back.
Rolling puts dirtiest surface of linen inward, lessening
contamination. The closer the linen is rolled to resi-
dent, the easier it is to remove from the other side.

12. Place and tuck in clean bottom linen. Finish Fig. 7-45.
with bottom sheet free of wrinkles. Make hos-
pital corners to keep bottom sheet wrinkle- 14. If using a waterproof pad, unfold it and
free (Fig. 7-44). center it on the bed. Tuck the side near you
Hospital corners prevent a resident’s feet from being under the mattress. Smooth it out toward the
restricted by or tangled in linen when getting in and
out of bed. resident. Tuck as you did with the sheet.
 7 194

15. If using a draw sheet, place it on the bed. sheet over the blanket about six inches.
Tuck in on your side, smooth, and tuck as Loosening the top linens over the feet prevents pres-
you did with the other bedding. sure on the feet, which can cause pressure sores.
Basic Nursing Skills

16. Raise side rail nearest you. Go to the other 22. Remove pillow. Do not hold it near your face.
side of the bed. Lower side rail. Help resident Remove the soiled pillowcase by turning it
to turn onto clean bottom sheet (Fig. 7-46). inside out. Place it in the hamper or bag.
Protect the resident from any soiled matter 23. Remove and discard gloves. Wash your
on the old linens. hands.
Provides for infection control.

24. With one hand, grasp the clean pillowcase at

the closed end. Turn it inside out over your
arm. Next, using the same hand that has the
pillowcase over it, grasp one narrow edge
of the pillow. Pull the pillowcase over it with
your free hand (Fig. 7-47). Do the same for
any other pillows. Place them under resi-
dent’s head with open end away from door.
Fig. 7-46.

17. Loosen soiled linen. Check for any personal

items. Roll linen from head to foot of bed.
Avoid contact with your skin or clothes. Place
it in a hamper or bag.
Always work from cleanest (head of bed) to dirtiest
(foot of bed) area to prevent spread of infection.
Rolling puts dirtiest surface of linen inward, lessening
contamination.

18. Pull and tuck in clean bottom linen, just like

the other side. Finish with bottom sheet free Fig. 7-47. After the pillowcase is turned inside out over
of wrinkles. your arm, grasp one end of the pillow. Pull the pillowcase
over the pillow.
19. Ask resident to turn onto her back. Help as
needed. Keep resident covered and comfort- 25. Make resident comfortable.
able, with a pillow under the head. Raise side
26. Return bed to lowest position. Lower side
rail.
rails if raised. Remove privacy measures.
20. Unfold the top sheet. Place it over the resi- Lowering the bed provides for safety.
dent. Ask the resident to hold the top sheet.
27. Place call light within resident’s reach.
Slip the bath blanket out from underneath.
Allows resident to communicate with staff as
Put it in the hamper or bag. necessary.
21. Place a blanket over the top sheet. Match 28. Take laundry bag or hamper to proper area.
the top edges. Tuck the bottom edges of top
sheet and blanket under the bottom of the 29. Wash your hands.
Provides for infection control.
mattress. Make hospital corners on each
side. Loosen the top linens over the resi- 30. Report any changes in resident to the nurse.
dent’s feet. At the top of the bed, fold the top Provides nurse with information to assess resident.
 195 7

31. Document procedure using facility ily get into bed. If resident will not be return-
guidelines. ing to bed immediately, leave bedding up.
What you write is a legal record of what you did. If
you don’t document it, legally it didn’t happen. 9. Remove pillows and pillowcases. Put on

Basic Nursing Skills

clean pillowcases. Replace pillows.

Making an unoccupied bed 10. Return bed to lowest position.

Equipment: clean linen—mattress pad, fitted or flat 11. Take laundry bag or hamper to proper area.
bottom sheet, waterproof bed protector if needed,
12. Wash your hands.
blanket(s), cotton draw sheet, flat top sheet,
Provides for infection control.
pillowcase(s), gloves
1. Wash your hands. 13. Document procedure using facility
Provides for infection control. guidelines.
What you write is a legal record of what you did. If
2. Place clean linen on clean surface within you don’t document it, legally it didn’t happen.
reach (e.g., bedside stand, overbed table, or
chair).
Prevents contamination of linen. A closed bed is a bed completely made with the
bedspread and blankets in place. It is made for
3. Adjust bed to a safe working level, usually
residents who will be out of bed most of the day.
waist high. Put bed in flattest position. Lock
It is also made when a resident is discharged. A
bed wheels.
closed bed is turned into an open bed by fold-
Allows you to make a neat, wrinkle-free bed.
ing the linen down to the foot of the bed. An
4. Put on gloves. open bed is a bed that is ready to receive a resi-
Prevents you from coming into contact with body dent who has been out of bed all day or who is
fluids.
being admitted to the facility.
5. Loosen soiled linen. Roll soiled linen (soiled
side inside) from head to foot of bed. Avoid
contact with your skin or clothes. Place it in a
9. Discuss dressings and bandages
hamper or bag. Sterile dressings cover open or draining wounds.
Always work from cleanest (head of bed) to dirtiest A nurse changes these dressings. Non-sterile
(foot of bed) area to prevent spread of infection.
Rolling puts dirtiest surface of linen inward, lessening dressings are applied to dry, closed wounds that
risk of contamination. have less chance of infection. Nursing assistants
may help with non-sterile dressing changes.
6. Remove and discard gloves. Wash your
hands.
Provides for infection control. Changing a dry dressing using non-sterile
technique
7. Remake the bed. Spread mattress pad and
bottom sheet, tucking under mattress. Make Equipment: package of square gauze dressings, ad-
hospital corners to keep bottom sheet wrin- hesive tape, scissors, 2 pairs of gloves
kle-free. Put on mattress protector and draw 1. Wash your hands.
sheet. Smooth and tuck under sides of bed. Provides for infection control.
8. Place top sheet and blanket over bed. Center 2. Identify yourself by name. Identify the resi-
these, tuck under end of bed and make hos- dent by name.
pital corners. Fold down the top sheet over Resident has right to know identity of his or her care-
the blanket about six inches. Fold both top giver. Addressing resident by name shows respect and
sheet and blanket down so resident can eas- establishes correct identification.
 7 196

3. Explain procedure to resident. Speak clearly, 13. Place call light within resident’s reach.
slowly, and directly. Maintain face-to-face con- Allows resident to communicate with staff as
tact whenever possible. necessary.
Promotes understanding and independence. 14. Report any changes in resident to the nurse.
Basic Nursing Skills

4. Provide for resident’s privacy with curtain, Provides nurse with information to assess resident.
screen, or door. 15. Document procedure according to facility
Maintains resident’s right to privacy and dignity. guidelines.
5. Cut pieces of tape long enough to secure the What you write is a legal record of what you did. If
you don’t document it, legally it didn’t happen.
dressing. Hang tape on the edge of a table
within reach. Open four-inch gauze square
Elastic, or non-sterile, bandages (sometimes
package without touching gauze. Place the
called “ACE® bandages”) are used to hold dress-
open package on a flat surface.
ings in place, secure splints, and support and
6. Put on gloves. protect body parts. In addition, these bandages
Protects you from coming into contact with body may decrease swelling that occurs with an
fluids.
injury.
7. Remove soiled dressing by gently peeling
NAs may be required to help with elastic ban-
tape toward the wound. Lift dressing off the
dages. Duties may include the following:
wound. Do not drag it over wound. Observe
• Bringing the bandage to the resident
dressing for any odor or drainage. Notice
color and size of the wound. Dispose of used • Positioning the resident to apply the
dressing in proper container. Remove and bandage
discard gloves. • Washing and storing the bandage
Avoids disturbing wound healing. Reduces risk of • Documenting observations about the
contamination. bandage
8. Wash your hands. Some states allow NAs to apply and remove elas-
Provides for infection control.
tic bandages. Follow your facility’s policies and
9. Put on new gloves. Touching only outer the care plan regarding elastic bandages. If you
edges of new four-inch gauze, remove it from are allowed to help with these bandages, check
package. Apply it to wound. Tape gauze in the bandage often. It can become wrinkled,
place. Secure firmly (Fig. 7-48). loose, or bunched-up. Check on the resident 15
Keeps gauze as clean as possible. minutes after the bandage is first applied to see
if there are any signs of poor circulation. Signs
and symptoms of poor circulation include:
• Swelling
• Bluish, or cyanotic, skin
• Shiny, tight skin
• Skin cold to touch
Fig. 7-48. Tape gauze in place to secure the dressing. Do
not completely cover all areas of the dressing with tape. • Sores
• Numbness
10. Remove and discard gloves. • Tingling
11. Wash your hands. • Pain or discomfort
Provides for infection control.
Loosen the bandage if you note any signs of poor
12. Remove privacy measures. circulation, and notify the nurse immediately.
 197 8

Nutrition and Hydration

Nutrition and Hydration

1. Identify the six basic nutrients and

explain MyPyramid

Good nutrition is very important. Nutrition

is how the body uses food to maintain health.
Bodies need a well-balanced diet with nutrients
and plenty of fluids. This helps us grow new
cells, maintain normal body function, and have
energy. Good nutrition in early life helps ensure
good health later. For the ill or elderly, a well- Fig. 8-1. Sources of protein.
balanced diet helps maintain muscle and skin
2. Carbohydrates. Carbohydrates supply the fuel
tissues and prevent pressure sores. A good diet
for the body’s energy needs. They supply extra
promotes healing. It also helps us cope with
protein and help the body use fat efficiently. Car-
stress.
bohydrates also provide fiber, which is necessary
A nutrient is something found in food that pro- for bowel elimination (Fig. 8-2). Carbohydrates
vides energy, promotes growth and health and can be divided into two basic types: complex and
helps regulate metabolism. Metabolism is the simple carbohydrates. Complex carbohydrates
process by which nutrients are broken down to are found in bread, cereal, potatoes, rice, pasta,
be used by the body for energy and other needs. vegetables, and fruits. Simple carbohydrates
The body needs the following six nutrients for are found in sugars, sweets, syrups, and jellies.
growth and development: Simple carbohydrates do not have the same nu-
tritional value that complex carbohydrates do
1. Protein. Proteins are part of every body cell.
(Fig. 8-2).
They are needed for tissue growth and repair.
Proteins also supply energy for the body. Sources
of protein include fish, seafood, poultry, meat,
eggs, milk, cheese, nuts, nut butters, peas,
dried beans or legumes, and soy products (tofu,
tempeh, veggie burgers) (Fig. 8-1). Whole grain
cereals, pastas, rice, and breads contain some
proteins, too.

Fig. 8-2. Sources of carbohydrates.

 8 198

3. Fats. Fat helps the body store energy. Body fat day. Water is the most essential nutrient for life.
also provides insulation. It protects body organs. Without it, a person can only live a few days.
In addition, fats add flavor to food. Fats also help Water assists in the digestion and absorption of
the body absorb vitamins. Excess fat in the diet food. It helps with waste elimination. Through
Nutrition and Hydration

is stored as fat in the body. Examples of fats are perspiration, water helps maintain normal body
butter, margarine, salad dressings, oils, and ani- temperature. Keeping enough fluid in our bod-
mal fats in meats, dairy products, fowl, and fish ies is necessary for good health.
(Fig. 8-3). The fluids we drink—water, juice, soda, cof-
fee, tea, and milk—provide most of the water
our bodies use. Some foods are also sources of
water, including soup, celery, lettuce, apples, and
peaches.
Most foods have several nutrients. No one food
has all the nutrients needed for a healthy body.
This is why it is important to eat a daily diet that
is well-balanced. There is not one single dietary
plan that is right for everyone. People have dif-
ferent nutritional needs depending upon their
age, gender, and activity level.
Fig. 8-3. Sources of fat.
In 1980, the U.S. Department of Agriculture
Monounsaturated vegetable fats (including olive (USDA) developed the Food Guide Pyramid to
oil and canola oil) and polyunsaturated vegetable help promote healthy eating practices. In 2005,
fats (including corn and safflower oils) are in response to new scientific information about
healthier fats. Saturated fats, including animal nutrition and health and new technology for
fats like butter, bacon, and other fatty meats, are support tools, MyPyramid was developed (Fig.
not as healthy. They should be limited. 8-4). MyPyramid replaces the Food Guide Pyra-
mid. MyPyramid is a personalized version of the
4. Vitamins. Vitamins are substances the body
Food Guide Pyramid that offers individual plans
needs to function. The body cannot make most
based on age, gender, and activity level.
vitamins. They can only be gotten from food.
Vitamins A, D, E, and K are fat-soluble vitamins.
This means they are carried and stored in body
fat. Vitamins B and C are water-soluble vitamins.
They are broken down by water in our bodies.
They cannot be stored in the body. They are
eliminated in urine and feces.
5. Minerals. Minerals form and maintain body
functions. They provide energy and control pro-
cesses. Zinc, iron, calcium, and magnesium are
examples of minerals. Minerals are found in
many foods.
6. Water. One-half to two-thirds of our body
Fig. 8-4. MyPyramid was developed to help promote
weight is water. We need about 64 ounces, or healthy eating practices. It offers individual plans based
eight 8-ounce glasses, of water or other fluids a on age, gender and activity level.
 199 8

The Pyramid is made up of six bands of differ- that grains are whole grains include: 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

Nutrition and Hydration

Vegetables. The vegetable group includes all
for milk, and purple for meat and beans. The
fresh, frozen, canned and dried vegetables and
different widths indicate that not all groups
vegetable juices. One cup of raw or cooked veg-
should make up an equal part of a healthy diet.
etables or vegetable juice or two cups of raw
The orange band, grains, is the widest. This
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 foods eaten.
orange vegetables, dry beans and peas, starchy
The smallest band, the yellow one, represents
vegetables, and other vegetables. A variety of
oils. Oils contain essential fatty acids. However,
vegetables from these subgroups should be eaten
this band is not emphasized because the body
every day. Dark green vegetables, orange veg-
needs 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
Vegetables are low in fat and calories and have
a reminder that there is 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% fruit juice or ½ cup of dried
top. They should be eaten less often. fruit can be counted as one cup from the fruit
group. Most choices should be whole or cut-up
The new Pyramid also emphasizes the impor- fruit rather than juice for the additional dietary
tance of physical activity, as represented by the fiber provided.
figure climbing the stairs. Physical activity goes
hand-in-hand with diet to make up an overall Fruits, like vegetables, are naturally low in fat,
healthy lifestyle. The USDA recommends at least sodium and calories and have no cholesterol.
30 minutes per day of vigorous activity for every- They are important sources of dietary fiber
one. Sixty minutes or more is even better. and many nutrients, including folic acid and
vitamin C.
Grains. The grains group includes all foods
made from wheat, rice, oats, corn, barley and Milk. The milk group includes all fluid milk
other grains. Examples are bread, pasta, oatmeal, products and foods made from milk that retain
breakfast cereals, tortillas, and grits. One slice of their calcium content, such as yogurt and cheese.
bread, one cup of ready-to-eat cereal, or ½ cup of Foods made from milk that have little to no
cooked rice, pasta, or cooked cereal can be con- calcium, such as cream cheese, cream, and but-
sidered a one-ounce equivalent from the grains ter, are not part of the group. Most milk group
group. choices should be fat-free or low-fat (Fig. 8-5).
One cup of milk or yogurt, 1½ ounces of natural
At least half of all grains consumed should be cheese, or two ounces of processed cheese can be
whole grains. Words on food labels that ensure counted as one cup from the milk group.
 8 200

Oils. Oils include fats that are liquid at room

temperature, such as canola, corn, olive, soybean
and sunflower oil. Some foods are naturally high
in oils, like nuts, olives, some fish, and avocados.
Nutrition and Hydration

Foods that are mainly oil include mayonnaise,

certain salad dressings, and soft margarine.
Most of the fats you eat should be polyunsatu-
rated (PUFA) or monounsaturated (MUFA) fats.
Oils are the major source of MUFAs and PUFAs
in the diet. PUFAs contain some fatty acids that
Fig. 8-5. Low-fat yogurt is a good source of calcium.
are necessary for health. These are called “es-
Foods in the milk group provide nutrients that sential fatty acids.” Most Americans consume
are vital for the health and maintenance of your enough oil in the foods they eat, such as nuts,
body. These nutrients include calcium, potas- fish, cooking oil, and salad dressings.
sium, vitamin D, and protein. Calcium is used Activity. Physical activity and nutrition work to-
for building bones and teeth and in maintain- gether for better health. Being active increases
ing bone mass. Milk products are the primary the amount of calories burned. As people age,
source of calcium in American diets. their metabolism slows. Maintaining energy bal-
ance requires moving more and eating less. For
Meat and Beans. One ounce of lean meat, poul-
health benefits, physical activity should be mod-
try, or fish; one egg; one tablespoon peanut but-
erate or vigorous and add up to at least 30 min-
ter; ¼ cup cooked dry beans; or ½ ounce of nuts
utes a day. For more information on MyPyramid,
or seeds can be counted as one-ounce equivalent
visit mypyramid.gov.
from the meat and beans group. Dry beans
and peas can be included as part of this group Older adults have different nutritional needs.
or part of the vegetable group. If meat is eaten Tufts University developed a version of MyPyra-
regularly, dry beans and peas should be included mid that is specifically designed for older adults.
with vegetables. If not, they should be included Due to slower metabolism and less activity, the
as part of this group. elderly need to eat less to maintain body weight.
Although calories can be reduced, daily needs
Most meat and poultry choices should be lean or
for most nutrients do not decrease. The “Modi-
low-fat. Diets that are high in saturated fats raise
fied MyPyramid for Older Adults” has a nar-
“bad” cholesterol levels in the blood. Fish, nuts,
rower base to reflect a decrease in energy needs.
and seeds contain healthy oils. These foods are
It emphasizes nutrient-dense foods, fiber, and
a good choice instead of meat or poultry. Some
water. Dietary supplements may be appropriate
nuts and seeds (flax, walnuts) are excellent
for many older people. For more information on
sources of essential fatty acids. These acids may
the “Modified MyPyramid for Older Adults,” visit
reduce the risk of cardiovascular disease. Some
nutrition.tufts.edu.
(sunflower seeds, almonds, hazelnuts) are good
sources of vitamin E.
2. Describe factors that influence food
Vegetarians get enough protein from this group
preferences
as long as the variety and amounts of foods
selected are adequate. Protein sources for veg- Culture, ethnicity, income, education, religion,
etarians from this group include eggs (for ovo- and geography all affect ideas about nutrition.
vegetarians), beans, nuts, nut butters, peas, and Food preferences may be formed by what you ate
soy products (tofu, tempeh, veggie burgers). as a child, by what tastes good, or by personal be-
 201 8

liefs about what should be eaten (Fig. 8-6). Some

resident refuses dinner, ask if there is something
people choose not to eat any animals or animal wrong with the food. He may tell you he is Jewish
products, such as steak, chicken, butter, or eggs. and cannot eat a pork chop because it is not kosher.
These people are vegetarians or vegans. Respond to requests for different food in a pleasant

Nutrition and Hydration

way. Explain that you will report to the nurse and will
get him another meal as quickly as possible. Remove
the tray. Take it to the dietician or dietary department
so that an alternative may be offered.

3. Explain special diets

A doctor sometimes places residents who are ill
on special diets. These diets are known as ther-
apeutic, modified, or special diets. Certain
nutrients or fluids may need to be restricted.
Fig. 8-6. Food likes and dislikes are influenced by what Medications may interact with certain foods,
you ate as a child. which then need to be eliminated. Doctors may
order special diets for residents who do not eat
The region or culture you grow up in often af- enough. Diets are also used for weight control
fects your food preference. People from the and food allergies.
southwestern U.S. may like spicy food. “South-
ern cooking” may include fried foods, like fried After a doctor prescribes a special diet, the di-
chicken or fried okra. Ethnic groups often share etitian plans the diet. The dietary department
common foods. These may be eaten at certain makes diet cards (Fig. 8-7). Diet cards list the
times of the year or all the time. Religious be- resident’s name and information about special
liefs affect diet, too. Some Muslim and Jewish diets, allergies, likes and dislikes and any other
people do not eat any pork. Mormons may not instructions.
drink alcohol, coffee, or tea.
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.
Fig. 8-7. Sample diet cards. (reprinted with permission of briggs
Residents’ Rights corporation, 800-247-2343, www.briggscorp.com)

Food Choices
Residents have the legal right to make choices about Several types of modified diets are available.
their food. They can choose what kind of food they Some residents may be on a combination of spe-
want to eat. They can refuse the food and drink cial diets. The care plan should specify any spe-
being offered. You must honor a resident’s personal
cial diet the resident is on (Fig. 8-8). Examples of
beliefs and preferences about selecting and avoiding
specific foods. Although residents have the right to special diets are listed below:
refuse, ask questions when they do. For example, if a
 8 202

Low-Fat/Low-Cholesterol Diet: People who have

high levels of cholesterol in their blood are at
risk for heart attacks and heart disease. People
with gallbladder disease, diseases that interfere
Nutrition and Hydration

with fat digestion, and liver disease are also

Fig. 8-8. The care plan specifies special diets or dietary placed on low-fat/low-cholesterol diets. Low-fat/
restrictions. low-cholesterol diets permit skim milk, low-
fat cottage cheese, fish, white meat of turkey
Low-Sodium Diet: Residents with high blood and chicken, veal, and vegetable fats (especially
pressure, heart disease, kidney disease, or fluid monounsaturated fats such as olive, canola, and
retention may be placed on a low-sodium diet. peanut oils) (Fig. 8-9). People who have gallblad-
Many foods have sodium, but people are most der disease or other digestive problems may be
familiar with it as an ingredient in table salt. placed on a diet that restricts all fats. A common
Salt is the first food to be restricted in a low- abbreviation for this diet is “Low-Fat/Low-Chol.”
sodium diet because it is high in sodium. For
residents on a low-sodium diet, salt will not be
used. Salt shakers or packets will not be on the
diet tray. Common abbreviations for this diet are
“Low Na,” which means low sodium, or “NAS,”
which stands for “No Added Salt.”
Fluid-Restricted Diets: The fluid taken into the
body through food and fluids must equal the
fluid that leaves the body through perspiration,
stool, urine, and expiration. This is fluid bal- Fig. 8-9. Vegetables are an important part of a low-fat/
low-cholesterol diet.
ance. When fluid intake is greater than fluid
output, body tissue becomes swollen with fluid.
Modified Calorie Diet: Some residents may
People with severe heart disease or kidney
need to reduce calories to lose weight or prevent
disease may have trouble processing fluid. To
weight gain. Other residents may need to in-
prevent further damage, doctors may restrict
crease calories because of malnutrition, surgery,
fluid intake. For residents on fluid restriction,
illness, or fever. Common abbreviations for this
you will need to measure and document exact
diet are “Low-Cal” or “High-Cal.”
amounts of fluid intake and report excesses to
the nurse. Do not offer additional fluids or foods Dietary Management of Diabetes: Calories and
that count as fluids, such as ice cream, pud- carbohydrates are carefully controlled in the
dings, gelatin, etc. If the resident complains of diets of diabetic residents. Protein and fats are
thirst or requests fluids, tell the nurse. A com- also regulated. The foods and the amounts are
mon abbreviation for this diet is “RF,” which determined by nutritional and energy needs. A
stands for “Restrict Fluids.” dietitian and the resident will make up a meal
plan. It will include all the right types and
Low-Protein Diet: People who have kidney dis- amounts of food for each day. The resident uses
ease may be on low-protein diets. Protein is re- exchange lists, or lists of similar foods that can
stricted because it breaks down into compounds substitute for one another, to make up a menu.
that may further damage the kidneys. The ex- Using meal plans and exchange lists, a person
tent of the restrictions depends on the stage of with diabetes can control his diet while still
the disease and if the resident is on dialysis. making food choices.
 203 8

To keep their blood glucose levels near normal, processors, or cutting utensils. Unlike the soft
diabetic residents must eat the right amount of diet, the mechanical soft diet does not limit
the right type of food at the right time. They spices, fat, and fiber. Only the texture of foods is
must eat all that is served. Encourage them changed. This diet is used for people recovering

Nutrition and Hydration

to do so. Do not offer other foods without the from surgery or who have trouble chewing and
nurse’s approval. If a resident will not eat what is swallowing.
directed, or if you think that he or she is not fol-
Pureed Diet. To puree a food means to chop,
lowing the diet, tell the nurse.
blend, or grind it into a thick paste of baby food
A diabetic’s meal tray may have artificial sweet- consistency. The food should be thick enough
ener, low-calorie jelly, and maple syrup. When to hold its form in the mouth. This diet does
serving coffee or tea to a diabetic resident, use not require a person to chew his or her food. A
artificial sweeteners rather than sugar. The com- pureed diet is often used for people who have
mon abbreviations for this diet are “NCS,” which trouble chewing and/or swallowing more tex-
stands for “No Concentrated Sweets,” or the tured foods.
amount of calories followed by the abbreviation
“ADA,” which stands for American Diabetic As- Nutritional Supplements
sociation. See Chapter 4 for more information on
Illness often causes residents to need extra nutrients,
diabetes. as well as additional calories. Sometimes a resident
Diets may also be modified in consistency: will be advised by his doctor or dietician to add a
high-nutrition supplement to the regular or modified
Liquid Diet. A liquid diet is usually ordered for a diet. Usually this is done to encourage weight gain or
short time due to a medical condition or before the intake of proteins, vitamins, or minerals. Nutri-
tional supplements may come in a powdered or liq-
or after a test or surgery. It is ordered when a
uid form. Supplements may be pre-mixed and ready
resident needs to keep the intestinal tract free of to drink. Some powdered supplements need to be
food. A liquid diet consists of foods that are in a mixed with a liquid before being taken. The care plan
liquid state at body temperature. Liquid diets are will include instructions on how much liquid to add.
When preparing supplements, make sure the supple-
usually ordered as “clear” or “full.” A clear liquid
ment is mixed thoroughly. Make sure the resident
diet includes clear juices, broth, gelatin, and pop- takes the supplement at the ordered time. Residents
sicles. A full liquid diet includes all the liquids who are ill, tired, or in pain may not have much of
served on a clear liquid diet with the addition 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
cream soups, milk, and ice cream.
encouraging. If a resident does not want to drink the
Soft Diet and Mechanical Soft Diet: The soft diet supplement, do not insist that he do so. However,
is soft in texture and consists of soft or chopped do report this to the nurse.
foods that are easier to chew and swallow. Foods
that are hard to chew and swallow, such as raw
4. Describe how to assist residents in
fruits and vegetables and some meats, will be re-
stricted. High-fiber foods, fried foods, and spicy
maintaining fluid balance
foods may also be limited. Doctors order this diet Most residents should be encouraged to drink
for residents who have trouble chewing and swal- at least 64 ounces of water or other fluids a day.
lowing due to dental problems or other medical Remember that water is essential for life (Fig.
conditions. It is also ordered for people who are 8-10). Proper fluid intake is important. It helps
going from a liquid diet to a regular diet. prevent constipation and urinary incontinence.
The mechanical soft diet consists of chopped or Without enough fluid, urine becomes concen-
blended foods that are easier to chew and swal- trated. More concentrated urine creates a higher
low. Foods are prepared with blenders, food risk for infection. Proper fluid intake also helps
 8 204

to dilute wastes and flush out the urinary sys- The abbreviation “NPO “ stands for “Nothing
tem. It may even help prevent confusion. by Mouth.” This means that a resident is not
allowed to have anything to eat or drink. Some
residents have such a severe problem with swal-
Nutrition and Hydration

lowing that it is unsafe to give them anything by

mouth. These types of residents will receive nu-
trition through a feeding tube or intravenously.
Some residents may be NPO for a short time be-
fore a medical test or surgery. You need to know
this abbreviation. Never offer any food or drink
to a resident with this order, not even water.

Dehydration occurs when a person does not

have enough fluid in the body. Dehydration is a
Fig. 8-10. Drinking enough water and other fluids pro- major problem among the elderly. People can be-
motes good health. Make sure you drink plenty of fluids come dehydrated if they do not drink enough or
every day. if they have diarrhea or are vomiting. Preventing
dehydration is very important.
The sense of thirst can lessen as people age. Re-
mind your elderly residents to drink fluids often
(Fig. 8-11). Some residents will drink more flu- Observing and Reporting: Dehydration
ids if they are offered them in smaller amounts,
rather than in one large glassful. However, some Report any of these to the nurse:
residents will have an order to force fluids (FF) Resident drinks less than six­8-oz. glasses of
or restrict fluids (RF) because of medical con- liquid per day
ditions. Force fluids means to encourage the
resident to drink more fluids. Restrict fluids Resident drinks little or no fluids at meals
means the person is allowed to drink, but must Resident needs help drinking from a cup or
limit the daily amount to a level set by the doc- glass
tor. When a resident has a restrict fluids order,
you cannot give the resident any extra fluids Resident has trouble swallowing liquids
or a water pitcher unless the nurse approves it. Resident has frequent vomiting, diarrhea, or
Make sure you know which residents have these fever
orders.
Resident is easily confused or tired

Report any of these symptoms:

Dry mouth

Cracked lips

Sunken eyes

Dark urine

Strong-smelling urine

Weight loss
Fig. 8-11. Encourage residents to drink every time you see
them. Complaints of abdominal pain
 205 8

container. Place scoop in proper receptacle

Guidelines: Preventing Dehydration
after each use.
G Report observations and warning signs to the Avoids contamination of ice.

Nutrition and Hydration

nurse immediately. 6. Take pitcher to resident.
G Encourage residents to drink every time you 7. Pour glass of water for resident. Leave pitcher
see them. and glass at the bedside.
G Offer fresh water or other fluids often. Offer Encourages resident to maintain hydration.
drinks that the resident enjoys. Some may 8. Make sure that pitcher and glass are light
not like water and prefer other types of bever- enough for resident to lift. Leave a straw if
ages, such as juice, soda, tea, or milk. Report the resident desires.
to the nurse if the resident tells you he does Demonstrates understanding of resident’s abilities
not like the fluids being served. Some resi- and/or limitations. Prevents dehydration.
dents do not want ice in their drinks. Honor 9. Place call light within resident’s reach.
personal preferences. Allows resident to communicate with staff as
necessary.
G Record fluid intake and output.
G Ice chips, frozen flavored ice sticks, and gela- 10. Remove and discard gloves.
tin are also liquids. Offer them often. Do not 11. Wash your hands.
offer ice chips or sticks if a resident has a Provides for infection control.
swallowing problem.
G If appropriate, offer sips of liquid between Fluid overload occurs when the body cannot
bites of food at meals and snacks. handle the fluid consumed. This often affects
people with heart or kidney disease.
G Make sure pitcher and cup are near enough
and light enough for the resident to lift.
Observing and Reporting: Fluid Overload
G Offer assistance if resident cannot drink with-
out help. Use adaptive cups as needed. Report any of these to the nurse:
Swelling/edema of extremities (ankles, feet,
Serving fresh water
fingers, hands); edema is swelling caused by
Equipment: water pitcher, ice scoop, glass, straw, excess fluid in body tissues
gloves
Weight gain (daily weight gain of one to two
1. Wash your hands. pounds)
Provides for infection control.
Less urine output
2. Identify yourself by name. Identify the resi- Shortness of breath
dent by name.
Resident has right to know identity of his or her care- Increased heart rate
giver. Addressing resident by name shows respect and Skin that appears tight, smooth, and shiny
establishes correct identification.

3. Put on gloves. 5. List ways to identify and prevent

Promotes infection control.
unintended weight loss
4. Scoop ice into water pitcher. Add fresh water.
Unintended weight loss is a serious problem for
5. Use and store ice scoop properly. Do not the elderly. Weight loss can mean that the resi-
allow ice to touch hand and fall back into dent has a serious medical condition. It can lead
 8 206

to skin breakdown. This leads to pressure sores. G Record meal/snack intake.

It is very important to report any weight loss you G Give oral care before and after meals, if the
notice, no matter how small. If a resident has di- resident requests it.
abetes, COPD, cancer, HIV, or other diseases, he
Nutrition and Hydration

is at a greater risk for malnutrition. (See Chapter G Position residents sitting upright for feeding.
4 for more information.) G If resident has had a loss of appetite and/or
seems sad, ask about it.
Observing and Reporting: Unintended Weight
Loss

Report any of these to the nurse:

Resident needs help eating or drinking
Resident eats less than 70% of meals/snacks
served
Resident has mouth pain
Resident has dentures that do not fit Fig. 8-12. Be social, friendly, and positive while helping
Resident has difficulty chewing or swallowing residents with eating. This helps promote appetite and
prevent weight loss.
Resident coughs or chokes while eating
Resident is sad, has crying spells, or with-
draws from others 6. Identify ways to promote appetites at
mealtime
Resident is confused, wanders, or paces
Mealtime is an important part of a resident’s
Guidelines: Preventing Unintended Weight Loss day. This is especially true because weight loss
and malnutrition issues are common among the
G Report observations and warning signs to the elderly. Illness, pain, and medications may cause
nurse. loss of appetite. Mealtime is not only the time
G Encourage residents to eat. Talk about food for getting proper nourishment. It is also a time
being served in a positive tone of voice. Use for socializing, which has a positive effect on
positive words (Fig. 8-12). eating. It can help prevent weight loss, dehydra-
tion, and malnutrition. It can also prevent loneli-
G Honor residents’ food likes and dislikes. ness and boredom.
G Offer different kinds of foods and beverages. Promoting healthy eating is an important part
G Help residents who have trouble feeding of your job. Mealtime should be a pleasant time.
themselves. Use the following tips to help promote appetites
G Food should look, taste, and smell good. The and to make dining enjoyable:
person may have a poor sense of taste and
smell. Guidelines: Promoting Appetites
G Season foods to residents’ preferences.
G Check the environment. The temperature
G Allow time for residents to finish eating. should be comfortable. Address any odors.
G Tell the nurse if residents have trouble using Keep noise level low. Do not shout or raise
utensils. your voice. Do not bang plates or cups.
 207 8

G Assist residents with grooming and hygiene 7. Demonstrate how to assist with eating
tasks before dining, as needed.
Before you begin serving or helping residents,
G Help residents wash hands before eating.
wash your hands. As you learned earlier in this

Nutrition and Hydration

G Give oral care before eating, if requested. textbook, it is very important to identify resi-
G Offer a trip to the bathroom or help with toi- dents before serving a meal tray. Feeding a resi-
leting before eating. dent the wrong food can cause serious problems,
even death. Identify each resident before placing
G Encourage the use of dentures, glasses, and
food in front of him or her.
hearing aids. If these are damaged, notify the
nurse. Residents will need different levels of help with
G Properly position residents for eating. The eating. Some residents will not need any help.
proper position is usually upright, at a Other residents will only need help setting up.
90-degree angle. This helps prevent swal- They may need help opening cartons and cut-
lowing problems. If residents use a wheel- ting and seasoning their food. Once that is done,
chair, make sure they are sitting at a table they can feed themselves. Check in with these
that is the right height. Most facilities have residents from time to time to see if they need
adjustable tables for wheelchairs. Residents anything else.
who use “geri-chairs”—reclining chairs on
Other residents will be completely unable to
wheels—should be upright, not reclined,
feed themselves. It will be your job to feed them.
while eating.
Residents who must be fed are often embar-
G Seat residents next to their friends or people rassed and depressed about their dependence on
with like interests. Encourage conversation. another person. Be sensitive to this. Give privacy
G Serve food at the correct temperature. Keep while they are eating. Do not rush them.
food covered until ready to serve. Do not Only give assistance as specified, when neces-
carry trays of food without covers. sary, or when the resident requests it. Encourage
G Plates and trays should look appetizing. residents to do what they can. For example, if a
G Give the resident proper eating tools. Use resident can hold and use a napkin, she should.
adaptive utensils if needed (Fig. 8-13). If she can hold and eat finger foods, offer them.
There are devices that help residents eat more
independently (see Fig. 8-13). More adaptive de-
vices are shown in Chapter 9.

Guidelines: Assisting a Resident with Eating

G Never treat the resident like a child. This is

embarrassing and disrespectful. It is hard for
Fig. 8-13. Cups with lids to avoid spills and utensils with
thick handles that are easier to hold are two examples of
many people to accept help with feeding. Be
adaptive devices that help with eating and drinking. supportive and encouraging.
(photos courtesy of north coast medical, inc., 800-821-9319, www.ncmedical.com)
G Sit at a resident’s eye level. Resident should
G Be cheerful, positive, and helpful. Make con- be sitting upright, at a 90-degree angle. Make
versation if the resident wishes. eye contact with the resident.
G Give more food when requested. G If the resident wishes, allow time for prayer.
 8 208

G Verify that you have the right resident. Check Residents’ Rights
the diet card against the resident’s ID photo
Clothing Protectors
or bracelet. Ask the resident to state his
Residents have the right to refuse to wear a clothing
name. Check that the diet on the tray is cor-
Nutrition and Hydration

protector. Offer a clothing protector, but do not in-

rect and matches the diet card. sist that a resident wear one. Respect the resident’s
wishes. Use the term “clothing protector” instead of
G Test the temperature of the food by putting “bib.” This promotes residents’ dignity and avoids
your hand over the dish to sense the heat. treating them like children.
Do not touch food to test its temperature. If
you think the food is too hot, do not blow on Feeding a resident who cannot feed self
it to cool it. Offer other food to give it time to
Equipment: meal tray, clothing protector, 2-3 wash-
cool. cloths or wipes
G Cut foods and pour liquids as needed. 1. Wash your hands.
G Identify the foods and fluids that are in front Provides for infection control.
of the resident. Call pureed foods by the cor- 2. Identify yourself by name. Identify the resi-
rect name. For example, ask, “Would you like dent by name.
green beans?” rather than referring to it as Resident has right to know identity of his or her care-
“some green stuff.” giver. Addressing resident by name shows respect and
establishes correct identification.
G Ask the resident which food he wants to eat
3. Explain procedure to resident. Speak clearly,
first. Allow him to make the choice, even if he
slowly, and directly. Maintain face-to-face con-
wants to eat dessert first.
tact whenever possible.
G Do not mix foods unless the resident Promotes understanding and independence.
requests it.
4. Pick up diet card. Ask resident to state his or
G Do not rush the meal. Allow time for the her name. Verify that resident has received
resident to chew and swallow each bite. Be the right tray.
relaxed. Tray should only contain foods, fluids, and condi-
ments permitted on the diet.
G Make conversation. Use appropriate topics,
such as the news, weather, the resident’s life, 5. Raise the head of the bed. Make sure resi-
things the resident enjoys, and food prefer- dent is in an upright sitting position (at a
ences. Say positive things about the food 90-degree angle).
Promotes ease of swallowing. Prevents aspiration of
being served, such as, “This smells really
food and beverage.
good,” and, “The [type of food] looks so
fresh.” 6. Adjust bed height to where you will be to able
to sit at resident’s eye level. Lock bed wheels.
G Give the resident your full attention. Do not
talk to other staff members while helping 7. Place meal tray where it can be easily seen by
residents eat. the resident, such as on the overbed table.

G Alternate food and drink. Alternating cold 8. Help resident to clean hands with hand
and hot foods or bland foods and sweets can wipes if resident cannot do it on her own.
Promotes good hygiene and infection control.
help increase appetite.
9. Help resident to put on clothing protector, if
G If the resident wants a different food from
desired.
what is being served, inform the dietitian so
Protects resident’s clothing from food and beverage
that an alternative may be offered. spills.
 209 8

10. Sit facing resident at the resident’s eye level 14. Make sure resident’s mouth is empty before
(Fig. 8-14). Sit on the stronger side if the resi- next bite or sip.
dent has one-sided weakness. Lessens risk of choking.
Promotes good communication. Lets resident know

Nutrition and Hydration

that he or she will not be rushed while eating. 15. Talk with the resident during the meal
(Fig. 8-16).
Makes mealtime more enjoyable.

Fig. 8-14. The resident should be sitting upright and you Fig. 8-16. Cheerful company and conversation can greatly
should be sitting at her eye level. increase how much a resident eats and drinks.

11. Tell the resident what foods are on tray. Ask 16. Use washcloths or wipes to wipe food from
what resident would like to eat first. resident’s mouth and hands as needed dur-
Resident has legal right to make decisions. ing the meal. Wipe again at the end of the
meal (Fig. 8-17).
12. Offer the food in bite-sized pieces, telling
Maintains resident’s dignity.
the resident the content of each bite of food
offered (Fig. 8-15). Alternate types of food, al-
lowing for resident’s preferences. Do not feed
all of one type before offering another type.
Report any swallowing problems to the nurse
immediately.
Small pieces are easier to chew and lessens the risk
of choking.

Fig. 8-17. Wiping food from the mouth during the meal
helps to maintain the resident’s dignity.

17. Remove clothing protector if used. Dispose

of in proper container.

18. Remove food tray. Check for eyeglasses, den-

tures, or any personal items before removing
Fig. 8-15. Offer the food in bite-sized pieces. Tell resident
tray. Place tray in proper area to be picked up.
the content of each bite of food.
19. Make resident comfortable. Make sure sheets
13. Offer sips of beverage to resident throughout are free from wrinkles and the bed free from
the meal. crumbs.
Promotes ease of swallowing. Wrinkles and crumbs can cause skin breakdown.
 8 210

20. Return bed to lowest position. Remove pri- you notice any of the following signs and symp-
vacy measures. toms of swallowing problems, notify the nurse
Provides for safety. immediately:
Nutrition and Hydration

21. Place call light within resident’s reach. • Coughing during or after meals
Allows resident to communicate with staff as
• Choking during meals
necessary.
• Dribbling saliva, food, or fluid from the
22. Wash your hands.
mouth
Provides for infection control.
• Food residue inside the mouth or cheeks
23. Report any changes in resident to the nurse.
during and after meals
Provides nurse with information to assess resident.
• Gurgling sound in voice during or after
24. Document procedure using facility
meals or loss of voice
guidelines.
What you write is a legal record of what you did. If • Slow eating
you don’t document it, legally it didn’t happen.
• Avoidance of eating
• Spitting out pieces of food
Food trays and plates should also be observed • Several swallows needed per mouthful
after the meal. It is important to observe food
• Frequent throat clearing during and after
trays and plates after a meal. This helps to
meals
identify residents with poor appetites. It may
also signal illness, a problem, such as dentures • Watering eyes when eating or drinking
that do not fit properly, or a change in food • Food or fluid coming up into the nose
preferences.
• Visible effort to swallow
All facilities keep track of how much food and
• Shorter or more rapid breathing while eating
liquid a resident consumes. The method varies.
or drinking
Some facilities use a percentage method. For ex-
ample: “R” Refused = 0% No food is eaten; “P” • Difficulty chewing food
Poor = 25% Very little food is eaten; “F” Fair = • Difficulty swallowing medications
50% Half of the food is eaten; “G” Good = 75%
Residents may have conditions that make eat-
Most of the food is eaten; and “A” All = 100%
ing or swallowing difficult. A stroke, or CVA,
Entire meal is eaten.
can cause weakness on one side of the body and
Other facilities may document the percentage paralysis. Nerve and muscle damage from head
of specific foods eaten—protein, carbohydrates, and neck cancer, multiple sclerosis, Parkinson’s
fats, etc. Follow your facility’s policy. Docu- or Alzheimer’s disease may be present. If a
ment food intake very carefully. Accuracy is resident has trouble swallowing, soft foods and
important. thickened liquids will be served. A special cup
will help make swallowing easier.
8. Identify signs and symptoms of Residents with swallowing problems may be
swallowing problems restricted to consuming only thickened liquids.
Thickening improves the ability to control fluid
Dysphagia means difficulty in swallowing. You
in the mouth and throat. A doctor orders the
need to be able to recognize and report signs
necessary thickness after the resident has been
that a resident has a swallowing problem. If
evaluated by a speech therapist. Special products
 211 8

are used for thickening. Some beverages arrive G Make sure mouth is empty before offering
already thickened from the dietary department. another bite of food or sip of drink.
In other facilities, the thickening agent is added
G Keep residents in the upright position for at
on the nursing unit before serving. If thickening

Nutrition and Hydration

least 30 minutes after eating and drinking.
is ordered, it must be used with all liquids. You
need to know what thickened liquids mean. Do When the digestive system does not function
not offer these residents regular liquids. Do not properly, hyperalimentation or total paren-
offer water, water pitchers, or any beverages to a teral nutrition (TPN) may be needed. With
resident who must have thickened liquids. Fol- TPN, a resident receives nutrients directly
low the directions for each resident. Three basic into the bloodstream. It bypasses the digestive
thickened consistencies are: system.

1. Nectar Thick: This consistency is thicker When a person is unable to swallow, he or she
than water. It is the thickness of a thick may be fed through a tube. A nasogastric
juice, such as a pear nectar or tomato juice. tube is inserted into the nose and goes to the
A resident can drink this from a cup. stomach. A tube can also be placed through the
skin directly into the stomach. This is called a
2. Honey Thick: This consistency has the thick-
percutaneous endoscopic gastrostomy (PEG)
ness of honey. It will pour very slowly. A
tube. The opening in the stomach and abdomen
resident usually uses a spoon to consume it.
is called a gastrostomy (Fig. 8-18). Tube feed-
3. Pudding Thick: With this consistency, the ings are used when residents cannot swallow
liquids have become semi-solid, much like but can digest food. Conditions that may prevent
pudding. A spoon should stand up straight swallowing include coma, cancer, stroke, refusal
in the glass when put into the middle of the to eat, or extreme weakness. Remember that
drink. A resident must consume these liq- residents have to the right to refuse treatment,
uids with a spoon. which includes insertion of tubes.
Swallowing problems put residents at high risk
for choking on food or drink. Inhaling food,
fluid, or foreign material into the lungs is called
aspiration. Aspiration can cause pneumonia or
death. Alert the nurse immediately if any prob-
lems occur while feeding.

Guidelines: Preventing Aspiration

G Position residents properly when eating.

They must sit in a straight, upright position.
Do not try to feed residents in a reclining
position.
G Offer small pieces or spoonfuls of food.
G Feed resident slowly.
Fig. 8-18. Nasogastric tubes are inserted through the
G Place food in the unaffected, or stronger, side nose. PEG tubes are inserted through the skin directly
of the mouth. into the stomach.
 8 212

NAs do not insert or remove tubes, do the feed- Skin sores or bruises
ing, or clean the tubes. You may take the per-
Cyanotic skin
son’s temperature or assemble equipment and
supplies and hand them to the nurse. You may Resident complaints of pain or nausea
Nutrition and Hydration

position the resident in a sitting position. You Choking or coughing

may also discard or clean used equipment and
supplies, clean, or store equipment and supplies. Vomiting
In addition, observe and document any changes Diarrhea
in the resident or problems with the feeding.
Swollen abdomen

Guidelines: Tube Feedings Fever

Tube falls out
G Make sure the tubing is not coiled or kinked
Problems with equipment
or resting underneath the resident.
Feeding pump alarm sounds
G Be aware if resident has an order for “noth-
ing by mouth,” or NPO. Resident’s inclined position changes
G The tube is only inserted and removed by
a doctor or nurse. If it comes out, report it 9. Describe how to assist residents with
immediately. special needs
G A doctor will prescribe the type and amount Residents with specific diseases or conditions,
of feeding. Do not place anything else into such as stroke, Parkinson’s disease, Alzheimer’s
the tube. The feedings will be in a liquid disease or other dementias, head trauma, blind-
form. The dietary department prepares them ness, or confusion may need special assistance
or they are prepackaged. when eating.
G During the feeding, the resident should
remain in a sitting position with the head
Guidelines: Dining Techniques
of the bed elevated at least 45 degrees. This
helps prevent serious problems, such as G Residents may benefit from physical and
aspiration. The elderly can develop pneumo- verbal cues. The hand-over-hand approach
nia or even die from improper positioning is an example of physical cuing. If a resident
during tube feedings. After the feeding, keep can help lift the utensils, put your hand over
the resident upright for as long as ordered, at his to help with eating. After the spoon is in
least 30 minutes. the resident’s hand, place your hand over the
G If your resident must remain in bed for long resident’s hand. Help the resident in getting
periods during feedings, give good skin care. some food on the spoon. Steer the spoon
This helps to prevent pressure sores on the from the food to the mouth and back. This
hips and sacral area. promotes independence.
G Verbal cues must be short and clear. They
Observing and Reporting: Tube Feedings should prompt the resident to do something.
Give verbal cues one at a time. Wait until the
Report any of these to the nurse immediately: resident has finished one task before asking
him or her to do another. Examples of verbal
Redness or drainage around the opening
cues include:
 213 8

• “Pick up your spoon.” G For residents who have Parkinson’s disease,

• “Put some carrots on your spoon.” tremors or shaking can make it difficult to
eat. Help by using physical cues. Place food
• “Raise the spoon to your lips.” and drinks close so that the resident can

Nutrition and Hydration

• “Open your mouth.” easily reach them. Use assistive devices as
needed.
• “Place the spoon in your mouth.”
G If a resident has poor sitting balance, seat
• “Close your mouth.”
him or her in a regular dining room chair
• “Take the spoon out of your mouth.” with armrests, rather than in a wheelchair.
• “Chew.” Proper position in chair means hips at a
90-degree angle, knees flexed, and feet and
• “Swallow.” arms fully supported. Push the chair under
• “Drink some water.” the table. Place forearms on the table. If a
resident tends to lean to one side, ask him or
G Use assistive devices such as utensils with
her to keep elbows on the table.
built-up handle grips, plate guards, and
drinking cups. These are ordered for specific G If a resident has poor neck control, a neck
residents. They should be included on the brace may be used to stabilize the head. Use
meal tray. assistive devices as needed. If resident is in a
geri-chair, a wedge cushion behind the head
G For visually-impaired residents, use the face
and shoulders may be used.
of an imaginary clock to explain the position
of what is in front of them (Fig. 8-19). G If the resident bites down on utensils, ask
him to open his mouth. Do not pull the
utensil out of the mouth. Wait until the jaw
relaxes.
G If the resident pockets food in his cheeks, ask
him to chew and swallow the food. Touch the
side of his cheek. Ask him to use his tongue
to get the food. Using your fingers on the
cheek (near the lower jaw), gently push food
toward teeth.
G If the resident holds food in his mouth, ask
him to chew and swallow the food. You may
need to trigger swallowing. To do this, gently
Fig. 8-19. Use the face of an imaginary clock to explain press down on the tongue when taking the
the position of food to visually-impaired residents.
spoon out of the mouth. You can also try to
G For residents who have had a stroke and have gently press down on the top of his head with
a paralyzed or weaker side, place food in the your hand. Make sure the resident has swal-
unaffected, or stronger, side of the mouth. lowed the food before offering more.
Make sure food is swallowed before offering
another bite.
G If a resident has “blind spots,” place food in
the resident’s field of vision. The nurse will
determine a resident’s field of vision.
 9 214

9
Rehabilitation and Restorative Care

Rehabilitation and Restorative

Care
1. Discuss rehabilitation and restorative
care
When a resident loses some ability to function
due to illness or injury, rehabilitation may be or-
dered. Rehabilitation is care that is managed by
professionals. It helps to restore a person to the
highest possible level of functioning. Rehabilita-
tion involves all parts of the person’s disability.
This includes physical (e.g. eating, elimination)
and psychosocial (e.g. independence, self-es- Fig. 9-1. A team of specialists, including doctors, physical
teem), needs. Goals of a rehabilitation program therapists, and other kinds of therapists, helps residents
with rehabilitation.
include:
• To help a resident regain function or recover
Guidelines: Restorative Care
from illness
• To develop and promote a resident’s G Be patient. Progress may be slow. The more
independence patient you are, the easier it will be for them
• To help a resident to feel in control of his or to regain abilities and confidence.
her life G Be positive and supportive.
• To help a resident accept or adapt to the G Focus only on small tasks and small
limitations of a disability accomplishments. Break tasks down into
Restorative care usually follows rehabilitation. small steps. Take everything one step at a
The goal is to keep the resident at the level time.
achieved by rehabilitative services. Both rehabili- G Recognize that setbacks occur. Progress
tation and restorative care take a team approach occurs at different rates. Reassure residents
(Fig. 9-1). that setbacks are normal.
Because you spend many hours with these resi- G Be sensitive to the resident’s needs. Some
dents, you are a very important part of the team. residents may need more encouragement
You play a critical role in recovery and indepen- than others. Some may be embarrassed by
dence. Follow these guidelines when helping encouragement. Understand what motivates
with restorative care: your residents.
 215 9

G Encourage independence. Independence The staff’s job is to keep residents as active as

improves self-image and attitude. It also possible—whether they are bedbound or are able
helps speed recovery. to walk (ambulate). Regular ambulation and ex-
ercise help improve these things:

Rehabilitation and Restorative Care

Observing and Reporting: Restorative Care • Quality and health of the skin
• Circulation
Any increase or decrease in abilities
• Strength
Any change in attitude or motivation, positive
• Sleep and relaxation
or negative
• Mood
Any change in general health, such as chang-
es in skin condition, appetite, energy level, or • Self-esteem
general appearance • Appetite
Signs of depression or mood changes • Elimination
• Blood flow
2. Describe the importance of promoting • Oxygen level
independence and list ways exercise Promoting social interaction and thinking abili-
improves health ties is important too. Most facilities have activi-
ties geared to residents’ ages and abilities. Social
Maintaining independence is vital during and
involvement should be encouraged. When pos-
after rehabilitation and restorative services.
sible, nursing assistants should join in activities
When an active and independent person be-
with residents. This promotes independence.
comes dependent, physical and mental problems
It also gives NAs a chance to observe residents’
may result. The body becomes less mobile. The
abilities.
mind is less focused. Studies show that the more
active a person is, the better the mind and body
work. 3. Discuss ambulation and describe
assistive devices and equipment
Inactivity and immobility can result in many
problems, including: Ambulation is walking. A resident who is am-
• Loss of self-esteem bulatory is one who can get out of bed and walk.
Many older residents are ambulatory, but need
• Depression
help to walk safely. Several tools, including gait
• Pneumonia belts, canes, walkers, and crutches, help with
• Urinary tract infection ambulation. Check the care plan before helping
a resident ambulate. Discuss the resident’s abili-
• Constipation
ties and disabilities with the nurse. Know the
• Blood clots resident’s limitations. Any time you help a resi-
• Dulling of the senses dent, communicate what you would like to do.
• Muscle atrophy Allow him to do what he can.

• Contractures Assisting a resident to ambulate

• Increased risk for pressure sores Equipment: gait belt, non-skid shoes for the resident
• Problems with independence and 1. Wash your hands.
self-esteem Provides for infection control.
 9 216

2. Identify yourself by name. Identify the resi-

dent by name.
Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
Rehabilitation and Restorative Care

establishes correct identification.

3. Explain procedure to resident. Speak clearly,

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

4. Provide for resident’s privacy with curtain,

screen, or door.
Maintains resident’s right to privacy and dignity. Fig. 9-2. Walk behind and to one side while holding onto
the gait belt when assisting with ambulation.
5. Before ambulating, properly fasten non-skid
footwear on resident. Without gait belt: Walk slightly behind and to
Promotes resident’s safety. Prevents falls. one side of resident for the full distance. Sup-
6. Adjust bed to a low position. Lock bed port resident’s back with your arm.
wheels. Assist resident to sitting position If the resident has a weaker side, stand on
with feet flat on the floor. that side. Use the hand that is not holding
Prevents injury and promotes stability. the belt or the arm not on the back to offer
7. Stand in front of and face resident. support on the weak side.

8. Brace resident’s lower extremities. Bend your 11. After ambulation, remove gait belt if used.
knees. Place one foot between the resident’s Help resident to the bed or chair and make
knees. If resident has a weak knee, brace it resident comfortable.
against your knee. 12. Return bed to lowest position. Remove pri-
Promotes proper body mechanics. Reduces risk of vacy measures.
back injury. Lowering the bed provides for safety.
9. With gait (transfer) belt: Place belt around 13. Place call light within resident’s reach.
resident’s waist over clothing (not on bare Allows resident to communicate with staff as
skin). Bend your knees and lean forward. necessary.
Grasp the belt on both sides. Hold him close 14. Wash your hands.
to your center of gravity. Tell the resident to Provides for infection control.
lean forward, push down on the bed with
15. Report any changes in resident to nurse.
her hands, and stand, on the count of three. Provides nurse with information to assess resident.
When you start to count, begin to rock. At
three, rock your weight onto your back foot. 16. Document procedure using facility
Assist resident to a standing position. guidelines.
What you write is a legal record of what you did. If
Without gait belt: Place arms around resi- you don’t document it, legally it didn’t happen.
dent’s torso under armpits, while assisting
resident to stand.
When helping a visually-impaired resident walk,
10. With gait belt: Walk slightly behind and to let the person walk beside and slightly behind
one side of resident for the full distance, you, as he rests a hand on your elbow. Walk at
while holding onto the gait belt (Fig. 9-2). a normal pace. Let the person know when you
 217 9

are about to turn a corner, or when a step is ap-

Guidelines: Cane or Walker Use
proaching. Tell him whether you will be step-
ping up or down. G Be sure the walker or cane is in good condi-

Rehabilitation and Restorative Care

Residents who have trouble walking may use tion. It must have rubber tips on bottom.
canes, walkers, or crutches to help themselves Walker may have wheels. If so, check the
(Fig. 9-3). Canes help with balance. Residents walker’s wheels for safety.
using canes should be able to bear weight on G Be sure the resident is wearing non-skid
both legs. If one leg is weaker, the cane should shoes that are securely fastened.
be held in the hand on the strong side.
G When using a cane, the resident should place
it on his stronger side.
G When using a walker, have the resident place
both hands on the walker. The walker should
not be over-extended. It should be placed no
more than 12 inches in front of the resident.
G Stay near the resident, on the weak side.
G Do not hang purses or clothing on the
walker.
Fig. 9-3. Canes, walkers, and crutches help with walking. G If height of the cane or walker does not
appear to be correct (too short, too tall, etc.),
A C cane is a straight cane with a curved handle
tell the nurse.
at the top. It has a rubber-tipped bottom to pre-
vent slipping. A C cane is used to improve bal- Assisting with ambulation for a resident using a
ance. A functional grip cane is similar to the C cane, walker, or crutches
cane, except that it has a straight grip handle,
Equipment: gait belt, non-skid shoes for resident,
rather than a curved handle. The grip handle
cane, walker, or crutches
helps improve grip control. It provides a little
more support than the C cane. A quad cane has 1. Wash your hands.
four rubber-tipped feet and a rectangular base. It Provides for infection control.
is designed to bear more weight than the other 2. Identify yourself by name. Identify the resi-
canes. dent by name.
A walker is used when the resident can bear Resident has right to know identity of his or her care-
giver. Addressing resident by name shows respect and
some weight on the legs. The walker gives stabil-
establishes correct identification.
ity for residents who are unsteady or lack bal-
ance. The metal frame may have rubber-tipped 3. Explain procedure to resident. Speak clearly,
feet and/or wheels. Crutches are used for resi- slowly, and directly. Maintain face-to-face con-
dents who can bear no weight or limited weight tact whenever possible.
on one leg. Some people use one crutch. Some Promotes understanding and independence.
use two. 4. Provide for resident’s privacy with curtain,
Your role is to ensure safety with any of these screen, or door.
devices. Stay near the person, on the weak side. Maintains resident’s right to privacy and dignity.
Make sure the equipment is in proper condition. 5. Before ambulating, properly fasten non-skid
It must be sturdy, and it must have rubber tips footwear on resident.
or wheels on the bottom. Promotes resident’s safety. Prevents falls.
 9 218

6. Adjust bed to a low position. Lock bed c. Crutches. Resident should be fitted for
wheels. Assist resident to sitting position crutches and taught to use them correctly by
with feet flat on the floor. a physical therapist or nurse. The resident
Prevents injury and promotes stability. may use the crutches several different ways.
Rehabilitation and Restorative Care

7. Stand in front of and face resident. It depends on what his weakness is. No
matter how they are used, weight should be
8. Brace resident’s lower extremities. Bend your on the resident’s hands and arms. Weight
knees. Place one foot between the resident’s should not be on the underarm area.
knees. If resident has a weak knee, brace it
against your knee. 11. Walk slightly behind and to one side of resi-
Promotes proper body mechanics. Reduces risk of dent. Stay on the weaker side if resident has
back injury. one. Hold the gait belt if one is used.
Provides security.
9. Place gait belt around resident’s waist over
clothing (not on bare skin). Grasp the belt on 12. Watch for obstacles in the resident’s path.
both sides, while helping resident to stand as Ask the resident to look ahead, not down at
previously described. his feet.
Promotes resident’s safety. Promotes resident’s safety. Prevents injury.
10. Help as needed with ambulation. 13. Encourage resident to rest if he is tired.
a. Cane. Resident places cane about 12 inches When a resident is tired, it increases the
in front of his stronger leg. He brings weaker chance of a fall. Let resident set the pace.
leg even with cane. He then brings stronger Discuss how far he plans to go based on the
leg forward slightly ahead of cane. Repeat. care plan.
Prevents falls.
b. Walker. Resident picks up or rolls the walker.
He places it about 12 inches in front of him. 14. After ambulation, remove gait belt. Help resi-
All four feet or wheels of the walker should dent to a position of comfort and safety.
be on the ground before resident steps for- 15. Leave bed in lowest position. Remove privacy
ward to the walker. The walker should not be measures.
moved again until the resident has moved
both feet forward and is steady (Fig. 9-4). The 16. Place call light within resident’s reach.
resident should never put his feet ahead of Allows resident to communicate with staff as
necessary.
the walker.
Promotes stability and prevents falls. 17. Wash your hands.
Provides for infection control.

18. Report any changes in resident to nurse.

Provides nurse with information to assess resident.

19. Document procedure using facility

guidelines.
What you write is a legal record of what you did. If
you don’t document it, legally it didn’t happen.

Many devices are available to help people who

are recovering from or adapting to a physi-
Fig. 9-4. The walker can be moved after the resident is cal condition. Assistive or adaptive devices
steady and both feet are forward.
are equipment that helps residents perform
 219 9

their ADLs. Each device supports a particular help residents maintain good alignment and
disability. make progress when they can get out of bed:
Personal care equipment includes long-handled

Rehabilitation and Restorative Care

brushes and combs. Plate guards prevent food Guidelines: Alignment and Positioning
from being pushed off the plate. They make it
easier to scoop food onto utensils. Reachers can G Observe principles of alignment. Proper
help put on underwear or pants. A sock aid can alignment is based on straight lines. The
pull on socks. A long-handled shoehorn assists spine should be in a straight line. Pillows
in putting shoes on without bending. Long-han- or rolled or folded blankets can support the
dled sponges help with bathing. small of the back and raise the knees or head
in the supine position. They can support the
Supportive devices, such as canes, walkers, and
head and one leg in the lateral position.
crutches, are used to assist residents with am-
bulation. Safety devices, such as shower chairs G Keep body parts in natural positions. In a
and gait or transfer belts, help prevent accidents. natural hand position, the fingers are slightly
Safety bars/grab bars are often installed in and curled. Use a rolled washcloth, gauze ban-
near the tub and toilet to give the resident some- dage, or a rubber ball inside the palm to
thing to hold on to while changing position. support the fingers in this position (Fig. 9-6).
More examples of adaptive devices are shown in Use bed cradles to keep covers from rest-
Figure 9-5. ing on feet in the supine position. Use foot-
boards to keep the resident’s feet properly
aligned.

Fig. 9-6. Handrolls help keep fingers from curling too

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

Fig. 9-5. Many adaptive items are available to help resi-

G Prevent external rotation of hips. When legs
dents adapt to physical changes. (photos courtesy of north coast
medical, inc. 800-821-9319) and hips turn outward during bedrest, hip
contractures can result. A rolled blanket or
towel tucked alongside the hip and thigh can
4. Explain guidelines for maintaining keep the leg from turning outward.
proper body alignment G Change positions often to prevent muscle
Residents who are confined to bed need proper stiffness and pressure sores. This should be
body alignment. This aids recovery and prevents done at least every two hours. The position
injury to muscles and joints. These guidelines used will depend on the resident’s condition
 9 220

and preference. Check the skin every time • Artificial limbs, such as for the hands, arms,
you reposition the resident. feet, and legs, are made to resemble the
body part that they are replacing (Fig. 9-8).
G Have plenty of pillows available to provide
Rehabilitation and Restorative Care

support in the various positions. • An artificial breast is made of a lightweight,

soft, spongy material.
G Use positioning devices (backrests, bed
cradles, draw sheets, footboards, and han- • An artificial eye, or ocular prosthetic, re-
drolls). Splints may be prescribed by a doc- places an eye that has been lost to disease or
tor to keep a resident’s joints in the correct injury.
position (Fig. 9-7). See Chapter 6 for more on • Dentures are artificial teeth. They may be
positioning devices. necessary when a tooth or teeth have been
damaged, lost, or must be removed.
• A hearing aid is a small, battery-operated
device that amplifies sound for persons with
hearing loss.

Fig. 9-7. One type of splint. (photo courtesy of lenjoy medical Fig. 9-8. One type of prosthetic arm. (motion control utah arm.
engineering “comfy splints tm” 800-582-5332, www.comfysplints.com)
photo by kevin twomey.)

G Give back rubs as ordered for comfort and

relaxation. Guidelines: Amputation and Prosthesis Care

G Residents who have had a body part ampu-

5. Describe care guidelines for prosthetic tated must make many physical, psychologi-
devices cal, social, and occupational adjustments to
their disability. Be supportive.
Amputation is the removal of some or all of
a body part. It is usually a foot, hand, arm or G Help residents with their ADLs.
leg. Amputation may be the result of an injury G Prostheses are specially-fitted, expensive
or disease. After amputation, some people feel pieces of equipment (some cost tens of thou-
that the limb is still there. They may feel pain sands of dollars). Care for them as assigned.
in the part that has been amputated. This is Handle them carefully.
called “phantom sensation.” It may last for a
G A nurse or therapist will demonstrate applica-
short time or for years. The pain or sensation is
tion of a prosthesis. Follow instructions to
caused by remaining nerve endings. It is real. It
apply and remove the prosthesis. Follow the
should not be ignored or made fun of.
manufacturer’s care directions.
A prosthesis is a device that replaces a body
G Keep a prosthesis and the skin under it dry
part that is missing or deformed because of an
and clean. The socket of the prosthesis must
accident, injury, illness, or birth defect. It is used
be cleaned at least daily. Follow the care plan
to improve a person’s ability to function and/or
and the nurse’s instructions.
to improve appearance. Examples of prostheses
include: G If ordered, apply a stump sock before putting
on the prosthesis.
 221 9

G Observe the skin on stump. Watch for signs You will not do ROM exercises without an order
of skin breakdown caused by pressure and from a doctor, nurse, or physical therapist. Fol-
abrasion. Report any redness or open areas. low the care plan. You will repeat each exercise
three to five times, once or twice a day. You will

Rehabilitation and Restorative Care

G Never try to fix a prosthesis. Report any prob-
work on both sides of the body. During ROM ex-
lems to the nurse.
ercises, begin at the resident’s head. Work down
G Do not show negative feelings about the the body. Exercise the upper extremities (arms)
stump during care. before the lower extremities (legs). Give support
G Phantom sensation is real pain. Treat it that above and below the joint. Stop the exercises if
way. Report complaints of pain to the nurse. the resident complains of pain. Report pain to
the nurse.
G If the resident has an artificial eye, review the
care plan with the nurse. Artificial eyes are These exercises are specific for each body area.
made of glass or plastic. Handle them care- They include these movements (Fig. 9-9):
fully. Never clean or soak the eye in alcohol.
It will crack the plastic and destroy it. If the • Abduction: moving a body part away from
eye must be removed, store it in water or the midline of the body
saline solution. Make sure the container is • Adduction: moving a body part toward the
labeled with the resident’s name and room midline of the body
number. The resident will usually know how
to remove, clean, and insert the eye. Know • Dorsiflexion: bending backward
any instructions for assisting with care.
• Rotation: turning a joint
G If the person has a hearing aid, make sure
he or she is wearing it and that it is working • Extension: straightening a body part
properly. • Flexion: bending a body part

• Pronation: turning downward

6. Describe how to assist with range of
motion exercises • Supination: turning upward
Range of motion (ROM) exercises put a joint
through its full arc of motion. The goal of ROM
exercises is to decrease or prevent contractures,
improve strength, and increase circulation. Pas-
sive range of motion (PROM) exercises are used • Abduction • Adduction • Dorsiflexion • Rotation

when residents cannot move on their own. A

staff member performs these exercises without
the resident’s help. When helping with PROM
exercises, support the resident’s joints. Move • Extension • Flexion • Pronation • Supination

them through the range of motion. Active range Fig. 9-9. Different range of motion body movements.
of motion (AROM) exercises are done by a resi-
dent himself. Your role in AROM exercises is Assisting with passive range of motion
to encourage the resident. Active assisted range exercises
of motion (AAROM) exercises are done by the
resident with some help and support from a staff 1. Wash your hands.
Provides for infection control.
member.
 9 222

2. Identify yourself by name. Identify the resi- Raise the arm to side position above head
dent by name. and return arm to side of the body. (abduc-
Resident has right to know identity of his or her care- tion/adduction) (Fig. 9-11).
giver. Addressing resident by name shows respect and
Rehabilitation and Restorative Care

establishes correct identification.

3. Explain procedure to resident. Speak clearly,

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

4. Provide for resident’s privacy with curtain,

screen, or door.
Maintains resident’s right to privacy and dignity.

5. Adjust bed to a safe level, usually waist high. Fig. 9-11.

Lock bed wheels.
Prevents injury to you and to resident. 9. Elbow. Hold the wrist with one hand. Hold
6. Position the resident lying supine—flat on the elbow with the other hand. Bend elbow
his or her back—on the bed. Position body in so that the hand touches the shoulder on
good alignment. that same side (flexion). Straighten arm (ex-
Reduces stress to joints. tension) (Fig. 9-12).

7. Repeat each exercise at least three times.

While supporting the limbs, move all joints
gently, slowly, and smoothly through the
range of motion to the point of resistance.
Stop if any pain occurs.
Rapid movement may cause injury. Pain is a warn-
ing sign for injury.

8. Shoulder. Support resident’s arm at elbow

and wrist while performing ROM for the
shoulder. Place one hand under the elbow Fig. 9-12.
and the other hand under the wrist. Raise the
Exercise forearm by moving it so palm is fac-
straightened arm from the side position for-
ing downward (pronation) and then upward
ward to above the head and return arm
(supination) (Fig. 9-13).
to side of the body (flexion/extension)
(Fig. 9-10).

Fig. 9-13.

10. Wrist. Hold the wrist with one hand. Use the
fingers of the other hand to help the joint
Fig. 9-10.
through the motions. Bend the hand down
 223 9

(flexion). Bend the hand backwards (exten-

sion) (Fig. 9-14).

Rehabilitation and Restorative Care

Fig. 9-17.

Bend thumb into the palm (flexion) and out

to the side (extension) (Fig. 9-18).

Fig. 9-14.

Turn the hand in the direction of the thumb

(radial flexion). Then turn the hand in the di-
rection of the little finger (ulnar flexion)
(Fig. 9-15).
Fig. 9-18.

12. Fingers. Make the hand into a fist (flexion).

Gently straighten out the fist (extension)
(Fig. 9-19).

Fig. 9-15.
Fig. 9-19.

11. Thumb. Move the thumb away from the index Spread the fingers and the thumb far apart
finger (abduction). Move the thumb back from each other (abduction). Bring the fin-
next to the index finger (adduction) gers back next to each other (adduction)
(Fig. 9-16). (Fig. 9-20).

Fig. 9-20.

Fig. 9-16. 13. Hip. Support the leg by placing one hand
under the knee and one under the ankle.
Touch each fingertip with the thumb (opposi- Straighten the leg. Raise it gently upward.
tion) (Fig. 9-17). Move the leg away from the other leg (abduc-
 9 224

tion). Move the leg toward the other leg (ad- ion). Return leg to resident’s normal position
duction) (Fig. 9-21). (extension) (Fig. 9-23).
Rehabilitation and Restorative Care

Fig. 9-23.

15. Ankles. Push/pull foot up toward head (dor-

siflexion). Push/pull foot down, with the toes
pointed down (plantar flexion) (Fig. 9-24).

Fig. 9-21.

Gently turn the leg inward (internal rotation).

Turn the leg outward (external rotation)
(Fig. 9-22).

Fig. 9-24.

Turn inside of the foot inward toward the

body (supination). Bend the sole of the foot
away from the body (pronation) (Fig. 9-25).

Fig. 9-22.

14. Knees. Support the leg under the knee and

ankle while performing ROM for the knee.
Fig. 9-25
Bend the leg to the point of resistance (flex-
 225 9

16. Toes. Curl and straighten the toes (flexion tify the nurse or the physical therapist if you
and extension) (Fig. 9-26). find increased stiffness or physical resistance.
Resistance may be a sign that a contracture
is developing.

Rehabilitation and Restorative Care

What you write is a legal record of what you did. If
you don’t document it, legally it didn’t happen.

7. List guidelines for assisting with

bladder and bowel retraining
Injury, illness, or inactivity may cause a loss of
Fig. 9-26.
normal bladder or bowel function. Residents
may need help to re-establish a regular routine
Gently spread the toes apart (abduction)
and function. Problems with elimination can be
(Fig. 9-27).
embarrassing or difficult to talk about. Be sensi-
tive. Always be professional when handling in-
continence or helping to re-establish routines.

Guidelines: Bladder or Bowel Retraining

G Follow Standard Precautions. Wear gloves

when handling body wastes.
G Explain the training schedule to the resident.
Follow the schedule carefully.
G Keep a record of the resident’s bladder and
bowel habits. When you see a pattern of elim-
Fig. 9-27. ination, you can predict when the resident
will need a bedpan or a trip to the bathroom.
17. Return resident to comfortable position. Re- G Offer a commode or a trip to the bathroom
turn bed to lowest position. Remove privacy before beginning long procedures.
measures.
Promotes resident’s safety. G Encourage residents to drink plenty of fluids.
Do this even if urinary incontinence is a prob-
18. Place call light within resident’s reach. lem. About 30 minutes after fluids are taken,
Allows resident to communicate with staff as
offer a trip to the bathroom or a bedpan or
necessary.
urinal.
19. Wash your hands.
G Encourage the resident to eat foods that are
Provides for infection control.
high in fiber. Encourage residents to follow
20. Report any changes in resident to nurse. special diets, as ordered.
Provides nurse with information to assess resident.
G Answer call lights promptly. Residents cannot
21. Document procedure using facility guide- wait long when the urge to go to the bath-
lines. Note any decrease in range of motion room occurs. Leave call lights within reach
or any pain experienced by the resident. No- (Fig. 9-28).
 9 226

G Some facilities use washable bed pads or

briefs. Follow Standard Precautions when
handling these items.
Rehabilitation and Restorative Care

G Keep an accurate record of urination and

bowel movements. This includes episodes of
incontinence.
G Praise successes and attempts to control
bowel and bladder. However, do not talk to
residents as if they are children. Keep your
voice low. Do not draw attention to any
aspect of retraining.
Fig. 9-28. Leave call lights within reach. Answer call
lights promptly. G Never show frustration or anger toward resi-
dents who are incontinent. This is considered
G Provide privacy for elimination—both in the abusive behavior. The problem is out of their
bed and in the bathroom. control. Negative reactions will only make
G If a resident has trouble urinating, try run- things worse. Be positive. Be patient when
ning water in the sink. Have him or her lean setbacks occur.
forward slightly. This puts pressure on the When the resident is incontinent or cannot
bladder. toilet when asked, be positive. Never make the
G Do not rush the resident. resident feel like a failure. Praise and encour-
agement are essential for a successful program.
G Help residents with good perineal care.
Some residents will always be incontinent. Offer
Urine and feces are irritating to the skin.
these persons extra care and attention. Skin
Giving proper, regular care helps prevents
breakdown may lead to pressure sores without
skin breakdown. It promotes proper hygiene.
proper care. Always report changes in skin.
Carefully observe for skin changes.
G Discard wastes according to facility rules. Residents’ Rights
G Discard clothing protectors and incontinence Bladder and Bowel Retraining
briefs properly (Fig. 9-29). Some facilities When residents need help with bladder and/or bowel
function, be kind, supportive, and professional. This
require double-bagging these items. This helps promote dignity. Residents have a legal right
stops odors from collecting. to privacy. Do not discuss accidents or any part of
retraining in public areas. When incontinence briefs
are used, do not refer to them as “diapers.” Resi-
dents are not children. This is disrespectful.

Fig. 9-29. A type of incontinence pad.

 227 10

10

Caring for Yourself

Caring for Yourself

1. Describe how to find a job • Identification, including driver’s license, so-

cial security card, birth certificate, passport,
You may soon be looking for a job. Nursing as- or other official form of identification
sistants may be able to work in long-term care
facilities, in assisted living facilities, in hospitals, • Proof of your legal status in this country and
in the home, and in other places. To find a job, proof that you are legally able to work, even
you must first find potential employers. Then if you are a U.S. citizen. Employers must
you must contact them to find out about job op- have files showing that employees are legally
portunities. To find employers, use the Internet, allowed to work in this country. Do not be
newspaper, telephone book, or personal contacts upset by this request.
(Fig. 10-1). You can also ask your instructor • High school diploma or equivalency, school
about potential employers. transcripts, and diploma or certificate from
your nursing assistant training course. Take
the name and phone number of your in-
structor with you as well.
• Contact information for references. Refer-
ences are people who can be called to recom-
mend you as an employee. They can include
former employers or former teachers. Do
not use relatives or friends. You can ask
them beforehand to write letters for you, ad-
Fig. 10-1. Searching the Internet is one good way to find dressed “To whom it may concern,” explain-
a job.
ing how they know you and describing your
Once you have a list of potential employers, you skills, qualities, and habits. Take copies of
need to contact them. Phoning first, unless they these with you.
mention not to do so, is a good way to find out Some potential employers will ask you for a
what jobs are available. Ask how to apply for a résumé. A résumé is a summary or listing of
job with each potential employer. relevant job experience and education. When
When making an appointment, ask what infor- creating your résumé, keep it brief (one page is
mation to bring with you. Make sure you have it best) and clear. Include this information:
when you go. Some of these documents may be • Your contact details: name, address, tele-
required: phone number, e-mail address
10 228

• A list of your educational experience, start- is being asked, find out before filling in that
ing with the most current first space. Fill in all of the blanks. Write “N/A” (not
applicable) if the question does not apply to you.
• A list of your work experience, starting with
Caring for Yourself

the most current first By law, your employer must do a criminal back-
ground check on all new aides hired. You may
• Any special skills, such as knowledge of
be asked to sign a form granting permission to
computer software, typing skills, or speaking
do this. Do not take it personally. It is a law in-
other languages
tended to protect patients, clients, and residents.
• Any memberships in professional
Use these tips to make the best impression at a
organizations
job interview:
• Volunteer work
• Shower or bathe. Use deodorant.
You may need to fill out a job application. On
• Brush your teeth.
one sheet of paper, write down the general in-
formation you will need. Take it with you, along • Apply makeup lightly.
with your résumé, if you have one. This will save
• Trim and clean your nails.
time and avoid mistakes. Include the following
information: • Style clean hair simply.

• Your address and phone number • Shave or trim facial hair before the interview
(men).
• Your birth date
• Dress neatly and appropriately. Make sure
• Your social security number
clothing is clean, ironed, and has no holes
• Name and address of the school or program in it. Avoid wearing jeans, shorts, or short
where you were trained and the date you dresses or skirts. Shoes should be clean and
completed it, as well as certification num- polished.
bers and expiration dates from a certification
• Wear little or no jewelry.
card, if you have one
• Do not wear perfume or cologne.
• Names, titles, addresses, and phone num-
bers of former employers, and the dates you • Arrive 10 or 15 minutes early.
worked there • Introduce yourself. Smile and shake hands
• Salary information from your former jobs (Fig. 10-2). Your handshake should be firm
and confident.
• Reasons why you left each of your former
jobs
• Names, addresses, and phone numbers of
your references
• Days and hours you can work
• A brief statement of why you are changing
jobs or why you want to work as a nursing
assistant
Fill out the application carefully and neatly.
Never lie. Before you write anything, read it all Fig. 10-2. Smile and shake hands confidently when you
arrive at a job interview.
the way through. If you do not understand what
 229 10

• Answer questions clearly and completely. • How soon will you be making a decision
about this position?
• Make eye contact to show you are sincere
(Fig. 10-3). Later in the interview, you may want to ask

Caring for Yourself

about salary if you have not already been told
• Avoid slang words or expressions.
what it would be. Listen carefully to the answers
• Never eat, drink, chew gum, or smoke in an to your questions. Take notes if needed. You will
interview. probably be told when you can expect to hear
• Sit up or stand up straight. Look happy to be from the employer. Do not expect to be offered a
there. job at the interview. When the interview is over,
stand up and shake hands again. Thank the em-
• Do not bring friends or children with you.
ployer for meeting with you.
• Relax. You have worked hard to get this far.
Send a thank-you letter after every job interview.
Be confident!
This states your continued interest in the job.
If you have not heard back from the employer
within the time frame you discussed with the
interviewer, call and ask if the job was filled.

2. Describe a standard job description

A job description is an agreement between the
employer and the employee. It states the respon-
sibilities and tasks of the job. It also includes the
Fig. 10-3. Be polite and make eye contact while skill required for the job, to whom the employee
interviewing. must report, and the salary range.
The job description provides protection for both
Be positive when answering questions. Empha-
parties. It protects the employee from the facility
size what you enjoy or think you will enjoy about
changing duties without notifying the employee.
being a nursing assistant. Do not complain
It protects the employee from being fired based
about previous jobs. Make it clear that you are
on something not related to his or her job de-
hardworking and willing to work with all kinds
scription. The employer is protected from the
of residents, clients and patients.
employee saying he or she did not know certain
Usually interviewers will ask if you have any duties were part of the job. The job description
questions. Have some prepared. Write them helps reduce misunderstandings. It can be used
down so you do not forget things you really want to document what was agreed upon if legal is-
to know. Questions you may want to ask include: sues occur.
• What hours would I work?
• What benefits does the job include? Is health 3. Discuss how to manage and resolve
insurance available? Would I get paid sick conflict
days or holidays?
Everyone experiences conflict at some point in
• What orientation or training will be his or her life. For example, families may argue
provided? at home, co-workers may disagree on the job,
• How will I communicate with my supervisor and so on. If conflict at work is not managed
when I have questions? or resolved, it may affect the ability to func-
10 230

tion well. The work environment may suffer. 4. Describe employee evaluations
When conflict occurs, there is a proper time and discuss appropriate responses to
and place to address it. You may need to talk to criticism
your supervisor for help. In general, follow these
Caring for Yourself

guidelines: Handling criticism is hard for most people.

Being able to accept and learn from criticism is
important in all relationships, including employ-
Guidelines: Resolving Conflict
ment. From time to time you will get evaluations
from your employer. They contain ideas to help
G Discuss the issue at the right time. Do not
you improve your job performance. Here are
start a conversation while you are helping
some tips for handling criticism and using it to
residents. Wait until the supervisor has decid-
your benefit:
ed on the right time and place. Privacy is
important. Shut the door. Limit distractions, • Listen to the message that is being sent. Do
such as TV and conversations. not get so upset that you cannot understand
the message.
G Agree not to interrupt the person. Do not be
rude or sarcastic, or name-call. Listen. Take • Hostile criticism and constructive criticism
turns speaking. are not the same. Hostile criticism is angry
and negative. Examples are, “You are use-
G Do not get emotional. Some situations may
less!” or, “You are lazy and slow.” Hostile
be upsetting. However, you will be more
criticism should not come from your em-
effective if you can keep your emotions out of
ployer or supervisor. You may hear hostile
it.
criticism from residents, family members,
G Check your body language. Make sure it is or others. The best response is something
not tense, unwelcoming, or threatening. like, “I’m sorry you are so disappointed,”
Maintain eye contact. Use a posture that says and nothing more. Give the person a chance
you are listening and interested. Lean forward to calm down before trying to discuss their
slightly. Do not slouch. comments.

G Keep the focus on the issue at hand. When • Constructive criticism may come from your
discussing conflict, state how you feel when employer, supervisor, or others. Construc-
a behavior occurs. Use “I” statements. First tive criticism is meant to help you improve.
describe the actual behavior. Then use “feel- Examples are, “You really need to be more
ing” words to describe how you feel. Let the accurate in your charting,” or, “You are late
person know how the problem has affected too often. You’ll have to make more of an ef-
you. For example, “When you are late to fort to be on time.” Listening to and acting
work, I feel upset because I end up doing on constructive criticism can help you be
your work along with my own.” more successful in your job. Pay attention to
it (Fig. 10-4).
G People involved in the conflict may need to
come up with possible solutions. Think of • If you are not sure how to avoid a mistake
ways that the conflict can be resolved. A solu- you have made, always ask for suggestions.
tion may be chosen by a supervisor that does Avoiding mistakes will help you improve
not satisfy everyone. You may have to com- your performance.
promise. Be prepared to do this.
 231 10

If you decide to change jobs, be responsible. Al-

ways give your employer at least two weeks’ writ-
I think you are having
a problem organizing ten notice that you will be leaving. Otherwise,
your facility may be understaffed. Both the resi-

Caring for Yourself

your time.
dents and other staff will suffer. Future employ-
ers may talk with past supervisors. People who
change jobs too often or who do not give notice
before leaving are less likely to be hired.

Yes, I have felt 5. Discuss certification and explain the

rushed lately. Do you have state’s registry
any suggestions on how I
can prioritize my tasks? To meet OBRA’s requirements, states must
regulate nursing assistant training, evaluation,
and certification. OBRA requires 75 hours as
the minimum level of initial training and a 12-
Fig. 10-4. Ask for suggestions when receiving constructive hour minimum for annual continuing education
criticism. (called “in-services”). Many states’ requirements
exceed the minimum hours. It is a good idea to
• Apologize and move on. If you have made
know your state’s rules.
a mistake, apologize as needed (Fig. 10-5).
This may be to your supervisor, a resident, After completing an approved training program,
or others. Learn from the incident and put NAs are given a competency evaluation (a certifi-
it behind you. Do not dwell on it or hold a cation exam or test) so that they can be certified
grudge. Responding professionally to criti- to work in a state. This exam usually has both
cism is important for success in any job. a written and skills evaluation. You must pass
both parts in order to be certified to work as a
nursing assistant.
I’m sorry I’ve been
late several times this month. OBRA also requires that each state keep a reg-
I know it’s inconvenient for you. istry of nursing assistants. This registry is kept
I am making more of an effort to
be on time, and I expect not to by a state department. Often this is the state’s
be late again. Department of Health. The registry contains
NA training information and results of certifica-
tion exams. It also has any findings of abuse,
neglect or theft by nursing assistants. Employers
Fig. 10-5. Be willing to apologize if you have made a are able to access this list to check if you have
mistake.
passed the certification exam. They can see if
your certification is current. They are also able
Evaluations will also cover overall knowledge,
to see if you have been investigated or found
conflict resolution, and team effort. Flexibility,
guilty of any abuse or neglect.
friendliness, trustworthiness, and customer
service will also be considered. Evaluations Each state has different requirements for main-
are often the basis for salary increases. A good taining certification. Follow them exactly or you
evaluation can help you advance within the facil- will not be able to keep working. Once you are
ity. Being open to criticism and suggestions for certified, you can lose your certification if you
improvement will help you be more successful. fail to follow your state’s rules. This can occur
10 232

if you do not work in long-term care for a pe- 7. Explain ways to manage stress
riod of time or fail to get the required number
of continuing education hours. You can also Stress is the state of being frightened, excited,
lose certification due to criminal activities, in- confused, in danger, or irritated. We may think
Caring for Yourself

cluding abuse and neglect. Learn your state’s only bad things cause stress. However, positive
requirements. situations cause stress, too. For example, getting
married or having a baby are usually positive
situations. But both can bring enormous stress
6. Describe continuing education from the changes they bring to our lives.
The federal government requires nursing as- You may be thrilled when you get a new job.
sistants have 12 hours of continuing education Starting work may also cause you stress. You
each year. Some states may require more. In-ser- may be afraid of making mistakes, excited about
vice continuing education courses help you keep earning money or helping people, or confused
your knowledge and skills fresh. Classes also about your new duties. Learning how to recog-
give new information about conditions, chal- nize stress and its causes is helpful. Then you
lenges in working with residents, or regulation can master a few simple methods for relaxing
changes. You need to be up-to-date on the latest and learn to manage stress.
that is expected of you. A stressor is something that causes stress. Any-
Your employer is responsible for offering in- thing can be a stressor. Some examples are:
service courses. You are responsible for attend- • Divorce
ing and completing them. You must do the
following: • Marriage

• Sign up for the course or find out where it is • New baby

offered. • Parenthood
• Attend all class sessions. • Children growing up
• Pay attention and complete all the class • Children leaving home
requirements.
• Feeling unprepared for a task
• Make the most of your in-service programs.
• Starting a new job
Participate! (Fig. 10-6)
• New responsibilities at work
• Losing a job
• Problems at work
• Supervisors
• Co-workers
• Residents
• Illness
Fig. 10-6. Pay attention and participate during in-service
courses. • Finances

• Keep original copies of all certificates and Stress is not only an emotional response. It is
records of your successful attendance so you also a physical response. When we have stress,
can prove you took the class. changes occur in our bodies. The endocrine
 233 10

system may make more of the hormone adrena- Not managing stress can cause many problems.
line. This can increase nervous system response, Some of these problems will affect how well you
heart rate, respiratory rate, and blood pressure. do your job. Signs that you are not managing
This is why, in stressful situations, your heart stress include:

Caring for Yourself

beats fast, you breathe hard, and you feel warm
• Showing anger or being abusive toward
or perspire.
residents
Each of us has a different tolerance level for
• Arguing with your supervisor about
stress. What one person would find overwhelm-
assignments
ing may not bother another person. Your toler-
ance for stress depends on your personality, life • Having poor relationships with co-workers
experiences, and physical health. and residents
• Complaining about your job and your
Guidelines: Managing Stress responsibilities
• Feeling work-related burnout (burnout is
To manage stress in your life, develop healthy
a state of mental or physical exhaustion
habits of diet, exercise, and lifestyle:
caused by stress)
G Eat nutritious foods.
• Feeling tired even when you are rested
G Exercise regularly (Fig. 10-7). You can exer-
• Having trouble focusing on residents and
cise alone or with a partner.
procedures
Stress can seem overwhelming when you try to
handle it yourself. Often just talking about stress
can help you manage it better. Sometimes an-
other person can offer helpful suggestions. You
may think of new ways to handle stress just by
talking it through. Get help from one or more of
these when managing stress:
• Your supervisor or another member of the
care team for work-related stress
• Your family
• Your friends
• Your place of worship
Fig. 10-7. Regular exercise, such as walking, is one
healthy way to decrease stress. • Your doctor
• A local mental health agency
G Get enough sleep.
• Any phone hotline that deals with related
G Drink only in moderation.
problems (check the Internet or your local
G Do not smoke. yellow pages )
G Find time at least a few times a week to do It is not appropriate to talk to your residents or
something relaxing, such as reading a book their family members about your personal or
or watching a movie. job-related stress.
10 234

One of the best ways of managing stress is to sometimes life versus death. Look in the face of
develop a plan. The plan can include nice things each of your residents. Know that you are doing
you will do for yourself every day and things to important work. Look in a mirror when you get
do in stressful situations. Before making a plan, home. Be proud of how you make your living
Caring for Yourself

you first need to answer these questions: (Fig. 10-8).

• What are the sources of stress in my life?
• When do I most often feel stress?
• What effects of stress do I see in my life?
• What can I change to decrease my stress?
• What do I have to learn to cope with because
I cannot change it?
When you have answered these questions, you
will have a clearer picture of the challenges you
face. Then you can come up with strategies for
managing stress. Fig. 10-8. Be proud of the work you have chosen to do. It
Sometimes a relaxation exercise can help you is important.
feel refreshed and relaxed in a short time. 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
each body part. Move up from the feet, focusing
on and relaxing the legs, knees, thighs, hips,
stomach, back, shoulders, neck, jaw, eyes, fore-
head, and scalp. Take a few very deep breaths.
Open your eyes.
Look back over all you have learned in this pro-
gram. Your work as a nursing assistant is very
important. Every day may be different and chal-
lenging. In a hundred ways every week you will
offer help that only a caring person like you can
give.
Value the work you have chosen to do. It is im-
portant. Your work can mean the difference
between living with independence and dignity
and living without. The difference you make is
 235

Abbreviations
Abbreviations F
FF
Fahrenheit or female
force fluids
OOB
oz
out of bed
ounce
ft foot p after
a before
h, hr, hr. hour peri care perineal care
ADL activities of daily
living H2O water per os, PO by mouth

am, AM morning, before HBV hepatitis B virus PPE  ersonal protective

p
noon HOB head of bed equipment

amb ambulate, ht height p.r.n., prn when necessary

ambulatory q every
HTN hypertension
amt amount q2h every two hours
hyper a bove normal, too
ap apical fast, rapid q3h every three hours
as tol as tolerated hypo low, less than q4h every four hours
ax. axillary (armpit) normal
R respirations, rectal
b.i.d., BID two times a day I&O intake and output
rehab rehabilitation
BM bowel movement inc incontinent
RF restrict fluids
BP, B/P blood pressure isol isolation
ROM range of motion
BPM beats per minute IV, I.V. intravenous (within
a vein) s without
BRP bathroom privileges
lab laboratory SOB shortness of breath
c with
lb. pound spec. specimen
C Centigrade
LTC long-term care stat immediately
cath. catheter
meds medications std. prec. Standard
CHF c ongestive heart Precautions
failure mL milliliter
T., temp temperature
c/o complains of mmHg  illimeters of
m
mercury TB tuberculosis
COPD chronic obstructive
MRSA methicillin-resistant t.i.d., TID three times a day
pulmonary disease
Staphylococcus TPR t emperature, pulse,
CPR c ardiopulmonary aureus and respiration
resuscitation
N/A not applicable UTI urinary tract
CVA c erebrovascular ac-
NKA no known allergies infection
cident, stroke
NPO nothing by mouth VS, vs vital signs
DAT diet as tolerated
O2 oxygen w/c, W/C wheelchair
DNR do not resuscitate
OBRA  mnibus Budget
O wt. weight
DON director of nursing
Reconciliation Act
Dx, dx diagnosis
Glossary 236

Glossary Alzheimer’s disease: a progressive, incurable

disease that causes tangled nerve fibers and pro-
tein deposits to form in the brain, which eventu-
ally cause dementia.
abdominal thrusts: method of attempting to re-
move an object from the airway of someone who ambulation: walking.
is choking. amputation: the removal of some or all of a
abduction: moving a body part away from the body part, usually a foot, hand, arm or leg; may
midline of the body. be the result of an injury or disease.

abrasion: an injury that rubs off the surface of angina pectoris: the medical term for chest
the skin. pain, pressure, or discomfort due to coronary
artery disease.
abuse: purposely causing physical, mental, or
emotional pain or injury to someone. antimicrobial: capable of destroying or resisting
pathogens.
active neglect: purposely harming a person by
failing to provide needed care. anxiety: uneasiness or fear, often about a situa-
tion or condition.
activities of daily living (ADLs): personal daily
care tasks, such as bathing, dressing, caring for apathy: a lack of interest.
teeth and hair, toileting, eating and drinking, aspiration: the inhalation of food, fluid or for-
walking, and transferring. eign material into the lungs; can cause pneumo-
acute care: care given in hospitals and ambula- nia or death.
tory surgical centers for people who have an im- assault: the act of threatening to touch a person
mediate illness. without his or her permission.
adaptive devices: special equipment that helps assisted living: living facilities for people who
a person who is ill or disabled to perform ADLs; do not need skilled, 24-hour care, although they
also called assistive devices. do require some help with daily care.
adduction: moving a body part toward the mid- assistive devices: special equipment that helps
line of the body. a person who is ill or disabled to perform ADLs;
adult daycare: care given at a facility during also called adaptive devices.
daytime working hours for people who need atrophy: the wasting away, decreasing in size,
some help but are not seriously ill or disabled. and weakening of muscles from lack of use.
advance directives: legal documents that allow autoimmune illness: an illness in which the
people to choose what kind of medical care they body’s immune system attacks normal tissue in
wish to have if they cannot make those decisions the body.
themselves.
battery: touching a person without his or her
affected side: a weakened side from a stroke or permission.
injury; also called the weaker or involved side.
bipolar disorder: type of mental illness that
ageism: prejudice toward, stereotyping of, and/ causes a person to swing from deep depression
or discrimination against older persons or the to extreme activity.
elderly.
 237

Glossary
bloodborne pathogens: microorganisms found Cheyne-Stokes: slow, irregular respirations or
in human blood, body fluid, draining wounds, rapid, shallow respirations.
and mucous membranes that can cause infec-
chronic: being long-term or long-lasting.
tion and disease in humans.
cite: in a long-term care facility, to find a prob-
body mechanics: the way the parts of the body
lem through a survey.
work together whenever a person moves.
claustrophobia: the fear of being in a confined
bony prominences: areas of the body where the
space.
bone lies close to the skin.
clean: in health care, a condition in which ob-
brachial pulse: the pulse inside the elbow,
jects are not contaminated with pathogens.
about 1 to 1 1/2 inches above the elbow.
clichés: phrases that are used over and over
cardiopulmonary resuscitation (CPR): medi-
again and do not really mean anything.
cal procedures used when a person’s heart or
lungs have stopped working. closed bed: a bed completely made with the
bedspread and blankets in place.
care plan: a plan developed for each resident to
achieve certain goals; it outlines the steps and Clostridium difficile (C-diff, C. difficile): bac-
tasks that the care team must perform. terial illness that causes diarrhea and can cause
colitis.
catastrophic reaction: overreacting to
something. cognition: the ability to think logically and
quickly.
catheter: a thin tube inserted into the body that
is used to drain or inject fluids. cognitive: related to thinking and learning.

causative agent: a pathogen or microorganism cognitive impairment: loss of ability to

that causes disease. think logically; concentration and memory are
affected.
Centers for Disease Control and Prevention
(CDC): a government agency under the Depart- combative: violent or hostile behavior.
ment of Health and Human Services (HHS) that combustion: the process of burning.
issues information to protect the health of indi-
communication: the process of exchanging in-
viduals and communities.
formation with others by sending and receiving
cerebrovascular accident (CVA): a condition messages.
that occurs when blood supply to a part of the
compassionate: caring, concerned, considerate,
brain is cut off suddenly by a clot or a ruptured
empathetic, and understanding.
blood vessel; also called a stroke.
condom catheter: catheter that has an attach-
chain of command: the line of authority in a
ment on the end that fits onto the penis; also
facility that helps make sure that residents get
called an external or “Texas” catheter.
proper health care.
confidentiality: the legal and ethical principle
chain of infection: way of describing how dis-
of keeping information private.
ease is transmitted from one living being to
another. confusion: the inability to think clearly.
charting: writing down important information conscientious: guided by a sense of right and
and observations about residents. wrong; having principles.
Glossary 238

conscious: the state of being mentally alert and diabetic ketoacidosis (DKA): complication of
having awareness of surroundings, sensations, diabetes that is caused by having too little insu-
and thoughts. lin; also called hyperglycemia or diabetic coma.
constipation: the inability to eliminate stool, or diagnosis: physician’s determination of an
the difficult and painful elimination of a hard, illness.
dry stool. diastolic: second measurement of blood pres-
constrict: to narrow. sure; phase when the heart relaxes or rests.
contracture: the permanent and often painful diet cards: cards that list the resident’s name
stiffening of a joint and muscle. and information about special diets, allergies,
likes and dislikes, and other instructions.
cultural diversity: the variety of people with
varied backgrounds and experiences who live digestion: the process of preparing food physi-
and work together in the world. cally and chemically so that it can be absorbed
into the cells.
culture: a system of learned behaviors, practiced
by a group of people, that are considered to be dilate: to widen.
the tradition of that people and are passed on direct contact: touching an infected person or
from one generation to the next. his secretions.
culture change: a term given to the process of dirty: in health care, a condition in which ob-
transforming services for elders so that they are jects have been contaminated with pathogens.
based on the values and practices of the person
receiving care; core values include choice, dig- disinfection: process that kills pathogens, but
nity, respect, self-determination, and purposeful not all microorganisms; it reduces the organism
living. count to a level that is generally not considered
infectious.
cyanotic: skin that is pale, blue, or gray.
disorientation: confusion about person, place,
dangle: to sit up with the feet over the side of or time.
the bed in order to regain balance.
disposable: only to be used once and then
defense mechanisms: unconscious behaviors discarded.
used to release tension or cope with stress.
disposable razor: type of razor, usually plastic,
dehydration: a condition that results from inad- that is discarded after one use; requires the use
equate fluid in the body. of shaving cream or soap.
delusions: persistent false beliefs. diuretics: medications that reduce fluid volume
dementia: a general term that refers to a seri- in the body.
ous loss of mental abilities, such as thinking, doff: to remove.
remembering, reasoning, and communicating.
domestic violence: physical, sexual, or emo-
dentures: artificial teeth. tional abuse by spouses, intimate partners, or
developmental disabilities: disabilities that are family members.
present at birth or emerge during childhood that don: to put on.
restrict physical or mental ability.
do-not-resuscitate (DNR): an order that tells
diabetes: a condition in which the pancreas medical professionals not to perform CPR.
does not produce enough or does not properly
use insulin. dorsiflexion: bending backward.
 239

Glossary
draw sheets: sheets that are placed under resi- false imprisonment: the unlawful restraint of
dents to help with turning, lifting, or moving up someone which affects the person’s freedom of
in bed. movement; includes both the threat of being
physically restrained and actually being physi-
durable power of attorney for health care: a
cally restrained.
signed, dated, and witnessed paper that appoints
someone else to make the medical decisions for fecal incontinence: the inability to control the
a person in the event he or she becomes unable bowels, leading to involuntary passage of stool;
to do so. also called anal incontinence.
dysphagia: difficulty swallowing. financial abuse: the act of stealing, taking ad-
vantage of, or improperly using the money, prop-
dyspnea: difficulty breathing.
erty, or other assets of another person.
edema: swelling caused by excess fluid in body
first aid: emergency care given immediately to
tissues.
an injured person.
electric razor: type of razor that runs on elec-
flammable: easily ignited and capable of burn-
tricity; does not require the use of soap or shav-
ing quickly.
ing cream.
flexion: bending a body part.
elimination: the process of expelling solid
wastes made up of the waste products of food fluid balance: taking in and eliminating equal
that are not absorbed into the cells. amounts of fluid.
elope: in medicine, when a person with Al- fluid overload: a condition that occurs when
zheimer’s disease wanders away from the pro- the body is unable to handle the amount of fluid
tected area and does not return. consumed.
emesis: the act of vomiting, or ejecting stomach foot drop: a weakness of muscles in the feet
contents through the mouth. and ankles that causes problems with the ability
to flex the ankles and walk normally.
emotional lability: laughing or crying without
any reason, or when it is inappropriate. force fluids: a medical order for a person to
drink more fluids.
empathy: entering into the feelings of others.
Fowler’s: position in which a person is in a
enema: a specific amount of water, with or with-
semi-sitting position (45 to 60 degrees).
out an additive, that is introduced into the colon
to eliminate stool. fracture: a broken bone.
ergonomics: the science of designing equip- fracture pan: a bedpan that is flatter than a
ment and work tasks to suit the worker’s regular bedpan.
abilities.
full weight bearing (FWB): able to bear 100
ethics: the knowledge of right and wrong. percent of the body weight on one or both legs
on a step.
expiration: exhaling air out of the lungs.
gait: manner of walking.
expressive aphasia: inability to speak or speak
clearly. gait belt: a belt made of canvas or other heavy
material used to assist people who are who are
extension: straightening a body part.
weak, unsteady, or uncoordinated; also called a
transfer belt.
Glossary 240

gastrostomy: surgical opening into the home health care: care that takes place in a
stomach. person’s home.
gestational diabetes: type of diabetes that ap- homeostasis: the condition in which all of the
pears in pregnant women who have never had body’s systems are working their best.
diabetes before but who have high glucose levels
hormones: chemical substances created by the
during pregnancy.
body that control numerous body functions.
glands: structures that produce substances in
hospice care: holistic, compassionate care given
the body.
in facilities or homes for people who have six
glucose: natural sugar. months or less to live.
gonads: sex glands. hygiene: practices used to keep bodies clean
grooming: practices to care for oneself, such as and healthy.
caring for fingernails and hair. hyperalimentation: the intravenous infusion of
hallucinations: illusions a person sees, hears, nutrients administered directly into the blood-
smells, tastes, or feels. stream, bypassing the digestive tract.
hand antisepsis: washing hands with water hypertension: high blood pressure.
and soap or other detergents that contain an an-
impairment: a loss of function or ability.
tiseptic agent.
incident: an accident or unexpected event dur-
hand hygiene: washing hands with either plain
ing the course of care that is not part of the nor-
or antiseptic soap and water and using alcohol-
mal routine in a healthcare facility.
based hand rubs.
incontinence: the inability to control the blad-
hat: in health care, a collection container that
der or bowels.
is sometimes inserted into a toilet to collect and
measure urine or stool. indirect contact: touching something contami-
healthcare-associated infections (HAIs): in- nated by an infected person.
fections that patients acquire within healthcare indwelling catheter: a type of catheter that
settings that result from treatment for other remains inside the bladder for a period of time;
conditions. the urine drains into a bag.
Health Insurance Portability and Account- infection: the state resulting from pathogens
ability Act (HIPAA): a federal law that requires invading the body and multiplying.
health information be kept private and secure
infection control: measures practiced in health-
and that organizations must take special steps to
care facilities to prevent and control the spread
protect this information.
of disease.
hemiparesis: weakness on one side of the body.
inflammation: swelling.
hemiplegia: paralysis on one side of the body.
informed consent: the process in which a per-
hepatitis: inflammation of the liver caused by son, with the help of his doctor, makes informed
infection. decisions about health care.
hoarding: collecting and putting things away in input: the fluid a person consumes; also called
a guarded manner. intake.
holistic care: a type of care that involves consid-
inspiration: breathing air into the lungs.
ering a whole system, such as a whole person,
rather than dividing the system into parts.
 241

Glossary
insulin: a hormone that converts glucose into major depression: a type of mental illness that
energy for the body. may cause a person to lose interest in everything
insulin reaction: complication of diabetes that he once cared about.
can result from either too much insulin or too malpractice: injury to a person due to profes-
little food; also known as hypoglycemia. sional misconduct through negligence, careless-
intake: the fluid a person consumes; also called ness, or lack of skill.
input. masturbation: to touch or rub sexual organs in
intravenous (IV): into a vein. order to give oneself or another person sexual
pleasure.
involuntary seclusion: separating a person
from others against the person’s will. Medicaid: a medical assistance program for low-
income people.
involved: term used to refer to the weaker, or af-
fected, side of the body after a stroke or injury. medical asepsis: the process of removing patho-
gens, or the state of being free of pathogens.
Isolation Precautions: method of infection
control used when caring for persons who are Medicare: a federal health insurance program
infected or suspected of being infected with for people who are 65 or older, are disabled, or
a disease; also called Transmission-Based are ill and cannot work.
Precautions. menopause: the end of menstruation.
lateral: position in which a person is lying on metabolism: physical and chemical processes by
either side. which substances are produced or broken down
laws: rules set by the government to help people into energy or products for use by the body.
live peacefully together and to ensure order and microbe: a living thing or organism that is so
safety. small that it can be seen only through a micro-
length of stay: the number of days a person scope; also called microorganism.
stays in a healthcare facility. microorganism: a living thing or organism that
liability: a legal term that means someone can is so small that it can be seen only through a mi-
be held responsible for harming someone else. croscope; also called microbe.

living will: a document that states the medical mid-stream: a type of urine specimen in which
care a person wants, or does not want, in case he the first and last urine are not included in the
or she becomes unable to make those decisions sample.
for him- or herself. Minimum Data Set (MDS): a detailed form
localized infection: an infection that is con- with guidelines for assessing residents in long-
fined to a specific location in the body and has term care facilities; also details what to do if resi-
local symptoms. dent problems are identified.

logrolling: method of moving a person as a unit mode of transmission: method of describing

without disturbing the alignment of the body. how a pathogen travels from one person to the
next person.
long-term care (LTC): care given in long-term
care facilities (LTCF) for persons who need 24- modified diets: diets for people who have cer-
hour, supervised nursing care. tain illnesses; also called special or therapeutic
diets.
Glossary 242

MRSA: stands for methicillin-resistant [i]Staphy- ombudsman: the legal advocate for residents;
lococcus aureus[i], an antibiotic-resistant infection helps resolve disputes and settle conflicts.
often acquired by people in hospitals and other
Omnibus Budget Reconciliation Act (OBRA):
healthcare facilities who have weakened immune
law passed by the federal government that in-
systems.
cludes minimum standards for nursing assistant
mucous membranes: the membranes that line training, staffing requirements, resident assess-
body cavities, such as the mouth, nose, eyes, rec- ment instructions, and information on rights for
tum, or genitals. residents.
nasogastric tube: a feeding tube that is in- open bed: a bed made with linen fanfolded
serted into the nose and goes to the stomach. down to the foot of the bed.
neglect: harming a person physically, mentally, oral care: care of the mouth, teeth, and gums.
or emotionally by failing to provide needed care.
orthotic device: a device that helps support and
negligence: actions, or the failure to act or pro- align a limb and improve its functioning and
vide the proper care, that result in unintended helps prevent or correct deformities.
injury to a person.
osteoarthritis: a common type of arthritis that
non-intact skin: skin that is broken by abra- usually affects the hips, knees, fingers, thumbs,
sions, cuts, rashes, acne, pimples, or boils. and spine.
nonverbal communication: communicating osteoporosis: a disease that causes bones to be-
without using words. come porous and brittle.
non-weight bearing (NWB): unable to support ostomy: a surgically-created opening from an
any weight on one or both legs. area inside the body to the outside.
nutrient: something found in food that provides outpatient care: care given for less than 24
energy, promotes growth and health, and helps hours for people who have had treatments or
regulate metabolism. surgery and need short-term skilled care.
nutrition: how the body uses food to maintain output: all fluid that is eliminated from the
health. body; includes fluid in urine, feces, vomitus,
objective information: information based on perspiration, and moisture in the air that is
what a person sees, hears, touches, or smells. exhaled.

obsessive compulsive disorder: disorder in pacing: walking back and forth in the same
which a person uses obsessive behavior to cope area.
with anxiety. palliative care: care that focuses on the comfort
obstructed airway: a condition in which the and dignity of the person, rather than on curing
tube through which air enters the lungs is him or her.
blocked. panic disorder: a disorder in which a person is
Occupational Safety and Health Administra- terrified for no known reason.
tion (OSHA): a federal government agency that paraplegia: loss of function of lower body and
makes rules to protect workers from hazards on legs.
the job.
partial weight bearing (PWB): able to support
occupied bed: a bed made while a person is in some weight on one or both legs.
the bed.
 243

Glossary
passive neglect: unintentionally harming a positioning: the act of helping people into posi-
person physically, mentally, or emotionally by tions that will be comfortable and healthy for
failing to provide needed care. them.
pathogens: harmful microorganisms. postmortem care: care of the body after death.
pediculosis: an infestation of lice. post-traumatic stress disorder: an anxiety-re-
lated disorder caused by a traumatic experience.
percutaneous endoscopic gastrostomy (PEG)
tube: a tube placed through the skin directly posture: the way a person holds and positions
into the stomach to assist with eating. his body.

perineal care: care of the genitals and anal area. pre-diabetes: a condition in which a person’s
blood glucose levels are above normal but not
perineum: the genital and anal area.
high enough for a diagnosis of type 2 diabetes.
perseverating: the repetition of words, phrases,
pressure points: areas of the body that bear
questions, or actions.
much of its weight.
personal: relating to life outside one’s job, such
pressure sore: a serious wound resulting from
as family, friends, and home life.
skin breakdown; also known as a bed sore or de-
personal protective equipment (PPE): equip- cubitus ulcer.
ment that helps protect employees from serious
procedure: a method, or way, of doing
workplace injuries or illnesses resulting from
something.
contact with workplace hazards.
professional: having to do with work or a job.
phantom sensation: pain or feeling from a
body part that has been amputated; caused by professionalism: how a person behaves when
remaining nerve endings. he or she is on the job; it includes how a person
dresses, the words he uses, and the things he
phobia: an intense form of anxiety.
talks about.
physical abuse: any treatment, intentional pronation: turning downward.
or not, that causes harm to a person’s body;
includes slapping, bruising, cutting, burning, prone: position in which a person is lying on his
physically restraining, pushing, shoving, or stomach.
rough handling. prosthesis: a device that replaces a body part
pillaging: taking things that belong to someone that is missing or deformed because of an ac-
else. cident, injury, illness, or birth defect; used to
improve a person’s ability to function and/or his
policy: a course of action that should be taken appearance.
every time a certain situation occurs.
psychological abuse: any behavior that causes
portable commode: a chair with a toilet seat a person to feel threatened, fearful, intimidated,
and a removable container underneath; used for or humiliated in any way.
elimination.
psychosocial needs: needs having to do with
portal of entry: any body opening on an unin- social interaction, emotions, intellect, and
fected person that allows pathogens to enter. spirituality.
portal of exit: any body opening on an infected psychotherapy: a method of treating mental ill-
person that allows pathogens to leave. ness that involves talking about one’s problems
with mental health professionals.
Glossary 244

puree: to chop, blend, or grind food into a thick scalds: burns caused by hot liquids.
paste of baby food consistency.
scope of practice: defines the things that
quadriplegia: loss of function of legs, trunk, healthcare providers are legally allowed to do and
and arms. how to do them correctly.
radial pulse: the pulse located on the inside of sentinel event: an accident or incident that re-
the wrist, where the radial artery runs just be- sults in grave physical or psychological injury or
neath the skin. death.
range of motion (ROM) exercises: exercises sexual abuse: forcing a person to perform or
that put a joint through its full arc of motion. participate in sexual acts against his or her will;
includes unwanted touching, exposing oneself,
receptive aphasia: inability to understand spo-
and sharing pornographic material.
ken or written words.
sexual harassment: any unwelcome sexual
rehabilitation: care given by a specialist to
advance or behavior that creates an intimidat-
restore or improve function after an illness or
ing, hostile, or offensive working environment;
injury.
includes requests for sexual favors, unwanted
reproduce: to create new life. touching, and other acts of a sexual nature.
reservoir: a place where a pathogen lives and sharps: needles or other sharp objects.
grows.
shock: a condition that occurs when organs and
Residents’ Rights: numerous rights identified tissues in the body do not receive an adequate
in OBRA that relate to how residents must be blood supply.
treated while living in a facility; they provide an
Sims’: position in which a person is in a left
ethical code of conduct for healthcare workers.
side-lying position; lower arm is behind the back
respiration: the process of breathing air into the and the upper knee is flexed and raised toward
lungs and exhaling air out of the lungs. the chest.
restraint: a physical or chemical way to restrict skilled care: medically necessary care given by
voluntary movement or behavior. a skilled nurse or therapist; is available 24 hours
restraint alternatives: any intervention used in a day.
place of a restraint or that reduces the need for a special diets: diets for people who have certain
restraint. illnesses; also called therapeutic or modified
restraint-free: the state of being free of re- diets.
straints and not using restraints for any reason. specimen: a sample that is used for analysis in
restrict fluids: a medical order for a person to order to try to make a diagnosis.
limit fluids. sputum: the fluid a person coughs up from the
rheumatoid arthritis: a type of arthritis in lungs.
which joints become red, swollen, and very pain- Standard Precautions: a method of infection
ful, and movement is restricted. control in which all blood, body fluids, non-intact
rotation: turning a joint. skin, and mucous membranes are treated as if
they were infected with an infectious disease.
safety razor: a type of razor that has a sharp
blade with a special safety casing to help prevent sterilization: a measure that destroys all micro-
cuts; requires the use of shaving cream or soap. organisms, including pathogens.
 245

Glossary
stoma: an artificial opening in body. tact: the ability to understand what is proper and
appropriate when dealing with others; being able
straight catheter: a catheter that does not re-
to speak and act without offending others.
main inside the person; it is removed immedi-
ately after urine is drained. terminal illness: a disease or condition that will
eventually cause death.
stress: the state of being frightened, excited,
confused, in danger, or irritated. therapeutic diets: diets for people who have
certain illnesses; also called special or modified
stressor: something that causes stress.
diets.
subacute care: care given in a hospital or in a
total parenteral nutrition (TPN): the intrave-
long-term care facility for people who have had
nous infusion of nutrients administered directly
an acute injury or illness or problem resulting
into the bloodstream, bypassing the digestive
from a disease.
tract.
subjective information: information that a
transfer belt: a belt made of canvas or other
person cannot or did not observe, but is based
heavy material used to assist people who are
on something reported to the person that may or
weak, unsteady, or uncoordinated; also called a
may not be true.
gait belt.
substance abuse: the use of legal or illegal
transient ischemic attack: a warning sign of a
drugs, cigarettes, or alcohol in a way that is
CVA/stroke resulting from a temporary lack of
harmful to the abuser or to others.
oxygen in the brain; symptoms may last up to 24
sundowning: becoming restless and agitated in hours.
the late afternoon, evening, or night.
Transmission-Based Precautions: method of
supination: turning upward. infection control used when caring for persons
supine: position in which a person lies flat on who are infected or suspected of being infected
his back. with a disease; also called Isolation Precautions.

suppository: a medication given rectally to tuberculosis (TB): an airborne disease that af-
cause a bowel movement. fects the lungs; causes coughing, trouble breath-
ing, fever, weight loss, and fatigue.
surgical asepsis: the state of being free of all
microorganisms, not just pathogens; also called tumor: a group of abnormally growing cells.
sterile technique. unoccupied bed: a bed made while nobody is in
susceptible host: an uninfected person who the bed.
could get sick. urinary incontinence: the inability to control
sympathy: sharing in the feelings and difficul- the bladder, which leads to an involuntary loss of
ties of others. urine.

systemic infection: an infection that is in the validating: giving value to or approving.

bloodstream and is spread throughout the body, verbal abuse: the use of language—spoken or
causing general symptoms. written—that threatens, embarrasses, or insults
systolic: first measurement of blood pressure; a person.
phase when the heart is at work, contracting and verbal communication: communicating using
pushing the blood from the left ventricle of the words or sounds, spoken or written.
heart.
Glossary 246

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: stands for vancomycin-resistant enterococ-
cus, a genetically changed strain of enterococcus
that originally developed in people who were ex-
posed to the antibiotic vancomycin.
wandering: walking around aimlessly.
workplace violence: verbal, physical, or
sexual abuse of staff by residents or other staff
members.
 247

Index
Index aging
myths of 64
anti-embolic stockings
procedure for putting on
137
137-138
aging, normal changes of antimicrobial 52
for circulatory system 84 anxiety
abbreviations 23, 235 for endocrine system 95 and HIV & AIDS 101
for gastrointestinal system 91-92 anxiety-related disorders 66-67
abdominal thrusts 36-37
for immune system 99 apathy 66
abduction 221 aphasia
for integumentary system 74
abuse 13 expressive 79
for lymphatic system 99
observing and reporting 14-15 receptive 79
for musculoskeletal system 75
reporting of 15 appetite
for nervous system 78
sexual 13 guidelines for promoting 206-207
for reproductive system 98
signs of 14 appetite, loss of
for respiratory system 88
types of 13-14 and cancer 102
for sense organs 83
acceptance for urinary system 90 and COPD 88
as a stage of grief 68 and HIV/AIDS 100
agitation
accident prevention 31-33 arthritis 75
and Alzheimer’s disease 111
care guidelines 76
acquired immunodeficiency AIDS, see acquired immune types of 76
syndrome (AIDS), see also human deficiency syndrome (AIDS) artificial eye 220, 221
immunodeficiency virus (HIV) 99
AIDS dementia complex 99-100 asepsis
and dementia 100
airborne infection isolation room 54 types of 43
and Residents’ Rights 101
Airborne Precautions 52 aspiration 140, 211
care guidelines 100-101
prevention of 211
diet 100-101 alarms, body 112, 181
assault 13
emotional support 101 alignment assisted living 2
transmission of 53 and body mechanics 30 assistive devices 218
activities director 7 and pain management 177 for ADLs 219
activities of daily living (ADLs) 2, 117 guidelines for 219-220 for ambulation 217
and Alzheimer’s disease 108-111 in a chair or wheelchair 155 for eating 213
activity 61 Alzheimer’s disease (AD) 105 atrophy 75
and activities of daily living 108-111 autoimmune illness 76
activity therapy 116
and diagnosis 106 axillary 165
acute care 2
and nutritional problems 110-111 procedure for measuring and
adaptive devices, see also assistive and personal care 108 recording temperature 170-171
devices 218-219 and Residents’ Rights 114-115 backrest 121
adduction 221 communication guidelines 106-108 back rub
ADLs, see activities of daily living difficult behaviors 111-114 procedure for 125-126
therapies for 115-116 bandages 196
admission
guidelines for 160-161 ambulation 215 bargaining
and visually-impaired as a stage of grief 68
admitting a resident
residents 216-217 barriers
procedure for 161-162
procedure for assisting with 215-216 to communication 23-24
adolescence 63 with assistive devices 217-218 base of support 30
adult daycare 2 ambulatory surgical centers 2 bathing
adulthood 64 a.m. care, see also personal care 117 and Alzheimer’s disease 109-110
American Cancer Society 102, 103 guidelines for 122
advance directive 68
amputation 220 importance of 121
and rights relating to 68
guidelines for care 220-221 procedure for bed bath 122-125
and the dying resident 68
anger procedure for shower or tub 128-130
affected side 135 as stage of grief 68 battery 13
procedure for dressing resident guidelines for communication 28-29 bed bath
with 136-137
angina pectoris 85 procedure for giving 122-125
ageism 64 care guidelines 86 bed cradle 121
Index 248

bedmaking carbohydrates 197 circulatory system

closed bed 195 cardiopulmonary resuscitation common disorders 85-87
guidelines for 192 (CPR) 36 NA’s role in assisting with 84
open bed 195 care plan 5 normal changes of aging 84
procedure for occupied bed 192-195 care team 5 observing and reporting 84-85
procedure for unoccupied bed 195 cataracts 84 structure and function 84
bedpan 143 catastrophic reaction 111-112
claustrophobia 67
procedure for assisting with 144-145 catheter, urinary 186
bed sore, see pressure sore condom 186
clean
benign prostatic hypertrophy 98 guidelines for care 186-187 and infection control 43
biohazard container 45, 51 indwelling 186 clean catch specimen
bipolar disorder 66 observing and reporting 187 procedure for collecting 184-185
bladder retraining procedure for care of 187-188
cliché 23
straight 186
guidelines for assisting with 225-226 clinical depression 66
bleeding causative agent 43
closed bed 195
procedure for controlling 39 C. difficile (C-diff ) 55
bloodborne pathogens 53 center of gravity 31 Clostridium difficile 55
blood pressure Centers for Disease Control and cognition 105
and hypertension 85
Prevention (CDC) 44
cognitive development 105
diastolic 172 Centers for Medicare & Medicaid
Services (CMS) 3 colostomy 93
normal range 164
procedure for one-step
central nervous system combative behavior 28
method 173-174 common disorders 79-83 combustion 188
procedure for two-step method 174 observing and reporting 79
communication
systolic 172 cerebrovascular accident (CVA)
and call light 23
and transfers 80
body fluids and cultural considerations 24
care guidelines 80-81
and Standard Precautions 44 and CVA 81
communication guidelines 81
body language 20 dressing 81 barriers to 23-24
body mechanics 30-31 problems experienced nonverbal 20
afterwards 79-80 verbal 20
body positions 147-148
signs of 41-42
with residents with Alzheimer’s
body systems, see individual system certification, maintaining 231-232 disease 106-108
body temperature, see temperature certified nursing assistant, see with residents with special
nursing assistant needs 25-29
bony prominence 118
chain of command 7 communication boards 81
boundaries, professional 13
chain of infection 43-44
bowel movement 92, 143 community resources 58, 103
charting, see documentation
bowel retraining chart, medical 17-18 computers 16, 18
guidelines for assisting with 225-226 chemotherapy confidentiality 16
brachial pulse 171 and cancer 102 conflict
Cheyne-Stokes respirations 69 guidelines for resolving 229-230
BRAT diet 93, 101
childhood 62-63 confusion 104
burns
guidelines for preventing 32 choking, see also obstructed airway congestive heart failure (CHF) 86
procedure for treating 39-40 preventing 33 care guidelines 87
call light 22, 190 procedure for clearing obstructed observing and reporting 87
and safety 29 airway 36-37
constipation 92
cancer chronic 1 constrict 74
care guidelines 102-103 chronic conditions 1 Contact Precautions 52
risk factors 102
chronic obstructive pulmonary contractures 75
treatments for 102
disease (COPD) 88
warning signs 102 conversion
care guidelines 89
cane table 182
observing and reporting 89
guidelines for use 217
coronary artery disease (CAD) 85-86
procedure for assisting resident circadian rhythm 164
with 217-218 CPR 36
 249

Index
criminal background check 228 development, human 62-64 disposable 50
criticism developmental disabilities 65 disruptive behavior
handling 230-231 care guidelines 66 and Alzheimer’s disease 113
crutches residents with 65-66 diuretics 85
procedure for assisting with 217-218 diabetes 95 documentation
cues and diet 202-203 guidelines for 17-18
and helping with eating 212-213 care guidelines 96-97
domestic violence 13
complications 40-41
cultural diversity 59 do-not-resuscitate (DNR) order 68
foot care 97
culture 25 dorsiflexion 221
signs and symptoms 96
and communication 25
types 96 draw sheet 121
and diet 200-201
urine and blood tests 97 dressing
and language 60
diabetic ketoacidosis (DKA) 41 and Alzheimer’s disease 108
and pain 176
diabetic resident and assistive devices 136
and touch 60
and nail care 130 guidelines for assisting with 135-136
culture change 3
guidelines for IVs 137
diagnosis 1
cyanotic 37 procedure for resident with
diarrhea 93 affected right arm 136-137
dairy products
and diet 199-200 diastolic pressure 172 with one-sided weakness 81

dangle 153 diet, see also nutrition dressings

diabetic 202-203 non-sterile 195-196
dangling 153-154
fluid-restricted 202 Droplet Precautions 52
death and dying, see also dying
liquid 203
resident durable power of attorney for
low-fat/low-cholesterol 202
and advance directives 68 health care 68
low-protein 202
and hospice care 72 dying resident, see also death and
low-sodium 202
and Kubler-Ross’ stages of grief 68 dying
mechanical soft 203
care guidelines 69 care guidelines 69
modified calorie 202
legal rights and 69-71 legal rights and 69-71
observing and reporting 210
physical changes after 71 dysphagia 210
pureed 203
postmortem care 71
soft 203 eating
signs of impending 68-69
diet cards 201 and Residents’ Rights 208
decubitus ulcer, see pressure sore assistive devices for 213
digestion 91
defense mechanisms 24 guidelines for assisting with 207-208
dignity guidelines for special needs 212-213
dehydration 204
and dying residents 70-71 independence with 207, 212-213
guidelines for preventing 205
and personal care 117-118 procedure for assisting with 208-210
observing and reporting 204
and Residents’ Rights 11, 59
warning signs of 204 edema 205
and sexual needs 57
delirium 104-105 elastic stocking
dilate 74
delusions procedure for applying 137-138
dirty
and Alzheimer’s disease 113 elimination 91
and infection control 43
dementia 105 emergency(ies), medical, see also
disability
denial specific emergency 35-36
and rehabilitation 214
as a stage of grief 68 emesis 42
disaster guidelines 35
dentures 142 emotional lability 80
discharging a resident
procedure for cleaning 142-143 empathy 9
procedure for 163-164
depression employment
disease, see specific disease
and Alzheimer’s disease 113 application 228
disinfection 50
and HIV & AIDS 101 job interviews 228-229
as stage of grief 68 disorientation job description 229
guidelines for communication 28 and falls 31 job seeking 227
types of 66 displacement 24 references 227
Index 250

endocrine system first aid grains

common disorders 95-97 procedures for responding to 36-43 and diet 199
NA’s role in assisting with 95 first impression grooming, see also personal care 117
normal changes of aging 95 and admission 160 hair
observing and reporting 95
flammable 188 procedure for combing/brushing 133
structure and function 94-95
flexion 221 procedure for shampooing 127-128
epilepsy 41
flossing teeth hallucinations
equipment and Alzheimer’s disease 113
procedure for 141-142
and isolation 53
fluid balance 182 hand and fingernail care
and resident’s unit 190-191
procedure for giving 130-131
handling 50-51 fluid overload
observing and reporting 205 hand antisepsis 46
personal protective 47-50
fluid-restricted diet 202 hand hygiene 45
ergonomics 154
food guide pyramid, see MyPyramid handrolls 121
ethics 10
footboard 121 handwashing
exchange lists 202
procedure for 46-47
exercise foot care
when to wash hands 46
and mobility 75 and diabetes 97
observing and reporting 131 head or spinal cord injuries
and stress 233
procedure for 131-132 guidelines for care 82-83
expiration 87
foot drop 121 healthcare team 5
expressive aphasia 79
force fluids 204 Health Insurance Portability and
extension 221
Accountability Act (HIPAA) 16
Fowler’s position 148
eyes and ears
hearing aid 25
common disorders 84 fracture 31
hearing impairment
face shields, see personal protective fracture pan 143
care guidelines 25-26
equipment fruits
heart attack
facility, healthcare and diet 199
care guidelines 86
types of 1-2 gait 81
responding to 38
fact gait belt 154 signs and symptoms of 38
vs. opinion 21 gastric tubes 211-212 height
fainting 40 gastroesophageal reflux disease 93 bed-bound resident 178
falls gastrointestinal system procedure for measuring and
prevention of 31-32 recording 178-179
common disorders 92-94
false imprisonment 14 NA’s role in assisting with 92 Heimlich maneuver, see abdominal
normal changes of aging 91-92 thrusts
family
role of 62 observing and reporting 92 hemiparesis 79
types 61-62 structure and function 91 hemiplegia 79
fats 198 gastrostomy 211 hemorrhoids 92
and diet 200 geriatric chair 179 hepatitis 53
fecal impaction 92 glands 94 and HIV & AIDS 100
fecal incontinence 92 glass thermometer 166 vaccination for type B 54

feeding residents, see also eating glaucoma 84 Hierarchy of Needs 56-57

procedure for 208-210 gloves high blood pressure
fingernail care and infection control 49 care guidelines 85
procedure for 130-131 procedure for putting on 49 HIPAA (Health Insurance Portability
fire procedure for taking off 49-50 and Accountability Act) 16
guidelines for safety 34-35 goggles hip replacement
hazards 188 procedure for putting on 48 care guidelines 77-78

fire extinguisher observing and reporting 77-78

gown
use 35 procedure for putting on 48 hoarding 114
 251

Index
holistic care 58 infection 43 liability 7
home health care 1 healthcare-acquired 43 lice 132-133
localized 43
homeostasis 73 licensed practical nurse (LPN) 5
systemic 43
hormones 94 licensed vocational nurse (LVN) 5
infection control 43
hospice care 2 lifting, see also body mechanics 30
Airborne Precautions 52
and cancer 103 linen, see also bedmaking
and CDC 44
goals of 72 guidelines for handling 50-51
and glove use 49
hospitals 2 chain of infection 43 liquid diet 203
human development Contact Precautions 52 living will 68
stages of 62-64 Droplet Precautions 52
localized infection 43
human immunodeficiency employee’s responsibilities 55
logrolling 151
virus (HIV), see also acquired employer’s responsibilities 55
procedure for 152-153
immunodeficiency syndrome (AIDS) hand hygiene 45
and Residents’ Rights 101 handwashing 45-46 long-term care (LTC) 1
care guidelines 100-101 Standard Precautions 44-45 loss
diet 100-101 Transmission-Based Precautions51-52 of independence 59
emotional support 101 inflammation 75 low-cholesterol diet 202
transmission of 53 informed consent 11 low-fat diet 202
human needs, basic 56 in-service (continuing education) 231 low-protein diet 202
hydration inspiration 87 low-sodium diet 202
documentation 182
insulin 95 lymphatic system
hygiene 117 NA’s role in assisting with 99
insulin reaction 40
hyperalimentation 211 normal changes of aging 99
intake 182
hypertension 85 observing and reporting 99
intake and output (I&O) 182
structure and function 99
ileostomy 93 procedure for measuring and
immobility 75, 118 recording urinary 183 masks, see personal protective
equipment
immune system integumentary system
and pressure sores 118-119 Maslow, Abraham 56
common disorders 99-103
NA’s role in assisting with 99 NA’s role in assisting with 74 massage, see also back rub
normal changes of aging 99 normal changes of aging 74 procedure for giving a 125-126
observing and reporting 99 observing and reporting 74 skin care 120
structure and function 99 structure and function 73-74 masturbation 57
impairment 25 interpreter 20 Material Safety Data Sheet (MSDS)33
hearing 25-26 intravenous (IV) 137 meal trays 207
visual 26-27 dressing resident with 137
meat and beans
inactivity 75, 118 observing and reporting 189
and diet 200
inappropriate behavior 114 involuntary seclusion 14
mechanical lifts 157
incident 19 Isolation Precautions, see also procedure for 158-159
guidelines for reporting 19 Transmission-Based Precautions 51
mechanical soft diet 203
incontinence 22 job, see employment
Medicaid 3
fecal 92 job interview
medical emergency, see also specific
guidelines for care 90-91 common questions to ask 228-229
emergency
urinary 90 Kaposi’s sarcoma 100 responding to 35-36
independence knee replacement 78 medical record, see documentation
and personal care 117
Kubler-Ross, Elisabeth 68 medical social worker (MSW) 6-7
loss of 59
language medical terminology 22-23, 235
promoting 58-59
and culture 25
indwelling catheter 186 Medicare 3
lateral position 148
infancy 62 menopause 76
laws 10
mental health 27
Index 252

mental illness 27 observing and reporting 79 Omnibus Budget Reconciliation Act

and communication 28 structure and function 78 (OBRA) 10-11, 231
care guidelines 67 nitroglycerin 86 open bed 195
observing and reporting 67
non-sterile dressings 195-196 opinion
types of 66-67
nonverbal communication 20 vs. fact 21
mental retardation 65
non-weight bearing 77 oral care 138
metabolism 73 and cancer 103
nothing by mouth (NPO) 204
methicillin-resistant Staphylococcus observing and reporting 138
nurse 5
aureus (MRSA) 54 procedure for 139
nursing assistant (NA, CNA) procedure for flossing teeth 141-142
microbe 43
as member of care team 5 procedure for unconscious
microorganism 43
educational requirements 10, 231 resident 140-141
military time 18 professionalism 8-9 oral reports 20, 22
minerals 198 qualities of 9-10
oral temperature
mode of transmission 44 role and duties 3-4
procedure for measuring and
modified calorie diet 202 nursing assistant’s role recording 166-168
and circulatory system 84 orthotic device 121
mood changes 14, 67
and endocrine system 95
Mormons 201 osteoarthritis 76
and gastrointestinal system 92
mouth care, see oral care osteoporosis 76
and immune system 99
mucous membranes 44 and integumentary system 74 ostomy 93
and musculoskeletal system 75 procedure for care 94
multiple sclerosis (MS)
care guidelines 82 and nervous system 79 outpatient care 2
and reproductive system 98 output 182
musculoskeletal system
and respiratory system 88 procedure for measuring and
common disorders 75-78
and sense organs 83 recording urinary 183
NA’s role in assisting with 75
and urinary system 90 oxygen
normal changes of aging 75
observing and reporting 75 nutrition safety guidelines for 188-189

structure and function 75 and Alzheimer’s disease 110-111 pacing 112

and appetite 206-207
myocardial infarction (MI) pain
and cancer 102
care guidelines 86 and cancer 103
and HIV/AIDS 100-101
responding to 38 and dying resident 69
basic nutrients 197-198
signs and symptoms of 38 as a vital sign 175
cultural factors 200-201
MyPyramid 198-200 barriers to managing 176
documentation 210
management of 175-177
nail care identifying residents 207
observing and reporting 176-177
procedure for providing 130-131 special diets 201-203
questions to ask resident 176
nasal cannula 189 USDA guidelines 198-200
scale 176
nasogastric tube 211 nutritional supplements 203 palliative care 72
needs objective information 21 panic disorder 67
basic physical 56 OBRA (Omnibus Budget paraplegia 82
Maslow’s Hierarchy of 56-57 Reconciliation Act) 10-11, 231
psychosocial 56 Parkinson’s disease 81-82
obsessive compulsive disorder 67
sexual 57 care guidelines 82
obstructed airway 36
spiritual 57-58 partial bath 122
Occupational Safety and Health
neglect 13 partial weight bearing 77
Administration (OSHA) 33
types of 13 PASS
occupational therapist (OT) 6
negligence 13 fire extinguisher use 34
occupied bed 192
nervous system passive neglect 13
procedure for making 192-195
common disorders 79-83 pathogens 43
NA’s role in assisting with 79 oils 200
pediculosis 132
normal changes of aging 78 ombudsman 15
 253

Index
percutaneous endoscopic skin care 120-121 quad cane 217
gastrostomy (PEG) tube 211 turning resident in bed 150-151 quadriplegia 82
performance positioning devices quality of life 11
evaluation 230-231 guidelines for 121
RACE
perineal care 49, 124-125 possessions, personal 11, 161 and fire evacuation 34
perineum 122 postmortem care radial pulse 171
peripheral vascular disease (PVD) 87 care guidelines 71 procedure for taking 171-172
perseverating 113 post-traumatic stress disorder 67 radiation
personal care pre-diabetes 96 and cancer 102
a.m. care 117 prehypertension 85 range of motion (ROM) exercises 221
bed bath 122-125 pressure points 118 procedure for 221-225
dressing 135-137 types 221
pressure sore(s)
foot care 131-132 and incontinence 90 rationalization 24
grooming 130-135 areas at risk 118 razors
hair care 133 guidelines for skin care 120-121 types of 134
nail care 130-131 observing and reporting 119-120 reality orientation 115
observing and reporting 118 stages of 119
p.m. care 117 receptive aphasia 79
pressure ulcer, see pressure sore
promoting dignity with 117-118 rectal temperature
promoting independence with 117 privacy procedure for measuring and
shampooing 127-128 and bowel elimination 226 recording 168-169
shaving 134-135 and dying resident 70 references
shower/tubs 128-130 and ostomy care 93 in employment 227
toileting 143-147 and personal care 117
registered dietician (RDT) 6
and Residents’ Rights 11
personal possessions 11, 161 registered nurse (RN) 5
and sexual needs 57, 98, 99
personal protective equipment and urination 226 registry of nursing assistants 231
(PPE) 47-50 guidelines for protecting 16-17 regression 24
phantom sensation 220 privacy curtain 190 rehabilitation 214
phobias 67 procedure 8 relaxation exercise
physical therapist (PT) 6 professional 8 and stress 234
physician (MD or DO) 5 professionalism 8 religion
pillaging 114 in employment 8-9 and spiritual needs 57-58
pillowcases 194 food preferences 60, 200-201
projection 24
p.m. care, see also personal care 117 religious differences 60
pronation 221
pneumonia 88 reminiscence therapy 115
prone position 148
and HIV & AIDS 100 repression 24
prostate gland 98
poisoning 33 reproductive system
prosthesis 220
policy 8 common disorders 98
prosthetic devices
NA’s role in assisting with 98
portable commode 146 care guidelines 220-221
normal changes of aging 98
procedure for assisting with 147
protein 197 observing and reporting 98
portal of entry 44 psychosocial needs 56 structure and function 97
portal of exit 44 puberty 63 reservoir 43
positioning 147 pulse resident(s)
basic body positions 147-148
common pulse sites 171 as member of care team 7
devices 121
normal ranges 171 identification of 33
logrolling 152-153
procedure for taking radial 171-172 nursing assistant’s relationship
moving resident to side of with 8-9
bed 149-150 pulse sites 171
resident advocacy organizations 58
moving resident up in bed 148-149 pureed diet 203
sitting up on side of bed 153-154
Index 254

Residents’ Rights 11-12 during bathing 128 social behavior, inappropriate 114
nursing assistant’s role 12 general guidelines 29-35 soft diet 203
Residents’ Rights boxes safety devices 154 special diets
admission, rights during 161 scalds 32 types of 201-203
advance directives 68
scope of practice 7 specimen
Alzheimer’s disease 114-115
seizures collecting clean catch
bladder and bowel retraining 226 (mid-stream) 184-185
procedure for responding to 41
clothing protectors 208 collecting routine urine 184
communicating with residents 29 self-care 59
collecting stool 185-186
culturally sensitive care 60 and Alzheimer’s disease 108
speech-language pathologist (SLP) 6
culture change 3 sense organs
speech loss
different languages 20 common disorders 84
and stroke 80
dignity and independence 59 NA’s role in assisting with 83
food choices 201 normal changes of aging 83 sphygmomanometer 172
maintaining boundaries 13 observing and reporting 84 spills, handling 51
names 21 structure and function 83 spinal cord injuries
oral care 142 senses care guidelines 83
ostomies 93 observing and reporting 21-22 types of 82
privacy curtains 190
sexual abuse 13 spirituality 56
privacy with bathing 128
sexual behavior, inappropriate 114 spiritual needs
resident as member of care team 7
sexual needs 57 assisting with 57-58
Residents’ Council 16
residents who cannot speak 81 shampooing hair sputum 44
residents with HIV/AIDS 101 procedure for 127-128 Standard Precautions 44
responsibility for residents 4 sharps 45 and HIV & AIDS 100
room or roommate change 162 guidelines for 45
shaving
sexual abuse 57 importance of 44-45
procedure for 134-135
sexual expression 99 state registry 231
shearing 120
specimens 183
sterilization 50
shock 37
resident unit 190-191
procedure for responding to 37 stockings, anti-embolic
respiration 87 procedure for putting on 137-138
shower
procedure for counting and
procedure for giving 128-130 stoma 93
recording 171-172
safety guidelines 128 stool specimen
respiratory system
signs and symptoms 21 procedure for collecting 185-186
common disorders 88-89
NA’s role in assisting with 88 Sims’ position 148 straight catheter 186
normal changes of aging 88 sit up stress 232
observing and reporting 88 procedure for helping resident guidelines for managing 233
structure and function 87 to 153-154 stress management 233
restorative care skeletal, see musculoskeletal system stressor(s) 232
guidelines 214-215 skin, see also integumentary stroke, see also cerebrovascular
observing and reporting 215 system accident (CVA)
restraint alternatives 181 observing and reporting 119-120 and transfers 80
restraint-free environment 180 skin care care guidelines 80-81
and cancer 103 communication guidelines 81
restraints
and dying resident 69 dressing guidelines 81
monitoring 181-182
problems associated with 180 and incontinence 90 subacute care 2
guidelines for 120-121 subjective information 21
restrict fluids 204
sleep sundowning 111
rheumatoid arthritis 76
importance of 191
rotation 221 supination 221
slide board 154
safety supine position 148
smoking
and oxygen use 188-189 supplements, nutritional 203
oxygen use 189
 255

Index
supportive devices 219 tubing vegetarian 201
suppository 92 care guidelines for catheters 186-187 verbal abuse 13
care guidelines for dressing someone
surgical asepsis 43 verbal communication 20
with an IV 137
susceptible host 44 care guidelines for oxygen 188-189 violent behavior
swallowing problems 210-211 care guidelines for tube feedings 212 and Alzheimer’s disease 112

systemic infection 43 observing and reporting for violent residents

catheters 187 responses to 28
systolic pressure 172, 173 observing and reporting for
IVs 189-190 vision impairment
tact 9
observing and reporting for tube and ambulation 216-217
teeth, see also oral care
feedings 212 and communication 26-27
flossing 141-142
tumor 101 and eating 213
temperature care guidelines 26-27
normal range 164
tympanic temperature
procedure for measuring and vital signs
procedure for axillary 170-171
recording 169 blood pressure 172-175
procedure for oral 166-168
uncircumcised penis normal range 164
procedure for rectal 168-169
and bathing 124-125 pain 175-177
procedure for tympanic 169
pulse 171
sites for measuring 165 unconscious resident
reporting change 164
procedure for oral care 140-141
terminal illness 1 respiration 171-172
unintended weight loss
terminology, medical 22-23, 235 temperature 166-171
guidelines for preventing 206
therapeutic diet 201 vitamins 198
observing and reporting 206
thermometers 165 walker
unit, resident’s
thickening consistencies 211 procedure for assisting resident
care of 191
with 217-218
toileting 143-147 standard equipment in 190
wandering
total parenteral nutrition (TPN) 211 unoccupied bed and Alzheimer’s disease 112
transfer belt 154 procedure for making 195
washing hands, see also hand hygiene
transfer board 154 urinal and hand antisepsis
procedure for assisting with 145-146 procedure for 46-47
transferring a resident
from bed to wheelchair 156-157 urinary incontinence 90-91 when to wash 46
using mechanical lift 158-159 urinary output water
transfers procedure for measuring and as a nutrient 198
recording 183
and Residents’ Rights 12 procedure for serving 205
one-sided weakness 80 urinary system weight
within a facility 162-163 common disorders 90-91
procedure for measuring and
NA’s role in assisting with 90 recording 177
transient ischemic attack (TIA) 42
normal changes of aging 90 weight loss, unintended
Transitions program 72
observing and reporting 90 guidelines for preventing 206
Transmission-Based Precautions 51 structure and function 89 observing and reporting 206
categories 52
urinary tract infection (UTI) 91 wheelchair
guidelines for 53
urine specimens, collecting 183-185 guidelines for assisting with 154-155
triggers
USDA 198 procedure for transferring from
and Alzheimer’s disease 111 bed to 156-157
vaginitis 98
trochanter rolls 121 wheelchair scale 178
validating 115
tub bath withdrawal
procedure for 128-130 validation therapy 115
as a sign of abuse 14
safety guidelines 128 vancomycin-resistant enteroccus as a sign of depression 66
tube feeding 211-212 (VRE) 54
workplace violence 13
care guidelines 212 vegan 201
observing and reporting 212 vegetables
tuberculosis 54 and diet 199
and HIV & AIDS 100