Patient Care

First Aid and CPR

• Be prepared to provide first aid and basic life support (BLS) in life-threatening situations.
• May be part of a rapid response team or assist nurses/providers with life-saving measures.
• Follow scope of practice within the facility when responding to emergencies.

Bleeding

• Apply pressure to the site with a gauze pad for several minutes; common causes include wounds, incisions, venipuncture, dermal puncture or post IV catheter removal.
• Avoid checking frequently to prevent dislodging clots.
• If bleeding is brisk and doesn't stop after a few minutes, call for assistance.

Nosebleed (Epistaxis)

• Have the patient sit up and lean forward.
• Apply pressure to the nostril by pinching the nose for 10 to 15 minutes.
• If still bleeding, insert gauze and notify the nurse.

Choking

• Look for signs of choking, such as grabbing the front of the neck (universal sign).
• Complete airway obstruction: patient unable to cough or speak, may hear high-pitched noise while inhaling or no noise at all.
• Immediately call for emergency response team.
• Administer abdominal thrusts (Heimlich maneuver) repeatedly until foreign body is expelled or the patient becomes unresponsive.

Administering Abdominal Thrusts (Heimlich Maneuver) to an Adult

• Stand or kneel behind the patient, wrapping arms around their waist.
• Make a fist with one hand, thumb against the patient’s abdomen in the midline, slightly above the navel and below the breastbone.
• Grasp fist with other hand and press into the abdomen with a quick, forceful upward thrust.
• Repeat thrusts until the object is expelled or the patient becomes unresponsive; use distinct movements for each thrust.

Seizures

• Take immediate action to prevent aspiration and injury.
• Do not restrain the patient or force anything into their mouth.
• Call for assistance and remove objects that could cause injury.
• After contractions subside, turn the patient’s head to one side (if no neck or spine injury) to allow secretions to drain.
• Stay with the patient until the seizure is over or emergency personnel arrive.

Shock

• Common symptoms: rapid pulse, increased shallow breathing, blank stare, cold, clammy, pale skin.
• Call for help if shock is suspected.
• Ensure open airway; position head below body if lying down.
• Keep the patient warm and safe until help arrives.

Fainting (Syncope)

• If a patient feels dizzy or about to faint, have them lie down and elevate their lower legs, or sit with their head between their knees.
• Stay with them and call the nurse.

Edema

• Fluid accumulation in a body part, area, or system.
• Can indicate various problems depending on location.
  • At IV site: Infiltration (IV fluid leaking into tissues).
  • Lower legs: Impaired circulation.
  • Other causes: Heart disease, respiratory disease, certain medications.
• Report edema to the nurse.
• Signs: Swelling, stretched and shiny skin, feeling of tightness.
• Pitting edema: Indentation remains after pressing on the area; depth indicates severity.
  • 2 mm indentation: 1+
  • 4 mm indentation: 2+
  • 6 mm indentation: 3+
  • 8 mm indentation: 4+

Emotional Support

• Build trust and honesty to create effective relationships with patients and their families.
• Treatment and recovery take time; patients and families need emotional support during physiologic healing.
• Be aware of their needs and encourage communication.
• Show empathy, and allow patients and families to express feelings without taking it personally.
  *Listening is the most fundamental component of communication skills; Active listening is mindfully hearing and attempting to comprehend the meaning of words.
  *It can involve making sounds or gestures that indicate attentiveness, as well as giving feedback in the form of a paraphrased version of what patients said.
• Signs of active listening include a smile, eye contact, erect posture, and paying attention to what the speaker conveys.
• Never pretend to listen while doing something else.
• Make repeated eye contact, respecting personal space, and convey genuine interest, warmth, empathy, sincerity, openness, and consideration.
• Verbal communication: Sharing information using recognizable spoken words.
• Nonverbal communication: Behavior that complements, negates, or substitutes for spoken words (gestures, mannerisms, facial expressions, posture, eye contact, touch, personal space, appearance).
• Therapeutic communication: Interaction to enhance patient comfort, safety, trust, health, and well-being.
• Focus on patients and use terminology they understand.
• Use specific strategies that convey understanding and respect to encourage patients to express feelings and ideas, be sensitive about their feelings.
  *All indications of active listening: Smile, Eye contact, Erect posture and Attention to what the speaker is saying.

Therapeutic Communication Techniques

Ineffective Communication

• Boundaries are necessary to keep patients the priority, avoid discussing your personal life, stay in the health care service role.
• Defense mechanisms are human nature, and understanding them can aid communication.
• Barriers to communication include differences in language, culture, cognitive level, developmental stage, sensory issues, and physical challenges.
• Patients have the right to full information about their care.
• Low health literacy can result in an inability to understand the provider’s medical jargon or complex instructions.
• Use layperson’s terminology and provide explanations when needed.
• Be aware of different viewpoints and personal biases to prevent miscommunication.
• Avoid figurative or colloquial language.
• Nonverbal communication is extremely important.
• Practice interpersonal skills (friendliness, empathy, genuineness, openness, sensitivity) to serve diverse populations effectively.
• Use a medical interpreter when there is important information to exchange.
• When a patient is not fluent in a language you speak, have written instructions available in other languages to demonstrate cultural competence and respect all cultural or personal preferences that arise.

Skin Care

• Reposition patients at least every 2 hours to minimize the risk of developing pressure ulcers.
• Use specialized beds, air mattresses, mattress overlays, bed cradles, elbow and heel pads, to relieve pressure that can result in these ulcers.
• Shearing force: Sliding of skin layers on each other can cause loss of skin integrity, move a patient by using lift devices reduces friction from dragging a patient’s skin across bed linens.
• Keep skin clean and dry, and free from gritty substances; some facilities restrict powder and cornstarch use.
• Incontinent patients are at high risk for skin breakdown.
  • Promptly remove wet or soiled clothing/linens.
  • Wash skin with warm water and mild soap if necessary, rinse it thoroughly, and to dry it carefully.
  • Pat the skin dry gently; do not rub it.
  • Apply a nonprescription moisture barrier ointment liberally, according to your facility’s protocol, to protect the skin from the next incontinent episode.
• Do not leave patients on bedpans or commodes longer than necessary.
• Encourage patients to ambulate at least every 2 hours.
• Place a pillow under the calves of patients who are supine in bed to take pressure off of the heels.
• Observe skin for signs of breakdown, especially over bony prominences (sacrum, heels, elbows, hips, back of the head) and in perineal and perianal areas of patients who are incontinent.
• Look for redness that doesn’t blanch (return to the skin’s usual color) when you apply pressure with a finger, which is the beginning of a pressure ulcer (stage 1).
• A stage 2 pressure ulcer looks like a blister, with surface skin that peels or cracks open.
• A stage 3 pressure ulcer has lost the skin layers, and underlying fat and tissue are visible.
• A stage 4 pressure ulcer resembles a crater, with damage all the way through to muscle and bone.
• Some ulcers are unstageable because the crater is full of dead tissue.
• Look for dryness, and apply moisturizing lotion according to facility policies; Report any skin changes to the nurse.
• Look for irritated areas and maceration (Softening and breaking down of skin due to prolonged exposure to moisture).
• Check skin integrity where tubing comes in contact with skin, such as oxygen tubing behind the ears.
• Protect these areas according to facility protocol. Also apply an emollient or lip balm to dry lips to prevent cracking.

Respiratory Care

• Spirometry: Using an incentive spirometer is a breathing exercise that helps prevent respiratory complications after surgery.
• Patients breathe deeply to raise the balls in the chamber by forcefully inhaling through the device.
  • Assist patients into a comfortable position.
  • Have patients breathe out in the usual way.
  • Tell patients to put their lips around the mouthpiece to create a seal around it.
  • Instruct patients to breathe in through the device. These devices have an indication of the amount of air breathed in to help them set and reach goals.
  • Patients should hold their breath for at least 3 seconds, and then exhale.
  • Encourage patients to repeat this cycle as many times as specified by the provider or facility protocol.
  • Encourage patients to repeat the use of the spirometer every 1 to 2 hours while awake.

Postmortem Care

• Treat the body with utmost respect and sensitivity, with thoughtful consideration of any specific needs or requests from the family.
• Ensure that the provider has certified the death and recorded the date and time before beginning postmortem procedures.
• Other legalities to consider include autopsy and organ donation, and the family’s cultural and spiritual practices.
• The nurse can inform you of any factors that might alter the routine care of the body after death.
• Prepare the body as soon as possible after death to prevent any tissue damage or disfigurement that might make the viewing additionally traumatic.
• Try to make the body look as natural and peaceful as possible.
• Also try to make the room look as neutral and peaceful as possible by removing any supplies and equipment, especially any soiled or bloody linens and other materials.
• Dim the lights, if possible.
• Close the eyes and mouth. Insert or keep dentures in place; if the mouth doesn’t stay closed, place a small towel under the chin to help it remain closed.
• Unless there will be an autopsy, remove all tubes and devices from the body. If tubes must stay in, cut them so that they protrude only 2.5 cm (1 inch) from the body and tape them in place.
• Position the body supine, with a small pillow under the head to prevent pooling of blood, which can discolor the face.
• Place the arms at the sides of the body, palms down, or across the abdomen; do not place one hand on top of the other.
• Replace soiled bandages or dressings with fresh ones.
• Bathe the patient enough to present a clean, odor-free appearance.
• Brush or comb hair.
• Place a clean gown on the body and a clean sheet with a top cuff up to the shoulders (not covering the face).
• Document any valuables on or with the body; place them in the appropriate bag or envelope, offer them to the family, if the facility policy specifies; the family might prefer keeping wedding and engagement rings on the body.
• Invite the family to visit with the body; offer to stay with them or give them privacy.
• Place a shroud (usually consisting of a sheet that will be wrapped around the patient) under the body.
• Attach the facility’s identification tags. One tag on the body’s right great toe, one on the shroud, and one on the belongings if the family has not collected them.
• Fold the bottom of the shroud over the feet and the top over the head; fold one side over, and the other side on top, and secure it in place.
• Inform the nurse or arrange transportation to the morgue. The funeral home staff might pick up the body directly from the room and not the morgue.
• Postmortem care can be emotionally difficult; allow yourself to express grief, and it might help to talk to a supervisor or other facility staff.

Vital Signs

• Measure vital signs at specific intervals.
• Know the range of vital sign measurements for all age groups.
• Report any findings outside the expected range to the nurse.
• Temperature
  • Oral: 36.5° to 37.5° C (97.6° to 99.6° F)
  • Tympanic: 37° C (98.6° F)
  • Axillary: 36° to 37° C (96.6° to 98.6° F)
  • Temporal: 36.5° to 37.5° C (97.6° to 99.6° F)
  • Rectal: 37.5° C (99.6° F)

Temperature

• Fever (pyrexia) is the body’s natural defense for fighting micro-organisms and is therefore a normal reaction to illness; the most common cause is infection.
• Patients who have a fever can also have chills, anorexia, weakness, thirst, and body aches.
• Measure temperature orally via a digital thermometer, aurally (in the ear) using a tympanic thermometer, or on the forehead using a temporal artery scanner; axillary and rectal temperatures determine skin and core temperature but are not common methods.
• Report findings that suggest a complication to the nurse.
• Older adults might have slightly lower body temperatures.

Heart Rate

• 60 to 100/min for adults, averages heart rates tend to slow with age.

• Newborns (birth to 1 month): 120 to 160/min

• Infants (1 to 12 months): 80 to 140/min

• Toddlers (1 to 3 years): 80 to 130/min

• Preschoolers (3 to 5 years): 80 to 120/min

• School-age children (6 to 15 years): 70 to 100/min

• Palpate a peripheral pulse site—preferably one where you can push an artery against a bone—to measure the pulse rate. Use your second and third fingers to palpate pulsations.

• Radial pulse, on the thumb side of the wrist, is the most common site for measuring an adult’s pulse.

• Brachial pulse, inside the upper arm, is the most common site for measuring children’s pulses.

• Carotid pulse, in the neck just below the jawbone, is most the common for use in emergency procedures.

• Other locations reflect circulation distal to the pulse site. For example, a strong femoral pulse demonstrates circulation to the lower extremity; if a pedal pulse is absent, circulation to the toes is poor.

• You can also measure heart rate via auscultation. Use a stethoscope to listen to and count the apical pulse rate at the apex of the heart.

• Evaluate the pulse for rate, rhythm or regularity, and volume or strength. A typical description is 70/min (rate), regular (rhythm), and thready (strength).

• Thready reflects a pulse that is difficult to detect or faint. Bounding describes a pulse that is very strong.

• Pulse rates vary with the patient’s condition, age, time of day, activity level, and medications.

Respiratory Rate

• 12 to 20/min for adults, respiratory rate decreases with age, health problems, and environmental factors.

• Newborns (birth to 1 month): 30 to 50/min

• Evaluate respirations for rate, rhythm, and depth

• Respiratory rhythm is the breathing pattern, depth describes how much air the patient inhales.

• One respiration includes an inhalation and an exhalation.

• When observing the patient’s chest, count the respiratory rate.

• When auscultating the chest, listen for abnormal sounds, such as wheezing; notify the nurse if you hear any unusual sounds.

• Patients might be tachypneic if they are anxious or have respiratory distress.

• They might have bradypnea as an adverse effect of some medications, such as opioid analgesics.

• Abnormal respiratory rates can be serious and result in acid-base imbalance, hypoxia, brain injury, and organ failure.

• Tachypnea greater than 20/min

• Bradypnea less tham 10/min

Blood Pressure (Manual)

• Systolic: Less than 120 mm Hg
• Diastolic: Less than 80 mm Hg
• Place a cuff of the appropriate size for the patient on the upper arm, with the lower edge of the cuff about 2.5 cm (1 inch) above the crease of the inner elbow.
• Avoid an arm on the side where a patient has had a mastectomy, an IV line, or injuries, because the pressure on the arm from inflating the cuff could result in complications.
• Have the patient sit comfortably with the arm at the level of the heart.
• Next, locate the radial pulse and inflate the cuff until you can no longer hear pulsations. Then inflate the cuff an additional 30 mm Hg.
• Place the stethoscope over the left brachial artery and slowly release the pressure in the cuff. The point at which you hear the first sound is the systolic (top number) blood pressure.
• Continue to listen over the brachial artery as you continue to release the pressure in the cuff. The point at which you no longer hear sound is the diastolic (bottom number) blood pressure.

Pulse Oximetry

• Oxygen saturation is sometimes considered a vital sign.
• A pulse oximetry reading of 95% or higher is expected.
• Attach the probe on the device to the patient’s finger or earlobe or finger.
• Remove nail polish prior to the test, as it blocks the infrared light the device uses and interferes with results.
• The pulse oximeter is unreliable if the patient has cold hands, colored nail polish or acrylic nails, edema, or carbon monoxide poisoning.
• Patients who have chronic respiratory disease might function normally with oxygen saturation levels below 95%.
• If the reading is unusually low, inform the nurse and observe for signs of adequate perfusion (warm skin, pink mucous membranes, strong peripheral pulses, capillary refill that is less than 2 seconds).
• Patients who have hypoxia might have anxiety, confusion, and an increased respiratory rate.

Anti-embolism Stockings/Compression Hose

• Prevent blood clots from forming in the deep veins of the legs and help prevent fluid buildup in the legs.
• Thromboembolic deterrent (TED) hose are made of elastic material that applies firm pressure to the lower legs.
• They have an opening at the top of the toe area to allow for checking circulation.
  • Have the patient lie supine.
  • Turn the stocking inside-out down to the heel.
  • Place your hand inside the stocking and grasp the tip where the patient’s toes will go.
  • Place the patient’s toes into the tip of the stocking, making sure the material is smooth and without wrinkles.
  • Slide the stocking over the rest of the patient’s foot and heel, making sure the heel fits into the heel portion of the stocking.
  • Slide or pull the rest of the stocking up over the calf. Be sure it is smooth, with no wrinkling, bunching, or twisting; Do not roll the stocking down at the top, because that could interfere with blood circulation in the leg and foot.
  • Repeat the procedure on the other leg.
  • Reposition the patient for comfort.
  • Remove the sleeves at least once per shift to check skin and circulation.

Bodily Functions

• Measure and document fluid intake and output in milliliters.
• Includes everything patients eat that becomes liquid at room temperature (flavored gelatin, sherbet) and what they drink, plus any IV fluids they received, ice chips they ingested, and enteral formulas they have received.
• Measurable output includes urine, emesis, diarrhea, and collections of fluids and drainage in suction containers, chest tube drainage systems, wound drainage reservoirs, and ileostomy pouches; you might have to estimate the fluid amount for some of these types of output.
• Instruct them not to empty or have visitors empty the urinal, and to let you know if they eat or drink anything that the staff has not provided, such as a beverage a visitor brought them.
• Also document the amount, color, and consistency of stool. Describe the consistency of stool as loose, semi-formed, soft, formed, or hard.
• Notify the nurse if a patient has not had a bowel movement in 3 days.
  *One ounce of fluid equals 30 mL.

Removing Peripheral IV Catheters

• Check with the nurse to make sure that the provider has prescribed discontinuing the IV infusion and removing the catheter.
• Follow infection-control guidelines (hand hygiene, gloving) to reduce the risk of infection at the site.
• Move the roller clamp on the tubing to the closed position to avoid spilling IV fluid.
• Remove any tape securing the tubing. Stabilizing the catheter at all times, pull the transparent dressing and tape toward the insertion site to avoid injuring the vein.
• Hold dry sterile gauze over the site and use a slow, steady motion to pull out the catheter, with the hub parallel to the skin; do not apply excessive pressure over the intravenous catheter when removing it, as this can be painful for the patient.
• Apply pressure over the insertion site for 2 to 3 minutes to make sure there is no bleeding. Apply gauze and tape or follow facility procedures for bandaging the site.
• Inspect the tip to be sure that it is intact. If it is not intact, notify the nurse immediately because, can cause an embolus, which could move through the patient’s circulation and cause a life-threatening blockage.
• Examine the insertion site for signs of infection (pain, redness, swelling, drainage). If the site looks infected, notify the nurse immediately.
• The provider might want the tip of the catheter to go to the laboratory for culture and sensitivity testing.
• Tell the patient to report any swelling, redness, pain, or leakage from the site.
• Remove your gloves, discard all waste material according to facility guidelines, and perform hand hygiene.

Ambulation, Transfers, and Transports

• Check with the nurse and clarify the patient’s activity and weight-bearing status.

Patient's Weight Bearing-Status

*Non-weight-bearing: The patient’s affected leg cannot touch the floor.
*Touch-down weight-bearing: The patient’s affected leg can only touch the floor for balance.
*Partial weight-bearing: The patient’s affected leg can only bear a portion of body weight.
*Weight-bearing as tolerated: The patient is able to stand or walk on the affected leg, bearing the amount of body weight only as tolerated.
*Full weight-bearing: The patient is able to bear full weight on the affected leg.

• If the patient is getting out of bed for the first time, unsteady, taking narcotics or sedatives, or is extremely weak, avoid ambulating the patient alone to prevent a fall.
• If the patient uses an assistive device for ambulation (walker, crutches, or cane), inspect the equipment prior to ambulation to ensure that it is in good working condition and adjusted for the patient; assistive devices should not be shared among patients.
• Allow the patient to sit up on the side of the bed for a specified amount of time prior to ambulation to reduce dizziness; apply a gait belt - safety device that you can use to support the patients while ambulating.
• Check that the patient is wearing secure footwear or nonskid socks and is appropriately dressed.
• Stand in front of the patient, place your feet at the sides of the patient’s feet, and bend your knees.
• Direct the patient to place their hands on the bed alongside the thighs. Grasp the gait belt (palms facing up) at each side and have the patient lean forward.
• On the count of three, have the patient push down on the bed while you are pulling the patient to a standing position by straightening your knees. If the patient requires an assistive device, this is the time to grasp them.
• While ambulating, always remember to stand on the patient’s weaker side and slightly behind the patient while holding onto the gait belt at the back. Encourage the patient to face forward and keep their head up.
• Have a predetermined distance in mind, but the patient might become fatigued easily, so be prepared for breaks. Having a chair nearby is helpful.
• Notify the nurse immediately if the patient does any of the following:
  • Reports shortness of breath or chest pain
  • Experiences a sudden headache
  • Feels any new pain while walking
  • Refuses to ambulate
  • Has a change in condition due to strength or ability
• If the patient starts to fall, assist the patient to the floor. Pull the patient close to you and wrap your arms around the patient’s waist. Position your leg under the patient’s buttocks and allow the patient to slide to the floor down your leg.
• As the patient moves closer to the floor, bend at your hips and knees, and gently ease the patient to the floor, supporting the head. Call for assistance; do not attempt to lift the patient off the floor until a provider or a nurse assesses the situation and determines the best way to assist the patient.

Range-of-Motion Exercises

• ROM exercises can help prevent contractures and loss of muscle mass.
• ROM exercises are active when the patient can perform them, but might need your encouragement or reminders to do so, at least twice daily.
• ROM exercises are passive when you perform them for the patient, moving the joint through its entire range of motion.
• When performing passive ROM exercises, support the body part above and below the joint with your hands or support the joint with a cupped hand.
• Repeat each sequence for each joint five times on each side of the body (except for the neck) before returning it to its neutral position.
• Stop if the patient reports pain, you meet resistance, or the muscles go into a spasm; never push a joint further than it can move.
  *Flexion movement that decreases the angle between two adjoining bones; bending of a limb at a joint.

ROM Exercises by Body Part