Study guide test 3

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