Arkansas Long Term Care Facility Nursing Assistant Training

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STATE OF ARKANSAS

LONG TERM CARE FACILITY NURSING ASSISTANT TRAINING CURRICULUM

Written by

The Curriculum Committee for the

Nursing Assistant Training Program

July 1988

(Revised July 1992)

(Revised July 2006)

(Revised January 2019)

For information and implementation of this curriculum contact:

Quality Assurance, Workforce Assessment, & Provider Engagement

Division of Provider Services and Quality Assurance

Department of Human Services

Post Office Box 8059 Slot S405

Little Rock, Arkansas 72203

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AUTHORITY

1. The following rules and regulations for the Long Term Care Facility Nursing

Assistant Training Program are duly adopted and promulgated by the

Department of Human Services pursuant to Arkansas Code 20–10–701 et seq.

2. This initiative is pursuant to the Federal mandates of Public Law 100–203

The Nursing Home Reform Act, Subtitle C of the Omnibus Budget

and Reconciliation Act of 1987 and technical amendments of OBRA

1989 and 1990 concerning the training and competency evaluation of

nursing assistants employed in long term care facilities and the

registry of certified nursing assistants.

3. The Federal Omnibus Budget Reconciliation Act (OBRA) of 1987, 1989, and

1990 and regulations issued by the U.S. Department of Health and Human

Services – Centers for Medicare and Medicaid Services (formerly Health Care

Financing Administration, or HCFA) established the minimum requirements for

nursing assistant training and competency evaluation programs in Section

1819(a) – (f) and 1919(a) – (f) of the Social Security Act.

II.

1. The Arkansas Nursing Assistant Scope of Practice identifies the Standards of

Practice that Certified Nursing Assistants (CNA) must follow in delivering care. If

a CNA delivers care outside of the defined Standards of Practice, whether it is on

the CNA’s own initiative or at the direction of a licensed nurse, the CNA may

have violated the Arkansas Adult and Long–Term Care Facility Resident

Maltreatment Act as defined in Arkansas Code Ann. 12–12–1707 et seq.

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TABLE OF CONTENTS

Lesson #1 Introduction to the Role of the Nurse Aide .................................... 11

I. Introduction to Long Term Care .......................................................... 17

II. The Role of the Nurse Aide ................................................................ 17

III. The Care Team and the Chain of Command ...................................... 19

IV. Communication and Interpersonal Skills ............................................ 19

V. Resident-Centered Care (Person-Centered Care) ............................. 22

Lesson #2 Resident Rights ................................................................................ 23

I. Resident Rights .................................................................................. 24

II. Abuse, Neglect, and Personal

Possessions/Misappropriation ............................................................ 26

Lesson #3 Infection Control ............................................................................... 29

I. Introduction to Infection Control .......................................................... 32

II. Infection Control Practices .................................................................. 35

III. Hand Hygiene ..................................................................................... 36

IV. Personal Protective Equipment – PPE ............................................... 37

V. Precautions ........................................................................................ 37

Lesson #4 Fire Safety and Other Resident Safety Concerns .......................... 39

I. Fire Safety .......................................................................................... 39

II. Side rails/Entrapment ......................................................................... 41

III. Resident Elopement ........................................................................... 41

IV. Smoking ............................................................................................. 43

Lesson # 5 Medical Concerns/Emergency Procedures .................................... 45

I. Accidents ............................................................................................ 46

II. Falls / Fall Prevention ......................................................................... 46

III. Choking .............................................................................................. 47

IV. Burns/Scalds ...................................................................................... 48

V. Poisoning ............................................................................................ 49

VI. Medical Emergency ............................................................................ 49

VII. Safety Measures/Prevention Strategies ............................................. 50

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Lesson #6 Basic Care Skills............................................................................... 52

I. Points to Remember ........................................................................... 54

II. Unoccupied Bed ................................................................................. 55

IV. Resident Room/Environment/Fall Prevention ..................................... 55

V. Promoting Proper Nutrition and Hydration .......................................... 56

Lesson #7 Common Diseases and Disorders – Respiratory and

Urinary Systems ............................................................................... 63

Respiratory System ....................................................................................... 63

I. Respiratory System ............................................................................ 63

II. Common Conditions of the Respiratory System ................................. 63

III. Normal Changes with Age .................................................................. 64

IV. Role of the Nurse Aide regarding the Respiratory System ................. 64

Urinary System .............................................................................................. 65

I. Urinary System ................................................................................... 65

II. Common Conditions of the Urinary System ........................................ 65

III. Normal Changes with Age .................................................................. 65

IV. Problems Caused by Incontinence ..................................................... 65

V. Role of the Nurse Aide regarding the Urinary System ........................ 65

Lesson #8 Oxygen Use ....................................................................................... 67

I. Oxygen Use ........................................................................................ 67

Lesson #9 Common Diseases and Disorders – Nervous, Circulatory and

Musculo–Skeletal Systems .............................................................. 71

Nervous System ............................................................................................ 72

I. Nervous System ................................................................................. 72

II. Conditions that Affect Nervous System .............................................. 72

III. Normal Nervous System Changes with Age ....................................... 73

IV. Role of the Nurse Aide regarding the Nervous System ...................... 73

Circulatory System ........................................................................................ 74

I. Circulatory System ............................................................................. 74

II. Conditions that Affect the Circulatory System .................................... 74

III. Normal Circulatory Changes with Age ................................................ 74

IV. Role of the Nurse Aide regarding Circulatory System ........................ 74

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Musculoskeletal System ................................................................................ 75

I. Musculoskeletal System ..................................................................... 75

II. Conditions that Affect Musculoskeletal System .................................. 75

III. Importance of Exercise or Range of Motion (ROM) ............................ 76

IV. Normal Musculoskeletal Changes with Age ....................................... 77

V. Role of the Nurse Aide regarding the Musculoskeletal

System ............................................................................................... 77

Lesson #10 Common Diseases and Disorders – Gastrointestinal

and Endocrine Systems ................................................................... 79

Gastrointestinal System ................................................................................ 80

I. Gastrointestinal System ...................................................................... 80

II. Common Conditions of the Gastrointestinal System .......................... 80

III. Normal Changes with Age .................................................................. 80

IV. Role of the Nurse Aide regarding the Gastrointestinal

System ............................................................................................... 80

Endocrine System ......................................................................................... 81

I. Endocrine System .............................................................................. 81

II. Common Conditions that Affect the Endocrine System ...................... 81

III. Normal Changes with Age .................................................................. 82

IV. Role of the Nurse Aide regarding the Endocrine System ................... 82

Lesson #11 Common Diseases and Disorders – Reproductive,

Immune/Lymphatic Systems ........................................................... 84

Reproductive System .................................................................................... 85

I. Reproductive System ......................................................................... 85

II. Common Conditions that Affect the Reproductive System ................. 85

III. Normal Changes with Age .................................................................. 85

IV. Role of the Nurse Aide regarding the Reproductive

System ............................................................................................... 85

Lymphatic and Immune Systems .................................................................. 85

I. Lymphatic System .............................................................................. 85

II. Immune System.................................................................................. 85

III. Common Conditions of the Immune and Lymphatic

Systems .............................................................................................. 86

IV. Normal Changes with Age .................................................................. 86

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V. Role of the Nurse Aide regarding the Immune and

Lymphatic Systems ............................................................................ 86

Lesson #12 Activities of Daily Living - Bathing, Shampoo,

Perineal Care .................................................................................... 88

I. Bathing and Shampooing Points to Remember .................................. 88

II. Perineal and Catheter Care Points to Remember……………………..89

Lesson #13 Activities of Daily Living - Oral Care, Grooming, Nail

Care ................................................................................................... 91

I. Grooming/Personal Hygiene .............................................................. 91

Lesson #14 Activities of Daily Living - Dressing, Toileting ............................... 94

I. Dressing ............................................................................................. 95

II. Toileting .............................................................................................. 95

Lesson #15 Activities of Daily Living – Positioning/Turning,

Transfers ......................................................................................... 100

I. Proper positioning and body alignment ............................................ 101

II. Commonly used positions ................................................................ 102

III. Proper transfer ................................................................................. 103

Lesson #16 Activities of Daily Living - Devices Used for Transfer ................. 108

I. Mechanical lifts ................................................................................. 108

II. Transfer resident to stretcher/shower bed ........................................ 109

III. Transfer – Two Person Lift ............................................................... 110

Lesson #17 Resident’s Environment ................................................................ 111

I. Occupied Bed…………………………………………………………….111

Lesson #18 Skin Care/Pressure Prevention ..................................................... 113

I. Understanding the Integumentary System and Basic Skin

Care .................................................................................................. 114

II. Risk Factors for Skin Breakdown ..................................................... 116

III. Pressure Ulcer Development ............................................................ 118

IV. Prevention of Skin Breakdown ......................................................... 118

Lesson #19 Activities of Daily Living Nutrition/Hydration .............................. 121

I. Promoting Proper Nutrition and Hydration ........................................ 121

II. Promoting the Use of Proper Feeding

Technique/Assisting a Resident with Special Needs ........................ 122

III. Caring for a Resident with a Tube Feeding and the

Resident at Risk for Aspiration ......................................................... 124

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Lesson #20 Basic Nursing Skills – Vital Signs, Height and Weight ............... 127

I. Initial Steps ....................................................................................... 128

II. Final Steps ....................................................................................... 128

III. Vital signs Provide Important Information ......................................... 128

IV. Measuring Height and Weight .......................................................... 130

Lesson #21 Restraints ........................................................................................ 133

I. Physical Restraint ............................................................................. 134

Lesson #22 Rehabilitation/Restorative Services .............................................. 138

I. Rehabilitation……………………………………………………………..138

II. Restorative Services…………………………………………………….139

III. Devices which may be applied per Restorative Nursing

Program ............................................................................................ 139

Lesson #23 Devices/Interventions - Prosthetics, Hearing Aides,

Artificial Eye, Eyeglasses, Dentures, Compression

Stockings ........................................................................................ 141

I. Purpose of a Prosthetic Device ........................................................ 141

II. Types of Prosthetic Devices ............................................................. 141

III. Role of the Nurse Aide regarding Amputations &

Prosthetic Care ................................................................................. 142

IV. Role of the Nurse Aide regarding Hearing Aids ................................ 142

V. Role of the Nurse Aide regarding Artificial Eye &

Eyeglasses ....................................................................................... 142

VI. Role of the Nurse Aide regarding Dentures ...................................... 143

VII. Role of the Nurse Aide regarding Elastic/Compression

Stockings (TED Hose) ...................................................................... 143

Lesson #24 Special Care Needs – Intravenous Fluids, Non–

Pharmacologic Pain Interventions ................................................ 145

I. IV or PICC Lines ............................................................................... 146

II. Role of the Nurse Aide in caring for IV/PICC .................................... 146

III. Infection Control ............................................................................... 147

IV. Pain Factors ..................................................................................... 147

V. Role of the Nurse Aide related to Pain ............................................. 147

Lesson #25 Cognitive Impairment/Dementia/Alzheimer’s ............................... 151

I. Conditions ........................................................................................ 152

II. Behaviors, Causes and Interventions ............................................... 155

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III. Methods/Therapies to Reduce Behaviors ......................................... 158

IV. Tips to Remember when Dealing with Cognitively

Impaired Residents........................................................................... 159

V. Communication Strategies ............................................................... 159

VI. Techniques to Handle Difficult Behaviors ......................................... 159

VII. Behavior Interventions ...................................................................... 160

VIII. Activity Chart .................................................................................... 163

IX. Safety Checklist ................................................................................ 165

X. Sleep Changes ................................................................................. 167

Lesson #26 Mental Health, Depression and Social Needs .............................. 171

I. Causes of Mental Illness .................................................................. 172

II. Response to Behaviors .................................................................... 172

III. Use of Defense Mechanisms – unconscious behaviors

used to release tension or cope with stress or

uncomfortable, threatening situations or feelings. ............................ 173

IV. Types of Mental Illness ..................................................................... 173

V. Behaviors Associated with Mental Disorders – actions

and interventions .............................................................................. 175

VI. Treatment for Mental Illness ............................................................. 175

VII. Special Considerations ..................................................................... 176

VIII. Mental Illness and Intellectual Disability ........................................... 176

Lesson #27 Admission/Transfer/Discharge ..................................................... 177

I. Admitting a New Resident to the Facility .......................................... 177

II. Assisting to Transfer a Resident to a Hospital (i.e., Care

Transition) ........................................................................................ 178

III. Assisting a Resident to Discharge Home or to Another

Facility .............................................................................................. 178

Lesson #28 End of Life ....................................................................................... 179

I. Advance Directives ........................................................................... 179

II. Role of Hospice ................................................................................ 180

III. Care of the Dying Resident .............................................................. 180

IV. Signs/Symptoms of Impending Death .............................................. 181

V. Post Mortem Care ............................................................................ 181

VI. Disposition of Personal Belongings .................................................. 182

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VII. Stages of Reaction to Dying ............................................................. 182

Lesson # 29 Daily Responsibilities .................................................................... 185

I. Day-to-day Time Management/Resident Care ................................. 185

II. Interdisciplinary Care Plan Meetings ................................................ 186

Lesson #30 Protecting Your Profession ........................................................... 188

I. Reducing Stress/Burnout .................................................................. 189

II. Abuse/Neglect/Misappropriation ....................................................... 190

III. Nurse Aide Testing/Certification ....................................................... 191

IV. Certification Renewal ........................................................................ 192

V. Course Review ................................................................................. 192

Works Cited.…………………………............................................................................193

APPENDIX A Supplemental Materials………………………………………………….195

APPENDIX B Answers to Review Questions...………………………………………..199

APPENDIX C Care Skills...………………………………………………………………207

APPENDIX D Task Performance Record ……………………………………………..302

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UNIT 1

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Lesson # 1 (1 hour)

Title: Introduction to the Role of the Nurse Aide

Lesson Objectives:

I. The student will be able to describe Long Term Care in comparison with other

healthcare settings.

II. The student will be able to describe the role of the Nursing Assistant, including

the Scope of Practice and the role of facility policies and procedures which may

govern care and conduct.

III. The student will be able to explain the members and roles of the Interdisciplinary

Care Team and the Chain of Command.

IV. The student will be able to describe the importance of both verbal and non–

verbal communication, barriers to effective communication, and interpersonal

skills.

V. The student will be able to explain culture change/resident-centered care and the

need to incorporate into daily care.

Key Terms:

Abuse – any intentional unnecessary physical act that inflicts pain on, or causes injury,

to an endangered person or an impaired person (nursing home resident);

A. Any intentional and unnecessary physical act that inflicts pain on or causes

injury to an endangered person or an impaired person, excluding court-

ordered medical care or medical care requested by the patient or long-term

care facility resident or a person legally authorized to make medical decisions

on behalf of the patient or long-term care facility resident;

B. Any intentional act that a reasonable person would believe subjects an

endangered person or an impaired person, regardless of age, ability to

comprehend, or disability, to ridicule or psychological injury in a manner likely

to provoke fear or alarm, excluding necessary care and treatment provided in

accordance with generally recognized professional standards of care;

C. Any intentional threat that a reasonable person would find credible and non-

frivolous to inflict pain on or cause injury to an endangered person or an

impaired person except in the course of medical treatment or for justifiable

cause; or

D. Any willful infliction of injury, unreasonable confinement, intimidation, or

punishment with resulting physical harm, pain, or mental anguish.

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Activity Director (AD) – an individual who plans the activities for the residents and

assists them to socialize and to stay physically and mentally active.

Activities of Daily Living (ADLs) – personal daily care tasks, including bathing,

dressing, caring for teeth and hair, toileting, eating, and drinking.

Acute – a current illness that has severe symptoms and may be as a result of a sudden

onset.

Administrator – manages all departments within the facility.

Adult Day Care – care given at a facility during day time hours; generally for individuals

who need some assistance and/or supervision but are not seriously ill or disabled;

usually reside outside of the facility.

Advanced Practice Nurse – a registered nurse having education beyond the basic

nursing education and certified by a nationally recognized professional organization in a

nursing specialty, or meeting other criteria established by a Board of Nursing.

Assisted Living – facilities where residents live who need limited assistance, but do not

require skilled care.

Bedfast – Bedridden. Confined to bed, especially for a long or indefinite period of time,

due to illness or injury

Call Light – a device used to communicate a need for assistance to staff.

Certified Nursing Assistant (CNA) – an individual who has completed a state-

approved course and has successfully completed certification testing. A CNA provides

direct care under the supervision of a Registered Nurse (RN) or a Licensed Practical

Nurse (LPN).

Certified Occupational Therapist Assistant (COTA) – helps patients develop,

recover, and improve the skills needed for daily living and working. Occupational

therapy assistants provide therapy to patients under the direct supervision of

occupational therapists.

Chain of Command – the line of authority in the facility which addresses to whom each

employee/department reports.

Chronic – the disease or condition is long term or will be long lasting.

Clichés – phrases that are used frequently and which often have a different meaning,

making it difficult for the resident to understand.

Communication – the process of exchanging information with others.

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Criminal Record Check – the process of reviewing an individual’s criminal history in

order to determine if he/she is eligible for employment in a long term care facility. State

and/or national records may be reviewed for this process.

Cultural Differences – beliefs, values, habits, diet and health practices that relate to a

person’s culture or religion.

Cultural Diversity – the variety of people living and working together in the facility.

Culture – the way of life, especially the general customs and beliefs, of a particular

group of people at a particular time.

Culture Change – a philosophy that focuses on providing person–centered care to

residents and creating a positive work environment for healthcare workers.

Denial – rejection of a thought or feeling.

Dependent – requires staff assistance to carry out activities of daily living.

Displacement – transferring a strong negative feeling to something or someone else.

Endangered Adult – A long-term care facility resident or an Arkansas State Hospital

resident who:

A. Is found to be in a situation or condition that poses an imminent risk of death

or serious bodily harm to the long-term care facility resident; and

B. Demonstrates a lack of capacity to comprehend the nature and

consequences of remaining in that situation or condition.

Exploitation – illegal or unauthorized use or management of an endangered person’s

or an impaired person’s (nursing home resident) funds, assets, or property;

A. Misappropriation of property of a long–term care facility resident, that is, the

deliberate misplacement, exploitation, or wrongful, temporary, or permanent

use of a long–term care facility resident’s belonging or money without the

long–term facility resident’s consent.

Health Insurance Portability and Accountability Act (HIPAA) – federal law that

protects the privacy of individually-identifiable health information; sets national

standards for the security of electronic, protected health information; and protects

identifiable information being used to analyze patient safety events and improve patient

safety.

Home Health Care – care provided in a person’s home.

Hospice Care – care for individuals who have an estimated six months or less to live.

Hospice provides physical and emotional care and comfort.

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Housekeeping Department – responsible to maintain the facility in a clean and

sanitary manner.

Impaired Person – a person eighteen (18) years of age or older who as a result of

mental or physical impairment is unable to protect himself or herself from abuse, sexual

abuse, neglect or exploitation. A long–term care facility resident is presumed to be an

impaired person.

Independent – able to carry out activities of daily living without staff assistance.

Intermediate Care Facilities/Individuals with Intellectual Disabilities (ICF/IID) –

facilities that specialize in providing care to developmentally disabled individuals.

Interdisciplinary Team – professionals from each discipline within the nursing facility

who meet to discuss and plan the care of the resident.

Laundry Department – oversees laundering of facility linens and residents’ personal

clothing.

Licensed Practical Nurse (LPN) – A licensed professional who has completed 1 to 2

years of nursing education and has passed an exam for licensure; nurse who provides

care under the direction of registered nurses or physicians.

Long Term Care (LTC) – care for persons who require 24-hour care and assistance.

Long Term Care Facility Resident – means a person, regardless of age, living in a

long–term care facility.

Long Term Care Facility Resident Maltreatment – abuse, exploitation,

misappropriation of a resident’s property, neglect, or sexual abuse of a long–term care

facility resident as defined by Arkansas law.

Maintenance Department – maintains facility and grounds in good repair.

Medical Director – physician who provides oversight to the nursing staff regarding care

provided to the residents.

Medical Doctor (MD) – physician

Medication Assistive Person (MAP) – a certified nursing assistant who has completed

required state training and has completed examination in an effort to administer

medications and certain treatments in accordance with the specific scope of practice of

the MAP.

Neglect – an act or omission by a caregiver responsible for the care and supervision of

an endangered person or an impaired person (nursing home resident) constituting:

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A. Negligently failing to provide necessary treatment, rehabilitation, care, food,

clothing, shelter, supervision, or medical services to an endangered person or

an impaired person;

B. Negligently failing to report health problems or changes in health problems or

changes in the health condition of an endangered person or an impaired

person to the appropriate medical personnel;

C. Negligently failing to carry out a treatment plan developed or implemented by

the facility; or

D. Negligently failing to provide goods or services to a long-term care facility

resident necessary to avoid physical harm, mental anguish, or mental illness.

Non–Verbal Communication – communication without using words, such as facial

expressions, tone of voice, posture, gestures, touch, body language, etc.

Objective Information – information based on what is factually seen, heard, touched or

smelled. A direct observation.

Occupational Therapist (OT) – a therapist who helps residents to learn to compensate

for their disabilities and assist them with activities of daily living.

Office of Long Term Care – state agency that oversees the long term care facilities in

Arkansas; commonly called OLTC.

Ombudsman – resident advocate who investigates complaints and assists to achieve

agreement between parties, often defending the rights of residents.

Optometrist – health care professional who examines eyes for defects, prescribes

correctional lenses, and treats diseases of the eye.

Palliative Care – care that focuses on the comfort and dignity of the person rather than

on curing him or her.

Person–Centered Care – a philosophical approach to nursing home care that honors

and respects the voice of elders and those working closest with them. It involves a

continuing process of listening, trying new things, seeing how they work, and changing

things in an effort to individualize care and de–institutionalize the nursing home

environment.

Physical Therapist (PT) – provides therapy in the form of heat, cold, massage,

ultrasound, electricity and exercise to residents with muscle, bone and joint problems.

A PT may help a person to safely use a walker, cane, or wheelchair

Podiatrist – a physician who examines and cares for the residents’ feet.

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Policy – a course of action determined by the facility that should be taken every time a

certain situation occurs.

Post–Acute Head Injury Facility – a facility which specializes in care and services for

persons with acute head injuries.

Procedure – the steps to be taken to carry out a task. A particular way of doing

something.

Professionalism – how a person behaves when he/she is on the job.

Projection – seeing feelings in others that are really one’s own.

Rationalization – making excuses to justify a situation.

Registered Dietitian (RD) – a professional who creates special diets for residents with

specific needs and plans menus to ensure residents’ nutritional needs are met.

Registered Nurse (RN) – a licensed professional who has completed 2 to 4 years of

nursing education and has passed an exam for licensure; professional who can provide

all levels of nursing care under the direction of a physician.

Regression – going back to an old, immature behavior.

Repression – blocking painful thoughts or feelings from the mind.

Residential Care Facility (RCF) – facility licensed to provide services 24 hours a day

to individuals older than 17 who are not capable of independent living and who require

assistance and supervision. Individuals in RCF must be independently mobile, capable

of responding to reminders and guidance from staff and capable of self-administering

medication.

Respiratory Therapist – provides breathing treatment(s) and special equipment for

respiratory conditions.

Sexual Abuse – deviant sexual activity, sexual contact, or sexual intercourse, as those

terms are defined in §5–14–101, with another person who is not the actor’s spouse and

who is incapable of consent because he or she is mentally defective, mentally

incapacitated, or physically helpless as those terms are defined in §5–14–101.

Scope of Practice – the tasks for which a person is trained, thus, allowed to perform.

Skilled Care – medically-necessary care given by a nurse or therapist.

Slang – terms/words used that may be specific to a generation and not easily

recognized and/or easily misinterpreted by the resident.

Social Worker (SW) – an individual who helps residents with psycho–social needs and

assists to arrange needed services.

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Speech Therapist (ST) or Speech Language Pathologist (SLP) – a therapist who

helps residents with speech, language and swallowing problems.

Subjective Information – information that could not be or was not observed.

Information based on what a person thinks, or something that was reported by another

person that may or may not be true.

Terminal illness – a disease or condition that will eventually cause death.

Tuberculosis (TB) – a bacterial infection that usually attacks the lungs, but can attack

any part of the body, such as the kidneys, spine, and brain. An airborne disease,

carried on droplets suspended in the air, that causes coughing, difficulty breathing, fever

and fatigue.

Verbal Communication – written or spoken messages.

Content:

I. Introduction to Long Term Care

A. Long Term Care – Acute, chronic and terminal illness

B. Skilled Care

C. Adult Day Care

D. Assisted Living

E. Residential Care Facility

F. Home Health Care

G. Hospice Care

H. Palliative Care

I. Intermediate Care Facilities/Individuals with Intellectual Disabilities

(ICF/IID)

II. The Role of the Nurse Aide

A. Requirements for working in Long Term Care

1. Criminal records check performed per the Office of Long Term Care

(OLTC) guidelines

2. Tuberculosis (TB) Skin Test (or health screen and physical) and

annual flu vaccination

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3. Completion of a state-approved training program

4. Pass the state competency examination within one year of training

completion; only three test attempts will be allowed; certificate must

remain active and in good standing (no flags/disqualifications)

B. Professionalism

Examples of professional interactions with the resident include, but are not

limited to:

1. Keeping a positive attitude while doing the assigned tasks you are

trained to perform.

2. Keeping information about the resident confidential

3. Being polite – not discussing your personal problems with a

resident or with a co–worker in front of a resident

4. Not using profanity, even if a resident uses profanity.

5. Listening to the resident.

6. Calling the resident by Mr., Mrs., Ms., or by the name he/she

prefers.

7. Always explaining the care, you will be providing before beginning

to provide the care.

8. Presenting a positive image through personal hygiene, appearance

and state of mind.

9. Accountability

10. Confidentiality–Health Insurance Portability and Accountability Act

(HIPAA)

C. Scope of Practice – The Arkansas Nursing Assistant Scope of Practice

identifies the Standards of Practice that Certified Nursing Assistants

(CNA) must follow in delivering care. If a CNA delivers care outside of the

defined Standards of Practice, whether it is on the CNA’s own initiative or

at the direction of a licensed nurse, the CNA may have violated the

Arkansas Adult and Long Term Care Facility Resident Maltreatment Act

as defined in Arkansas Code Ann. §12–12–1707 et seq.

D. Provide care according to the resident’s comprehensive care plan.

1. Direct care needs/Use of a Nurse Aide Assignment Sheet

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E. Actively listen to and communicate with the resident, the family, and the

health care team.

F. Observe and report any change in the resident’s appearance, behavior or

mood to the nurse.

1. Objective observation/information

2. Subjective observation/information

3. Observations that indicate an acute condition requiring immediate

attention from the nurse include but are not limited to: severe pain,

fall/accident, seizures, swelling, bleeding, loss of consciousness,

difficulty breathing.

4. Acute change in mental status – confusion, lethargy, delirium.

G. Participate in care planning, when requested.

H. Follow policies and procedures.

I. Follow the nurse aide assignment for your shift.

III. The Care Team and the Chain of Command

A. Interdisciplinary Team – often includes Activity Director, Certified Nursing

Assistant, Licensed Practical Nurse, Medical Doctor, Social Worker,

Occupational Therapist, Physical Therapist, Medication Assistive Person,

Dietary Manager and/or Registered Dietitian, Registered Nurse, Speech

Therapist, Administrator.

1. Resident and Family Member/Responsible Party.

2. Ombudsman, upon resident request.

B. Chain of Command

1. Administrator

2. Director of Nursing

3. Licensed Nurse (charge nurse/supervisor)

4. Certified Nursing Assistant/ Medication Assistive Person

IV. Communication and Interpersonal Skills

A. Effective Communication

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1. Formulate the message.

2. Receive the message (listen).

3. Observe for feedback.

B. Verbal and Non–Verbal Communication

C. Barriers to Communication

1. Clichés

2. Slang

3. Impairments

a. A person who is visually impaired relies on verbal cues,

including words and tone of voice.

i. State your name before beginning a conversation.

ii. Describe persons, things and environment.

iii. Inform the resident when you are entering or leaving

the room.

iv. Explain in detail what you are doing and ask the

resident what they would like to do independently.

v. Touch the resident, if appropriate.

vi. Read resident’s mail or personal documents, only if

asked

vii. Sit where resident can easily see you if resident has

partial vision.

b. A person who is hearing impaired relies on nonverbal cues

including body language, sign language, and writing.

i. Speak slowly and distinctly.

ii. Use short sentences.

iii. Face the resident.

iv. Use facial expressions and gestures.

v. Reduce outside distraction

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vi. Use sign language and communication boards, if

appropriate.

vii. Be certain that the resident’s hearing aid is in place

and is working properly, if applicable. (Glasses also)

4. A person who is cognitively impaired relies on both verbal and

nonverbal cues and may need messages repeated frequently,

using short sentences and simple words.

5. Denial – refusal to acknowledge existence of something: a refusal

to believe in something or admit that something exists.

6. Displacement – transfer of emotions or behavior: the transfer of

emotion from the original focus to another less threatening person

or object, or the substitution of one response or piece of behavior

for another.

7. Rationalization – a defense mechanism whereby people attempt to

hide their true motivations and emotions by providing reasonable or

self–justifying explanations for irrational or unacceptable behavior.

8. Regression – reversion to earlier state: a return to an earlier or less

developed condition or way of behaving.

9. Repression – a mechanism by which people protect themselves

from threatening thoughts by blocking them out of the conscious

mind.

D. Call Lights as the resident’s means to Communicate with Staff

1. Ensure residents have access to their call light when they are in

their room; always place call light on the resident’s unaffected side

and within easy reach.

2. Staff should respond immediately to call lights and provide any

necessary/requested assistance upon answering.

E. Promoting resident’s independence

1. Independence versus Dependence – relying on self vs. others to

perform tasks

2. Activities of Daily Living (ADLs) – allow residents to perform as

much of the skill/duty as possible, offering assistance as needed.

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V. Resident–Centered Care (Person–Centered Care)

A. Respecting resident choice/preference

1. Provide a home–like and safe living environment with daily routines

designed to meet the resident’s specific needs and in accordance

with former lifestyle.

B. Practices which reflect resident–centered care includes, but not limited to:

1. Time to awake/retire to bed

2. Frequency of bath/shower

3. Preferred activities

4. Choice of clothing

5. Choice of mealtimes

6. Choice of toileting times

C. Cultural Diversity

D. Respecting Cultural Differences

E. Respecting Religious Preferences

Review Questions --- Lesson #1

1. To whom does the CNA report?

2. What is the difference between an objective and a subjective observation?

3. Give examples of resident choices which could be honored by the facility

to promote person–centered care.

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Lesson # 2 (1.5 hours)

Title: Resident Rights

Lesson Objectives:

I. The student will be able to explain the importance of residents’ rights.

II. The student will be able to describe the components/areas that are residents’

rights.

III. The student will be able to demonstrate ways to protect residents’ rights.

IV. The student will be able to describe the types of abuse, neglect and

misappropriation.

Key Terms:

Abuse – the willful infliction of injury, unreasonable confinement, intimidation, or

punishment with resulting physical harm, pain or mental anguish; abuse can be verbal

(something said–oral, written or gestured), physical (something done to the resident–

rough handling/treatment, hitting, slapping, pinching, etc.), emotional/mental

(humiliation, harassment, threats of punishment or deprivation) or sexual (harassment,

coercion or sexual assault). Any sexual relationship with a resident is considered to be

abuse.

Confidentiality – maintaining information as private.

Consensual – agreed to by the people involved; done with the consent of the people

involved.

Health Insurance Portability and Accountability Act (HIPAA) – federal law that

protects the privacy of individually-identifiable health information; sets national

standards for the security of electronic, protected health information; and protects

identifiable information being used to analyze patient safety events and improve patient

safety.

Informed Consent – a person, if competent, after having been informed of potential

negative outcomes, makes informed decisions about their healthcare.

Involuntary Seclusion – separation of a resident from other residents or from his/her

room or confinement to his/her own room against the resident’s will, or the will of the

resident’s legal representative.

Misappropriation – the deliberate misplacement, exploitation, or wrongful, temporary

or permanent use of a resident’s belongings or money without the resident’s consent.

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Neglect – failure to provide goods and services necessary to avoid physical harm,

mental anguish, or mental illness; failure to follow a prescribed order of treatment or the

care plan; negligently failing to provide necessary treatment, rehabilitation, care, food

clothing, shelter, supervision , or medical services; negligently failing to report health

problems or changes in health problems or changes in health condition of a resident to

the appropriate medical personnel, and failing to carry out a prescribed treatment plan

developed or implemented by the facility.

Omnibus Budget Reconciliation Act (OBRA) – law passed by federal government

establishing minimum standards for nursing home care and for nursing assistant

training.

Privacy – free of being observed or disturbed by other people.

Residents’ Rights – rights identified by OBRA relative to residents in long term care

facilities; informs residents and others of the residents’ rights within the facility.

Restraints – to physically restrict voluntary movement or use chemicals to

revise/restrict resident behavior.

Content:

I. Residents’ Rights

A. Origin – Omnibus Budget Reconciliation Act (OBRA) —passed in 1987

due to reports of poor care and abuse in nursing homes.

B. Purpose

1. Inform a resident how he/she is to be treated.

2. Provide an ethical code of conduct for healthcare workers.

C. These rights include the resident’s right to:

1. Exercise his or her rights;

2. Be informed about what rights and responsibilities he or she has;

3. If he or she wishes, have the facility manage his or her personal

funds;

4. Choose a physician, treatment and participate in decisions and

care planning;

5. Privacy and confidentiality;

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6. Voice grievances and have the facility respond to those grievances;

7. Examine survey results;

8. Work or not work;

9. Privacy in sending and receiving mail;

10. Visit and be visited by others from outside the facility;

11. Use a telephone in privacy;

12. Retain and use personal possessions to the maximum extent that

space and safety permit;

13. Share a room with a spouse or another, if mutually agreeable;

14. Refuse a transfer from a distinct part, within the facility;

15. Be free from any physical or chemical restraints; and

16. Be free from verbal, sexual, physical and mental abuse, corporal

punishment and involuntary seclusion.

D. Protection of Residents’ Rights:

1. Never abuse — know your limits.

2. Types of abuse (Refer to Lesson 30) (Arkansas Adult Maltreatment

Act, Act 584 of 2013, codified as Ark. Code Ann. § 12-12-701 et

seq.)

3. Report signs/symptoms of abuse, neglect and misappropriation

(examples provided later).

E. Privacy

1. Avoid unnecessary exposure.

2. Do not open mail without permission.

3. Knock and request permission before entering room.

F. Confidentiality

1. No gossip.

2. No sharing of resident information except with care team members.

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a. Health Insurance Portability and Accountability Act (HIPAA) – law

to keep health information private.

b. Social Media – posting any resident’s information without that

resident’s consent is considered a violation of privacy rights and

may lead to abuse as defined in the Abuse Maltreatment Act.

G. Resident Care

1. Involve resident in care.

2. Explain procedures.

3. Respect refusal in care.

4. Report refusal in care.

Note: Introduce CARE SKILLS #1 and #2– “Initial Steps” and “Final Steps”

to reinforce acknowledgement of Resident Rights. Following these steps

will help to ensure that residents’ rights are observed when providing care.

H. Report and Document

1. Be honest and truthful.

2. Notify supervisor immediately of abuse, neglect and/or

misappropriation.

3. Contact nurse with questions about caring for residents.

4. Report changes in condition.

5. Mandated reporter- person legally required to report suspected or

witnessed abuse and/or neglect. Nursing assistants are mandated

reporters. Failure to report abuse or neglect is a crime that can

result in criminal charges.

II. Abuse, Neglect, and Personal Possessions/Misappropriation

A. Types of Abuse

1. Physical - something done to the resident – rough

handling/treatment, hitting, slapping, pinching, etc.

2. Sexual - harassment, coercion or sexual assault. Any sexual

relationship with a resident is considered to be abuse.

3. Mental - humiliation, harassment, threats of punishment or

deprivation

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4. Verbal - something said – oral, written or gestured

5. Financial – improper or illegal use of the resident’s money or

possessions. Accepting money from the resident for special care or

stealing from the resident is considered financial abuse.

B. Neglect/Negligence

C. Involuntary Seclusion

D. Misappropriation

1. Personal property

2. Gifts

3. Temporary or permanent misuse of a resident’s property.

E. Signs and Symptoms

1. Abuse

a. Conditions– suspicious marks, bruises, bite marks, fractures,

dislocations, burns, scalp tenderness, nose bleeds, swelling,

welts

b. Observations– fear, pain, withdrawal, mood changes, acting

out, anxiety, guarding

c. Catastrophic reactions- are extraordinary reactions of

residents to ordinary stimuli, such as the attempt to provide

care.

2. Neglect

a. Conditions – pressure ulcers, dehydration, weight loss,

anger, sadness, fear

b. Observations – unclean, soiled bedding or clothing,

unanswered call lights, wrong clothes, no glasses/hearing

aids, uneaten food/snacks, no water available

c. Negligently failing to carry out a prescribed treatment plan

developed or implemented by the facility

3. Misappropriation

a. Conditions – anger, sadness, fear

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b. Observations – missing items, comments from resident or

family

F. Reporting

1. Know federal requirements, state requirements and requirements in

the Adult and Long–Term Care Facility Resident Maltreatment

Reporting Acts, Act 584 of 2013, codified as Ark. Code Ann. § 12-

12-701 et seq.

CARE SKILLS:

Introduce the students to:

• Initial Steps – #1

• Final Steps – #2

Review Questions --- Lesson #2

1. Give examples of Resident Rights.

2. How can Resident Rights be protected?

3. What are the different types of abuse?

4. Give examples of neglect.

5. Give an example of misappropriation.

6. What is the first thing that should be done if you feel a resident has been

abused?

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Lesson #3 (2 hours)

Title: Infection Control

Lesson Objectives:

I. The student will be able to explain the importance of Infection Control.

II. The student will be able to describe the chain of infection.

III. The student will be able to explain the importance of hand hygiene.

IV. The student will be able to describe the importance of personal protective

equipment (PPE).

V. The student will be able to explain both Standard and Transmission-Based

Precautions.

VI. The student will be able to describe conditions that are associated with

infections.

VII. The student will be able to demonstrate proper handwashing technique and

proper use of PPE.

VIII. The student will be able to describe the importance of a clean environment.

IX. The student will be able to verbalize rationale related to following proper

technique for handwashing and use of PPE.

Key Terms

Acquired Immune Deficiency Syndrome (AIDS) – a disease of the human immune

system caused by Human Immunodeficiency Virus (HIV). The illness interferes with the

immune system, making those with AIDS much more likely to get infections. Although

considered a sexually transmitted disease, it is also spread through blood, infected

needles, or to the fetus from its mother.

Airborne Precautions – measures used to protect against diseases that are

transmitted through the air after expelled.

Aseptic– preventing infection; free or freed from pathogenic microorganisms.

Blood-borne Pathogens – microorganisms in human blood which can cause infection

and disease in humans.

Body Fluids – saliva, sputum, urine, feces, semen, vaginal secretions, and pus or other

wound drainage.

Causative Agent – a biological agent (pathogen) that causes a disease.

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Centers for Disease Control and Prevention (CDC) – federal agency that issues

guidelines to protect and improve health.

Chain of Infection – an illustration to describe how a disease is transmitted from one

person (or source) to another.

Clostridium Difficile (C–Diff) – bacteria which causes severe watery diarrhea and

other intestinal disease when competing bacteria have been wiped out by antibiotics; It

is spread by spores that are difficult to kill and can be carried on the hands of caregivers

who have direct contact with residents or an environmental surface (i.e., floors, toilets,

bedpans).

Contact Precautions – measures used when there is risk of transmitting or contracting

a microorganism from touching an infected object or person.

Direct Contact – touching an infected person, or his/her secretions.

Disinfect – to decrease the spread of pathogens and disease by destroying pathogens.

Disinfection – process used to decrease the spread of pathogens by destroying them.

Chemicals are often used in this method of cleaning.

Disposable – a product designed for short–term or single use.

Droplet Precautions – measures used to protect against disease-causing

microorganisms that do not stay airborne and only travel a short distance after being

expelled.

Hand Hygiene – washing hands with soap and water or using alcohol–based hand rub.

Healthcare-Associated Infection (HAI) – infection acquired in a hospital or other

healthcare setting; also known as a nosocomial infection.

Hepatitis – inflammation of the liver caused by infection.

Indirect Contact – transmission of a disease without physical contact (e.g., touching a

common object).

Infection Control – methods used to control and prevent the spread of germs that are

present in the environment.

Influenza – an infectious disease caused by a virus. The most common symptoms

include chills, fever, sore throat, muscle pains, severe headache, coughing,

weakness/fatigue, and general discomfort. Influenza is a more severe disease than the

common cold.

Isolation – measure taken to separate (isolate) the potentially harmful microorganism

and prevent spread to other residents.

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Jaundice – a yellow/gold tint to the skin and eyes often seen in liver disease, such as

hepatitis, or liver cancer.

Localized Infection – an infection contained to a specific body part.

Methicillin-Resistant Staphylococcus Aureus (MRSA) – an antibiotic resistant

infection often acquired in hospitals and other facilities; spread by direct physical

contact.

Mode of Transmission – how the pathogen travels from one person to another.

Transmission can happen through the air, or through direct or indirect contact.

Nosocomial Infection – infection acquired in a hospital or other healthcare setting; also

known as HAI (healthcare-associated infection).

Occupational Safety and Health Administration (OSHA) – federal agency that

protects workers from hazards on the job.

Pathogen – harmful microorganism; the causative agent.

Pediculosis – an infestation of lice.

Personal Protective Equipment (PPE) – barrier between a person and a potentially

harmful microorganism.

Portal of Entry – the way pathogens enter the body (e.g., mouth, nose, skin breaks,

urinary tract and anus).

Portal of Exit – the ways pathogens leave the body (e.g., urine, feces, saliva, tears,

drainage from wounds, sores, blood, excretion from respiratory tract or genitals).

Reservoir – where pathogens live and multiply.

Scabies – a contagious skin infection that occurs among humans and other animals.

Caused by a tiny and usually not directly visible parasite which burrows under the host's

skin, causing intense allergic itching.

Standard Precautions – treating all blood, body fluids, non–intact skin and mucous

membranes as if they are infected.

Sterilization – technique that destroys all microorganisms, not just pathogens.

Susceptible Host – the person who could be infected (e.g., elderly, persons who are

not in good health, people who do not follow proper infection control precautions).

Systemic Infection – infection that occurs when pathogens enter one’s bloodstream

and move throughout the body causing general symptoms.

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Transmission-Based Precautions – special precautions implemented on the basis of

how the disease spreads.

Tuberculosis – a bacterial infection that affects the lungs, causing coughing and

difficulty breathing, fever and fatigue. It is an airborne disease, carried on droplets

suspended in the air.

Vancomycin-Resistant Enterococcus (VRE) – a strain of enterococcus that cannot be

controlled with antibiotics; it is spread through direct and indirect contact.

Content:

I. Introduction to Infection Control

A. Definition of Infection Control — methods used to prevent and control the

spread of disease, especially in a healthcare setting.

B. Role of Centers for Disease Control and Prevention (CDC)

1. CDC is the nation’s health protection agency, working 24/7 to

protect America from health and safety threats, regardless of the

origin of the threat.

C. Chain of Infection Links

1. Causative Agent – a pathogen or microorganism that causes

disease.

2. Reservoir – a place where a pathogen lives and grows.

3. Portal of Exit – a body opening on an infected person that allows

pathogens to leave.

4. Mode of Transmission – method of describing how a pathogen

travels from one person to the next person.

5. Portal of Entry – a body opening on an uninfected person that

allows pathogens to enter.

6. Susceptible Host – an uninfected person who could get sick (e.g.,

elderly, persons who are not in good health, people who do not

follow proper infection control precautions.

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D. Types of infections

1. Systemic – an infection that is in the bloodstream and spreads

throughout the body, causing general symptoms.

2. Localized – an infection that is confined to a specific location in the

body and has local symptoms.

3. Healthcare-Associated Infections (HAIs)/Nosocomial – infections

that patients acquire within healthcare settings that result from

treatment for other conditions.

E. Facility Infection Control Policy

1. Key components

a. Procedures – steps or methods that will be followed.

b. Reporting – contacting or informing required parties (such as

a nurse, doctor, Administrator, local health unit/department,

OLTC, etc.) when concerns arise or to provide updates on

previously-informed information.

c. Surveillance – monitoring surroundings and individuals to

identify potential concerns, such as the onset or first

appearance of an infection or signs that an infection has

spread.

d. Compliance – process of ensuring that steps are being

followed accordingly.

F. Infectious Disease/Infectious Condition

1. Acquired Immune Deficiency Syndrome (AIDS) – a disease of

the human immune system caused by human immunodeficiency

virus (HIV). The illness interferes with the immune system, making

those with AIDS much more likely to get infections. Although

considered a sexually transmitted disease, it is also spread through

blood, infected needles, or to the fetus from its mother.

a. Transmission – blood or body fluids; usually through contact

with blood or sexual contact.

b. Prevention– Standard Precautions

2. Clostridium Difficile (C–Diff) – bacteria which causes severe

watery diarrhea and other intestinal disease when competing

bacteria have been wiped out by antibiotics; It is spread by spores

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that are difficult to kill and can be carried on the hands of caregivers

who have direct contact with residents or an environmental surface

(i.e., floors, toilets, bedpans).

a. Transmission – spores which may survive up to six months

on inanimate objects.

b. Prevention – Contact Precautions; requires caregiver to

wash hands; do not use alcohol–based hand rubs.

3. Hepatitis – inflammation of the liver caused by infection.

a. Transmission – fecal/oral; contaminated blood or needles;

sexual intercourse.

b. Prevention – Standard Precautions; requires caregiver to

wash hands; do not use alcohol–based hand rubs

4. Influenza – an infectious disease caused by a virus. The most

common symptoms include chills, fever, sore throat, muscle pains,

severe headache, coughing, weakness/fatigue and general

discomfort. Influenza is a more severe disease than the common

cold.

a. Transmission – direct or indirect contact; may also be

airborne; when a person with the flu coughs, sneezes, or

talks, tiny droplets can land in the mouths or noses of people

nearby; the virus can also enter a person’s body if they touch

an object that has droplets on it and then touch their eyes,

mouth, or nose

b. Prevention – Standard Precautions; may require Droplet

Precautions. Frequent handwashing

5. Methicillin-Resistant Staphylococcus Aureus (MRSA) – is

bacteria that is resistant to many antibiotics. Infectious – with

symptoms. Colonized – without symptoms

a. Transmission – direct or indirect contact

b. Prevention—Standard Precautions (colonized); Contact

Precautions (infectious) dependent upon provider type;

Droplet Precautions for a respiratory infection.

6. Pediculosis – an infestation of lice.

a. Transmission –direct or indirect contact; common use of

combs/brushes, hats, linens.

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b. Prevention – Contact Precautions

7. Scabies – a contagious skin infection that occurs among humans

and other animals. Caused by a tiny and usually not directly visible

parasite which burrows under the host’s skin, causing intense

allergic itching.

a. Transmission – direct and indirect contact, by sharing

clothing, towels, or bedding

b. Prevention – Contact precautions

8. Tuberculosis – is a disease caused by a bacterium called

Mycobacterium tuberculosis.

a. Transmission–airborne; a resident who is suspected as

having active Tuberculosis will be immediately transferred to

a location where respiratory precautions (such as air

exchange limited only to the room of the resident and use of

respirators by caregivers) can be implemented.

b. Prevention – Airborne Precautions; relocation to an

appropriate environment.

9. Vancomycin-Resistant Enterococcus (VRE) – enterococci that

have become resistant to the drug Vancomycin, and thus are called

vancomycin–resistant enterococci

a. Transmission – direct or indirect contact

b. Prevention – Standard Precautions; may require Contact

Precautions.

II. Infection Control Practices

A. Environmental cleaning

1. High touch areas – bedrails, bedside equipment, remote control.

B. Disposal of contaminated items/infectious waste

1. Sharps containers

2. Bio–hazardous waste containers

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C. Linen

1. Handling clean linen

2. Handling/securing soiled linen

III. Hand Hygiene

A. Handwashing – when hands are visibly soiled

1. Washing hands is the single most important infection control

practice.

B. Alcohol–based hand rub/ hand sanitizer

C. Five Moments for hand hygiene – World Health Organization (WHO)

1. Before resident/patient contact

2. Before aseptic task

3. After exposure to blood/body fluids

4. After resident/patient contact

5. After contact with resident/patient surroundings

D. Other Handwashing moments

E. Important factors related to Hand Hygiene

1. Visibly soiled with blood or body fluids

2. Exposure to potential pathogens

a. Spores/Clostridium Difficile (C–Diff) – requires handwashing

F. Other factors related to Hand Hygiene

1. Fingernails – long fingernails harbor organisms.

2. Jewelry

3. Intact skin

G. Procedure for handwashing – (See CARE SKILLS #3)

1. Demonstrate proper handwashing.

2. Explain rationale for each step.

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IV. Personal Protective Equipment – PPE

A. Purpose of PPE – creates a barrier of protection against infectious

materials, so that the caregiver does not become contaminated; when

used correctly, PPE minimizes the spread of infection

B. Types of PPE

1. Gloves (See CARE SKILLS #4)

2. Gown (See CARE SKILLS #5)

3. Mask (See CARE SKILLS #6)

C. Procedure for PPE

V. Precautions

A. Standard Precautions - treating all blood, body fluids, non–intact skin and

mucous membranes as if they are infected.

1. Hand Hygiene

2. Personal Protective Equipment

3. Disposal of contaminated equipment/supplies

B. Transmission-Based Precautions – special precautions implemented on

the basis of how the disease spreads.

1. Airborne Precautions

2. Droplet Precautions

3. Contact Precautions

CARE SKILLS:

• Handwashing/Hand rub – #3

• Gloves – #4

• Gown – #5

• Mask – #6

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Review Questions --- Lesson #3

1. What are the links in the "Chain of Infection"?

2. What is the most important action a healthcare worker can take to prevent

spread of infection?

3. Describe the 5 Moments of Hand Hygiene.

4. Explain the importance of proper usage of personal protective equipment.

5. Provide examples of how direct contact can spread infection.

6. Provide examples of how indirect contact can spread infection.

7. If a resident has Clostridium Difficile, is an alcohol–based hand rub

effective?

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Lesson #4 (2 hours)

Title: Fire Safety and Other Resident Safety Concerns

Lesson Objectives:

I. The student will be able to describe fire safety and necessary emergency

response should a fire occur and manner of resident evacuation.

II. The student will be able to explain the rationale for use of side rails and potential

entrapment dangers associated with side rail use.

III. The student will be able to describe residents at risk of elopement and

interventions to help prevent elopement.

IV. The student will be able to explain the smoking policy, safety concerns and

interventions to promote safe smoking.

Key Terms:

Evacuation Plan – plan developed by the facility by which residents would be relocated

to a safe area within the facility, outside the facility, or to an alternate location.

Entrapment – a resident’s body part becomes lodged between the bed frame and/or

mattress and the bed rail.

Elopement – a resident exiting the facility whose whereabouts are unknown to the staff.

Fire Drill – plan executed frequently to help workers learn what to do in the case of a

fire.

Flammable – easily ignited; capable of burning quickly.

Pacing – walking back and forth in the same area of the facility.

Wandering – walking aimlessly throughout the facility.

Content:

I. Fire Safety

A. General

1. Know the evacuation plan.

2. Know how much assistance is needed, and which residents to

relocate first (i.e., ambulatory, those who need assistance, totally

dependent).

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3. Dangers of smoke inhalation

a. Stay low and cover mouth with wet cloth.

b. Shut residents’ doors.

4. Fire drills and procedures

a. Role of the nursing assistant during a fire drill and/or

evacuation.

b. Know the locations of all exits and stairways.

c. Know the locations of fire alarms, extinguishers and fire

blankets.

5. Never use an elevator in the event of a fire.

6. If your clothing catches on fire, STOP, DROP and ROLL to smother

the flames. A fire blanket, if available, can also be used to help

smother the flames.

7. A supervisor or charge nurse will give directions during an

emergency.

B. Guidelines in case of fire (See CARE SKILLS #7)

1. Remove residents from area of immediate danger.

2. Activate the fire alarm.

3. Contain the fire, if possible (close doors).

4. Extinguish, if possible.

C. Use of the fire extinguisher (See CARE SKILLS #8)

1. Pull the pin.

2. Aim at the base of the fire.

3. Squeeze the handle.

4. Sweep back and forth at the base of the fire.

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D. Types of fires

A= paper, wood, cloth

B= oil, grease

C=electrical

E. During an emergency, stay calm, listen carefully and follow directions

given.

II. Side rails/Entrapment

A. Purpose of side rail use

1. Enabling or self–help if used to assist the resident to move

independently.

2. Restrictive if their use results in confining the resident in bed;

restricting voluntary movement.

B. Zones/areas of potential bed entrapment

1. Ensure that the resident does not get caught between the bed

and/or mattress and/or side rails. Being trapped between the

spaces can result in serious injury or death.

2. Refer to the picture in Appendix A to identify zones on the bed

where entrapment can occur.

III. Resident Elopement

A. Exit-seeking behavior

1. Frequently remaining at or near exit doors.

2. Shaking door handles.

3. Pacing to and from the exit doors.

4. Voicing a desire to leave the facility and/or return home.

5. Packing clothing/belongings.

6. Wearing shoes, coat, hat, etc., although in the facility.

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B. Resident identification and monitoring

1. Facility assessment and identification of residents at risk of

elopement.

2. Pictures, logs or other means to identify residents at risk of

elopement.

C. Electronic bracelets

1. Worn by residents at risk for elopement.

2. Checked for presence and function per established facility

frequency.

3. Exits become secured when a resident with such a bracelet

approaches the exit.

4. Be cautious, as residents may remove bracelet with nail clippers,

knife, etc.

D. Coded entries

1. Requires a code to be entered to release/open the door.

2. Code should be known/available to alert and oriented residents,

visitors and staff.

3. Coded entries are unlocked during a fire alarm and must be

monitored.

E. Alarmed doors

1. Staff should suspect a resident has exited unattended when the

alarm is heard.

2. Check panel for source door sounding the alarm.

3. Immediately assess grounds near exit. If source of alarm sounding

is not visualized, conduct a headcount to confirm all residents are

safe within the facility.

4. Never silence an alarm without knowing “why” the alarm sounded.

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IV. Smoking

A. Facility policy

1. Supervised vs. unsupervised smoking per resident assessment of

ability.

2. If the facility allows unsupervised smoking, the facility should direct

how the resident is to store/manage smoking materials (i.e., lighter,

cigarettes).

3. The facility may be a “non–smoking” campus.

B. Potential safety concerns/assistive devices

1. Ability to manipulate smoking materials/cigarette extension.

2. Smoking apron if concerned with ashes dropped on clothing.

3. Appropriate non–flammable ashtrays/containers.

4. Oxygen use prohibited when smoking.

a. Oxygen supports combustion (the process of burning).

b. Never allow open flames near oxygen.

5. Monitoring for non–compliance with smoking policy.

a. Smoke odor in room.

b. Burn holes in clothing/bedding.

c. Smoking materials supplied by family members.

6. Electronic cigarettes

CARE SKILLS:

• Fire – #7

• Fire Extinguisher – #8

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Review Questions --- Lesson #4

1. Explain the acronym “RACE.”

2. Describe the proper use of the fire extinguisher using the acronym

“PASS.”

3. Describe the action to be taken should your clothing catch fire.

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Lesson #5 (2 hours)

Title: Medical Concerns/Emergency Procedures

Lesson Objectives:

I. The student will be able to explain the need for safety and prevention

measures/interventions.

II. The student will be able to explain risk factors related to different types of

accidents.

III. The student will be able to demonstrate prevention strategies for different types

of accidents.

Key Terms:

Cardiac Arrest – heart function and circulation stop.

Choking – a complete blockage of the airway requiring immediate action.

Disorientation –confusion related to time and/or place.

Environment – circumstances or conditions that surround an individual.

Fainting – sudden loss of consciousness because of inadequate blood supply to the

brain.

Fracture – broken bone.

Hemiplegia – total paralysis of the arm, leg and torso on one side of the body.

Hemorrhage – excessive loss of blood from a blood vessel.

Paralysis – loss or impairment of the ability to move a body part, usually as a result of

damage to its nerve supply.

Poisoning – to cause injury, illness, or death by chemical means.

Risk Factor – a characteristic, condition, or behavior that increases the possibility of

injury.

Scald – burn caused by hot liquids in contact with the skin.

Seizure (Convulsions) – sudden contractions of muscles due to a disturbance in brain

activity.

Shock – state of being when vital parts of the body (brain, heart and lungs) do not get

enough blood.

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Content:

I. Accidents

A. Types of Accidents

1. Falls/Fainting

2. Burns

3. Poisoning

4. Choking

B. Is the accident Neglect under Arkansas Law?

II. Falls – the consequences of falls can range from minor bruises to fractures and

life–threatening injuries.

A. Risk factors

1. Personal

a. Medications

b. Gait or balance problems

c. Diagnosis – paralysis, hemiplegia, weakness, disorientation

d. Fainting – the sudden loss of consciousness because of

inadequate blood supply to the brain. The cause can be

pain, fatigue, hunger or medical conditions.

e. Bowel/Bladder status – urgency, incontinence

f. Improperly fitting shoes or clothing

2. Environment

a. Clutter

b. Slippery/wet floors or floors that have shiny waxed finishes.

c. Uneven surfaces

d. Poor lighting

e. Call light out of reach

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f. Side rails

B. Prevention

1. Know residents that are at high risk for falls.

2. Frequent toileting program.

3. Respond to call lights promptly.

4. Use of proper shoes/clothing.

5. Keep environment clear or free of obstacles.

C. Intervention

1. If a resident begins to fall, never try to stop the fall. Gently ease the

resident to the floor and:

a. Call for help immediately, and

b. Keep the resident in the same position until the nurse

examines the resident.

D. Falling or Fainting (See CARE SKILLS #9)

III. Choking – a blockage of the airway. This can occur when eating, drinking or

swallowing.

The resident often gasps or clutches throat (the universal sign for choking).

A. Risk Factors

1. Diagnosis – stroke, swallowing difficulty

2. Medications

3. Mental Status

a. Unconscious

b. Cognitive impairment – wandering, eating others’ food at an

inappropriate consistency.

B. Prevention

1. Know residents who are at risk

2. Special diets/thickened liquids

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a. Soft/mechanical soft/pureed diets

b. Liquids – consistencies

i. Nectar thick – thicker than water

ii. Honey thick – pours very slowly

iii. Pudding thick – semi–solid (spoon should stand up

straight)

C. Choking - (See CARE SKILLS #10)

IV. Burns/Scalds

A. Risk Factors

1. Diagnosis/Conditions – stroke, paralysis, diabetes

2. Mental Status/Cognitive impairment

3. Heating appliances/equipment

4. Smoking

5. Hot liquids

B. Prevention

1. Know residents who are at risk.

2. Check/report use of heating appliances.

3. Check water temperatures (bath, shower).

4. Supervise smoking, when indicated.

5. Encourage use of smoking apron, cigarette extension, etc., when

indicated.

6. Know location of nearest fire extinguisher or fire blanket.

7. Pour hot liquids away from residents.

8. Mugs with lids/adaptive devices (specific to resident).

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V. Poisoning

A. Risk Factors

1. Diagnosis/Conditions – Dementia, Alzheimer’s disease, confusion

2. Other factors

a. Wandering

b. Hoarding

B. Prevention

1. Proper storage of medications/supplies.

2. Lock storage/cleaning rooms, closets and carts.

3. Material Safety Data Sheet (MSDS) — all chemicals have a sheet

that details the ingredients, dangers, emergency response to be

taken, and safe handling procedure; required by OSHA.

VI. Medical Emergency

A. Types of Medical Emergencies

1. Heart Attack/Cardiac Arrest – symptoms may include crushing pain

(like someone sitting on the chest) which may go down left arm, be

felt in neck or in jaw and doesn’t go away.

a. Notify the nurse immediately.

b. Loosen clothing around the neck.

c. Do not give food or fluids.

d. Be prepared to initiate CPR if qualified.

e. Remain with resident until help arrives.

2. Stroke/Cerebral Vascular Accident (CVA) – symptoms may include

dizziness, blurred vision, nausea/vomiting, headache, uneven grip

or smile, slurred speech.

a. Report symptoms to nurse immediately.

3. Seizures/Convulsions (See CARE SKILLS #11)

a. Call for nurse and stay with resident.

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b. Assist the nurse with positioning the resident on his/her side.

c. Place padding under head and move furniture away from

resident.

d. Do not restrain resident or place anything in mouth.

e. Loosen resident’s clothing, especially around the neck.

f. After the seizure stops, assist nurse to check for injury.

g. Note duration of seizures and areas involved.

4. Bleeding/hemorrhage

a. Use Standard Precautions.

b. Apply direct pressure over the area with a sterile dressing or

a clean piece of linen.

c. Raise the limb above the level of the heart, if possible.

VII. Safety Measures/Prevention Strategies

A. Prevention is the key to safety.

B. Observe for safety hazards, correct or remove hazard, report needed

repair.

C. Know residents’ risk factors for accidents.

D. Safety measures to follow:

1. Call light available.

2. Clean/clear environment.

3. Report observations that are unsafe and/or equipment in need of

repair.

CARE SKILLS:

• Falling or Fainting – #9

• Choking – #10

• Seizures – #11

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Review Questions --- Lesson #5

1. What is the universal sign that indicates choking?

2. What document provides first aid/response should a resident drink a chemical?

3. Explain the actions of the caregiver if a resident is having a seizure?

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Lesson #6 (3 hours)

Title: Basic Care Skills

Lesson Objectives:

I. The student will be able to explain the importance of individualization of the

resident’s environment.

II. The student will be able to demonstrate competence in making an unoccupied

bed.

III. The student will be able to explain environmental concerns of each resident and

any revisions necessary to accommodate the visually impaired resident or the

resident at risk for falls.

IV. The student will be able to explain the importance of proper nutrition/hydration.

V. The student will be able to identify measures and demonstrate competence in

serving a meal tray.

VI. The student will be able to identify steps to help residents remain independent

while eating.

VII. The student will be able to demonstrate competence in assisting the resident with

special needs during mealtime (i.e. plate guards, thickened liquids, etc.).

VIII. The student will be able to demonstrate competence in passing fresh ice water

and providing thickened liquids to the resident.

Key Terms:

Aspiration – inhalation of food or fluids into the lungs, which has the potential to cause

pneumonia or death.

Call Light – a means to call for assistance, when needed

Calories – the fuel or energy value of food

Carbohydrates – the main source of energy for all body functions

Closed Bed – a bed completely made with the bedspread and blankets in place.

Dehydration – excessive loss of fluid from the body.

Draw Sheet – turning sheet that is placed under residents who are unable to assist with

turning, lifting or moving up in bed.

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Fats – help the body store energy and use certain vitamins.

Fluid Overload – condition in which the body is unable to handle the amount of fluids

consumed.

Fluid Restriction – a restriction of the amount of fluids a resident may have per day;

usually divided between nursing (i.e. fluids taken with medications) and dietary (i.e.

fluids with meals).

Fortified Food – nutrients/calories added to a food; used for weight loss.

Hydration – fluids consumed. The process of providing adequate fluids/liquids to

maintain or restore a sufficient balance in the body.

Minerals – compounds found in the diet or dietary supplements; builds body tissue,

regulates body fluids, promotes bone and tooth formation, affects nerve and muscle

function.

NPO – nothing by mouth (nil per os).

Nutrients – substances found in food which provide nourishment

Nutrition – nourishment; the process by which the body takes in food to maintain

health.

Occupied Bed – bed made while a resident is in the bed

Open Bed – folding the linen down to the foot of the bed

Proteins – complex compounds found in all living matter; promote growth and repair of

tissue.

Unoccupied Bed – a bed made while no resident is in the bed.

Vitamins – organic compounds obtained from one’s diet or dietary supplements; helps

the body function.

Water – H20 (one molecule of oxygen and two molecules of hydrogen); most essential

nutrient for life.

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Content:

I. Points to Remember:

A. When a resident enters a nursing facility, he/she experiences the loss of

home and belongings. Familiar things create a positive and home–like

environment. The staff should encourage the resident to bring items from

home, as space permits.

B. The room should be arranged according to resident preference, as

possible.

C. The residents’ personal belongings should be safeguarded, as possible.

D. Types of beds may vary in each facility. Most beds have controls to raise,

lower and adjust positions. A low bed may be used for a resident at risk for

falls.

E. Temperature of the resident’s room/environment should be considered.

The resident’s condition and preferences should determine the

appropriate temperature.

F. Lighting should be sufficient for the resident’s needs/preferences. Indirect

lighting is preferable, in that glare causes fatigue, and contributes to

confusion and the potential for falls.

G. The resident’s environment should be cleaned of spills immediately, as

spills are safety hazards contributing to falls.

H. Excessive noise levels in the environment can provoke irritation and

problematic behaviors. Facilities should maintain equipment in good repair

and refrain from overhead paging.

I. Fresh ice water should be maintained and within reach in an effort to

encourage hydration, unless the resident’s fluids are restricted by the

physician. (thicken liquids)

J. The call light should be placed within the resident’s reach upon completion

of care/staff assistance.

K. Defective or unsafe equipment should be taken out of service and

reported to the nurse immediately.

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II. Unoccupied Bed (see CARE SKILLS #12)

A. Bed making Tips

1. Carry clean linens away from your body and uniform.

2. Do not shake linens when making bed.

3. Do not place clean or dirty linens on the floor.

4. Do not place clean linens on a dirty surface.

5. Check for personal belongings between the linens before removing

them from the bed (i.e. dentures, glasses, hearing aid, etc.).

6. Remove gloves after handling dirty linens. A new pair of gloves

should be worn to handle clean linens.

7. Avoid bringing unnecessary linens into a resident’s room. Unused

linens are considered contaminated once they have been in

someone’s room. Do not attempt to use them in another resident’s

room, as transferring linens from room to room increases the

spread of germs and infection. Discard unused linens as you would

soiled linens.

8. Always change soiled linens. Urine, feces, food, etc. that remain on

linens can cause irritation and sores to develop on the resident’s

skin.

9. Report damaged or odorous mattress to charge nurse immediately.

10. Ensure mattress is free of urine/feces/other body fluids. Clean

mattress as needed per facility policy.

III. Resident Room/Environment/Fall Prevention

A. Each room may have slightly different equipment. Standard room contents

include: bed, bedside stand, overbed table, chair, call light and privacy

curtain.

B. Always ensure call light is within the resident’s reach, in working condition

and answered immediately.

C. Clean the overbed table after use and place within residents reach if

commonly used items are stored on the table.

D. Remove anything that might cause odors or become safety hazards, such

as trash, clutter, spilled fluids, etc.

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E. Clean up spills promptly.

F. Report signs of insects or pests when observed.

G. Fall Prevention - to reduce the risk of falls

1. Clear all walkways of clutter and cords.

2. Use non–skid mats when needed.

3. Assist residents to wear non–skid socks or shoes. Make certain

shoes are tied and fit properly.

4. Ensure residents wear clothing that fits properly (e.g. not too tight,

not too loose, or not too long).

5. Keep frequently used items in reach of resident.

6. If ordered, ensure any devices or alarms are in place and functional

per the care plan.

7. Lock wheelchairs before assisting residents to transfer.

8. Offer to toilet resident frequently/according to toileting schedule to

prevent unassisted attempts to toilet.

9. Visual cues or devices may be used, such as a large face clock,

calendar, etc. Familiar pictures, symbols, or personal items may be

displayed or hung to assist the resident with cognitive impairment to

recognize his/her room, restroom, closet, etc.

IV. Promoting Proper Nutrition and Hydration

A. Proper Nutrition

1. Promotes physical health

2. Helps maintain muscle

3. Helps maintain skin and tissues

4. Helps prevent pressure sores

5. Increases energy level

6. Aids in resisting illness

7. Aids in the healing process

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B. Six Basic Nutrients

1. Carbohydrates

a. Provide energy for the body

b. Provide fiber for bowel elimination

2. Fats

a. Aid in absorption of vitamins

b. Provide insulation and protect organs

3. Minerals

a. Build body tissue and cell formation

b. Regulate body fluids

c. Promote bone and tooth formation

d. Affect nerve and muscle function

4. Proteins

a. Promote growth and tissue repair

b. Found in body cells

c. Provide an alternate supply of energy

5. Vitamins

a. Two types: water soluble and fat soluble

b. Body cannot produce

c. Help the body function

6. Water

a. Most essential nutrient for life

b. Up to 75% water in the human body

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C. Diet Specifics

1. Diet Cards

a. Specific to a resident

2. Basic or “regular”

3. Therapeutic/special/modified diets

a. No Added Salt (NAS)

b. No Concentrated Sweets (NCS) or Restricted Concentrated

Sweets (RCS)

c. Fortified

d. NPO (nil per os) (nothing by mouth)

e. Bland

f. High/low fiber

g. Low fat

h. High/low protein

i. Low sodium

j. Modified calorie/calorie count

k. Liquid

l. High potassium

4. Mechanically Altered Diets

a. Mechanical Soft/ground meat

b. Pureed

c. Chopped meat

5. Thickened Liquids (see CARE SKILLS #13)

a. Ordered for residents who have difficulty swallowing.

b. Always check care plan and thicken liquids to the proper

consistency ordered for the resident.

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c. Three consistencies of thickened liquids

i. Nectar thick

ii. Honey thick

iii. Pudding thick

d. Pudding thick liquids must be spoon-fed to residents.

6. Monitoring meal consumption/recording food consumed

a. Observation

b. Facility policy for recording

D. Proper Hydration

1. Promotes physical health

a. Aids digestion and elimination

b. Maintains normal body temperature

c. Helps prevent dehydration

2. Encourage fluids

a. Implemented by physician’s order or nursing care plan

b. Document per facility policy

3. Fluid Restriction

a. Implemented by physician’s order due to concerns with fluid

overload

b. Daily amount is limited and divided between dietary and

nursing

4. Recording Total Fluid Intake (See CARE SKILLS #14)

a. Use metric measurement (cubic centimeters = cc) 30cc = 1

ounce; example 8-ounce glass/carton of milk = 240cc

b. Accurately record intake of oral fluids per care plan

c. Report to charge nurse low fluid intake

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d. Approximately 2000-2500cc daily

E. Passing Fresh Ice Water (see CARE SKILLS #15)

Ice pitchers should be refilled/refreshed at least once every shift, or more

frequently if needed. Always check the resident’s care plan for special

instructions before filling the pitcher.

1. Individuals on thickened liquids also need thickened water;

prepackaged, thickened water can be kept cool at the bedside per

facility policy; if prepackaged water is not available, be sure to

thicken liquids according to facility policy and the consistency

ordered for the resident.

2. Be sure the ice scoop is stored properly when not in use. It should

not be left in the ice when filling the resident’s pitchers.

4. Make sure the resident’s water is placed within reach when

returning it to the room.

5. Know your residents. If the container is too heavy for the resident to

hold, then they won’t be able to use it. Provide a smaller container

such as a cup or glass.

F. Role of the Nurse Aide

1. Review the diet card before serving the meal to the resident to

confirm correct diet.

2. Encourage resident to eat as much of their meal as possible.

3. Note foods resident avoids or dislikes and report to the nurse.

4. Be aware of food brought in to the resident from an outside source

and potential conflict with ordered diet; report to charge nurse as

needed.

5. Record food intake according to facility policy.

6. Remind resident to drink often or offer ice/popsicles, when not on

restriction.

7. Have fresh ice water available and within the resident’s reach at all

times unless on a fluid restriction.

G. Promoting the Use of Proper Feeding Technique/Assisting a Resident with

Special Needs

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NOTE – The caregiver should provide any necessary care and offer to assist the

resident to toilet prior to meal service in an effort to promote a positive

experience.

1. Serving a Meal Tray (see CARE SKILLS #16)

a. Provide oral care before meals. Residents may eat better if

they have a clean mouth.

b. Always check the diet card and the items on the tray before

taking the tray to the resident.

c. As a safety precaution, never leave a resident who needs to

be fed unattended with a tray.

d. If a resident refuses to eat, or even if he/she is not in the

facility (in the hospital, on a home visit) when the tray

arrives, you are not allowed to eat their food.

e. Clothing protectors are optional. Ask their preference and

honor their decision.

f. Inform the nurse if the resident complains about the

flavor/taste of thickened liquids.

g. Never blow on a resident’s food to cool it. Instead, try

spreading the food out over the plate. The increased surface

area helps cool the food quicker. Cutting food into smaller

pieces also helps it to cool faster.

h. Encourage residents to do as much for themselves as

possible.

i. Be sure residents are provided with their necessary assistive

devices during each meal.

j. Inform resident of food items on tray, especially if meal is

pureed or mechanically altered.

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CARE SKILLS:

• Unoccupied bed – #12

• Thickened Liquids – #13

• Measure and Record Fluid Intake – #14

• Passing Fresh Ice Water – #15

• Serving a Meal Tray – #16

Review Questions --- Lesson #6

1. The call light should always be placed within the resident’s reach. (True

or False)

2. Excessive noise levels in the environment can provoke irritation and

problematic behaviors. (True or False)

3. What is the most essential nutrient for life?

4. What are the three types of thickened liquids?

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Lesson #7 (1 hour)

Title: Common Diseases and Disorders – Respiratory and Urinary Systems

Lesson Objectives:

I. The student will be able to describe common disease processes of the

respiratory system which affect the elderly resident.

II. The student will be able to describe common disease processes of the urinary

tract which affect the elderly resident

Key Terms:

Expiration – breathing out.

Urinary Incontinence – inability to control the bladder.

Inspiration – breathing in.

Sputum – fluid that is coughed up.

Content: Respiratory System

I. Respiratory System – brings oxygen into your body and removes carbon dioxide

and other harmful gases; consists of the mouth, nose, trachea, and lungs.

II. Common Conditions of the Respiratory System

A. Upper Respiratory Infection (URI) or cold.

B. Pneumonia – lung infection caused by a bacterial, viral or fungal infection.

C. Bronchitis – swelling of the main air passages to the lung.

D. Asthma – disorder that causes the airways to swell and become narrow.

E. Emphysema – progressive lung disease that causes shortness of breath.

A symptom of COPD.

F. Chronic Obstructive Pulmonary Disease (COPD) – chronic disease in

which residents have difficulty breathing, particularly getting air out of the

lungs.

G. Lung Cancer

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H. Tuberculosis (TB) – a contagious bacterial infection of the lungs.

III. Normal Changes with Age

A. Lung capacity decreases as chest wall and lungs become more rigid.

Deep breathing is more difficult. Air exchange decreases causing the

resident to breathe faster to get enough air when exercising, ill, or

stressed.

B. Decreased lung strength

1. Decreased lung capacity.

2. Decreased oxygen in blood.

3. Weakened voice.

IV. Role of the Nurse Aide regarding the Respiratory System

A. Observe and Report:

1. Change in respiratory rate.

2. Coughing or wheezing.

3. Complaint of pain in the chest.

4. Shallow breathing or difficulty breathing.

5. Shortness of breath.

6. Bluish color of lips or nail beds.

7. Spitting or coughing up of thick sputum or blood.

8. Need to rest with mild exertion.

B. Interventions to avoid respiratory problems

1. Encourage fluids.

2. Oxygen should be in use, if ordered.

3. Encourage exercise and movement.

4. Encourage deep breathing and coughing.

5. Frequent hand hygiene, especially during cold/flu season.

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Content – Urinary System:

I. Urinary System – gets rid of waste products through urine and helps to maintain

water balance in the body; it consists of kidneys, ureters, urinary bladder, and

urethra.

II. Common Conditions of the Urinary System

A. Urinary Tract Infection (UTI) or cystitis

B. Calculi (kidney stones)

III. Normal Changes with Age

A. Kidney function decreases, slowing removal of waste. Bladder tone

decreases, resulting in more frequent urination, incontinence, bladder

infections and urinary retention.

B. Decreased ability of kidney to filter blood.

C. Weakened bladder muscle tone.

D. Bladder holds less urine, resulting in more frequent urination.

E. Bladder does not empty completely.

IV. Problems Caused by Incontinence

A. Skin problems around the buttocks, hips, genitals, and the area between

the pelvis and the area between the pelvis and rectum (perineum).

B. Excess moisture in these areas makes skin problems such as redness,

peeling, irritation, and yeast infections likely.

C. Bedsores (pressure sores) may also develop.

V. Role of the Nurse Aide regarding the Urinary System

A. Observe and Report to the nurse

1. Changes in frequency and amount of urination.

2. Foul smelling urine or visible change in color of urine.

3. Inadequate fluid intake.

4. Pain or burning with urination.

5. Swelling in extremities.

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6. Complaint of being unable to urinate or bladder feeling full.

7. Incontinence or dribbling.

8. Pain in back or kidney region.

B. Interventions to avoid urinary problems

1. Encourage fluids.

2. Frequent toileting.

3. Keep resident clean and dry.

4. Avoid anger or frustration if resident is incontinent.

Review Questions --- Lesson #7

1. Green, yellow or blood-tinged sputum should be reported to the nurse.

(True or False)

2. Complaints of pain or burning with urination should be reported to the

nurse. (True or False)

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Lesson #8 (1 hour)

Title: Oxygen Use

Lesson Objectives:

I. The student will be able to describe the various manners in which oxygen is

supplied for a resident.

II. The student will be able to describe necessary safety precautions to be

implemented when oxygen is in use.

Key Terms:

Combustion – the process of burning.

Oxygen – a chemical that is found in the air that has no color, taste, or smell, and that

is necessary for life.

Flammable – easily ignited and capable of burning quickly.

Content:

I. Oxygen Use

A. Oxygen is prescribed by a physician; however, a nurse may initiate

oxygen in response to a medical emergency.

B. Nursing assistants are never allowed to stop (refers to turning oxygen off

and/or removing the nasal cannula or mask from face/nostrils), adjust

(refers to increasing or decreasing the amount of oxygen the resident

receives), or initiate (refers to turning oxygen on and/or placing the nasal

cannula in nares or the mask on the face) the use of oxygen. Nursing

Assistants may provide care, such as washing the face or oral care.

Ensure NC or mask is properly positioned in nares or on the resident’s

face after care.

C. Nasal Cannula – Delivery of oxygen through a long tubing from the source

to the cannula, with prongs placed in each nostril and the tubing tucked

behind the resident’s ears.

1. Observe for irritation behind the ears, as the tubing can cause skin

breakdown. Notify the nurse, if observed.

2. Provide nasal cannula care per facility policy and resident care

plan. (see CARE SKILLS #17)

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D. Mask – delivery of oxygen through a long tubing from the source to a

mask placed on the resident’s face with a band around the back of the

head.

1. Observe for irritation around the face mask and notify the nurse, if

observed.

E. Concentrator – a device that sits on the floor and plugs into the wall which

changes air in the room into air with more oxygen.

F. Liquid Oxygen – at extremely cold temperatures, oxygen changes from

gas to a liquid. The liquid oxygen is stored in a vessel similar to a

thermos. A large central unit is located in an area away from electrical

equipment that is well ventilated. Liquid oxygen can be trans–filled to a

bedside unit or can be trans–filled into a portable unit.

1. Contact with liquid oxygen or its vapors can quickly freeze tissues.

It is common to see vapors when filling a small vessel from the

large vessel. The vapors evaporate quickly and then are harmless.

To prevent injury, never touch liquid oxygen, or the frosted parts of

liquid oxygen vessels. Avoid getting the vapors in your face.

G. Portable Tank – oxygen that is stored as a gas under pressure in a

cylinder equipped with a flow meter and regulator to control the flow rate.

This system is generally prescribed when oxygen therapy is required in

emergency or for a short period of time (e.g., during transport).

Compressed oxygen tanks are under extreme pressure and must be kept

upright and handled with care.

H. Vaporizers/Humidifiers – A vaporizer works by heating water until it turns

into hot steam, a humidifier creates a cool mist. Either one may be

prescribed by a physician to loosen congestion of the resident.

1. When humidifiers and vaporizers are in use, they must be kept

clean. Germs thrive wherever there is water, thus, the device must

be periodically drained and cleaned according to facility policy.

Otherwise, the bacteria that accumulate can become vaporized into

the air and affect the resident’s lungs, where they can cause

infection.

2. Prepare vaporizer/humidifier according to manufacturer’s

instructions.

3. Position vaporizer/humidifier on the bedside stand or nearby table.

4. Plug vaporizer into electrical outlet.

5. Steam should be permitted to flow generally into the room.

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6. Frequently check the water level; refill as necessary.

7. Clean vaporizers/humidifiers routinely according to facility policy.

I. CPAP/BIPAP – Positive Airway Pressure (PAP) is respiratory ventilation

used to treat breathing disorders and supply a consistent pressure on

inspiration and expiration. As mechanical ventilation, CPAP (continuous

positive airway pressure), or BIPAP (Bi–level Positive Airway Pressure)

machines, are devices which help residents inhale more air into the lungs.

Both of these devices are used for the treatment of medical disorders like

COPD, pulmonary edema, etc. Settings of the machines are prescribed

by the physician and may only be administered and adjusted by the

licensed nurse.

J. Ventilator – a machine that supports breathing. These machines are

mainly used in hospitals. Ventilators deliver oxygen into the lungs and

remove carbon dioxide from the body. Carbon dioxide is a waste gas that

can be toxic. The ventilator breathes for people who have lost all ability to

breathe on their own. Settings of the ventilator are prescribed by the

physician and may only be adjusted by the licensed nurse.

K. Safety Precautions

1. Remember oxygen supports combustion.

2. Fire hazards should be removed from the resident’s room when

oxygen is in use.

3. Never allow candles or open flames in the area where oxygen is in

use.

4. Never allow smoking in the area where oxygen is in use.

5. Do not use electrical equipment (e.g., electric razors, hairdryers,

electric blankets, and electric heaters) in an oxygen–enriched

environment. Electrical equipment may spark and cause a fire.

6. Do not use flammable products such as rubbing alcohol, or oil–

based products such as Vaseline® near the oxygen. Use a water–

based lubricant to moisten the resident’s lips or nose.

CARE SKILLS:

• Nasal Cannula Care – #17

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Review Questions --- Lesson #8

1. It is permissible for nursing assistants to adjust the level of oxygen

administration. (True or False)

2. Smoking must never be allowed where oxygen is used or stored. (True or

False)

3. Oxygen tanks must be kept upright and handled with care. (True or False)

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Lesson #9 (1 hour)

Title: Common Diseases and Disorders – Nervous, Circulatory & Musculo–

Skeletal Systems

Lesson Objectives:

I. The student will be able to describe common disease processes of the nervous

system which affect the elderly resident.

II. The student will be able to describe common disease processes of the circulatory

system which affect the elderly resident.

III. The student will be able to describe common disease processes of the musculo–

skeletal system which affect the elderly resident.

Key Terms:

Arthritis – a disorder that involves inflammation of one or more joints.

Atrophy – wasting away, decreasing in size, and weakening of muscles.

Cerebrovascular Accident (CVA) – stroke; loss of brain function usually caused by an

effect on the flow of blood to the brain. Two main types of stroke are the hemorrhagic

stroke and occlusive (blockage) stroke.

Congestive Heart Failure (CHF) – the heart is severely damaged and cannot pump

oxygen-rich blood to the rest of the body effectively. Blood may back up in other areas

of the body, and fluid may build up in the lungs, liver, gastrointestinal tract, arms and

legs.

Contracture – permanent stiffening of a joint and muscle.

Epilepsy – brain disorder in which a resident has reported seizures (convulsions).

Medication is ordered to control/lessen seizure activity.

Fracture – broken bone.

Heart Attack (Myocardial Infarction) – blood flow to the heart is completely blocked

and oxygen cannot reach the cells in the region that is blocked.

Hypertension – high blood pressure.

Hypotension – low blood pressure.

Osteoporosis – condition when the bones become brittle and weak; may be due to

age, lack of hormones, not enough calcium in bones, alcohol, or lack of exercise.

Parkinson’s Disease – a progressive movement disorder.

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Peripheral Vascular Disease (PVD) – condition in which the extremities (commonly

legs and feet) do not have enough blood circulation due to fatty deposits in the vessels

that harden over time.

Range of Motion – exercises which put a joint through its full range of motion.

Content – Nervous System:

I. Nervous System – control and message center of the body; it controls and

coordinates all body functions and senses, and it also interprets information from

outside the body; includes the brain, spinal cord, and nerves.

II. Conditions that Affect the Nervous System

A. Dementia

1. Affects thought process: memory, communication

2. As the process progresses it will become difficult for the resident to

perform ADLs (e.g., eating, dressing, toileting, etc.).

B. Alzheimer’s disease

1. A brain disease that slowly destroys memory and thinking skills

and, eventually, the ability to carry out the simplest task. It begins

slowly and gets worse over time. Currently it has no cure.

2. Maintain regular schedule for bathing, toileting, exercise.

3. Use repetition in daily activities.

C. Parkinson’s Disease

1. A progressive, degenerative disease that affects the brain.

2. As the disease progresses, it becomes more difficult for the

resident to perform ADLs. Hands often tremor, and the limbs and

trunk become rigid.

3. Assist by placing food and drink close; use assistive devices.

D. Cerebrovascular Accident (CVA) or stroke

1. A stroke is a “brain attack”. It can happen to anyone at any time. It

occurs when blood flow to an area is cut off. It is caused by a clot or

ruptured blood vessel. When this happens, brain cells are deprived

of oxygen and begin to die.

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2. F.A.S.T. is an easy way to remember the sudden signs of a stroke.

a. Face Drooping

b. Arm Weakness

c. Speech Difficulty

d. Time to call 911

3. When dressing a resident, address the weaker side first to prevent

unnecessary bending or stretching. When undressing, address the

stronger side first.

4. Use a gait belt when walking or transferring the resident for safety

precautions. Stand on the weaker side.

E. Epilepsy

1. Seizure symptoms can vary widely. Some people with epilepsy

simply stare blankly for a few seconds during a seizure, while

others repeatedly twitch their arms or legs.

2. Observe for seizure activity; report to nurse.

3. Don’t leave the resident unattended during a seizure; have

someone else get help, if possible.

4. Keep the resident safe by moving furniture or other objects out of

the way; do NOT put anything in his/her mouth.

III. Normal Nervous System Changes with Age

A. Nerve cells die, causing decreased perception of sensory stimuli and less

awareness of pain and injury.

B. Slow responses and reflexes.

C. Sensitivity to heat and cold decreases.

D. May experience short–term memory loss.

IV. Role of the Nurse Aide regarding the Nervous System

A. Observe and Report

1. Shaking or trembling.

2. Complaints of numbness or tingling.

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3. Inability to speak clearly.

4. Inability to move one side of the body.

5. Changes in vision or hearing.

6. Difficulty swallowing.

7. Depression or mood changes.

8. Memory loss or confusion.

9. Behavior changes.

Content – Circulatory System:

I. Circulatory System – transports blood and body fluids throughout the body;

consists of the heart and blood vessels (veins, arteries, capillaries); also called

the cardiovascular system.

II. Conditions that Affect the Circulatory System

A. High blood pressure (hypertension)

1. Symptoms: headache, blurred vision, dizziness

B. Heart Attack (Myocardial Infarction)

C. Coronary Artery Disease (CAD)

D. Angina (chest pain)

E. Cerebrovascular Accident (CVA) – stroke

III. Normal Circulatory Changes with Age

A. Blood vessels become more rigid and narrow. Heart muscle has to work

harder which may result in high blood pressure and poor circulation.

IV. Role of the Nurse Aide regarding Circulatory System

A. Observe and report

1. Complaint of headache

2. Chest pain

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3. Blurred vision

4. Dizziness

5. Nausea

6. Shortness of breath, changes in breathing patterns, problems

breathing

7. Weight gain

8. Change in vital signs

9. Swelling of hands and feet

10. Pale or bluish discoloration to hands, feet, or lips

11. Weakness or fatigue

Content – Musculoskeletal System:

I. Musculoskeletal System – gives the body shape and structure, allows the body to

move, and also protects the organs; consists of the muscles, bones, ligaments,

tendons, and cartilage.

II. Conditions that Affect Musculoskeletal System

A. Fracture

1. Common Types:

a. Open fracture (also called compound fracture) – the bone

exits and is visible through the skin, or a deep wound that

exposes the bone through the skin.

b. Closed Fracture (also called simple fracture) – the bone is

broken, but the skin is intact.

c. Compression – the bone is crushed, causing the broken

bone to be wider or flatter in appearance.

d. Stress Fracture – (also called hairline fracture) – the bone

has tiny cracks.

2. Symptoms of fracture include: change in skin color, bruising, pain,

and swelling.

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B. Osteoporosis

1. Bones become brittle and can break easily.

2. Take caution when repositioning and/or transferring the resident.

C. Arthritis

1. Two common types of arthritis include: osteoarthritis and

rheumatoid.

2. Encourage independence in ADLs to preserve ability.

3. As needed, use cane or other aids.

D. Contracture

1. A contracture deformity is the result of a stiffness or constriction in

your muscles, joints, tendons, ligaments, or skin that restricts

normal movement.

2. Impaired mobility can affect all aspects of daily living such as

bathing, eating, dressing.

III. Importance of Exercise or Range of Motion (ROM)

A. Maintains physical and mental health.

B. Prevents problems related to immobility.

C. Problems/complications from lack of exercise or range of motion:

1. Loss of self– esteem

2. Depression

3. Pneumonia

4. Urinary Tract Infections

5. Constipation

6. Blood clots

7. Dulling of senses

8. Muscle atrophy or contractures

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IV. Normal Musculoskeletal Changes with Age

A. Bones become more brittle and porous and may fracture more easily.

B. Loss of muscle strength and tone causes weakness and feeling tired.

C. Less flexible joints make moving more difficult.

D. Changes in spine and feet result in height loss, postural changes and

difficulty walking.

V. Role of the Nurse Aide regarding the Musculoskeletal System

A. Observe and Report:

1. Pain with movement

2. Bruising

3. Change in movement and/or activity

4. Change in range of motion

5. Swelling of joints

6. Aches and/or pains

7. Red, pale, warm, or shiny areas over a joint

B. Fall prevention:

1. Keep mobile

2. Encourage activities and exercise

3. Participate in care

4. Proper positioning

5. Use of assistive devices

6. Keep pathways clear of spills, clutter, etc.

7. Answer call lights immediately

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CARE SKILLS:

• Passive Range of Motion – CARE SKILL #69 – to be discussed,

demonstrated, and checked-off during Lesson #22

Review Questions --- Lesson #9

1. When a resident complains of headache and blurred vision, the caregiver

must report their complaint to the nurse immediately. (True or False)

2. When assisting a resident who has had a stroke to dress, the caregiver

should dress the stronger side first. (True or False)

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Lesson #10 (45 minutes)

Title: Common Diseases and Disorders – Gastrointestinal and Endocrine Systems

Lesson Objectives:

I. The student will be able to describe common disease processes of the

gastrointestinal system which affect the elderly resident.

II. The student will be able to describe common disease processes of the endocrine

system which affect the elderly resident.

Key Terms:

Colostomy – a surgically-made opening on the abdomen that has a section of the

colon attached; the opening allows stool to be evacuated from the body and emptied

into a bag that adheres to the abdomen;

Diabetes Mellitus – the body does not produce enough or properly use insulin.

Diarrhea – frequent elimination of liquid or semi–liquid stool.

Digestion – the process of breaking down food so that it can be absorbed by the cells

of the body.

Elimination – the process of expelling solid wastes that are not absorbed into the cells

of the body.

Emesis – vomit.

Gastroesophageal Reflux Disease (GERD) – chronic condition in which the liquid

contents of the stomach back up into the esophagus.

Hemorrhoids – enlarged veins in the rectum.

Hyperthyroidism – overactive thyroid gland – excess of thyroid hormone.

Hypothyroidism – underactive thyroid gland – thyroid hormone produces below

normal.

Ileostomy – section of the intestine is removed and the stool will be evacuated through

a stoma and emptied into a bag adhered to the abdomen of the resident.

Ostomy – creation of an opening from an area inside the body to the outside of the

body.

Peptic Ulcer – ulcer that forms in the lining of the stomach, duodenum, esophagus.

Stoma – The opening of an ostomy.

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Ulcerative Colitis – chronic inflammatory bowel disease.

Content – Gastrointestinal System:

I. Gastrointestinal System – breaks down the food that is taken into the body and

absorbs the water and nutrients needed for energy; rids the body of solid wastes;

consists of the mouth, esophagus, stomach, large and small intestines, rectum,

and anus; other organs that assist with digestion include the gallbladder, liver,

and pancreas; also called the digestive system.

II. Common Conditions of the Gastrointestinal System

A. Gastroesophageal Reflux Disease (GERD)

B. Peptic Ulcer

C. Ulcerative Colitis

D. Hemorrhoids

E. Constipation

1. If a resident has not had a bowel movement within three days, most

facilities have protocols for intervention to prevent impaction (hard

stool in the rectal vault).

F. Colostomy/Ileostomy

G. Diarrhea

III. Normal Changes with Age

A. Taste buds lose sensitivity causing decreased appetite.

B. Tooth and gum problems result in inability to eat properly.

C. Digestion is less efficient causing constipation and food intolerance.

IV. Role of the Nurse Aide regarding the Gastrointestinal System

A. Observe and Report to the nurse

1. Difficulty chewing and/or swallowing, including problems with

dentures and teeth.

2. Loss of appetite.

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3. Abdominal pain or complaint of cramping.

4. Diarrhea

a. Frequency, amount, consistency

b. Observe for blood

5. Nausea and/or vomiting

a. If vomitus looks like coffee grounds, immediately report to

nurse.

6. Constipation

a. Frequency, consistency and size of bowel movements.

b. Observation of stool for blood; notify nurse.

B. Interventions to avoid problems with digestion

1. Offer fluids frequently, especially while eating.

2. Provide regular oral care, making sure that dentures are clean and

fit properly.

Content – Endocrine System:

I. Endocrine System – a collection of glands in the body that produces and

secretes hormones that regulate body functions, such as metabolism, growth and

development, reproduction, sleep and mood; also responsible for maintaining the

levels of sugar in the blood and calcium in the bones; consists of pituitary,

thyroid, parathyroid, pineal, and adrenal glands, pancreas, ovaries, testes,

thymus, and hypothalamus.

II. Common Conditions that Affect the Endocrine System

A. Diabetes Mellitus

1. Hypoglycemia (low blood sugar)

a. Sign/symptoms: cold, clammy skin, double or blurry vision,

shaking/ trembling, hunger, tingling or numbness of skin;

increased confusion.

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2. Hyperglycemia (high blood sugar)

a. Signs/symptoms: shortness of breath, breath smells fruity,

nausea/vomiting, frequent urination, thirst.

3. Hyperthyroidism

a. Sign/symptoms: can’t tolerate being hot.

b. Increased heart rate and enlarged thyroid (goiter).

4. Hypothyroidism

a. Sign/symptoms: confusion, tired.

b. Inability to tolerate the cold.

III. Normal Changes with Age

A. Insulin production decreases possibly causing excess sugar in blood.

B. Adrenal secretions decrease reducing ability to handle stress.

C. Thyroid secretions decrease slowing metabolism.

D. Levels of estrogen and progesterone decrease, which signals the onset of

menopause.

IV. Role of the Nurse Aide regarding the Endocrine System

A. Observe and Report

1. Diabetic residents who refuse meal/snack or consume less than

half of meal/snack.

2. Immediately report resident who has signs and symptoms of

hypoglycemia.

3. Diabetic resident eating foods in conflict with ordered diet; could

cause hyperglycemia.

B. Interventions to avoid problems

1. Identify residents in your care who are diabetic.

2. Encourage proper nutrition.

3. Eliminate or reduce stress when possible; offer encouragement and

listen to the resident.

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Review Questions --- Lesson #10

1. List signs/symptoms of hypoglycemia (low blood sugar).

2. The nurse must be notified immediately if (or when) the resident’s vomit

looks like coffee grounds. (True or False)

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Lesson #11 (45 minutes)

Title: Common Diseases and Disorders – Reproductive, Immune/Lymphatic

Systems

Lesson Objectives:

I. The student will be able to describe common disease processes of the

reproductive system which affect the elderly resident.

II. The student will be able to describe common disease processes of the lymphatic

system which affect the elderly resident.

Key Terms:

Genitals – the external male or female sexual organs.

HIV/AIDS – life–threatening condition that damages the immune system and interferes

with the body’s ability to fight disease.

Lymph – clear, yellowish fluid that moves in the lymph system from tiny capillaries in

the circulatory system; carries disease–fighting cells called lymphocytes.

Perineum – the area between the anus and the scrotum (male) or vulva (female).

Reproductive Systems

Female – Ovaries – produce estrogen, progesterone and ova (eggs).

A. Fallopian tubes – carry eggs from ovaries to the uterus.

B. Uterus – muscular sac where the eggs can develop.

C. Vagina – muscular canal leading out of the body.

D. Vulva – external genitalia of the female, including the labia and

clitoris.

E. Breasts – holds mammary glands which produce nutrients for

infants.

Male – Testes – glands that produce testosterone and sperm.

A. Scrotum – sac which contains the testes.

B. Prostate Gland – gland which produces the fluid for sperm.

C. Penis – external organ through which males ejaculate and urinate.

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Content: Reproductive System

I. Reproductive System – organs that work together for the purpose of producing

new life; consists of testes, scrotum, penis, and prostate gland for males;

consists of vulva, vagina, uterus, fallopian tubes, and breasts for females.

II. Common Conditions that Affect the Reproductive System

A. Breast, prostate and ovarian cancer.

B. Vaginitis – inflammation of the vagina; symptoms may include any of the

following: burning or discomfort, especially when voiding, itching or

irritation to the genital area, increase in vaginal discharge, foul odor.

III. Normal Changes with Age

A. Hormone production decreases.

B. Decreased estrogen in females causes menopause.

C. Decreased testosterone in males slows sexual response.

D. Prostate gland may become enlarged causing difficulty when urinating.

IV. Role of the Nurse Aide regarding the Reproductive System

A. Observe and Report

1. Abnormal bleeding.

2. Complaints of pain.

3. Discharge from the penis or vagina.

4. Swelling of the genitals.

5. Sores on the genitals.

6. Changes in the breast, such as lumps, size, shape, discharge from

nipple.

Content – Lymphatic and Immune Systems

I. Lymphatic System – removes excess fluids and waste products from the body’s

tissues; it works closely with the Immune and Circulatory Systems; consists of

the lymph nodes, lymph vessels, lymph, spleen, and thymus gland.

II. Immune System – fights infection, by protecting the body from disease–causing

bacteria, viruses, and microorganisms; works closely with the Lymphatic System;

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III. Common Conditions of the Immune and Lymphatic Systems

A. HIV/AIDS

1. Requires Standard Precautions unless coming in contact with blood

or body fluids for which Contact Precautions would be necessary.

B. Lymphoma (cancer of the immune system).

IV. Normal Changes with Age

A. Increased risk of infection.

B. Increased drying of tissue – causes irritation.

V. Role of the Nurse Aide regarding the Immune and Lymphatic Systems

A. Observe and Report

1. Fever

2. Diarrhea

3. Increased fatigue/weakness

B. Interventions

1. Wash hands before and after care.

2. Encourage resident to eat meals and drink plenty of fluids, assisting

as needed.

3. Keep the environment clean.

4. Remove gloves and other Personal Protective Equipment, such as

gowns, face masks, etc., before leaving the resident’s room.

5. Know and follow the infection control practices of the facility.

Review Questions --- Lesson #11

1. Fever and/or fatigue must be reported to the nurse. (True or False)

2. Abnormal bleeding from the vaginal area and/or complaint of

pain/cramping must be reported to the nurse. (True or False)

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UNIT 2

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Lesson #12 (5 hours)

Title: Activities of Daily Living (Bathing, Shampoo, Perineal Care)

Lesson Objectives:

I. The student will be able to demonstrate competence in assisting a resident to

bathe/shower.

II. The student will be able to demonstrate competence in assisting the resident to

shampoo his/her hair.

III. The student will be able to demonstrate competence in providing perineal care.

Key Terms:

Activities of Daily Living (ADL) – personal care tasks performed daily, such as

bathing, dressing, caring for teeth and hair, toileting, eating and drinking and moving

around.

Perineal Area – the area of the body between the genitals and the anus.

Content:

I. Bathing and Shampooing Points to Remember (see CARE SKILLS #18-22)

A. Bathing is an opportunity to observe the resident’s skin. Should a concern,

such as lice, a new bruise, blister, rash or open area be noted, the nurse

must be notified immediately.

B. The resident’s face, hands, underarms, and perineal area should be

washed at least daily.

C. The elderly may bathe only twice a week. Since their skin produces less

perspiration and oil, frequent bathing could cause excessive dryness.

D. Before beginning the bathing process, the caregiver should make certain

the room is warm enough and all linens and supplies are gathered so the

resident is not left alone.

E. Respect the resident’s privacy when transporting to and from the shower

room and during the shower or bath. Be certain the resident’s body is not

unnecessarily exposed.

F. If no-rinse soap or shampoo is used, be sure that it is diluted and/or used

per manufacturer’s instructions.

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G. Never leave the resident unattended during bathing.

H. Keep the water clean and at a comfortably warm temperature.

I. Back rubs are often performed after bathing. They are a good way to help

the resident relax, improve circulation, and decrease pain. When using

lotion/oils for back rubs, be sure to warm in hands before applying to

resident’s skin.

J. Hair should be shampooed at least weekly, unless otherwise noted in care

plan. Hair should be combed daily and kept neat at all times.

K. Not all residents can get out of bed to have their hair shampooed in the

shower, tub, etc. There are hair products available so that water is not

needed when shampooing hair in bed. Follow care plan to ensure proper

hair products are being used when shampooing hair in bed.

L. Do not use oils, lotions, powder, or other products that can cause the

surface of showers, tubs, whirlpools, etc. to become slippery.

M. Whirlpool baths increase circulation and promote wound healing. Be sure

to follow manufacturer’s instructions for filling the tub with water, getting

the resident in and out of the tub, and for general use of the whirlpool tub.

N. Always check the resident’s care plan before providing care. Be sure to

follow the care plan instructions at all times.

II. Perineal and Catheter Care Points to Remember (see CARE SKILLS #19)

A. Always wash from front to back.

B. Be sure to change linens if they are soiled.

C. Allow the resident to clean themselves if possible, assisting as needed.

D. Avoid pulling on the catheter and tubing. The tip of the catheter is much

larger than what is seen on the outside. If it is improperly pulled out or

dislocated, it can be very painful and cause damage to the areas involved.

E. Keep the catheter and tubing free of any kinks that could prevent the urine

from draining properly.

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CARE SKILLS:

• Shower/Shampoo – #18

• Bed Bath/Catheter Care/Perineal Care – #19

• Back Rub - #20

• Shampoo Hair in Bed – #21

• Whirlpool - #22

Review Questions --- Lesson #12

1. Explain the procedure to cleanse the perineal area (both male and female)

and rationale of importance.

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Lesson #13 (4 hours)

Title: Activities of Daily Living (Oral Care, Grooming, Nail Care)

Lesson Objectives:

I. The student will be able to explain the importance of and demonstrate

competence in the provision of oral care/denture care.

II. The student will be able to explain the importance of and demonstrate

competence in the provision of grooming, including hair and facial hair.

III. The student will be able to explain the importance of and demonstrate

competence in the provision of fingernail and foot care.

Key Terms:

Foot Care – care of the feet, including inspection for areas of concern to be reported to

the nurse.

NPO – nothing by mouth.

Oral Care – care of mouth, teeth and gums. Cleaning the teeth, gums, tongue, inside

of mouth and dentures, if used.

Content:

I. Grooming/Personal Hygiene (see CARE SKILLS #23-30)

A. Points to Remember:

1. Always allow the resident to do as much as possible for

themselves.

2. Allow the resident to make choices and respect those choices.

3. Be sensitive to established routines of the resident, incorporating

those routines into daily care, as possible.

4. Oral care (including denture care) must be performed at least twice

a day, but it’s recommended to occur more often. Unconscious oral

care should be performed more frequently to keep resident’s mouth

moist.

5. Oral care reduces the number of pathogens in the mouth, improves

the resident’s sense of well–being and appearance and improves

sense of taste, enhancing appetite.

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6. Oral care eliminates particles from beneath the gums, preventing

injury and improving ability to chew and consume meals.

7. Dentures should be handled carefully and stored in cool, clean

water in a labeled denture cup when not in use. Be sure that the

cup is kept in a safe place. Always follow manufacturer’s

instructions for cleaning dentures.

8. The caregiver should observe for ill–fitting dentures and report

concerns to the nurse. Ill–fitting dentures could affect speech and

chewing ability, thus, ultimately affecting meal consumption and

contributing to potential weight loss.

9. More frequent oral care is needed for residents who are

unconscious, breathe through their mouth, are being given oxygen,

are in the process of dying and/or are NPO.

10. Observe and report to nurse: irritation, raised areas, coated or

swollen tongue, sores, complaints of mouth pain, white spots,

loose/chipped or decayed teeth.

11. Be certain that the resident wants you to shave him/her or assist

him/her to shave before you begin.

12. Wear gloves when shaving a resident.

13. Be sure to dispose of razors in the sharps container accordingly.

14. Always use hair care products that the resident prefers for his/her

type of hair.

15. Nail care is provided when assigned or if nails appear dirty or have

jagged edges.

16. Check fingers and nails for color, swelling, cuts or splits. Check

hands for extreme heat or cold. Report any unusual findings to

nurse before continuing procedure.

17. Support the foot and ankle when providing foot care.

18. Poor circulation occurs in the resident with diabetes. Even a small

sore on the foot can become a large wound.

19. Careful foot care, including regular daily inspection is important.

20. During foot care, the feet should be checked for irritation or sores

and reported to the nurse, if observed.

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21. Soak feet in warm water to soften nails. Remove feet one at a time

and wash, using a soapy washcloth. Be sure to rinse soap from feet

prior to drying them.

22. Toenails are to be cut straight across with heavy nail clippers.

**Check with the charge nurse before trimming the resident’s toenails. Residents

with poor circulation to the feet or diseases such as diabetes will usually have

their toenails trimmed by a podiatrist. For residents without these problems, you

will need to trim the toenails regularly.

CARE SKILLS:

• Oral Care – #23

• Oral Care for Unconscious – #24

• Denture Care – #25

• Shaving with an Electric Razor – #26

• Shaving with a Safety Razor – #27

• Comb/Brush Hair – #28

• Fingernail Care – #29

• Foot Care – #30

Review Questions --- Lesson #13

1. Explain observations made during oral care that should be reported to the

nurse.

2. Explain why a nurse aide should not clip the toenails of a diabetic resident.

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Lesson #14 (4 hours)

Title: Activities of Daily Living (Dressing, Toileting)

Lesson Objectives:

I. The student will be able to demonstrate competence in dressing or undressing

the resident.

II. The student will be able to demonstrate competence in assisting the resident with

toileting needs.

Key Terms:

Catheter – tube used to drain urine from the bladder.

Condom Catheter – external catheter that has an attachment on the end that fits over

the penis; also called a Texas catheter.

Elimination – process of expelling solid waste not absorbed into the cells.

Enema – specific amount of water flowed into the colon to eliminate stool.

Fecal Impaction – hard stool in the rectum that cannot be expelled.

Fracture Pan – bedpan used for a resident who cannot assist with raising hips onto the

regular bedpan.

Hemiparesis – weakness on one side of the body.

Hemiplegia – paralysis on one side of the body, weakness, or loss of movement.

Incontinence – inability to control the bladder or bowels.

Indwelling Catheter – catheter that remains in the bladder for a period of time.

Paraplegia – loss of function of lower body and legs.

Portable Commode (Bedside) – chair with a toilet seat and a removable container

underneath.

Prosthesis – artificial body part.

Quadriplegia – loss of function of legs, trunk and arms.

Suppository – medication given rectally to cause a bowel movement.

Void – urination.

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Content:

I. Dressing (see CARE SKILLS #31-32)

A. Residents have their own style and preferences and should be honored to

the extent possible.

B. Residents should be encouraged to dress in their own clothing of choice

each day.

C. Each piece of the resident’s clothing should be inventoried according to

facility policy, adding new items and deleting discarded items as

necessary.

D. Resident clothing should be labeled/identified in an inconspicuous place.

E. Affected limbs should be dressed first and undressed last.

F. Avoid pullover garments if the resident has an affected side or difficulty

with the neck or shoulders, unless requested by the resident.

II. Toileting

A. Assist to Bathroom or Bedside Commode (see CARE SKILLS #33-34)

1. Ensure bedside commode is in good repair, clean and odor free and

has intact rubber stops to prevent commode from moving with resident

weight, potentially causing a fall.

2. After assisting a resident to toilet, it may be necessary for the nursing

assistant to perform perineal care.

a. Ensure the resident can stabilize while standing, utilizing a walker,

side grab bars, and/or with the assistance of a second caregiver

utilizing a gait/transfer belt.

b. Make sure that the resident is standing firmly, with their feet spread

apart.

c. Wipe from front to back, using a different part of the washcloth for

each stroke. Change the washcloth as necessary.

d. Rinse the resident’s perineum and pat it dry prior to raising

undergarments or applying a brief.

B. Bedpan/Fracture Pan (see CARE SKILLS #35)

1. A fracture pan is a bedpan that is flatter than a normal bedpan. It is

used for residents who cannot assist to raise their hips onto a

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regular bedpan. When using a fracture pan, position with the

handle toward the foot of the bed. If the resident cannot help, roll

the resident onto their far side, slip the fracture pan under the hips

and roll the resident back toward you onto the bedpan.

2. A standard bedpan is positioned with the wider part of the pan

aligned with the resident’s buttocks.

C. Urinal (see CARE SKILLS #36)

1. Keep urinal in easy reach of resident.

2. Empty and clean urinal after each use.

3. Avoid using hot water to rinse the urinal.

D. Bowel and Bladder Training

1. Incontinent residents may be identified as candidates for bowel and

bladder training. If so, the following guidelines will apply:

a. A record of the resident’s bowel and bladder habits will be

maintained and then observed for a pattern of elimination. A

pattern will predict the frequency in which the resident will

need to be assisted to use the bedpan or to toilet.

b. Explain the training schedule to the resident and attempt to

follow the schedule closely.

c. Offer a trip to the commode or bathroom prior to beginning

long procedures, as well as before and after meals.

d. Encourage residents to drink sufficient fluids. About 30

minutes after fluids are consumed, offer a trip to the

bathroom or use of the urinal or bedpan.

e. Answer the resident’s call light promptly, as residents cannot

wait long when the urge to void is felt.

f. Provide privacy for elimination.

g. Praise successes and attempts to control bowel and bladder.

E. Emptying urinary drainage bag/leg bag (see CARE SKILLS #37)

1. Be sure to use an alcohol pad to clean the spout once the bag is

completely drained.

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2. Measure and record output, per facility policy. (See CARE SKILLS

#14)

F. Catheter Care (see CARE SKILLS #19)

1. If a resident has a catheter, care is normally provided on each shift.

2. CNAs are NOT allowed to disconnect the urinary drainage bag

and/or tubing from the catheter. Only licensed nurses are allowed

to change the drainage and/or leg bag.

3. Privacy bags should be used for residents with catheters.

a. Privacy bags keep the catheter bag and its contents hidden

from visitors and others in the facility, which improves privacy

and dignity.

b. Privacy bags help secure the drainage bag to wheelchairs,

beds, etc., so that the drainage bag never touches the floor.

4. Be sure that the tubing and urinary drainage bag are not dragging

or touching the floor as residents ambulate, especially when in a

wheelchair.

G. Urine Specimen Collection (see CARE SKILLS #38)

1. Random urine specimens do not have to be collected directly into

the specimen container. Also, it is not necessary to clean the

resident’s genitalia before collecting the specimen. (Urine can be

poured into the container from a bedpan, bedside commode, urinal,

etc.) Clean-catch specimens are collected directly into the

specimen container and should not include the first and last part of

the urine voided.

2. If a clean–catch (midstream) urine specimen is ordered, using the

towelettes supplied, the caregiver will assist the resident to clean

the area around the meatus. For females, separate the labia. Wipe

from front to back along one side. Discard the towelette. With a new

towelette, wipe from front to back along the other side. Using a new

towelette wipe down the middle. For males, clean the head of the

penis. Use circular motions with the towelettes. Clean thoroughly,

changing the towelette after each circular motion. Discard after use.

If the male is uncircumcised, pull back the foreskin of the penis

before cleaning. Hold it back during urination. Make sure it is pulled

back down after collecting the specimen. Ask the resident to begin

urination, but to stop before urination is complete. Place the

container under the urine stream and ask the resident to begin

urinating again. Fill the container at least half full. Remove the

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container and allow the resident to finish urinating in bedpan, urinal

or toilet.

H. Stool Specimen Collection (see CARE SKILLS #39)

1. Ask the resident to inform you when he or she can have a bowel

movement.

2. Be ready to collect the specimen.

I. Application of Incontinent Brief (see CARE SKILLS #40)

1. Ensure brief is appropriate size for resident.

2. Ensure appropriate application in a manner not to cause abrasion

due to being too tight or having tape applied to skin.

3. Monitor frequently for needed perineal care and change of brief.

J. Measure and record output (urine and emesis) (see CARE SKILLS #14)

1. Graduated measuring container.

2. Use metric measurement (cubic centimeters =cc).

3. Record all fluids that go into resident (intake). Include oral intake, IV

fluids, tube feedings, medications, dialysis fluids, and flushes.

Nurses are responsible for measuring and recording fluids related

to medication administration.

4. Record all fluids excreted or withdrawn from the body (output).

This includes urine, liquid stools, drainage from drains or chest

tubes.

CARE SKILLS:

• Change Gown – #31

• Dressing a Dependent Resident – #32

• Assist to Bathroom – #33

• Assist to Bedside Commode – #34

• Bedpan/Fracture Pan – #35

• Urinal – #36

• Empty Urinary Drainage Bag – #37

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• Urine Specimen Collection – #38

• Stool Specimen Collection – #39

• Application of Incontinent Brief – #40

• Measure and Record Urinary Output #14

Review Questions --- Lesson #14

1. Explain the difference between a routine urine specimen and a clean–

catch (mid–stream) urine specimen.

2. Affected limbs should be dressed first and undressed last. (True or False)

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Lesson #15 (2 hours, 30 minutes)

Title: Activities of Daily Living (Positioning/Turning, Transfers)

Lesson Objectives:

I. The student will be able to demonstrate the importance of proper positioning and

body alignment.

II. The student will be able to recognize four commonly-used resident positions.

III. The student will be able to demonstrate competence in proper transfer

techniques.

IV. The student will be able to demonstrate competence in assisting with ambulation.

Key Terms:

Alignment – put in a straight line; shoulders directly above hips, head and neck

straight, arms and legs in a natural position.

Ambulation – walking.

Assistive Devices – equipment used to help resident increase independence.

Body Mechanics – using the body properly to coordinate balance and movement.

Cane – assistive device used by the resident with weakness on one side.

Dangle – sitting up with feet over the edge of the bed.

Deformities – abnormally formed parts of the body.

Fowler’s Position – head of bed elevated 45 to 60 degrees.

Lateral Position – lying on side, either right or left.

Logrolling – to turn or move the resident without disturbing the alignment of their body.

Pivot – to turn with one foot remaining stationary.

Positioning – the placement and alignment of the resident’s body when assisting the

resident to sit, lie down or turn.

Semi–Fowler’s Position – head of bed elevated 30 to 45 degrees.

Supine Position – lying flat on back.

Transfer – moving the resident from one surface to another.

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Transfer Belt (Gait Belt) – a safety belt used to assist the resident who is weak or

unsteady during transfers or walking.

Walker – assistive device used for support and steadiness.

Content:

I. Proper positioning and body alignment

A. Positioning

1. Frequency of repositioning

a. Recommended every 2 hours or more frequently, if

warranted.

i. Prevent deformities, development of pressure sores,

respiratory complications and decreased circulation.

B. Alignment

1. Proper alignment

a. Shoulders above hips, head and neck straight, and arms and

legs in natural position.

b. Benefits

i. Promotes physical comfort.

ii. Relieves strain.

iii. Promotes blood flow.

iv. Promotes efficient body function.

v. Prevents deformities and complications (i.e.,

contractures and prevention of pressure sores, etc.).

C. Role of the Nurse Aide

1. Provide privacy.

2. Check resident’s body alignment after position change.

3. Keep resident’s body in good alignment, as possible.

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4. Support affected limbs during repositioning.

5. Review care plan to determine which position(s) is safe for the

resident.

6. Do not cause the resident pain or injury.

a. Be gentle.

b. Do not rush.

c. Do not slide or drag resident on bed linen.

d. Use appropriate side rail when turning resident (if side rail is

used).

i. Side rail up on side of bed resident is turning toward.

e. Return bed to appropriate height and position.

7. Encourage resident to assist with positioning, if able.

8. Assist resident in moving to head of bed as needed (See CARE

SKILLS #41)

II. Commonly used positions

A. Supine Position (see CARE SKILLS #42) – Flat

1. Ensure resident is placed at the head of the bed to prevent

resident’s feet/heels from touching or resting against the footboard.

This will also help keep the trunk in position should the head of the

bed be elevated.

2. Procedures which may require supine position

a. Bed making

b. Bed bath

c. Perineal care

B. Lateral Position (see CARE SKILLS #43) – Resident placed on left or right

side

1. Reposition to side

2. Logrolling

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3. Reduces pressure on one side.

C. Fowler’s Position (see CARE SKILLS #44)

1. Head of bed elevated 45 to 60 degrees

a. Promotes breathing.

b. Caution: this position adds pressure to coccyx (tailbone).

2. Procedures which may require Fowler’s position

a. Grooming

b. Oral care

c. Eating

D. Semi–Fowler’s Position (see CARE SKILLS #45)

1. Head of bed elevated 30 to 45 degrees

a. Promotes breathing

b. Less pressure to coccyx

III. Proper transfer

A. Role of the Nurse Aide

1. Gather equipment.

2. Arrange furniture.

3. Awareness of catheters, tubing or devices.

4. Resident in shoes with non–skid soles, gripper socks, or shoes.

5. Assess need for assistance from coworker; refer to assignment

sheet.

6. Provide for privacy and encourage the resident to help as much as

possible to promote independence.

7. Use proper body mechanics.

a. Place feet shoulder-width apart.

b. Bend knees and keep back straight.

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c. Keep the weight of the resident close to you.

d. Lift using thigh muscles in a smooth motion.

e. Never lift and twist at same time.

8. Check the resident’s care plan and/or assignment sheet before

moving the resident.

9. Be patient and give the resident time to adjust to changes in

position.

10. Be aware of resident’s limbs when transferring.

11. Check condition of assistive devices.

12. Report any misuse of (or refusal of) device to nurse.

13. Observe resident for signs of discomfort or fatigue.

14. When assisting resident to walk with cane, stand on weaker side.

15. Know how to properly use wheelchair and geriatric chair. (See

CARE SKILL #46)

a. Nurse aide should know how to remove/replace equipment

as necessary (i.e., armrests and footrests on wheelchair),

lock/unlock wheels and other parts of chair, and raise/lower

adjustable parts of chair.

16. Follow safety guidelines when transporting a resident in a chair.

a. Push the wheelchair from behind, except when going in and

out of elevators. Pull the chair into and out of an elevator.

b. If moving a resident down a ramp, take the chair down

backwards. Glance over your shoulder to be sure of your

direction and to prevent collisions and falls.

c. Always place resident’s feet on footrest before moving chair.

Never push wheelchair if resident’s feet are not on footrests.

Doing so could cause serious injury to the resident.

d. Pay attention to surroundings to avoid collisions and injury to

resident. Slow down at corners and look before proceeding.

B. Transfer from bed to chair (See CARE SKILLS #47)

1. Determine if resident has weakness on one side.

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a. Place chair on unaffected side and transfer resident towards

his/her unaffected side.

2. Brace chair firmly against the bed facing the foot of the bed.

3. Lock chair wheels & remove arm and leg rests, if wheelchair.

4. Allow resident to sit on side of bed/dangle (see CARE SKILLS #48)

for approximately 10–15 seconds.

a. Feet flat on floor.

b. Regain balance.

5. Apply transfer/gait belt before transferring the resident.

6. Use proper body mechanics.

C. Using transfer/gait belt (see CARE SKILLS #49).

1. Secure belt around resident’s waist and over their clothes. Never

place gait belt on bare skin.

2. Most used when resident has fragile bones or recent fractures.

a. May not be used when resident has had abdominal surgery

or has difficulty breathing.

b. Avoid using gait belt if resident has G-tube or other

ostomies/stomas on abdomen.

3. Check for proper fit; not too tight; should not slide.

4. Use proper body mechanics.

D. Ambulation/walking (See CARE SKILLS #50)

1. Encourage/assist throughout the day.

a. Promote physical and mental well–being.

2. Stand to side and slightly behind the resident.

a. Weakness on one side, stand on that side.

3. Arm on residents back (if no gait belt).

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E. Assistive devices

1. Fitted to each resident.

a. Measurements obtained by PT or nurse.

2. Walker (see CARE SKILLS #51)

a. Used by resident who can bear weight.

b. Used for support/balance.

c. Design

i. Light weight

ii. Rubber stops should be in good repair.

iii. Wheels

d. Walking sequence

i. Walker is placed at a comfortable distance in front of

resident.

ii. Feet/wheels on ground.

iii. Resident moves to the walker, weaker side first.

3. Cane (see CARE SKILLS #52)

a. Used by resident to help maintain balance.

i. Resident should be able to bear weight.

ii. Not for weight bearing.

b. Designs

i. Curved handle

ii. Straight handle

iii. Four feet (quad–cane)

iv. Rubber stops should be in good repair.

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CARE SKILLS:

• Assist to Move to Head of Bed – #41

• Supine Position – #42

• Lateral Position – #43

• Fowler’s Position – #44

• Semi–Fowler’s Position – #45

• Use of Wheelchair and Geriatric Chair – #46

• Transfer to Chair – #47

• Sit on Edge of Bed – #48

• Using a Gait Belt to Assist with Ambulation – #49

• Walking – #50

• Assist with Walker – #51

• Assist with Cane – #52

Review Questions --- Lesson #15

1. What is proper body alignment?

2. List the four commonly used positions.

3. Which position raises the head of the bed 30–45 degrees?

4. Does this position put more or less pressure on the coccyx than Fowler’s

position?

5. When transferring a resident with right-sided weakness from the bed to

the chair, the chair should be placed on the resident’s right side. (True or

False)

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Lesson #16 (1 hour, 30 minutes)

Title: Activities of Daily Living (Devices Used for Transfer)

Lesson Objectives:

I. The student will be able to demonstrate competence in transferring a resident

using a mechanical lift.

II. The student will be able to explain how to transfer a resident to a stretcher or

shower bed.

III. The student will be able to explain how to and when to use a two-person transfer.

Key Terms:

Mechanical Lift – a hydraulic or electric device used to transfer dependent or obese

residents between surfaces. The lift may also have a scale to weigh the resident.

Stretcher – gurney; device for transporting residents unable to use a wheelchair or to

walk; a means of transporting the severely ill or an immobile resident.

Content:

I. Mechanical lifts

A. Common names and types

1. Sling– some Brand names include Hoyer and Invacare.

2. Sit to Stand– one brand name is Arjo ® Sara Lift.

B. Proper use of mechanical lifts

1. Be sure to always follow:

a. Manufacturer’s instructions – normally requires at least two

caregivers.

b. Facility policy.

C. Transferring with mechanical lift (See CARE SKILLS #53) – general

principles (but may vary with type of lift)

1. Position sling.

2. Base open and under bed, or around/straddling chair.

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3. Place the overhead bar above the resident.

4. Attach the sling.

5. Place resident’s arms across chest. Stabilize resident’s head and

neck.

6. Raise sling/resident.

7. Coworker support resident’s legs.

8. Lower sling/resident to chair or stretcher (bed).

9. Position for comfort and place sling in a manner to protect the

resident’s dignity.

D. Role of the Nurse Aide

1. Review assignment sheet before transferring.

2. Be aware of manufacturer’s instructions and facility policy.

3. Make sure lift is in proper working order.

4. Provide privacy for the resident during the transfer.

5. Be aware of catheter or tubing the resident may have.

6. Never leave resident alone in device.

II. Transfer resident to stretcher/shower bed

A. From bed to stretcher (see CARE SKILLS #54)

1. Need at least two workers to assist.

B. Return resident to bed.

1. Height of stretcher slightly higher than bed.

C. Role of the Nurse Aide.

1. Explain to the resident what you are about to do prior to

transferring.

2. Provide the resident with privacy when transferring.

3. Keep the resident covered.

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4. Be aware of any catheter or tubing the resident may have.

5. Use proper body mechanics.

6. Lock wheels on bed.

7. Ensure resident is positioned for comfort prior to exiting the room.

III. Transfer – Two Person Lift (see CARE SKILLS #55)

ONLY TO BE USED IN AN EMERGENCY – IF RESIDENT UNABLE TO BEAR

WEIGHT, A LIFT SHOULD BE USED.

A. For transferring resident unable to bear weight (i.e., history of stroke).

B. Role of the Nurse Aide.

1. Explain to the resident what you are about to do prior to the

transfer.

2. Lock wheelchair brakes.

3. Be aware of catheter or tubing the resident may have.

4. Use proper body mechanics.

CARE SKILLS:

• Transfer Using Mechanical Lift - #53

• Transfer to Stretcher/Shower Bed – #54

• Transfer: Two Person/Lift– emergency only – #55

Review Question --- Lesson #16

1. The manufacturer’s instructions state the mechanical lift can safely be used by two

qualified staff persons to transport a resident. The facility’s policy states two qualified

staff members are required to transport a resident. You were trained on how the lift

functions and are competent to use it. Mrs. Smith would like to get up in her

wheelchair. You have the lift ready to assist in the transfer. Cindy, another CNA, is

coming to help with the transfer. Five minutes have passed, and Cindy has not

arrived. It is acceptable for you to transfer Mrs. Smith by yourself. (True or False)

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Lesson #17 (2 hours)

Title: Resident’s Environment

Lesson Objectives:

I. The student will be able to demonstrate competence in making an occupied bed.

Key Terms:

Occupied Bed – bed made while a resident is in the bed.

Content:

I. Occupied Bed (see CARE SKILLS #56)

A. Points to Remember

1. Wrinkles from the linens can cause problems with circulation and

result in sores on the resident’s skin. Keep sheets as wrinkle-free

as possible.

2. Always leave extra room at the foot of the bed for the toes to move

freely.

3. Use safety precautions to ensure that the resident does not fall out

of the bed. Follow facility protocol regarding side rails.

4. Keep the resident covered throughout the procedure to ensure

privacy and comfort are maintained.

5. Before beginning an occupied bed change, check to see if the

resident has tubes or lines attached to them. If so, be sure that the

lines aren’t being pulled or pinched during the linen change.

a. Move the drainage bag to the side of the bed that the

resident will be facing while the linens are being changed.

Before moving to the second side of the bed, be sure to

move the bag, so that the resident will again be facing it

once turned onto their other side.

6. The CNA is never allowed to stop a feeding pump or to disconnect

the feeding tube for any reason. If necessary, have the nurse stop

the pump or disconnect the lines. Always be sure to notify the nurse

when you are finished, so that the resident’s feeding can be

resumed.

7. Report to the nurse if the resident refuses to have the linens

changed, or if the resident complains of pain before you begin.

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CARE SKILLS:

• Occupied Bed – #56

Review Questions --- Lesson #17

1. Wrinkled sheets under a resident do not cause problems for their skin?

(True or False)

2. You are beginning an occupied bed change for Mrs. Smith, who has an

indwelling catheter with a urinary drainage bag attached. Which side of the

bed should you place the bag on, if you are about to turn Mrs. Smith onto

her left side?

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Lesson #18 (2 hours)

Title: Skin Care/Pressure Prevention

Lesson Objectives:

I. The student will be able to explain the importance of an intact integumentary

system and basic skin care.

II. The student will be able to describe residents at risk for skin breakdown.

III. The student will be able to describe the need for pressure reducing devices.

Key Terms:

Bony Prominence – area of the body where the bone is in close proximity to the skin

(e.g., ankles, hip bones, elbows, etc.).

Dermis – inner layer of skin.

Epidermis – outer layer of skin.

Friction – skin repeatedly rubs another surface.

Integumentary System – skin and associated structures that form a natural protective

covering for the body

Offload – assisting a resident to stand, to completely remove the pressure from the

area; Any process in which pressure on the appendage is reduced

Pressure Point – any area on the body that bears the body’s weight when lying or

sitting and where a bone is close to the skin’s surface.

Pressure Sore (also called “Bed Sore” or “Decubitus Ulcer”) – a localized injury to the

skin and/or underlying tissue. Usually occurs over a bony prominence as a result of

pressure, or pressure in combination with shear and/or friction.

Reverse Push–Up – asking a resident to lift up off their buttocks using their arms in a

reverse push– up.

Shear – skin stays in one position, but underlying bone and tissue roll in the opposite

direction.

Subcutaneous tissue – the lowest layer of skin; fatty tissue.

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Content:

I. Understanding the Integumentary System and Basic Skin Care

A. The Integumentary System

1. The structure

a. Skin

b. Hair

c. Epidermis

d. Dermis

e. Subcutaneous tissue

f. Nails

g. Glands

i. Oil

ii. Sweat

h. Nerve endings

2. Function

a. Largest organ of the body

b. Sense organ

i. Heat/cold

ii. Pain

iii. Pressure

iv. Touch

c. Internal organ protection

d. Body temperature regulation

e. Bacterial protection

f. Excretes waste

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g. Prevents loss of too much water

h. Vitamin D production

3. Changes with age

a. Skin dries

b. Skin becomes more fragile

c. Subcutaneous (fatty) tissue thins

d. Brown spots develop

e. Wrinkles appear

f. Hair grays and becomes thin

g. Nails thicken

4. Care of the skin

a. Skin should be clean and dry.

i. Provide frequent care for residents who are

incontinent.

ii. Change linens/clothing.

iii. Check resident at least every 2 hours for needed care

and encourage repositioning.

b. Observe for:

i. Rashes

ii. Abrasions

iii. Dryness

iv. Changes in skin color

1. Pale

2. Red

3. Purple/Blue

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v. Pressure areas

1. Reposition at least every 2 hours.

2. No wrinkles in bottom sheet.

vi. Temperature

1. Complaints of warmth or burning

vii. Bruising

viii. Swelling

ix. Blisters

1. Ensure resident has proper fitting

shoes/slippers.

x. Scratching

xi. Broken skin

xii. Drainage

xiii. Wound or ulcer

xiv. Redness or broken skin between toes or around nails.

II. Risk Factors for Skin Breakdown

A. Sensory Perception

1. The ability to feel pressure. In general, people move regularly to

keep pressure from building up.

2. Individuals with limited sensory perception may not realize they

have not moved for a while, which increases their risk for pressure

ulcers. Medications, medical conditions, or mental status may all

cause an individual’s sensory perception to change.

B. Moisture

1. Healthy skin stays clean and dry. Individuals at risk of pressure

ulcers may have skin that stays moist because of incontinence

(urine or stool) or perspiration (sweat). When an area at risk for a

pressure ulcer is moist, a pressure ulcer is more likely to form.

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C. Activity

1. Activity means an individual’s ability to physically move (like

walking). Individuals who can walk rarely get pressure ulcers.

Individuals who are bedfast or chair bound are at higher risk of

developing pressure ulcers.

D. Mobility

1. Mobility refers to the ability to change and control body position.

Individuals with good mobility move their bodies regularly.

Individuals who are immobile or have limited mobility are at greater

risk for developing pressure ulcers because they cannot move to

relieve the pressure.

E. Nutrition

1. Everyone needs to eat the right food and drink enough liquids to

stay healthy.

Individuals who do not eat enough of the right foods or drink

enough of the right liquids are at greater risk for pressure ulcers

because their bodies do not have the energy they need.

F. Friction and Shear

1. Friction happens when skin rubs another surface over and over

(like a rough wheelchair seat rubbing the back of the individual’s

leg).

2. Shear is similar to friction, but it occurs when skin stays in one

position but the underlying bone and tissue roll in the opposite

direction (like someone sliding across a bed).

3. The rubbing and pulling of friction and shear break down the skin,

which contributes to pressure ulcers. Pressure ulcers are more

likely to develop when there is increased shear or friction.

G. Additional Risk Factors

1. Chronic conditions or illnesses (diabetes, cancer) – body is fighting

several problems at once.

2. Age– skin becomes fragile and breaks down easily.

3. Medical devices– the device may rub the skin over and over or

cause pressure to that area.

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4. Depression or mental illness– Higher risk due to individuals

neglects their own care.

5. History of pressure ulcers– old pressure ulcer scars make the skin

in that area weaker and more likely to break down.

III. Pressure Ulcer Development

A. Skin breakdown can develop when individuals stay in one position for too

long (as little as two hours) without shifting their weight.

B. The pressure of body weight reduces blood supply, causing skin and

surrounding tissue to become damaged or even die.

C. Pressure ulcers can be painful. They can cause infection, damage to

muscle and bone, and even death.

1. For the stages of pressure sores, please refer to the picture in the

Appendix A.

D. Treatment can take weeks, months, or years.

IV. Prevention of Skin Breakdown

A. Observe skin upon admission and during the provision of daily care

1. Skin Inspection (See CARE SKILLS #57)

a. Drape resident to allow you to see, feel and smell the area

you are inspecting. This can easily be done when the

individual is dressing or undressing.

b. Remove pressure – Lift heels, turn or move the individual to

inspect the skin.

i. Report to the nurse if you find redness that is not

relieved within 15 minutes of removing pressure.

c. Inspect – Focus on bony prominences, where pressure

ulcers are most likely to develop. Observe and prevent skin–

to–skin contact. Additional areas at risk are the ears, under

the breasts, the scrotum, and any skin– to–skin contact.

d. Note observations and report to the nurse – When a

potential problem is observed, notify the nurse for

assessment of the area.

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i. Report areas of discoloration, blisters, skin tears,

changes in the way the skin feels, or any other

area(s) of concern.

B. Encourage and maintain nutrition and hydration.

C. Manage moisture by providing prompt care.

D. Minimize pressure.

1. Pressure–reducing mattress

2. Pressure–reducing cushion to chair

a. Heel boots – specialty devices that surround the feet and

calves and create a cushion between the heels and the bed.

They should not be used with residents who walk. The

manufacturer’s instructions must be followed.

b. When using any device, check the other areas of the legs to

ensure you are not moving the pressure to another area, like

the calves.

3. Other pressure-reducing devices

a. Use pillows to float heels (See CARE SKILLS #58) when

residents are in bed. Pillows should also be used to help

reduce pressure under top arm when resident is side-lying.

b. Bed cradles (See CARE SKILLS #59) can be used to keep

covers from touching toes when residents are in bed. Be

sure to use per manufacturer’s instructions and drape top

covers over the cradle properly.

E. Prevent Friction and Shearing

1. Do not pull residents across surfaces when repositioning or

transferring.

2. Use the draw sheet to turn, lift, or move residents who are in bed.

3. Ask for assistance when turning, lifting, or moving residents.

F. Identify residents who have been assessed by nursing as “at risk”.

1. Braden Scale– standardized risk assessment tool completed by the

nurse.

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2. Newly-admitted residents are likely to fall into this category, due to

the number of risk factors they face and the sudden change(s) in

their body.

CARE SKILLS

• Inspecting Skin – #57

• Float Heels – #58

• Bed Cradle – #59

Review Questions --- Lesson #18

1. Most pressure ulcers develop within a few weeks of admission. (True or

False)

2. Pressure ulcers can lead to life–threatening infection. (True or False)

3. Caregivers should use draw sheets to turn, lift or move the resident up in

bed to prevent skin damage caused by shearing. (True or False)

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Lesson #19 (3 hours)

Title: Activities of Daily Living (Nutrition/Hydration)

Lesson Objectives:

I. The student will be able to demonstrate competence in proper feeding

techniques and provision of assistance for the resident with special needs.

II. The student will be able to explain the importance of following care guidelines for

a resident receiving tube feedings and observations of resident condition that

must be reported, if observed.

Key Terms:

Aspiration – inhalation of food or drink into lungs which has the potential to cause

pneumonia or death.

Gastrostomy Tube (G–Tube) – tube placed through the abdomen directly into the

stomach and used to provide nourishment.

Jejunostomy (J–Tube) – tube placed into the second part of the small intestines and

used to provide nourishment.

Nasogastric Tube – tube placed through the nose to the stomach and used to provide

nourishment.

PEG (Percutaneous Endoscopic Gastrostomy) – tube placed endoscopically, directly

into the stomach and used to provide nourishment. Often called a “G–tube”.

Content:

I. Promoting Proper Nutrition and Hydration

A. Fluid Balance

1. Observe for signs of dehydration and report to the nurse:

a. Mild symptoms (include but are not limited to): thirst, loss of

appetite, dry skin, flushed skin, dark colored urine, dry

mouth, fatigue or weakness, chills.

b. Advancing dehydration symptoms (include but are not

limited to): increased heart rate, increased respirations,

decreased sweating, decreased urination, increased body

temperature, extreme fatigue, muscle cramps, headaches,

and nausea.

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c. severe dehydration symptoms (include but are not limited

to)– muscle spasms, vomiting, racing pulse, shriveled skin,

dim vision, painful urination, confusion, difficulty breathing,

seizures.

2. Observe for and report to the nurse signs of fluid overload which

may include:

a. stretched and shiny–looking skin over a swollen area,

increased abdomen size (ascites), shortness of breath or

difficulty breathing (pulmonary edema), tightness of jewelry,

clothing or accessories, low output of urine, even when the

resident is drinking as much fluid as normal, a dimple in the

skin covering the swollen area that remains for a few

seconds after the pressing finger has been released.

b. Symptoms of more serious fluid overload include difficulty

breathing, shortness of breath when lying down, coughing,

cold hands or feet.

c. Measure Intake & Output accurately.

II. Promoting the Use of Proper Feeding Technique/Assisting a Resident with

Special Needs (See CARE SKILLS #60)

NOTE - The caregiver should provide any necessary care and offer to assist the

resident to toilet prior to meal service in an effort to promote a positive experience.

A. Tips for feeding

1. As a safety precaution, never leave a resident who needs to be fed

unattended with a tray.

2. Add salt, pepper, sugar, condiments, etc., to the resident’s

preference and in accordance with their prescribed diet. Adding the

extra flavor can help increase their appetite.

3. Reheat food if necessary.

4. Do not eat while feeding residents.

5. Avoid talking to coworkers, or others in the room, as it can make

the resident feel neglected or unimportant and cause them to stop

eating.

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B. Assistive Devices

1. Plate guards

2. Utensils with enlarged (built–up) handles

3. Drinking cups (nosey cups)

4. Divided plates

5. Non–skid plate/place mat

C. Visually impaired

1. Speak in a normal tone while facing the resident.

2. Read menu to the resident.

3. Position their food on the plate according to hands of a clock.

Explain where food items are on plate.

4. When feeding the resident, ask them to open their mouth at

appropriate time.

5. When feeding the resident, tell them what food you are giving them.

D. History of stroke

1. Place food in resident’s sight.

2. Supply assistive device(s), as appropriate, to unaffected side.

3. Report any difficulty swallowing and observe for signs of choking.

4. Report to nurse coughing and/or observed pocketing of food.

5. When feeding the resident, make sure the resident swallows before

giving more food.

6. If resident’s mouth is paralyzed, place food on the unaffected side

when feeding.

E. History of Parkinson’s Disease

1. Supply assistive devices, as appropriate.

2. Food and drinks should be placed within reach.

3. Assist the resident as needed; promote independence.

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III. Caring for a Resident with a Tube Feeding and the Resident at Risk for

Aspiration

A. Tube Feedings

1. Feeding tubes are used when food cannot pass normally from the

mouth into the esophagus and then into the stomach. The resident

who is unable to take food or fluids by mouth, or is unable to

swallow, may be fed through a tube.

The two types of tubes most commonly used in long–term care

facilities are nasogastric tubes and gastrostomy tubes.

2. A nasogastric (NG) tube is a tube that is placed through the nose

into the stomach. (“Naso” is the medical term for nose and “gastric”

means stomach.) It may be abbreviated as NG tube. An NG tube

may also be used by the nurse to suction and remove fluids from

the body.

3. A gastrostomy tube (g–tube) is a tube that is placed directly into the

stomach for feeding. A small surgical opening is made through the

abdominal wall into the stomach, and the tube is sutured to hold it

in place. This type of tube is often used for a resident who may

need tube feedings for a long time. The abbreviation for a

gastrostomy tube is G–tube. This tube can also be called a PEG

(percutaneous endoscopic gastrostomy) tube.

4. Usually the NG tube or the G–tube will be attached to an electronic

feeding pump that controls the flow of fluid. Most pumps have an

alarm that sounds when something is wrong. You must notify the

nurse immediately if the alarm sounds.

5. The resident who has a feeding tube should be observed

frequently. If the pump is not working properly, the resident may

receive the wrong amount of food or the fluid may enter too quickly.

This can cause nausea, vomiting, and aspiration. The NG tube may

have moved out of the stomach and into the lungs. Aspiration

pneumonia may result if feeding enters the lungs.

6. Residents with feeding tubes are often NPO. NPO is the

abbreviation for nothing by mouth. PO is the abbreviation used

when a person can have something by mouth.

7. Do not give the resident who has a feeding tube anything to eat or

drink without checking with the nurse.

8. The NG tube is uncomfortable and irritating to the nose and throat.

The G– tube may become dislodged from the stomach, or the skin

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may become irritated at the site of insertion. Infection can occur

with either tube, if infection control practices are not carefully

followed.

9. The resident with a feeding infusing should not lie flat. The head of

the bed should be elevated at least 30°. Some procedures will need

to be changed slightly for the resident with a feeding tube. For

example, an occupied bed cannot be flattened to change the linen

or to provide incontinence care with the feeding infusing. If the bed

must be flattened, seek the nurse’s assistance to turn off the pump

prior to the procedure and turn the pump back on after the

procedure. Your major responsibility concerning the resident with a

feeding tube is to make regular observations and promptly report

any problem.

10. Report any choking or coughing to the nurse immediately.

B. Observations to be reported to the nurse immediately:

1. Nausea

2. Discomfort during the tube feeding

3. Vomiting

4. Diarrhea

5. Distended (enlarged and swollen) abdomen

6. Coughing

7. Complaints of indigestion or heart burn

8. Redness, swelling, drainage, odor, or pain at the tube insertion site

9. Elevated temperature

10. Signs and symptoms of respiratory distress

11. Increased pulse rate

12. Complaints of flatulence (gas)

C. Comfort Measures

1. The resident with a feeding tube is usually NPO. Dry mouth, dry

lips, and sore throat are sources of discomfort. The resident’s care

plan will include frequent oral hygiene and lubricant for the lips.

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D. Risk of Aspiration

1. Any resident with ordered thickened liquids, a pureed or

mechanical soft diet, or having a diagnosis of esophageal reflux,

GERD, or respiratory difficulty is a resident who is at risk of

aspiration. The caregiver must always elevate the head of the bed

or assist the resident to an upright position prior to offering food or

fluids if the resident is at risk of choking/aspiration. Should a

resident begin to cough, gurgle or regurgitate, attempts to feed

should STOP and the nurse should be alerted immediately to

assess the resident.

2. Residents at risk of choking/aspiration should be encouraged to sit

up or remain with the head of the bed elevated for at least 30

minutes (or as long as tolerated) following consumption of food or

fluids.

3. Know your residents and ensure residents receive snacks, meals

and fluids at the ordered consistency.

CARE SKILLS:

• Feeding – #60

Review Questions --- Lesson #19

1. Name two symptoms of dehydration.

2. When a tube feeding is infusing, the head of the bed must be elevated.

(True or False)

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Lesson #20 (8 hours)

Title: Basic Nursing Skills (Vital Signs, Height and Weight)

Lesson Objectives:

I. The student will be able to demonstrate competence in completion of initial steps

to be taken prior to initiating a procedure as well as final steps following any

procedure executed.

II. The student will be able to demonstrate competence in taking and recording vital

signs.

III. The student will be able to demonstrate competence in measuring and recording

height and weight.

Key Terms:

Apical Pulse – located on the left side of the chest, under the breastbone; taken with a

stethoscope.

Brachial Pulse – located at the bend of the elbow, used for taking blood pressure

measurement.

Carotid Pulse – located on either side of the neck, supplies the head and neck with

oxygenated blood.

Diastolic Blood Pressure – the phase when the heart relaxes; the pressure in the

arteries between heartbeats. bottom number of blood pressure reading

Expiration – exhaling air out of the lungs.

Hypertension – high blood pressure.

Hypotension – low blood pressure.

Inspiration – breathing air into the lungs.

Orthostatic Hypotension – a drop in blood pressure when a resident suddenly rises

from a lying to a sitting or standing position.

Pulse Oximetry – a procedure used to measure the oxygen level (or oxygen saturation)

in the blood. It is considered to be a noninvasive, painless, general indicator of oxygen

delivery to the peripheral tissues (such as the finger, earlobe, or nose).

Radial pulse – the pulse site found on the inside of the wrist.

Respiration – the process of breathing air into lungs and exhaling air out of the lungs.

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Systolic Blood Pressure – the phase when the heart is at work, contracting and

pushing blood from the left ventricle; the pressure in the arteries when the heart beats;

top number of a blood pressure reading

Content:

I. Initial Steps– These are consistent steps to be taken prior to executing any

procedure with a resident. (See CARE SKILLS #1).

A. Includes asking the nurse about the resident’s needs, abilities and

limitations.

B. Includes following infection control guidelines and providing the resident

privacy during care.

II. Final Steps– These are consistent steps to be taken following the completion of

any procedure with a resident. (See CARE SKILLS #2).

A. Includes ensuring the resident is comfortable and safe.

B. Includes removing supplies and equipment from the resident’s room and

reporting any unexpected findings to the nurse and documenting care

provided.

III. Vital signs provide important information

A. How the body is functioning

B. How the resident is responding to treatment

C. How the resident’s condition is changing

D. Taking and Recording Vital Signs

1. Temperature (oral, axillary, tympanic) – the measurement of heat in

the body affected by time of day, age, exercise, emotional state,

environmental temperature, medication, illness and menstruation.

Types of thermometers include glass, electronic with probe cover,

paper/plastic tape, tympanic with probe cover. Glass thermometers

are seldom used. NOTE* A facility may have specific instructions in

regard to equipment to be used and/or the cleaning and disinfection

of common use equipment for those residents who require

isolation. The facility policies should be followed in regard to

residents in isolation.

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a. Oral (by mouth) – normal range 97.6 to 99.6 F (See CARE

SKILLS #61)

b. Axillary (placed in the armpit) – normal range 96.6– 98.6 F

(See CARE SKILLS #62)

c. Aural/tympanic (placed in ear) – normal range 98.6– 100.6 F

d. The above ranges are for general use. Report values that

are more than 2.4 degrees from the resident’s baseline

(normal) temperature.

2. Pulse rate is the measurement of the number of heart beats per

minute – Normal range 60 – 100 (See CARE SKILLS #63)

a. Affected by age, sex, emotions, body position, medications,

illness, fever, physical activity and fitness level.

i. Pulse points most often used are: carotid, apical,

radial, and brachial

ii. When taking the pulse rate, note the rate (number of

beats per minute), rhythm and force.

3. Respirations/Respiratory Rate – the measurement of the number of

times a person inhales per minute – Normal rate is 12-20 (See

CARE SKILLS #63).

a. Affected by age, sex, emotional stress, medication, lung

disease, heat and cold, heart disease, and physical activity.

b. When taking respirations, note rate (number of respirations

per minute; rhythm (the regularity or irregularity of

breathing); and character (the type of breathing, such as

shallow, deep or labored).

c. Without removing your fingers from resident’s wrist (or

stethoscope from resident’s chest), count respirations after

taking pulse, so that the resident is unaware that their

breathing is being monitored.

d. If resident is agitated or sleeping, place hand on resident’s

chest to feel it rise and fall during breathing.

4. Pulse Ox – A pulse oximeter continuously measures the level of

oxygen saturation of hemoglobin in the arterial blood. (See CARE

SKILLS #64)

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a. Affected by poor circulation, movement, bright light, nail

polish and fake nails (if probe is placed on finger).

b. Place probe on opposite arm of blood pressure cuff.

c. Normal ranges are typically between 95%-100% but can

vary from person to person. Report an increase or decrease

in oxygen levels to the nurse.

5. Blood Pressure – A measurement of the force the blood exerts

against the walls of the arteries. Normal range for Systolic blood

pressure is 90–139; Normal range for Diastolic blood pressure is

60–89. (See CARE SKILLS #65)

a. Abnormally high blood pressure is called hypertension.

Measurements higher than 140/90 are considered high for

adults.

b. Abnormally low blood pressure is called hypotension.

Measurements below 90/60 are considered low for adults.

c. Electronic equipment may provide both odd and even

numbers for someone’s BP. However, a manual cuff only

displays even numbers.

d. The above ranges are for general use. It is important to

know the resident’s baseline (normal) BP range and to report

values obtained outside of that range to the nurse.

* Caution: If resident has a history of mastectomy or has a dialysis

access, the blood pressure is not to be taken on the affected

side/extremity.

IV. Measuring Height and Weight

A. Height (See CARE SKILLS #66)

1. Residents who are able to stand should utilize a standing balance

scale.

2. Residents who are unable to stand should be measured while lying

flat in bed. Height can be determined by using a tape measure to

measure the distance between a mark made at the top of the

resident’s head and one made at the bottom of the resident’s feet.

3. Residents who are unable to lay flat in bed should be measured

using a tape measure. Follow the procedure used by the facility to

determine height in this manner.

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B. Weight – (See CARE SKILLS #67)

1. Have resident wear the same type of clothing each time he/she is

weighed.

2. If daily weights are ordered, attempt to weigh at approximately the

same time each day.

3. If resident wears a prosthetic device, the weight should consistently be

taken with the device in place, or not in place, to eliminate inaccurate

weight changes.

4. Follow the manufacturer’s guidelines for use of the scale.

CARE SKILLS:

• Review Initial/Final Steps – #1 and #2

• Oral Temperature – #61

• Axillary Temperature – #62

• Pulse and Respiration – #63

• Pulse Oximeter – #64

• Blood Pressure –#65

• Height – #66

• Weight – #67

Review Questions --- Lesson #20

1. What is the normal heart rate for adults?

2. What is the normal blood pressure for adults?

3. If a resident is sleeping, describe how the respiratory rate can be taken?

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UNIT 3

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Lesson #21 (1 hour)

Title: Restraints

Lesson Objectives:

I. The student will be able to explain the resident’s right to be free of physical and

chemical restraints.

II. The student will be able to explain the need for monitoring physical restraint use

and routine release.

III. The student will be able to describe devices which are enabling versus

restrictive.

IV. The student will be able to explain the potential negative outcomes of side rail

use.

Key Terms:

Chemical Restraint – any drug that is used for discipline or convenience and not

required to treat medical symptoms. A drug used to restrict the freedom of movement

of a resident or sedate a resident.

Convenience – any action taken by the facility to control or manage a resident’s

behavior with a lesser amount of effort by the facility and not in the resident’s best

interest.

Discipline – any action taken by the facility for the purpose of punishing or penalizing

residents.

Entrapment – the act of getting caught in or trapped in something.

Medical Symptom – an indication or characteristic of a physical or psychological

condition.

Physical Restraint – any manual method or physical or mechanical device, material, or

equipment attached or adjacent to the resident’s body that the individual cannot remove

easily which restricts freedom of movement or normal access to one’s body.

Side Rail – a barrier device attached to the side of a bed.

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Content:

I. Physical Restraint

A. Resident Rights – The resident has the right to be free from any physical

or chemical restraints imposed for purposes of discipline or convenience,

and not required to treat the resident’s medical symptoms.

B. Types – “Physical restraints” include, but are not limited to, leg restraints,

arm restraints, hand mitts, soft ties or vests, lap cushions, and lap trays

the resident cannot remove easily. Also included as restraints are facility

practices that meet the definition of a restraint, such as:

1. Using side rails that keep a resident from voluntarily getting out of

bed;

2. Tucking in or using Velcro to hold a sheet, fabric, or clothing tightly

so that a resident’s movement is restricted;

3. Using devices in conjunction with a chair, such as trays, tables,

bars or belts, that the resident cannot remove easily, that prevent

the resident from rising;

4. Placing a resident in a chair that prevents a resident from rising;

and

5. Placing a chair or bed so close to a wall that the wall prevents the

resident from rising out of the chair or voluntarily getting out of bed.

C. Medical Symptoms/Rationale for Use – an indication or characteristic of a

physical or psychological condition for which the device improves the

resident’s function or quality of life.

D. Guidelines for Applying Restraints (See CARE SKILLS #68)

1. A restraint shall be applied by an individual who has been properly

trained, according to facility policy.

2. A restraint shall be applied in a manner that permits rapid removal

in case of fire or another emergency.

3. Check pulse in area to ensure circulation is not occluded (cut off)

4. Nursing Assistants can only use/apply restraint when instructed to

do so by the charge nurse.

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E. Monitoring and Release

1. A record of physical restraint and seclusion of a resident shall be

kept.

2. Each resident under restraint and seclusion shall be visited by a

member of the nursing staff at least once every hour and more

frequently if the resident's condition requires. If the restraint is not

applied correctly, the resident can suffer serious injuries or even

death. It is important to check the resident frequently (every 15

minutes) to ensure that circulation and bony prominences are not

affected by the restraint. If the restraint is not removed frequently,

the skin in the area can easily become irritated and even begin to

breakdown. Restraints can also affect the resident mentally. They

can cause the resident to suffer from anxiety, stress, depression,

sleep disturbances, and loss of dignity.

3. Each physically restrained or secluded individual shall be

temporarily released from restraint or seclusion at least every two

(2) hours or more often if necessary except when the resident is

asleep.

* When the resident in restraint is temporarily released, the resident

shall be assisted to ambulate, toileted, or changed in position as

the resident's physical condition permits.

F. Self–Releasing Devices – Devices used as a reminder that the resident

needs to call for assistance and/or to assist to keep the resident seated;

the resident can self–release the device upon request. Thus, the device

does not restrict freedom of voluntary movement.

G. Side rails – Side rails sometimes restrain residents. The use of side rails

as restraints is prohibited unless they are necessary to treat a resident’s

medical symptoms. Residents who attempt to exit a bed through,

between, over or around side rails are at risk of injury or death. The

potential for serious injury is more likely from a fall from a bed with raised

side rails than from a fall from a bed where side rails are not used. They

also potentially increase the likelihood that the resident will spend more

time in bed and fall when attempting to transfer from the bed. The same

device may have the effect of restraining one individual but not another,

depending on the individual resident’s condition and circumstances. For

example, partial rails may assist one resident to enter and exit the bed

independently while acting as a restraint for another. Orthotic body

devices may be used solely for therapeutic purposes to improve the

overall functional capacity of the resident.

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H. Entrapment Zones

1. Ensure that the resident does not get caught between the bed

and/or mattress and/or side rails. Being trapped between the

spaces can result in serious injury or death.

2. Refer to the picture in the Appendix to identify zones on the bed

where entrapment can occur.

I. An enclosed framed wheeled walker, with or without a posterior seat,

would not meet the definition of a restraint if the resident could easily open

the front gate and exit the device. If the resident cannot open the front

gate (due to cognitive or physical limitations or because the device has

been altered to prevent the resident from exiting the device), the enclosed

framed wheeled walker would meet the definition of a restraint since the

device would restrict the resident’s freedom of movement (e.g.,

transferring to another chair, to the commode, or into the bed). The

decision on whether framed wheeled walkers are a restraint must be

made on an individual basis.

CARE SKILLS

• Application of Physical Restraints – #68

Review Questions --- Lesson #21

1. A resident has the right to be free from any physical or chemical restraint

imposed for purposes of discipline or convenience, and not required to

treat the resident’s medical symptoms. (True or False)

2. How often must a resident with a physical restraint in place be visited by a

staff member?

3. How frequently must the physically restrained resident be temporarily

released to ambulate, toilet or change position?

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Lesson #22 (1 hour, 30 minutes)

Title: Rehabilitation/Restorative Services

Lesson Objectives:

I. The student will be able to describe the role of rehabilitative services.

II. The student will be able to describe the role of restorative services.

III. The student will demonstrate competence in performance of range of motion

exercises.

Key Terms:

Abduction – moving a body part away from the body.

Adduction – moving a body part toward the body.

Ambulation – walking.

Contracture – the permanent stiffening of a joint and muscle.

Dorsiflexion – bending backward.

Extension – straightening a body part.

Flexion – bending a body part.

Occupational Therapy – formal therapy which assists the resident to learn to

compensate for their disabilities and assist them with activities of daily living.

Physical Therapy – formal therapy, which uses heat, cold, massage, ultrasound,

electricity and exercise, for residents with muscle, bone and joint problems. A physical

therapist may help a person to safely use a walker, cane or wheelchair.

Pronation – turning downward.

Range of Motion – exercises which put a joint through its full range of motion.

Active Range of Motion – exercises are done by the resident himself.

Passive Range of Motion – caregivers support and move the resident’s joints through

the range of motion when the resident cannot move on their own.

Rehabilitation – services managed by professionals to restore a resident to his/her

highest practicable level of functioning following a loss of ability to function due to illness

or injury.

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Restorative Services – a planned approach to keep the resident at the level achieved

by formal rehabilitation.

Rotation – turning a joint.

Speech Therapy – formal therapy which assists residents with speech and swallowing

problems.

Splint – device that remains in place at the direction of the physician to maintain a body

part in a fixed position.

Supination – turning upward.

Content:

I. Rehabilitation

A. Role of Formal Therapy

1. Physical Therapy

2. Occupational Therapy

3. Speech Therapy

B. Assistive or Adaptive Devices– devices made to support a particular

disability by helping resident complete ADLs (e.g., long–handled brushes

and combs, divided plate, built–up silverware, reacher/grabber, etc.).

II. Restorative Services

A. Ambulation

1. Cane

2. Walker

3. Gait/transfer belt

B. Range of Motion (see CARE SKILLS #69)

1. Active Range of Motion (AROM)

2. Passive Range of Motion (PROM)

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C. Points to Remember:

1. Be patient when working with the resident.

2. Be supportive and encouraging.

3. Break tasks into small steps to promote small accomplishments.

4. Be sensitive to the resident’s needs and feelings.

5. Encourage the resident to do as much for self as possible.

D. Observe and report to the nurse

1. An increase or decrease in the resident’s ability.

2. A change in motivation.

3. A change in general health.

4. Indication of depression or mood changes.

E. Splint Application (see CARE SKILLS #70)

1. Splints vary from resident to resident. Be sure you have the correct

splint for your resident and make sure it is applied properly.

2. If you notice redness, swelling, or any other concerns in the area

that the splint is to be applied, notify the nurse before putting the

device on the resident.

III. Devices which may be applied per Restorative Nursing Program

A. Abdominal Binder (see CARE SKILLS #71) – may be used to secure G–

tube and prevent resident from picking at the insertion site or to provide

support to the abdomen due to hernia or recent surgery.

B. Abduction Pillow (see CARE SKILLS #72) – may be ordered to be in place

following a surgical procedure to maintain lower extremities in an

abducted position and prevent the resident from crossing the lower legs or

ankles.

C. Knee Immobilizer (see CARE SKILLS #73) – may be ordered to be in

place following a surgical procedure to keep the leg straight while the

bone is healing. Should only be removed at the direction of the licensed

nurse.

D. Palm Cone (see CARE SKILLS #74) – may be ordered to be placed in the

palm of a resident who is at risk for developing contractures of the digits

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(i.e., prevent the fingers/nails from turning into the palm permanently and

causing skin breakdown).

CARE SKILLS:

• Passive Range of Motion – #69

• Splint Application – #70

• Abdominal Binder – #71

• Abduction Pillow – #72

• Knee Immobilizer – #73

• Palm Cones – #74

Review Questions --- Lesson #22

1. Describe the difference in “active” range of motion and “passive” range of

motion.

2. The permanent stiffening of a joint and muscle is called a _____.

3. A planned approach to keep the resident at a level achieved by formal

rehabilitation is called _____.

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Lesson #23 (1 hour, 30 minutes)

Title: Devices/Interventions – Prosthetics, Hearing Aids, Artificial Eye,

Eyeglasses, Dentures, Compression Stockings

Lesson Objectives:

I. The student will be able to describe the necessary care and maintenance of

various devices used by residents.

II. The student will be able to describe the need to monitor for complications with

the use and maintenance of devices used by residents.

Key Terms:

Amputation – the removal of some or all of a body part, usually as a result of injury or

disease.

Elastic/Compression Stockings – stockings that decrease blood pooling in the lower

extremities. The stockings help with circulation in the lower legs and decrease the risk

for blood clots. They are also referred to as TED (thromboembolic deterrent) hose.

Phantom Pain/Sensation – feeling like the limb is still there after the amputation due to

the remaining nerve endings.

Prosthesis/Prosthetic Devices – device that replaces a body part that is missing or

deformed due to accident, injury, illness or birth defect.

Content:

I. Purpose of a Prosthetic Device

A. Improve resident’s functional ability.

B. Improve appearance.

II. Types of Prosthetic Devices

A. Artificial limbs – arm, leg/foot

B. Other prosthetic devices

1. Hearing aids

2. Artificial eyes

3. Eyeglasses

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4. Dentures

III. Role of the Nurse Aide regarding Amputations & Prosthetic Care

A. Be supportive – amputation can be difficult for a resident to accept due to

the change in body image.

B. Follow care plan – know what is required related to care and needs.

C. Follow instructions for applying and removing the prosthesis.

D. Keep skin under prosthesis clean and dry – follow care plan.

E. Handle with care – prosthesis is fitted to the resident and specially made.

A prosthesis can be very expensive.

F. Observe skin on stump. Watch for pressure, redness, warmth, tenderness,

or open area. Report any concerns to the nurse.

IV. Role of the Nurse Aide regarding Hearing Aids

A. Hearing Aid – small battery-operated device that fits into the ear to amplify

sound.

B. Assisting with Hearing Aids (see CARE SKILLS #75)

1. Be sure to follow the manufacturer’s instructions when inserting the

hearing aid into the resident’s ear.

2. Be sure to follow the manufacturer’s instructions on cleaning the

hearing aid.

V. Role of the Nurse Aide regarding Artificial Eye & Eyeglasses

A. Artificial Eye – device that resembles natural eye. The resident cannot

see with the artificial eye. The artificial eye is held in the eye socket by

suction.

B. Care of artificial eye

1. Artificial eye – can be removed and reinserted. This should be done

by the nurse or independently by the resident.

2. Nurse Aide needs to observe that eye is clean.

3. If eye is removed, make sure it is stored in a safe place with proper

solution to avoid drying or cracking of artificial eye.

4. Follow directions on care plan.

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5. Provide privacy when assisting with eye care.

6. Resident with artificial eye may be able to provide self–eye care –

follow directions on care plan.

C. Care of eyeglasses

1. Make sure eyeglasses are clean.

2. Make sure resident has eyeglasses on.

3. Keep eyeglasses in a safe place when not in use.

VI. Role of the Nurse Aide regarding Dentures

A. Dentures – artificial tooth or teeth, necessary when resident’s natural tooth

or teeth have been removed due to damage or decay. Dentures may be

partial or full.

B. Care of dentures (See CARE SKILLS #25)

1. Make sure resident has dentures in place for meals.

2. Resident may want dentures removed at night.

3. Make sure dentures are cleaned.

4. Make sure dentures are in a safe place when not in use.

VII. Role of the Nurse Aide regarding Elastic/Compression Stockings (TED Hose)

(see CARE SKILLS #76)

A. Make certain stockings are on when resident is up, if ordered by the

physician.

B. Follow care plan directions in regards to when stockings are to be applied

and removed.

CARE SKILLS:

• Assisting with Hearing Aids – #75

• TED Hose Application – #76

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Review Questions --- Lesson #23

1. List potential observations of a stump which should be reported to the

nurse.

2. When assisting the resident with eyeglasses, it is important to ensure the

glasses are clean. (True or False)

3. When elastic/compression stockings are applied, the caregiver must

ensure there are no wrinkles or twists in the stockings. (True or False)

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Lesson #24 (1 hour, 30 minutes)

Title: Special Care Needs – Intravenous Fluids, Non–Pharmacologic Pain

Interventions

Lesson Objectives:

I. The student will be able to explain the purpose of IV/PICC lines.

II. The student will be able to describe the importance of observing and reporting

complications related to IV/PICC lines.

III. The student will be able to explain the signs/symptoms of pain and acknowledge

interventions to be attempted to relieve resident pain.

Key Terms:

Antibiotic – compound or substance that kills or slows down the growth of bacteria.

Chemotherapy – treatment of cancer with an antineoplastic drug or with a combination

of such drugs into a standardized treatment regimen; often administered intravenously

(IV).

Hydration – the supply and retention of adequate water to keep one from dehydrating.

Intravenous (IV) – refers to a soft, flexible catheter (tube) that is inserted by a nurse or

physician into a vein.

Pain – an unpleasant sensory and emotional experience arising from actual or potential

tissue damage.

Peripherally Inserted Central Catheter –PICC– a soft, flexible catheter (tube) that is

inserted by a specially trained nurse or physician into a vein for administration of

medication, total parenteral nutrition (TPN), chemotherapy, or blood products for an

extended period of time.

IV Pump – device to regulate the flow of the fluid into the vein. The pump will alarm if

there is a problem with flow, and must be managed by the licensed nurse.

Total Parenteral Nutrition (TPN) – no food is given by other routes, only intravenously.

Vein – blood vessels that carry blood toward the heart.

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Content:

I. IV or PICC Lines

A. Purpose of IV or PICC lines

1. Medication administration, such as antibiotics

2. Nutrition administration

3. Hydration

4. Blood products

5. Solutions are administered by gravity or through a portable pump

II. Role of the Nurse Aide in caring for IV/PICC

A. Observe and Report

1. If the IV or PICC line is not in place, or if it is removed by the

resident, or accidentally by staff when providing care.

2. Blood present anywhere in the tubing.

3. Tubing is disconnected.

4. Complaint of pain.

5. Fluid in bag is not observed dripping.

6. Fluid in bag is nearly gone or finished.

7. Pump is alarming.

8. Site is swollen or discolored.

9. Dressing is wet or soiled.

B. Take special caution when moving or caring for resident – avoid pulling

the tubing and make sure that it does not get caught on anything when

providing care.

C. Never disconnect IV or PICC from pump.

D. Never lower bag below IV/PICC site. Can potentially cause a back flow of

fluids from the vein, resulting in blood entering into the tubing and/or bag.

E. Do not take blood pressure in arm with IV or PICC.

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III. Infection Control

A. Use proper hand hygiene.

B. Observe site for signs of infections and report to the nurse if observed:

1. Redness

2. Swelling

3. Pain

IV. Pain Factors

A. Vital Signs should be taken, if directed by nurse to do so.

B. Information related to pain:

1. Location

2. When did it start

3. What was resident doing when pain started

4. Rate the pain, i.e., mild, moderate or severe on scale of 1–10

5. How long has resident been having pain

6. Describe the pain, i.e., ache, stabbing, crushing, dull, constant,

burning

7. Use resident’s words/description to report to nurse

V. Role of the Nurse Aide related to Pain

A. Observe and report to the nurse signs/symptoms of pain, which may

include, but are not limited to:

1. Change in vital signs – B/P, Pulse, Respiration

2. Nausea

3. Vomiting

4. Sweating

5. Tearful or frowning

6. Sighing, moaning or groaning

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7. Breathing heavy or shortness of breath

8. Restless or having difficulty moving

9. Holding or rubbing a body part

10. Tightening jaw or grinding teeth

11. Anxiety, pacing

B. Interventions to reduce pain

1. Report complaints of pain or unrelieved pain (after receiving pain

medication) to the nurse.

2. Position the resident’s body in good alignment or assist the resident

in changing to a more comfortable position.

3. Offer a back rub to the resident.

4. Assist the resident to the bathroom or offer the bedpan or urinal.

5. Encourage the resident to take slow, deep breaths.

6. Provide a quiet and calm environment.

7. Use soft music to distract the resident.

8. Be patient, caring, gentle and sympathetic in assisting the resident.

9. Observe the resident’s response to interventions attempted and

report to the nurse.

C. Barriers for resident regarding pain

1. Fear of addiction to pain medication.

2. Feeling caregivers are too busy to deal with pain.

3. Fear pain medication will cause other problems, i.e. drowsiness,

sleepiness, constipation.

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Review Questions --- Lesson #24

1. What are possible signs/symptoms of pain?

2. What are the reasons for an IV or PICC line?

3. Why would a resident not admit to having pain?

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BARBARA BROYLES ALZHEIMER AND DEMENTIA

TRAINING PROGRAM FOR NURSING ASSISTANTS

Do not ask me to remember.

Don’t try to make me understand.

Let me rest and know you’re with me.

Kiss my cheek and hold my hand.

I’m confused beyond your concept.

I am sad and sick and lost.

All I know is that I need you.

To be with me at all cost.

Do not lose your patience with me.

Do not scold or curse or cry.

I can’t help the way I’m acting.

Can’t be different though I try.

Just remember that I need you.

That the best of me is gone.

Please don’t fail to stand beside me.

Love me ‘til my life is done.

Author unknown

This Alzheimer’s/Dementia curriculum was developed to encompass provisions set forth

in Act 1184 of 2005 and incorporated into the Arkansas’ Office of Long Term Care

regulations for Nursing Assistant Training Curriculum.

Arkansas Department of Human Services

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Lesson #25 (15 hours)

Title: Cognitive Impairment/Dementia/Alzheimer’s

Lesson Objectives:

I. The student will be able to explain conditions associated with cognitive

impairment.

II. The student will be able to describe behaviors related to cognitive impairment.

III. The student will be able to identify therapies/methods used to reduce challenging

behaviors.

IV. The student will be able to demonstrate communication strategies and

techniques for use with the cognitively impaired resident.

V. The student will be able to identify one out of each six categories on safety

checklist.

VI. The student will be able to describe reasons why recreational activities are

important.

Key Terms:

Activity therapy – increased activities with a goal.

Agitation – restlessness; emotional state of excitement or restlessness.

Alzheimer’s disease – a progressive, degenerative and irreversible disease.

Alzheimer’s disease is caused by the formation of tangled nerve fibers and protein

deposits in the brain.

Aphasia – inability to speak, or to speak clearly.

A. Expressive aphasia – may be slow to speak or to formulate sentences.

B. Receptive aphasia – may be slow to respond to communication attempts due to

delay in processing the communication and the response.

Catastrophic reaction – reactions or mood changes of the resident in response to

what may seem to be minimal stimuli that can be characterized by weeping, blushing,

anger, agitation, or stubbornness.

Cognition – ability to think logically/quickly.

Cognitive impairment – inability related to thinking, concentrating, and/or

remembering.

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Confusion – inability to think clearly, trouble focusing, difficulty making decisions,

feelings of disorientation.

Delirium – state of sudden severe confusion that is usually temporary.

Delusions – believing things that are untrue. Fixed false beliefs.

Dementia – serious loss of mental abilities (thinking, remembering, reasoning and

communication).

Depression – state of low mood and lack of interest in activity.

Elopement – a cognitively impaired resident is found outside the facility and whose

whereabouts had been unknown to staff.

Hallucinations – seeing/hearing things not there. False sensory perceptions.

Hoarding – collecting and storing items in a guarded manner.

Interventions – actions to be taken by staff in response to an event or behavior.

Pacing – walking back and forth in the same area.

Pillaging – taking items that belong to someone else.

Reminiscence therapy – used to encourage residents to talk about the past.

Repetitive Phrasing – continually repeating the same phrase over and over.

Sundowning – behavioral changes that occur in the evening with improvement or

disappearance during the day.

Validation therapy – concept of validation or the returned communication of respect,

which confirms that the other person’s opinions are acknowledged, respected, and

heard, and that they are being treated with genuine respect as a legitimate expression

of their feelings.

Wandering – walking aimlessly around the facility.

Content:

I. Conditions:

A. Confusion – characterized by the inability to think clearly, trouble focusing,

difficulty making decisions, feeling of disorientation.

B. Delirium – state of sudden severe confusion that is usually temporary.

Delirium is a serious condition, occurring rapidly over hours or a few days.

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C. Dementia – a general term that refers to serious loss of mental abilities,

such as thinking, remembering, judgement, reasoning, and

communicating. Dementia is not a normal part of aging.

D. Alzheimer’s disease – a progressive, degenerative and irreversible

disease.

Alzheimer’s disease is caused by the formation of tangled nerve fibers and

protein deposits in the brain. Alzheimer’s disease is the most common

cause of dementia. Alzheimer’s disease is characterized by stages:

1. Stage 1 – no impairment (normal function) – the resident does not

experience any memory problems.

2. Stage 2 – very mild cognitive decline (may be normal age–related

changes or earliest signs of Alzheimer’s disease) – the resident

may feel as if he or she is having memory lapses – forgetting

familiar words or the location of everyday objects.

3. Stage 3 – mild cognitive decline (early stage Alzheimer’s can be

diagnosed in some, but not all, individuals with these symptoms) –

friends, family or co–workers begin to notice difficulties.

a. Noticeable problems coming up with the right word or name.

b. Trouble remembering names when introduced to new

people.

c. Having noticeably greater difficulty performing tasks in social

or work settings.

d. Forgetting material that one has just read.

e. Losing or misplacing a valuable object.

f. Increasing trouble with planning or organizing.

4. Stage 4 – moderate cognitive decline (mild or early–stage

Alzheimer’s disease) – at this point, a careful medical interview

should be able to detect clear–cut symptoms in several areas:

a. Forgetfulness of recent events.

b. Impaired ability to perform challenging mental arithmetic –

for example, counting backward from 100 by 7s.

c. Greater difficulty performing complex tasks such as planning

dinner for guests, paying bills or managing finances.

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d. Forgetfulness about one’s own personal history.

e. Becoming moody or withdrawn, especially in socially or

mentally challenging situations.

5. Stage 5 – moderately severe cognitive decline (moderate or mid–

stage Alzheimer’s disease) – gaps in memory and thinking are

noticeable, and residents begin to need help with day–to–day

activities. At this stage, those with Alzheimer’s may:

a. Be unable to recall their address or telephone number or the

high school or college from which they graduated.

b. Become confused about where they are or what day it is.

6. Stage 6 – severe cognitive decline (moderately severe or mid–

stage Alzheimer’s disease) memories continues to worsen,

personality changes may take place and individuals need extensive

help with daily activities. At this stage, residents may:

a. Lose awareness of recent experiences as well as of their

surroundings.

b. Remember their own name but have difficulty with their

personal history.

c. Distinguish familiar and unfamiliar faces but have trouble

remembering the name of a spouse or caregiver.

d. Need help dressing properly and may, without supervision,

make mistakes such as putting pajamas over daytime

clothes or shoes on the wrong feet.

e. Experience major changes in sleep patterns – sleeping

during the day and becoming restless at night.

f. Need help handling details of toileting (for example, flushing

the toilet, wiping or disposing of tissue properly).

g. Having increasingly frequent trouble controlling their bladder

or bowels.

h. Experience major personality and behavioral changes,

including suspiciousness and delusions (such as believing

that their caregiver is an imposter) or compulsive, repetitive

behavior like hand– wringing or tissue shredding.

i. Tend to wander or become lost.

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7. Stage 7 – very severe cognitive decline (severe or late–stage

Alzheimer’s disease) – in the final stages of this disease, residents

lose the ability to respond to their environment, to carry on a

conversation and, eventually, to control movement. They may still

say words or phrases. At this stage, residents need help with much

of their daily personal care, including eating or using the toilet.

They may also lose the ability to smile, to sit without support and to

hold their heads up. Reflexes become abnormal. Muscles grow

rigid. Swallowing impaired.

II. Behaviors, Causes and Interventions

A. Agitation –could be caused by noise, other residents’ behaviors, pain,

thirst, or hunger, over/under stimulation, infection, need to toilet or be

cleaned etc.).

1. Remove trigger(s), if known.

2. Maintain calm environment.

3. Stay calm.

4. Assess basic needs.

5. Patting, stroking may/may not reassure resident.

6. Validate feelings.

B. Pacing/Wandering – could be stress or fear, searching for something or

someone, boredom, basic need not met, following past routine (mailman,

security officer), a need to exercise, resident has forgotten location of

room or chair, hungry, need to toilet, pain, etc.

1. Ensure resident is in a safe area.

2. Ensure resident is wearing appropriate footwear

3. Assess basic needs.

4. Validate feelings then redirect to another activity of interest if

resident appears tired and may become at risk for falls.

C. Elopement – may be evident through exit–seeking actions, verbalizing

wanting to leave, staying close/near doors, trying to open doors/windows.

1. Redirect and engage in other activities.

2. Ensure doors remain secured/alarms functional.

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3. Report missing resident immediately.

D. Hallucinations/Delusions – may be caused by acute illness or psychiatric

diagnosis/condition.

1. Ignore harmless hallucinations or delusions. A new onset of

hallucinations should be reported to M.D. to make sure there is not

a medical cause (illness).

2. Provide reassurance.

3. Do not argue.

4. Stay calm.

5. Validate feelings then redirect to activities or to another discussion.

6. Notify nurse of hallucination(s)/delusion(s).

E. Sundowning – as this occurs in the evening, consider need for increased

activities and/or staffing in the evening.

1. Remove trigger(s).

2. Avoid stress in environment.

3. Keep environment calm and quiet.

4. Reduce/remove caffeine from evening fluids/diet, if possible.

5. Validate feelings then Redirect; offer activity or favorite food.

F. Catastrophic Reaction – may be caused by fatigue or over stimulation.

1. Remove trigger(s), if possible.

2. Offer food or quiet activity.

3. Validate feelings then Redirect.

4. May be the result of abuse or neglect and it is reportable according

to law and regulations.

G. Repetitive Phrasing – may be caused by habit, sense of insecurity or

cognitive impairment. May be caused by the person trying to express a

specific concern, ask for help, or cope with frustration (self–soothing),

anxiety and insecurity or a habit.

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1. Be patient and calm.

2. Look for reason behind repetitive phrase/question.

3. Answer question.

4. Do not try to silence or stop.

5. Validate feelings then Redirect.

H. Violence – may be caused by delusion, hallucination, acute illness,

cognitive impairment, provocation by another resident, physical

discomfort, etc.

1. Step out of reach.

2. Block blows with open hand or forearm.

3. Do not strike back or grab resident.

4. Call for help.

5. Stay calm.

6. Identify triggers and remove, if possible.

7. Give the resident space.

8. Do not take resident’s actions personal.

I. Disruptive actions – may be caused by delusion, hallucination, acute

illness, cognitive impairment, provocation by another resident, physical

discomfort etc.

1. Remain calm.

2. Avoid treating like a child.

3. Gently direct to a private area, provide distraction or activity.

4. Explain procedure(s) or change in normal pattern.

5. Be reassuring.

J. Challenging Social Acts – may be caused by delusion, hallucination, acute

illness, cognitive impairment, provocation by another resident, physical

discomfort etc.

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1. Remain calm.

2. Identify trigger, if possible.

3. Gently redirect to private area.

4. Report physical or verbal abuse to the nurse.

K. Challenging Sexual Acts – may be provoked by a thought, visual, etc.

1. Do not over–react.

2. Be sensitive.

3. Try to redirect or relocate to a private area.

4. Ensure the safety of other residents, if potentially involved.

5. Report to nurse.

L. Pillaging/Hoarding – note that either activity is not stealing, rather, a

behavior often associated with a psychiatric diagnosis.

1. Label personal belongings of all residents.

2. Regularly check rooms for items which might belong to others.

3. Provide direction to resident’s own room (a visual cue could be

helpful).

4. Mark other residents’ room with symbols or labels to avoid

residents from entering.

III. Methods/Therapies to Reduce Behaviors

A. Validation Therapy – allowing the resident to express feelings and

emotions. Caregiver not only listens but acknowledges and respects the

resident’s thoughts/concerns.

B. Reminiscence Therapy – encouraging the resident to remember; to talk

about the past. Can be accomplished through communication, pictures,

music, smells, etc.

C. Activity Therapy – using activities that the resident enjoys to prevent

boredom and frustration.

D. Music Therapy – form of sensory stimulation; hearing familiar songs can

cause a response in residents that do not respond to other therapies.

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E. Re–direction – gently and calmly encouraging the resident to do a different

action; change focus of attention.

IV. Tips to Remember when Dealing with Cognitively Impaired Residents

A. Not personal – residents do not have control over words or actions.

B. Talk with family – learn about the resident’s life, names of family

members, occupation, hobbies, pets, foods, favorites.

C. Team work – report changes or observations; be flexible and patient.

D. Handle behaviors/situations as they occur – remember that the resident

has lost the ability to remember prior directions given.

E. Know your limits – watch for signs of stress, frustration and burnout.

V. Communication Strategies

A. Always identify yourself.

B. Speak slowly, calmly in a low tone.

C. Avoid loud, noisy environments.

D. Avoid startling or scaring; approach from the front, remain visible to the

resident.

E. Allow the resident to determine how close you should be.

F. Listen to resident; Validate feelings.

G. Avoid arguing.

H. Give visual clues.

I. Ensure your body language and facial expressions are appropriate.

VI. Techniques to Handle Difficult Behaviors

A. Anxiety/Fear

1. Stay calm, speak slowly.

2. Reduce noise or distractions.

3. Explain what you are doing.

4. Use simple words and short sentences.

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5. Watch your body language and ensure it is not threatening.

B. Forgetful/ Memory Loss

1. Repeat, using same words.

2. Give short simple instructions.

3. Answer questions with brief answers.

4. Watch tone, facial expressions and body language.

C. Unable to express needs

1. Ask to point or gesture.

2. Use pictures or written words.

3. Offer comfort if resident is becoming frustrated.

D. Unsafe or abusive language or activities

1. Avoid saying “don’t” or “no”.

2. Validate feeling then Redirect to another activity or discussion.

3. Remove hazard, if possible.

4. Don’t take the residents actions/words personally.

E. Depressed, lonely or crying.

1. Take time with resident; do not rush.

2. Really listen and provide comfort.

3. Try to involve in activities to redirect resident focus.

4. If continues or repeats, report to nurse.

VII. Behavior Interventions

A. Bathing

1. Schedule at time that resident is agreeable.

2. Be organized.

3. Explain what you are going to do in simple steps.

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4. Allow resident to assist as much as possible.

5. Take your time.

6. Provide privacy.

7. Make sure resident is not afraid of tub/shower.

8. Have resident assist, as able.

9. Maintain safety; do not leave alone.

10. Do not argue with resident; if upset, try again at another time.

B. Dressing

1. Encourage to choose what to wear.

2. Do not rush.

3. Provide privacy.

4. Use simple steps; short step–by–step directions.

5. Allow resident to assist.

6. Take time and be calm.

C. Toileting

1. Encourage fluids – lack of fluids can cause dehydration and

constipation.

2. Establish a toileting schedule; for example, take to bathroom every

2 hours.

3. Toilet before and after meals.

4. If incontinent – watch for patterns to determine resident routine for

a 2–3-day period (this is also effective for night time incontinence).

5. Identify bathroom with sign or picture.

6. Avoid dark or unlit bathrooms or hallways.

7. Check briefs frequently; change when soiled and observe skin.

8. Document/track bowel movements (constipation may cause

increase in behaviors).

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9. Document and report any changes in bowel/bladder patterns as it

could be a sign of infection/illness.

D. Eating/Meals

Helping with Nutrition:

Many people with Alzheimer’s have challenges with eating. An individual

might lose his/her appetite or the ability to evaluate if food is too hot or

cold. In addition, an individual might forget that he/she has eaten and ask

you for another meal.

The individual may be experiencing physical difficulties that are causing

the changes in eating habits. Sores in the mouth, poor–fitting dentures,

gum disease or dry mouth may make eating difficult. Individuals will lose

the ability to recognize and use utensils appropriately.

To ensure the individual with dementia is receiving the proper nutrition,

you must work to prevent eating and nutrition problems. Consult with the

individual’s physician and/or dietician for guidance.

1. Schedule meals at regular times.

2. Provide adequate lighting and space.

3. Avoid delays – have meal ready, i.e., pre–cut, opened cartons or

packages.

4. Watch temperatures – avoid very hot foods.

5. Simple (white) dishes, no extra items which could confuse resident.

6. Avoid overwhelming with too many different foods.

7. Give simple instructions.

8. If the resident needs to be fed, use slow, calm, relaxed approach.

9. Watch for chewing, swallowing or pocketing issues and report to

nurse. (Pocketing refers to holding food in the mouth, especially in

the cheeks.)

10. Ensure adequate fluid intake during meal.

E. Recreational Activities: Recreational activities are an important part of a

healthy life with dementia. The benefits include:

1. Improves eating and sleeping patterns.

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2. Lessens wandering, restlessness, anxiety.

3. Reduces complications with sun downing.

4. Improved socialization and cooperation.

5. Delays deterioration of skills.

6. Eases behavior management.

7. Source of pleasure and rewards.

* It is important to find activities that are meaningful and provide

success. Meaningful activities create a sense of usefulness and

accomplishment and promote self–esteem. To promote this, match

activities to the abilities and interests of the individual. Focus on

enjoyment, not achievement. Be sure to observe the individual’s

behavior during the activity to watch for signs of boredom or tiring.

Keep activities adult–like but you may have to use children’s

materials. Do a variety of activities to hold their interest. Alternate

active and passive activities.

1. Card games or board games

2. Reminiscing and memory stimulation

3. Music

4. Crafts and art projects

5. Outings

6. Gardening

7. Pets

8. Visits from others

9. Spiritual activities

VIII. Activity Chart

A. Waking Hours (low key)

1. Personal cares

2. Reading paper

3. Discussing day ahead

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4. Having a cup of coffee

5. Engaging in conversation

B. Early Morning (quiet)

1. Clipping coupons

2. Folding laundry

3. Winding yarn balls

4. Craft projects

C. Late Morning

1. Group exercises

2. Board Games

3. Meal prep– set table, pour milk

4. Outside Walks

5. Individual projects

D. Lunchtime/early afternoon

1. Eating and sharing

2. Resting/napping

3. Helping with serving and clean up

E. Midafternoon (active)

1. Physical game skills

2. Exercising/walking

3. Music: singing along, dancing, exercising

4. Crafts

5. Memory stimulation games

6. Cleaning house

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F. Late afternoon (quiet)

1. Reminiscing

2. Helping with meal prep

3. Checkers

4. Watering plants

G. Dinnertime

1. Meal prep, serve, clean up

2. Eating and sharing

H. Early evening (quiet)

1. Soothing music

2. Walking through neighborhood

3. Reminiscing

4. Evening cares– washing and dressing for bed

I. Other examples of useful activities

1. Polishing silverware

2. Sorting buttons

3. Putting coins into rolls

4. Shelling nuts

5. Folding and stuffing envelopes, stapling, applying labels

6. Dusting furniture, sweeping floor

7. Organizing closet/drawers

8. Washing and drying dishes

IX. Safety Checklist

A. Kitchen precautions. Proper storage of:

1. Knives, utensils, gadgets; toaster, grill, etc.

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2. Remove controls for stove, cover burners

3. Locks on fridge and cupboards

4. Cover for garbage disposal

B. Bathroom precautions. Proper storage of:

1. Shavers, blow dryers, cosmetics, medicines, etc.

2. Non–skid mats in tub/shower and on floor

3. Safety rails

4. Use shower chair

5. Monitor water temperature

C. Fall precautions:

1. Remove scatter rugs

2. Keep pathways clear of clutter

3. Adequate lighting, non–glare

4. Don’t move furniture around

5. Safety rails in halls, bathrooms, and stairways

6. Gates or locks to keep person out of unsafe areas

D. Visual aids:

1. Nightlights placed throughout home.

2. Cover doorknobs with cloth same color as the door; use childproof

knobs (personal home only).

3. Camouflage doors by painting them same color as the walls

(personal home only).

4. Use black tape or paint to create a two–foot black threshold in front

of the door (personal home only).

5. Place STOP sign on door to prevent entrance into restricted area.

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E. General:

1. Post emergency numbers by phone (numbers should be 1–5).

2. Lock doors and windows.

3. Cover outlets.

4. Working smoke detectors.

5. Hot water heater secured.

F. General. Proper storage of:

1. Chemicals: cleansers, pesticides, paint

2. Medications– childproof caps

3. Sharps: scissors, glass, knives

4. First aid supplies

5. Yard tools

X. Sleep Changes

A. Common sleep changes

Many people with Alzheimer’s experience changes in their sleep patterns.

Scientists do not completely understand why this happens. As with

changes in memory and behavior, sleep changes somehow result from

the impact of Alzheimer’s on the brain. Many older adults without

dementia also notice changes in their sleep, but these disturbances occur

more frequently and tend to be more severe in Alzheimer’s. There is

evidence that sleep changes are more common in later stages of the

disease, but some studies have also found them in early stages.

Sleep changes in Alzheimer’s may include:

1. Difficulty sleeping. Many people with Alzheimer’s wake up more

often and stay awake longer during the night. Brain wave studies

show decreases in both dreaming and non–dreaming sleep stages.

Those who cannot sleep may wander, be unable to lie still, or yell

or call out, disrupting the sleep of their caregivers.

2. Daytime napping and other shifts in the sleep–wake cycle.

Individuals may feel very drowsy during the day and then be unable

to sleep at night. They may become restless or agitated in the late

afternoon or early evening, an experience often called “sun–

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downing.” Experts estimate that in late stages of Alzheimer’s,

individuals spend about 40 percent of their time in bed at night

awake and a significant part of their daytime sleeping. In extreme

cases, people may have a complete reversal of the usual daytime

wakefulness–nighttime sleep pattern.

B. Contributing medical factors

A person experiencing sleep disturbances should have a thorough

medical exam to identify any treatable illnesses that may be contributing to

the problem. Examples of conditions that can make sleep problems worse

include:

1. Depression

2. Restless legs syndrome, a disorder in which unpleasant “crawling”

or “tingling” sensations in the legs cause an overwhelming urge to

move them.

3. Sleep apnea, an abnormal breathing pattern in which people briefly

stop breathing many times a night, resulting in poor sleep quality.

* For sleep changes due primarily to Alzheimer’s disease, there are

non–drug and drug approaches to treatment. Most experts and the

National Institutes of Health (NIH) strongly encourage use of non–

drug measures rather than medication.

* Studies have found that sleep medications generally do not

improve overall sleep quality for older adults. Use of sleep

medications is associated with a greater chance of falls and other

risks that may outweigh the benefits of treatment.

C. Non–drug treatments for sleep changes

Non–drug treatments aim to improve sleep routine and the sleeping

environment and reduce daytime napping. Non–drug coping strategies

should always be tried before medications, since some sleep medications

can cause serious side effects. To create an inviting sleeping environment

and promote rest for a person with Alzheimer’s:

1. Maintain regular times for meals and for going to bed and getting

up.

2. Seek morning sunlight exposure.

3. Encourage regular daily exercise, but no later than four hours

before bedtime.

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4. Avoid caffeine and nicotine.

5. Treat any pain. Be alert to verbal and non–verbal cues for pain.

6. Make sure the bedroom temperature is comfortable.

7. Provide nightlights and security objects.

8. If the person awakens, discourage staying in bed while awake; use

the bed only for sleep.

9. Discourage watching television during periods of wakefulness.

10. 12 Tips to promote Regular Sleep Patterns

a. Try keeping bedtime rituals consistent.

b. Go to bed at similar times each night.

c. Close blinds to demonstrate differences in light levels.

d. Keep lighting dim. Use night lights if there is a safety

problem or the dark promotes anxiety.

e. Relaxing in a bathtub or having a warm shower can promote

sleep.

f. A peaceful evening with less stimulation may encourage

sleep. Play any music softly, choose relaxing music, T.V.

programs.

g. A snack before bed may help. Hunger can wake and make a

person restless.

h. Restrict caffeine and excess intake of fluids before bedtime.

i. Use the bathroom before going to bed.

j. Restlessness during the night may be due to hunger, the

need to go to the bathroom, heat or cold, discomfort.

k. Discourage naps in the day. If a nap is important try to limit

the time.

l. Encourage exercise and stimulating activities in the day.

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Review Questions --- Lesson #25

1. Believing something that is not true, for example, that you are the

President, is considered a hallucination or a delusion?

2. Should a cognitively impaired resident leave the facility unattended and

that resident’s whereabouts is unknown to staff, it is called __________.

3. Allowing the resident to believe what he or she believes to be true, without

correcting or trying to bring the resident back to current reality is called

__________.

4. Behavioral change that occurs in the evening which may result in

challenging behavior that improves or disappears during the day is called

__________.

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Lesson #26 (1 hour, 15 minutes)

Title: Mental Health, Depression and Social Needs

Lesson Objectives:

I. The student will be able to describe interventions to use in response to

challenging or problematic resident behavior.

II. The student will be able to describe the difference between mental illness and

intellectual disability (mental retardation).

III. The student will be able to explain the importance of immediately reporting

challenging or problematic behavior to the nurse.

Key Terms:

Anxiety – uneasiness or fear of a situation or condition.

Apathy – lack of interest.

Bipolar Disorder – a psychiatric diagnosis that describes mood disorders defined by

the presence of one or more episodes of abnormally elevated energy levels, cognition,

and mood with or without one or more depressive episodes. The resident experiences

extreme highs and lows.

Claustrophobia – fear of having no escape and being closed in small spaces or rooms.

Defense Mechanisms – unconscious behaviors used to release tension or cope with

stress or uncomfortable, threatening situations or feelings.

Depression – a persistent feeling of sadness and loss of interest.

Intellectual Disability – a developmental disability that causes below average mental

functioning.

Manic Depression – fluctuation between deep depression to extreme activity, including

high energy, little sleep, big speeches, rapid mood changes, high self–esteem,

overspending and/or poor judgment.

Mental Health – level of cognitive or emotional well–being or an absence of a mental

disorder.

Mental Illness – disruption in a person’s ability to function at a normal level in a family,

home, or community, often producing inappropriate behaviors.

Obsessive Compulsive Disorder (OCD) – uncontrollable need to repeat or perform

actions in a repetitive or sequential manner.

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Panic Disorder – fearful, scared or terrified for no specific reason.

Paranoid Schizophrenia – a schizophrenic disorder in which the person has false

beliefs that somebody (or some people) are plotting against them.

Phobias – an extreme form of anxiety/fears.

Post–Traumatic Stress Disorder (PTSD) – anxiety related to a disorder caused by a

traumatic experience or event.

Psychotherapy – sessions with mental health professionals during which the resident

discusses problems or issues.

Psychotropic Medication – drugs taken which affect the mental state and are used to

treat mental disorders.

Schizophrenia – a complex mental disorder that makes it difficult to tell the difference

between real and unreal experiences, to think logically, and to behave normally in social

situations.

Content:

I. Causes of Mental Illness

A. Physical factors – illness, disability, aging, substance abuse or chemical

imbalance.

B. Environmental factors – weak interpersonal skills, weak family support,

traumatic experiences.

C. Heredity – possible inherited traits.

D. Stress – inability to handle or cope with stress.

II. Response to Behaviors

A. Remain calm.

B. Do not treat as a child.

C. Be aware of body language and facial expression.

D. Maintain a normal distance.

E. Use simple, clear language.

F. Avoid arguments.

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G. Maintain eye contact.

H. Listen carefully.

I. Show respect and concern.

III. Use of Defense Mechanisms – unconscious behaviors used to release tension or

cope with stress or uncomfortable, threatening situations or feelings.

A. Denial – rejection of a thought or feeling.

B. Projection – seeing feelings in others that are really one’s own.

C. Displacement – transferring a strong negative feeling to something or

someone else.

D. Rationalization – making excuses to justify a situation.

E. Repression – blocking painful thoughts or feelings from the mind.

F. Regression – going back to an old immature behavior.

IV. Types of Mental Illness

A. Anxiety related disorders

1. Anxiety – uneasiness or fear about a situation or condition that

cannot be controlled or relieved when the cause has been

removed.

2. Panic Disorders – fearful, scared or terrified for no specific reason.

3. Obsessive Compulsive Disorders – OCD – uncontrollable need to

repeat or perform actions in a repetitive or sequential manner.

4. Post–traumatic Stress Disorder – PTSD – anxiety related to a

traumatic experience.

5. Phobias – intense fear of certain things or situations.

6. Symptoms – sweating, dizziness, choking, dry mouth, racing heart,

fatigue, shakiness, muscle aches, cold or clammy feeling,

shortness of breath or difficulty breathing.

B. Depression

1. Clinical depression – depression ranges in seriousness from mild,

temporary episodes of sadness to severe, persistent depression.

The term “clinical depression” is used to describe the more severe

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form of depression also known as “major depression” or “major

depressive disorder”.

a. Clinical depression symptoms may include:

i. Depressed mood most of the day, nearly every day.

ii. Loss of interest or pleasure in most activities.

iii. Significant weight loss or gain.

iv. Sleeping too much or not being able to sleep nearly

every day.

v. Slowed thinking or movement that others can see.

vi. Fatigue or low energy nearly every day.

vii. Feelings of worthlessness or inappropriate guilt.

viii. Loss of concentration or indecisiveness.

ix. Recurring thoughts of death or suicide.

2. Bipolar Disorder – sometimes called manic–depressive disorder –

is associated with mood swings that range from the lows of

depression to the highs of mania. When the resident becomes

depressed, he/she may feel sad or hopeless and lose interest or

pleasure in most activities. When the resident’s mood shifts in the

other direction, he/she may feel euphoric and full of energy. Mood

shifts may occur only a few times a year, or as often as several

times a day.

3. Schizophrenia – brain disorder that affects a person’s ability to think

and communicate. It affects the way a person acts, thinks, and

sees the world.

a. Does not mean “split personality”.

b. Symptoms – delusions, hallucinations, thought disorder,

disorganized behavior, loss of interest in everyday activities,

appearing to lack emotion, reduced ability to plan or carry

out activities, neglect of personal hygiene, social withdrawal,

and loss of motivation.

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V. Behaviors Associated with Mental Disorders – actions and interventions

A. Combative

1. Actions – hitting, kicking, spitting, pinching, pushing, pulling hair,

and cursing.

2. Interventions – remain calm, don’t take personal, step out of way,

remove other residents, never strike back or respond verbally,

leave resident alone to de–escalate (calm)– but only if safe, report

to nurse.

B. Anger

1. Actions – shouting, yelling, threatening, throwing things, pacing,

withdrawal, sulking.

2. Interventions – remain calm, do not argue, try to understand what

triggered anger, empathize with resident, listen, stay at a safe

distance, explain what you are doing.

C. Sexual Behaviors

1. Actions – sexual advances, comments, sexual words or gestures,

removing clothing, inappropriate touching of self or others,

exposing body parts or masturbation.

2. Interventions – do not overreact; be “matter–of–fact” and try to

redirect; gently direct to private area, report to nurse, and maintain

safety of other residents.

3. Special consideration – check for possible explanation for behavior,

such as clothing not fitting, skin irritation, need for toileting,

remember to report all inappropriate sexual behavior to the nurse.

VI. Treatment for Mental Illness

A. Medications – numerous medications are available. Physician orders the

medication dependent on diagnosis and conditions that need to be

addressed. The nursing staff is responsible for monitoring and

administration of these medications.

B. Psychotherapy –sessions during which the residents discuss problems or

issues with mental health professionals in order to identify and address

problems and develop interventions for staff to follow when caring for the

resident.

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VII. Special Considerations

A. Talk of suicide or death – any verbalization of suicide, “death wish” or

self–inflicted injury, REPORT IMMEDIATELY.

B. Changes in conditions – any changes in mood, activity, eating, extreme

behaviors or reactions, more upset or excitable, withdrawn, hallucinations

or delusions. Report to nurse immediately.

VIII. Mental Illness and Intellectual Disability

A. Intellectual Disability– a developmental disability that causes below–

average mental functioning.

1. Intellectual Disability vs. Mental Illness:

a. Intellectual Disability is a permanent condition; mental illness

can be temporary.

b. Intellectual Disability is present at birth or early childhood;

mental illness can develop at any age.

c. Intellectual Disability affects mental ability; mental illness

may or may not affect mental function.

d. No cure for Intellectual Disability. Some mental illnesses can

be cured or controlled with treatment, such as medication or

therapy.

Review Questions --- Lesson #26

1. If a resident verbalizes thoughts of suicide or an intention to cause harm to

self, when should this be reported to the nurse?

2. If a resident starts kicking or hitting you, what actions should you take?

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Lesson #27 (1 hour, 15 minutes)

Title: Admission/Transfer/Discharge

Lesson Objectives:

I. The student will be able to explain the role of the direct caregiver in familiarizing

the newly-admitted resident to their new home.

II. The student will be able to explain the role of the direct caregiver in preparing a

resident for transfer to an appointment or to the hospital.

III. The student will be able to explain the role of the direct caregiver in assisting a

resident to discharge to home or to another health care facility.

Key Terms:

Admission – resident arrival to reside at the facility.

Discharge – resident departure from the facility; no longer a resident of the facility.

Personal Inventory Record – record of personal items brought to the facility and

belonging to the resident.

Transfer – resident relocates to another location or to another area of the facility (e.g.,

Medicaid to Medicare unit).

Room Change – resident moves to another room in the same facility with the same

status.

Content:

I. Admitting a New Resident to the Facility (See CARE SKILLS #77)

A. Role of the Nurse Aide

1. Prepare the room for the resident’s arrival.

2. Introduce self to resident and family/responsible party and explain

role.

3. Explain surroundings to resident, including the use of the call light

to communicate with staff, if needed.

4. Create a trusting relationship.

5. Be available to family.

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6. Become a resource and support for the family.

7. Refer family members requesting information about a resident to

the nurse.

II. Assisting to Transfer a Resident to a Hospital (i.e., Care Transition)

A. Role of the Nurse Aide

1. Follow any instructions given by the nurse to prepare the resident

for transfer, particularly if the transfer is for an emergent condition.

2. If resident is leaving for a non–emergent appointment, ensure that

the resident has received appropriate care, assistance with

grooming, toileting and is appropriately dressed for the weather

conditions during transport.

3. Assist emergency medical personnel, as requested, to ensure safe

transfer of the resident.

III. Assisting a Resident to Discharge Home or to Another Facility (see CARE SKILL

#78)

A. Role of the Nurse Aide

1. Follow instructions given by the nurse to prepare the resident for

discharge.

2. Assist to gather personal belongings, as requested, in preparation

for transfer/discharge, using the personal inventory as reference to

personal items on site.

CARE SKILLS:

• Admission of a Resident – #77

• Transfer/discharge of the Resident – #78

Review Questions --- Lesson #27

1. Describe ways to welcome a new resident to his/her new environment.

2. The list used to describe the resident’s belongings brought to the facility is

called the ______.

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Lesson #28 (1 hour, 15 minutes)

Title: End of Life

Lesson Objectives:

I. The student will be able to explain the resident’s right to formulate an advance

directive which must be honored by staff.

II. The student will be able to describe interventions to make the dying resident as

comfortable as possible.

III. The student will be able to demonstrate the steps to be taken to provide post

mortem care to the deceased resident and prepare belongings for disposition.

Key Terms:

Advance Directive – the resident’s spoken and/or written instruction about future

medical care and treatment.

Cheyne–Stokes – a pattern of breathing with gradual increase in depth and sometimes

in rate, followed by a decrease resulting in apnea (no breathing); the cycles ordinarily

are 30 seconds to 2 minutes in duration, with 5–30 seconds of apnea (no breathing).

Cyanotic – bluish discoloration of the skin, mucous membranes, lips or nails due to lack

of sufficient oxygen in the blood.

DNR (Do not resuscitate) – no heroic measures are to be taken should the resident’s

respirations cease.

Hospice – support services provided to a resident with a terminal illness who is

anticipated to have six months or less to live.

Mottling – the skin, especially on the hands and feet, appear blue and blotchy; caused

by slow blood circulation. The underside of the body may become darker. There may be

a bluish gray color around the mouth or paleness in the face.

Content:

I. Advance Directives

A. Purpose – by stating health care choices in an advance directive, the

resident helps his/her family and physician understand their wishes about

the resident’s medical care.

B. Advance directives are normally one or more documents that list the

resident’s health care instructions. An advance directive may name a

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person of choice to make health care choices when the resident cannot

make the choices for themselves. If desired, the resident may use an

advance directive to prevent certain people from making health care

decisions on their behalf.

C. An advance directive will not take away the resident’s right to decide

his/her current health care. As long as the resident is able to decide and

express their own decisions, the resident’s advance directive will not be

used. This is true even under the most serious medical conditions. An

advance directive will only be used when the resident is unable to

communicate or when the physician decides that the resident no longer

has the mental competence to make their own choices.

* Arkansas recognizes the following types of advance directives:

1. Talking directly to your physician and family.

2. Organ and tissue donation.

3. Health Care Representative.

4. Living Will Declaration or Life–Prolonging Procedures

Declaration.

5. Psychiatric Advance Directive.

6. Out of Hospital Do Not Resuscitate Declaration and Order.

7. Power of Attorney.

II. Role of Hospice

A. Participation – Resident is not expected to live more than six months.

B. Licensed nurse, clergy, social service and primary caregiver services may

be provided.

C. Focus is on comfort measures and pain management.

D. Preserves dignity, respect and choice.

E. Plan of care is to be coordinated between facility staff and hospice staff.

F. Offers empathy and support for the resident and the family.

III. Care of the Dying Resident

A. Place resident in most comfortable position for breathing and avoiding

pain. Maintain body alignment as much as possible.

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B. Bathe and groom resident as desired by the resident/family to promote

self-esteem, yet do not be disruptive.

C. Keep resident’s environment as normal as possible, as desired by the

resident.

D. Provide skin care, including back rubs/comfort measures, frequently.

E. Provide frequent oral care as needed. Keep dry/cracked lips lubricated for

comfort.

F. Offer fluids frequently.

G. Keep the resident’s skin/linens clean.

H. Offer resident’s favorite foods.

I. Communicate with the resident, even if he is not responsive, by identifying

self and explaining everything you are doing.

J. Be guided by the resident’s attitude.

K. Respect each resident’s idea of death and spiritual beliefs.

L. Give the resident and the family privacy, but do not isolate them.

IV. Signs/Symptoms of Impending Death

A. Circulation – slows as heart fails; extremities become cool; pulse becomes

rapid and weak.

B. Respiration – irregular, rapid and shallow or slow and heavy; Cheyne

Stokes.

C. Muscle tone – jaw may sag; body becomes limp; bodily functions slow and

become involuntary.

D. Senses – sensory perception declines; the resident may stare yet not

respond; hearing is believed to be the last sense to be lost.

V. Post Mortem Care (See CARE SKILLS #79)

A. Respect the family’s religious restrictions regarding care of the body, if

applicable.

B. Provide privacy and assist a roommate to leave the area until the body is

prepared and removed.

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C. Place the body in the supine position with one pillow under the head to

prevent facial discoloration.

D. Put in dentures. Notify nurse to remove any tubes or dressings.

E. Wash the body, as necessary, and comb hair.

F. Put on a clean gown and cover perineal area with a pad.

VI. Disposition of Personal Belongings

A. Assist the family/responsible party to gather personal belongings and

compare to the personal inventory record to ensure the personal

belongings of the resident are accounted for and returned to the

family/responsible party.

B. Send dentures, eyeglasses and prosthetic devices with the body to the

mortuary.

VII. Stages of Reaction to Dying:

A. DENIAL – denying that death will occur

1. Behaviors:

a. Unrealistically cheerful.

b. Ask lots of questions.

c. Disregard medical orders.

2. Response to this behavior:

a. Listen and be accepting.

b. Do not probe.

B. ANGER – anger that this is happening to me, and anger at others

because it is not happening to them

1. Behaviors:

a. Complaining.

b. Unreasonable requests.

c. Anger at family, doctor, and nursing staff.

2. Response to this behavior:

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a. Listen.

b. Remain open and calm.

c. Don’t try to place blame.

C. BARGAINING – trying to make an agreement for postponing death

1. Behaviors:

a. May be difficult to observe this stage.

b. Person vacillates between doubt and hope.

2. Response to this behavior:

a. Listen.

b. Do not contradict plans.

c. Promote a sense of hope.

D. DEPRESSION – reality of death is unavoidable; is a reaction to getting

sicker; and is grieving for the losses they will experience

1. Behaviors:

a. Turn face away from people.

b. Not speak or speaks in expressionless voice.

c. Separating self from the world.

2. Response to behaviors:

a. Stay with the person as much as is possible.

b. Avoid cheery phrases and behavior.

c. Encourage the person to express feelings.

E. ACCEPTANCE– realizes that death is inevitable.

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CARE SKILLS:

• Post Mortem Care – #79

Review Questions --- Lesson #28

1. Blue discoloration of the skin and mucous membranes is called what?

2. Hospice services are intended to provide support to the resident who is

anticipated to have six months or less to live. (True or False)

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Lesson #29 (45 minutes)

Title: Daily Responsibilities

Lesson Objectives:

I. The student will be able to explain the importance of prioritization, organization

and time management when providing daily care.

II. The student will be able to describe the importance of the interdisciplinary team

and the ongoing revision of the care plan based upon the resident’s changing

condition/needs.

Key Terms:

Abbreviation – a shortened form of a word.

Assignment sheet – a document which lists the residents assigned to a caregiver and

the specifics regarding care to be provided.

Care plan – a plan developed for each resident by the interdisciplinary team to achieve

certain goals.

Care team – people with different education and experience who help care for

residents. It is often called the “interdisciplinary team” or “IDT”.

Chronological order – the sequence in which events occur.

Content:

I. Day-to-day Time Management/Resident Care

A. Beginning of Shift Report.

B. Use of assignment sheets/communication of resident needs.

C. Ancillary duties/assignments (e.g., cleaning, stocking supplies, etc.).

D. Documentation/Flow Records.

1. Resident’s name on each page.

2. All entries in ink, neat and legible.

3. Entries are accurate and in chronological order as they occurred.

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4. Never document before a procedure is completed.

5. Use facility–approved abbreviations.

6. No ditto marks or copycat documentation.

7. Time and date entries; sign with name and title, unless initials are

acceptable per facility policy.

8. Never document for someone else.

9. If correcting an error, draw a single line through the error, print word

“error” above entry and initial and date the correction.

10. Some facilities may use military time. In this case, for the hours

between 1:00 p.m.to 11:59 p.m., add 12 to the regular time. For

example, to change 2:00 p.m. to military time, add 2 + 12. The time

would be 1400 hours.

11. Some facilities use computers/electronic medical records. When

using, make certain information seen on the screen remains

private. Do not share confidential information with anyone except

other caregivers on the team.

12. Be sure you are documenting on the correct resident.

E. Reporting

1. Routine reporting.

2. Immediate reporting of resident change in condition, unusual

occurrence, accident, etc. Failure to do so may be neglect under

the law.

F. End of Shift Report

1. Report pertinent concerns regarding resident status.

2. Communicate any duties unable to be completed on your shift.

3. Report any resident condition that will need the attention of the

oncoming shift (e.g., resident is on the bedpan, etc.).

II. Interdisciplinary Care Plan Meetings

A. Revisions of the plan of care/communication to direct caregivers

1. The Care Plan Team reviews the plan at least quarterly and with

any significant change in condition.

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2. The care plan is reviewed and revised to reflect the current

condition(s) and needs of the resident.

3. The care plan must be accessible for review by all caregivers.

4. When revisions are made to the care plan, the assignment sheet

used by direct care staff should also be updated accordingly.

Review Questions – Lesson #29

1. Explain the procedure for correcting an error in documentation.

2. Describe information that should be communicated to the oncoming shift

during report.

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Lesson #30 (45 minutes)

Title: Protecting Your Profession

Lesson Objectives:

I. The student will be able to describe the common causes of stress/burnout in the

healthcare industry.

II. The student will be able to describe abuse/neglect/misappropriation of resident

property and will be able to explain his/her responsibility to respond and report

any allegations of abuse/neglect/misappropriation of resident property.

III. The student will be able to explain the requirements for certification and renewal

to maintain professional status.

Key Terms:

Abuse – the willful infliction of injury, unreasonable confinement, intimidation, or

punishment with resulting physical harm, pain or mental anguish. Abuse can be verbal

(something said–oral, written or gestured), physical (something done to the resident–

rough handling, hitting, slapping, pinching, etc.), emotional/mental (humiliation,

harassment, threats of punishment or deprivation) or sexual (harassment, coercion or

sexual assault). Any sexual relationship with a resident is considered to be abuse.

Burnout – a condition of feeling stressed and/or overworked to the point that the care

provided to residents is negatively affected.

Catastrophic Event – are extraordinary reactions of residents to ordinary stimuli, such

as the attempt to provide care.

Consensual – agreed to by the people involved; done with the consent of the people

involved.

Involuntary Seclusion – a separation of a resident from other residents or from their

room or confinement against the resident’s will, or the will of the legal representative.

Neglect – failure to provide goods and services necessary to avoid physical harm,

mental anguish, or mental illness; failure to follow a prescribed order of treatment or the

care plan; Negligently failing to provide necessary treatment, rehabilitation, care, food

clothing, shelter, supervision , or medical services; Negligently failing to report health

problems or changes in health problems or changes in health condition of a resident to

the appropriate medical personnel, and failing to carry out a prescribed treatment plan

developed or implemented by the facility.

Misappropriation – the deliberate misplacement, exploitation, or wrongful, temporary

or permanent use of a resident’s belongings or money without the resident’s consent.

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Stress – the state of being frightened, excited, confused, in danger, or irritated, which

can result in an emotional and/or physical response.

Stressor – something that causes stress (divorce, marriage, new baby, new job, losing

a job, etc.).

Content:

I. Reducing Stress/Burnout

A. Manage stress

1. Develop healthy habits of diet and exercise.

2. Get sufficient rest/sleep.

3. Drink alcohol in moderation.

4. Do not smoke.

5. Find time for relaxing activities such as taking walks, reading

books, etc.

B. Signs that you are not managing stress

1. Exhibiting anger toward co–workers and/or residents.

2. Arguing with a supervisor or co–workers about assignments.

3. Complaining about responsibilities.

4. Feeling tired, even when you are well-rested.

5. Difficulty focusing on residents and job duties.

C. Develop a plan to manage stress.

1. Identify the sources of stress in your life.

2. Identify when you most often feel stress.

3. Identify what effects of stress are evident in your life.

4. Identify what can be changed to decrease the stress that you are

feeling.

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5. Identify the things in your life that you will have to learn to cope with

due to an inability to change them.

II. Abuse/Neglect/Misappropriation

A. Responsibility to immediately protect the resident should a staff member

witness abuse/neglect.

1. You must stay with the resident and call for assistance.

2. Ask a caregiver to leave the room if he/she is witnessed to be

abusive to the resident

B. Know the Arkansas state law and regulation regarding reporting abuse.

Failure to report is against the law in Arkansas.

1. To whom should the Nurse Aide report? His/her immediate/direct

supervisor

2. How should you report?

a. Verbally – to your immediate/direct supervisor.

b. In writing – if requested by your immediate/direct supervisor.

c. Form used – be familiar with the facility form to report

concerns voiced by staff, family or residents.

3. When should a Nurse Aide report?

a. Immediately!

4. The Nurse Aide Must Report When He/She…

a. Receives any “allegation”, witnessed event, or reason to

suspect abuse, neglect or theft.

b. Observe signs that “suggest” abuse or neglect may have

happened, including a change in the resident's

behavior/demeanor (e.g., a resident becomes quiet,

withdrawn, or flinches as if fearful when touched), or

suspicious injuries such as teeth marks, belt buckle or strap

marks, old and new bruises, dislocation, burns of unusual

shape and in unusual locations, scratches, etc. If the aide

hears of an alleged incident from a resident or co–worker

then it must be reported according to the law.

5. The nurse aide doesn’t make a determination that abuse or neglect

“has” or “has not” occurred and then decide whether to report. If the

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resident makes an allegation (even if it doesn’t seem that it can’t be

true) it must be reported to the direct supervisor immediately. If the

nurse aide hears of an alleged incident from a resident or co–

worker, it must be reported to the direct supervisor immediately.

6. NA Investigation

a. Conducted by the administrator or the designated

representative according to state regulations using the

investigative packet provided the Arkansas Office of Long

Term Care.

b. May result in revocation of certification.

III. Nurse Aide Testing/Certification

A. To Maintain Certification

1. The CNA must renew certification with the AR CNA Registry

according to the current regulations.

2. To be eligible for renewal, the CNA must work at least one 8-hour

shift as a CNA for pay during their certification period.

3. The CNA must not have a verified complaint against them on the

registry. If a complaint of abuse or misappropriation of resident’s

property/funds is found to be valid, the CNA will lose certification in

all 50 states permanently.

4. The CNA must not be disqualified to work based on DPSQA

Criminal Record Check guidelines.

5. The nurse aide must exhibit professional behavior.

a. Be responsible, calling the facility if unable to work the

scheduled shift.

b. Be on time for your scheduled shift.

c. Arrive to work clean and neatly dressed and groomed.

d. Maintain a positive attitude.

e. Follow facility policies and procedures.

f. Document and report carefully and correctly.

g. Always ask questions, if uncertain.

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h. Report anything that keeps you from completing your

duties/assignment.

i. Offer suggestions for improving the living and working

environment.

IV. Certification Renewal

A. The CNA must renew certification with the AR CNA Registry every other

year.

1. Renewals can be processed online by the CNA, or by submitting

the renewal application to the AR Registry through the mail.

2. Renewals can be submitted and processed up to 60 days prior to

the expiration of the certificate.

3. CNAs who do not renew within the 24-month grace period, or those

who do not work during their certification period, are required to

take the State competency exam in order to have their certification

reinstated.

V. Course Review

A. Brief overview of each lesson.

B. Review of CARE SKILLS.

Review Questions – Lesson #30

1. Name common signs of stress and burnout in the healthcare industry.

2. What is the minimum work requirement for a CNA to maintain

certification?

Page 193 of 307

Works Cited

Alzheimer’s Association. (c2018). Wandering. Retrieved from https://www.alz.org/help-

support/caregiving/stages-behaviors/wandering.

Alzheimer’s Association. (c2018). Stages and behaviors. Retrieved from

https://www.alz.org/help-support/caregiving/stages-behaviors.

Alzheimer’s Foundation of America. (c2018). About Dementia. Retrieved from

https://alzfdn.org/about-dementia/.

Arkansas State Board of Nursing. (2018). Nurse practice act of the state of Arkansas.

Little Rock, AR: ARSBN. Retrieved from

https://www.arsbn.org/Websites/arsbn/images/NURSEPRACTICEACT_2018.February2

018.pdf.

Frank Broyles and the University of Arkansas Board of Trustees. (2006). Coach broyles’

playbook for alzheimer’s caregivers: A practical tips guide. Fayetteville, AR: Broyles

Foundation.

Centers for Medicare & Medicaid Services. (2017). Guidance to surveyors for long term

care facilities. State Operations Manual, Appendix PP. Retrieved from

https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.

Fazio, S., Pace, D., Maslow, K., Zimmerman, S., & Kallmyer, B. (2018). Alzheimer’s

Association Dementia Care Practice Recommendations. The Gerontologist, 58(S1),

S1–S9. doi: 10.1093/geront/gnx182

Fazio, S., Pace, D., Maslow, K., Zimmerman, S., & Kallmyer, B. (2018). The

Fundamentals of Person-Centered Care for Individuals With Dementia. The

Gerontologist, 58(S1), S10–S19. doi: 10.1093/geront/gnx122

Kandelman, N. (2017). Risk factors for burnout among caregivers working in nursing

homes. Journal of Clinical Nursing, 27(1-2), e147-e153. doi: 10.1111/jocn.13891

Mangar Health. (2016, October 20). The prevention of pressure ulcers. Retrieved from

https://mangarhealth.com/us/news/prevention-pressure-ulcers.

Manthorpe, J., & Samsi, K. (2016). Person-centered dementia care: current

perspectives. Clinical Interventions in Aging, 11, 1733–1740. doi: 10.2147/CIA.S104618

Power, A. (2010). Dementia Beyond Drugs: Changing the Culture of Care. Baltimore,

MD: Health Professions Press.

Power, A. (2014). Dementia Beyond Disease: Enhancing Well-Being. Baltimore, MD:

Health Professions Press.

Page 194 of 307

Sorrentino, S. A. & Gorek, B. (2014). Mosby’s Essentials for Nursing Assistants (5th

ed.). St. Louis, MO: Elsevier, Inc.

United States Health and Human Services, Food and Drug Administration, Center for

Devices and Radiological Health. (2006). Guidance for Industry and FDA Staff: Hospital

Bed System Dimensional and Assessment Guidance to Reduce Entrapment. Rockville,

MD: Division of Dockets Management, Food and Drug Administration. Retrieved from

https://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidance

documents/ucm072729.pdf.

University of Arkansas for Medical Sciences, Donald W. Reynolds Department of

Geriatrics. (2005). Dementia Care Manual. Little Rock, AR: UAMS.

University of Arkansas for Medical Sciences, Department of Psychiatry. (2001).

Behavioral Interventions Pocket Reference. Little Rock, AR: UAMS.

Woodhead, E. L., Northrop, L., & Edelstein, B. (2016). Stress, social support, and

burnout among long-term care nursing staff. Journal of Applied Gerontology, 35(1), 84-

105. doi: 10.1177/0733464814542465.

Page 195 of 307

Appendix A

Supplemental Materials

Page 196 of 307

ZONES/AREAS OF POTENTIAL BED ENTRAPMENT

https://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidance

documents/ucm072729.pdf

Page 197 of 307

Stage 1:

The skin is not broken. Redness that is not relieved within 15-30 minutes of pressure

being removed. Skin can be warmer than in other areas.

Stage 2:

Top layer of skin is broken. Blister or shallow sore can be seen. Second layer of skin

can be affected. Affected area is usually painful.

Stage 3:

Wound is deeper and may extend into the subcutaneous layer.

Stage 4:

Wound extends to muscle or bone, causing severe damage to the affected areas.

https://mangarhealth.com/us/news/prevention-pressure-ulcers

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COMMON MEDICAL ABBREVIATIONS

Time Abbreviations

a.m. -morning stat -immediately

p.m. -afternoon or evening noc -night

a.c. -before meals P.R.N. -whenever necessary

p.c. -after meals q.d. -every day

B.I.D. -twice a day q.h. -every hour

T.I.D. -three times a day q.o.d. -every other day

Q.I.D. -four times a day q3h -every three hours

H.S. -bedtime (hour of sleep) q4h -every four hours

Resident Orders

amt -amount NPO -Nothing by mouth

ax -axilla (sometimes NBM)

BM -bowel movement P.T. -physical therapy

BRP -bathroom privileges R -rectal or right

c -with ROM -range of motion

s -without spec. -specimen

ad lib -as desired DC -discontinued

ht -height w/c -wheelchair

wt -weight TPR -temperature, pulse,

I&O -Intake and Output respiration

ADL -activities of daily living BP -blood pressure

V.S. -vital signs (TPR & BP)

Diagnostic Terms

MI -Myocardial Infarction GI -gastro intestinal

(heart attack) or Mental Illness GU -genito-urinary

CVA -cerebrovascular accident or stroke CHF -congestive heart failure

H.O.H. -hard of hearing Ca -cancer

S.O.B. -short of breath CV -cardiovascular

fx -fracture

Page 199 of 307

Appendix B

Answers to Review Questions

Page 200 of 307

Lesson #1

1. The licensed nurse.

2. An objective observation is factually seen, heard, felt or smelled by the person

reporting; a subjective observation is what one “thinks” or “heard” happened from

someone else.

3. Time to get dressed in the morning; whether to shower or bathe in a tub; what

time to go to bed in the evening.

Lesson #2

1. Examine survey results, voice grievances, self–administer medications.

2. The caregiver must immediately report signs/symptoms of abuse, neglect or

misappropriation.

3. Verbal, physical, emotional/ mental, sexual, neglect, involuntary seclusion,

misappropriation.

4. Leaving a resident in bed soiled. Leaving the call light or water out of resident

reach.

5. Using a resident’s personal telephone to make calls. Taking a resident’s money

or personal belongings.

6. Report it immediately. Follow your facility’s policies and procedures for reporting

abuse.

Lesson #3

1. Causative Agent, Reservoir, Portal of Exit, Mode of Transmission, Portal of Entry,

Susceptible Host.

2. Handwashing.

3. Before resident/patient contact, before aseptic task, after exposure to blood/body

fluids, after resident/patient contact, after contact with resident/patient

surroundings.

4. Proper usage will provide a barrier between the caregiver and the pathogen,

thus, preventing the spread of infection.

5. Touching an infected person and then proceeding to touch another person

without washing one’s hands.

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6. Touching a contaminated object and then proceeding to touch a person without

washing one’s hands.

7. No.

Lesson #4

1. Remove residents from area of immediate danger; Activate the fire alarm;

Contain the fire, if possible (close doors); Extinguish, if possible.

2. Pull the pin; Aim at the base of the fire; Squeeze the handle; Sweep back and

forth at the base of the fire.

3. Stop, drop and roll to smother the flames.

Lesson #5

1. Clutching throat (hands around throat).

2. Material Safety Data Sheet.

3. Call/notify nurse; stay with resident; position resident on side; move furniture

away from resident; place padding under head; loosen clothing; check for injury;

note duration and areas involved; do NOT place anything in mouth; do NOT

restrain resident.

Lesson #6

1. True.

2. True.

3. Water.

4. Nectar thick, honey thick, and pudding thick.

Lesson #7

1. True.

2. True.

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Lesson #8

1. False.

2. True.

3. True.

Lesson #9

1. True.

2. False.

Lesson #10

1. Cold/clammy skin, double or blurry vision, shaking/trembling, hunger, tingling or

numbness of skin.

2. True.

Lesson #11

1. True.

2. True.

Lesson #12

1. Female: Separate labia; wash urethral area first; wash between and outside

labia in downward strokes, alternating from side to side and moving outward to

thighs. Use a different part of washcloth for each stroke.

Male: Pull back foreskin if male is uncircumcised. Wash and rinse the tip of the

penis using circular motion beginning with urethra. Continue washing down the

penis to the scrotum and inner thighs.

Rationale/Importance: Prevents the spread of infection by washing pathogens

away from the urethra and not toward the urethra where pathogens could enter.

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Lesson #13

1. Irritation, raised areas, coated or swollen tongue, sores, complaint of mouth pain,

white spots, loose/chipped or decayed teeth.

2. Due to poor circulation, even a small sore on the foot can become a large wound.

Lesson #14

1. A clean catch mid–stream requires that genitalia be cleansed prior to collecting

the urine specimen.

2. True.

Lesson #15

1. The resident’s shoulders are directly above their hips; their head and neck are

straight; their arms and legs are in a natural position.

2. Supine, Lateral, Fowler’s and Semi–Fowler’s.

3. Semi–Fowler’s.

4. Less.

5. False.

Lesson #16

1. False.

Lesson #17

1. Dry mouth, weight loss, foul smelling urine, dark urine, cracked lips and sunken

eyes.

2. True.

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Lesson #18

1. True.

2. True.

3. True.

Lesson #19

1. False.

2. On the side she will be facing – her left.

Lesson #20

1. 60 – 100 beats per minute.

2. The average BP range for adults is systolic blood pressure: 90–139; Normal

range for Diastolic blood pressure is 60–89. However, baseline ranges vary from

person to person.

3. Place your hand on the resident’s chest and feel the chest rise and fall during

breathing.

Lesson #21

1. True.

2. At least once every hour and more frequently if the resident’s condition requires.

3. At least every two hours, or more often if necessary except when the resident is

asleep.

Lesson #22

1. Active range of motion exercises are done by the resident himself; Passive range

of motion exercises are done by caregivers providing support and moving the

resident’s joints through the range of motion when the resident cannot move on

their own.

2. Contractures.

3. Restorative Services.

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Lesson #23

1. Redness, warmth, tenderness, open area.

2. True.

3. True.

Lesson #24

1. Change in vital signs – B/P, pulse, respiration, nausea, vomiting, sweating,

tearful or frowning, sighing, moaning or groaning, breathing heavy or shortness

of breath, restless or having difficulty moving, holding or rubbing a body part,

tightening jaw or grinding teeth.

2. Medication administration, such as antibiotics, nutrition administration, hydration,

blood products, solutions are administered by gravity or through a portable pump.

3. Fear of addiction to pain medication, feeling caregivers are too busy to deal with

pain, fear pain medication will cause other problems, i.e., drowsiness,

sleepiness, constipation.

Lesson #25

1. A delusion – a fixed, false belief.

2. An elopement.

3. Validation Therapy.

4. Sundowning.

Lesson #26

1. Immediately.

2. Remain calm, step out of the way, remove other residents, never strike back or

respond verbally, leave the resident alone to calm down (if safe) and report the

behaviors to the nurse immediately.

Lesson #27

1. Prepare the room for the resident’s arrival; introduce self to resident and

family/responsible party and explain role; explain surroundings to resident,

including use of call light to summon help, if needed; create a trusting

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relationship; be available to family; become a resource and support for the family;

refer family members requesting information about a resident to the nurse.

2. Personal inventory record.

Lesson #28

1. Cyanosis.

2. True.

Lesson #29

1. Draw a single line through the error, print word “error” above entry and initial and

date the correction.

2. Report any resident condition that will need the attention of the oncoming shift

(e.g., resident is on the bedpan, etc.)

Lesson #30

1. Exhibiting anger toward co–workers and/or residents; arguing with a supervisor

or co-workers about assignments; complaining about responsibilities; feeling

tired, even when you are well rested; difficulty focusing on residents and job

duties.

2. The CNA must work at least one 8-hour shift as a CNA for pay during their

certification period

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Appendix C

Care Skills

Page 208 of 307

1. Initial Steps

2. Final Steps

3. Handwashing/Hand rub

4. Gloves

5. Gown (PPE)

6. Mask

7. Fire

8. Fire Extinguisher

9. Falling or Fainting

10. Choking

11. Seizures

12. Unoccupied Bed

13. Thickened Liquids

14. Measure and Record Fluid Intake/Urinary Output

15. Passing Fresh Ice Water

16. Serving Meal Tray

17. Nasal Cannula Care

18. Shower/Shampoo

19. Bed Bath/Catheter Care/Perineal Care

20. Back Rub

21. Shampoo Hair in Bed

22. Whirlpool

23. Oral Care

24. Oral Care for the Unconscious Resident

25. Denture Care

26. Shaving with an Electric Razor

27. Shaving with a Safety Razor

28. Comb/Brush Hair

29. Fingernail Care

30. Foot Care

31. Change a Resident’s Gown

32. Dressing a Dependent Resident

33. Assist to Bathroom

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34. Bedside Commode

35. Bedpan/Fracture Bedpan

36. Urinal

37. Empty Urinary Drainage Bag

38. Urine Specimen Collection

39. Stool Specimen Collection

40. Application of Incontinent Brief

41. Assist Resident to Move to Head of Bed

42. Supine Position

43. Lateral Position & Side to Side

44. Fowler’s Position

45. Semi-Fowler’s Position

46. Use of Wheelchair/Geriatric Chair

47. Transfer to Chair

48. Sit on Edge of Bed

49. Using a Gait Belt to Assist with Ambulation

50. Walking

51. Assist with Walker

52. Assist with Cane

53. Using a Portable Mechanical Resident Lift

54. Transfer to Stretcher/Shower Bed

55. Transfer: Two Person Lift

56. Occupied Bed

57. Inspecting Skin

58. Float Heels

59. Bed Cradle

60. Feeding

61. Oral Temperature (Electronic)

62. Axillary Temperature

63. Pulse and Respiration

64. Practical Use of the Pulse Oximeter

65. Blood Pressure

66. Height

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67. Weight

68. Application of Physical Restraints

69. Passive Range of Motion

70. Splint Application

71. Abdominal Binder

72. Abduction Pillow

73. Knee Immobilizer

74. Palm Cones

75. Assisting with Hearing Aids

76. Elastic/Compression Stocking Application or Ted Hose

77. Admission of a Resident

78. Transfer/Discharge of the Resident

79. Postmortem Care

Page 211 of 307

CARE SKILLS #1: INITIAL STEPS (Lesson #2)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Ask nurse about resident’s needs, abilities

and limitations, if necessary and gather

necessary supplies.

1. Prepares you to provide best possible care

to resident.

2. Knock and identify yourself before entering

the resident’s room. Wait for permission to

enter the resident’s room.

2. Maintains resident’s right to privacy.

3. Greet resident by name per resident’s

preference.

3. Shows respect for resident.

4. Identify yourself by name and title. 4. Resident has right to know identity and

qualifications of their caregiver.

5. Explain what you will be doing; encourage

resident to help as able.

5. Promotes understanding and

independence.

6. Gather supplies and check equipment. 6. Organizes work and provides for safety.

7. Close curtains, drapes and doors. Keep

resident covered, expose only area of

resident’s body necessary to complete

procedure.

7. Maintains resident’s right to privacy and

dignity.

8. Wash your hands. 8. Provides for Infection Control.

9. Wear gloves as indicated by Standard

Precautions.

9. Protects you from contamination by bodily

fluids.

10. Use proper body mechanics. Raise bed

to appropriate height and lower side rails (if

raised).

10. Protects yourself and the resident from

injury.

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CARE SKILLS #2: FINAL STEPS (Lesson #2)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Remove gloves, if applicable, and wash

your hands.

1. Provides for Infection Control.

2. Be certain resident is comfortable and in

good body alignment. Use proper body

mechanics.

2. Reduces stress and improves resident’s

comfort and sense of well–being.

3. Lower bed height and position side rails (if

used) as appropriate.

3. Provides for safety.

4. Place call light and water within resident’s

reach.

4. Allows resident to communicate with staff

as necessary and encourages hydration.

5. Ask resident if anything else is needed. 5. Encourages resident to express needs.

6. Thank resident. 6. Shows your respect toward resident.

7. Remove supplies and clean equipment

according to facility procedure.

7. Facilities have different methods of

disposal and sanitation. You will carry out

the policies of your facility.

8. Open curtains, drapes and door according

to resident’s wishes.

8. Provides resident with right to choose.

9. Perform a visual safety check of resident

and environment.

9. Prevents injury to you and resident.

10. Report unexpected findings to nurse. 10. Provides nurse with necessary

information to properly assess resident’s

condition and needs.

11. Document procedures according to

facility procedure.

11. What you document is a legal record of

what you did. If you don’t document it, legally,

it didn’t happen.

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CARE SKILLS #3: HANDWASHING/HAND RUB (Lesson #3)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

Wash hands when visibly soiled or prior to

giving care.

1. Handwashing is the single most effective

barrier to transmission of bacteria.

1. Turn on faucet.

2. Adjust water to acceptable temperature. 3. Hot water opens pores which may cause

irritation.

3. Angle arms down holding hands lower than

elbows. Wet hands and wrists.

4. Water should run from most clean to most

soiled.

4. Apply enough soap to cover all hand and

wrist surfaces. Work up a lather.

NOTE: Direct caregivers must rub hands

together vigorously for at least 20 seconds,

covering all surfaces of the hands, fingers

and wrists.

5. Use friction to distribute soap and create

lather cleansing front and back of hands,

between fingers, around cuticles, under nails,

and on wrists.

5. Lather and friction will loosen pathogens to

be rinsed away.

6. Rinse hands with water down from wrists

to fingertips.

6. Soap left on the skin may cause irritation

and rashes.

7. Dry thoroughly with single use towels.

8. Use towel to turn off faucet and discard

towel.

8. Prevents contamination of clean hands.

How to Use Hand Rub:

9. Apply a quarter size amount of the product

in a cupped hand.

9. Refer to label for estimated amount of

product to be placed in palm.

10. Rub hands together to distribute product

on front and back of hands, between fingers,

around cuticles, under nails, and on wrists.

10. Thorough application will reach all

surfaces of concern.

11. Allows hands to dry. Waterless hand rubs

must be rubbed for at least 10 seconds or

until dry to be effective.

11. The product must be dry to be effective.

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CARE SKILLS #4: GLOVES (Lesson #3)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Wash hands.

2. Put gloves on, one hand at a time.

3. Interlace fingers to secure gloves for a

comfortable fit.

4. Check for tears/holes and replace glove, if

necessary.

4. Damaged gloves do not protect you or the

resident.

5. If wearing a gown, pull the cuff of the

gloves over the sleeves of the gown.

5. Covers exposed skin of wrists.

6. Perform procedure.

7. Remove first glove by grasping outer

surface of other glove, just below cuff and

pulling down.

7. Both gloves are contaminated and should

not touch unprotected skin.

8. Pull glove off so that it is inside out. 8. The soiled part of the glove is then

concealed.

9. Hold the removed glove in a ball of the

palm of your gloved hand. Do not dangle the

glove downward.

9. To ensure the first glove goes into the

second glove.

10. Place two fingers of ungloved hand under

cuff of other glove and pull down so first

glove is inside second glove.

10. Touching the outside of the glove with an

ungloved hand causes contamination.

11. Dispose of gloves without touching

outside of gloves and contaminating hands.

11. Hands may be contaminated if gloves are

rolled or moved from hand to hand.

12. Wash hands.

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CARE SKILLS #5: GOWN [Personal Protective Equipment] (Lesson #3)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Wash your hands.

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

Let the clean gown unfold without touching

any surface.

2. Prevents contamination of the gown.

3. Slip your hands and arms through the

sleeves and pull the gown on.

4. Tie neck ties in a bow. 4. They can easily be un–tied later.

5. Overlap back of the gown and tie waist

ties.

5. Ensures that your uniform is completely

covered.

6. If gloves are required, put them on last.

7. Perform procedure.

8. Remove gloves.

9. Remove goggles and/or face shield.

10. Untie or break the waist ties.

11. Untie or break the neck ties.

12. Pull the sleeve off by grasping each

shoulder at the neckline and turn the sleeves

inside out as you remove them from your

arms.

12. Not touching the outside surface of the

gown with your bare hands prevents

contamination. The back of the gown should

not be soiled.

13. Fold gown with clean side out and place

in laundry or discard if disposable.

13. Gowns are for one use only. They must

be either discarded or laundered after each

use.

14. Wash your hands.

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CARE SKILLS #6: MASK (Lesson #3)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Wash your hands.

2. Place upper edge of the mask over the

bridge of your nose and tie the upper ties. If

mask has elastic bands, wrap the bands

around the back of your head and ensure

they are secure.

2. Your nose should be completely covered.

3. Place the lower edge of the mask under

your chin and tie the lower ties at the nape of

your neck.

3. Your mouth should be completely covered.

4. If the mask has a metal strip in the upper

edge, form it to your nose.

4. This will prevent droplets from entering the

area beneath the mask.

5. Perform procedure.

6. If the mask becomes damp or if the

procedure takes more than 30 minutes, you

must change your mask.

6. Dampness of the mask will reduce its

ability to protect you from pathogens. The

effectiveness of the mask as a barrier is

greatly diminished after 30 minutes.

7. If wearing gloves, remove them first. 7. This will prevent contamination of the

areas you will touch when untying the mask.

8. Wash your hands.

9. Untie each set of ties and discard the mask

by touching only the ties. Masks are

appropriate for one use only.

9. Hands may be contaminated if you touch

an area other than the ties. Masks must be

discarded after each use.

10. Wash your hands.

Page 217 of 307

CARE SKILLS #7: FIRE (Lesson #4)

STEP RATIONALE

1. Remove residents from area of immediate

danger.

1. Residents may be confused, frightened or

unable to help themselves.

2. Activate fire alarm. 2. Alerts entire facility of danger.

3. Close doors and windows to contain fire. 3. Prevents drafts that could spread fire.

4. Extinguish fire with fire extinguisher, if

possible.

4. Prevents fire from spreading.

5. Follow all facility policies. 5. Facilities have different methods of

responding to emergencies. You need to

follow the procedures for your facility.

Page 218 of 307

CARE SKILLS #8: FIRE EXTINGUISHER (Lesson #4)

STEP RATIONALE

1. Pull the pin. 1. Allows the extinguisher to be functional.

2. Aim at the base of the fire. 2. Targets the source of the flames, which

should be found at the base.

3. Squeeze the handle. 3. Releases the chemical(s) to extinguish the

fire.

4. Sweep back and forth at the base of the

fire.

4. Fully extinguishes the source of the fire.

CARE SKILLS #9: FALLING OR FAINTING

(Lesson #5)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Call for nurse and stay with resident. 1. Allows you to get help, yet continuously

provide for resident’s safety and comfort.

2. Check if resident is breathing. 2. Provides you with information necessary to

proceed with procedure.

3. Do not move resident. Leave in same

position until the nurse examines the

resident.

3. Prevents further damage if resident is

injured.

4. Talk to resident in calm and supportive

manner.

4. Reassures resident.

5. Apply direct pressure to any bleeding area

with a clean piece of linen.

5. Slows or stops bleeding.

6. Take pulse and respiration. 6. Provides nurse with necessary information

to properly assess resident’s condition and

needs.

7. Assist nurse as directed. Check resident

frequently according to facility policy and

procedures. Assist in documentation.

Page 219 of 307

CARE SKILLS #10: CHOKING (Lesson #5)

STEP RATIONALE

1. Call for nurse and stay with resident. 1. Allows you to get help, yet continuously

provide for resident’s safety and comfort.

2. Ask if resident can speak or cough. 2. Identifies sign of blocked airway (not being

able to speak or cough).

3. If not able to speak or cough, move behind

resident and slide arms under resident’s

armpits.

3. Puts you in correct position to perform

procedure.

4. Place your fist with thumb side against

abdomen midway between waist and ribcage.

4. Positions fist for maximum pressure with

least chance of injury to resident.

5. Grasp your fist with your other hand. 5. Allows you to stabilize resident and apply

balanced pressure.

6. Press your fist into abdomen with quick

inward and upward thrust.

6. Forces air from lungs to dislodge object.

7. Repeat until object is expelled.

8. Assist with documentation.

* Note: Discuss and demonstrate administering abdominal thrust for an unconscious

resident or for someone who is lying down.

Page 220 of 307

CARE SKILLS #11: SEIZURES (Lesson #5)

STEP RATIONALE

1. Call for nurse and stay with resident. 1. Allows you to get help, yet continuously

provide for resident’s safety and comfort.

2. Place padding under head and move

furniture away from resident.

2. Protects resident from injury.

3. Do not restrain resident or place anything

in mouth. Assist nurse with placing resident

on his/her side.

3. Any restriction may injure resident during

seizure. Positioning resident on his/her side

prevents choking if the resident should vomit.

4. Loosen resident’s clothing especially

around neck.

4. Prevents injury or choking.

5. Note duration of seizure and areas

involved.

5. Provides nurse with necessary information

to properly assess resident’s condition and

needs.

Page 221 of 307

CARE SKILLS #12: UNOCCUPIED BED (Lesson #6)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Collect clean linen in order of use. 2. Organizing linen allows procedure to be

completed faster.

3. Carry linen away from your uniform. 3. If linen touches your uniform, it becomes

contaminated.

4. Place linen on clean surface (bedside

stand, over bed table or back of chair).

4. Prevents contamination of linen.

5. Place bed in flat position. 5. Allows you to make a neat, wrinkle free

bed.

6. Loosen soiled linen. Roll linen from head

to foot of bed and place in barrel at door of

room or in bag or pillow case and place at

foot of bed or chair.

6. Always work from cleanest (head of bed) to

dirtiest (foot of bed) to prevent spread of

infection. Rolling dirtiest surface of linen

inward, lessening contamination.

7. Fanfold bottom sheet to center of bed and

fit corners.

8. Fanfold top sheet to center of bed.

9. Fanfold blanket over top sheet.

10. Tuck top linen under foot of mattress and

miter corner.

10. Mitering prevents resident’s feet from

being restricted by or tangled in linen when

getting in or out of bed.

11. Move to other side of bed. 11. Completing one side of bed at a time

allows procedure to be completed faster and

reduces strain on the caregiver.

12. Fit corners of bottom sheet, unfold top

linen, tuck it under foot of mattress, and miter

corner.

13. Fold top of sheet over blanket to make

cuff.

14. With one hand, grasp the clean pillow

case at the closed end, turning it inside out

over your wrist.

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15. Using the same hand that has the pillow

case over it, grasp one narrow edge of the

pillow and pull the pillow case over it with

your free hand.

16. Place the pillow at head of bed with open

edge away from the door.

16. Creates a neater, more uniform look to

rooms and beds.

17. For open bed: make toe pleat and fanfold

top linen to foot of bed with top edge closest

to center of bed.

17. Top edge of top linen must be closest to

head of bed so resident can easily reach

covers.

18. For closed bed: pull bedspread over

pillow and tuck bedspread under lower edge

of pillow.

18. Toe pleat automatically reduces pressure

of top linen on feet when resident returns to

bed.

19. Removed soiled linens. 19. Prevents contamination.

20. Do final steps.

Page 223 of 307

CARE SKILLS #13: THICKENED LIQUIDS (Lesson #6)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Obtain thickener and measuring spoon. 2. Measuring spoon is required to ensure

proper amount of thickener is utilized to

obtain ordered thickness. Follow your facility

policy for thickening liquids.

3. Thicken liquids to desired consistency

following manufacturer’s instructions.

3. Physician will specify thickness. Various

brands of thickener require different amounts

of product to be added.

4. Offer thickened fluid to resident.

Encourage resident to consume thickened

fluids.

4. Decreases risk of resident becoming

dehydrated.

5. Ensure the water pitcher has been

removed from the bedside unless facility

policy states otherwise.

5. Resident may attempt to drink liquids that

have not been thickened which will increase

risk of choking.

6. Do final steps.

Page 224 of 307

CARE SKILLS #14: MEASURE & RECORD FLUID INTAKE & URINARY OUTPUT

(Lessons #6 & #14)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Put on gloves, if necessary. 2. Gloves are not generally required for

measuring fluid intake, but they are required

for measuring urinary output.

Fluid Intake:

3. Note the amount of fluids in the container

before serving it to the resident. If necessary,

document the amount.

3. Different containers hold different amounts

of fluids. Check labels to determine how

much fluid each container holds.

4. Once the resident is finished with the

meal/snack, note the amount of fluid

remaining in the container. (If necessary,

pour the remaining fluid into a graduated

container and read it at eye level to

measure.)

4. Measuring the remaining fluid is more

accurate, but this technique is not always

necessary. Reading at eye level ensures

accuracy.

5. Subtract the remaining amount of fluid

from the total amount that was in the

container. The difference is the amount of

fluid consumed by the resident. Document

the amount according to the facility’s policy.

6. Dispose of food/drinks accordingly. (If

used, be sure to rinse, sanitize, and store the

graduated cylinder according to the facility’s

policy.)

6. Leaving unconsumed food/drinks in the

room could lead to pest concerns and can

also result in amounts being documented

multiple times. Fluids that were measured in

cylinder are now considered contaminated

and should not be consumed by the resident.

7. Wash hands.

8. Do final steps.

Urinary output:

1. Empty urine into a graduated cylinder.

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2. Place container on a flat, level surface. Be

sure to use a protective barrier between the

container and the surface, including the floor.

1. If the surface is not level, the liquid will tilt,

resulting in inaccurate readings. A barrier

should be used to avoid cross-contamination.

3. Measure the amount of urine inside of the

container at eye level.

2. Ensures accuracy.

4. Dispose of urine accordingly. Rinse,

sanitize, and store the graduated cylinder

according to the facility’s policy.

5. Remove gloves.

6. Document the amount according to the

facility’s policy.

7. Do final steps.

Page 226 of 307

CARE SKILLS #15: PASSING FRESH ICE WATER (Lesson #6)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Obtain cart, ice container, ice scoop and

go to ice machine. Keep ice scoop covered.

3. Fill container with ice using ice scoop.

4. Replace ice scoop in proper covered

container or cover it with a clean towel or

plastic bag to prevent contamination.

4. Keeping the ice scoop covered maintains

infection control practices.

5. Proceed to resident rooms, noting any fluid

restriction(s) prior to pass and any residents

who require thickened liquids.

5. Residents who require a fluid restriction or

thickened liquids should not have a water

pitcher placed at the bedside unless facility

policy states differently.

6. Empty water from pitcher and bedside

glass into the sink. If resident is on I&O’s –

record intake of water.

6. Emptying the pitcher of old water will allow

you to fill it with ice and fresh water. Emptying

the glass will allow you to fill it with fresh

water.

7. Take pitcher into hall and fill it with ice.

NOTE: Do not touch the pitcher with the ice

scoop.

7. The ice scoop is utilized for all residents

thus should not be contaminated by touching

a water pitcher.

8. Replace the scoop in covered container or

cover with a fresh, clean towel or plastic bag

between rooms to prevent contamination.

8. Maintains infection control practices.

9. Return to resident’s room and fill pitcher

with water at bathroom sink, not allowing

pitcher to touch faucet.

9. Ensures that resident has fresh ice water

in pitcher.

10. Pour fresh water into bedside glass and

leave a straw with the glass, if needed.

10. Ensures that water is available and ready

for resident when he/she desires it.

11. Offer the resident a drink of fresh water if

resident is present.

11. Resident may be unable to independently

obtain a drink of water.

12. Repeat procedure until all residents have

been provided with fresh ice water.

12. Ensures that all residents receive fresh

ice water.

13. Do final steps.

Page 227 of 307

CARE SKILLS #16: SERVING MEAL TRAY (Lesson #6)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Confirm diet card/tray. Check name, diet,

utensils and condiments.

2. This will ensure that the resident is being

served the diet as ordered; at the appropriate

consistency.

3. Confirm any adaptive equipment is

present, if indicated.

3. Provision of adaptive equipment will

encourage resident participation.

4. Assist to protect the resident’s clothing, if

desired.

4. Use of a napkin or clothing protector (if

resident desires) preserves dignity by

keeping clothing clean and free of spillage.

5. Assist to open carton(s), arrange food

items within reach, season foods per resident

preference, etc.

5. The resident may have limited hand

dexterity and/or weakness, making it difficult

to open cartons/containers.

6. Contact the nurse if the resident appears

to be having difficulty during meal, and you

are not trained on how to feed a resident If

properly trained, then offer assistance.

6. Residents may refrain from “asking” for

assistance, thus, staff should be pro–active in

observing the need for assistance and offer

the same.

7. Offer to assist in cleansing resident’s

hands/face following the meal.

7. Promotes good hygiene.

8. Assist resident to room or location of

choice.

9. Do final steps. Measure and record I&O’s if

required.

Page 228 of 307

CARE SKILLS #17: NASAL CANNULA CARE (Lesson #8)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Put on gloves. 2. Protects you from contamination by bodily

fluids.

3. Adjust and lift nasal cannula tubing

enough to observe the skin underneath and

to clean and dry nostrils as needed. Use a

soft cloth or tissue for cleaning area once

each shift or as needed. Do not remove

cannula from nostrils.

3. Removes any accumulation of dried

drainage that may be present. Removing the

cannula from the nostrils is considered

stopping/discontinuing the treatment/therapy,

which cannot be performed by nursing

assistants.

4. Note any redness or irritation of the nares

or behind the ears and notify nurse if present.

Continue procedure only if instructed.

4. Provides nurse with necessary information

to properly assess resident’s condition and

needs.

5. Readjust nasal cannula so that it fits

comfortably for resident. Ensure that sides

are not too tight.

5. Nasal cannula too tight can cause

discomfort. Incorrect placement could result

in decrease flow of oxygen to resident and/or

discomfort.

6. Remove gloves.

7. Do final steps.

Page 229 of 307

CARE SKILLS #18: SHOWER/SHAMPOO (Lesson #12)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Clean/disinfect shower area and shower

chair as per facility policy. Prep the bathing

area per facility policy. Gather supplies and

take them into the shower area.

2. Reduces pathogens and prevents spread

of infection. Have the supplies ready when

you bring the resident in the shower room to

ensure resident safety.

3. Help resident remove clothing. Provide

resident privacy—ensure door is shut,

curtains pulled, blinds closed.

3. Maintains resident’s dignity and right to

privacy by not exposing body. Keeps

resident warm.

4. Turn on water and check temperature.

Also allow resident to check water

temperature for comfort, if able.

4. Resident’s sense of touch may be different

than yours; therefore, resident is best able to

identify a comfortable water temperature.

5. Assist resident into shower via wheelchair.

Lock wheels of shower chair and wheelchair.

Transfer resident to shower chair. Use safety

belt to secure resident stability, if indicated.

Never take your eyes off the resident or turn

your back to the resident while in the shower.

5. Chair may slide if resident attempts to get

up. Ensure resident safety at all times. Never

transport resident through the facility in

shower chair. Keep eyes on resident at all

times in shower room to ensure safety (i.e.,

prevent falls, ingestion of chemicals, etc.).

Shampoo:

6. Give resident a washcloth to cover his/her

eyes during the shampoo, if he/she desires.

Place cotton balls in resident’s ears if

desired.

6. Prevents soap and water from entering the

resident’s eyes and ears.

7. Wet the resident’s hair.

8. Put a small amount of shampoo into the

palm of your hand and work it into the

resident’s hair and scalp using your

fingertips.

8. Using fingertips instead of fingernails to

massage the scalp decreases the risk of

scratching the resident.

9. Rinse the resident’s hair thoroughly. 9. Leaving soap in the hair can cause dry

scalp.

10. Use a conditioner if the resident desires

you to do so. Rinse.

Shower continued:

11. Let resident wash as much as possible, 11. Encourages resident to be independent.

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starting with face. Assist as needed to wash

and rinse the entire body going from head to

toe. Use a separate washcloth to cleanse the

perineal area last.

12. Turn off the water. Cover resident with

bath blanket or towel.

12. Prevents resident from getting cold.

13. Remove cotton balls from the resident’s

ears, if utilized.

14. Give resident towel and assist to pat dry.

Ensure that hair, neck, and ears are dried.

Thoroughly dry under breasts, between

skinfolds, in the perineal area, and between

toes.

14. Patting dry prevents skin tears and

reduces chaffing. Water left in areas,

especially in skin folds, can cause pathogens

to grow, leading to irritation and skin

breakdown.

15. Apply lotion to skin and assist resident

with dressing and combing hair. Blow dry

hair if necessary.

16. Be sure that floor is dry before assisting

resident out of shower chair. Apply non-slip

device to floor if available. Ensure shoes are

on and fit properly. Assist resident out of

shower room.

16. Wet floors and transferring resident

without shoes or nonskid socks on

17. Do final steps. Report skin

abnormalities to the nurse.

Page 231 of 307

CARE SKILLS #19: BED BATH/CATHETER CARE/PERINEAL CARE (Lesson #12)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Offer resident urinal or bedpan. 2. Reduces chance of urination during

procedure which may cause discomfort and

embarrassment.

3. Provide Resident privacy—including

closing doors, windows and curtains.

3. Maintains resident’s dignity and right to

privacy by not exposing body. Keeps

resident warm.

4. Fill bath basin with warm water and have

resident check water temperature for comfort,

if able.

4. Resident’s sense of touch may be different

than yours; therefore, resident is best able to

identify a comfortable water temperature.

5. Put on gloves. 5. Protects you from contamination by body

fluids.

6. Fold washcloth and wet.

7. Gently wash eye from inner corner to outer

corner, using a different part of cloth to wash

other eye. Be sure to use a different part of

the cloth with each wipe throughout

procedure/bed bath.

7. Helps prevent eye infection. Always wash

from clean to dirty. Using separate area of

cloth reduces contamination.

8. Wet washcloth and apply soap, if

requested. Wash, rinse and pat dry face,

neck, ears and behind ears.

8. Patting dry prevents skin tears and

reduces chaffing.

9. Remove resident’s gown.

10. Place towel under far arm. 10. Prevents linen from getting wet.

11. Wash, rinse and pat dry hand, arm,

shoulders and underarm.

11. Soap left on the skin may cause itching

and irritation.

12. Repeat steps with other arm.

13. Place towel over chest and abdomen.

Lower bath blanket to waist.

13. Maintains resident’s right to privacy.

14. Lift towel and wash, rinse and pat dry

chest and abdomen.

14. Exposing only the area of the body

necessary to do the procedure maintains

resident’s dignity and right to privacy.

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15. Pull up bath blanket and remove towel.

16. Uncover and place towel under far leg. 16. Prevents linen from getting wet.

17. Wash, rinse and pat dry leg and foot. Be

sure to wash, rinse and dry well between the

toes.

17. Soap left on the skin may cause itching

and irritation.

18. Repeat with other leg and foot.

19. Change bath water and gloves, wash

hands and use clean gloves and towel.

19. Water is contaminated after washing feet.

Clean water should be used for neck and

back.

20. Assist resident to spread legs and lift

knees, if possible.

20. Exposes perineal area.

21. Wet and soap folded washcloth. 21. Folding creates separate areas on cloth

to reduce contamination.

Catheter Care:

22. If resident has catheter, check for

leakage, secretions or irritation. Secure

tubing, then gently wipe four inches of

catheter from meatus out.

22. Washes pathogens away from the

meatus.

Perineal Care:

23 Wipe from front to back and from center of

perineum to thighs. If washcloth is visibly

soiled, change cloths.

For Females:

Separate labia. Wash urethral area first.

Wash between and outside labia in

downward strokes, alternating from side to

side and moving outward to thighs. Use

different part of washcloth for each stroke.

For Males:

Pull back foreskin if male is uncircumcised.

Wash and rinse the tip of penis using circular

motion beginning with urethra. Continue

washing down the penis in a circular motion

to the scrotum and inner thighs. Rinse off

soap and dry. Return foreskin over the tip of

the penis.

23. Prevents spread of infection.

Females: Removes secretions in skin folds

which may cause infection or odor.

Males: Removes secretions from beneath

foreskin which may cause infection and odor.

Page 233 of 307

24. Change water in basin. Wash hands and

change gloves. With a clean washcloth, rinse

area thoroughly in the same direction as

when washing.

24. Water used during washing contains soap

and pathogens. Soap left on the body can

cause irritation and discomfort.

25. Gently pat area dry with towel in same

direction as when washing.

25. If area is left wet, pathogens can grow

more quickly. Patting dry prevents skin tears

and reduces chaffing.

26. Assist resident to lateral position, facing

away from you.

27. Wet and soap washcloth.

28. Clean anal area from front to back. Rinse

and pat dry thoroughly.

28. Prevents spread of infection.

29. Change bath water and gloves. Use clean

washcloth and towel.

29. Water and linen are contaminated after

washing anal area.

30. Wash, rinse and pat dry from neck to

buttocks.

30. Always wash from clean to dirty.

31. Return to supine position.

32. Wash hands and change gloves.

33. Help resident put on clean gown,

undergarments or clothing of choice.

34. Do Final Steps.

35. Report any reddened areas, abrasions or

bruises to the nurse.

Page 234 of 307

CARE SKILLS #20: BACK RUB

(Lesson #12)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Place lotion in warm water. Shake

occasionally if necessary to ensure lotion is

warm all the way through. If hands are cold,

hold them under warm water.

2. Warm water will help warm the lotion and

hands. May need to remain in water several

minutes.

3. Assist resident with turning on side or

lying on abdomen.

4. Expose the resident’s back to the top of

the buttocks.

5. Pour small amount of lotion into palm of

hand. If not warm enough, rub lotion between

hands. Do not pour lotion directly onto

resident’s skin.

5. The friction of rubbing hands together will

help warm the lotion. Pouring lotion directly

onto the skin is cold and uncomfortable for

most individuals.

6. Use the palm of both hands to apply the

lotion to the back using long firm strokes,

beginning at the base of the back on both

sides. (Let the resident know that the lotion

may feel cool at first.) Continue strokes from

the buttocks to the back of the neck and

shoulders, exerting firm upward pressure.

7. Use gentle downward pressure rubbing in

small circular motions with palm of hands.

Do not lift hands.

Alternate method – Circle hands outward at

shoulders, then use gentle pressure to rub

down the outer edges of the back. Circle

hands again when you reach the top of the

buttocks, and firmly massage in long strokes

in the center of the back until you reach the

shoulders again. Circle out and back down

again. Repeat.

7. Regardless of the technique used,

massaging will help relieve tension and relax

resident. Whichever method the resident

prefers is what should be used.

8. Give special attention to all bony

prominences using circular motion.

8. Helps stimulate circulation and prevent

skin damage. If areas are discolored,

massage around them and be sure to report

areas to nurse.

Page 235 of 307

9. Continue rhythmic rubbing for one (1) to

three (3) minutes. Let resident know when

you are almost done.

10. Dry resident’s back by patting with a

towel.

10. Helps to remove excess lotion.

11. Assist resident with getting dressed.

12. Perform final steps.

Page 236 of 307

CARE SKILLS #21: SHAMPOO HAIR IN BED

(Lesson #12)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Gently comb and brush resident’s hair. 2. Reduces hair breakage, scalp pain, and

irritation.

3. Place a towel around resident’s neck and

shoulders. Lower head of bed.

3. Decreases the chance of resident getting

wet.

4. Have resident check temperature of water,

if able.

4. Resident’s sense of touch may be different

than yours, therefore, resident is best able to

identify a comfortable water temperature.

5. Place bed shampoo basin under resident’s

head according to manufacturer’s

instructions. If available, place protective

covering such as a pad, on the bed before

adding basin.

5. Pad will protect linens and mattress from

getting wet. If equipment is not applied

according to manufacturer’s instruction,

discomfort or injury could result.

6. Place wash basin or other receptacle on

chair to catch water flowing from shampoo

basin.

7. Pour water carefully over resident’s hair.

8. Lather hair with shampoo using fingertips.

Rinse thoroughly. Apply conditioner to

resident’s hair if requested. Rinse thoroughly.

8. Utilizing fingertips massages the scalp and

decreases the risk of scratching resident.

9. Squeeze excess water from hair. Towel

dry hair.

10. Replace gown or pajama top if

necessary.

11. Comb and brush resident’s hair. Dry hair

with dryer if resident wishes.

11. Helps maintain resident’s dignity and

self–esteem.

12. Do final steps.

Page 237 of 307

CARE SKILLS #22: WHIRLPOOL

(Lesson #12)

STEP – Type of whirlpool, trolley, etc., may

alter actions. Always refer to facility policy

and/or manufacturer’s instructions.

RATIONALE

1. If possible, fill tub with water before

bringing resident to bathing area.

1. Having water ready saves time.

2. Transport resident to whirlpool.

3. If tub is already filling, have resident check

water temperature for comfort. Adjust if

necessary.

3. Water should be at the resident’s desirable

temperature vs. the temperature that suits the

staff.

4. Assist resident into lift bath trolley or into

the tub per facility policy and manufacturer’s

instructions. Remove clothing and secure

straps around resident, if applicable. Lower

lift bath trolley and resident into the tub. If tub

is not already filled with water, do so now,

adjusting the temperature to the resident’s

comfort. When tub is filled, turn the system

on.

4. Secure straps for resident’s safety. Some

tubs/whirlpools are made to be pre-filled.

Others cannot be filled until the resident is

inside. Some whirlpools/tubs require the use

of a lift to lower resident inside tub. Others

have a door, allowing resident to step inside

tub. Follow manufacturer’s instructions and

the facility’s policy on when to fill tub with

water and how to get resident in/out of tub.

5. Let resident wash as much as possible,

starting with face.

5. Encourages independence.

6. You may shower the resident by using the

shower handle to gently spray over the

resident’s body. Stay with resident during

procedure.

6. Leaving resident unattended can result in

serious injury or death.

7. Turn system off after completion of bath

and return shower handle to hook, if used.

Drain water from tub.

8. Raise trolley out of tub. Assist resident to

pat dry as needed. Be sure to dry areas that

are touching the trolley, skinfolds, underneath

breasts, and the perineal area.

8. Leaving areas wet can cause irritation and

skin breakdown.

9. Assist resident with dressing and getting

out of trolley/tub. Comb hair.

10. Help resident return to room or desired

location. If necessary, leave indicator for

others to know that tub has not been

sanitized.

10. Tub should be cleaned between use.

Leaving indicator for others ensures that tub

will not be used before being cleaned.

Page 238 of 307

11. Sanitize tub per manufacturer’s

instructions.

11. Tub should be properly cleaned after use.

12. Do final steps.

Page 239 of 307

CARE SKILLS #23: ORAL CARE FOR THE ALERT AND ORIENTED RESIDENT (Lesson

#13)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps. Check with nurse if the

resident is on swallowing precautions.

2. Raise head of bed so resident is sitting up. 2. Prevents fluids from running down

resident’s throat, causing choking.

3. Put on gloves. 3. Brushing may cause gums to bleed.

Protects you from potential contamination.

4. Drape towel under resident’s chin. 4. Protects resident’s clothing and bed linen.

5. Wet toothbrush and apply small amount of

toothpaste.

5. Water helps distribute toothpaste.

6. First brush upper teeth and then lower

teeth. Gently brush inner, outer, and chewing

surfaces of teeth. Clean entire mouth,

including the tongue and the gum line.

6. Brushing upper teeth minimizes production

of saliva in lower part of mouth.

7. Hold emesis basin under resident’s chin.

8. Ask resident to rinse mouth with water and

spit into emesis basin.

8. Removes food particles and toothpaste.

9. If requested, give resident mouthwash

diluted with half water.

9. Full strength mouthwash may irritate

resident’s mouth.

10. Check teeth, mouth, tongue and lips for

odor, cracking, sores, bleeding and

discoloration. Check for loose teeth. Report

unusual findings to nurse.

10. Provides nurse with necessary

information to properly assess resident’s

condition and needs.

11. Remove towel and wipe resident’s mouth.

12. Remove gloves.

13. Do final steps.

Page 240 of 307

CARE SKILLS #24: ORAL CARE FOR AN UNCONSCIOUS RESIDENT (Lesson #13)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Drape towel over pillow and a towel under

resident’s chin.

2. Protects linen.

3. Turn resident onto unaffected side. 3. Prevents fluids from running down

resident’s throat, causing choking.

4. Put on gloves. 4. Protects you from contamination by bodily

fluids.

5. Place an emesis basin under resident’s

chin.

5. Protects resident’s clothing and bed linen.

6. Dip swab in cleaning solution of ½

mouthwash and ½ water and wipe teeth,

gums, tongue and inside surfaces of mouth,

changing swab frequently.

6. Stimulates gums and removes mucous.

7. Rinse with clean swab dipped in water. 7. Removes solution from mouth.

8. Check teeth, mouth, tongue and lips for

odor, cracking, sores, bleeding and

discoloration. Check for loose teeth. Report

unusual findings to nurse.

8. Provides nurse with necessary information

to properly assess resident’s condition and

needs.

9. Cover lips with thin layer of lip moisturizer. 9. Prevents lips from drying and cracking.

Improves resident’s comfort.

10. Remove gloves.

11. Do final steps.

Page 241 of 307

CARE SKILLS #25: DENTURE CARE (Lesson #13)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Raise head of bed so resident is sitting up. 2. Prevents fluids from running down

resident’s throat, causing choking.

3. Put on gloves. 3. Protects you from contamination by bodily

fluids.

4. Drape towel under resident’s chin. 4. Protects resident’s clothing and bed linen.

5. Remind resident that you are going to

remove their dentures. Remove upper

dentures by placing your index finger at the

ridge on top of the right upper denture and

gently moving them up and down to release

suction. Turn lower denture slightly to lift out

of mouth. If able, have resident to remove

their dentures.

5. Prevents injury or discomfort to resident

and reduces chance of resident biting staff.

Removing upper dentures first is more

comfortable for the resident and placing your

finger at the ridge decreases the chance of

stimulating the gag reflex. Allowing resident

to remove their own dentures encourages

independence.

6. Put dentures in denture cup marked with

resident’s name and take to sink.

7. Line sink with towel and fill halfway with

water.

7. Prevents dentures from breaking if

dropped.

8. Apply denture cleaner to toothbrush.

9. Hold dentures over sink and brush all

surfaces.

9. If dropped, the dentures will fall into the

sink. The towel and water in sink will prevent

dentures from breaking.

10. Rinse dentures under warm water. Place

in a clean cup and fill with cool water.

10. Hot water may damage dentures.

11. Clean resident’s mouth with swab if

necessary. Help resident rinse mouth with

water or mouthwash diluted with half water, if

requested.

11. Removes food particles. Full strength

mouthwash may irritate resident’s mouth.

12. Check teeth, mouth, tongue and lips for

odor, cracking, sores, bleeding and

discoloration. Check for loose teeth. Report

unusual findings to nurse.

12. Provides nurse with necessary

information to properly assess resident’s

condition and needs.

Page 242 of 307

13. Help resident place dentures in mouth, if

requested. Moisturize the lips.

13. Restores resident’s dignity and keeps lips

from drying and cracking. Improves resident

comfort.

14. Remove gloves.

15. Do final steps.

Page 243 of 307

CARE SKILLS #26: SHAVING WITH AN ELECTRIC RAZOR (Lesson #13)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Raise head of bed so resident is sitting up. 2. Places resident in more natural position.

3. Do not use electric razor near any water

source, when oxygen is in use or if resident

has pacemaker.

3. Electricity near water may cause

electrocution. Electricity near oxygen may

cause explosion. Electricity near some

pacemakers may cause an irregular

heartbeat.

4. Drape towel under resident’s chin. 4. Protects resident’s clothing and bed linen.

5. Put on gloves. 5. Shaving may cause bleeding. Protects

you from potential contamination.

6. Apply pre–shave lotion as resident

requests.

7. Hold skin taut and shave resident’s face

and neck according to manufacturer’s

guidelines.

7. Smooth out skin. Shave beard with back

and forth motion in direction of beard growth

with foil (oscillating blades) shaver. Shave

beard in circular motion with three head

(rotary, circular blades) shaver.

8. Check for any breaks in the skin. Apply

aftershave lotion as resident requests.

8. Decreases risk of pain from aftershave

getting into any breaks in the skin. Improves

resident’s self–esteem.

9. Remove towel from resident. 9. Restores resident’s dignity.

10. Remove gloves.

11. Do final steps.

Page 244 of 307

CARE SKILLS #27: SHAVING WITH A SAFETY RAZOR (Lesson #13)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Raise head of bed so resident is sitting up. 2. Places resident in more natural position.

3. Fill bath basin halfway with warm water. 3. Hot water opens pores and causes

irritation.

4. Drape towel under resident’s chin. 4. Protects resident’s clothing and bed linen.

5. Put on gloves. 5. Shaving may cause bleeding. Protects you

from potential contamination.

6. Moisten beard with washcloth and spread

shaving cream over area.

6. Softens skin and hair.

7. Hold skin taut and shave beard in

downward strokes on face and upward

strokes on neck.

7. Maximizes hair removal by shaving in the

direction of hair growth.

8. Rinse resident’s face and neck with

washcloth.

8. Removes soap which may cause irritation.

9. Pat dry with towel.

10. Apply after–shave lotion, as requested. 10. May decrease skin irritation, especially

with sensitive skin. Improves resident’s self–

esteem.

11. Remove towel.

12. Remove gloves.

13. Do final steps.

Page 245 of 307

CARE SKILLS #28: COMB/BRUSH HAIR (Lesson #13)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Raise head of bed so resident is sitting up. 2. Places resident in position to access hair.

3. Drape towel over pillow. 3. Protects resident’s clothing and bed linen.

4. Remove resident’s glasses and any

hairpins or clips.

5. Remove tangles by dividing hair into small

sections and gently combing out from the

ends of hair to scalp.

6. Use hair products, as resident requests.

7. Style hair as resident requests. 7. Improves resident’s self–esteem.

8. Offer mirror.

9. Do final steps.

Page 246 of 307

CARE SKILLS #29: FINGERNAIL CARE (Lesson #13)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Check fingers and nails for color, swelling,

cuts or splits. Check hands for extreme heat

or cold. Report any unusual findings to nurse

before continuing procedure.

2. Provides nurse with information to properly

assess resident’s condition and needs.

3. Raise head of bed so resident is sitting up. 3. Places resident in more natural position.

4. Fill bath basin halfway with warm water

and have resident check water temperature

for comfort. Add soap to water. If possible

use non–rinse soap, being sure to follow

manufacturer’s instructions for dilution. If no–

rinse solution is not available, and regular

soap is used, then aide must rinse hands by

using a pitcher of water, or by taking resident

to sink, or by emptying and refilling basin.

4. Resident’s sense of touch may be different

than yours; therefore, resident is best able to

identify a comfortable water temperature.

Adding soap helps to clean resident’s hands.

5. Soak resident’s hands and pat dry. 5. Nail care is easier if nails are softened.

6. Put on gloves. 6. Nail care may cause bleeding. Protects

you from potential contamination.

7. Clean under nails with orange stick. 7. Pathogens can be harbored beneath the

nails.

8. Clip fingernails straight across, then file in

a curve.

8. Clipping nails straight across prevents

damage to skin. Filing in a curve creates

smooth nails and eliminates edge which may

catch on clothes or cause skin tear.

9. Remove gloves.

10. Do final steps.

Page 247 of 307

CARE SKILLS #30: FOOT CARE (Lesson #13)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Fill the basin halfway with warm water.

Have resident check the water temperature.

2. To prevent resident from scalding or

burning his/her feet.

3. Place basin on towel or bathmat.

4. Remove resident’s socks. Completely

submerge resident’s feet in water and soak

for five to ten minutes.

4. Soaking allows for softening skin

depending on thickness of calluses, etc.

5. Put on gloves.

6. Remove one foot from water. Wash entire

foot, including between the toes and around

the nail beds using a soapy washcloth.

7. Rinse entire foot, including between the

toes.

7. Soap left on the skin may cause itching

and irritation.

8. Dry entire foot, including between the toes.

Inspect the feet and in between all toes for

condition of skin, presence of corns or

callouses or other foot problems.

8. Thoroughly drying skin reduces irritation

and chaffing.

9. Check with the charge nurse before

trimming the resident’s toenails. If trimming

is allowed, trim the toenails straight across to

prevent the edges from becoming ingrown.

9. Facility may not allow nurse aides to trim

toenails and/or fingernails. Certain residents

may require licensed staff (nurses, doctors,

podiatrist, etc.) to trim their toenails,

especially if they are diabetic or have poor

circulation.

10. Repeat steps with the other foot.

11. Place lotion in hand, warm lotion by

rubbing hands together, and then massage

lotion into entire foot (top and bottom) except

between toes, removing excess with a towel.

12. Assist resident to replace socks and

shoes, as desired.

13. Do final steps.

Page 248 of 307

14. Report any cuts, sores, or other findings

to the nurse.

Page 249 of 307

CARE SKILLS #31: CHANGING RESIDENT’S GOWN (Lesson #14)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Untie and/or unbutton soiled gown as

needed.

2. Maintains resident’s dignity and right to

privacy by not exposing body. Keeps

resident warm.

3. Raise top sheet over resident’s chest.

4. Remove resident’s arms from gown,

unaffected arm first.

4. Undressing unaffected arm first requires

less movement.

5. Roll soiled gown from neck down and

remove from beneath top sheet. Place soiled

gown in dirty linen bag.

5. Rolling reduces spread of infection.

6. Slide resident’s arms into clean gown,

affected arm first.

6. Dressing affected side first requires less

movement and reduces stress to joints.

7. Tie or button gown as needed.

8. Remove top sheet from beneath clean

gown and cover resident.

8. Maintains resident’s dignity and right to

privacy.

9. Do final steps.

Page 250 of 307

CARE SKILLS #32: DRESSING A DEPENDENT RESIDENT

(Lesson #14)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps. Check care plan to see if

resident is a one person or two-person assist.

2. Assist resident to choose clothing. 2. Allows resident as much choice as

possible to improve self–esteem.

3. Move resident onto back.

4. Provide privacy. 4. Maintains resident’s dignity and right to

privacy by not exposing body. Keeps

resident warm.

5. Guide feet through leg openings of

underwear and pants, affected leg first. Pull

garments up legs to buttocks.

5. Dressing affected side first requires less

movement and reduces stress to joints.

6. Slide arm into shirt sleeve, affected side

first.

6. Dressing lower and upper body together

reduces number of times resident needs to

be turned.

7. Turn resident onto unaffected side. Pull

lower garments over buttocks and hip. Tuck

shirt under resident.

8. Turn resident onto affected side. Pull

lower garments over buttocks and hip and

straighten shirt.

9. Turn resident onto back and slide arm into

shirt sleeve, align and fasten garments.

10. Do final steps.

Page 251 of 307

CARE SKILLS #33: ASSIST TO BATHROOM (Lesson #14)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps. Check care plan to see if

resident is a one person or two-person assist.

2. Assist resident to put on non–skid socks/

footwear.

3. Walk with resident into bathroom.

4. Assist resident to lower garments and sit. 4. Allows resident to do as much as possible

to help promote independence.

5. Provide resident with call light and toilet

tissue if resident has been identified as safe

to be provided privacy. Remain with the

resident if required to do so.

5. Ensures ability to communicate need for

assistance. Provides for resident’s right to

privacy.

6. Put on gloves. 6. Protects you from contamination by bodily

fluids.

7. Assist resident to wipe area from front to

back.

7. Prevents spread of pathogens toward

meatus which may cause urinary tract

infection.

8. Remove gloves. Wash hands.

9. Assist resident to raise garments.

10. Assist resident to wash hands. 10. Handwashing is the best way to prevent

the spread of infection.

11. Walk with resident back to bed or chair.

12. Do final steps.

Page 252 of 307

CARE SKILLS #34: BEDSIDE COMMODE (Lesson #14)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Assist resident to put on non–skid socks/

footwear.

3. Place commode next to bed on resident’s

unaffected side.

3. Helps stabilize commode and is the

shortest distance for resident to turn.

4. Assist resident to transfer to commode by

transferring the safest way the resident is

able. Check care plan to see if resident is a

one person or two person assist.

5. Give resident call light and toilet tissue if

resident has been identified as safe to be

provided privacy and not attended by staff.

5. Ensure ability to communicate need for

assistance. Provides resident’s right to

privacy.

6. Put on gloves. 6. Protects you from contamination by bodily

fluids.

7. Assist resident to wipe from front to back. 7. Prevents spread of pathogens toward

meatus which may cause urinary tract

infection.

8. Assist resident to bed or chair.

9. Remove and cover pan and take to

bathroom.

9. Pan should be covered to prevent the

spread of infection.

10. Prior to disposal, observe urine and/or

feces for color, odor, amount &

characteristics and report unusual findings to

nurse.

10. Changes may be the first sign of a

medical problem. By alerting the nurse, you

ensure that the resident receives prompt

attention.

11. Dispose of urine and/or feces, sanitize

pan and return pan according to facility

policy.

11. Facilities have different methods of

disposal and sanitation. You need to carry

out the policies of your facility.

12. Remove gloves. Wash hands.

13. Assist resident to wash hands. 13. Handwashing is the best way to prevent

the spread of infection.

14. Do final steps.

Page 253 of 307

CARE SKILLS #35: BEDPAN/FRACTURE BEDPAN (Lesson #14)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Lower head of bed. 2. When bed is flat, resident can be moved

without working against gravity.

3. Put on gloves. 3. Protects you from contamination by bodily

fluids.

4. Turn resident away from you.

5. Place bedpan or fracture pan under

buttocks according to manufacturer

directions.

5. Equipment used incorrectly may cause

discomfort and injury to resident.

6. Gently roll resident back onto pan and

check for correct placement.

6. Prevents linen from being soiled.

7. Cover resident with sheet/blanket. 7. Provides for resident’s privacy.

8. Raise head of bed to comfortable position

for resident.

8. Increases pressure on bladder to

encourage with elimination.

9. Give resident call light and toilet paper. 9. Ensures ability to communicate need for

assistance.

10. Leave resident and return when called. 10. Provides for resident’s privacy.

11. Lower head of bed. 11. Places resident in proper position to

remove pan.

12. Press bedpan flat on bed and turn

resident.

12. Prevents bedpan from spilling.

13. Wipe resident from front to back. Wash

hands and change gloves.

13. Prevents spread of pathogens toward

meatus which may cause urinary tract

infection.

14. Provide perineal care, if necessary.

15. Cover bedpan and take to bathroom. 15. Pan should be covered to prevent the

spread of infection.

16. Check urine and/or feces for color, odor,

amount and characteristics and report

unusual findings to nurse.

16. Changes may be first sign of medical

problem. By alerting the nurse you ensure

that the resident receives prompt attention.

Page 254 of 307

17. Dispose of urine and/or feces, sanitize

pan and return pan according to facility

policies.

17. Facilities have different methods of

disposal and sanitation. You need to carry

out the policies of your facility.

18. Remove gloves. Wash hands.

19. Assist resident to wash hands. 19. Handwashing is the best way to prevent

the spread of infection.

20. Do final steps.

Page 255 of 307

CARE SKILLS #36: URINAL (Lesson #14)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Raise head of bed to sitting position. 2. Increases gravity on top of bladder to

encourage urination.

3. Put on gloves. 3. Protects you from contamination by bodily

fluids.

4. Offer urinal to resident or place urinal

between his legs and insert penis into

opening. Remove gloves.

4. Allows resident to do as much as possible

to help promote independence.

5. Cover resident. 5. Maintains resident’s right to privacy.

6. Give resident call light and toilet paper. 6. Ensures ability to communicate need for

assistance.

7. Leave resident and return when called. 7. Provides for resident’s privacy.

8. Put on gloves. Remove and cover urinal. 8. Urinal should be covered to prevent the

spread of infection.

9. Take urinal to bathroom, check urine for

color, odor, amount and characteristics and

report unusual findings to nurse.

9. Changes may be first sign of medical

problems. By alerting the nurse you ensure

that the resident receives prompt attention.

10. Dispose of urine, rinse urinal, sanitize and

return urinal according to facility policies.

10. Facilities have different methods of

disposal and sanitation. You need to carry

out the policies of your facility.

11. Remove gloves. Wash hands.

12. Assist resident to wash hands. 12. Handwashing is the best way to prevent

the spread of infection.

13. Do final steps.

Page 256 of 307

CARE SKILLS #37: EMPTY URINARY DRAINAGE BAG (Lesson #14)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Put on gloves. 2. Protects you from contamination by bodily

fluids.

3. Place paper towel on floor beneath bag

and place graduated cylinder on paper towel.

3. Reduces contamination of graduate

cylinder and protects floor from spillage.

4. Detach spout (if bag has one) and point

the drainage tube into center of graduated

cylinder without letting tube touch sides.

4. Prevents contamination of tubing.

5. Unclamp spout and drain urine.

6. Clamp spout. Clean using alcohol wipe. 6. Removes contaminates from spout.

7. Replace spout in holder.

8. Check urine for color, odor, amount and

characteristics and report unusual findings to

nurse.

8. Changes may be first signs of medical

problem. By alerting the nurse you ensure

that the resident receives prompt attention.

9. Measure and accurately record amount of

urine.

9. Accuracy is necessary because decisions

regarding resident’s care may be based on

your report. What you write is a legal record

of what you did. If you don’t document it,

legally it didn’t happen.

10. Dispose of urine, rinse, sanitize and

return graduated cylinder according to facility

policies.

10. Facilities have different methods of

disposal and sanitation. Follow facility policy

and procedures.

11. Remove gloves.

12. Do final steps.

Page 257 of 307

CARE SKILLS #38: URINE SPECIMEN COLLECTION (Lesson #14)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Prepare label for specimen with

appropriate information and place it on

specimen container, not the lid.

2. Label contains resident’s identifying

information which is essential for the

laboratory. Label should be placed on the

specimen container in the event the lid is

misplaced or thrown away.

3. Put on gloves. 3. Protects you from contamination by bodily

fluids.

4. Assist resident to bathroom or commode,

or offer bedpan or urinal.

5. Provide perineal care to the resident. 5. To ensure area is clean and free of

possible contamination of the specimen.

6. Ask resident to void into the urine hat

placed on the toilet, or to urinate in the

bedpan. Ask the resident not to put toilet

paper with the sample.

6. A clean collection device is necessary for

accurate lab evaluation. Toilet paper will

contaminate the urine and produce an

inaccurate result.

7. After urination, assist the resident as

necessary with perineal care and to wash the

resident’s hands. Change your gloves and

wash your hands.

8. Take bedpan, urinal, and commode pail to

bathroom and pour urine in to the specimen

container. The container should be at least

half full.

9. Cover the urine container with its lid. Do

not touch the inside of the container. Wipe

off the outside with a paper towel.

9. Touching the inside can contaminate the

specimen, causing inaccurate results.

10. Place the specimen container in the bag

supplied by the lab for transport.

11. Discard excess urine in bedpan or urinal;

clean and disinfect equipment as per facility

policy.

12. Do final steps.

Page 258 of 307

CARE SKILLS #39: STOOL SPECIMEN COLLECTION (Lesson #14)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Prepare label for specimen with

appropriate information and place it on

specimen container, not the lid.

2. Label contains resident’s identifying

information which is essential for the

laboratory. Label should be placed on the

specimen container in the event the lid is

misplaced or thrown away.

3. Put on gloves. 3. Protects you from contamination by bodily

fluids.

4. When the resident is ready to move

bowels, ask him/her not to urinate at the

same time. Ask the resident not to put toilet

paper in with the sample.

4. A clean collection device is necessary for

accurate lab evaluation. Urine contaminated

stool will produce an inaccurate result.

5. Provide the resident with a bedpan,

assisting if needed.

6. After the bowel movement, assist as

needed with perineal care.

7. Remove gloves, wash hands and put on

clean gloves.

8. Using two tongue blades, take about two

tablespoons of stool and put in the container.

Try to collect material from different areas of

the stool.

8. In order to ensure adequate amount of

stool for test ordered. Obtaining material

from different areas ensures that all possible

contents will be identified.

9. Cover the container with lid. Label as

directed per facility policy and procedure and

place in the plastic bag supplied by the lab for

transport. Dispose of remaining stool; clean

and disinfect equipment as per facility policy.

Notify nurse of collection.

10. Do final steps.

Page 259 of 307

CARE SKILLS #40: APPLICATION OF INCONTINENT BRIEF (Lesson #14)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Put on gloves.

3. Provide the resident privacy.

4. Unfasten and remove brief resident is

currently wearing and place in small plastic

trash bag for disposal in soiled utility bag.

4. Residents should have soiled briefs

removed promptly to decrease risk of skin

breakdown.

5. Provide perineal care as indicated. 5. Prevents infection, odor, and skin

breakdown; improves resident’s comfort.

6. Wash hands and change gloves.

7. Place back of brief under resident’s hips,

plastic side of disposable brief away from

resident’s skin.

7. Plastic may cause irritation of the

resident’s skin.

8. Bring front of brief between resident’s legs

and up to his/her waist.

9. Fasten each side of brief and adjust fit. 9. Adjusting brief to a snug fit will prevent

leakage.

10. Apply resident’s clothing.

11. Do final steps.

Page 260 of 307

CARE SKILLS #41: ASSIST RESIDENT TO MOVE TO HEAD OF BED

(Lesson #15)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps. Ask another CNA to assist

you if needed.

2. Lower head of bed and lean pillow against

head board. Adjust bed height as needed.

2. When bed is flat, resident can be moved

without working against gravity. Pillow

prevents injury should resident hit the head of

bed. Adjusting the bed height decreases risk

of injury.

3. Ask resident to bend knees, put feet flat on

mattress.

3. Gives resident leverage to help with move.

4. Place one arm under resident’s shoulder

blades and the other arm under resident’s

thighs. If a draw sheet or pad is under

resident, two caregivers should grasp the

sheet or pad firmly, with trunk centered

between hands.

4. Putting your arm under resident’s neck

could cause injury. Use of a draw sheet/pad

causes less stress on caregiver and reduces

risk of injury.

5. Ask resident to push with feet on count of

three.

5. Enables resident to help as much as

possible and reduces strain on you.

6. Place pillow under resident’s head. 6. Provides for resident’s comfort.

7. Do final steps.

Page 261 of 307

CARE SKILLS #42: SUPINE POSITION

(Lesson #15)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Lower head of bed. 2. When bed is flat, resident can be moved

without working against gravity.

3. Move resident to head of bed if necessary. 3. Places resident in proper position in bed.

4. Position resident flat on back with legs

slightly apart.

4. Prevents friction in thigh area.

5. Align resident’s shoulder and hips. 5. Reduces stress to spine.

6. Use supportive padding and/or float heels,

if necessary.

6. Maintains position, prevents friction and

reduces pressure on bony prominences.

Padding may be used under neck, shoulders,

arms, hands, ankles, lower back. Never use

padding under knees, unless directed by

nurse, as it may restrict blood flow to lower

legs.

7. Do final steps.

Page 262 of 307

CARE SKILLS #43: LATERAL POSITION & SIDE TO SIDE (Lesson #15)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Place resident in supine position. 2. Places resident in proper position and

alignment.

3. Move resident to side of bed closest to

you.

3. Allows resident to be positioned in center

of bed when turned.

4. Cross resident’s arms over chest. 4. Reduces stress on shoulders during move.

5. Slightly bend knee of nearest leg to you or

cross nearest leg over farthest leg at ankle.

5. Reduces stress on hip joint during turn.

6. Place your hands under resident’s

shoulder blade and buttock. Turn resident

away from you onto side.

6. Prevents stress on shoulder and hip joints.

7. Place supportive padding behind back,

between knees and ankles and under top

arm.

7. Maintains position, prevents friction and

reduces pressure on bony prominences.

8. Do final steps.

Moving a Resident in Bed from Side to Side:

1. Do initial steps. Ask another CNA to assist

you if needed.

2. Put the side rail in the up position on the

far side of the bed.

3. Loosen the top sheets but do not expose

the resident.

4. Place your feet in a good position – one in

close to the bed – one back. Slide both of

your arms under the resident’s back to his far

shoulder and then slide the resident’s

shoulders toward you by rocking your weight

to your back foot. If a second aide is present,

use the draw sheet to move the resident in

bed.

5. Keep your knees bent and your back

straight as you slide the resident.

Page 263 of 307

6. Slide both your arms as far as you can

under the resident’s buttocks and slide

his/her buttocks toward you in the same way.

Use a draw sheet whenever possible for

helpless residents.

7. Place both your arms under the resident’s

feet and slide them toward you.

8. Place pillows under resident accordingly to

ensure spine is in proper alignment.

9. Do final steps.

Page 264 of 307

CARE SKILLS #44: FOWLER’S POSITION

(Lesson #15)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Move resident to supine position. 2. Places resident in proper position and

alignment.

3. Elevate head of bed 45 to 60 degrees. 3. Improves breathing, allows resident to see

room and visitors.

4. Use supportive padding if necessary. 4. Maintains position, prevents friction and

reduces pressure on bony prominences.

Padding may be used under neck, shoulders,

arms, hands, ankles, lower back. Never use

padding under knees, unless directed by

nurse, as it may restrict blood flow to lower

legs.

5. Do final steps.

CARE SKILLS #45: SEMI–FOWLER’S POSITION (Lesson #15)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Move resident to supine position. 2. Places resident in proper position and

alignment.

3. Elevate head of bed 30 to 45 degrees. 3. Improves breathing, allows resident to see

room and visitors.

4. Use supportive padding if necessary. 4. Maintains position, prevents friction and

reduces pressure on bony prominences.

Padding may be used under neck, shoulders,

arms, hands, ankles, lower back. Never use

padding under knees, unless directed by

nurse, as it may restrict blood flow to lower

legs.

5. Do final steps.

Page 265 of 307

CARE SKILLS #46: USE OF WHEELCHAIR/GERIATRIC CHAIR (Lesson #15)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Be sure you know how to properly operate

chair before transferring resident into it.

Reading manufacturer’s instructions may be

necessary.

2. Not all wheelchairs are made alike.

Electronic vs manual chairs differ in use.

Improper use can result in damage to chair

and injury to resident and staff.

3. Inspect the chair to ensure that it is clean

and works properly. Most wheelchairs can be

opened by pressing down on the bars on

either side of the seat. To fold, lift the center

edges of the seat.

3. Decreases spread of pathogens and

likelihood of injury.

4. Engage and disengage the wheel lock by

moving the braking device towards and away

from the wheel.

4. Locking wheels helps to ensure chair will

not move during transfers.

5. To move the footrests, press or pull the

release lever and swing it out towards the side

of the wheelchair. To remove the footrest, lift it

off when it is at the side of the chair. To

replace it, put the footrest back onto the pins

at the side of the wheelchair. Swing footrest

back to the front of the chair to lock it into

place.

5. Leaving footrest in front of chair can cause

injury and/or falls for the aide and/or the

resident during transfers.

6. Remove armrests by releasing lock and

pulling armrest straight up. Not all armrests

are detachable from chair.

6. Removing armrests can help prevent injury

during transfer.

7. To adjust footrest up or down, activate the

release mechanism before pulling or pushing

the footrest into desired position. Always

support the leg/foot when moving footrest.

7. Decreases injury and adds comfort for

resident.

8. Follow manufacturer’s instructions on how

to properly recline and engage locks for geri-

chair.

8. Process varies depending on brand of chair.

9. Do final steps.

Page 266 of 307

CARE SKILLS #47: TRANSFER TO CHAIR/WHEELCHAIR (Lesson #15)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Place chair on resident’s unaffected side.

Brace firmly against side of bed.

2. Unaffected side supports weight. Helps

stabilize chair and is shortest distance for

resident to turn.

3. Assist resident to sit on edge of bed.

Encourage resident to sit for a few seconds

to become steady. Check for dizziness.

3. Allows resident to adjust to position

change. A significant change in position may

cause dizziness due to a drop in blood

pressure.

4. Stand in front of resident and apply gait

belt around resident’s abdomen. (Refer to

Using a Gait Belt to Assist with Ambulation

for instructions on applying gait belt.)

4. Gait belts reduce strain on your back and

provides for security for the resident.

5. Grasp the gait belt securely on both sides

of the resident.

5. Provides security for the resident and

enables them to turn.

6. Ask resident to place his hands on your

upper arms or shoulders.

6. You may be injured if resident grabs

around your neck.

7. On the count of three, help resident into

standing position by straightening your

knees.

7. Allows you and resident to work together.

Minimizes strain on your back.

8. Allow resident to gain balance, check for

dizziness.

8. Change of position may cause dizziness

due to drop in blood pressure.

9. Move your feet to shoulder’s width apart

and slowly turn resident.

9. Improves your base of support and allows

space for resident to turn.

10. Lower resident into chair by bending your

knees and leaning forward.

10. Minimizes strain on your back.

11. Align resident’s body. Remove gait belt. 11. Shoulders and hips should be in straight

line to reduce stress on spine and joints.

12. Place feet on footrests and reattach

armrest if necessary.

13. Unlock wheels and transport resident to

desired location, as needed.

14. Do final steps.

Page 267 of 307

CARE SKILLS #48: SIT ON EDGE OF BED

(Lesson #15)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Adjust bed height to lowest position. 2. Allows resident’s feet to touch floor when

sitting. Reduces chance of injury if resident

falls.

3. Move resident to side of bed closest to

you.

3. Resident will be close to edge of bed when

sitting up.

4. Raise head of bed to sitting position, if

necessary.

4. Resident can move without working

against gravity.

5. Place one arm under resident’s shoulder

blades and the other arm under resident’s

thighs.

5. Placing your arm under the resident’s neck

may cause injury.

6. On count of three, slowly turn resident into

sitting position with legs dangling over side of

bed.

7. Allow time for resident to become steady.

Check for dizziness.

7. Change of position may cause dizziness

due to a drop in blood pressure.

8. Assist resident to put on shoes or slippers. 8. Prevents sliding on floor and protects

resident’s feet from contamination.

9. Move resident to edge of bed so feet are

flat on floor.

9. Allows resident to be in stable position.

10. Do final steps.

Page 268 of 307

CARE SKILLS #49: USING A GAIT BELT TO ASSIST WITH AMBULATION

(LESSON #15)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Assist resident to sit on edge of bed.

Encourage resident to sit for a few seconds

to become steady. Check for dizziness.

2. Allows resident to adjust to position

change. A change in position may cause

dizziness due to drop in blood pressure.

3. Place belt around resident’s waist with the

buckle in front (on top of resident’s clothes)

and adjust to a snug fit ensuring that you can

get your hands under the belt. Position one

hand on the belt at the resident’s side and the

other hand at the resident’s back.

3. Buckle is difficult to release if in back and

may cause injury to ribcage if on side.

Placing the belt on top of resident’s clothes

maintains proper infection control

procedures. The belt must be snug enough

that it doesn’t slip when you are assisting

resident to move. Ensure a female resident’s

breasts are not under the belt.

4. Assist the resident to stand on count of

three.

4. Allows you and resident to work together.

5. Allow resident to gain balance. Ask the

resident if dizzy.

5. Change in position may cause dizziness

due to a drop in blood pressure.

6. Stand to side and slightly behind resident

while continuing to hold onto belt.

6. Allows clear path for the resident and puts

you in a position to assist resident if needed.

7. Walk at resident’s pace. 7. Reduces risk of falling.

8. Return resident to chair or bed and remove

belt.

9. Do final steps.

Page 269 of 307

CARE SKILLS #50: WALKING (Lesson #15)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Assist resident to sit on edge of bed.

Encourage resident to sit for a few seconds

to become steady. Check for dizziness.

2. Allows resident to adjust to position

change.

3. Assist resident to stand on count of three. 3. Allows you and resident to work together.

4. Allow resident to gain balance, check for

dizziness.

4. Change in position may cause dizziness

due to a drop in blood pressure.

5. Stand to side and slightly behind resident. 5. Allows clear path for the resident and puts

you in a position to assist resident if needed.

6. Walk at resident’s pace. 6. Reduces risk of resident falling.

7. Do final steps.

Page 270 of 307

CARE SKILLS #51: ASSIST WITH WALKER (Lesson #15)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Assist resident to sit on edge of bed. 2. Allows resident to adjust to position

change.

3. Place walker in front of resident as close to

the bed as possible.

4. Have resident grasp both arms of walker. 4. Helps steady resident.

5. Brace leg of walker with your foot and

place your hand on top of walker.

5. Prevents walker from moving.

6. Assist resident to stand on count of three.

Check for balance and dizziness.

6. Allows you and resident to work together.

7. Stand to side and slightly behind resident. 7. Puts you in a position to assist resident if

needed.

8. Have resident move walker ahead 6 to 10

inches, then step up to walker moving the

weak or injured leg forward to the middle of

the walker while pushing down on the

handles of the walker, and then bringing the

unaffected leg forward even with the

weak/injured leg. Continue sequence until

desired destination is reached.

8. Resident may fall forward if he steps too

far into walker.

9. Do final steps.

Page 271 of 307

CARE SKILLS #52: ASSIST WITH CANE (Lesson #15)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Check the cane for presence of rubber

tip(s).

2. Presence of intact rubber tips decreases

the risk of falls by improving traction and

preventing slipping.

3. Assist resident to sit on edge of bed. 3. Allows resident to adjust to position

change.

4. Assist resident to stand on count of three. 4. Allows you and resident to work together.

5. Allow resident to gain balance. Check for

dizziness.

5. Change in position may cause dizziness

due to a drop in blood pressure.

6. Have resident place cane approximately 4

inches to the side of his/her stronger/

unaffected foot. The height of the cane

should be level with resident’s hip.

7. Stand to the affected side and slightly

behind resident.

7. Allows clear path for the resident and puts

you in a position to assist resident if needed.

8. Have resident move cane forward about 4–

6 inches, step forward with weak (affected)

leg to a position even with the cane. Then

have resident move strong leg forward and

beyond the weak leg and cane. Repeat the

sequence.

8. Reduces risk of resident falls.

9. Do final steps.

Page 272 of 307

CARE SKILLS #53: USING A PORTABLE MECHANICAL RESIDENT LIFT

(Lesson #16)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Never use a lift that you have not been

properly trained to use. Facility should ensure

that each aide is properly trained over facility

policy and manufacturer’s instructions for

use.

1. Misuse could result in serious injury to

resident. Different manufacturers provide

different instructions for equipment. Aide

must know how to properly work the

equipment they are responsible for using.

2. Never use a lift alone. There should always

be two aides present to transfer resident with

lift.

2. One aide should guide the lift, while the

other aide guides the resident and ensures

resident is not injured during transfer.

3. Before transferring resident, ensure that

battery for lift is charged. Also check other

equipment (i.e., lift pad, sling, straps, etc.) to

ensure it works properly and is not in need of

repair.

3. If battery is not charged, lift could shut

down during transfer. Fraying, holes, tears,

etc. on lift pad could result in resident falling.

4. Do initial steps.

5. Follow manufacturer’s instructions and

facility’s policy on transfers using the lift.

6. Be sure all locks and straps are fastened

securely. Lock brakes on lift once it is in

position. Brakes on wheelchair should be

locked before transferring resident.

6. Brakes should be locked to ensure

equipment does not move during transfer,

which could result in serious injury to resident

and/or staff.

7. Reassure and talk to resident during

transfer.

7. Helps calm anxiety and fear of falling.

8. After transfer is complete, ensure resident

is comfortable. Remove sling/lift pad if

indicated.

9. Perform final steps.

Page 273 of 307

CARE SKILLS #54: TRANSFER: TO STRETCHER/SHOWER BED (Lesson #16)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Loosen sheet directly under resident and

roll edges close to resident.

2. This sheet will be utilized to slide resident

from bed to stretcher.

3. Place stretcher/shower bed at bedside.

NOTE: Make certain wheels are locked. After

locking wheels, ensure bed and

stretcher/shower bed are at the same height.

Then lower side rails.

3. Wheels must be locked to prevent

stretcher from moving.

4. Staff should be present at the bedside as

well as on the opposite side of the

stretcher/shower bed. (Requires a minimum

of two staff members, except when use of

additional staff is specified in care plan and/or

facility policy.)

4. To prevent resident from falling/rolling off

the bed or stretcher.

5. Grasp sheet on each side of resident. On

the count of three, slide resident laterally onto

stretcher/shower bed.

5. Counting to three enables staff members

to work together to distribute weight evenly

and prevent injury to resident and/or staff.

6. Center and align resident. Place pillow

under his/her head, cover with a blanket, and

raise the rails of stretcher/shower bed.

6. Place resident in proper position and

alignment. Pillow provides comfort; blanket

maintains dignity, provides privacy, and

keeps resident warm; raising the rails

prevents resident injury.

7. Do final steps.

Page 274 of 307

CARE SKILLS #55: TRANSFER - TWO PERSON LIFT (Lesson #16)

*ONLY TO BE USED IN AN EMERGENCY*

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Place chair at bedside. Brace it firmly

against side of bed. Lock wheels of

wheelchair or Geri chair.

2. Helps stabilize chair and is the shortest

distance for staff to turn. Wheel locks

prevent chair from moving.

3. Assist resident to sit on edge of bed.

Ensure there is staff on each side of the

resident.

3. Allows resident to adjust to position

change.

4. Reach around resident’s back and grasp

other assistant’s forearm above wrist. Have

resident place arms around your shoulders

(not your neck) or on your upper arms.

4. Having resident place arms on your

shoulders or upper arms reduces the chance

of injury to your neck.

5. Each NA should reach under resident’s

knees and grasp other assistant’s forearm

above wrist.

5. Grasping your partner’s forearm provides

for support and prevents resident from

slipping out of your grasp.

6. On the count of three lift resident. 6. Allows you to work together and allows

weight to be distributed evenly to prevent

injury to resident or staff.

7. Pivot and lower resident into chair.

8. Align resident in chair. 8. Shoulders and hips should be in a straight

line to reduce stress on spine and joints.

9. Do final steps.

Page 275 of 307

CARE SKILLS #56: OCCUPIED BED (Lesson #17)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Collect clean linen in order of use. 2. Organizing linen allows procedure to be

completed faster.

3. Carry linen away from your uniform. 3. If linen touches your uniform, it becomes

contaminated.

4. Place linen on clean surface (bedside

stand, over bed table or back of chair).

4. Prevents contamination of linen.

5. Lower head of bed and adjust bed to a

safe working level, usually waist high. Lock

bed wheels.

5. When bed is flat, resident can be moved

without working against gravity.

6. Drape the resident.

7. The caregiver will make the bed one side

at a time. The caregiver will raise the side rail

on far side of bed (if rail not in use, ensure

there is a second caregiver on the opposite

side of the bed to ensure that the resident

does not roll over the side of bed). Assist

resident to turn onto side, moving away from

you toward raised side rail (or second

caregiver).

8. Loosen bottom soiled linen on the side of

bed on which you are working. Put on gloves.

9. Roll bottom soiled linen toward resident

and tuck it snuggly against the resident’s

back. Change gloves to avoid cross–

contamination after working with soiled/dirty

linens.

9. Rolling puts dirtiest surface of linen inward,

lessening contamination. The closer the linen

is rolled to resident, the easier it is to remove

from the other side.

10. Place clean bottom linen on unoccupied

side of bed and roll remaining clean linen

under resident in the center of the bed.

11. Smooth bottom sheet out and ensure

there are no wrinkles. Roll all extra material

toward resident and tuck it under the

resident’s body.

Page 276 of 307

12. Raise the side rail nearest you (or remain

in place if a second caregiver is being

utilized) and assist the resident to turn onto

clean bottom sheet. Inform resident that

he/she may feel hump due to the covers

being rolled up. Move to opposite side of

bed, as resident will now be facing away from

you.

13. While resident is lying on side, loosen

soiled linen and roll linen from head to foot of

bed, avoiding contact with your skin or

clothing.

13. Always work from cleanest (head of bed)

to dirtiest (foot of bed) to prevent spread of

infection. Rolling dirtiest surface of linen

inward, lessening contamination.

14. Place soiled linen in barrel or bag at foot

of bed or in chair. Change gloves to prevent

possible cross contamination.

15. Pull clean bottom linen as was done on

the opposite side.

16. Assist resident to roll onto back, keeping

resident covered and comfortable.

17. Unfold the top sheet placing it over the

resident. Request the resident to hold the

clean top sheet, slip the bath blanket or

previous sheet out from underneath the clean

sheet.

17. Maintains resident’s dignity and right to

privacy by not exposing body.

18. Assist resident with blanket over the top

sheet and tuck the bottom edges of the top

sheet and blanket under the bottom of the

mattress. Miter the corners and loosen the

top linens over the resident’s feet.

18. Mitering prevents resident’s feet from

being restricted by or tangled in linen when

getting in or out of bed. Prevents pressure

on feet which can cause pressure sores.

19. Remove pillow and remove the soiled

pillow case by turning it inside out.

20. With one hand, grasp the clean pillow

case at the closed end, turning it inside out

over your wrist.

21. Using the same hand that has the pillow

case over it, grasp one narrow edge of the

pillow and pull the pillow case over it with

your free hand.

21. Prevents contamination.

22. Place the pillow under resident’s head

with open edge away from the door.

22. Creates a neater, more uniform look to

rooms and beds.

Page 277 of 307

23. Assist resident to comfortable position

and return the bed to the appropriate

position.

24. Remove soiled linens from room –

carrying away from uniform.

25. Do final steps.

Page 278 of 307

CARE SKILLS #57: INSPECTING SKIN (Lesson #18)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Provide the resident privacy. 2. Maintains resident’s dignity and right to

privacy by not exposing body. Keeps

resident warm.

3. Check bony areas including ears, shoulder

blades, elbows, coccyx, hips, knees, ankles

and heels for redness and warmth.

3. Redness and warmth indicates that the

skin is under pressure and position should be

changed more frequently.

4. Check friction areas including under

breasts and arms, between buttocks, groin,

thighs, skin folds, contracted areas, and

around any tubing for redness, irritation,

moisture and odor.

4. Pressure, rubbing and perspiration will

cause skin to break down.

5. Remove drape from resident, if one was

used, and assist resident with getting

comfortable and changing position if

necessary.

6. Report any unusual findings to the nurse

immediately.

6. Provides nurse with necessary information

to properly assess resident’s condition and

needs.

7. Do final steps.

Page 279 of 307

CARE SKILLS #58: FLOAT HEELS (Lesson #18)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Lift resident’s lower extremity.

3. Inspect the skin, especially the heels. 3. To identify any potential skin

problems/breakdown.

4. Place a full pillow under calves, leaving

heels in the air and free from pressure. (Do

not use rolled pillows or blankets.)

4. Placing the pillow directly under the heels

can increase pressure on heels.

5. Do final steps.

CARE SKILLS #59: BED CRADLE

(Lesson #18)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Place bed cradle on bed according to

manufacturer’s instructions.

2. If equipment is not applied according to

manufacturer’s instructions, discomfort or

injury could result.

3. Cover bed cradle with top sheet and

bedspread/blanket.

3. Keeps the top linens from applying

pressure/weight to toes, feet and lower legs.

4. Do final steps.

Page 280 of 307

CARE SKILLS #60: FEEDING (Lesson #19)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps. Assist resident with

toileting if needed, change brief if soiled.

2. Confirm diet card/tray. Check name, diet,

utensils and condiments.

2. This will ensure that the resident is being

served the diet as ordered; at the appropriate

consistency.

3. Explain procedure.

4. Have resident wash hands, help the

resident if needed.

4. Provides good hygiene in preparation for

meal consumption.

5. Sit on unaffected side eye level with

resident and facing them.

5. Encourages interaction with the resident

and placement of spoon at an appropriate

angle.

6. Resident’s head should be elevated at

least 45 degrees, if in bed.

6. Places resident at an angle to promote

swallowing and reduce risk of choking.

7. Protect the resident’s clothing with a

clothing protector or per facility policy and

procedures.

7. Use of a napkin or clothing protector (if

resident desires) preserves dignity by

keeping clothing clean and free of spillage.

8. Offer different foods; ask resident’s

preference.

8. Involving the resident encourages

consumption.

9. Food should be in bite sized pieces or with

the spoon half full. Food should be fed to the

unaffected side of the mouth.

9. Reduces risk of choking.

10. Allow time for resident to chew and empty

mouth between bites. Notify nurse

immediately should choking occur.

10. Reduces risk of choking.

11. Frequently offer beverage. 11. Encourages swallowing.

12. Make conversation with the resident;

atmosphere should be pleasant.

12. Enhances meal experience, thus

encourages consumption.

13. Cleanse the resident’s hands/face as

needed during the meal and after.

13. Promotes good hygiene.

14. Do final steps. If required, measure and

record I&O’s and percentage of food eaten.

Page 281 of 307

CARE SKILLS #61: ORAL TEMPERATURE [ELECTRONIC] (Lesson #20)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

Do not take oral temperature for a resident

who is unconscious, uses oxygen, or who is

confused/disoriented.

1. Remove thermometer from storage/ battery

charger.

2. Do initial steps.

3. Position resident comfortably in bed or

chair.

4. Put on disposable sheath and place

thermometer under the tongue and to one

side, press button to activate the

thermometer.

4. The thermometer measures heat from

blood vessels under the tongue.

5. The resident should be directed to breathe

through their nose.

6. Instruct resident to hold thermometer in

mouth with lips closed. Assist as necessary.

6. The lips hold the thermometer in position.

7. Leave thermometer in place until signal is

heard, indicating the temperature has been

obtained.

8. Read the temperature reading on the face

of the electronic device, remove the

thermometer, discard the sheath, and record

the reading.

8. Record temperature immediately so you

won’t forget. Accuracy is necessary because

decisions regarding resident’s care may be

based on your report. What you document is

a legal record of what you did. If you don’t

document it, legally, it didn’t happen.

9. Do final steps.

10. Return thermometer to storage/battery

charger.

11. Report unusual reading to nurse. 11. Provides nurse with necessary

information to properly assess resident’s

condition and needs.

Page 282 of 307

CARE SKILLS #62: AXILLARY TEMPERATURE (Lesson #20)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

Often taken when inappropriate to take an

oral temperature; particularly if resident is

confused or combative

1. Remove thermometer from storage/

battery charger.

2. Do initial steps.

3. Position resident comfortably in bed or

chair.

4. Put on disposable sheath, remove

resident’s arm from sleeve of gown, wipe

armpit and ensure it is dry. Hold thermometer

in place with end in center of armpit and fold

resident’s arm over chest.

4. Places thermometer against blood vessels

to get reading.

5. Press button to activate the thermometer.

6. Hold thermometer in place until signal is

heard, indicating the temperature has been

obtained.

7. Read the temperature reading on the face

of the electronic device, remove the

thermometer, discard the sheath, and record

the reading.

7. Record temperature immediately so you

won’t forget. Accuracy is necessary because

decisions regarding resident’s care may be

based on your report. What you document is

a legal record of what you did. If you don’t

document it, legally, it didn’t happen.

8. Assist the resident to return arm through

sleeve of clothing/gown.

9. Do final steps.

10. Return thermometer to storage/battery

charger.

11. Report unusual reading to nurse. 11. Provides nurse with necessary

information to properly assess resident’s

condition and needs.

Page 283 of 307

CARE SKILLS #63: PULSE AND RESPIRATION (Lesson #20)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Place resident’s hand on comfortable

surface.

2. Feel for pulse above wrist on thumb side

with tips of first three fingers.

2. Because of artery in your thumb, pulse

would not be accurate if you use your thumb.

3. Count beats for 60 seconds, noting rate,

rhythm and force.

3. Ensures accurate count. Rate is number

of beats. Rhythm is regularity of beats. Force

is strength of beats.

4. Continue position as if feeling for pulse.

Count each rise and fall of chest as one

respiration.

4. Resident could alter breathing pattern if

aware that respirations are being taken.

5. Count respirations for 60 seconds noting

rate, regularity and sound.

5. Ensure accurate count. Rate is number of

breaths. Regularity is pattern of breathing.

Sound is type of auditory breaths heard.

6. Record pulse and respiration rates. 6. Record pulse and respirations immediately

so you won’t forget. Accuracy is necessary

because decisions regarding resident’s care

may be based on your report. What you write

is a legal record of what you did. If you don’t

document it, legally, it didn’t happen.

7. Report unusual findings to nurse. 7. Provides nurse with information to assess

resident’s condition and needs.

8. Do final steps.

Page 284 of 307

CARE SKILLS #64: PRACTICAL USE OF THE PULSE OXIMETER

(Lesson #20)

STEP – Initial Steps: Turn the pulse oximeter

on: it will go through internal calibration and

checks.

RATIONALE

1. Select the appropriate probe with particular

attention to correct sizing and where it will go

(usually finger, toe or ear).

1. If used on a finger or toe, make sure the

area is clean. Remove any nail varnish.

2. Connect the probe to the pulse oximeter.

3. Position the probe carefully; make sure it

fits easily without being too loose or too tight.

3. If possible, avoid the arm being used for

blood pressure monitoring as cuff inflation will

interrupt the pulse oximeter signal.

4. Allow several seconds for the pulse

oximeter to detect the pulse and calculate the

oxygen saturation.

5. Look for the displayed pulse indicator that

shows that the machine has detected a

pulse. Without a pulse signal, any readings

are meaningless.

6. Once the unit has detected a good pulse,

the oxygen saturation and pulse rate will be

displayed.

7. Like all machines, oximeters may

occasionally give a false reading – if in doubt,

rely on your clinical judgment, rather than the

machine.

7. The function of the oximeter probe can be

checked by placing it on your own finger.

Aide is to record pulse ox % (as in other vital

signs).

9. Adjust the volume of the audible pulse

beep to a comfortable level for your theatre –

ever use on silent.

9. Always make sure the alarms are on.

10. Record measurements as displayed on

monitor, per facility policy, and report to

charge nurse accordingly.

10. Further treatment may be needed,

depending on values that are reported. If the

numbers are not documented, then the skill

cannot be considered performed.

Page 285 of 307

CARE SKILLS #65: BLOOD PRESSURE (Lesson #20)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Clean earpieces and diaphragm of

stethoscope with antiseptic wipe.

1. Reduces pathogens; prevents spread of

infection.

2. Uncover resident’s arm to shoulder.

3. Rest resident’s arm, level with heart, palm

upward on comfortable surface.

3. A false low reading is possible, if arm is

above heart level.

4. Wrap proper sized sphygmomanometer

cuff around upper unaffected arm

approximately 1–2 inches above elbow.

4. Cuff must be proper size and placed on

arm correctly so amount of pressure on

artery is correct. If not, reading will be falsely

high or low.

5. Put earpieces of stethoscope in ears. 5. Earpieces should fit into ears snugly to

make hearing easier.

6. Place diaphragm of stethoscope over

brachial artery at elbow.

7. Close valve on bulb. If blood pressure is

known, inflate cuff to 20 mm/hg above the

usual reading. If blood pressure is unknown,

inflate cuff to 30 mm/hg past the point of

occlusion.

7. Inflating cuff too high is painful and may

damage small blood vessels.

8. Slowly open valve on bulb. 8. Releasing valve slowly allows you to hear

beats accurately.

9. Watch gauge and listen for sound of pulse.

10. Note gauge reading at first pulse sound. 10. First sound is systolic pressure.

11. Note gauge reading when pulse sound

disappears or changes.

11. Last sound is diastolic pressure.

12. Completely deflate and remove cuff. 12. An inflated cuff left on resident’s arm can

cause numbness and tingling. If you must

take blood pressure again, completely deflate

cuff and wait 30 seconds. Never partially

deflate a cuff and then pump it up again.

Blood vessels will be damaged and reading

will be falsely high or low.

Page 286 of 307

13. Accurately record systolic and diastolic

readings.

13. Record readings immediately so you

won’t forget. Accuracy is necessary because

decisions regarding resident’s care may be

based on your report. What you write is a

legal record of what you did. If you don’t

document it, legally, it didn’t happen.

14. Do final steps.

15. Report unusual readings to nurse. 15. Provides nurse with information to

properly assess resident’s condition.

Page 287 of 307

CARE SKILLS #66: HEIGHT (Lesson #20)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Using standing balance scale: Assist the

resident onto the scale, facing away from the

scale. Ask the resident to stand straight.

Raise the rod to a level above the resident’s

head. Lower the height measurement device

until it rests flat on the resident’s head.

1. Measurements are written on the rod in

inches.

2. When a resident is unable to stand: Flatten

the bed and place resident in supine position.

Place a mark on the sheet at the top of the

head and another at the bottom of the feet.

Measure the distance.

2. Places resident in proper position and

alignment; allows you to measure resident

accurately.

3. If the resident is unable to lay flat due to

contractures: Utilize a tape measure and

beginning at the top of the head, follow the

curves of the spine and legs, measuring to

the base of the heel.

3. Allows you to obtain an accurate

measurement for the resident who cannot

fully extend body.

4. Accurately record resident’s height. Assist

resident off the scale.

4. Record height immediately so you won’t

forget. Accuracy is necessary because

decisions regarding resident’s care may be

based on your report. What you write is a

legal record of what you did. If you don’t

document it, legally, it didn’t happen.

5. Do final steps.

Page 288 of 307

CARE SKILLS #67: WEIGHT (Lesson #20)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Balance scale. 1. Scale must be balanced on zero for weight

to be accurate.

2. Depending on scale used, assist resident

to stand on platform or sit in chair with feet on

footrest or transport wheelchair onto scale

and lock brakes.

2. When using chair scale, if resident has feet

on floor, weight will not be accurate. Wheel

locks prevent chair from moving when using

a wheelchair scale.

3. When using a standard scale –lower

weight to fifty-pound mark that causes arm to

drop. Move it back to previous mark. Move

upper weight to pound mark that balances

pointer in middle of square. Add lower and

upper marks. When using a digital scale –

press weigh button. Wait until numbers

remain constant.

3. When arm drops, weight is too high. When

pointer is suspended, weight is accurate.

Total gives accurate weight.

4. Subtract weight of wheelchair from total

weight, if applicable.

5. Accurately record resident’s weight. 5. Record weight immediately so you won’t

forget. Weight changes are an indicator of

resident’s condition. Accuracy is necessary

because decisions regarding resident’s care

may be based on your report. What you write

is a legal record of what you did. If you don’t

document it, legally, it didn’t happen.

6. Do final steps.

7. Report unusual reading to nurse. 7. Provides nurse with information to assess

resident’s condition and needs.

Page 289 of 307

CARE SKILLS #68: APPLICATION OF PHYSICAL RESTRAINTS (Lesson #21)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Check with the nurse before gathering

supplies. Verify the type of restraint that was

ordered for the resident. The NA should

ensure that he/she was properly trained by

the facility on how to use the restraint per the

manufacturer’s instructions and facility’s

policy.

1. NA/CNA can only use/apply restraints

when instructed to do so by the charge nurse.

Ensures that the correct restraint will be used,

as ordered by the physician. NA/CNA should

not apply a restraint that he/she has not

received training for. Although restraints

appear the same, manufacturers can provide

different instructions/guidance for use and

application. Improper application can result in

serious harm and/or death for the resident.

2. Do initial steps.

3. Follow manufacturer’s instructions and

facility’s policy on applying the restraint.

3. Same as previously stated.

4. If resident is in bed, be sure to tie restraint

to the part of the bed that moves with the

resident. Never tie restraints to side rails or

the fixed part of the bed frame (that does not

move with the resident when repositioning).

4. Tying restraints to the fixed portion of the

frame or to side rails will cause the restraint

to tighten as the bed is moved for positioning.

This can cause discomfort, pain, and

problems with circulation and lead to more

serious concerns.

5. Make sure that the restraint is not too tight.

Check pulse in the affected areas to ensure

circulation is not occluded (cut off). Make

sure that breasts and skin are not caught in

the restraint.

5. Occlusion can lead to serious

consequences for the resident, including

nerve damage, loss of use, etc.

6. Place call light in easy reach.

7. Check resident and restraint every 15

minutes, or more frequently if necessary or

instructed.

7. Constant monitoring helps to ensure that

the resident is not in distress or experiencing

discomfort due to the restraint.

8. Release the restraint at least every two

hours or more frequently as needed or

instructed. Assist the resident with toileting,

ambulating, changing position, and other

ADLs as needed.

9. Document according to facility policy.

10. Perform initial/final steps as needed when

checking on the resident.

Page 290 of 307

CARE SKILLS #69: PASSIVE RANGE OF MOTION (Lesson #22)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Position resident in good body alignment. 2. Reduces stress to joints.

3. Observe joints. If swelling, redness or

warmth is present, or if resident complains of

pain, notify nurse. Continue procedure only if

instructed.

3. Indicates inflammation in joint which can

be worsened if procedure is continued.

4. Support limb above and below joint.

5. Begin range of motion at shoulders and

include the shoulders, elbows, wrists,

thumbs, fingers, hips, knees, ankles and

toes.

5. Allows you to control joint movement and

minimize resident’s discomfort.

6. Slowly move joint in all directions it

normally moves.

6. Rapid movement may cause injury.

7. Repeat movement per facility policy or

care plan.

7. Ensures benefit from procedure.

8. Encourage resident to participate as much

as possible.

8. Promotes resident’s independence and

self–esteem.

9. Stop procedure at any sign of pain and

report to nurse immediately.

9. Pain is a warning sign for injury.

10. Do final steps.

Page 291 of 307

CARE SKILLS #70: SPLINT APPLICATION (Lesson #22)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Observe affected joints. If swelling,

redness, or warmth is present or if resident

complains of pain, notify nurse. Continue

procedure only if instructed.

2. Indicates inflammation in joint which can

be worsened if splint is applied.

3. Apply splint according to therapy

recommendation and physician’s order.

3. Application of splint not in accordance with

therapy recommendation could cause injury

or discomfort to resident.

4. Remove splint after designated period of

time. Cleanse the skin, dry thoroughly and

again observe for swelling, redness, warmth,

complaint of pain or open area. Notify the

nurse if present.

4. Indicates inflammation in joint. Notifying

nurse provides him/her with information to

assess resident’s condition and needs.

5. Do final steps.

Page 292 of 307

CARE SKILLS #71: ABDOMINAL BINDER (Lesson #22)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Check the skin for redness, open areas, or

needed incontinence care.

2. Allows you to identify early signs of skin

breakdown and the need for cleansing prior

to binder application.

3. Place binder flat on the bed and ask

resident to lie down with upper border at the

upper waist and lower border at the level of

the gluteal fold. If resident is in bed, assist

him/her to roll side–to–side while placing

binder underneath him/her in the same

position.

3. A binder placed above the waist interferes

with breathing; one placed too low interferes

with elimination and walking.

4. Bring the ends of binder around the

resident, and overlap them. Beginning at the

bottom of the binder, secure the Velcro

fastener strip so that the binder fits snugly.

4. A snug fit provides maximum support. If

the binder is too loose, efficacy is impaired. If

it is too tight, resident may be uncomfortable.

5. Ensure that there are no wrinkles or

creases in the binder.

5. Wrinkles and creases put pressure on the

skin increasing the risk for excoriation.

6. Do final steps.

Page 293 of 307

CARE SKILLS #72: ABDUCTION PILLOW (Lesson #22)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Place the pillow between the supine

resident’s legs. Slide it with the narrow end

pointing toward the groin until it touches the

legs all along its length.

3. Place the upper part of both legs in the

pillow’s indentations. Raise each leg slightly

by lifting under the knee and ankle to bring

straps under and around leg and then secure

the straps to the pillow.

3. Securing the straps prevents the pillow

from slipping out of place.

4. Do final steps.

5. Report resident intolerance or complaint of

pain upon application to the nurse.

5. Provides nurse with information to assess

resident’s condition and needs.

Page 294 of 307

CARE SKILLS #73: KNEE IMMOBILIZER (Lesson #22)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. With resident lying supine in bed, one

caregiver will support the leg above the knee

and at the ankle and lift the leg in one motion,

providing enough height for a second

caregiver to place the immobilizer under the

affected leg. Check skin prior to applying the

immobilizer.

2. It is important to maintain the leg in a

straight position while placing the immobilizer

and to monitor for any skin

problems/breakdown.

3. The caregiver will lower the leg into the

open immobilizer, keeping the leg straight.

4. Pull both sides of the immobilizer to center

of front of leg and wrap one side over the

other, securing the Velcro strip holding the

immobilizer in place. Make sure the Velcro

stabilizer bar strips are attached to opposite

sides of the immobilizer to prevent any

motion of the knee medially or laterally.

5. Bring straps around each side and secure

to stabilize the immobilizer.

6. When removing the immobilizer for

bathing/care, support the leg in the same

manner, keeping the leg straight at all times.

Observe for any reddened areas, particularly

at the upper and lower edge of the

immobilizer, which is in contact with the

resident’s skin.

6. Constant contact with the edge of the

immobilizer can place the skin at risk of

breakdown. Early detection of any concern

can prevent further breakdown.

7. Report to the nurse any skin irritation,

open area, or complaint of pain.

7. Reporting to the nurse will ensure that

treatment is obtained, if needed.

8. Do final steps.

Page 295 of 307

CARE SKILLS #74: PALM CONES (Lesson #22)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Cleanse and thoroughly dry resident’s

hand.

2. Cleansing and drying of hands prevents

odor and infection.

3. Place cone with clean cover in resident’s

palm.

4. Observe hand(s) every shift; cleanse and

thoroughly dry hands. Observe for areas of

redness, swelling or open areas and report to

the nurse, if noted.

4. Allows you to identify early signs of skin

breakdown.

5. Note covering of palm cone and send to

laundry when soiled, re–covering cone with a

clean covering, as needed.

5. Maintaining cleanliness enhances

resident’s dignity.

6. Do final steps.

Page 296 of 307

CARE SKILLS #75: ASSISTING WITH HEARING AIDS (Lesson #23)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Gently clean resident’s ear with a damp

washcloth. Clean hearing aid of wax and dirt

when needed according to manufacturer’s

instructions.

2. To ensure ears are clean prior to insertion

of hearing aids, thus ensuring maximum

acuity.

3. Insert hearing aid into resident’s ear.

4. Assist to adjust the volume control to a

desired level.

4. To ensure that aid is turned up high

enough for resident to hear, but not so high

that noises will hurt resident’s ear(s).

5. Do final steps.

6. Report any abnormalities to nurse. 6. Provides nurse with necessary information

to properly assess resident’s condition and

needs.

7. Keep hearing aid in safe place when not in

use.

7. Helps reduce risk of damage to device.

Page 297 of 307

CARE SKILLS #76: ELASTIC/COMPRESSION STOCKING APPLICATION OR TED HOSE

(Lesson #23)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Observe skin prior to applying the

stockings for any redness, warmth, swelling,

excessive dryness, or open area. Notify

nurse if abnormalities present. Continue

procedure only if instructed.

2. Provides nurse with information to assess

resident’s condition and needs.

3. Apply the hose before resident gets out of

bed.

3. Hose should be applied before veins

become distended and edema (swelling)

occurs.

4. Hold heel of stocking and gather the rest in

your hand turning hose inside out to mid foot

area.

5. Support foot at the heel and slip the front

of the stocking over the toes, foot and heel.

6. Pull the stocking up until it is fully

extended.

7. Smooth away any wrinkles or twisted

areas.

7. Wrinkles, creases, or twisted areas can

irritate the skin and interfere with circulation.

8. Remove the hose at least twice daily for

skin care unless otherwise indicated by

physician.

8. Allows you to identify early signs of skin

break down.

9. Do final steps.

Page 298 of 307

CARE SKILLS #77: ADMISSION OF A RESIDENT (Lesson #27)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Prepare the room for the resident by

making sure that all necessary equipment

and furniture are in its proper place, in good

working condition and clean. Make sure bed

is made with clean linen and all space is

clean. Check for adequate lighting and

provide ventilation. Apply resident’s name

label on door, etc. as needed.

2, Preparing the room in advance can help

the resident feel more welcomed and at ease

upon arrival, and it allows more time to focus

on the resident.

3. Identify the new resident by asking his/her

name and by checking the identification.

Identify yourself. Greet the resident and

family courteously. Call resident by proper or

preferred name. Introduce yourself and state

your position.

3. Greeting the resident and family and

showing kindness helps ease anxiety.

Identifying them by proper name shows

respect and allows the resident the

opportunity to establish how they prefer to be

addressed.

4. Take the resident and family to the room. If

semi-private room, be sure to introduce

resident to roommate.

4. Resident should be introduced to other

residents and employees. Helps establish

bonds and ease anxiety.

5. Assist resident with getting comfortable in

the room. Provide privacy and assistance as

needed with transferring to bed/chair,

dressing/undressing, or any other task as

requested by resident and/or nurse.

6. Place call light within reach of resident and

explain how and why it is used.

6. Gets the resident familiar with how they will

contact the staff if assistance is needed.

7. Care for clothing and personal articles

according to facility policy. Assist with

unpacking and labeling clothing. Label all

personal articles and store in bedside table

(or appropriate place). Be certain that

resident and/or family member(s) know

where to place these articles.

7. Labeling articles helps the staff to identify

what items belongs to which resident.

Ensures that items will be returned to

appropriate person. Establishing placement

of articles alleviates confusion, especially

when room is being shared with another

resident.

Page 299 of 307

8. Follow and explain to the resident and

family the facility policy for inventory and

safekeeping of valuables.

8. Same rationale as above.

9. Give instructions to resident and/or family

as to time and place of meals and, as

appropriate, provide other orientation such as

facility premises, introduction to other staff,

etc.

9. Orienting resident and family to facility and

staff helps them learn the daily routine,

addresses questions/concerns they may

have, and helps get them familiar with their

new home and caregivers. Alleviates

confusion regarding their new surroundings.

10. Obtain vital signs, including temperature,

pulse, respiration, and blood pressure. Also

obtain weight and height. Record according

to facility policy. Follow guidelines for

performing each skill accordingly.

10. Establishes baseline levels for nurses to

compare to later.

11. Ensure resident is comfortable and has

call light available. If permitted, leave fresh

ice water within reach.

12. Record/report completion of procedure.

Report to charge nurse: resident’s vital

signs; any bruises, sores, etc. on the

resident’s body; any special observations

made about the resident.

Perform any additional final steps

accordingly.

Page 300 of 307

CARE SKILLS #78: TRANSFER/DISCHARGE OF THE RESIDENT

(Lesson #27)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Inform the resident of the move and let

them know you are there to assist. Questions

or concerns that arise should be addressed

by the nurse, unless informed otherwise.

2. Some information may be different from

what you were previously told. It is best for

the nurse to provide updates and address

any concerns/questions.

3. Collect all personal items that are to be

moved with the resident and assist with

packing as needed. Secure valuables per

facility policy. Ensure that all items on the

inventory list are there. Report to the nurse if

items are missing.

Take items to designated pick-up area.

3. Nurse should be aware of missing items so

that attempts can be made to locate them. If

possible, take belongings to designated area

first to make transporting the resident easier.

4. Assist the resident with getting dressed if

necessary.

5. Before the resident leaves the unit, confirm

with the nurse that all discharge procedures

have been completed.

5. Helps to ensure that steps are not being

missed.

6. Speak with the nurse to determine how the

resident is to be transported (in his/her own

bed, wheelchair, or stretcher). Transport

accordingly.

7. Allow and assist the resident to say

goodbye to the staff and other residents while

being transported to the designated pick-up

area.

8. Assist resident with getting into the vehicle

and ensure that their belongings are also

loaded.

9. Wash hands. Document and report.

Perform any additional final steps

accordingly.

Page 301 of 307

CARE SKILLS #79: POSTMORTEM CARE

(Lesson #28)

STEP – Initial Steps: Check the resident’s

care plan/closet care plan first.

RATIONALE

1. Do initial steps.

2. Put on gloves. 2. Protects you from contamination by bodily

fluids.

3. Respect the family’s religious restrictions

regarding the care of body, if applicable.

3. Residents/families have the right to

freedom of religion.

4. Assist roommate to leave the area until

body is prepared and removed, if applicable.

4. Reduces the roommate’s stress.

5. Place body in supine position. 5. Prepares body for procedure.

6. Place one pillow beneath resident’s head. 6. Prevents blood from discoloring the face by

settling in it.

7. Close the eyes.

8. Insert dentures, if this is the facility policy,

and close the mouth.

8. It is easier to put dentures in the mouth

right away and gives the face a natural

appearance.

9. Cleanse body as necessary. Comb hair. 9. Prepares the body for viewing by family

and friends.

10. Place a pad under the buttocks to collect

any drainage.

10. Due to total loss of muscle tone, urine

and/or stool may drain from the body even

after death.

11. Put a clean hospital gown on resident

and place body in a comfortable looking

position to allow family and friends to view

the body.

12. Remove gloves.

13. Do final steps.

14. After the mortuary has removed the body,

strip the bed and clean the room according to

facility policy.

Page 302 of 307

Appendix D

Task Performance Record

Page 303 of 307

Trainee’s Name

SS#

Primary Instructor’s Name

Program Name

Program’s Address

Telephone

TASK PERFORMANCE

Satisfactory

Performance

Date

Supervising Instructor’s

Initials

Clinical

Performance Date

Initial Steps

Final Steps

Handwashing/Hand Rub

Gloves

Gown (PPE)

Mask

Fire

Fire Extinguisher

Falling or Fainting

Choking

Seizures

Unoccupied Bed

Thickened Liquids

Page 304 of 307

TASK PERFORMANCE

Satisfactory

Performance

Date

Supervising Instructor’s

Initials

Clinical

Performance Date

Measure & Record Fluid Intake/Urinary

Output

Passing Fresh Ice Water

Serving Meal Tray

Nasal Cannula Care

Shower/Shampoo

Bed Bath/Catheter Care/Perineal Care

Back Rub

Shampoo Hair in Bed

Whirlpool

Oral Care

Oral Care for the Unconscious Resident

Denture Care

Shaving with an Electric Razor

Shaving with a Safety Razor

Comb/Brush Hair

Fingernail Care

Foot Care

Change a Resident’s Gown

Page 305 of 307

TASK PERFORMANCE

Satisfactory

Performance

Date

Supervising Instructor’s

Initials

Clinical

Performance Date

Dressing a Dependent Resident

Assist to Bathroom

Bedside Commode

Bedpan/Fracture Bedpan

Urinal

Empty Urinary Drainage Bag

Urine Specimen Collection

Stool Specimen Collection

Application of Incontinent Brief

Assist Resident to Move to Head of Bed

Supine Position

Lateral Position & Side to Side

Fowler’s Position

Semi-Fowler’s Position

Use of Wheelchair/Geriatric Chair

Transfer to Chair

Sit on Edge of Bed

Using a Gait Belt to Assist with Ambulation

Page 306 of 307

TASK PERFORMANCE

Satisfactory

Performance

Date

Supervising Instructor’s

Initials

Clinical

Performance Date

Walking

Assist with Walker

Assist with Cane

Using a Portable Mechanical Resident Lift

Transfer to Stretcher/Shower Bed

Transfer: Two Person Lift

Occupied Bed

Inspecting Skin

Float Heels

Bed Cradle

Feeding

Oral Temperature (Electronic)

Axillary Temperature

Pulse and Respiration

Practical Use of the Pulse Oximeter

Blood Pressure

Height

Weight

Page 307 of 307

TASK PERFORMANCE

Satisfactory

Performance

Date

Supervising Instructor’s

Initials

Clinical

Performance Date

Application of Physical Restraints

Passive Range of Motion

Splint Application

Abdominal Binder

Abduction Pillow

Knee Immobilizer

Palm Cones

Assisting with Hearing Aids

Elastic/Compression Stocking Application or

Ted Hose

Admission of a Resident

Transfer/Discharge of the Resident

Postmortem Care

I, as Primary Instructor, attest to the competency/skills observations shown on this Task Performance Record, whether performed by

me or designated to another training instructor.

Primary Instructor’s Signature Date

DMS-741 (Revised 01-19)