RCC CNA Modules 12 & 14 Comprehensive Study Guide

Emergency Procedures and Response Foundations

• Emergency Response Protocol: When a possible emergency occurs, response is guided by combining a subjective hunch, objective data, and formal training. Essential actions include:

  • Identifying signs and symptoms of distress.
  • Reporting the emergency orally to the nurse immediately.
  • Knowing and applying the ABCs (Airway, Breathing, Circulation).
  • Keeping oneself safe.

• Signs vs. Symptoms of Distress:

  • Signs: Objective, observable, or measurable physical findings.
  • Symptoms: Subjective complaints experienced and reported directly by the individual.

• Objective Signs of Distress:

  • Excessive bleeding.
  • Decreased or rapid respirations.
  • Decreased or rapid heart rate.
  • Decreased or elevated blood pressure.
  • Nonresponsiveness.
  • Altered mental state.

• Subjective Symptoms of Distress:

  • Difficulty breathing.
  • Feeling the throat closing.
  • Chest pain or chest pressure.
  • Numbness or tingling in the face, lips, or extremities.
  • Nausea.
  • Visual disturbances.

Airway Obstruction and Cardiac Emergency Interventions

• Partial Airway Obstruction:

  • Defined by a situation where the resident is choking but still exchanging some air.
  • Action: Do not interfere; encourage coughing, remain close, and monitor continuously for signs of complete obstruction.

• Complete/Severe Airway Obstruction:

  • Identified by little to no air exchange accompanied by a high-pitched wheeze or complete silence.
  • Action: Activate Emergency Medical Services (EMS) immediately, stay with the resident, obtain consent, and perform abdominal thrusts or the Five-and-Five approach (if trained/allowed or if the resident loses consciousness).
  • Obese or Pregnant Residents: Perform chest thrusts over the sternum instead of abdominal thrusts.

• Cardiac Arrest:

  • Definition: A state in which the heart is unable to contract and pump blood throughout the body.
  • Causes: Heart attack, physical trauma, choking, drowning, or drug overdose.
  • Management: Early intervention is vital to survival and must continue until a qualified person takes over, the resident is revived, or a physician pronounces death.
  • Survival Tools: Early application of a defibrillator significantly increases the survival rate.

Syncope, Seizures, and Emergency Neurological Protocol

• Syncope (Fainting):

  • Definition: A temporary, sudden loss of consciousness caused by a decreased level of oxygen delivery to the brain.
  • Warning Signs: Feeling shaky or weak, clammy skin, and visual disturbances.
  • Etiology/Causes: Low blood volume, orthostatic hypotension, cardiac arrhythmias, low blood sugar, respiratory disease, straining during a bowel movement, fasting, pregnancy, fear, high-intensity exercise, hyperventilation, and anxiety.
  • Prevention During Transfers/Ambulation: Allow dangling at the bedside before transfer, utilize assistive devices, move slowly, and use a gait belt as specified on the care plan.
  • Emergency Action: Assist the resident into a safe position, activate EMS, ensure the nurse assesses the resident promptly, and follow all nurse directives.

• Seizures:

  • Definition: Disrupted electrical activity within the brain.
  • Causes: High fever, brain tumors, medications, previous brain injury, drug/alcohol use, or unknown causes (most occur without a known cause).
  • Pre-Seizure Phenomena: Some residents experience an aura or a specific trigger prior to seizure onset.
  • Classifications:
  • Absence Seizure: Involves a small area of the brain; the person remains conscious; lasts from seconds to a couple of minutes; presents with staring, repetitive extremity movements, or expressive/receptive aphasia.
  • Generalized (Grand Mal / Tonic-Clonic) Seizure: Involves large parts of the brain; results in loss of consciousness, collapse, and uncontrollable shaking; carries risks of bowel/bladder incontinence and physical injury from falls, shaking, or aspiration.
  • Status Epilepticus: A life-threatening continuous seizure lasting longer than $5\,\text{minutes}$. Severe risks include permanent brain damage, hyperthermia, cardiac arrest, and respiratory arrest.
  • EMS Activation Threshold: Activate EMS immediately if a seizure lasts longer than $2\,\text{minutes}$.
  • Actions During a Seizure: Note exact start and end times; move the resident to safety; remove nearby objects they could strike; place in recovery position if vomiting occurs; NEVER insert anything into the mouth; NEVER restrain movement; report all seizures.
  • Post-Seizure Care: Place in recovery position until full mobility returns; provide hygiene care and fresh clothing; obtain vital signs; maintain a quiet environment; allow sleep as needed.

Hemorrhage, Shock, Poisoning, and Burn Management

• Hemorrhages & Bleeding Control:

  • Internal Hemorrhage: Results from internal organ trauma or excessive anticoagulant medication. Signs include blood in urine (hematuria), blood in feces, severe bruising, a distended abdomen, and black tarry stools.
  • Distinguishing Arterial vs. Venous Bleeding:
  • Arterial Bleeding: Bright red blood that spurts rhythmically with each heartbeat.
  • Venous Bleeding: Darker red blood that flows steadily.
  • Severe External Bleeding Protocol: Ensure scene safety -> don gloves and personal protective equipment (PPE) -> cover wound with clean absorbent material -> maintain firm pressure -> add additional material directly over saturated dressings (do not remove saturated layers) -> apply direct pressure to the supplying artery above the wound if bleeding fails to slow -> maintain pressure until EMS arrives.
  • Epistaxis (Nosebleed) Protocol: Don gloves, gather absorbent material, instruct resident to lean forward and pinch nostrils while breathing through the nose, and maintain position for $10\,\text{to}\,15\,\text{minutes}$. If bleeding persists beyond this time, the nurse takes over.

• Shock:

  • Definition: Severe disruption of the cardiovascular system in which the heart fails to pump blood effectively, leading to inadequate tissue oxygenation. Untreated shock causes death.
  • Classifications:
  • Cardiogenic Shock: Heart cannot pump effectively (e.g., caused by myocardial infarction).
  • Anaphylactic Shock: Uncontrolled systemic vasodilation (e.g., caused by an allergic reaction).
  • Hypovolemic Shock: Result of extreme loss of blood or fluid volume (e.g., caused by gunshot wounds or motor vehicle accidents).
  • Clinical Findings: Rapid pulse, cool clammy skin, low blood pressure, increased respirations, anxiety, nausea/vomiting, and altered mental status.
  • Management Responsibilities: Activate EMS immediately; assist resident to a lying position with legs elevated; cover with a blanket; obtain vital signs; report details to the nurse or EMS.

• Burns:

  • Classifications by Depth:
  • Superficial (First-Degree): Involves the epidermis only; skin is reddened, swollen, and very sensitive.
  • Partial-Thickness (Second-Degree): Involves the epidermis and dermis; very painful; skin is red, swollen, and blistered.
  • Full-Thickness (Third-Degree): Involves epidermis, dermis, and subcutaneous tissue; may affect underlying tendons and deep muscles; may not hurt initially due to nerve destruction; requires intensive surgery and rehabilitation.
  • Emergency Burn Care: FIRST action is ensuring scene safety before approaching -> Activate EMS -> don gloves -> cleanse skin and remove clothing as needed -> cover burned area with a moistened sterile dressing -> maintain comfort -> obtain vital signs -> report to nurse -> follow nurse and EMS directives.

• Poisoning:

  • Clinical Findings: Nausea, vomiting, reddened areas or chemical burns around the mouth, and a chemical odor on the breath.
  • High-Risk Populations: Residents with dementia or cognitive disabilities are at elevated risk for unintentional poisoning.
  • Action Steps: Search the immediate area for empty chemical or medication containers; ask the resident if they ingested poison; gather essential information; activate EMS immediately.

Fall Risk Assessment, Prevention, and Post-Fall Management

• Fall Risk Factors:

  • Resident-Specific Factors: History of falls (highest risk factor), medication use and interactions, orthostatic hypotension, vision or hearing loss, ear wax buildup, fatigue, low activity tolerance, weakness/muscle atrophy, balance impairment, foot neuropathy, acute new illness, restraint use, immobility, fear of falling, pain, dehydration, dementia or cognitive changes, poor foot care, alcohol use, and inadequate or absent footwear.
  • Environmental/Care Factors: Loose objects on the floor, unmet resident needs, and inaccessible assistive devices.
  • Healthcare System Factors: Unpaid provider fall-prevention education, lack of provider fall-prevention training, and inadequate inter-provider communication.

• Fall Prevention During Transfers and Ambulation:

  • Concentrate fully on the resident during movement.
  • Utilize more physical assistance than indicated on the care plan if clinical assessment indicates need.
  • Immediately sit the resident back down on the bed or wheelchair if dizziness occurs.

• Managing a Fall in Progress:

  • Do NOT attempt to keep the resident upright or catch them.
  • Grasp the gait belt firmly with both hands using an underhand grip.
  • Guide the resident down to the ground while protecting their head.
  • Lower the resident to the floor and immediately call for help.

• Post-Fall Protocol:

  • Remain with the resident on the floor, offering reassurance and emotional support.
  • Keep the resident on the floor until a registered nurse completes a full assessment.
  • Serious Injury Exceptions: If serious injury occurs, keep the resident on the floor until emergency medical services arrive. Take vital signs as directed.
  • Re-positioning Technique (Assisting Residents): Instruct the resident to get onto their hands and knees, place a chair directly in front of them, have them grab the chair, and assist them to stand.
  • Re-positioning Technique (Non-Assisting Residents): Utilize a mechanical lift to transfer the resident from the floor.
  • Post-Fall Follow-Up: The nurse updates the care plan. Vital signs are taken once per shift for $24\,\text{to}\,72\,\text{hours}$ or as directed. Promptly report any status changes.

• Injury Prevention Strategies & Fall Alarms:

  • Broad Strategies: Interdisciplinary fall-risk reviews, individualized care plan interventions, education for older adults, and balance/strength training (e.g., Tai Chi).
  • Environmental Interventions: Wipe up spills immediately, install non-skid strips, maintain daily exercise programs, encourage family visits, answer call lights promptly, provide one-on-one staffing when indicated, install grab bars, and maintain functional vision/hearing aids.
  • Specialized Equipment: Anti-rollback wheelchair brakes and soft bedside floor pads for non-ambulatory residents.
  • Fall Alarms: Alert staff when a resident leaves a bed or wheelchair, but are NOT fall-prevention strategies. Review facility policy before use.

Restraints Protocol, Physical Risks, and Primary Alternatives

• Restraint Definition & Core Rules:

  • A restraint is defined as anything preventing free movement within the environment. Restraints may be physical or chemical.
  • Restraints are NOT safety devices and do NOT prevent falls or behavioral outbursts; they increase physical and psychological harm.

• Operational Rules for Restraint Use:

  • Check the restraint site every $15\,\text{minutes}$.
  • Release restraints completely every $2\,\text{hours}$.
  • Secure restraints using a quick-release knot.
  • Attach restraint straps directly to the moveable bed frame, NEVER to a side rail.
  • Remove restraints during mealtimes.

• Restraint Site Safety Checks:

  • Monitor local skin color, temperature/warmth, tactile sensation, physical function, and blood circulation.
  • Inquire directly about pain.

• Care Required During Restraint Release ($2\,\text{Hours}$):

  • Toileting and incontinence care.
  • Range-of-motion (ROM) exercises or ambulation.
  • Body repositioning.
  • Provision of food and fluids.
  • Socialization and addressing physical and emotional needs.

• Classifications of Restraints:

  • Mechanical Restraints: Physical items such as wrist, waist, vest, or mitt restraints.
  • Chemical Restraints: Anti-anxiety or antipsychotic medications administered specifically to limit purposeful movement.
  • Environmental Restraints: Structural barriers within the physical space preventing purposeful movement.
  • Side Rail Restraints: Side rails are classified as restraints unless used by the resident for purposeful movement while in bed. Use requires informed consent and can be life-threatening.

• Risks Associated with Restraints:

  • Physical Risks: Functional dependency, reduced mobility, bowel and bladder incontinence, muscle soreness/atrophy, pressure injuries, respiratory infections, constipation, fecal impaction, urinary tract infections (UTIs), falls, and death.
  • Emotional Risks: Agitation, severe loss of dignity, behavioral issues, clinical depression, and decreased self-worth.

• Restraint Alternatives:

  • Alternatives must be attempted and documented prior to restraint application and continued after application.
  • Primary Prevention Strategies: Consistently meet basic needs; toilet and change garments every $2\,\text{hours}$; offer frequent food and fluids; encourage rest, exercise, and activities; minimize stimulation; utilize therapeutic communication; provide one-on-one staffing.

Emergency Response Codes

• Facility Codes Protocol:
  • Emergency codes convey emergency information quickly across a facility.
  • Staff must strictly follow response policies upon activation.
  • Code training is provided upon hire and must be reviewed regularly.

Rehabilitation, Restorative Care, and Multidisciplinary Therapy

• Encouraging Independence:

  • Promoting self-care maintains mobility, physical strength, range of motion, muscle mass, and personal self-esteem.

• Therapy Disciplines:

  • Physical Therapy (PT): Restores gross motor skills required for ADLs, such as walking, stair climbing, and fall prevention. Treats post-stroke, post-surgical, or post-injury individuals. Physical therapists are the best professionals to train a resident on using a new prosthetic leg.
  • Occupational Therapy (OT): Focuses on fine motor skill rehabilitation and retraining for ADLs and instrumental activities of daily living (IADLs), including bathing, dressing, laundering clothes, and cooking.
  • Speech Therapy (ST): Evaluation and treatment conducted by a Speech-Language Pathologist (SLP) for speech, language, cognitive, and swallowing disorders resulting from stroke, traumatic brain injury, dementia, or cancer.

• Restorative Care:

  • Definition: Care activities designed to maintain a resident's physical ability level and promote ADL independence.
  • Providers: Nursing assistants or restorative aides.
  • Activities: Ambulation programs, range-of-motion exercises, and walk-and-dine programs. In facilities lacking a restorative aide, the nursing assistant provides ROM exercises and ambulation.

Mobility Devices, ADL Adaptations, and Family Engagement

• Mobility Equipment Guidelines:

  • Canes: Hold the cane in the strong (unaffected) hand. The nursing assistant stands on the weak (affected) side. Quad canes provide greater stability.
  • Walkers: Available in standard or rolling/wheeled forms. Height must rest just below the resident's waist. Instruct residents NEVER to pull on a walker to stand up. Assist with steering as needed.
  • Crutches: Check designated weight-bearing status on the affected leg and review care plan directives.
  • Weight-Bearing Classifications: Weight-bearing as tolerated (WBAT), partial weight-bearing, toe touch weight-bearing, and non-weight-bearing (NWB).

• Adaptive Equipment for ADLs:

  • Mealtime Adaptive Tools: Maintain or increase nutritional intake while keeping residents as independent as possible.
  • ADL Adaptive Devices: Elastic shoelaces, grabber tools, button aids, toilet seat risers, and sock aids.
  • Update Responsibilities: Notify the nurse whenever a resident requires significantly more or less help with ADLs than indicated on the care plan.

• Family Involvement:

  • Family visits improve general well-being.
  • Families can participate in activities and reminiscence therapy.
  • Family-centered care fosters a holistic care environment.
  • Confidentiality (HIPAA) must be strictly maintained during all family interactions.

Physiological Systems, Immobility Risks, and Ambulation Levels

• Systemic Physiological Effects of Movement:

  • Psychological/Self-Esteem: Executing tasks enhances self-respect; assist with ambulation at least once per shift.
  • Digestive System: Increases gut motility, reduces constipation risk, and prevents or eases gas and abdominal bloating.
  • Cardiovascular System: Keeps heart strong and effective, reduces lower-leg edema, promotes venous return, and reduces blood clot risk.
  • Integumentary System: Decreases pressure injury risk, enhances tissue blood flow, and promotes skin health and repair.
  • Musculoskeletal System: Maintains muscle tone, improves balance, preserves joint flexibility, increases/maintains ROM, and prevents contractures and muscle atrophy.

• Dangers of Falls and Immobility:

  • Falls are a major cause of accidental death in older adults, causing physical injury, financial strain, higher level-of-care requirements, and emotional stress.
  • Side Effects of Immobility: Pressure injuries, venous blood clots, joint contractures, decreased self-worth, respiratory complications, loss of muscle strength and tone, malnutrition, and dehydration.

• Levels of Ambulation Assistance:

  • Independent: Resident requires no physical assistance. Provide verbal encouragement for daily exercise and out-of-room activities.
  • Stand-By Assist (SBA): Resident needs occasional assistance. Remain close, provide verbal encouragement, and use a gait belt for extra safety.
  • One-Assist: Requires at least one nursing assistant. A gait belt MUST be used; remain close with at least one hand on the gait belt.
  • Two-Assist: Requires at least two assistants. A gait belt MUST be used; both assistants aid in standing and guiding ambulation.

Range of Motion (ROM) Concepts, Terminology, and Thermal Therapies

• Active vs. Passive Range of Motion:

  • Active Range of Motion (AROM): Resident actively participates and moves the joint independently. The nursing assistant provides verbal reminders and encouragement.
  • Passive Range of Motion (PROM): The nursing assistant physically moves the joint because the resident cannot participate or has minimal movement capability.

• Purposes of ROM Exercises:

  • Preventing fixed joint contractures.
  • Rehabilitating paralyzed extremities following a stroke.
  • Strengthening weakened extremities after injury.

• ROM Safety Rules:

  • Instruct the resident to report any pain immediately.
  • Support the joint above and below the movement site.
  • Move joints slowly and smoothly.
  • NEVER force a joint past the point of resistance.
  • Stop the exercise immediately and report to the nurse if pain occurs.
  • Follow all care plan directions.

• Anatomical ROM Terminology:

  • Flexion: Decreases the angle of a joint.
  • Extension: Increases the angle of a joint.
  • Hyperextension: Movement of a joint posterior to anatomical position.
  • Plantarflexion: Pointing toes downward.
  • Dorsiflexion: Pointing toes upward.
  • Abduction: Movement away from the body's midline.
  • Adduction: Movement toward the body's midline.
  • Additional Movements: Lateral flexion, rotation, supination, pronation, ulnar flexion, radial flexion, inversion, eversion, rotation outward, and rotation inward.

• Hot and Cold Application Rules:

  • Purpose: Used to relieve pain and swelling.
  • Duration: Apply for $10\,\text{to}\,15\,\text{minutes}$.
  • Precautions: Avoid direct skin contact to prevent burns or frostbite; do NOT apply to residents with dementia or confusion; follow facility policy strictly.

High-Yield Priority Application & Practice Scenarios

• Choking with Air Exchange: Resident is choking but coughing and exchanging air. Best Action: Encourage coughing and stay close to monitor for complete obstruction.

• Choking without Air Exchange: Resident choking has no sound and little to no air exchange. Priority Action: Activate EMS immediately and perform thrusts after obtaining consent.

• Pre-Syncope Presentation: Resident reports visual disturbances, weakness, and clammy skin before standing. Condition: Syncope.

• Seizure Management Error: Restraining a resident during an active seizure is incorrect and unsafe. Correct actions are removing nearby objects, timing the duration, turning to recovery position if vomiting, and reporting.

• Seizure Duration Threshold: A seizure lasts $3\,\text{minutes}$. Action: Activate EMS immediately (required for any seizure exceeding $2\,\text{minutes}$).

• Bright Red Pulsatile Bleeding: Bright red blood spurting with each heartbeat indicates Arterial Bleeding.

• Saturated Dressing Intervention: External wound bleeding soaks through the first dressing. Action: Add more absorbent material directly over the saturated dressing and maintain firm pressure.

• Clinical Shock Presentation: Rapid pulse, low blood pressure, cool clammy skin, and rapid respirations indicate Shock.

• Blistered Burn Classification: A burn that is painful, red, swollen, and blistered is a Partial-Thickness Burn.

• Suspected Poisoning Action: A confused resident has an empty medication bottle nearby. Priority Action: Gather details and activate EMS immediately.

• Dizziness During Ambulation: Resident becomes dizzy while walking. Action: Immediately sit the resident back down on the bed or wheelchair.

• Fall in Progress: Resident begins to fall while wearing a gait belt. Action: Do not keep them upright; grasp the gait belt with both hands using an underhand grip, assist them safely to the ground, and protect their head.

• Post-Fall Management: A resident who fell states they are uninjured and asks to get up. Action: Keep the resident on the floor until the nurse completes a thorough assessment.

• Restraint Release Action: Restraint has been applied for $2\,\text{hours}$. Action: Release restraint, perform checks, and address toileting, movement, positioning, nutrition, hydration, and psychological needs.

• Restraint Fastening Error: Fastening a restraint to a bed side rail is dangerous and incorrect. Always secure restraint straps directly to the moveable bed frame.

• ADL Retraining Discipline: Resident needs help relearning bathing, dressing, laundry, and cooking. Appropriate Discipline: Occupational Therapy.

• Gross Motor Therapy Discipline: Resident recovering from surgery needs help with walking and stair navigation. Appropriate Discipline: Physical Therapy.

• Cane Usage with Unilateral Weakness: Resident has left-sided weakness. Placement: Place cane in the right hand (strong side), and position the nursing assistant on the left side (affected side).

• One-Assist Ambulation Safety: When ambulating a one-assist resident, a Gait Belt is mandatory, held with at least one hand.

• Pain During Passive ROM: Resident reports pain during passive shoulder exercises. Action: Stop the exercise immediately and inform the nurse.