Basic nursing exam #2

Vital signs

temperature, pulse, respirations, and blood pressure. Never guess any of them

Draw sheet

turning sheet that is placed under residents who are unable to assist with turning, lifting or moving up in bed

Bathing steps

1.) eyes 2.) face 3.) ears 4.) neck 5.) arms, axilla, and hands 6.) chest and abdomen 7.) legs and feet 8.) back 9.) personal area 10.) butt

Disposable equipment

Cups, tissues, gloves, paper gowns, mask, disposable razors, and pads. Disposal equipment prevents the spread of micro organisms. Nursing assistance should dispose of this equipment in the proper container. Gloves should be worn when using or discarding some types of equipment such as razors and pads. Some equipment such as urinals and bed pans is cleaned after each use.

Hair care

Daily hair care affects the way residence look and feel about themselves. Nursing assistance help keep residence hair clean and sold. It is important that residents be allowed to choose their own hair cells. Here ornaments should be used only as requested, and residents hair should never becomes or brush into childish styles. Combs and brushes in their containers may need to be labeled with the residents name and room number. Because hair thins as people age, pieces of hair can be pulled out of the head while combing or brushing it. The skin on elderly people whose heads is fragile. Nursing assistance must handle residence hair very gently. Nursing assistant should never cut residents hair, even if residents request it or if the hair is extremely mad at her tangled

Skin care

Eyes, face, ears, neck, arms and hands, chest and abdomen, legs and feet, back, private areas, butt area

Fever

An increase in body temperature may indicate an infection or disease. In addition to an elevated temperature reading, signs and symptoms of a fever include headache, fatigue, muscle aches, and chills. Skin may feel warm and look flushed. Residents with darker skin tones may exhibit more subtle skin color changes. When an NA suspects a fever. She should always take a temperature. Fevers can develop quickly. It is possible to detect an ideation early and prevent complications from occurring. Fevers should be reported to nurse immediately.

Dressing

Dressing and undressing residents is an important part of daily care. When helping with dressing. The NA should know what limitations the resident has. Residents may have one side of the body that is weaker than the other side due to stroke or injury. That side is called the weaker, affected, or invoked side. When dressing residents, the NA should begin with the weaker side of the body to reduce the risk of injury. The acronym POW can be used to remember to put clothing on the weak side. Put on weak. When removing clothing, the opposite should be done. The NA should begin with the stronger, or unaffected, side first when undressing.!

dietary habits

Drinking or eating products with caffeine, such as soda or chocolate, can prevent sleep. Eating heavy meals before bedtime can cause restlessness or discomfort. This can make it harder to fall asleep or can cause wakefulness during the night.

Factors affecting sleep

Environment, noise level and lighting, problems with odors and inadequate ventilation, temperature problems, anxiety, illness, aging changes, dietary habits, medications, alcohol, and cigarettes

Pain

Increased pulse, respirations, blood pressure, sweating, nausea, vomiting, tightening the jaw, squeezing Eyes shut, holding or guarding a body part, frowning, grinding teeth, increase restlessness, agitation or tension, change in behavior, crying, sighing, groaning, breathing heavily, or difficulty moving or walking

linen

Must be changed when they are wet, soiled, or when they are too wrinkled for comfort. Residents can develop pressure ulcers when left in wet, wrinkled, or soiled linens. Make sure to remove and change disposable pads whenever they become soiled or wet

Transferring a resident with a weak side

NA's must plan the move so that the stronger side moves first and the weaker side follows. It is difficult for the weaker arm and leg to bear enough weight for the transfer if moved first.

Personal care- promoting independency

NA's provide will depend upon each residents needs and abilities. The way in which a NA gives this card is important to promoting residents self esteem and dignity. NA should encourage residents to perform self-care whenever they can. This may make some tasks, such as getting dressed, take longer. In addition to promoting dignity and independence. Doing self care also helps keep the body functioning as well.

Nail care

Proper grooming includes regular no care. Fingernails can collect and Harbor Microorganisms. It is important to keep hands and nails clean to help prevent infection. In addition, long and ragged nails can easily scratch residents, visitors, and staff. Cleaning and caring for the nails is a part of the bathing process. Soak the residents hands and nails in the basin of water. Soak all 10 fingertips for at least five minutes. Remove hands from water. Wash hands with soapy washcloth. Rinse. Pat hands dry with towel, including between fingers. Remove hand from basin. Place residents hand on the towel. Gently clean under each finger no with orange would stick.

Denture care

Remove the lower denture first. The lower denture is easier to remove because it floats on the gumline of a lower jaw. Grasp the lower denture with a gauze Square and remove it. The upper denture is sealed by suction. Firmly grasp the upper denture with a gauze square. Give a slight downward pull to break the suction. Turn it at an angle to take it out of the mouth. Rinse dentures and clean moderate/cool running water before brushing them. Do not use hot water. Hot water may warp or damage dentures. Apply denture cleanser to toothbrush. Brush the dentures on all surfaces. Rinse denture cup and lid before placing clean dentures into the cup. Placed in tours and clean, labeled denture cup with solution or moderate/cool water. Denture should be completely covered with solution. Place lid on denture cup and return denture cup to storage.

Weighing a resident

Residence height and weight will be checked when they are admitted . Nursing assistance also check weight as a part of regular care. Height is usually not checked as often as weight. Changes in a residents weight can be a sign of illness. Na's must report any weight loss or gain, no matter how small

Transfer Belt (Gait Belt)

Safety device used to transfer residents who are weak, unsteady, or uncoordinated. It is called a gait belt when it is used to help residents walk. The belt is made of canvas or other heavy material, it has a strong buckle and sometimes has handles.

Hygiene

Term used to describe practices to keep the body clean. Hygiene and grooming, along with other personal care tasks, are called activities of daily living or ADL. ADL include grooming, dressing, bathing, eating, and drinking, transferring, and elimination

Ambulating a visually impaired resident

The NA should let the person walk beside and slightly behind her, as he rests a hand on the NA's elbow. The NA should walk at the residents normal pace. She would let the resident know when they are about to turn a corner or when a step is approaching. The NA should state whether they will be stepping up or stepping down.

Oral care

The care of the mouth, teeth, and gums. This care must be provided at least twice a day, but some residents will need or want oral care done more often. Oral care consist of brushing the teeth, tongue, and gums, flossing teeth, caring for lips, and caring for dentures.

Respiration

The most common site for counting pulse beats. The pulse is found on the inside of the wrist on the thumb side of the body. A pulse may be regular, having the same amount of time between beats, or irregular, having varying amounts of time between the beats. When checking a residents pulse. The NA should observe the following: •the pulse rate (the number of beats in one minute, the normal range is 60 to 100 beats per minute) •the overall pattern of the pulse: is the pulse regular or irregular. •the quality or type of pulse is the pulse weak or strong?

Positioning

The positioning of the body plays an important role in the proper functioning of the body. Whether standing, sitting, or lying down the body shouldn't be incorrect alignment and exhibiting good posture. Posture is the way a person holds and positions his body. Positioning means helping residents into positions that prompt comfort and good health.

Temperature

There are different sites on the body for measuring temperature. Mouth (oral), the rectum (rectal), the armpit (axillary), the ear (tympanic). A rectal temperature is considered to be the most accurate, while an axillary temperature is considered to be at least accurate.

Pulse

You can use a stethoscope to hear the apical pulse. When doing a radial pulse you count the beats for one full minute and record the pulse rate, date, time and method used. Record the respiratory rate in the pattern or character of breathing.

NA role in helping new residents in admission

• wash your hands then gather any necessary equipment to bring to the residents room. • an admissions pack or kit contains personal care items for resident examples are a wash basin, Emesis basin, bed pan, urinal, toothbrush, toothpaste, soap, tissues, and water pitcher in a cup • stethoscope and a sphygmomanometer •a thermometer •a facility gown or pajamas, depending upon the resident •prepare the residents room before the resident arrives •make the bed according ti the nurses instructions •when the resident arrives, introduce yourself •do not rush the process or the resident •introduce the new resident to her roomate and other residents in the rooms on either side and across the hall •explain day to day life in the facility •show the residents how to work the bed controls •make sure the call light is close to the bed •explain how to work the television and the telephone •handle all the residents personal items with care and respect

wheelchair safety

•Check wheel locks •Check for flat or loose tires •Check wheel spokes •Be sure casters point forward for balance and stability •Be sure person's feet are on footplates before pushing or repositioning (feet cannot touch or drag on floor) •Push chair forward when transporting person, going backward ONLY through a doorway •Lock both wheels before you transfer person to or from the wheelchair •Follow care plan for keeping wheels locked when not mving wheelchair (locking would keep person from moving or getting out of chair is so desired) •DO NOT let person stand on footplates •DO NOT let footplates fall back onto person's legs •Make sure person has needed safety belt, pouch, tray, lapboard or cushions •Remove armrests (if able) when transferring person to bed, toilet, commode, tub, or car •Swing front rigging out of way to transfer to & from wheelchair (some detach) •Clean wheelchair according to agency policy •Ask nurse or PT to show you how to propel wheelchair up steps, ramps, and over curbs •Follow measure to prevent equipment accidents

Beside table, overbed table, resident unit

•The bedside stand is used for storing equipment like emesis basins, bath basins, urinals, and bedpans. Basins are generally placed on the top shelf, and bedpans and urinals are on the lower shelf in the section underneath. A telephone, along with personal items, may be placed on the top stand. •overbed stand May be used for residents meals or personal care. It is a clean area and must be kept clean and free of clutter. Bedpans, urinals and soiled linen should not be placed on overbed tables because theses tables are used for food. Right before mealtime, the NA should clear this table so that the meal tray can slide smoothly onto it. A water pitcher and cup are routinely kept on the overbed table. •Residents units are their living spaces. They contain their beds, other furniture, and personal items. These units must be kept clean and neat, while also honoring residents personal choices. Valuing each residents choice is part of person centered care. This room is the residents home. Nursing assistants should always knock and wait for permission before entering.

NA role in house transfer

•collect the items to be moved onto the cart, and ask another staff member to help take them to the new location •lock wheelchair or stretcher wheels. Help the resident into the wheelchair or onto the stretcher. •introduce new residents and staff. •proved for the residents privacy with a curtain •lock wheelchair or stretcher wheels. Transfer the resident to the new bed if needed. •unpack all belongings. Help the resident put personal items away •make resident comfortable •place call light within residents reach •wash your hands •be courteous and respectful at all times • Report to the charge nurse when the transfer is complete. Report any changes in the resident to the nurse

NA role in discharge

•measure the residents vital signs •compare the inventory list to the items being packed. Ask resident to sign if all items are there •carefully put the items to be taken onto the cart, ask a staff member to help •help the resident dress in clothing or her choice. Make sure the nurse has removed all dressings, IVs, and tubes that need to be removed prior to discharge •lock wheelchair or stretcher wheels. Help her safely into the wheelchair or onto the stretcher. •help resident say her goodbyes to other residents and the staff • take resident to the pick up area. And help her into the vehicle •say goodbye to the resident. You are responsible for the resident until she is safely in the vehicle and the door is closed. •was your hands •document procedure using the facility guidelines

Bed bath

•place a bath blanket or towel over resident. Ask him to hold onto it as you remove or fold. •fill basin with warm water. Water temperature should be no higher than 105 Fahrenheit. •put on gloves •ask resident to participate in washing, help him do this when needed. •uncover only one part of the body at a time. Place a towel or bed pad under the body part being washed •wash, rinse, and dry one part of the body at a time. Start with the head and work down and complete the front first.

Bathing

•prepare the room and gather all equipment before moving the resident there •make sure the room is warm enough before starting a bath or shower •wear gloves while bathing a resident and change gloves before performing perineal care •make sure all soap residue is removed this prevents further dying and irritation of the skin •during the bath, you will have the chance to observe the resident closely every time you bathe residents. Check the skin carefully at this time you bathe residents.