CNA Mega Review (IL)

Chapter 1-4

  • OBRA- Law that regulates the care people receive in nursing facilities

  • OSHA- Regulates workplace safety

  • DHHS- Government agency for regulating health

  • PPO (Preferred Provider Organization)- Contract between healthcare providers and an insurance company

  • HMO (Health Maintenance Organization)- Managed care system that contracts with health care providers to provide healthcare services for a prepaid fee

  • Survey Process- Inspection of nursing home carried out by government

  • Accreditation- Official recognition of a facility meets standards

  • DON (Director of Nursing)- Registered nurse who directs all nursing care

  • RN- Registered Nurse

  • LPN- Licensed Practical Nurse; usually has less education than RN

  • MDS (Minimum Data Set)- Focuses on the degree of healthcare a resident needs

  • ADL’s- Activities of daily living

  • Sympathy

  • Conscientiousness

  • Professional

  • Professionalism

  • Work ethic

  • Accountability

  • Empathy

  • HIPAA- Rules regarding confidentiality in healthcare

  • Holistic approach to health care- Considering resident’s emotions

  • The Health Care System



Organizations:

  • Hospitals

  • Long-term care facilities- Provides care for people who are unable to care for themselves at home; nursing home

  • Skilled nursing facilities or subacute care unit- Unit that focuses on rehab and helps patient move from hospital to home

  • Assisted living facilities- Residents live in their own apartments but have close access to food and healthcare

  • Hospice organizations- For dying patients

  • Home health care agencies



  • Team nursing- Model for organizing the nursing team’s efforts in which a team leader determines all of the nursing needs

  • Primary nursing- One nurse is assigned multiple patients

  • Functional nursing- Each member of the nursing team carries out the same assigned task



Government and Private Regulations:

  • Government- DHHS (Dept of Health and Human Services)

  • Private- Joint Commission (Independent non-profit organization)



  • Medicare- Funded by social security; all people 65 or older can be eligible

  • Medicaid- Federally funded program to pay for healthcare for low income people



  • Delegation (5 rights)-

    • The right task

    • The right circumstance

    • The right person

    • The right direction

    • The right supervision

  • Scope of practice- What tasks nursing assistant is eligible to perform

  • Registry- Official record of people who completed nursing assistant training program

  • Reciprocity- Certification will be valid in other states

  • Competency



Legal Terms

  • Litigation- Lawsuit or legal action

  • Negligence- Failing to do what a careful and reasonable person would do

  • Abuse- Repetitive and deliberate infliction of injury

  • Assault- Threatening or attempting to touch a person without consent

  • Battery- Touching a person without consent

  • False imprisonment- Confining a person against their will

  • Defamation- Making untrue statements that hurt another person’s reputation

  • Larceny- Stealing

  • Beneficence- Doing good for others



  • What are the tasks beyond the nursing assistant’s scope of practice?

    • Tasks that require professional judgment

    • Tasks that require interpretation of data

  • What are the guidelines for accepting or refusing a task?

    • Not in job description

    • Harm to patient or resident

    • Illegal or unethical

    • No supervisor

    • Unclear directions

    • Lack of proper equipment

    • Inadequate training



Chapter 5

  • Define verbal and non-verbal communication

    • Verbal Communication- Use of language either spoken or written

    • Nonverbal Communication- Giving information through facial expressions/body language

  • List effective communication techniques from the text

    • Speak loudly and clearly

    • Speak face to face

    • Ask for feedback

  • What are the tactics that enhance good communication

    • Make sure your message is clear

    • Learn techniques for encouraging people to talk

    • Provide and seek feedback

    • Be mindful of your body language and tone of voice

    • Remember the value of silence and a comforting touch



  • Positive body language:

    • Facing the person

    • Nodding as they speak

  • Negative body language:

    • Crossing arms

    • Tapping feet

    • Rolling eyes



  • Why is silence and comforting touch important?

    • They say more than words can sometimes

  • Make sure your resident is comfortable with comforting touch



  • What are blocks to effective communication?

    • Not listening carefully

    • Being judgmental

    • Assuming what others are thinking

  • Name ways to resolve conflict

    • Ask to speak privately

    • Focus on the specific area of conflict

    • Be specific

    • Be gracious and apologize for misunderstandings

    • Ask for insight



  • What kind of info is the CNA responsible for reporting?

    • Subjective data: Information that can not be measured or assessed (i.e. complaints of pain)

    • Objective data: Information you can obtain directly, through measurements or through your senses

  • Why is it important to document?

    • So that everyone on the nursing team will be in the know, and they can track patterns

  • Define electronic medical record (EMR), medical record, Kardex

    • EMR: Computer information system that stores patient information

    • Medical Record (Chart): Legal document containing information about the person’s current condition

    • Kardex: Card file containing a condensed version of each patient’s medical record

  • What are the advantages and disadvantages to the EMR?

    • Advantages: Easy access, quick to update, etc

    • Disadvantages: Confidentiality could be compromised

  • What is the nursing process?

    • Assessment 

    • Diagnosis

    • Planning

    • Implementation

    • Evaluation



Chapter 6 

  • Growth and development

    • Occurs throughout a person’s life span

    • Head to toe

    • Simple tasks to complex, 

    • Occurs at variable rates for each individual

  • List and give examples of Maslow’s Hierarchy of needs from basic to complex

    • Physiological 

    • Safety and Security

    • Love and Belonging

    • Self-Esteem

    • Self-Actualization

  • What actions can the CNA take to help the resident meet each of these needs?

    • Help with ADLs

    • Perform safety protocol

    • Explaining procedures

    • Giving residents a smile or a kind word

    • Provide for privacy

  • Define and give examples of

    • acute illness: Rapid onset and short recovery time; pneumonia, broken bone

    • chronic illness: Ongoing condition; diabetes, asthma, arthritis

    • terminal illness: Recovery is not expected; cancer, emphysema, some heart conditions



Chapter 7: Overview of Long Term Care

  • What is the purpose of OBRA and what does it cover?

    • OBRA

      • The goal of OBRA is to improve the quality of care patients receive. This is done by setting standards for the facility, training requirements, and towards resident care. 

  • Different Type of Healthcare Facilities

    • Hospital

      • A person who has a severe illness or whose condition is unstable and who requires a great deal of care and close monitoring would visit the hospital. 

    • Nursing Home (Long Term Care Facilities) 

      • This facility is for people who are unable to care for themselves at home, yet do not need to be hospitalized. 

    • Skilled Nursing Facility

      • Patients go here after being released from a hospital. The care received at this facility is from a skilled healthcare professional. 

    • Assisted Living Facility

      • Provides residents with limited assistance with tasks like personal care, transportation, meals, medication administration, etc. 

      • Residents of assisted living facilities live in small apartments that have a kitchen, bathroom, living area, and bedroom. There are also common areas where the residents can socialize.

    • Adult Day Care

      • Like a normal day care, this facility plans out activities to keep the adult in supervised care during the day. 

    • Continuing Care Retirement Community

      • The CCRC provides a continuum of care by including facilities for independent living, assisted living, and nursing home care. 

  • What is the purpose of the Centers for Medicare and Medicaid Services (CMS)?



  • They monitor nursing homes to make sure they are following OBRA regulations and meeting the government’s standards.

  • Government payment for services depends on whether or not the facility is meeting the required standards.

  • Which facilities are overseen by the government?

    • Hospital, Nursing Homes, Skilled nursing facilities

  • What is required for a long term care stay to be paid for by medicare

    • 3 consecutive days stayed and must be classified as a patient.

Chapter 8

  • What are coexisting medical conditions?

    • Multiple medical conditions at one time. 

  • What is the difference between ADL’s and IADL’s

    • IADL

      • Instrumental Activities of daily living are more complex tasks that a person must be able to do in order to continue to live independently (telephone, groceries, preparing meals)

    • ADLS

      • Activities of daily living include bathing, toileting, eating, moving

  • What is a degenerative disease?

    • Degenerative diseases occur when the tissues of the body wear out or break down. Examples are arthritis, muscular dystrophy, osteoporosis, Alzheimer's disease. 

  • How can the CNA assist in the transition for a newly admitted resident into a nursing home?

    • Include their family into the transition and allow the patient keep control over his schedule and activities. 

  • What care guidelines are provided by OBRA for an older resident? A younger resident?

    • Same care guidelines for both residents. 

Chapter 9 

  • What is Dementia?

    • The permanent and progressive loss of mental functions, caused by damage to the brain tissue. 

  • What would a person with dementia experience?

    • Problems with memory, especially short term memory

    • Difficulty communicating

    • Problems with judgement

    • Disorientation

    • An inability to manage activities of daily living.

  • How is Delirium different?

    • Delirium is the temporary state of confusion. 

    • What is the Cause?

      • A symptom of an underlying disorder, such as an infection.

  • What are the stages of Dementia?

    • Early Stage

      • Memory Loss

    • Middle Stage

      • Difficulty communicating, difficult recognizing people, difficulty remembering steps to complete familiar tasks. 

    • Late Stage

      • Loses the ability to walk, speak, swallow, smile, incontinent of urine and feces

      • Eventually dies.

  • Alzheimer’s Disease

    • When is the onset?

      • The risk increases with age, people 85 years and older are at the highest risk for developing the disease.

  • What are plaques and tangles?

    • Protein deposits found in the brains of people with Alzheimer's disease. 

  • What is the cure?

    • Not curable 

  • What is vascular dementia?

    • Mental functions are lost because multiple areas of the brain tissue die due to the lack of adequate oxygen and nutrition. 

    • This affects what age group?

      • 55-75 years

  • Define the difference b/w Lewy Body Dementia and Frontotemporal Dementia?

    • Frontotemporal Dementia

      • Caused by damage to the frontal and temporal lobes of the brain. The frontal lobe is the area of the brain that is responsible for personality and behavior. 

    • Lewy Body Dementia 

      • Caused by the built up of abnormal protein deposits in areas of the brain that are responsible for thinking and movement.

  • Define the following behaviors associated with Dementia

    • Wandering Pacing

      • People may stray away from home and this is especially dangerous because the person could be confused and disoriented.

    • Repetition/Perseveration

      • Repeating the same thing over and over again. 

    • Rummaging

      • The person goes through drawers or closets, searching for an item that he is never able to find. 

    • Delusions and Hallucinations

      • The person may think she is someone she is not, like the Queen of England, for example. Do not correct the delusions. 

    • Agitation

      • The patient may become very upset and excited. 

    • Catastrophic Reactions

      • Overreact to something that would cause a healthy person minimal or no stress. 

    • Sundowning

      • The worsening of a person’s behavioral symptoms in the late afternoon and evening.

  • Inappropriate Sexual Behaviors

    • May attempt to get into bed with a resident who is not her spouse. Person could masturbate or undress in a public area as well. 

Chapter 10

  • Microbe

    • Cause no harm and are actually essential for healthy living. Also known as a microorganism. 

  • Opportunistic Microbe

    • Microbes that can change from harmless to pathogenic. 

    • (Example E.COLI)

  • Pathogens

    • Microbes that can cause illness.

  • Bacteria

    • Can cause many of the infections encountered in the health care setting.

  • Illnesses caused by Bacteria 

    • Strep throat, UTI, TB, Lyme disease

  • Viruses

    • The smallest of all microbes can only be seen using a special microscope. 

  • Illnesses caused by Viruses

    • HIV/AIDS, hepatitis, fever blisters, common cold. 

  • Fungi

    • A group of plant-like organisms that scientists have classified together because of certain characteristics. 

  • Illnesses caused by Fungi

    • Ringworm, athletes foot, oral yeast infections

  • Parasites

    • Parasites live in or on a host, and use that host for food and protection. 

  • Illnesses caused by Parasites

    • Scabies, pediculosis (lice)

  • Defense Against Communicable Diseases

    • 1) IMMUNE SYSTEM-

      • Nonspecific Defense Mechanisms

        • Healthy intact skin and mucous membranes. 

    • Specific Defense Mechanisms

      • Antibodies, which help our bodies to fight off specific microbes. 

  • What are the S&S of INFECTION in the body

    • Difficulty breathing, coughing, fever

  • What are 2 types of bacteria that have become resistant to Antibiotics?

    • Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE)

  • Chain of Infection

    • Name the 6 key elements

      • Pathogen, Reservoir, Portal of exit, method of transmission, portal of entry, susceptible host. 

  • What is Nosocomial Infection?

    • Infections acquired by patients or residents while they are in a healthcare facility. 

  • Medical Asepsis

    • Physically removing or killing pathogens, primarily achieved through processes involving soap, water, antiseptics, disinfectants, or heat. 

  • What are the 4 techniques?

    • Sanitization

    • Antisepsis

    • Disinfection

    • Sterilization

  • What is double bagging?

    • Double bagging helps to keep any pathogens that may be on the outside of the bag from spreading to other places. 

  • Explain the difference between clean and dirty.

    • Dirty

      • When something is visibility soiled with dirt, blood, other body fluids or substances.

    • Clean

      • Something that is free from dirt, blood, body fluids, or other substances

  • Barrier Methods

    • A barrier is an object that physically prevents microbes from reaching a healthy care provider’s skin or mucous membranes.

    • PPE

  • What is PPE?

    • Personal protective equipment. Gloves, masks, gowns, protective eyewear

  • Name the components and the order of PPE and why

  • Isolation (transmission based) precautions

    • Airborne Precautions

    • Droplet Precautions

    • Contact Precautions

Chapter 11

  • Blood borne Pathogens

    • What is it and how is it transmitted?

      • Transmitted through blood or other body fluids. 

    • Diseases Caused by Blood borne Pathogens

      • Hep B,C,D

      • AIDS

      • Malaria

      • Syphilis

      • Ebola

  • What is the Cna at most risk for?

    • Hepatitis and HIV pose the greatest occupational risk to the health care worker.

  • Types of Hepatitis Review

    • Hep A) Transmitted through the oral fecal route

    • Hep B) Bloodborne pathogen, transmitted through transfusion of infected blood.

    • Hep C) Bloodborne pathogen, most common cause of chronic viral hepatitis.

    • Hep D) Bloodborne pathogen found only in people infected with HBV. 

    • Hep E) Transmitted through the oral fecal route like HAV. 

  • What are the OSHA Bloodborne Pathogen standards?

    • People in the healthcare field must treat every patient or resident as if he or she may be infected with a blood borne pathogen. 

    • People working in an are where exposure to bloodborne pathogens is possible must receive training on the risks associated with bloodborne pathogens. 

    • Employees must make the hep b vaccine available to workers who are at risk. 

  • Airborne Pathogens

    • Disease producing microbes that are transmitted through the air. 

  • TB define and what does it affect?

    • Infection caused by a bacterium that usually infects the lungs. 

  • Airborne Precautions? What are they and when do you need to use them?

    • High filtration respirators 

    • A surgical mask should be placed over the patient’s face.

Chapter 12

  • ABC’s of Body Alignment

    • Alignment

    • Balance 

    • Coordinated Movements

  • Evenly distribute weight by spreading your feet further apart

  • Transfer body weight to help movement

  • Use muscles in thighs hips and buttocks

  • Steps for lifting heavy object

    • Plant 

    • Get close

    • Lift with legs

  • How to assist resident with falling

    • Keep body close

    • Squat with them

    • Sit with them

  • MSDS or SDS

    • Information on safety for each substance and what to do in the event of emergency

  • R.A.C.E.

    • Remove

    • Alarm

    • Contain

    • Extinguish

  • P.A.S.S.

    • Pull out safety pin

    • Aim the hose toward the base of the fire

    • Squeeze the handle

    • Spray the contents of the fire extinguish in sweeping motion

  • Beginning Tasks

  • ENding Tasks

Chapter 13

  • What puts residents at risk?

    • Age

    • Medication effects

    • Paralysis

    • Poor mobility

    • Sensory impairment

    • Limited awareness of surroundings

  • Entrapment

    • Head gets stuck between the rail and mattress

  • Paraplegia

    • Paralysis from waist down

  • Tetrapelegia

    • Paralysis from the neck down

  • Hemiplegia

    • Paralysis on one side of the body

  • Fall Prevention

    • Evaluate risk for fall

    • Include prevention measures in care plan

  • Preventing burns

    • Water can only be between 110F and 115F

    • Warn patients of hot food or drinks

  • Incident reports

    • Report immediately and an incident report is filed promptly

      • Used for follow up

  • Restraints

    • Stop freedom of movement

    • Prevent reaching for parts of body

    • Physical of chemical

    • Doctor orders

    • Nurse applies

    • Monitoring

      • Take off every two hours for ten minutes

      • Visit every 15 minutes

    • Alternatives

      • Help from family members 

      • Use postural support

  • Tell nurse if

    • Shortness of breath

    • Blueness, paleness, or coldness of the skin

    • Complaints of pain, numbness, or tingling at or below a restraint body part

    • Skin is red, blistered, broken, or bruised

    • Person has become more confused, disorientated, or agitated

Chapter 14

  • Complications due to immobility

    • Pressure ulcers

    • Contractures

    • Pneumonia

    • Blood clots

  • Basic Positions

    • Supine

      • On back

    • Lateral

      • On left side 

    • Sims’ 

      • on right

    • Prone

      • On stomach

    • Fowler’s Position

      • High

        • 60 degrees

      • Normal

        • 45 degrees

      • Low

        • 30 degrees

  • Tell the Nurse if

    • Redness

    • Pale, white, or shiny skin over bony area

    • Tears, scapes, or skin that look burned

    • Hot, reddened, painful areas in the lower legs

    • New occurrence of urinary or bowel incontinence

    • New complaints of pain of movement

    • Any disconnected or heavily draining tubes or drains

Chapter 20

  • Pain management

    • Acute Pain

      • Short sharp pain that is healable and curable

    • Chronic Pain

      • Long-lasting pain

    • Breakthrough pain

      • Pain that comes between normal schedule of medication

    • Pain threshold

      • Point at which you feel pain

    • Pain tolerance

      • Point at which you need medication for pain

    • Radiating pain

      • Pain moves away from original site

    • Pain scale

      • Tool that helps translate subjective experience of pain into objective data

    • Treatments

      • Medication

        • Used for patients when pain has become intolerable

      • Physical Therapy

        • Exercise

          • Musculoskeletal pain

        • Ultrasound

          • Sound waves cause tissue and blood vessels to relax

        • Transcutaneous electrical nerve stimulation (TENS)

          • Shock therapy helps block pain signals

      • Cold application

        • Decreases bleeding and swelling, constrict blood vessels

      • Heat applications

        • Relaxes muscles, promotes blood flow to area, relieves pain

  • Sleep

    • Sleep Apnea

      • Difficulty breathing caused by tongue

    • CPAP

      • Continuous pressure airway pathway

      • Make sure it fits and is on

    • Difficulty with sleep

      • Insomnia

        • Sleep onset

          • Cant go to sleep

        • Sleep maintenance insomnia

          • Cant stay asleep

Chapter 21

  • AM Care

    • Toileting, bathing, oral care, shaving, hair care, dressing, make up

  • Afternoon Care

    • After lunch and dinner

    • Toileting

    • washing hands, face

    • Oral care

  • HS Care

    • Preparation for sleep

    • Change clothes

    • Oral care

    • Relaxing activities (music)

  • PRN Care

    • As needed (needs to use the bathroom often)

  • Edentulous

    • Without teeth

  • Peri-care

    • Clean to dirty

  • Oral Care

    • Hold at 45

    • Dental Caries

      • Cavities

    • Halitosis

      • Bad breath

    • Gingivitis

      • Inflammation of the gums

    • Periodontitis

      • Inflammation of tissue supporting teeth

    • Dentures

      • Use lukewarm water

  • Bathing

    • Partial Bath

      • Only face, hands, armpits, back, buttocks,and perineal area

    • Bed Bath

      • Wash clothes or bag bath cloths

    • Shower

      • Use chair

Chapter 22

  • Tinea Pedis

    • Fungal infection of feet

    • Athlete's foot

  • Tinea Capitis

    • Fungal infection of scalp

  • Alopecia

    • Hair loss

  • Pediculosis capitis 

    • lice

    • Nits

      • Eggs of lice

  • Nail

    • Cut straight to avoid hangnails

    • Podiatrist for feet

  • Dressing

    • POW

      • Put on weak

    • TOSS

      • Take off strong side

    • Adaptive devices

  • Shaving

    • Electric

    • Safety razor

Chapter 23

  • Types of diets

    • House Diet

      • No restrictions

    • Mechanical diet

      • Remove foods that are hard to digest

    • Clear liquids

      • Liquids at room temp

      • Transparent 

    • Full liquid

      • Clear liquids along with anything liquid at room temp

    • Pureed

      • Blended to a smooth consistency similar to pudding

    • Low cholesterol

      • Less fats

    • Low-carb

      • For diabetes

      • Less glucose and carbohydrates

    • NPO

      • Nothing by mouth

  • Supplements

    • Usually come in small gummies or pills

  • Serving

    • Hot foods hot (140F until served)

    • Cold foods cold

  • Relaxed environment encourages appetite

  • Preparing for meals

    • Toileting

    • Basic hygiene

    • Position for eating

    • Pleasant environment

  • Feeding

    • Use assistive utensils

    • Rock blade to cut

    • Place cup hold on drink

    • Always use spoon

      • Fill one third full

  • Other ways for feeding

    • IV Therapy

      • Tell nurse about 

        • IV is disconnect

        • Bag is empty

        • Not dripping

        • Blood in IV tubing

        • Complaints of pain

        • Swelling or redness

    • Enteral nutrition

      • Placing food directly in stomach

  • Dehydration

    • Too little fluid

  • Enema

    • Too much fluid

    • Lack of kidney function

  • Intake

    • Restrict or push fluids

      • encourage or limit

    • Only liquids

  • Output

    • Only liquid 

      • Vomiting, urine

Chapter 15

  • Respiratory arrest

    • Breathing has stopped

  • Cardiac arrest

    • Heart has stopped

  • Clinical death

    • Breathing has stopped

    • Reversible

  • Biological death

    • Brain dies

    • Not reversible

  • CNA’s responsibilities

    • Recognize Emergency

    • Decide to act

    • Check for consciousness

    • Activate EMS

    • Provide care until EMS arrive

    • Record care you provided

  • Signs of problems

    • Heart Attack

      • Pain in chest which may extend out

      • Pale skin

      • Excessive sweating

      • Trouble breathing

      • Nausea or heartburn like pain

    • Stroke

      • Unconsciousness or difficult to arouse

      • Sudden confusion

      • Slurs speech

      • Drooling

      • Eyelid or mouth drooping

      • Sudden headache

      • Weakness or paralysis in arms, fingers, leg, or side of face

      • Change in vitals

    • Syncope (fainting)

      • Dizziness

      • Temporary loss of vision

      • Clammy skin

      • Slow breathing

      • Weak pulse

    • Seizures

      • Grand mal

        • Violent jerking 

      • Petit mal

        • Absence seizure 

        • Momentary 

    • Hemorrhage

      • Arterial

        • Spurts or pulses

      • Venous

        • Steady flow

    • Shock

      • Hemorrhagic

        • Massive blood loss

      • Septic

        • Bacterial infection

      • Cardiogenic

        • Heart is unable to pump out enough oxygen

      • Anaphylactic

        • Severe allergic reaction

  • BLS

    • CPR

      • CAB

        • Compressions

        • Airway

        • Breathing

          • 30 to 2 for adult

          • 30 to 2 for child/infant

            • 15 to 2 for two ppl

Chapter 19

  • Hypertension

    • high blood pressure

  • Orthostatic hypertension

    • Sudden decrease in blood person when someone gets up 

  • Febrile

    • Having a fever

  • Afebrile

    • Without fever

  • Palpate

    • Examine by touch

  • Auscultation

    • Listening with a stethoscope

  • Tachycardia

    • Excessively fast heart rate

  • Bradycardia

    • Slow heart rate

  • Respiration

    • Dyspnea

      • Difficult respirations

    • SOB

      • Short of breath

    • Tachypnea

      • Higher than normal respiration

    • Normal ranges (breaths/min)

      • Infant: 30-60

      • Toddler: 20-40

      • Preschooler: 20-34

      • School Age:15-25

      • Adolescent: 15-20

      • Adult: 12-20

  • Pulse

    • Pulse rate

      • Number of pulses in one minute

    • Pulse rhythm

      • Pattern of pulsations

    • Pulse amplitude

      • Strength of pulsations

    • Popliteal

      • Behind knee

    • Apical

      • Chest

    • Carotid

      • Neck

    • Femoral

      • Groin

    • Radial

      • Wrist

    • Brachial

      • Inside of elbow

    • Record after 1 min

    • Normal ranges (beats/min)

      • Infant: 80-180

      • Toddler: 80-140

      • Preschooler: 80-120

      • School Age: 75-110

      • Adolescent: 60-100

      • Adult: 60-100

  • Blood Pressure

    • Factors

      • Age

      • Gender

      • Race

    • Place on brachial artery on arm

    • Normal ranges (mmHg)

      • Infant: 73/55

      • Toddler: 90/55

      • Preschooler: 95/75

      • School Age: 100/62

      • Adolescent: 102/80

      • Adult: 120/80

  • Temperature

    • Rectal

      • 1 inch for adults

      • Half inch for children

Chapters 16

  • Types of rooms 

    • Hospitals

      • Private single occupancy

      • More specialized furniture

    • Long term care facility

      • Home-like

      • Residents encouraged to bring furniture and personal items

    • Assisted Living facilities

      • Resident’s unit remains almost entirely independent

  • Work Areas

    • Nurses’ Station

      • Base of operations for nurses and CNA's

    • Medication room

      • Stores medication and supplies for administering medications

    • Clean Utility room

      • All clean linens and sterile supplies

    • Soiled utility room

      • All dirty supplies

    • Nourishment room

      • Snacks and beverages stored

  • OBRA Patient comfort

    • Size of room

    • Lighting must be available

    • Temperature of facility (71F - 81F)

    • Air quality

    • Noise control

    • Furnishings

    • Safety modifications

    • Allowance for personal items

    • Privacy

  • Lighting

    • General lighting

      • Illumination for all corners of room

      • Required for safety

    • Task lighting

      • Focused light aimed at helping one perform specific task

  • Beds

    • Gatches

      • Adjustable points of bed

    • Trendelenburg's position

      • Feet up, head flat

      • Shock, central line

    • Reverse Trendelenburg’s Position

      • Feet flat, head up

      • Spinal cord injury or in traction

Chapter 17

  • Admissions process

    • Doctor writes order for specific needs of person

    • Arrival to healthcare facility; admissions handler completes admissions sheet

      • Name, address, date of birth, social security number

    • Taken to room

    • CNA helps resident unpack

    • Nursing history

      • Completed my nurse about preferences specific to patient

    • Family is encouraged to help with admissions process

      • Second source of information

      • Make resident feel more comfortable

  • Admissions materials

    • Admissions pack

      • Basin

      • Water pitcher

      • Drinking cup

      • Tissues

      • Personal care items

    • Resident inventory sheet

      • Lists all of residents items objectively

  • Transfers

    • From one room to another

    • One unit to another

    • One facility to another

    • CNA responsibilities

      • Pack personal items

      • Assisting in transporting 

      • Reporting personal care assistance information

  • Discharges

    • Ama

      • Without doctor's order

      • Tell nurse

    • Discharge Planning

      • As soon as they are admitted

      • Make sure they continue to receive high quality care

Chapter 18

  • Bed Making

    • Mattress Pad

      • Placed on top of mattress to make it more comfortable

      • May be waterproof

    • Bottom sheet

      • Can be fitted or no fitted but is placed directly on mattress pad

    • Top sheet

      • Flat sheet on top of bottom sheet

    • Draw sheet

      • Small flat sheet placed in middle of bed

      • Protects mattress from moisture

      • Protects person skin from rubbing against rubber (if draw sheet is rubber)

    • Lift sheet

      • Can also be draw sheet

      • Placed in middle and used to lift resident

    • Bed Protector

      • Absorbent fabric soiree that is used to create waterproof layer above mattress and bottom sheet

    • Blankets

    • Bedspreads

      • May come from home

    • Pillows

    • Bath Blanket

      • Used for privacy in bath

    • Pressure relieving mattress

      • Stops skin breakdown through the use of foam pads

      • For people who have to stay in bed for long periods

    • Bed board

      • Piece of wood under mattress

      • Keeps mattress from sagging

    • Bed cradle

      • Placed between top sheet, blanket, and person’s feet

      • Stops skin breakdown in the feet

    • Footboard

      • Upright board at foot of bed 

      • acts as rest to keep feet in alignment

    • Stack linens in order they are used

  • Types of beds

    • Closed bed

      • Empty bed (no one sleeps there)

    • Open bed

      • Ready to receive a patient

      • Fanfolded

    • Surgical bed

      • Opened bed with linens fan folded to either left or right

    • Occupied bed

      • Bed is made while person is still in bed

Chapter 27

  • Cell

    • Basic unit of life

    • Organelles

  • Tissues

    • Epithelial tissue

      • Protect body

    • Connective

      • Supports parts of body

      • Bones, blood, cartilage, ligaments, tendons, fatty tissues

    • Muscle tissue

      • Produces movement

      • Skeletal

      • Smooth

      • Cardiac 

    • Nervous tissue

      • Made of up nerve that send impulses

  • Diseases

    • Acute

      • Short

    • Degenerative

      • Gets worse over time

    • Neoplastic

      • Tumor (cancer)

  • Homeostasis

    • State of balance in body

  • Body systems

    • Integumentary

      • Skin protects body

    • Skeletal

      • Serves as framework for body

    • Muscular

      • Allows for movement

    • Respiratory

      • Allow o2 movement

    • Cardiovascular

      • Moves blood through to cells

    • Nervous 

      • Sends impulses to control functions

    • Endocrine

      • Controls bodily function through hormones

    • Digestive

      • breaks down food

    • Urinary

      • Gets rid of waste

    • Reproductive 

      • Creates new life

Chapter 28

  • Integumentary system

    • Protections

    • Fluid balance

    • Regulation of temperature

    • Sensation

    • Vitamin d production

    • Elimination and absorption 

  • Necrosis

    • Cell death

  • Erythema

    • Reddening of skin

  • Excoriation

    • Scratching

  • Fissure

    • Crack in skin

  • Ulcer

    • Crater in skin formed by pressure

  • SKin color

    • Jaundice

      • Yellow

      • Liver disorders

    • Flushing

      • May be normal

      • Sickness/fever

    • Pallor

      • Paleness

    • Cyanosis

      • Blue

      • Not enough oxygen

  • Glands

    • Sebaceous

      • Secretes sebum

        • Lubricates skin to prevent drying

    • Apocrine

      • Axillae and perineum

        • Mix with bacteria to make body odor

    • Exocrine 

      • Sweat glands

  • Signs of aging

    • Wrinkles (loss of collagen)

    • Age spots and gray hair (loss of melanin)

  • Pressure ulcers

    • Stage I

      • Reddened area on skin that does not return to normal after pressure is removed

    • Stage II

      • Looks like blister, abrasion, or small crater

      • Epidermis is broken

    • Stage III

      • Epidermis and dermis are gone

      • May be drainage

    • Stage IV

      • Crater extends to bone

  • Wounds

    • Intentional

      • Made for a reason (surgical)

    • Unintentional

      • Trauma that causes wound in skin

    • Pressure ulcer

      • Crater caused my immobility

    • Burns

      • 1st degree

        • Epidermis is damaged

        • Goes away after a few days

      • 2nd degree

        • Break into dermis 

        • Painful and increases risk of infection

      • 3rd degree

        • Damage reaches subcutaneous tissue

        • Severe disfigurement and contractures

    • Wound drain

      • Allows excess fluid to move out of wound, preventing further infection

    • Rashes

      • Take precautions based on reason for rash

      • Local

        • In one place

      • Systemic

        • All over the body

    • Lesions

      • Break in skin

Chapter 29

  • Musculoskeletal system

    • Protection

    • Support

    • Movement

    • Heat production

    • Calcium storage

    • Production of blood cells

  • Osteoarthritis

    • Wear and tear on joints causes breakdown of cartilage of joints

    • Specific ambulation instructions

  • Rheumatoid arthritis

    • Autoimmune disorder where immune system attacks joints’ cartilage

  • Muscle atrophy

    • Muscles lose strength

  • Osteoporosis

    • Severe loss of bone tissue

    • Handly r/p gently

  • Gangrene

    • Tissue death

    • Only treatment is amputation

  • Hip replacement

    • Ambulation

      • No where and where not to bear weight

    • Toileting

    • Abduction pillow

      • Prevents legs from crossing

  • Traction

    • Skin

      • Weight is suspended from traction unit and exert pull to keep bone in alignment

    • Skeletal 

      • Pins driven into bone to support weight

  • ROM Exercises

    • Stops bone tissue loss and muscular dystrophy

    • AROM

      • Nurse gives verbal instructions

    • PROM

      • No active involvement from r/p

    • AAROM

      • r/p performs exercise with some hands-on help

Chapter 30

  • Respiratory System and Aging

    • Less efficient ventilation

      • Tired more easily

    • Increased risk for infections

  • Disorders and Symptoms

    • Pneumonia

      • Fever 

      • Pain when breathing

      • Cyanosis

      • Productive cough

        • sputum/phlegm

        • Hemoptysis

          • Blood in sputum

    • Pleurisy

      • Often comes with pneumonia

      • Pain while breathing

    • Bronchitis

      • Dry barking cough

      • Can turn into pneumonia

    • Influenza

      • Sore throat

      • Dry cough

      • Stuffy nose

      • Headache and body aches

      • weakness

      • Fever

    • Pneumothorax

      • Air in chest cavity

    • Hemothorax

      • Blood in chest cavity

  • ASTHMA

    • Bronchi and bronchioles constrict

    • Treated with bronchodilators

  • COPD

    • Emphysema and chronic bronchitis

      • Emphysema

        • Damage to alveoli

      • Chronic bronchitis

        • Long term irritation of bronchi and bronchioles

  • Respiratory Therapy

    • Treatment to help reach satisfactory respiration

    • Oxygen therapy

      • Oxygen provided to increase amount of oxygen inhaled

    • Safety

      • Fire hazard

    • Pulse oximeter

      • Measure of oxygenated blood

      • Normal is 95-100

      • Report anything 90 and under

    • Mechanical Ventilation

      • Breathes for a person who can't

      • Endotracheal Tube

        • Inserted in nose of mouth

        • Secured with balloon

      • Tracheostomy

        • Surgical opening into trachea through neck

Chapter 31

  • The Heart

    • Arteries

      • Carry blood away

      • More smooth muscle 

        • pressure

    • Veins

      • Carry blood to heart

    • Blood Pressure

      • Systole 

        • Heart constricts, blood moves out

        • Top number

      • Diastole

        • Heart relax blood rushes back in

        • Bottom number

  • Disorders

    • Myocardial Infarction

      • Reduced blood flow to heart causes tissue death

      • Heart attack

    • Angina pectoris

      • Chest pain

      • Heart muscle doesn't receive enough oxygen

    • Ischemia

      • Abnormal beating of heart

    • Edema

      • Swelling

    • Anemia

      • Red blood cells cannot carry oxygen as well

    • Leukemia

      • Excessive production of white blood cells

  • Lymphatic System

    • Returns fluid that leaks out back into blood stream

  • Aging

    • Less efficient contraction of heart

      • Tires easily

    • Decreased elasticity

      • Blood pressure is harder to control

    • Decreased number of blood cells

      • Higher risk for infections

  • Diseases

    • Bleeding Disorder

      • Thrombi

        • Blood clot

      • Embolus

        • Clot that moves

      • Blood can either clot too easily or not clot enough

    • Heart Failure

      • Monitor fluid intake and output

    • Coronary Artery Disease

      • Coronary arteries narrow, heart is unable to meet needs of activity

    • Deep vein thrombosis

      • Clotting in deep veins

      • Signs

        • Pain, redness, swelling, and warmth in lower legs

Chapter 32

  • Nervous System

    • Sends and receives information

    • Sensory neurons 

      • receive sensations

    • Motor neurons

      • Control muscles

  • Aging

    • SLow conduction times

      • Slower reflexes and reactions

    • Memory changes

      • Loose short term memories more easily

  • Dementia

    • Significant loss of mental capabilities

  • Transient Ischemic Attacks

    • Temporary episodes of dysfunction

    • Caused by reduced blood flow to part of brain

    • Symptoms

      • Dizziness, nausea, blurring, loss of vision, partial paralysis of face, inability to speak of swallow

  • Stroke (CVA)

    • Signs

      • personality changes

      • Drooping of eyelid or corner of mouth

      • Slurring of speech

      • Paralysis

      • Severe headache

      • Loss of consciousness

    • Causes

      • Impeded blood flow to brain

    • Effects

      • Hemiplegia

      • Aphasia

        • Expressive

          • Damage to motor centers for mouth

          • Cannot form words, difficult to swallow

        • Receptive 

          • Difficulty understanding words

    • Treatment

      • Depends of specifics of stroke

      • Aggressive physical therapy

  • Parkinson’s

    • Causes

      • Insufficient dopamine production

    • Effects

      • Tremors

      • Rigidity

        • stiffness

      • Akinesia

        • Slowed movement

      • Postural instability

        • Difficulty with balance

    • Treatment

      • Dopamine medication

      • Speech therapy

      • Physical therapy

  • Epilepsy

    • Chronic seizure activity

  • Multiple Sclerosis

    • Auto-immune disorder where immune system attacks myelin sheaths

Chapter 33

  • Definitions

    • Myopia

      • Nearsightedness

    • Hyperopia

      • Farsightedness

    • Astigmatism

      • Abnormally curved cornea

    • Cerumen

      • Ear wax

    • Otitis media

      • Infection of middle ear

    • Otitis externa

      • Infection of lining of ear canal

    • Vertigo

      • Periodical episodes of dizziness

    • Referred pain

      • Same as radiating pain

  • Eyes

    • Disorders

      • Glaucoma

        • Pressure is increased within eye

      • Conjunctivitis (pink eye)

        • Inflammation of conjunctiva

      • Cataract

        • Gradual yellowing and hardening of lens

      • Diabetic Retinopathy

        • Blood vessels in retina burst continually, damaging retina

      • Macular Degeneration

        • Deposits build up in macula

        • Causes blindness

    • Caring for….

      • Eyeglasses

        • Use special cloth and solution

      • Contact lenses

        • Keep in case with correct solution

      • Prosthetic Eyes

        • Clean properly review procedure

  • Ears

    • Deafness/ imparied hearing

      • Communication

        • Face person

        • Write instructions on notepad

        • Make sure person understands

        • Consider sign language

  • Aging

    • Taste and Smell

      • Chemoreceptors are lost

        • Taste is less intense

          • Less sensitive to dangerous smells or tastes

            • Gas leak or spoiled food

Chapter 34

  • Function

    • Control other organs through hormones

  • Normal Aging

    • Hormone decrease

      • Metabolisms decrease

      • Menopause

  • Thyroid Gland

    • Controls metabolism

    • Thyroxine

  • Hyperthyroidism

    • Thyroxine is too high

    • Metabolism is too fast

    • Increased hunger, weight loss

  • Hypothyroidism

    • Thyroxine is too low

    • Metabolism is too slow

    • Fatigue, weakness, weight gain, constipation

  • Diabetes

    • Type 1

      • Body cannot produce insulin by itself

    • Type 2

      • Cells in body become unable to respond to insulin

      • More common

      • Risk factors

        • Obesity

        • Increasing age

    • How to manage

      • Diet

      • Exercise

      • Medication

  • Blood Glucose

    • Normal is between 70 and 120 mg/dL

    • Liver stores excess glucose as glycogen 

  • Hyperglycemia

    • Blood glucose is too high

  • Hypoglycemia

    • Blood glucose is too high

  • DIabetes

    • Atherosclerosis

    • Hypertension

    • Heart disease

    • Kidney disease

    • Diabetic retinopathy

      • Blindness

    • Nerve damage

Chapter 35

  • Accessory organs

    • Teeth, tongue, salivary glands, liver, gallbladder and pancreas.

  • Peristalsis

    • Movement of the smooth muscle along GI tract

  • Endoscopy

    • Method of view digestive tract through mouth

  • Colonoscopy

    • Method of viewing digestive tract through anus

  • Chemical digestions

    • Digestive by enzymes

  • Mechanical digestion

    • Digestion by physically breaking down food

  • Effects of again

    • Less efficient chewing and swallowing

      • Increased risk for choking

    • Less efficient digestion

    • Increased risk for constipation

      • Slowing passage through digestive tract leads to drier feces

  • Hernias

    • Inguinal/femoral

      • Loop of intestine breaks through abdominal wall

    • Umbilical

      • Around navel

    • Hiatal 

      • Stomach passes through hiatus

      • Small frequent meals

      • Sit up for 2 hours after meal

    • Strangulated

      • Muscle tightens around trapped tissue

  • Ulcers

    • Mucosa becomes worn away

    • Causes

      • Smoking

      • Pain medications

      • Helicobacter pylori (bacteria)

    • Uncomfortable or nauseous after eating

    • Stomach pain after eating

  • Cancer

    • S&S

      • Loss of appetite

      • Indigestion

      • Pain

      • Vomiting

      • Constipation

      • Blood in stool

      • Changes in bowel movements

  • Gallstones

    • Block bile flow out of gall bladder

    • S&S

      • Serve pain

      • Indigestion

      • Pale or floating feces

    • Treatments

      • Laser or surgery

Chapter 36

  • Renal

    • Involving the kidneys

  • Neurogenic bladder

    • Bladder that is either overactive or underactive as a result of nerves losing control of bladder.

  • Renal Calculi

    • Kidney stones

  • Dialysis

    • Machine helps filter out waster due to lack of kidney function

  • Ureterostomy

    • Uteruses are brought through the abdominal wall and into ostomy bag

  • Urostomy

    • Ureters are attached to small intestine and then into ostomy bag

  • Anuria

    • No urine

  • Oliguria

    • Scant urine

  • Polyuria

    • Excessive urination

  • Hematuria

    • Blood in urine

  • Aging

    • Less efficient filtration

    • Decreased muscle tone

    • Enlargement of prostate gland (men)

    • Increased risk of UTI

  • Water

    • Vital for filtration process

    • Allows for liquid for waste to be flush into

  • Infections

    • Urethritis

      • Infection of urethra

    • Cystitis

      • Infection of bladder

    • Pyelonephritis

      • Infection of kidney

  • UTI’s

    • S&S

      • Burning,

      • Cramping

      • Older p/r

        • Change in voiding habits

        • Change in appearance or odor of urine

  • Renal failure

    • Acute

      • Emergency causes decreased blood flow to kidney

    • Chronic 

      • Gradual decrease in kidney’s ability

    • Signs

      • Dehydration

      • Swelling in tissues

      • Hypertension

      • Oliguria

  • Diagnosis

    • Urinalysis

      • Collect urine sample to be tested

    • Imaging Studies

      • Ways of seeing abnormalities in bladder

    • Cystoscopy

      • scope is inserted through urethra to view inside bladder

    • Ureteroscopy

      • Scope is inserted in urethra to view it

Chapter 37

  • Aging

    • Difficulty becoming pregnant

    • Decreased production of hormones

  • Female

    • Amenorrhea

      • No menstruation after puberty

    • Dysmenorrhea

      • Painful menstruation

    • Menorrhagia

      • Excessive bleeding during period

    • Infertility

      • Inability to carry a pregnancy to term

    • Cysts

      • Growths inside ovaries

    • Fibroids

      • Masses that form on muscle wall of uterus

    • Prolapse

      • Organ shifts down and ito vagina wall

    • Cancer

      • Cervical

      • Endometrial

      • Ovarian

      • Breast

  • Male

    • Aging

      • Decreased frequency and duration of erections

      • Enlargement of prostate

    • Disorders

      • Erectile dysfunction

      • Cancer

        • Testicular

        • Prostate 

        • Penile

  • STI’s

    • Herpes simplex

      • Cold sores

      • Blisters

    • Gonorrhea

      • Burning and green discharge in men

      • Pelvic inflammatory disease in women

    • Chlamydia

    • Genital Warts

      • Wart like growths around genitals

Chapter 38

  • Disability

    • Impaired function

  • Rehabilitation

    • Help person return to highest level of functioning

  • Restorative Care

    • Care provided to support rehab

  • Supportive Devices

    • Stabilize joints or limbs

  • Assistive devices

    • Make tasks easier

  • Prosthetic devices

    • Artificial replacements

  • Phases of Rehabilitation

    • Acute

      • Aims to keep person alive

    • Subacute

      • Focused on stabilizing medical condition

    • Chronic

      • Addition of rehabilitation care program

Chapter 39

  • Developmental Disabilities

    • Acquired

      • Developed after trauma or illness

    • Congenital

      • From birth

    • Levels

      • Mild

        • Trouble reading writing

        • Can reach a third to sixth grade level

      • Moderate

        • Difficulty with motor and speech development

        • Can reach second grade level

        • Trouble with socially appropriate behavior

      • Severe

        • Can only learn basic communication and life care skills

      • Profound

        • Need constant assistance with ADLs and supervision

    • Down Syndrome

      • Congenital developmental disability

      • May have cardiovascular defects and frequent respiratory tract infections due to muscle weakness

    • Autism

      • Difficulty communicating or relating to surroundings

      • No specific cause known

      • Main problems center on social skills

    • Cerebral palsy

      • Can be congenital or acquired

      • damaged cerebrum can cause spasms and/or shortening

    • Fragile X syndrome

      • Congenital

      • Defect in X chromosome causes intellectual disability, delayed communication skills

    • Fetal Alcohol syndrome

      • Congenital disability that can be both physical and intellectual

    • Spina Bifida

      • Congenital

      • Spinal deformity that can vary from case to case

    • Hydrocephalus

      • Congenital disability where spinal fluid builds in brain

      • Can also be acquired

Chapter 40

  • Coping mechanisms

    • Positive

      • Healthy, promote growth 

    • Negative

      • Unhealthy and can lead to further problems

    • Compensation

      • Making up for loss with another thing (food)

    • Conversion

      • Changing unwanted emotion into something more reasonable 

        • Fear turns into excitement

    • Denial

      • Refusal to accept reality

    • Displacement

      • Moving emotions onto less intimidating object

    • Projection

      • Cast own emotions onto someone else

    • Rationalization

      • Finding precarious rationales for events

    • Repression

      • Inability to remember traumatic event(s)

  • Mental illness

    • Anxiety disorders

      • Panic disorder

        • May feel like a heart attack

          • Many of the same symptoms

      • Obsessive compulsive disorder

        • Obsessions and compulsions control behavior

      • Phobias

        • irrational fears 

      • Post traumatic stress disorder

        • Variety of negative psychological effects of trauma

    • Mood disorders

      • Depression

      • Bipolar Disorder

    • Schizophrenia

      • Difficulty discerning reality from delusions and hallucinations

  • Substance Abuse and addiction

    • S&S

      • Tremors

      • Mood changes

      • Delirium

      • Hallucinations

      • Restlessness

      • Anxiety and fear

      • Insomnia

      • Nausea and vomiting 

      • Sweating 

      • Heart palpitations

      • Seizures

  • Eating Disorders

    • Anorexia Nervosa

      • Refuse to eat

    • Bulimia Nervosa

      • Binge eat and then purge

    • Binge eating

      • Continual eat even though they are full

  • Aging

    • Risk for mental illness increases

    • May have imparied ability to perform ADL’s

Chapters 25 and 26

  • Stages of Grief

    • Denial

    • Anger

    • Bargaining

    • Depression

    • Acceptance

  • Wills

    • Legal document that outlines that distribution of possessions

  • Advance Directive

    • Medical guidelines outlined by patient before they are incapacitated

  • Durable Power of Attorney

    • Person put in place of patients health care decisions

  • Palliative Care

    • Focuses on making patient comfortable

  • Supportive care

    • Makes person more comfortable

Chapter 41

  • Tumors

    • Benign

      • Not cancerous

    • Malignant

      • Cancerous

      • Will divide rapidly (Metastasis)

  • Risk Factors

    • Environtent

    • Lifestyle

    • Herediary

Chapter 42

  • AIDS

    • Usually die from infection they cant fight off

  • HIV

    • Flu like symptoms for first 2 to 4 weeks

    • Symptoms

      • Loss of appetite

      • Weight loss

      • Fever

      • dysphagia

      • Fatigue

      • Swollen lymph nodes

      • Pneumonia

      • Sores

      • Kaposi’s sarcoma

      • Dementia

      • Vision loss

      • Confusion

    • Transmitted through bodily fluids

    • Take standard precautions

Chapter 43

  • Anesthetics

    • General Anesthesia

      • Loss of consciousness

      • Risk for nausea or vomiting

    • Regional Anesthesia

      • Loss of sensation in part of body

      • Person is still conscious

    • Local Anesthesia

      • Loss of sensation in small part of body

        • Eye surgeries

  • Peri-operative Care

    • Pre-op

      • NPO status 

        • Prevents vomiting or aspiration

      • Pre-op teaching

      • Bathing

      • Grooming

      • Dressing

      • Enema

    • Intra-op

      • In surgery

    • Post-op

      • Placed in PACU

      • Prepare equipment for arrival

      • Coughing exercises and deep breathing

      • Thrombus prevention

Chapters 46 and 47

  • Home health

    • Respite

      • Caregiver leaves and comes back

  • Insurance controls time and length of each visit

  • Home health Aide

    • Responsibilities

      • In care plan

    • Do not accept compensation or gifts from client

    • Tote bag

      • Place specimens in plastic bag in dirty side

    • Prioritize individual needs

    • Be prepared/ plan out day and route