2.  State the purpose of a
resident comprehensive
assessment
 State the purpose of a
resident care plan
 State the purpose of the
resident care conference
 Identify the role of the STNA
in the care planning
conference
 Describe the STNA’s role in
gathering and
documenting information

3.  Identifies specific
therapeutic actions for
resident based on their
individualized need
 STNA should attend care
conferences at periodic
intervals to gain insight
into caring for residents
with emotional needs

4.  Resident care problems
and strengths to be
addressed by the health
care team are identified
and ways to help the
resident are identified.
 Resident care plans are
communicated to all 3
shifts and to all staff
involved in the resident’s
care to ensure
consistency.

5.  A member of the care
team.
 Provides/gathers data
and information that will
be helpful for the
assessment and care
planning process.

6.  Vital Signs
› Temperature, Pulse,
Respirations
 Skin Care
› Bathing, Turning &
Positioning
 Elimination
› Urine, Bowel Movements
 Ambulation
› Walking, devices to help
walking
 Mobility
› Independent?
› Staff Assistance?

8.  Identify the purpose of a
medical record
 Identify ways the NA can
contribute to the medical
record
 Identify common medical
abbreviations
 Identify the proper
methods of
documentation

9.  Chronological record of
the resident’s condition
and care.
 Legal record of medical
and nursing care.
 Way for the health care
team to communicate
information about the
person.
 Can be used as court
evidence of a person’s
problems, treatment and
care.

10.  Observing the resident
 Reporting changes to
the nurse in charge
 Recording information
according to facility
policy.
 Participating in care
conferences.

11.  Always remember – if it is
not documented, it was
not done.

12.  Use ink
 Legible & neat
 Agency-approved
abbreviations
 Correct spelling,
punctuation & grammar
 No erasing or white out
 Agency policy for error
correction
 Sign with first initial, last
name, and title

13.  Military Time

14.  Never skip lines
 No spaces between
entry and signature
 Fill in empty space with a
line
 Record what you did
and/or saw
 Chronological order
 Use direct quotes from
resident with quotation
marks
 Record safety measures
 Correct chart

15.  I & O Sheets
 Meal Records
 Restorative Records
 Vital Sign Sheets &
Graphic Records
 ADL Records
 Bowel & Bladder
Program Records
 Examples in Chapter 6
beginning on page 66

17.  Do your friends tell you
that you notice EVERTHING
– or maybe NOTHING?
 Observation is critical in
your role as a nursing
assistant
 Key objectives:
› Discuss the importance of
observation
› Describe various observation
techniques
› Identify observations to be
made during resident care
› Demonstrate how to report
and record observations

19.  Are there cars parked on
the sides of the road?
 What color is the pickup
truck driving in the road?
 Any minivans around?
 What does the blue sign
say?
 What’s the speed limit?
 Are there any
pedestrians on the road?

21.  How many cars did you
see?
 How many trucks?
 How many of the
vehicles in the parking
lot can you describe?

23.  How many vehicles where
in the intersection?
 Across the street, are there
any vehicles parked on
the side?
 Can you describe at least
one of the vehicles driving
through the intersection?
 Are there any potential
witnesses?
› If so, what was the witness
doing?
› If so, where was he or she?
 What was the speed limit?
 Was there anyone parked
in the first parking spot?

24.  Your observations can
alert you to changes in
the resident’s condition
 Observations should be
made continuously
during resident care
 BE ALERT at ALL TIMES

25.  SEE
› What might we see?
 FEEL
› What might we feel?
 HEAR
› What might we hear?
 SMELL
› What might we smell?

26.  What is the resident’s
general appearance?
 Is the resident alert,
confused, drowsy?
 What is their activity level?
 What is the color of his/her
skin, mouth, fingernails?
 What is the condition of
his/her breathing?
 How does the resident
manage eating, drinking,
elimination?
 Has there been a change
in his/her sleeping habits?
 What is his/her mood or
behavior?

27.  Objective: Signs
› Observed through the 5
senses: seen, felt, heard,
smelled or tasted
 Subjective: Symptoms
› Things the resident tells
you that you cannot
observe through the
senses

28.  Breathing is labored
(difficult)
› Objective
 Chest pain
› Subjective
 Pulse
› Objective
 Dark urine
› Objective
 Nausea
› Subjective
 Sweating
› Objective
 Breath is “fruity”
› Objective
 Fearful
› Subjective

29.  Changes in the
resident’s condition are
reported to the nurse
immediately.
 Observations are
reported and recorded
exactly as seen, felt,
heard or smelled, or in
the resident’s own
words.

31.  Identify basic emotional needs
of the residents in a LTCF
 Identify actions the STNA can
take to meet the emotional
needs of the resident
 Recognize common behaviors
displayed when emotional
needs are not met
 Describe therapeutic
interventions the STNA may use
in response to a resident’s
behavior
 Describe the role of the care
plan and care conference in
responding to a resident’s
behavior

32.  Human Psychologist
 Believed that individuals
are controlled by their
values and the choices
they make
 Model of human needs
› Hierarchy of Needs

33.  Physiological Needs
› Survival
 Food
 Water
 Air
 Sleep
 Sex
Physiological Needs

34.  Safety
› Security, stability, keeping
us from harm
 Physical Security
 Shelter
 Safe environment
Physiological Needs
Safety

35.  Love/Belonging
› Need to give and receive
love and affection
 Friendship
 Family
 Sexual intimacy
Physiological Needs
Safety
Love/Belonging

36.  Esteem
 Confidence
 Content
 Respect self and others’
respect
 Prestige & Power
Physiological Needs
Safety
Love/Belonging
Esteem

37. Physiological Needs
Safety
Love/Belonging
Esteem
Self
Actualization
Become what we
are capable of
becoming

39. Independence
 Promote by
› Encouraging self care
› Encouraging decision
making
 Clothing
 Food
 Activities

40. Supportive Environment
 Promote by
› Physical Environment
 Proper medical and
dental care
 Safe, comfortable clothing
 Rooms and halls clutter
free
 Protection from others
(and self, if needed)
› Emotional Environment
 Treat with respect,
acceptance and
patience
 Supportive of family

41. Social Interaction
 Promote by
› Encouraging contact with
other residents
› Encouraging contact with
family and friends outside
the LTCF

42. Recognition as an
Individual
 Promote by
› Be respectful
› Allow for privacy
› Encouraging self
expression through crafts,
reminiscing and
recognizing past
accomplishments

43. Self Actualization
 Promote by
› Respect beliefs – don’t
impose yours
› Learn needs and
preferences that assist
› Encouraging activities that
promote self actualization

44.  Anger
 Demanding
 Self-centered
 Aggressive
 Withdrawl
 Inappropriate sexual
behavior

45.  Acknowledge frustration or
frightening situations
 Treat with dignity and
respect
 Answer questions clearly
and thoroughly
 Keep them informed
 Do not keep them waiting
 Explain reasons for long waits
 Stay calm and professional
 Do not argue
 Listen – use silence
 Protect yourself from violent
behaviors
 Report inappropriate
behavior to the nurse