CNA Course

negligence

• failure to provide standard and reasonable care

• results in unintended injury (as compared to the intentional assault/abuse/battery)

• example: spilling hot tea on a resident

abuse

• a deliberate action (can be physical, verbal, financial, or sexual)

• results in harm

assault

• threats to touch, or attempt to touch, a person without proper consent

battery

• the actual deliberate touching or striking of a person without their consent

• example: forcing a medication into a patient’s mouth against their will

RACE (Action Plan)

• rescue: move residents that are in immediate danger away from smoke or flames to a safe area

• activate: sound the facility fire alarm and immediately dial the internal emergency number or 911

• confine: close all doors and windows to contain the fire and slow the spread of smoke

• extinguish/evacuate: extinguish the fire if it is small; if not, evacuate as directed by fire personnel

pre-procedures

1. Check resident’s care plan

2. Enter by knocking and introducing yourself

3. Assemble all necessary equipment

4. Wash hands and put on additional PPE

5. Ask for resident’s input

6. Respect patient’s privacy

7. Explain the procedure and answer any questions

post-procedures

1. Place call light within resident’s reach

2. Wash hands

3. Do a safety check of the room

4. Position (according to care plan) and lock bed

5. Scan floor for clutter or spills

6. Document results

what do you do always before entering a patient’s room?

knock on the patient’s door and introduce yourself

closed bed

• one of four bed configurations in which the bed is freshly made

• top linens are not folded back

• generlaly for a new resident or one that is out of bed during the day

open bed

• one of four bed configurations in which the bed is in use

• top linens are fan folded back so that the resident is free to move in and out of bed

occupied bed

• one of four bed configurations in which the bed is made with the person in bed

surgical bed

• one of four bed configurations

• bed is optimized to safely transfer a patient from a stretcher

• bed is at stretcher height in its highest position and the top linens are fan-folded toward the side opposite the door (side closest is free to receive patient)

drawsheet

• bedsheet that nursing assistants place under a person’s midsection

• serves as an aid to safely lift, roll, or reposition bedridden patients

• minimzes caregiver back strain and prevents skin friction

• note that because plastic and rubber retain heat and moisture, they can cause resident discomfort and skin breakdown

vital signs to report to nurse

1. drastic change compared to prior mesaurements

2. above the normal range

3. below the normal range

thermometer colors

• blue: oral (two to three minutes)

oral temperatures

• takes 2-3 minutes using a blue thermometer

• do not take oral temperature if patient is under 5 years old, is unconscious, has injury/surgery to cephalic region, is receiving oxygen therapy (changes oral temperature), needs to breathe through mouth, has gastronasal tube, paralyzed on one side of body, has seizure disorders, is disoriented, has smoked/eaten/taken fluids in last ten minutes

rectal temperatures

• must use a lubricated red rectal thermometer

• roll patient onto side and hold thermometer while inside to prevent injury

• takes between two to three minutes

• used only when other options are not available

• do not use if patient has diarrhea, has a recetal injury, has had rectal surgery, has heart disease, or is confused/agitated

tympanic membrane temperature

• take temperature on inside of ear

• fewer microbes than mouth or anus (reduced risk of infection)

• do not use if patient has ear disorder, drainage, or infection

temporal artery temperature

• non-invasive, making it appropriate for use at any time

• gently move device across patient forehead from side to center of forehead

• generally used when patient is confused or maybe resisting care

axillary temperature

• taken under patient’s dry armpit (don’t take after bathing)

• thermometer stays in place for 5-10 minutes

• less reliable than other sites, meaning it should be used less often

acceptable range for human temperatures

• average temperature for most is 98.6 but older people generally have lower body temps (~96.8)

• oral: 97.6-99.6 (baseline 98.6)

• rectal: 98.6-100.6 (baseline 99.6)

• tympanic membrane: 98.6

• temporal artery: 99.6

• axillary: 96.6-98.6 (baseline 97.6)

resting pulse rate by age

• birth to 1 year: 80-190

• 2 years: 80-160

• 6 years: 75-120

• 10 years: 70-110

• 12 years and up: 60-100

heart rates out of normal range

• tachycardia: HR above 100 BPM

• bradycardia: HR below 60 BPM

strength of pulse

• forceful pulses: strong, full, bounding

• weak pulses: weak, thready, feeble

sites of pulse identification

• can be detected where blood vessels are closest to surface of skin

• there are 9 different types of pulses: temporal, carotid (neck), apical (chest), brachial, radial, femoral, popliteal, posterior tibial, and pedal

apical-radial pulse

• provider simultaneously measures heart rate at chest (apical) and wrist (radial) to check for pulse deficit

• pulse deficit=higher radial pulse rate-lower apical pulse rate

• pulse deficits occur when an individual’s heart contractions aren’t fast enough (often due to heart disease)

respiration rate

• at rest, 12-20 breaths per minute

• higher rate can signal heart or respiration issue

• should be measured for 30 seconds to a minute

taking radial pulse and respiration

1. perform hand hygiene: cover all surfaces with hand sanitizer and rub together until completely dry

2. explain procedure to patient

3. locate radial pulse with fingertips

4. count radial pulse for a full minute-tell the RN observer when you start and stop counting

5. record radial pulse rate reading on previously signed recording form

6. my pulse rate should be within 8 beats of RN observer’s rate

7. count respiration for one full minute-tell the RN observer when you start and stop counting

8. record resident’s respiration reading on previously signed recording form

9. respiration rate should be within 4 breaths of RN’s recorded rate

10. place call light or signaling device within easy reach of resident

11. maintian respectful, courteous interpersonal interactions at all times

12. perform hand hygiene

blood pressure reading interpretation

• blood pressure: measure of force of blood as it moves through vessels

• measures force of contraction and volume of blood pumped

• top number: systolic pressure; heart is contracting (higher number)

• bottom number: diastolic pressure; heart is relaxing (lower number)

• normal BP=120/80 mmHg

• hypertension=140/90 mmHg

• hypotension=90/60 mmHg

factors that influence blood pressure

• age: BP increases as you get older

• sex: women generally have lower BP

• blood volume: bad injury or severe bleeding reduce BP

• stress/pain: generally increases with stress or pain

• extreme pain: if pain is bad enough to induce shock, BP will decrease

• exercise: increases BP

• weight: overweight people have higher BP

• race: African Americans have higher BP

• position: higher when someone is lying down, lower when standing up

dorsal recumbent position

• used to examine abdomen and chest area

• patient lies flat on their back, knees are bent, hips are opened

• generally drape patient from neck down, exposing areas only as they are examined

lithotomy position

• used to examine a woman’s vagina and cervix

• woman lies on her back, bends her knees, and puts her feet in stirrups

• usually drape patient from waist down

genupectal position

• aka knee-chest position

• head and arms are flat on table, buttocks facing upwards, and knees drawn to chest

• generally drape patient from waist down, covering lower back, buttocks, and thighs

• some patients may be unable to assume this position, so you instead place them on their side with knees to chest

Sims’ position

• aka lateral recumbent or semiprone side position

• ocassionally used to examine rectum or vagina

• patient lies on their left side with chest inclined forward, left leg remaining straight, right hip and knee sharply bent and drawn toward chest

• patient is usually draped from neck down, covering back, buttocks, and thighs

• pillow should be placed beneath head and shoulder, and upper arm

emergency ABCs

• airway: must be open and clear of obstructions; highest priority

• breathing: once airway is confirmed, must evaluate effectiveness of breathing (rate, depth, chest rise symmetry)

• circulation: aka cardiac; checked via pulse, BP, capillary refill, skin color, and active bleeding

hemorrhaging

• heavy or uncontrollable bleeding occuring when a damaged blood vessel allows blood to escape circulation

• can be internal (into tissues and organs) or external (through a wound)

• those with internal bleeding may experience pain, shock, vomiting, coughing up blood, loss of consciousnessoccurring

emergency medical situation protocol

1. activate EMS

2. keep the person safe and comfortable

3. only move patient if in immediate danger

4. do not leave the patient

external bleeding first aid

1. follow emergency procedures

2. do not remove objects

3. elevate injured area above heart

4. apply pressure over the wound (or artery above site of bleeding)

5. once bleeding stops, bind wound

if someone is about to faint

• help person sit down and put head between knees

• loosen tight clothing

• stand behind falling person or guide them to the ground

• let person stay on ground

shock

• circulatory failure that deprives vital organs of essential blood flow and. oxygen

• typically presents with sudden drop in BP, rapid and/or weak pulse, confusion, clammy skin, rapid respiration, restless behavior, thirst

shock emergency procedure

• follow emergency protocol

• control bleeding and keep airway open

• elevate the patient’s legs above their heart

• keep the patient wwarm

anaphylactic shock

• presents as sudden drop in BP, rapid and/or weak pulse, difficulty breathing with closing airway, clammy skin, rapid respiration, restless behavior, thirst, confusion

stroke emergency prcedure

• activate EMS system immediately and keep person safe and comfortable

• place the patient in the recovery position on their limp, affected side

• loosen the patient’s close and raise their head to promote breathing

epilepsy

• neurological disorder that causes seizures

• common causes include brain injury during pregnancy/childbirth, infection during pregnancy, head injuries, poor nutrition, brain tumors, fevers in childhood, poisoning, infection, stroke

• there is no cure for epilepsy, only treatments

types of seizures

• partial: limited to part of brain; individual does not lose consciousnes and symptoms are localized to a specific area of body

• generalized tonic-clonic (grand mal): loss of consciousness (tonic) followed by jerking movements (clonic); because muscles loosen during clonic stage, person may lose control of bowels or bladder

• generalized absence (petite mal): brief loss of consciousness; patient may fall

seizure care protocol

• guide person to floor and clear area of objects

• note time of seizure’s start and end

• do not attempt to control patient’s movements

• place pillow under head and loosen tight-fitting clothing

• turn patient to side to prevent choking

• do not put anything in the patient’s mouth as they may bite down

• monitor breathing

burn degrees

• first degree: mild and result in red, swollen skin; cool with water

• second degree: blistering skin

• third degree: charred or cooked skin, exposed bone, fat, or muscle; rarely felt by patients as nerves as destroyed

treating burns

• determine if environment is safe and contact EMS

• look for burn-causing hazards and address if found

• stop the burning process by using cool water or wrapping individual in blanket

• do not remove clothing that is sticking to skin (DO remove clothing that is not stuck)

• keep person safe until help arrives

dry dressings

• a type of non-sterile dressing used to absorb excess fluid

• place gauze over the wound and add additional layers as needed

• can stick to wounds as they heal so must take care to not rip wound when removing a dry dressing

wet dressings

• a type of non-sterile dressing that actively promotes healing by softening dead tissue and preventing the wound bed from drying

• has a solution (usually an antibacterial or antifungal agent) applied to the gauze to prevent infection

• once placed over a wound, should be covered with a dry layer of gauze and secured with medical tape

medical tape

• comes in a variety of sizes

• if someone is allergic to the glue in adhesive tape, you can use paper, plastic, or cloth tapes

• do not use to wrap entire wound, rather, you should use just enough to secure the dressing

applying a non-sterile dressing

1. perform pre-procedure steps and collect materials

2. expose the wound and gently remove the dressing, pealing each layer of gauze away from the wound (may need to use adhesive remover)

3. may apply a saline solution to final layer of gauze touching the wound to prevent gauze from sticking

4. contain the soiled gauze and tape in a plastic bag (eventually disposed of in biohazard bin)

5. observe wound site for color, drainage, redness, or heat around site

6. remove gloves and practice hand hygiene

7. open a new dressing and put on clean gloves

8. clean wound with saline (if requested by nurse) and pat dry with gauze

9. apply a new dressing and secure in place

10. remove gloves and other PPE and place in biohaazrd bag for disposal

11. practice hand hygiene and other post-procedure steps

rescue breathing

• open person’s airway by lifting chin and tilting head back

• pinch nose closed to prevent air from escaping

• take normal breath and place mouth over patient’s mouth, creating a seal with lips

• breathe every 5-6 seconds

• ensure person’s chest rises and falls with each breath (air is getting into their lungs)

• check pulse every two minutes

• if there is no pulse, begin CPR

mouth to stoma breathing

• keep mouth closed

• do not tilt head back

• seal your mouth around the stoma and blow air into it

• watch chest rise and fall

• pinch nose if necessary

CPR for unconscious individuals

• kneel beside person and check for responsiveness; if person does not respond, call for help, activate EMS (or call 911), and send for an AED

• check for carotid pulse and listen for signs of breathing

• if person is not breathing and has no pulse, begin CPR

• perform 30 quick chest compressions (at least 2 inches deep) at a rate of at least 100 per minute

• perform 2 rescue breaths then check again for carotid pulse

• continue CPR until 1. you feel a pulse and the person begins to breathe again 2. help arrives to take over CPR 3. you are too tired to continue

proper technique for chest compressions

• position heel of one hand on lower third of sternum (do not place over the xiphoid process)

• place free hand over other hand and press down with 30 quick compressions at least 2 inches deep

CPR with two people

• general procedure remains the same: 2 rescue breaths followed by 30 rapid chest compressions

• one rescuer should be positioned by the person’s head and focus on the person’s airway by providing rescue breathing and checking the person’s airway

• the second rescuer should focus on providing chest compressions

child CPR

• check for responsiveness, breathing, and a pulse

• if there is no breathing or pulse, initate CPR

• be careful with chest compressions as it will take much less force to compress a child’s chest 2 inches

• may need to use one hand instead of two depending on the size of the child

infant CPR

• when providing rescue breathing, position the head gently

• cover the infant’s nose and mouth with your own

• do not blow too hard into the infant’s lungs; two small puffs should be enough

• use two fingers to perform chest compressions and check pulse

• check for brachial rather than carotid pulse

traction

• application of a slow, steady pulling force to a part of the body

• uses devices like weights, pulleys, and ropes to reduce muscle spasms, correct tissue deformities or muscle shortening (contractures)

• depending on injury, traction can be applied to neck, arms, legs, or pelvis

positioning to prevent skin breakdown

• involves regularly shifting a peron’s weight to relieve pressure on vulnerable areas like bony prominences

• done when residents are immobile, confined to beds or wheelchairs, experiencing incontinence, or showing signs of redness

• failure to do so may lead to tissue ischemia and necrosis, friction and shear injuries, deep pressure ulcers, and contractures

people who have had hip replacement surgery must not…

• cross their legs

• sit in a low chair

high carbohydrate diets

• specific metabolic disorders (e.g., glycogen storage disease)

• lung diseases such as COPD

• may also be given to patients with specific liver condtions to prevent overburdening the liver

osteoarthritis

• most common form of arthritis in which protective cartilage covering bones gradually wears away

• symptoms include pain, stiffness, and joint swelling

• because there is no cure, treatment involves weight management, physical therapy, pain medications and ointments, etc.

heat applications

• most often used to reduce pain, relax muscles, and reduce stiffness

• dilate blood vessels and increase blood flow, thereby can promoting healing and reducing tissue swelling

• need to pay special attention when applied to older individuals (sensitive skin) or those with dementia/memory loss (may not be able to feel burn), metal implants (conducts heat)

• options include: hot compresses, hot soaks, sitz baths (perineal area), hot packs

dry vs wet cold/hot applications

• dry applications stays at desired temperature longer

• dry applications needs to be hotter/wetter and applied for longer periods of time to achieve same depth as wet heat (increases burn risk)

• wet applications sink more deeply into tissue

cold applications

• causes vasoconstriction and reduced blood flow, decreasing swelling and pain

• risks include burns, blisters, and reduced circulation

hot compress procedure

• fill basin half full with hot water

• place compress in water

• ring excess water from compress

• apply compress over area and note time

• cover compress to retain heat

• leave compress on for required time

• check skin every 5 minutes

hot soak procedure

• fill container half full with hot water

• measure water temperature

• pat edge of container with towel and place patient’s body part inside

• note the time and make person comfortable

• leave body part in for required time and check skin every 5 minutes

Sitz bath procedure

• place disposable sitz bath on top of toilet seat

• fill sitz bath 2/3 full with warm water

• measure water temperature

• move person’s gown above their waist and secure it

• help person into the Sitz bath and note the time

• make the person comfortable and allow them to sit in bath for required time (check every 5 minutes)

• if person is unsteady, do not leave

hot or cold pack procedure

• break, strike, or massage pack to release heat or cold

• place pack in a cover

• apply the pack and note the time

• secure the pack in place

• make the person comfortable

• leave pack on for required time and check skin every five minutes

cold compress procedure

• place ice and water into a basin

• place compress into basin

• wring excess water from compress

• apply compress over the affected area and note the time

• cover the compress to retain the temperature

• leave compress on for required time and check skin every 5 minutes

aquathermia pad

• a type of dry heat application that uses contained hot or warm water to deliver heat to an area of the resident’s body

• consists of a pump to heat water and deliver water, tubes to carry hot water to the heating pad, and a pad which is applied to the affected area to deliver heat therapy

• the pad itself does not get wet on the outside

aquathermia pad procedure

• place the pad on a clear space without clutter

• check pad and tubing for damage or flaws/kinks

• use a flannel cover to insulate the pad

• secure the pad in place on the resident’s affected area

• ensure the pad does not sit under the resident’s affected area as this position may cause too much heat to build up

• monitor the resident’s skin for burns frequently

individual resident care plan

• meant to be revised at least every 90 days to adapt to changes in resident’s health and wellbeing

• lists each resident’s medical, nursing, and psychosocial needs with their corresponding goals, approaches, and staff

wound

• a break in the skin or mucous membrane (lines organs and muscles)

• are characterized by their various depths (aka thickness)

pressure ulcer

• also known as bedsores

• serious wounds caused by poor circulation, resulting from pressure

• often result from an area of the body continually touching the bed

wound depths

• partial thickness: skin is broken

• full thickness: very deep; may expose muscle or bone

types of wounds

• abrasion: partial thickness wounds where skin is scraped or rubbed away

• contusion: a bruise; a closed wound caused by a blunt blow to the affected area

• incision: a slice caused by a very sharp instrument

• laceration: jagged open wound with torn tissue, caused by skin getting caught and torn

• penetrating: broken wound that breaks skin and enters body (e.g., bullet wound)

• puncture wound: an open wound made by a sharp, pointed object

• ulcer: shallow or deep crater-like sore on the skin or mucous membrane

skin tear

• one of the most common wounds in long-term residential care

• a break/rip in skin caused by friction, falls, holding a body part too tightly, removing an adhesive, pulling zippers over skin, pressure on skin in bed, etc.

• risik factors: need help moving, poor nutrition, dehydration, frailty, dementia/memory loss

preventing skin tears

• keeping nails short and smooth

• refrain from wearing jewelry

• be aware of potential for shearing and friction

• dressing residents carefully

• prevent falls

• keeping skin well cared for

• keep residents hydrated

• remove adhesives or bandages carefully

circulatory ulcer

• slow-healing open wounds on lower legs and feet caused by poor blood flow

• venous ulcers: blood pooling due to weak vein valves

• arterial ulcers: blocked arteries restricting oxygen

phases of wound healing

• inflammatory phase: belading ceases and scab forms over wound, protecting it from microbe invasion; blood supply increases to promote healing (causing inflammation)

• proliferative phase: body’s cells rapidly multiply to heal wound

• maturation phase: after 21 days and up to two years, wound’s scar becomes stronger and more robust, losing red color and becoming thin and pale

common types of wound healing

• incision and lacerations: edges of wound are brought together with stitches, staples, or glue adhesive strips to promote healing

• infected wounds: tissue is removed and wound is left open to heal slowly; leaves a large scar

• infected tissue: wound is left open and closed later, combining the first two intentions

signs of wound infection

• expanding redness around wound

• yellow or greenish-colored pus or cloudy wound drainage

• red streaking speading from wound

• increased swelling, tenderness, or pain at wound site

• fever

• foul odor emanating from wound

dehiscence

• surgical complication in which the layers of a previously closed wound or incision begin to separate

• common with abdominal injuries since person may cough or vomit

evisceration

• a severe complication of dehiscence

• incision completely opens and the internal organs (usually abdominal) protrude outwards

purulent drainage

• is a thick and green/yellow/brown fluid that oozes from a wound

• strong indicator of a bacterial infection

• if the wound doesn’t drain, the fluid can build up, causing inflammation and preventing healing

• measured by: 1. weighing dressings before and after applying 2. noting number and size, color, and type of drainage 3. measure fluid that collects in a closed collection container

medical asepsis

• environment free of disease-producing microbes

• two goals: 1. remove or destroy pathogens 2. prevent pathogens from spreading (between people or locations)

disinfected vs sterilized

• disinfected: free from most bacteria

• sterilized: free from all pathogens

wound drainage

• drainage systems help to move pus and other fluid away from a wound site, promoting healing and reducing change of infection

• serous drainage: clear, thin, watery solution often associated with blisters

• sanguinous drainage: red and signifies active bleeding; bright red signals fresh bleeding while duller/darker red signifies earlier bleeding

• serosanguinous drainage: thin, watery (sero), and red, also signifying bleeding

• purulent drainage: thick, green/yelllow/brown drainage that signifies an infection

gravity drains

• uses force of gravity to help move fluid and other waste away from site of wound

• since system uses gravity, collection container must always be placed below insertion site

• should never be raised above wound site as this can cause fluid to flow back into the wound, causing an infection

negative pressure drainage systems

• also referred to as closed drainage systems, using negative pressure to drain fluid from wounds

• must be emptied frequently to drain properly

• must always compress (expel air) from the drainage port before closing it

• examples include Jackson-Pratt and Hemovac systems

surgical evacuators

• use suction to help remove drainage from a wound

• pay special attention to signs of infection, kinks in tubing, and to site of drainage system

• must also ensure that the suction does not damage the tissue

sump drain system

• a type of wound drainage system used to remove large amounts of fluid or pus from deep wounds or cavities

• consists of an outer tube (lumen) with a smaller lumen within it

• air enters through the smaller lumen and displaces the fluid so that it drains through the larger lumen

• as with all drainage systems: pay attention to the wound site, look for signs of infection, and take special care with the suctioning process

handwashing procedure

• ensure you have soap, a nail file/orange stick, paper towels, and trash can

• push watch or any long sleeves up at least 4-5 inches

• stand away from sink so that clothes do not touch sink

• never touch the inside of the sink

• wet your hands and wrist 3-4 inches above wrist

• rub palms together and interlace fingers to work up a good lather

• wash for at least 30 seconds

• clean underneath fingernails by rubbing tips of fingers against palms

• rinse by starting at wrists and working towards hands

• turn off faucet with clean and dry paper towel to prevent cross contamination

hepatitis B

• vacinne-preventable liver infection caused by the hepatitis B virus

• transmitted through contact with blood, semen, or other body fluids (i.e., unprotected sex, shared needles, childbirth, etc.)

• acute infections clear on their own, but chronic cases can lead to severe liver damage

• once chronic, hepatitis B cannot be cured (though antiviral meds can suppress the virus and symptoms)

hepatitis C

• a bloodborne viral infection that causes liver inflammation

• primarily spread via blood-to-blood transmission (sharing needles, unsterile medical equipment, blood transfusions prior to 1992)

• no vaccine is available but is curable in about 97% of cases using 8 to 12 weeks of oral antiviral medications

putting on sterile gloves

1. note left and right gloves

2. lay the gloves flat on the table

3. place fingers under each lip

4. pinch the inside of the cuff and place the other hand inside the glove

5. slide gloved hand underneath cuff of second glove without touching the inside of the glove

bloodborne pathogens standard

• OSHA standards that protect all workers who have a reasonable expectation of occupational exposure to blood or other potentially infectious materials (OPIM)

• requires employers to implement a written exposure control plan, provide PPE, offer free Hepatitis B vaccines, ensure engineering controls, and mandate annual training

• in the event of an exposure, employers are legally required to provide free, immediate, confidential medical evaluation and follow-up