certified nurse assistant module 9 patient care procedures section 1 define key terminology a review the terms listed in the terminology section b spell the listed terms accurately c pronounce the terms correctly d use the terms in their proper context section 2 the nurse assistant's role in collecting specimens sputum urine and or stool a sputum specimens purpose respiratory disorders cause the secretion of mucus from lungs bronchi and trachea mucous secretion is called sputum which is not related to saliva expectorated from upper airways sputum is studied for blood microorganisms and abnormal cells assisting the patient or resident in raising sputum for a specimen secretions are more easily coughed up after the patient or resident wakes up in the early am allow the patient a resident to rinse their mouth with water as this reduces the amount of saliva in the mouth and removes food particles do not use mouthwash as this may destroy some of the organisms coughing up sputum may be embarrassing to the patient or resident and may nauseate others nearby the specimen itself may be perceived as unpleasant keep container covered and place in bag privacy is important use standard precautions specimen needs to be labeled with the patients or residents full name room and bed number time and date the specimen was collected observations color odor consistency blood document the specimen obtained and where taken urine specimens purpose urine is collected for a laboratory examination or testing in the unit to help the physician diagnose a problem or evaluate treatment methods for collecting urine specimens a midstream b clean catheter urine specimen c 24-hour urine specimen rules to follow in collecting urine specimens wash hands before and after collecting a specimen use standard precautions use the correct and clean container for each specimen label the container accurately with the patient's name room and bed number date and time the specimen was collected collect the specimen directly into container at time specified do not touch the inside of the container or the lid ask the patient or resident not to have a bowel movement while the specimen is being collected ask the patient or resident to place toilet tissue in the toilet or waste basket take the specimen and the requisition slip to the designated lab pickup station document that the specimen was obtained and where it was taken in the patient or resident record observations difficulty obtaining specimen color clarity and odor particles complaints of discomfort and or urgency stool specimens stool is collected for a laboratory test to check for the presence of blood fat microorganisms worms or parasites and any abnormal contents general rules for collection maintain the patient or residence privacy use standard precautions use a clean container give the patient or resident clear instructions on how to defecate for the specimen must not contaminate with urine or toilet tissue label the container accurately with the patients or residents name the room and bed number date and time when specimen was collected clarify if the specimen must be kept at room temperature or refrigerated check on the specific lab test take the specimen and the requisition slip to the designated area observations difficulty in obtaining the specimen color amount consistency and where taken any complaints of pain or discomfort document the specimen obtained and where it was taken section 3 procedures for bed making and maintaining proper body mechanics bed making is an important part of the nurse assistance role a clean dry neat bed makes the patient or resident more comfortable the body exerts uneven points of pressure over bony prominences like the elbow or sacrum etc when against the mattress for extended periods use a mattress pad if ordered bed linen must be wrinkle free to prevent it from becoming an irritant to the skin the state of mind of the patient or resident is affected by the condition of the bed to create and maintain a positive attitude the bed should be kept in good repair clean bed frame by damp dusting daily well made and wrinkle free and attractive with the use of a bed spread keep call bell in place clipped to the linen keep the patient or resident reality oriented by using patient or resident's personal pillow afghan etc any familiar objects bed linen can act as an irritant to the patient or resident's skin use sheets to separate the blanket from the patient or resident's skin thus preventing blanket fibers from causing irritation keep the bottom linens tucked in and wrinkle free cover the plastic draw sheet with a cotton draw sheet straighten and tighten loose sheets blankets and bed spreads whenever necessary strong laundry soaps may cause skin irritation observe for patient or resident skin problems and report aseptic technique is important when handling bed linen follow standard precautions wash hands germs spread by cross-contamination hold and carry linen away from your uniform dirty linen is dirtier than the uniform and could transfer microorganisms to the uniform clean linen however is cleaner than the uniform shaking linens or fluffing them in the air is avoided during bed making since this practice will spread dust and germs keep linen off of the floor or off of the overbed table as soiled linen can transfer germs to these areas soiled linen should be immediately placed in a linen hamper or rolled tightly and tucked at the foot of the bed between the mattress and the frame until it can be carried to the linen hamper soiled linen hampers should be kept covered to prevent spread of infection and odors body mechanics proper body mechanics is required to make a bed to prevent injury and fatigue know your limitations don't try to lift turn or move a patient alone if you have any doubts about your ability to do so get close to the side of the bed don't make beds from the head of the bed or the foot of the bed keep your back straight and your knees bent keep your feet apart to give a broader support base move your feet to turn in the direction wanted and avoid twisting your back face in the direction you are working at the side of the bed raise the bed to a comfortable height make one side of the bed before beginning the other side section 4 types of beds and bed positions check your cna study guidebook for pictures of bed positions functions and structures of a hospital bed manually operated beds have hand cranks at the foot of the bed which raise or lower the head foot or total bed cranks are to be kept down when not in use electric beds have electric controls located on the side or the foot of the bed for the patient or resident and staff use side rails uses to prevent the patient or resident from falling out of bed to provide security to give the patient or resident support to hold on to or grasp when moving or turning when in bed regulations regarding use they are considered restraints and must have consent to use need for use must be noted in the patient or residence record and the care plan the patient or resident must be checked frequently if the side rails are ordered bed positions high position encourages the staff to use good body mechanics when giving care to patients or residents when moving patients or residents to stretchers or when making the bed the low position is used to encourage the ambulatory patient or resident to get in and out of bed with ease and safety fowler's position with the back rest raised 45 degrees to 90 degrees is used for patients or residents comfort to eat meals and to breathe more easily in certain respiratory and cardiac conditions semi fowler's position with the backrest 45 degrees and their knees raised 15 degrees is used for comfort and to keep the patient or resident from sliding down in the bed trendelenburg position is when the head of the bed is lowered and the foot of the bed is raised this position requires a doctor's order reverse trendelenburg position is when the head of the bed is raised and the foot of the bed is lowered this position also requires a doctor's order objective 5 ways to maintain the patient or residence environment patients and residents spend a lot of time in their rooms rooms should be comfortable control the temperature ventilation noise light and odor rooms should also be safe maintain furniture and equipment for communicating in a safe and effective manner the patient or resident's rights to privacy should be considered when furnishing a room allow the patient to resident choices and selection of their own furniture from home to the extent to facility policies make sure bed wheels are locked when given care or transferring patients in residence general rules for maintaining the patient or residence unit make sure patient or resident can reach the bedside stand and the overbed table arrange their personal belongings the way the patient or resident prefers with their safety in mind and within easy reach keep the call bell within the patient or residence reach at all times make sure patient or resident can reach the telephone television controls and light controls provide the patient or resident with tissues toilet paper and a waste container adjust lighting and temperature for the patient or residence comfort respect the patient or resident's belongings keep the environment clean straighten bed linens as needed section 6 the nurse assistant's role in administering an enema an enema is the introduction of fluids into the rectum and lower colon ordered by a doctor the purpose of an enema is to stimulate a bowel movement relieve constipation or fecal impaction cleanse the bowel of feces prior to surgery and diagnostic procedures or remove flatus or gas types of enemas cleansing enemas remove feces from the colon and rectum they usually consist of tap water and soap suds oil retention enema is given for constipation or fecal impaction for lubrication of feces commercial mixtures are also given for constipation i.e fleets general rules to follow when giving an enema before the nursing assistant administers an enema make sure the state governing board allows nursing assistants to give enemas the procedure is in the job description you have obtained the necessary education and training and there is a nurse available to supervise the procedure the temperature of the solution should be 105 degrees fahrenheit the amount of the solution is between 500 and 1000 milliliters for adults patient or resident should be positioned in left sims position the height of the enema bag should be no more than 18 inches above the mattress depth of tube insertion is about 2-4 inches into the rectum and the tube must be lubricated administer solutions slowly over 10 to 15 minutes the solution is usually held in the rectum for a variable length of time until urge to defecate occurs hold the enema tube in place while administering make sure the toilet facility is nearby and available observe the results of the enema use standard precautions section 7 the nurse assistant's role in giving a suppository a rectal suppository is used to stimulate to empty the bowel and lubricate the stool to ease evacuation the nurse assistant's role facility policy dictates if the nurse assistant may insert a suppository general rules to follow when inserting a suppository nurse assistants may not administer medicaid suppositories identify the patient or resident by checking their armband remove the wrapper from the suppository if wrapped place suppository one to one and a half inches past the anal sphincter using gloved hand and index finger instruct the patient or resident to hold the suppository in the rectum for as long as possible observe for results of the suppository report the results to the licensed nurse section 8 types and uses of gastrointestinal or gi tubes nasogastric tube inserted through the nose into the stomach or intestine to drain the gi tract by means of suction to prevent postoperative vomiting obstruction or gas formation to diagnose a disease to wash out stomach contents or to provide a route for feeding one who is unable to take food by mouth gastrostomy tube or peg tube is surgically inserted through the abdominal wall into the stomach the purpose of the tube is for feeding the patient or resident section 9 major nursing care activities for patients or residents with feeding tubes nasogastric or gastrostomy care of the patient or resident with a nasogastric tube give frequent oral hygiene and keep the lips and mouth moist the mouth becomes very dry and may have a bad taste nose and nostrils need to be cleaned frequently increase freedom of movement by securing the tubing with a clamp or tape to the patient to resident's clothing to permit maximum activity check to see that the patient or resident does not sit or lie on the tubing tubing must be free of kinks check to see if the suction machine is operating satisfactorily and reporting it at once if it is not working if suction is ordered permitting the patient or resident if allowed to suck on ice chips throat lozenges or hard candy to keep the throat slightly moist patient or resident is usually npo nothing by mouth positioning the patient or resident with head of the bed elevated at 45 degrees during the feeding and for 30 to 60 minutes afterward and then 30 degrees after the feeding care of patient or resident with a gastrostomy tube give a frequent oral hygiene and keep the lips and mouth moist the mouth becomes very dry and may have a bad taste increase freedom of movement by securing the gastrostomy tube with a clamp or tape to the patient or resident's clothing to permit maximum activity check to see that the patient or resident does not sit or lie on the tubing the tubing must be free of kinks permit the patient or resident if allowed to suck on ice chips throat lozenges or hard candy to keep their throat as well as the tube slightly moist position the patient or resident with head of bed elevated at all times 20 degrees to 30 degrees to prevent reflux removing dressing from the g-tube clean and dry the area replace according to the care plan reporting any unusual conditions observed during procedure the same as nasogastric tube redness swelling drainage odor or pain at the ostomy site nursing care is provided to maintain a patient's or resident's mental and emotional comfort by keeping the environment clean tidy and well ventilated as the patient or resident is often very sensitive to odors which can cause nausea and vomiting answering call lights promptly checking frequently and giving emotional support giving an extra back rub straightening or changing bed linen in the evening pm asking patient a resident to express concerns about their tube encouraging the patient or resident to be up dress in day clothes and join in activities as tolerated assist the patient or resident to attend family and group activities observe report and record routine care and any unusual events such as nausea vomiting diarrhea discomfort a distended abdomen coughing care of indigestion or heartburn elevated temperature signs and symptoms of respiratory distress increased pulse rate or care of flatulence section 10 nursing care activities for a patient or resident receiving intravenous iv therapy reasons for using iv therapy iv therapy provides the body with needed elements that can be given as rapidly or efficiently by other means ivs may contain blood plasma nutritional requirements for water salt sugar etc or medications the rate of the iv flow is often controlled by an infusion pump nursing assistant responsibilities include observing for flow from iv keeping tubing free of twisting or kinking observing the position of tubing and the condition of the injection site for any infiltration an infiltrated iv is one in which the needle has come out of the vein and the iv leaks into the tissue causing swelling report this condition immediately to the charge nurse checking restraints or soft protective devices to be sure that they are not blocking the vein follow your agency's policy regarding restraints and soft protective measures nursing assistant responsibilities maintain a patient or resident's physical comfort bathe at the patient or resident according to a daily routine wash gently around the area where the needle is inserted do not loosen the tape that holds the needle in place when drying do not rub over the area pat gently to avoid dislodging the needle assist the patient or resident with eating by cutting food preparing liquids and arranging utensils conveniently assist the patient or resident with feeding as little as possible to encourage self-care assist the patient or resident to ambulate provide a portable iv stand assist out of bed observe closely for weakness support the iv arm to ensure continuous flow a sling may be used to rest the arm patients or residents may grasp the iv pole for support with iv hand this provides support for the arm and lets them move at their own pace leaving their other hand free for balance by holding onto railings section 11 the nursing assistant role in assisting the patient or resident to maintain fluid balance the importance of maintaining fluid balance next to oxygen water is the most important physical need death can result from taking in inadequate fluids from losing too much fluid or too much fluid intake water enters the body through food and fluid water is lost through urine sweat feces and lungs balance between the amount of fluid taken in and the amount of fluid lost is necessary to maintain health the amount of fluid taken in and the amount of fluid lost must be equal an adult needs about 2000 milliliters of fluid a day edema fluid intake exceeds fluid output tissues swell with water dehydration fluid output exceeds fluid intake a decrease in the amount of fluid in tissues patients or residents depend on nursing personnel to meet part or all of their food and fluid needs encourage increase in fluid intake forcing fluids when a physician orders force fluids it means to have the patient or resident drink an increased amount of fluid they may order a specific amount of fluid for a 24-hour period this maintains fluid balance and may be for general or a specific amount of fluid the nurse assistant's responsibility to encourage fluid intake keep a record of the amount taken in provide a variety of fluids place them within the patient or resident's reach offer fluids frequently to patients or residents who cannot feed themselves restricting fluid intake when a physician orders restrict fluids it means fluids are restricted to a specific amount the nurse assistant's responsibility a sign posted above the bed water is offered in small amounts keep the water pitcher out of sight or removed from the room keep an accurate intake and output record be aware of shift fluid requirements provide the patient or resident with frequent oral hygiene explain to the patient or resident and family the reason for limiting their fluids removing the water pitcher etc nothing by mouth npo this is ordered before and after surgery before certain lab tests and x-rays in the treatment of some illnesses nurse assistant's responsibility for the npo patient or resident an npo sign above the bed remove the water pitcher and glass offer frequent oral hygiene no swallowing of any fluid 12 the purpose and procedure for measuring the amount of fluid taken in and fluids excreted by the patient or resident see module 7 the purpose of intake and output ino measurement the doctor or nurse may want to keep track of a patient or resident's fluid intake and output to evaluate fluid balance kidney function or response to medical treatment accurate measurement is needed and documented on the ino record measurement of patients or residence intake this is usually measured in milliliters ml determine the fluid capacity of bowls dishes cups pitchers glasses and other containers used to serve fluids count as intake water milk coffee juice soup etc all food in liquid form when eaten or those that later revert to liquid such as jello or ice cream a conversion table is provided on the intake and output record used to chart intake a container called a graduated cylinder is used to measure fluid measurement of patient or residence output measure all fluids excreted by the patient or resident done in milliliters all liquid output will be measured including urine vomitus liquid stool drains and suctions plastic urinals and emesis basins may be calibrated use standard precautions when measuring output recording intake and output ino record at bedside document amounts when fluid is taken in or excreted amounts are totaled at the end of the shift and entered in the patient's record other special forms as required by facility reporting intake and output report any unusual occurrences such as refusing to drink fluid special fluid likes or dislikes and blood in the urine section 13 the nursing assistant role in the use of bandages binders and dressings purpose of bandages and binders apply pressure compression in order to stop bleeding or swelling and to assist in absorbing tissue fluids provide for immobilization of an injured patient a fractured broken arm for instance hold dressings in place protect open wounds from contaminants apply warmth to a joint as for persons suffering from painful joints due to arthritis provide support and aid in venus return blood flow circulation as when bandaging the leg of a patient or resident suffering from varicose veins or limited circulation in the extremities arms or legs dressings are ordered by the physician and initially applied by the licensed nurse the nursing assistant's role is to apply simple dry non-sterile dressings to uncomplicated wounds and assist the licensed nurse with complex wounds the licensed nurse will inform the nurse assistant when to change a dressing and what supplies to use materials used for dressings and bandages dressings are made from a variety of materials mainly gauze which comes in two inch three inch and four inch squares the size depends on the area of the body involved and the purpose of the dressing bandages and binders are made from muslin gauze flannel rubber and elastic fiber dressings are held in place with hypoallergenic tape plastic tape elastic tape paper tape silk tape adhesive tape and binders or bandages the type depends on the purpose and the patient or resident principles of bandaging 1. apply the bandage so pressure is evenly distributed to the area if a joint is involved in bandaging support it in a comfortable position with a slight flexion on the joint attach the bandage securely to avoid friction and rubbing of underlying tissue which could cause irritation start at the lower or distal part of the extremity work upward to the top or proximal part rationale for removing elastic bandages elastic bandages should be removed every eight hours unless ordered more frequently to allow for inspection of underlying skin replace a moist or soil bandage reapply a loose or wrinkled bandage observation and reporting to the licensed nurse any swelling pain change in color decrease or increase of temperature drainage color consistency and amount and odor section 14 describe the use and method of applying anti-embolic hose or elastic stockings anti-embolic hose or elastic stockings are used to increase circulation by improving venous return from the legs to the heart key points when applying elastic stockings always apply before the patient or resident gets out of bed check for wrinkles check skin color and temperature check popliteal pulse anti-embolic hose and elastic stockings are to be removed every eight hours or according to a facility policy section 15 the nurse assistant's role in the care of patients in resident skin conditions and the use of non-prescription ointments lotions or powders the nurse assistant can provide care to patients or residents with the following intact skin conditions foot care dandruff and dry skin the nurse assistant must report the following existing skin conditions to the licensed nurse acne minor burns rash excoriation abrasions and skin tears eczema or psoriasis poison ivy or poison oak minor wounds insect bites and stings the nurse assistant can apply over-the-counter ointments lotions or powders to intact skin surfaces only the nurse assistant does not apply ointments lotions or powders to irritated skin surfaces or open lesions over-the-counter ointments lotions or powders that the nurse assistant may apply to intact skin these include zinc oxide a and d ointment clearasil stridex medicated pads sells in carry lotion corn huskers johnson's medicated powder and tinactin foot powder general rules for application of ointment lotion or powder prepare the patient or resident position the patient or resident cleanse the skin protect the surrounding skin applying ointments lotions or powders apply as directed and wear gloves creams or liniments are rubbed in by hand lotions are padded on with a cotton ball ointments are applied with a wooden tongue blade or a cotton swab sprinkle powder onto hand or cloth and then apply to the patient to resident charge and report observations make a note of the appearance of the skin describe any changes in the appearance identify any signs of irritation section 16 explain the role of the nurse assistant in the admission of a patient or resident to the facility admission to a long-term facility is stressful to both the patient or resident and their family first impressions of the facility are important for the adjustment of the patient or resident to the facility the new patient or resident may have many feelings of loss such as loss of home possessions independence loss of family freedom privacy or control over one's life welcome the patient or resident greet them by name introduce yourself explain what you're doing collect baseline information about the patient or resident measure patient or resident's height and weight measure patient or residence vital signs observe the patient or residence grooming condition of hair and nails condition of skin mental alertness sight and hearing the presence of any prosthesis and their ability to move around report all questions and concerns of the patient or resident or the family to the licensed nurse orient the patient to resident and their family to the facility review facility routine introduce the patient or resident to roommates and staff tour the facility with them explain the operation of bed controls tv controls and the nurse call system care for personal belongings the patient or resident must know that they have control over their possessions and can decide where to put them fill out the facility's list of possessions encourage the patient or resident to send valuables home with their family objectively describe valuables that are being kept at the facility label the items with the patient or resident's name section 17 the role of the nurse assistant in transferring a patient or resident from one area to another within the facility tell the patient or resident in advance about the transfer and explain the reason for moving collect all of the patient to residents belongings and take them to the new room be careful not to lose any items check all drawers and closets for personal items introduce the patient or resident to their new roommates new surroundings may cause confusion orient the patient or resident to the new room continue to remind the patient a resident about their new room section 18 the role of the nurse assistant in the discharge of a patient or resident collect baseline information about the patient or resident measure the patient or resident's height and weight measure the patient or resident's vital signs observe the patient or residence grooming condition of hair and nails condition of skin mental alertness sight and hearing presence of any prosthesis and their ability to move around collect all personal belongings of the patient or resident check all drawers and closets for personal items review the facility list of possessions for any items that might be in the safe or a locked cabinet or the laundry assist the patient or resident to his or her vehicle or designated mode of transportation after checking with the licensed nurse patients and residents usually leave by wheelchair