nha

Eating

ome patients need assistance with feeding. This can be due to weakness or physical or neurologic eficits. Check with the nurse about any dietary restrictions or precautions, such as NPO status or clear liquid diet. Also check whether the patient has diabetes or difficulty swallowing, as the patient might remind you the nurse miat ase to administer insulin or pure or thicken food prior te Communication with patients is key. You might offer to assist the patient with toileting prior to mealtime. Some patients have rituals such as a prayer before a meal or a preference for the order of eating their food. Raise the head of the bed or have the patients sit in a chair to prevent choking.

Create a friendly environment by sitting across from patients when possible; standing over them could make them feel rushed. This also gives you the opportunity to determine if the patient is having difficulty swallowing. It might be difficult for patients who have had a stroke to chew on the affected side. Direct the food toward the nonaffected side of the mouth. Using a spoon is safer than a fork when assisting with feeding. Make sure the bites are not too large, and give patients adequate time to chew and swallow their food before offering more. Have water available in a cup with a flexible straw. Allow the patients to feed themselves as much as they can do so.

WEIGHING PATIENTS

It is important to weigh patients accurately because weight determines many treatments and medication dosages. For patients who have heart failure, an increase of a few pounds can be significant. Become familiar with the scales in your facility. You might use an upright (electronic or mechanical), bed, chair, or sling scale. Make sure the scale is set to zero prior to use. Ensure the safety by eliminating tripping hazards near the scale. Encourage patients to use safety features such as ramps and handrails to get on and off the scale.

When using a mechanical scale, start by moving all of the weights to the left side of the balance bar.

Check that the balance bar pointer is centered in the middle of the balance frame. Assist the patient onto the scale. Slide the large weight on the bottom to the groove closest to but still lower than the patient's estimated weight. Then move the smaller weight on the top to the right until the balance bar pointer is floating in the center of the balance frame. Now record the patient's weight.

1.3 Wheelchair scale

If the patient is in a wheelchair and you are using a chair scale, wheel the patient onto the scale and subtract the weight of the wheelchair before recording the patient's weight.

Bed and sling scales vary by facility. Seek training on their use prior to operating them. When weighing a patient using an in-bed scale, subtract the weight of the bedding and equipment (such as a portable heart monitor in the bed. Explain the procedure to the patient and assure them that they are safe. Ensure that all connections are secure before raising the patient for the weight measurement.

EMOTIONAL SUPPORT

need emotional support while you perform the tasks that support their physiologic healing. Be aware of their needs, and encourage them to communicate them to you. Show empathy at all times Often, patients and their families need to express feelings of anger, frustration, fear, or anxiety.

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 attention to what the speaker is conveying. Never pretend to listen while doing something else.

Make eye contact repeatedly, while also respecting patients' personal space, smiling, and conveying genuine interest, warmth, empathy, sincerity, openness, and consideration.

Verbal communication is the sharing of information between individuals using recognizable spoken words. Nonverbal communication is behavior that complements, negates, or substitutes for spoken words. It includes gestures, mannerisms, facial expressions, body posture, stance, eye contact and movements, touch, personal space, and overall appearance. Both verbal and nonverbal communication elements are important when providing high-quality patient care.

Therapeutic communication is an interaction between a health care professional and a patient that aims to enhance the patient's comfort, safety, trust, health, and well-being. You can focus on patients and help them better understand a procedure or interaction through verbal and nonverbal communication. The objective is to communicate using terminology patients readily understand Therapeutic communication involves specific strategies that convey understanding and respect, with the intention of encouraging patients to express their feelings and ideas. Patients can be anxious or apprehensive. Be sensitive about their feelings.

Every health diagnosis comes with its own language and medical terminology, which can be difficult

Be aware of different viewpoints and personal biases, and pay close attention to words and actions that could cause miscommunication. Avoid figurative or colloquial language, such as "'m all ears." Remember that nonverbal communication is extremely important, and keep the conversation straightforward and brief. It takes practice and patience to accomplish all of this while also remaining compassionate and caring. Interpersonal skills-such as friendliness, empathy, genuineness, openness, and sensitivity-can help tremendously in serving diverse populations.

When a patient is not fluent in a language you speak, ensure that each party understands what the other is conveying. If it is a brief and routine encounter, patients might be able to communicate well enough nonverbally. When there is important information to exchange, seek the assistance of a medical interpreter. If you often encounter patients who are not fluent in the language you speak, have written instructions available in other languages to demonstrate cultural competence. Respect all cultural or personal preferences that arise, such as a patient wishing to pray before allowing an invasive procedure.

EQUIPMENT

Oxygen equipment

After surgery, some patients require supplemental oxygen. Patients who have respiratory disorders might require oxygen in the hospital and at home. Patient care technicians work with many patients who require oxygen therapy. Because oxygen is a medication, the provider must prescribe the flow rate and method of delivery. Only a licensed provider can initiate oxygen therapy, but you need to be familiar with the equipment to monitor patients and report any changes in their status to the nurse.

In the hospital setting, oxygen delivery is usually through a wall-mounted system using a valve and a flow meter. If the patient is ambulatory, a portable oxygen tank is needed. Most often, a nasal cannula delivers oxygen to the patient. However, a face mask can be used depending on the patient's condition and oxygen prescription.

1.6 Oxygen nasal cannula and face mask

When assisting with oxygen, first verify the order with the nurse. Explain the procedure and answer any questions the patient has about the need for oxygen, the equipment, and safety precautions.

Safety guidelines

Safety guidelines during oxygen use include the following.

• Make sure there is adequate signage in the

• Make sure oxygen and is not a tripping hazard.

• Avoid using electrical equipment-such as electric • Know the location of fire extinguishers in

your facility.

electrical devices are in good working condition.

• Keep oxygen cylinders away from heat sources.

Steps to take

Gather supplies. If the patient has a prescription for oxygen delivery by nasal cannula, place a nasal prong in each nostril and then loop the tubing over and behind the patient's ears. Adjust the tubing to a comfortable position under the chin. Add padding to the tubing behind the ears if needed, as skin breakdown can occur from the pressure of the tubing against the skin. If the provider prescribes oxygen by face mask, place the mask over the patient's nose and mouth. Place the strap over the patient's head and behind the ears. Adjust to a comfortable position using the straps and nose clip.

Assess the functioning of the equipment. For a nonrebreather mask, the bag connected to the mask should be expanding when the patient exhales but should not totally collapse when inhaling.

Complications

ygen can cause the patient's nasal cavity and mouth to become dry. If the patient is receivil veen at a flow rate greater than 4 L/min or has symptoms of dryness, attach the flow meter to humidifier. Check that the humidifier is bubbling and that the level of water does not get too low.

Applying water-soluble lubricant to the nares and providing oral care frequently can also make the patient more comfortable.

When caring for the patients receiving oxygen therapy, monitor for symptoms of hypoxia.

• Anxiety

• Lack of concentration or focus

• Fatigue

• Hypertension

• Cyanosis (bluish discoloration)

• Dyspnea

• Increase or decrease in heart rate or

Notify the nurse immediately if you observe the following.

• Pulse oximetry reading less than 90%

• Portable oxygen tank that is almost empty

• Discrepancy between the prescribed oxyge flow rate and the flow rate on the flow mete

• Any sudden change in patient condition

Do not change or adjust the flow rate of oxygen.

Always check with the nurse before removing oxygen from the patient.

respiratory rate

Suction equipment

Patients can require suctioning to remove mucus, blood, vomit, secretions, or other substances from their mouth and throat to keep their airway open. Suctioning a patient's airway is a task a nurse might delegate to you, depending on the stability of the patient and your allowed job duties.

Check your facility's and State's scope of practice regulations before performing suctioning.

Oropharyngeal suctioning (mouth and throat) is most common after surgery.

1.7 Suction catheter

Explain the procedure to the patient and warn them that suctioning can cause coughing, gagging, and sneezing. Gather your supplies and raise the head of the bed to 45°. Position unconscious patients on their side. Check with the nurse and facility protocol for suction settings, type of catheter, and size. Connect the suction catheter to the tubing and turn on the suction. Test the suction by inserting the tip of the catheter into a basin with sterile normal saline. Then gently insert the tip of the catheter into one side of the patient's mouth and move it toward the oropharynx. Glide the catheter around the patient's mouth until you are removing secretions, but for no more than 15 seconds at a time. For patients who are conscious and able, have them cough and breathe deeply between suctioning. Clean or discard the catheter according to facility policy after each use.

ROUNDING.

"Can I assist you into a more comfortable position?"

"Do you need to go to the bathroom?"

"Is there anything I can get for you that is out of your reach?"

Rounding is also an opportunity to observe any changes in the patient's condition and report them to the nurse. This could be a change in level of consciousness, shortness of breath, increased signs of pain, incontinence, agitation, psychological or emotional changes, or difficulty in mobility. When prioritizing patient needs, consistent rounding can help you assess which patients need assistance first. Overall, rounding can keep the patients safe and well cared for.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey is a national, standardized, publicly reported survey of patients' perspectives of hospital care. Patients' experiences can directly affect a hospital's public record. This report is based solely on the patients' views of and satisfaction with their hospital experience. Rounding is a proactive activity that can directly affect patients' perception of their hospital experience.

REMOVING PERIPHERAL IV CATHETERS

Removing a peripheral intravenous (IV) catheter is a relatively quick and simple procedure. Before you remove an IV catheter, check with the nurse to make sure that the provider has prescribed discontinuing the IV infusion and removing the catheter. When removing the catheter, follow infection-control guidelines (hand hygiene, gloving) to reduce the risk of infection at the site.

When removing an IV catheter, first 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. once you hurtmore the here hat the i he the in a lent, act,

could move through the patient's circulation and cause a life-threatening blockage. Also, 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 to ite it sentely testine the ale to emote any scling today guare, age

perform hand hygiene.

STERILE AND ASEPTIC DRESSINGS

Sterile dressings

Aseptic dressings

You will replace dressings that require aseptic-or clean-technique. Dressings protect and cover wounds and incision sites. Most often, you will replace simple dry-gauze dressings. To reduce the risk of causing an infection, strictly follow facility policies and procedures for changing dressings. Make sure the patient is aware that removing dressings can be painful because they expose and can adhere to the wound. If you anticipate significant pain, check with the nurse about giving the patient an analgesic 30 min prior to the dressing change. If the dressing adheres to the skin, moisten it with sterile water or sterile normal saline solution. Removing tape can also be painful, so do it slowly and carefully.

Methods for changing a simple dressing vary, but most include the following steps.

1. Perform hand hygiene.

7. Establish an aseptic working area. Open a

2. Assist the patient into a comfortable position.

package of sterile gauze and saturate it with

1. Remove the old dressing. Observe the wound. Note the amount, color, and odor of any drainage.

2. Dispose of the dressing in a biohazard bag.

3. Remove gloves. Perform hand hygiene.

1. Cleanse the wound. Observe the wound's size, depth, color, and odor.

2. Apply a new dressing.

3. Dispose of the cleansing gauze and any other used materials.

4. Remove gloves. Perform hand hygiene.

OSTOMY CARE

An ostomy is a surgically created opening from the intestines to the outside of the body and into an ostomy appliance. A colostomy opens from the large bowel and expels feces (ranging in consistency from liquid to semi-liquid to solid) into an ostomy appliance. The usual consistency can vary with the location of the ostomy. If it is closer to the rectum, the stool will be more solid. If it is closer to the small intestine, it will have more liquid. An ileostomy drains liquid stool from the distal part of the small bowel into an ileostomy appliance. Surgeons create these temporary or permanent ostomies to treat cancer, trauma, or inflammatory bowel disease.

When caring for a patient who has an ostomy, you are likely to perform the tasks of emptying the pouch, cleansing the ostomy and the skin around it, and reapplying the appliance. Patients often have difficulty adjusting to new ostomies, emotionally and in terms of caring for it, so be sensitive when interacting with these patients. Policies vary with how much ostomy care you may perform.

Ostomy supplies vary considerably, so familiarize yourself with the type the patient is using. Some are one-piece systems, so removing the pouch removes the skin barrier as well. Others are two-piece systems, where removing the pouch leaves an attachment device or flange and the skin barrier in place.

Some have drainable pouches for the patient to rinse and reuse. Some have a pre-cut skin protectant barrier or wafer that fits over the ostomy, while others require cutting an opening 1/16 inch larger than the circumference of the stoma before fitting it into place. Some connect to a belt that fits around the patient.

Empty ostomy pouches when they are half-full.

1.9 Ostomy appliance

If you are only emptying the pouch, perform hand hygiene, and use a bed protector under the

ostomy bag (side view)

patient to protect the bed linens. Wearing clean gloves, detach the clamp and empty the contents into the container your unit uses for this purpose.

Wipe the lower 5.1 cm (2 in) of the pouch, turn it up like a cuff, and reapply the clamp. Discard the stool in the toilet, and rinse and clean the container. Remove gloves and perform

stoma

hand hygiene.

stoma and wafer

To perform ostomy care, collect the supplies, perform hand hygiene, use a bed protector under the patient to protect the bed linens, and don Clean gloves. Then perform the following steps.

The stoma can attach at various points to the large or small intestines, depending on the cause

• or need for the ostomy.

1. Remove the ostomy belt, if the patient has the type of system that includes a belt.

2. Hold the skin taut and peel off the ostomy appliance from the top, while gently pushing the skin away from the skin barrier portion of the appliance.

3. Put the appliance in a bedpan.

4. Wipe away any feces on the stoma and around the stoma gently with toilet paper and put the toilet paper in the bedpan.

5. Place gauze over the stoma in case any stool comes out while you are performing ostomy care.

6. Take the bedpan to the bathroom and dispose of its contents and your gloves.
   Perform hand hygiene.

7. Return to the patient with a basin of warm water, 40.5° to 43.3° C (105° to 110° E), clean gloves, and a washcloth folded into a mitt ound your hand, as you would for routi

1. Remove the gauze and wash the skin around the stoma with plain water. Rinse the area and dry it thoroughly.

2. Apply skin adhesive if it is necessary with the type of pouching system the patient has.

3. Place a clean ostomy belt around the patient if the appliance type includes one

4. Check that the opening on the new appliance is the right size.

5. Remove the backing from the skin protectant wafer and center the opening over the stoma. Press the wafer against the skin for 1 to 2 minutes to ensure a good seal.

6. Fold the bottom edge of the pouch up into a cuff and apply the clamp. Attach the belt, if the patient wears one.

7. Assist the patient into a comfortable position. Discard supplies, remove gloves, and perform hand hygiene. AMBULATION, TRANSFERS, AND TRANSPORTS

   • 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.

   Ambulating using assistive devices

   For patients who are safe to ambulate, determine whether they require a one- or two-person assist.

   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.

   This can reduce dizziness. While the patient is sitting up, you can apply a gait belt. A gait belt is a safety device that you can use to support the patients while ambulating. It is usually made of a canvas material, wraps around patient's waist, and is secured by a buckle. 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

Transferring weight-bearing patient from bed to wheelchair

At times, a patient might be unsafe to ambulate or the distance is too far, such as for a trip to the radiology department on the opposite end of the hospital. Transfer the patient from the bed to a wheelchair with the patient's strong side to the chair. Place the wheelchair next to the bed at a 45° angle facing either the foot or head of the bed-depending on the patient's strong side—-and lock the wheels. Make sure that the bed is in the lowest position and the head of the bed is raised. Guide the patient's shoulders while assisting to swing the patient's legs to the side of the bed. Ensure that proper footwear and attire are in place. Using a gait belt, 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. Assist the patient to swing around and sit in the wheelchair, guiding the patient on the way down. Place a blanket over the patient's legs.

Transferring non-weight-bearing patient

If the patient has a non-weight-bearing status, transfers can use mechanical lifts or transfer boards. Mechanical lifts are used for lifting and moving patients. You should become familiar with the specific device your facility uses to prevent injury to you and patients.

Mechanical lift. Lifting devices typically have a sling and a metal frame with a hydraulic lift mechanism. Explain the procedure to the patient. Lock the wheels on the lift. Place the sling under the patient and connect it to the metal frame. Check that all connections are secure, and engage the lifting mechanism. Lift patients only high enough to safely transfer them. Once the patient is over the desired location (bed, wheelchair, stretcher) lower the patient, guiding the sling into position.

Communicate continuously with patients during the lift process to assure them of their safety.

Transfer board. Another method of transferring a patient from a bed to a stretcher-or from a stretcher to another flat surface such as a bed or x-ray table-is a transfer or roller board. This is best performed with a three-person assist. First, roll the patient onto one side, and position the board under the patient. Then place the transfer board and a slide sheet under the patient.

Make sure that both surfaces (the one you are transferring the patient from and the one you are transferring the patient to) are aligned next to each other at the same height, and both have their wheels in the locked position. The transfer board should bridge both surfaces. Two people should be on one side ready to pull the patient toward them onto the new surface, and one should be on the other side able to assist if needed in guiding the patient. If the patient is unable to assist, additional staff members might be necessary to guide the patient's head and feet. Be aware of any IV lines, indwelling urinary catheters, or drains, and position them so they can accommodate the change in position. Direct the patient to place their hands across their chest. Make sure everyone is in position and is holding the slide sheet, and count to three. On three, slide the patient in one motion onto the new surface. Remove the transfer board and slide sheet, and make sure the patient is comfortable.

Transport patient via bed, stretcher, or wheelchair

In inpatient facilities, you might have to transport a patient-using a bed, wheelchair, gurney, or precation beationing pathe hopel orsuade the facility to a vehice. There are spectice

• Raise all side rails on beds and stretchers before unlocking wheels and moving the conveyance.

• Make sure IV bags are on an attached pole or another staff member is holding them at an appropriate height.

• If the patient has a urinary drainage bag to an indwelling urinary catheter, attach it to the conveyance below the level of the patient's bladder.

• Move slowly and carefully over bumps, uneven flooring, thresholds, and pavement or ground outside.

• Be especially cautious when backing in or out of elevators. Make sure there is enough room, and check that the patient is securely inside the boundaries of the conveyance and that the drainage bag, IV bag, and footrests on a wheelchair will not brush against the elevator doors, walls, or other occupants.

• In emergency situations, if other people are in the elevator, ask them to step out and wait for the next one. In nonemergency situations when the elevator has other occupants and there is not enough room, wait for the next elevator.

• When you have to take the wheelchair up a curb, face the curb and put the front wheels up onto the curb first, following with the larger rear wheels.

• When you have to take a wheelchair down a curb, back the larger rear wheels off the curb first, and then back the front wheels off the curb. Then reverse to a forward-moving position.

28

IMMOBILITY SPLINTS

A splint stabilizes an extremity after injury or surgery and provides temporary support to broken bony structures or operative areas. If applied correctly, splints minimize the pain of dislocations, fractures, soft tissue injuries, and postoperative pain.

Splints vary greatly with the type and the purpose, each requiring specific application techniques.

However, there are a few rules common to all splint applications.

• Apply them from the distal part of the extremity to the proximal part. For example, when applying a splint to the forearm, start at the wrist and work your way to the elbow.

• Always remove jewelry on the affected limb prior to applying a splint.

• After applying the splint, check for circulation, movement, and sensation in the areas beyond the splint. For example, after applying an arm splint, check the fingers, comparing them with the fingers on the unaffected extremity. Are they the same temperature and color? If the fingers are colder or look pale or blue, notify the nurse immediately. Also inform the nurse if the pain in the extremity is worsening or if movement is more limited than previously. Has the patient reported any numbness or tingling in the fingers? If so, report it immediately.

In most cases, the provider will instruct the patient to keep the extremity with the splint elevated.

Reinforce this with the patient. Elevation helps reduce edema, which helps reduce pain. Most splints have a small opening in the front to allow for some swelling without impairing circulation.

SKIN CARE

A vital part of your job is preventing skin breakdown. To help do this, reposition patients

shear

at least every 2 hours to minimize the risk of developing pressure ulcers. Specialized beds, air mattresses, mattress overlays, bed cradles, elbow and heel pads, and other equipment can also relieve the pressure that can result in these

ulcers. Another cause of a loss of skin integrity is shearing force, which is a sliding of skin layers on each other-for example, when the head of the bed is elevated but the patient slides down toward the flat part of the bed. When moving a patient, using lift devices reduces friction from dragging a patient's skin across bed linens.

Skin care is also essential for preventing skin breakdown. Keep skin clean and dry, and make sure patients' skin has no contact with gritty substances, such as food crumbs between the bed linens and the skin. Some facilities do not allow the use of powder and cornstarch, because these products can become gritty and abrade the skin.

Patients who have episodes of incontinence are at high risk for skin breakdown from the exposure to moisture. Remove wet or soiled clothing, linens, and protective pads promptly. Wash skin with warm water and mild soap if necessary, to rinse it thoroughly, and to dry it carefully. Pat the skin dry gently; do not rub it. Then 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, to avoid the pressure that sitting on that equipment causes. Encourage patients who are able to ambulate at least every 2 hours.

Place a pillow under the calves of patients who are supine in bed to take pressure off 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. This 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 supine

of dead tissue.

Look for dryness, and apply moisturizing lotion according to facility policies. Look for irritated areas and maceration. Check skin integrity

prone

where tubing comes in contact with skin, such as oxygen tubing behin the ears. Protect these areas according to facility protocol. Also apply ar emollient or lip balm to dry lips to prevent cracking. Report any skin changes to the nurse.

Fowler's

when repost an ine patient ery the hast poetin in the toling

those positions. The nurse can advise you of any special positioning

Sequential compression devices

Sequential compression devices (SCDs) help prevent blood clots from forming in the lower legs. Blood clots become life-

1.11 Sequential

compression device

threatening if they become mobile and block circulation to the brain, lungs, or heart.

Patients require SCDs most often after surgery. Place the sleeves that attach to the devices on each leg. The sleeves connect to an air compressor that inflates and deflates them around the legs or feet. This continuous compression-decompression device promotes blood flow in the legs and feet, preventing blood-clot formation.

The following are the steps to take when applying SCD sleeves.

• Place the SCD sleeve under the patient's leg, following the positioning indications on the inner lining of the sleeve.

• Make sure the back of the knee is at the popliteal opening and the ankle is at the ankle indication on the sleeve.

• Wrap the sleeve securely around the leg, making sure you can fit two fingers beneath the sleeve. (Less space between the sleeve and leg could interfere with circulation to the leg when the sleeve inflates.)

• Plug the connector on the sleeve into the connector that goes to the device.

• Turn the device on and observe that it is functioning correctly.

• Repeat the procedure on the other leg.

• Reposition the patient for comfort.

• Remove the sleeves once during an 8-hour shift to check the patient's skin and circulation.

• Antiembolism stockings/compression hose

  Antiembolism stockings prevent blood clots from forming in the deep veins of the legs. They also help prevent fluid buildup in the legs. Antiembolism stockings—or 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.

  Take the following steps when applying antiembolism stockings.

  • Have the patient lie supine.

  • Slide or pull the rest of the stocking up

  • Turn the stocking inside-out down to

  over the calf. Be sure it is smooth, with no

  the heel.

  wrinkling, bunching, or twisting. Do not roll the stocking down at the top, because that

  • Place your hand inside the stocking and gras

  could interfere with blood circulation in the

  ne tip where the patient's toes will g

  leg and foot.

  • Place the patient's toes into the tip of the

  • Repeat the procedure on the other leg.

  stocking, making sure the material is smooth and without wrinkles.

  • Reposition the patient for comfort.

  • Slide the stocking over the rest of the

  • Remove the sleeves at least once per shift to check skin and circulation.

  patient's foot and heel, making sure the heel fits into the heel portion of the stocking.

  RESPIRATORY CARE

  Turning, coughing, and deep breathing

  After surgery, patients are at risk for complications in multiple body systems. You can encourage measures to prevent some of these complications. Respiratory complications are an important consideration. Feeling drowsy after anesthesia and pain medication, plus experiencing postoperative pain, can make it difficult for lungs to keep functioning optimally and remove fluid and mucus. irning, coughing, and deep breathing (TCDB) helps prevent respiratory complications. Tu tients from side to side, reposition them frequently and—when they can independently

Spirometry

Using an incentive spirometer is a breathing exercise that helps prevent respiratory complications after surgery. With this device, patients breathe deeply to raise the balls in the chamber by forcefully inhaling through the device. The steps for using the incentive spirometer are as follows.

• 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. The style of these devices varies, but they all show an indication of the amount of air breathed in to help them set and reach goals. One type has balls patients have to raise to achieve a desirable amount of inhaled air.

• After inhaling, 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.

FIRST AID AND CPR

Be prepared to give first aid and provide basic life support (BLS) when you are the first to arrive during potentially life-threatening situations. You might be part of a rapid response team, responding immediately to emergencies within your facility. Or you might assist nurses and providers who are providing life-saving measures. Follow your scope of practice or range of functions within the facility when responding to emergencies.

First aid

Bleeding

Basic first aid involves steps to take in a variety of situations. One of the most common is bleeding, possibly from a wound, an incision, a venipuncture, a dermal puncture (for capillary blood), or after the removal of an IV catheter. Apply pressure to the site with a gauze pad for several minutes.

Do not keep checking to see if the bleeding has stopped, because that can dislodge clots that are beginning to form. If the bleeding is brisk and does not stop after a few minutes, call for assistance.

You might encounter a nosebleed, or epistaxis. To stop a nosebleed, take the following steps.

• Have the patient sit up and lean forward.

• Apply pressure to the nostril by pinching the nose.

• Maintain pressure for 10 to 15 minutes to allow adequate clotting.

• If the nose is still bleeding, insert gauze and notify the nurse.

Choking

Choking also requires emergency first aid. First, look for signs that the patient is choking. The universal sign for choking is grabbing the front of the neck. When a foreign body completely obstructs the airway, the patient is unable to cough or speak. You may hear a high-pitched noise while the patient inhales or no noise at all. The patient will soon be unable to breathe and lose consciousness without intervention. Immediately call for assistance from the emergency response team. Prepare to deliver abdominal thrusts repeatedly to force the patient to expel the foreign body from the airway. Continue abdominal thrusts until the foreign body is expelled or the patient becomes unresponsive.

Administering abdominal thrust (Heimlich maneuver) to an adult

• Stand or kneel behind the patient.

• Wrap your arms around the patient's waist.

• Make a fist with one hand and place the thumb of the fist against the patient's abdomen, in the midline, slightly above the navel and well below the breastbone.

• Grasp your fist with the other hand and press your fist into the patient's abdomen with a quick, forceful upward thrust

• Repeat thrusts until the patient expels the foreign body or becomes unresponsive.

• Give each new thrust with a separate, distinct movement to relieve the obstruction.

Seizures

Seizures require immediate action to prevent aspiration and injury. Do not attempt to restrain the patient or force anything into the mouth. Call for assistance, and remove anything from the area that can injure the patient. After uncontrolled muscular contractions subside, turn the patient's head to one side—if no neck or spine injury is evident-so secretions can drain out of the mouth. Stay with the patient until the seizure is over or emergency personnel have arrived.

Shock

Identifying shock is difficult. Common symptoms are rapid pulse, increased shallow breathing, blank stare, and cold, clammy, pale skin. If you suspect shock, call for help. Ensure that the patient has an open airway. If the patient is lying down, position the head below the body. Keep the patient warm and safe until help arrives.

Fainting

Also known as syncope, fainting requires immediate assistance. When patients tell you they feel dizzy or about to faint, have them lie down and elevate their lower legs or sit and place their head between their knees. Stay with them and call the nurse.

CPR

Patient care technicians must obtain certification in BLS, which includes cardiopulmonary resuscitation (CPR). The American Heart Association (AHA) updates the steps to take for CPR often, so o ed to cat othere a ey an ected and ion the AFA provides to ensure

If you find a patient unresponsive, shake the patient's shoulders and ask, "Are you okay?" If there is no response, activate the facility's emergency response system or call to someone to do so. Then proceed with the steps you learned in your BLS certification course to establish an open airway, deliver rescue breaths, and chest compressions if indicated until help arrives. Know where the facility's automated external defibrillator (AED) is. AEDs can deliver an electrical shock to patients in cardiac arrest, and early use increases the patient's survival rate. Generally, the nurse or the emergency response team will handle this. If you are delegated to do this, obtain the device, turn it on, place it near the patient's left ear, and attach the electrodes to the patient's chest. Following the instructions on the device, activate the device's analysis of the need for defibrillation and the audio instructions for what to do.

REPORTING INFORMATION

Changes in a patient's condition

Report any changes in a patient's condition to the nurse. Some findings are more urgent than others, and you will have to report them immediately. As you develop experience in your role, you will develop a sense for what can wait a little while and what cannot wait at all. A good rule of thumb is to remember that airway, breathing, and circulation (ABC) take precedence over everything else.

A patient's report of postoperative pain-although important-is not as urgent as another patient's report of difficulty breathing.

Situations that require activating the facility's emergency response team include the following

• No pulse

• No breathing

• Cyanosis

Situations that require immediate notification of the nurse include the following.

• Changes in and loss of

consclousess

• Falls

• Uncontrollable bleeding

• Shortness of breath

• Choking

• Difficulty breathing

• Sudden unbearable pain

You can sometimes relieve shortness of breath and dyspnea by placing the patient in an upright position. Then call the nurse immediately.

Facilities vary in the forms or electronic records for I&O, so document accordingly. A facility might have on these forms some simple conversions for fluid intake from dietary department containers, such as coffee cups and soup bowls, indicating whether they hold 6 or 8 ounces, plus the metric conversions for those amounts. One ounce of fluid equals 30 mL.

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.

Edema

Edema is the result of an accumulation of fluid in a body part, area, or system. Depending on its location, edema can be a sign of various problems. At an IV catheter's insertion site, it can mean an infiltration, which is a leaking of the IV fluid into the tissues. In the lower legs, it can mean an impairment of circulation. Edema can also result from heart disease, respiratory disease, and other disorders, as well as from the use of some medications.

It is essential to recognize edema and report it to the nurse. You will see swelling, and the skin might appear stretched and shiny. The patient might report a feeling of tightness in the area. Pitting edema means that you'll see an indentation if you press on the edematous area with your finger.

The depth of the indentation indicates the severity of the edema. A 2 mm indentation is 1+, a 4 mm indentation is 2+, a 6 mm indentation is 3+, and an 8 mm indentation is 4t:

Pain using a pain scale

A detailed assessment of patients' pain is the nurse's responsibility. However, you need to know when a patient's pain has increased enough or the patient is uncomfortable enough to require a nurse to intervene.

Numeric pain scales are commonly used in hospitals, so you might have a patient say, "My pain is a 7." You need to know what that means and whether it is a significant change from the patient's last self-report of pain. A general statement health care professionals use to quantify the severity of a patient's pain is to say, "Rate your pain on a scale from zero to 10, where zero is no pain at

all and 10 is the worst pain you can imagine." When a

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depict faces or emotions, are used for patients who have difficulty using numbers to express the severity of their pain.

Although pain scales are subjective and not precise, health care staff must always believe and accept what the patient says their severity of pain is. Pain is what the patient says it is. Many things can temporarily distract patients from their pain, but that doesn't make it any less real for them.

Cultural, spiritual, or personal beliefs might prevent patients from reporting pain. A patient might believe that pain is a punishment for wrongdoing, something to endure stoically, or something to ask a higher power to relieve instead of taking medications. Many patients fear addiction and are therefore reluctant to request pain medication. Watch for nonverbal signs that a patient is in moderate to severe pain, and report them to the nurse for a thorough pain assessment.

• Clenching the jaw or teeth

Acute pain can cause changes in vital signs, but those findings are not completely reliable indicators of pain. Sometimes, acute pain can elevate pulse, respiratory rate, and blood pressure, but other times it has none of these effects. Or the onset of pain might cause these changes, but they stabilize soon afterwards.

Wound infection

Indications of a wound infection include the following,

• Redness

• Increasing pain and discomfort

• Swelling

• Foul odor

• Drainage

• Warmth around

• Fever

the wound

Fluid and other materials can leak from a wound (drainage) or pool in the wound (exudate). Drainage that is purulent (contains pus) is a clear indication of infection. Report this and any other changes in wound drainage to the nurse immediately. Treatment of the wound will change, but you will not perform wound irrigations or apply topical medications. You might perform or assist the nurse or the provider with some dressing changes.

ndications that a wound dressing requires replacement are moisture or drainage soaking the Iressing, looseness of the dressing, and nonadherence of the adhesive portion of the dressing or the tape securing it. Report these findings to the nurse.

from accumulating in the wound and delaying its healing. Be very careful not to exert any pulling pressure on the drain's tubing, which could pull out the drain.

Surgical wounds that require frequent dressing changes might have ties or straps around the dressing, instead of potentially skin-damaging tape. Observe the ties and make sure they have not loosened, because the patient's movements might shift the dressing away from the incision. Report any changes, loosening of a dressing, or drainage to the nurse.