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Respiration
The process that supports oxygen to the cells and removes carbon dioxide from cells
Stealth respiration
Merrium Webster the way of moving or proceeding intended to avoid detection
Check respiration right after checking pulse without hand to wrist
Tend to change pattern if resident is safe of it being checked
Pulse sits
Temporal
Carotid
Apical
Brachial
Radial
Femoral
Popiteal
Pedal
Structure and function of heart
The pump of the cardiovascular circulatory system consisting of four chambers
Top number is systolic pressure and pressure of the heart pumps blood out
Bottom is diastolic pressure when the hearts resets as the heart fills with blood
Blood pressure value
Measured in millimeters of mercury (mmhg)
Recorded as a fraction ex. 120/80
Top number is systolic
Bottom number is diastolic
Ex. 120 over 80
Blood pressure values (2)
Systolic (too number) - 90mm hg
Diastolic (bottom number ) 60m hg to 79 mg hg
Document on record
If above 120/80 document on the record let the nurse know
Abnormal blood pressure values
Nothing over or under 90/60 140/99
Factors affect temperature
Older people have lower temperature than younger people
Illness
Stress
Environment
Exercise
Time of day
Reading the non-mercury liquid filled glass thermometers
Oral rectal or axillary
Blue or green for oral
Red for rectrum
Long line represents one
Shirt line represents two tenths ex . (2/10)
Takes 3-10mins based on site
Held at the stem of the thermometer and read at eye level
Why do most health providers use fahrenheit
Scale to measure temperature even though fahrenheit and Celsius is seen on the thermometer
Weights of resident in long term facility’s
Weekly for the first 4 weeks after admission and at least monthly thereafter to help identify weight loss and gain
Weight is obtained accurately and consistently so comparison along
Urinary structure and function: urinary bladder
Ureters
Narrow tube
Connect the kidneys for urinary bladder
About 12 inches
Urinary bladder - muscular Sal
Seven to or 8 inches in males
One and half inches for females
Foley catheter
Held in place of the balloon
Urinary incontinence
Inability to control the bladder leading to an involuntary loss of urine
Water
Accounts for 50-60 % of the body weight
Foods low in fat
skim milk
Cottage cheese
Lean meat, poultry, fish (baked)
Vegetables
Fruits
Foods in high protein
meats
Fish
Poultry
eggs
Milk and milk products
Beans and peas
Nuts
Something to remember for test
Cane held on strong leg
Sodium controlled (low salt) purpose
Heat/liver some kidneys, diseases, and fluid retention
Intake (11oz-30cc /ml)
Amounts of fluids taken in each day
Infection prevention
always follow standard precautions
Always wash from clean to dirty
Good hygiene prevents body order and infections
Legal
Nurse aid who leave a resident are liable for abuse and neglect
Report any bruises or abrasions to the nurse
Safety
When rolling a resident wash back side rails, should be in the opposite side of the bed
Be aware of position and placement of resident when rolling
Use comfortable water temperature 100 and 109 older adults need lower temperature
Communication
Use positive approach address the resident about good hygiene offer skin and hair products
Documentation
Report to the nurse and document any abnormal changes such as
Color
Texture
Bruises
Cuts
Tears
Drainage
Swelling
Foul orders
Assist with dining / feeding
Wash your hands and resident hands before meal
Never put dirty equipment such as bedpans urinals or specimens on the bed table
Be careful not to contaminate ice when scooping it
Vital signs
Temporal - located temple bone
Carotid - beside the Adam’s apple
Apical - at apex of the heart
Brachial - bend of the arm at the elbow
Femoral - in the groin
Popiteal - behind the knee
Pedal - on top of the foot
Pulses
Normal pulse 72 ranges 60–100
Normal respiration 16 ranges 12/24
Blood pressure 120/80 ranges 90/60 to 140/90
Dressing and undressing
Provide privacy
Do not expose resident
Encourage resident wear street clothes during the day and nightwear during night
Fingernail care - safety
Be sure the surrounding of the nail is not cut
Checking care plan for diabetic diagnosis
Never cut nail for a diabetic
Smooth nails prevent injury
Fingernail person centered care
Do nail based on resident schedule
Check policy for use of nails
Provide Information to the family about nail opportunities
Mouth care
Nurse aids should exercise caution against putting finger nails in mouth
Always keep their hands out their mouth when doing mouth care
Resident with dementia consider using rubber handed toothbrush to keep mouth open
Never put any quantity liquids into resident mouth
Unconscious resident should be placed lateral position prior mouth care
Providing complete bed bath skill
adjust bed to safe and comfortable working level
Avoid stretching across resident
Should only need 4 wash clothes
Water should be 105 degrees
Use minimal of soap
Support limbs with your forearm
Rinse skin thoroughly
After washing body get fresh water and clean wash cloths
At any time during the bath change the water if it gets to dirty
Roms and back rubs
Try to wash cleanest to dirtiest
TOSS
Take off strong side
POW
Put on weak side
Dressing/ undressing skill
encouraging patient to move much as possible
Let confused residents chose between 2 choices of clothing
Signaling device strong side
Keep the resident covered
Take the gown to the linen container
Toss - take of strong side
Pow - put on weak side
Be careful not to mirror
Support weak arm
Avoid referring to weak affected side
Providing perineal care skill
use a minimum of 4 washcloths
Best practice 3 strokes wash and rinse
Always wash front to the back
Use minimum soap
Be gentle
Pat dry moving front to back
Remain professional
Males use circular motion
Providing mouth care for unconscious resident skill
provide mouth care on unconscious resident at least every 2 hours
Oxygen mouth breathing , and less saliva can cause crust to form on the lips
The greater risk is aspiration
Unconscious resident do not wear dentures
Assist with shaving
do not share razors between residents
Do not have a dementia resident taking anticoagulants with a blade razor
Use standard precautions wear gloves
Soften facial hair warm wet washcloth
If the resident has a mustache or beard do not shave groom according to their preference
For males shave in direction of hair growth
For females shave underarm in direction of hair growth and legs opposite of hair growth
Hold skin taut
Apply direct pressure to any nicks or cuts
Clean and electric razor before use
Lather cream or soap before shaving
Do not use razor or shaver if the resident has oxygen
Providing hair care
observe scalp for flaking crusting scaling redness or itching
Clean comb or brush before and after use
Do not share comb or brushes between residents
Style resident hair age appropriate
The skin on an elderly resident bead is fragile be gentle
Do not cut a resident hair
Shampooing can be done in shower using shampoo trough shampoo cap and at the sink or in basin
Providing backrub
Given after the bath or at bedtime
Do not rub the skin that is reddened inform nurse if so
Do not give backrub for resident with broken ribs or who has had recent back surgery
Increase circulation and is relaxing
Observe skin for reddened area, non blsnchable areas boney area that skin does not return to normal color pale white shiny skin over boney area
Measuring and recording vital signs
when taking pulse you must find the radial pulse at the thumb side
Never use your thumb to find a pulse
Remember 1 respiration is inspiration and expiration
Observe for regularity and strength of pulse
Observe for labored shallow breathing or if both sides of the chest do not rise
BP should be record in even numbers
State where started and stop
The earpiece of the stethoscope should be pointed slightly forward
Make sure stethoscope that has a bell and diaphragm make sure turned toward the diaphragm
Measuring and recording rectal temperature
Rectal thermometers are color coded red
Assist with dining feeding
Meal tray should be prepared with 2 different types of fruit from fruit cocktail on paper plate with spoon and small cup of water
Be ready to feed resident when serving the tray
Do not talk to other staff members
Cheerful company can increase how much a resident consumes
Patient wants to pray before they eat let them
Identify names of food
Do not mix food unless resident request it
Do not touch the food to test it’s temperature
Do not blow on resident food
If patient is weak on one side direct in strong side
Ask resident open mouth chew on the spoon while serving
Make sure bed free of crumbs