basic nursing care provided by the nurse aide notes

what physical changes should be reported?

• pressure sores

• bruising or injuries

• flaking skin

• rashes

• broken skin

• fluid draining from skin

• pain

• discoloration

• signs of infection

• physical limitations

what behavioral changes should be reported?

• confusion

• loss of abilities

• extreme thirst

• extreme hunger

• defensiveness

• fatigue

• hyperactivity

• irritability

• any change in normal b

chest pain situation

1) comfort the person

• loosen the clothing, comfortable position, no foods or liquids

2) monitor for worsening condition

• monitor pulse and respirations, potential cpr

3) report

cardiac arrest situation

1) activate emergency response system

2) begin cpr

3) maintain bls certification

respiratory distress situation

1. provide rest

2. assist with deep breathing

3. deport

difficulty swallowing (dysphagia) signs

• coughing during meals

• choking

• dribbling

• food residue in mouth

• gurgling

• eating slowly

• spitting out food

• watering eyes

• visible effort to swallow

thickness consistencies of food

• nectar thick

• honey thick

• pudding thick

choking/aspiration situation

1) assess choking severity

• if they can make noise/cough, DNI

2) abdominal thrust

3) repeat

how to prevent aspiration

keep residents in upright position after eating

vomiting/emesis situation

1) measure if able (emesis basin)

2) document (time, color, amount, odor, consistency)

3) clean up

seizure situation

1) call for help; don’t leave

2) ensure safety

• move furniture, glasses. lower to the ground and protect head

3) after seizure…

• turn to side if there are no injuries

• check breathing + pulse

• report

signs of stroke

Face: is one side dropping

Arms: is one arm weak or numb

Speech: is speech slurred

Time: time to act is any questions were yes; alert nurse

insulin reaction; hyperglycemia

• too much insuline or too little food

• dizzy, nervous, perspiration, headache

• give milk, juice, or water w/ sugar

diabetic ketoacidosis

• too little insulin

• increased hunger, thirst, urination

• abdominal pain or deep labored breathing

fall situation

1) prevention

• keep a clear, organized floor and use as many safety precautions as needed

2) ease to the floor

• if a resident begins to fall, don’t try to catch them —> ease them to floor

3) report

bleeding situation

1) apply pressure

• use sterile dressing

2) apply layers

3) bandage to keep dressing in place

mild burns

• apply cool water to the burn

• use sterile dressing

major burns

• remove resident from heat source

• do not use ointment, water, etc.

• don’t pull away clothing

• monitor vital signs

strokes also known as

cerebrovascular accident

delirium

acute situation where memory/attention is lost + confusion and agitation

dementia

chronic situation where patient becomes confused and agitated

somnolent

sleep, only arousing to verbal stimuli

stupor

person is sleeping, only arouses to painful stimuli

coma

pt can’t be aroused at all, either by verbal or painful stimuli

which position can affect blood pressure readings

crossed legs

hemoptysis

coughing up blood

hematemesis

blood in vomit

hematopoiesis

creating new blood cells in the body

hematochezia

rectal bleeding

the most serious side effect of vomiting is…

dehydration

displacement

redirecting your negative feelings towards someone else

reaction formation

when you feel negative but act positively

intellectualization

when a person focuses on minute details of the situation rather than coping with the negative emotions associated with it

undoing

when a person has done something wrong and acts excessively in the opposite way to redeem themselves

grand mal seizure

muscle rigidity, convulsions, unconsciousness

absence seizure

brief loss of consciousness where the pt stares into space

myoclonic seizure

the body makes jerking movements

tonic seizure

characterized by rigidity and stiffness of the muscles

veins

carry blood back to the heart from the body

arteries

carry blood from the heart to the body

capillaries

where arteries and veins exchange O2 and CO2 at the tissue level

symptoms of myocardial infarction (heart attack)

• clutching chest, sweating, SOB

• pain spreading to left arm

what is the first thing to do when a patient loses consciousness + unresponsive

activate the emergency response system

why would a patient be at risk for hypoglycemia

• missed meals

• missed regular insulin