Terminology #1Terminology #1
Activities of Daily Living (ADL)Activities of Daily Living (ADL)
ObservationObservation
Medical terminologyMedical terminology
AbbreviationAbbreviation
SuffixSuffix
prefixprefix
Terminology #2Terminology #2
RootRoot
Combining vowelCombining vowel
Patient care planPatient care plan
KardexKardex
assessmentassessment
Senses used for evaluationSenses used for evaluation
SightSight
TouchTouch
HearingHearing
SmellSmell
ABC’s of observationABC’s of observation
AppearanceAppearance
BehaviorBehavior
communicationcommunication
Objective and subjectiveObjective and subjective
observationsobservations
Objective-signs that you see, hear,Objective-signs that you see, hear,
smell (factual)smell (factual)
Subjective-what the resident tellsSubjective-what the resident tells
you (symptoms)you (symptoms)
Types of charting documentsTypes of charting documents
Patient record and patient chartPatient record and patient chart
KardexKardex
Nursing care planNursing care plan
Graphic chartGraphic chart
ADL sheetADL sheet
Charting proceduresCharting procedures
Write legibly and neatlyWrite legibly and neatly
Place events in proper sequencePlace events in proper sequence
Chart for facility/policy standardsChart for facility/policy standards
Be conciseBe concise
Always use inkAlways use ink
Errors-cross out with one line, do notErrors-cross out with one line, do not
eraseerase
Charting procedures #2Charting procedures #2
Include resident’s completeInclude resident’s complete
informationinformation
Never skip linesNever skip lines
Sign your name at end of entrySign your name at end of entry
Always date and time entriesAlways date and time entries
Chart only proceduresChart only procedures you haveyou have
performedperformed
Chart only true observationsChart only true observations
Legal issues of chartingLegal issues of charting
Resident record is a legal documentResident record is a legal document
Information in chart must be keptInformation in chart must be kept
confidentialconfidential
Information in chart should beInformation in chart should be
accurate, objective, and truthfulaccurate, objective, and truthful
Word elementsWord elements
RootRoot
PrefixPrefix
SuffixSuffix
Combining wordCombining word
Abbreviation is a shortened form ofAbbreviation is a shortened form of
words or phrases, and are commonlywords or phrases, and are commonly
used in health care settingsused in health care settings
Terminology #2Terminology #2
IntegumentaryIntegumentary
DermisDermis
EpidermisEpidermis
AbrasionAbrasion
CyanosisCyanosis
ExcoriationExcoriation
Decubitus ulcerDecubitus ulcer
Terminology #3Terminology #3
NecrosisNecrosis
UrineUrine
ProsthesisProsthesis
UrinalUrinal
UrinationUrination
CatheterCatheter
Terminology #4Terminology #4
FecesFeces
EliminationElimination
Fecal impactionFecal impaction
Anal incontinenceAnal incontinence
FlatulenceFlatulence
ConstipationConstipation
DiarrheaDiarrhea
Terminology #5Terminology #5
OstomyOstomy
ColostomyColostomy
ileostomyileostomy
StoolStool
StomaStoma
DefecationDefecation
Daily routine care/Early MorningDaily routine care/Early Morning
Offer bedpan/urinal or assist toOffer bedpan/urinal or assist to
bathroombathroom
Wash face and handsWash face and hands
Offer oral hygieneOffer oral hygiene
Straighten bed and unitStraighten bed and unit
Position resident for breakfastPosition resident for breakfast
Morning care after breakfastMorning care after breakfast
Oral hygieneOral hygiene
Offer bedpan/urinal or assist toOffer bedpan/urinal or assist to
bathroombathroom
BathingBathing
ShavingShaving
Skin careSkin care
DressingDressing
Hair careHair care
Change bed linensChange bed linens
Prepare for mealsPrepare for meals
Lunch and dinnerLunch and dinner
Offer bedpan/urinal or assist toOffer bedpan/urinal or assist to
bathroombathroom
Wash hands/faceWash hands/face
Straighten bed/unitStraighten bed/unit
Position for mealPosition for meal
Afternoon careAfternoon care
Offer bedpan/urinal or assist toOffer bedpan/urinal or assist to
bathroombathroom
Wash face and handsWash face and hands
Oral hygieneOral hygiene
Grooming as necessaryGrooming as necessary
Change soiled linenChange soiled linen
Straighten unitStraighten unit
Evening (HS) careEvening (HS) care
Offer bedpan/urinal or assist toOffer bedpan/urinal or assist to
bathroombathroom
Wash face and handsWash face and hands
Oral hygieneOral hygiene
Change soiled linenChange soiled linen
Dress for bedDress for bed
Back massageBack massage
Straighten unitStraighten unit
Benefits of bathingBenefits of bathing
CleanlinessCleanliness
Reduce bacteria and germsReduce bacteria and germs
Promote skin integrityPromote skin integrity
Stimulate circulationStimulate circulation
Provide movement and exerciseProvide movement and exercise
RelaxationRelaxation
Sense of well-beingSense of well-being
Opportunity for communication andOpportunity for communication and
observationobservation
Body areas that require bathingBody areas that require bathing
FaceFace
Underarms (axilla)Underarms (axilla)
HandsHands
Perineal areaPerineal area
Any area where skin folds or creasesAny area where skin folds or creases
Types of bathsTypes of baths
ShowerShower
Tub/whirlpool, medicinalTub/whirlpool, medicinal
Complete bed bathComplete bed bath
Partial bed bathPartial bed bath
General guidelines for bathingGeneral guidelines for bathing
residentsresidents
Check with nurse regarding type ofCheck with nurse regarding type of
bathbath
Refer to procedure manual forRefer to procedure manual for
special bathsspecial baths
Identify skin care products to beIdentify skin care products to be
usedused
Check resident’s personal choicesCheck resident’s personal choices
Collect necessary equipmentCollect necessary equipment
Provide privacyProvide privacy
General guidelines for bathingGeneral guidelines for bathing
residents #2residents #2
Assure adequate comfortAssure adequate comfort
Use comfortably warm water, changeUse comfortably warm water, change
it when it becomes soapy, dirty orit when it becomes soapy, dirty or
coldcold
Bathe areas soiled by fecal materialBathe areas soiled by fecal material
or urineor urine
Wash from cleanest to dirtiest areaWash from cleanest to dirtiest area
Rinse off all soapRinse off all soap
Pat skin dryPat skin dry
Safety Guidelines for bathingSafety Guidelines for bathing
Monitor correct water temperatureMonitor correct water temperature
Use safety equipmentUse safety equipment
Stay with residentStay with resident
Use correct body mechanicsUse correct body mechanics
Privacy during bathingPrivacy during bathing
Close doorClose door
Pull curtain around residentPull curtain around resident
Only uncover area being washedOnly uncover area being washed
Observations to be made duringObservations to be made during
bathing/skinbathing/skin
ColorColor
RashesRashes
DrynessDryness
BruisesBruises
OdorsOdors
SwellingSwelling
Observations/Fingernails,toenails,Observations/Fingernails,toenails,
hair,eyes and Mental Status #2hair,eyes and Mental Status #2
Presence of nitsPresence of nits
Color of scleraColor of sclera
Orientation/alertnessOrientation/alertness
MoodMood
AttitudeAttitude
Observations that require reportingObservations that require reporting
skinskin
ColorColor
New rashesNew rashes
New bruises, broken skin, bleedingNew bruises, broken skin, bleeding
Unusual odorsUnusual odors
Complaints of painComplaints of pain
Observations that requiredObservations that required
reporting/ Fingernails, hairreporting/ Fingernails, hair
New Yellow, thickened nailsNew Yellow, thickened nails
New significant hair lossNew significant hair loss
FlakingFlaking
Sore scalpSore scalp
NitsNits
Observations that require reportingObservations that require reporting
Eyes and Mental statusEyes and Mental status
RednessRedness
Yellowing of scleraYellowing of sclera
DisorientationDisorientation
DepressionDepression
Development of unresponsivenessDevelopment of unresponsiveness
Types of medicinal bathsTypes of medicinal baths
BranBran
OatmealOatmeal
StarchStarch
Sodium bicarbonateSodium bicarbonate
Epsom saltsEpsom salts
Pine productsPine products
SulfurSulfur
SaltSalt
Purposes of medicinal bathsPurposes of medicinal baths
Soothing sedationSoothing sedation
Relief of pruritisRelief of pruritis
Relief of skin disorder (dry skin,Relief of skin disorder (dry skin,
irritation, rash)irritation, rash)
Oral hygiene / PurposeOral hygiene / Purpose
Cleanliness of mouth and teethCleanliness of mouth and teeth
Prevent mouth odor and infectionPrevent mouth odor and infection
Prevent tooth lossPrevent tooth loss
ComfortComfort
Pleasant tastePleasant taste
Improve taste of foodImprove taste of food
Oral hygiene / When to performOral hygiene / When to perform
On awakeningOn awakening
After each mealAfter each meal
Bed timeBed time
Oral hygiene / SpecialOral hygiene / Special
circumstancescircumstances
UnconsciousUnconscious
Mouth breatherMouth breather
O2O2
NG tubeNG tube
Elevated temperatureElevated temperature
Steps of oral hygieneSteps of oral hygiene
Carry out procedure using standardCarry out procedure using standard
precautionsprecautions
Examine oral cavity and reportExamine oral cavity and report
findingsfindings
Steps in cleaning and care ofSteps in cleaning and care of
denturesdentures
Use standard precautionsUse standard precautions
Examine oral cavity and reportExamine oral cavity and report
findingsfindings
Nurse assistant role for residentNurse assistant role for resident
nail carenail care
Easier to clean after soaking inEasier to clean after soaking in
warm, soapy waterwarm, soapy water
Be cautious to prevent damage toBe cautious to prevent damage to
tissuestissues
Report unusual conditions to nurseReport unusual conditions to nurse
Follow facility procedureFollow facility procedure
Nurse assistant role / caring for hairNurse assistant role / caring for hair
Part of daily carePart of daily care
Important for identity and self-Important for identity and self-
esteemesteem
Accommodate resident preferencesAccommodate resident preferences
for style, hair productsfor style, hair products
Nurse assistant role / typesNurse assistant role / types
shampooshampoo
Shower / tubShower / tub
SinkSink
BedBed
Nurse assistant role / purpose ofNurse assistant role / purpose of
Medicinal ShampooMedicinal Shampoo
Eradicate liceEradicate lice
ScabiesScabies
Soothe / heal irritated skinSoothe / heal irritated skin
Shaving a resident / GuidelinesShaving a resident / Guidelines
Use either electric or safety razorUse either electric or safety razor
Use appropriate safety precautionsUse appropriate safety precautions
for electrical equipmentfor electrical equipment
Safety razors can cause nicks or cutsSafety razors can cause nicks or cuts
Use standard precautions to preventUse standard precautions to prevent
contact with bloodcontact with blood
Functions of the integumentaryFunctions of the integumentary
systemsystem
Provides protective barrier againstProvides protective barrier against
microorganismsmicroorganisms
Enables the body to feel pain,Enables the body to feel pain,
pressure, and temperaturepressure, and temperature
Shields body tissue from injuryShields body tissue from injury
Insulates against heat and coldInsulates against heat and cold
Eliminates waste productsEliminates waste products
Produces Vitamin D for body useProduces Vitamin D for body use
How to maintain healthy skinHow to maintain healthy skin
Encourage well-balanced diet andEncourage well-balanced diet and
fluidsfluids
Maintain skin careMaintain skin care
Observe color and temperatureObserve color and temperature
Give special attention to bonyGive special attention to bony
prominencesprominences
Age –related changes affecting theAge –related changes affecting the
skinskin
Excessively dry areasExcessively dry areas
Elasticity decreased, causing wrinklesElasticity decreased, causing wrinkles
Thinner layersThinner layers
Residents at risk for skinResidents at risk for skin
breakdownbreakdown
Elderly residentsElderly residents
Residents who have no sensation ofResidents who have no sensation of
painpain
Paralyzed residentsParalyzed residents
Residents with edemaResidents with edema
Thin residentsThin residents
Diabetic, Overweight, in castsDiabetic, Overweight, in casts
Unconscious, sedated residentsUnconscious, sedated residents
Conditions which cause decubitusConditions which cause decubitus
ulcersulcers
PressurePressure
Decreased blood flow to an areaDecreased blood flow to an area
Wet skinWet skin
Scratches from fingernailsScratches from fingernails
Dry skinDry skin
Decubitus ulcers #2 / Signs andDecubitus ulcers #2 / Signs and
symptoms or stagessymptoms or stages
Stage oneStage one
Stage twoStage two
Stage threeStage three
Decubitus ulcers #3 / BonyDecubitus ulcers #3 / Bony
prominencesprominences
SacrumSacrum
HeelsHeels
KneesKnees
ShouldersShoulders
Back of headBack of head
HipsHips
Ankles, Elbows and EarsAnkles, Elbows and Ears
Decubitus ulcers / PreventiveDecubitus ulcers / Preventive
nursing care measuresnursing care measures
Keep skin clean and dryKeep skin clean and dry
Use only small amounts of powderUse only small amounts of powder
and lotionand lotion
Wash after each incontinent episodeWash after each incontinent episode
Keep safety devices, clothing, andKeep safety devices, clothing, and
bedding from being too tightbedding from being too tight
Keep edges of casts and braces fromKeep edges of casts and braces from
pressing against the skinpressing against the skin
Decubitus ulcers / PreventiveDecubitus ulcers / Preventive
nursing care measures #2nursing care measures #2
Remove crumbsRemove crumbs
Avoid wrinkles in beddingAvoid wrinkles in bedding
Keep tubes from pressing on the skinKeep tubes from pressing on the skin
Remove residents from toilets andRemove residents from toilets and
bedpans promptlybedpans promptly
Keep your nails short and smoothKeep your nails short and smooth
Decubitus ulcers / Use of pressure-Decubitus ulcers / Use of pressure-
reducing devices # 3reducing devices # 3
Bed cradleBed cradle
SheepskinSheepskin
Heel and elbow protectorsHeel and elbow protectors
Egg crate mattressEgg crate mattress
Alternating pressure matressAlternating pressure matress
Clinitron bedClinitron bed
Trochanter rollsTrochanter rolls
Flotation pads or cushionsFlotation pads or cushions
Decubitus ulcers # 4Decubitus ulcers # 4
Turn or change resident’s positionTurn or change resident’s position
every two hoursevery two hours
Encourage circulation by gentleEncourage circulation by gentle
massage around areamassage around area
Teach resident to change positionTeach resident to change position
frequentlyfrequently
Assist with range of motion exercisesAssist with range of motion exercises
Apply lotion to dry skin areasApply lotion to dry skin areas
Dressing Residents / Types ofDressing Residents / Types of
ClothingClothing
CardiganCardigan
PulloverPullover
PantsPants
Disposable briefDisposable brief
Shoes and stockingsShoes and stockings
AccessoriesAccessories
Physical factors that limit aPhysical factors that limit a
resident’s ability to dressresident’s ability to dress
Lack of maturationLack of maturation
Brain impairmentBrain impairment
WeaknessWeakness
PainPain
FracturesFractures
ContracturesContractures
ParalysisParalysis
Lack of visionLack of vision
Psychological factorsPsychological factors
Caring for resident clothingCaring for resident clothing
Label garmentsLabel garments
Avoid cuttingAvoid cutting
Do not discardDo not discard
Store in the resident’s unitStore in the resident’s unit
Fold neatly or hang in closetFold neatly or hang in closet
Assist resident or family to chooseAssist resident or family to choose
clothing that meets physical needsclothing that meets physical needs
Purposes for dressing a residentPurposes for dressing a resident
How we look influences the way weHow we look influences the way we
feel about ourselvesfeel about ourselves
It encourages resident to beIt encourages resident to be
independentindependent
It discourages incontinenceIt discourages incontinence
Guidelines for dressing andGuidelines for dressing and
undressing a residentundressing a resident
Provide for privacyProvide for privacy
Encourage the resident to do asEncourage the resident to do as
much as possiblemuch as possible
Allow residents to choose what toAllow residents to choose what to
wearwear
Remove clothing from the strong orRemove clothing from the strong or
good side firstgood side first
Put clothing on weak side firstPut clothing on weak side first
Ways the body eliminates wasteWays the body eliminates waste
Urinary elimination (Urine)Urinary elimination (Urine)
Bowel elimination (Feces)Bowel elimination (Feces)
Urinary EliminationUrinary Elimination
The body excretes 1000 to 1500 mlThe body excretes 1000 to 1500 ml
of urine / dayof urine / day
Urine consists of the wastes andUrine consists of the wastes and
excess fluidsexcess fluids
Residents have different urinationResidents have different urination
needsneeds
Keep resident’s routine as normal asKeep resident’s routine as normal as
possiblepossible
Characteristics of normal urineCharacteristics of normal urine
ClearClear
Amber ( Medium Yellow) colorAmber ( Medium Yellow) color
Mild odorMild odor
Frequency of urinationFrequency of urination
Amount of fluid ingestedAmount of fluid ingested
Personal habitsPersonal habits
Availability of toilet facilitiesAvailability of toilet facilities
Physical activitiesPhysical activities
IllnessIllness
Ranges from every 2-3 hours toRanges from every 2-3 hours to
every 8-12 hoursevery 8-12 hours
Observations to be made aboutObservations to be made about
urineurine
ColorColor
ClarityClarity
OdorOdor
AmountAmount
Information to report about urineInformation to report about urine
CloudyCloudy
Pinkish or reddish tintPinkish or reddish tint
Resident complaints burning onResident complaints burning on
urinationurination
Difficulty in urinationDifficulty in urination
Feeling of pressureFeeling of pressure
FrequencyFrequency
Strong OdorStrong Odor
Urinary incontinenceUrinary incontinence
Inability to control the passage ofInability to control the passage of
urine from the bladderurine from the bladder
Constant dribbleConstant dribble
Occasional dribble when laugh,Occasional dribble when laugh,
cough or sneezecough or sneeze
No controlNo control
Urinary incontinence / CausesUrinary incontinence / Causes
Central nervous systemCentral nervous system
Spinal cord injurySpinal cord injury
Aging and confusionAging and confusion
MedicationsMedications
Weak pelvic musclesWeak pelvic muscles
Urinary tract infectionUrinary tract infection
Prostate problemsProstate problems
Prolapse of uterus and bladderProlapse of uterus and bladder
Catheter / DefinitionCatheter / Definition
Plastic or rubber tube used to drainPlastic or rubber tube used to drain
or inject fluid through a bodyor inject fluid through a body
opening, most commonly used toopening, most commonly used to
drain the bladder.drain the bladder.
Catheter TypesCatheter Types
Indwelling CathetersIndwelling Catheters
– FoleyFoley
– RetentionRetention
Straight CathetersStraight Catheters
Catheter PurposeCatheter Purpose
Complete loss of bladder controlComplete loss of bladder control
Urinary retentionUrinary retention
Before, during and after surgicalBefore, during and after surgical
proceduresprocedures
Catheter CareCatheter Care
Tubing should not be kinkedTubing should not be kinked
Bag placed below level of the bladderBag placed below level of the bladder
Bag should be attached to the bedBag should be attached to the bed
frame NOT the side table or side railframe NOT the side table or side rail
Should be secured to the inner thighShould be secured to the inner thigh
Catheter Care #2Catheter Care #2
Clean the perineal area and aroundClean the perineal area and around
the catheterthe catheter
Bag should be emptied andBag should be emptied and
measured each shift ( or more oftenmeasured each shift ( or more often
if ordered )if ordered )
Report complaints promptly to theReport complaints promptly to the
nursenurse
Follow the rules of asepsis at allFollow the rules of asepsis at all
timestimes
Bladder TrainingBladder Training
Goal is voluntary control of bladderGoal is voluntary control of bladder
Two basic methods:Two basic methods:
Scheduled use of bedpan, urinal orScheduled use of bedpan, urinal or
toilettoilet
Clamping of catheter on a scheduleClamping of catheter on a schedule
basisbasis
Bowel EliminationBowel Elimination
The excretion of wastes from the gastro-The excretion of wastes from the gastro-
intestinal systemintestinal system
Normal StoolNormal Stool
BrownBrown
SoftSoft
FormedFormed
Characteristic odorCharacteristic odor
Bowel Elimination #2Bowel Elimination #2
Pattern: each person is differentPattern: each person is different
Frequency – daily to every 2-3 daysFrequency – daily to every 2-3 days
Time of day – morning or eveningTime of day – morning or evening
Factors influencing bowelFactors influencing bowel
movementmovement
PrivacyPrivacy
AgeAge
DietDiet
FluidsFluids
ActivityActivity
MedicationsMedications
Common Problems in eliminationCommon Problems in elimination
ConstipationConstipation
Hard, dry stoolHard, dry stool
Feces that moves too slowly throughFeces that moves too slowly through
the bodythe body
Caused by decreased fluids, diet,Caused by decreased fluids, diet,
inactivity, ignoring the urge toinactivity, ignoring the urge to
defecatedefecate
Common Problems in eliminationCommon Problems in elimination
#2#2
Fecal ImpactionFecal Impaction
Stool is unable to pass from theStool is unable to pass from the
rectumrectum
Results from unrelieved constipationResults from unrelieved constipation
Common Problems in eliminationCommon Problems in elimination
#3#3
DiarrheaDiarrhea
Liquid or unformed stoolLiquid or unformed stool
Feces that moves rapidly through theFeces that moves rapidly through the
intestinesintestines
Caused by infection, medications,Caused by infection, medications,
irritating foodsirritating foods
Common Problems in eliminationCommon Problems in elimination
#4#4
Anal IncontinenceAnal Incontinence
Inability to control the passage ofInability to control the passage of
feces and gasfeces and gas
Possible cause due to injury orPossible cause due to injury or
diseases of the nervous systemdiseases of the nervous system
May result when residents do notMay result when residents do not
receive the assistance they need in areceive the assistance they need in a
timely mannertimely manner
Common Problems in eliminationCommon Problems in elimination
#5#5
Flatulence ( gas )Flatulence ( gas )
Excessive formation of gas in theExcessive formation of gas in the
stomach and intestinesstomach and intestines
Caused by foods, medications, or air-Caused by foods, medications, or air-
swallowingswallowing
Maintaining Normal EliminationMaintaining Normal Elimination
PatternPattern
Provide the bedpan, urinal orProvide the bedpan, urinal or
commodecommode
Assist to get into normal positionAssist to get into normal position
Cover the resident for privacyCover the resident for privacy
Remain nearby if the person is weakRemain nearby if the person is weak
or frailor frail
Place signal light and toilet tissuePlace signal light and toilet tissue
nearbynearby
Maintaining Normal EliminationMaintaining Normal Elimination
Pattern #2Pattern #2
Allow the resident enough timeAllow the resident enough time
If resident has difficulty, ask themIf resident has difficulty, ask them
what kinds of things they did atwhat kinds of things they did at
homehome
Provide perineal care if neededProvide perineal care if needed
Offer opportunity to eliminate atOffer opportunity to eliminate at
regular intervalsregular intervals
Bowel TrainingBowel Training
Suppository at a regular timeSuppository at a regular time
Increase fluidsIncrease fluids
DietDiet
ActivityActivity
PrivacyPrivacy
Purpose of an OstomyPurpose of an Ostomy
Artificial opening most commonlyArtificial opening most commonly
into colon or small intestineinto colon or small intestine
Allow healing of intestine afterAllow healing of intestine after
surgery or diseasesurgery or disease
Can be temporary or permanentCan be temporary or permanent
Types of OstomiesTypes of Ostomies
CecostomyCecostomy
ColostomyColostomy
IleostomyIleostomy
JejunostomyJejunostomy
DuodenostomyDuodenostomy
Location depends on the disease or injuryLocation depends on the disease or injury
Characteristics of stool from differentCharacteristics of stool from different
ostomiesostomies
Ostomy CareOstomy Care
EquipmentEquipment
Emptying the bagEmptying the bag
Skin careSkin care
Odor managementOdor management
Ostomy Care – Role of NAOstomy Care – Role of NA
Assist with personal hygieneAssist with personal hygiene
Provide for privacyProvide for privacy
Changing appliancesChanging appliances
Emptying ostomy bagEmptying ostomy bag
Provide skin careProvide skin care
Use Standard PrecautionsUse Standard Precautions
Measuring weight and heightMeasuring weight and height
On admission and as orderedOn admission and as ordered
Wears gown or pajamasWears gown or pajamas
Urinate before being weighedUrinate before being weighed
Do routine weights at the same timeDo routine weights at the same time
each dayeach day
Types of prosthetic devices /Types of prosthetic devices /
Artificial limbsArtificial limbs
Nursing considerationsNursing considerations
Ask charge nurse for guidelinesAsk charge nurse for guidelines
Observe ability to participate in ADL’sObserve ability to participate in ADL’s
Assist resident to apply braceAssist resident to apply brace
Maintain body alignmentMaintain body alignment
Keep call bell within reachKeep call bell within reach
ROM to affected musclesROM to affected muscles
Nursing considerations #2Nursing considerations #2
Pad bracePad brace
Give constant praise for rehabilitativeGive constant praise for rehabilitative
effortsefforts
Provide skin careProvide skin care
Observe for complaint ofObserve for complaint of
pain,numbness, or weaknesspain,numbness, or weakness
Artificial eyesArtificial eyes
Daily removal are not necessaryDaily removal are not necessary
Special concern to prevent infectionSpecial concern to prevent infection
of the eye socketof the eye socket
Report redness, drainage, or crustingReport redness, drainage, or crusting
of eyelashesof eyelashes
Store the artificial eye in a containerStore the artificial eye in a container
labeled with the resident’s namelabeled with the resident’s name
Hearing aidsHearing aids
Check the batteryCheck the battery
Do not drop or try to repair theDo not drop or try to repair the
devicedevice
Apply to the ear it is designed forApply to the ear it is designed for
Do not allow thr device to get wetDo not allow thr device to get wet
Purposes of a hearing aidPurposes of a hearing aid
Restore hearingRestore hearing
Always face the resident whenAlways face the resident when
talkingtalking
Speak clearlySpeak clearly
Parts of a hearing aidParts of a hearing aid
MicrophoneMicrophone
AmplifierAmplifier
EarmoldEarmold
CordCord
On / off switchOn / off switch
Placement of the hearing aidPlacement of the hearing aid
Turn down the volumeTurn down the volume
It should fit tightly but comfortablyIt should fit tightly but comfortably
Turn it on and adjust volumeTurn it on and adjust volume
Check the placement if the residentCheck the placement if the resident
complains of an unpleasant whistlecomplains of an unpleasant whistle
Check the batteriesCheck the batteries
Caring for the hearing aidCaring for the hearing aid
Never wash a hearing aidNever wash a hearing aid
Never drop the hearing aidNever drop the hearing aid
Do not expose to heatDo not expose to heat
Do not let moisture get into theDo not let moisture get into the
hearing aidhearing aid
Do not use any kind of hair sprayDo not use any kind of hair spray
Talking to a partially deaf personTalking to a partially deaf person
Face the residentFace the resident
Speak slowly and clearlySpeak slowly and clearly
Don’t cover your mouth or chew gumDon’t cover your mouth or chew gum
Sit on the side of the better earSit on the side of the better ear
Use short sentencesUse short sentences
Repeat and rephrase statementsRepeat and rephrase statements
Facial expressions and body languageFacial expressions and body language
Reduce background noiseReduce background noise

Module15

  • 1.
    Terminology #1Terminology #1 Activitiesof Daily Living (ADL)Activities of Daily Living (ADL) ObservationObservation Medical terminologyMedical terminology AbbreviationAbbreviation SuffixSuffix prefixprefix
  • 2.
    Terminology #2Terminology #2 RootRoot CombiningvowelCombining vowel Patient care planPatient care plan KardexKardex assessmentassessment
  • 3.
    Senses used forevaluationSenses used for evaluation SightSight TouchTouch HearingHearing SmellSmell
  • 4.
    ABC’s of observationABC’sof observation AppearanceAppearance BehaviorBehavior communicationcommunication
  • 5.
    Objective and subjectiveObjectiveand subjective observationsobservations Objective-signs that you see, hear,Objective-signs that you see, hear, smell (factual)smell (factual) Subjective-what the resident tellsSubjective-what the resident tells you (symptoms)you (symptoms)
  • 6.
    Types of chartingdocumentsTypes of charting documents Patient record and patient chartPatient record and patient chart KardexKardex Nursing care planNursing care plan Graphic chartGraphic chart ADL sheetADL sheet
  • 7.
    Charting proceduresCharting procedures Writelegibly and neatlyWrite legibly and neatly Place events in proper sequencePlace events in proper sequence Chart for facility/policy standardsChart for facility/policy standards Be conciseBe concise Always use inkAlways use ink Errors-cross out with one line, do notErrors-cross out with one line, do not eraseerase
  • 8.
    Charting procedures #2Chartingprocedures #2 Include resident’s completeInclude resident’s complete informationinformation Never skip linesNever skip lines Sign your name at end of entrySign your name at end of entry Always date and time entriesAlways date and time entries Chart only proceduresChart only procedures you haveyou have performedperformed Chart only true observationsChart only true observations
  • 9.
    Legal issues ofchartingLegal issues of charting Resident record is a legal documentResident record is a legal document Information in chart must be keptInformation in chart must be kept confidentialconfidential Information in chart should beInformation in chart should be accurate, objective, and truthfulaccurate, objective, and truthful
  • 10.
    Word elementsWord elements RootRoot PrefixPrefix SuffixSuffix CombiningwordCombining word Abbreviation is a shortened form ofAbbreviation is a shortened form of words or phrases, and are commonlywords or phrases, and are commonly used in health care settingsused in health care settings
  • 12.
  • 13.
  • 14.
    Terminology #4Terminology #4 FecesFeces EliminationElimination FecalimpactionFecal impaction Anal incontinenceAnal incontinence FlatulenceFlatulence ConstipationConstipation DiarrheaDiarrhea
  • 15.
  • 16.
    Daily routine care/EarlyMorningDaily routine care/Early Morning Offer bedpan/urinal or assist toOffer bedpan/urinal or assist to bathroombathroom Wash face and handsWash face and hands Offer oral hygieneOffer oral hygiene Straighten bed and unitStraighten bed and unit Position resident for breakfastPosition resident for breakfast
  • 17.
    Morning care afterbreakfastMorning care after breakfast Oral hygieneOral hygiene Offer bedpan/urinal or assist toOffer bedpan/urinal or assist to bathroombathroom BathingBathing ShavingShaving Skin careSkin care DressingDressing Hair careHair care Change bed linensChange bed linens
  • 18.
    Prepare for mealsPreparefor meals Lunch and dinnerLunch and dinner Offer bedpan/urinal or assist toOffer bedpan/urinal or assist to bathroombathroom Wash hands/faceWash hands/face Straighten bed/unitStraighten bed/unit Position for mealPosition for meal
  • 19.
    Afternoon careAfternoon care Offerbedpan/urinal or assist toOffer bedpan/urinal or assist to bathroombathroom Wash face and handsWash face and hands Oral hygieneOral hygiene Grooming as necessaryGrooming as necessary Change soiled linenChange soiled linen Straighten unitStraighten unit
  • 20.
    Evening (HS) careEvening(HS) care Offer bedpan/urinal or assist toOffer bedpan/urinal or assist to bathroombathroom Wash face and handsWash face and hands Oral hygieneOral hygiene Change soiled linenChange soiled linen Dress for bedDress for bed Back massageBack massage Straighten unitStraighten unit
  • 21.
    Benefits of bathingBenefitsof bathing CleanlinessCleanliness Reduce bacteria and germsReduce bacteria and germs Promote skin integrityPromote skin integrity Stimulate circulationStimulate circulation Provide movement and exerciseProvide movement and exercise RelaxationRelaxation Sense of well-beingSense of well-being Opportunity for communication andOpportunity for communication and observationobservation
  • 22.
    Body areas thatrequire bathingBody areas that require bathing FaceFace Underarms (axilla)Underarms (axilla) HandsHands Perineal areaPerineal area Any area where skin folds or creasesAny area where skin folds or creases
  • 23.
    Types of bathsTypesof baths ShowerShower Tub/whirlpool, medicinalTub/whirlpool, medicinal Complete bed bathComplete bed bath Partial bed bathPartial bed bath
  • 24.
    General guidelines forbathingGeneral guidelines for bathing residentsresidents Check with nurse regarding type ofCheck with nurse regarding type of bathbath Refer to procedure manual forRefer to procedure manual for special bathsspecial baths Identify skin care products to beIdentify skin care products to be usedused Check resident’s personal choicesCheck resident’s personal choices Collect necessary equipmentCollect necessary equipment Provide privacyProvide privacy
  • 25.
    General guidelines forbathingGeneral guidelines for bathing residents #2residents #2 Assure adequate comfortAssure adequate comfort Use comfortably warm water, changeUse comfortably warm water, change it when it becomes soapy, dirty orit when it becomes soapy, dirty or coldcold Bathe areas soiled by fecal materialBathe areas soiled by fecal material or urineor urine Wash from cleanest to dirtiest areaWash from cleanest to dirtiest area Rinse off all soapRinse off all soap Pat skin dryPat skin dry
  • 26.
    Safety Guidelines forbathingSafety Guidelines for bathing Monitor correct water temperatureMonitor correct water temperature Use safety equipmentUse safety equipment Stay with residentStay with resident Use correct body mechanicsUse correct body mechanics
  • 27.
    Privacy during bathingPrivacyduring bathing Close doorClose door Pull curtain around residentPull curtain around resident Only uncover area being washedOnly uncover area being washed
  • 28.
    Observations to bemade duringObservations to be made during bathing/skinbathing/skin ColorColor RashesRashes DrynessDryness BruisesBruises OdorsOdors SwellingSwelling
  • 29.
    Observations/Fingernails,toenails,Observations/Fingernails,toenails, hair,eyes and MentalStatus #2hair,eyes and Mental Status #2 Presence of nitsPresence of nits Color of scleraColor of sclera Orientation/alertnessOrientation/alertness MoodMood AttitudeAttitude
  • 30.
    Observations that requirereportingObservations that require reporting skinskin ColorColor New rashesNew rashes New bruises, broken skin, bleedingNew bruises, broken skin, bleeding Unusual odorsUnusual odors Complaints of painComplaints of pain
  • 31.
    Observations that requiredObservationsthat required reporting/ Fingernails, hairreporting/ Fingernails, hair New Yellow, thickened nailsNew Yellow, thickened nails New significant hair lossNew significant hair loss FlakingFlaking Sore scalpSore scalp NitsNits
  • 32.
    Observations that requirereportingObservations that require reporting Eyes and Mental statusEyes and Mental status RednessRedness Yellowing of scleraYellowing of sclera DisorientationDisorientation DepressionDepression Development of unresponsivenessDevelopment of unresponsiveness
  • 33.
    Types of medicinalbathsTypes of medicinal baths BranBran OatmealOatmeal StarchStarch Sodium bicarbonateSodium bicarbonate Epsom saltsEpsom salts Pine productsPine products SulfurSulfur SaltSalt
  • 34.
    Purposes of medicinalbathsPurposes of medicinal baths Soothing sedationSoothing sedation Relief of pruritisRelief of pruritis Relief of skin disorder (dry skin,Relief of skin disorder (dry skin, irritation, rash)irritation, rash)
  • 35.
    Oral hygiene /PurposeOral hygiene / Purpose Cleanliness of mouth and teethCleanliness of mouth and teeth Prevent mouth odor and infectionPrevent mouth odor and infection Prevent tooth lossPrevent tooth loss ComfortComfort Pleasant tastePleasant taste Improve taste of foodImprove taste of food
  • 36.
    Oral hygiene /When to performOral hygiene / When to perform On awakeningOn awakening After each mealAfter each meal Bed timeBed time
  • 37.
    Oral hygiene /SpecialOral hygiene / Special circumstancescircumstances UnconsciousUnconscious Mouth breatherMouth breather O2O2 NG tubeNG tube Elevated temperatureElevated temperature
  • 38.
    Steps of oralhygieneSteps of oral hygiene Carry out procedure using standardCarry out procedure using standard precautionsprecautions Examine oral cavity and reportExamine oral cavity and report findingsfindings
  • 39.
    Steps in cleaningand care ofSteps in cleaning and care of denturesdentures Use standard precautionsUse standard precautions Examine oral cavity and reportExamine oral cavity and report findingsfindings
  • 40.
    Nurse assistant rolefor residentNurse assistant role for resident nail carenail care Easier to clean after soaking inEasier to clean after soaking in warm, soapy waterwarm, soapy water Be cautious to prevent damage toBe cautious to prevent damage to tissuestissues Report unusual conditions to nurseReport unusual conditions to nurse Follow facility procedureFollow facility procedure
  • 41.
    Nurse assistant role/ caring for hairNurse assistant role / caring for hair Part of daily carePart of daily care Important for identity and self-Important for identity and self- esteemesteem Accommodate resident preferencesAccommodate resident preferences for style, hair productsfor style, hair products
  • 42.
    Nurse assistant role/ typesNurse assistant role / types shampooshampoo Shower / tubShower / tub SinkSink BedBed
  • 43.
    Nurse assistant role/ purpose ofNurse assistant role / purpose of Medicinal ShampooMedicinal Shampoo Eradicate liceEradicate lice ScabiesScabies Soothe / heal irritated skinSoothe / heal irritated skin
  • 44.
    Shaving a resident/ GuidelinesShaving a resident / Guidelines Use either electric or safety razorUse either electric or safety razor Use appropriate safety precautionsUse appropriate safety precautions for electrical equipmentfor electrical equipment Safety razors can cause nicks or cutsSafety razors can cause nicks or cuts Use standard precautions to preventUse standard precautions to prevent contact with bloodcontact with blood
  • 45.
    Functions of theintegumentaryFunctions of the integumentary systemsystem Provides protective barrier againstProvides protective barrier against microorganismsmicroorganisms Enables the body to feel pain,Enables the body to feel pain, pressure, and temperaturepressure, and temperature Shields body tissue from injuryShields body tissue from injury Insulates against heat and coldInsulates against heat and cold Eliminates waste productsEliminates waste products Produces Vitamin D for body useProduces Vitamin D for body use
  • 46.
    How to maintainhealthy skinHow to maintain healthy skin Encourage well-balanced diet andEncourage well-balanced diet and fluidsfluids Maintain skin careMaintain skin care Observe color and temperatureObserve color and temperature Give special attention to bonyGive special attention to bony prominencesprominences
  • 47.
    Age –related changesaffecting theAge –related changes affecting the skinskin Excessively dry areasExcessively dry areas Elasticity decreased, causing wrinklesElasticity decreased, causing wrinkles Thinner layersThinner layers
  • 48.
    Residents at riskfor skinResidents at risk for skin breakdownbreakdown Elderly residentsElderly residents Residents who have no sensation ofResidents who have no sensation of painpain Paralyzed residentsParalyzed residents Residents with edemaResidents with edema Thin residentsThin residents Diabetic, Overweight, in castsDiabetic, Overweight, in casts Unconscious, sedated residentsUnconscious, sedated residents
  • 49.
    Conditions which causedecubitusConditions which cause decubitus ulcersulcers PressurePressure Decreased blood flow to an areaDecreased blood flow to an area Wet skinWet skin Scratches from fingernailsScratches from fingernails Dry skinDry skin
  • 50.
    Decubitus ulcers #2/ Signs andDecubitus ulcers #2 / Signs and symptoms or stagessymptoms or stages Stage oneStage one Stage twoStage two Stage threeStage three
  • 51.
    Decubitus ulcers #3/ BonyDecubitus ulcers #3 / Bony prominencesprominences SacrumSacrum HeelsHeels KneesKnees ShouldersShoulders Back of headBack of head HipsHips Ankles, Elbows and EarsAnkles, Elbows and Ears
  • 52.
    Decubitus ulcers /PreventiveDecubitus ulcers / Preventive nursing care measuresnursing care measures Keep skin clean and dryKeep skin clean and dry Use only small amounts of powderUse only small amounts of powder and lotionand lotion Wash after each incontinent episodeWash after each incontinent episode Keep safety devices, clothing, andKeep safety devices, clothing, and bedding from being too tightbedding from being too tight Keep edges of casts and braces fromKeep edges of casts and braces from pressing against the skinpressing against the skin
  • 53.
    Decubitus ulcers /PreventiveDecubitus ulcers / Preventive nursing care measures #2nursing care measures #2 Remove crumbsRemove crumbs Avoid wrinkles in beddingAvoid wrinkles in bedding Keep tubes from pressing on the skinKeep tubes from pressing on the skin Remove residents from toilets andRemove residents from toilets and bedpans promptlybedpans promptly Keep your nails short and smoothKeep your nails short and smooth
  • 54.
    Decubitus ulcers /Use of pressure-Decubitus ulcers / Use of pressure- reducing devices # 3reducing devices # 3 Bed cradleBed cradle SheepskinSheepskin Heel and elbow protectorsHeel and elbow protectors Egg crate mattressEgg crate mattress Alternating pressure matressAlternating pressure matress Clinitron bedClinitron bed Trochanter rollsTrochanter rolls Flotation pads or cushionsFlotation pads or cushions
  • 55.
    Decubitus ulcers #4Decubitus ulcers # 4 Turn or change resident’s positionTurn or change resident’s position every two hoursevery two hours Encourage circulation by gentleEncourage circulation by gentle massage around areamassage around area Teach resident to change positionTeach resident to change position frequentlyfrequently Assist with range of motion exercisesAssist with range of motion exercises Apply lotion to dry skin areasApply lotion to dry skin areas
  • 56.
    Dressing Residents /Types ofDressing Residents / Types of ClothingClothing CardiganCardigan PulloverPullover PantsPants Disposable briefDisposable brief Shoes and stockingsShoes and stockings AccessoriesAccessories
  • 57.
    Physical factors thatlimit aPhysical factors that limit a resident’s ability to dressresident’s ability to dress Lack of maturationLack of maturation Brain impairmentBrain impairment WeaknessWeakness PainPain FracturesFractures ContracturesContractures ParalysisParalysis Lack of visionLack of vision Psychological factorsPsychological factors
  • 58.
    Caring for residentclothingCaring for resident clothing Label garmentsLabel garments Avoid cuttingAvoid cutting Do not discardDo not discard Store in the resident’s unitStore in the resident’s unit Fold neatly or hang in closetFold neatly or hang in closet Assist resident or family to chooseAssist resident or family to choose clothing that meets physical needsclothing that meets physical needs
  • 59.
    Purposes for dressinga residentPurposes for dressing a resident How we look influences the way weHow we look influences the way we feel about ourselvesfeel about ourselves It encourages resident to beIt encourages resident to be independentindependent It discourages incontinenceIt discourages incontinence
  • 60.
    Guidelines for dressingandGuidelines for dressing and undressing a residentundressing a resident Provide for privacyProvide for privacy Encourage the resident to do asEncourage the resident to do as much as possiblemuch as possible Allow residents to choose what toAllow residents to choose what to wearwear Remove clothing from the strong orRemove clothing from the strong or good side firstgood side first Put clothing on weak side firstPut clothing on weak side first
  • 61.
    Ways the bodyeliminates wasteWays the body eliminates waste Urinary elimination (Urine)Urinary elimination (Urine) Bowel elimination (Feces)Bowel elimination (Feces)
  • 62.
    Urinary EliminationUrinary Elimination Thebody excretes 1000 to 1500 mlThe body excretes 1000 to 1500 ml of urine / dayof urine / day Urine consists of the wastes andUrine consists of the wastes and excess fluidsexcess fluids Residents have different urinationResidents have different urination needsneeds Keep resident’s routine as normal asKeep resident’s routine as normal as possiblepossible
  • 63.
    Characteristics of normalurineCharacteristics of normal urine ClearClear Amber ( Medium Yellow) colorAmber ( Medium Yellow) color Mild odorMild odor
  • 64.
    Frequency of urinationFrequencyof urination Amount of fluid ingestedAmount of fluid ingested Personal habitsPersonal habits Availability of toilet facilitiesAvailability of toilet facilities Physical activitiesPhysical activities IllnessIllness Ranges from every 2-3 hours toRanges from every 2-3 hours to every 8-12 hoursevery 8-12 hours
  • 65.
    Observations to bemade aboutObservations to be made about urineurine ColorColor ClarityClarity OdorOdor AmountAmount
  • 66.
    Information to reportabout urineInformation to report about urine CloudyCloudy Pinkish or reddish tintPinkish or reddish tint Resident complaints burning onResident complaints burning on urinationurination Difficulty in urinationDifficulty in urination Feeling of pressureFeeling of pressure FrequencyFrequency Strong OdorStrong Odor
  • 67.
    Urinary incontinenceUrinary incontinence Inabilityto control the passage ofInability to control the passage of urine from the bladderurine from the bladder Constant dribbleConstant dribble Occasional dribble when laugh,Occasional dribble when laugh, cough or sneezecough or sneeze No controlNo control
  • 68.
    Urinary incontinence /CausesUrinary incontinence / Causes Central nervous systemCentral nervous system Spinal cord injurySpinal cord injury Aging and confusionAging and confusion MedicationsMedications Weak pelvic musclesWeak pelvic muscles Urinary tract infectionUrinary tract infection Prostate problemsProstate problems Prolapse of uterus and bladderProlapse of uterus and bladder
  • 69.
    Catheter / DefinitionCatheter/ Definition Plastic or rubber tube used to drainPlastic or rubber tube used to drain or inject fluid through a bodyor inject fluid through a body opening, most commonly used toopening, most commonly used to drain the bladder.drain the bladder.
  • 70.
    Catheter TypesCatheter Types IndwellingCathetersIndwelling Catheters – FoleyFoley – RetentionRetention Straight CathetersStraight Catheters
  • 71.
    Catheter PurposeCatheter Purpose Completeloss of bladder controlComplete loss of bladder control Urinary retentionUrinary retention Before, during and after surgicalBefore, during and after surgical proceduresprocedures
  • 72.
    Catheter CareCatheter Care Tubingshould not be kinkedTubing should not be kinked Bag placed below level of the bladderBag placed below level of the bladder Bag should be attached to the bedBag should be attached to the bed frame NOT the side table or side railframe NOT the side table or side rail Should be secured to the inner thighShould be secured to the inner thigh
  • 73.
    Catheter Care #2CatheterCare #2 Clean the perineal area and aroundClean the perineal area and around the catheterthe catheter Bag should be emptied andBag should be emptied and measured each shift ( or more oftenmeasured each shift ( or more often if ordered )if ordered ) Report complaints promptly to theReport complaints promptly to the nursenurse Follow the rules of asepsis at allFollow the rules of asepsis at all timestimes
  • 74.
    Bladder TrainingBladder Training Goalis voluntary control of bladderGoal is voluntary control of bladder Two basic methods:Two basic methods: Scheduled use of bedpan, urinal orScheduled use of bedpan, urinal or toilettoilet Clamping of catheter on a scheduleClamping of catheter on a schedule basisbasis
  • 75.
    Bowel EliminationBowel Elimination Theexcretion of wastes from the gastro-The excretion of wastes from the gastro- intestinal systemintestinal system Normal StoolNormal Stool BrownBrown SoftSoft FormedFormed Characteristic odorCharacteristic odor
  • 76.
    Bowel Elimination #2BowelElimination #2 Pattern: each person is differentPattern: each person is different Frequency – daily to every 2-3 daysFrequency – daily to every 2-3 days Time of day – morning or eveningTime of day – morning or evening
  • 77.
    Factors influencing bowelFactorsinfluencing bowel movementmovement PrivacyPrivacy AgeAge DietDiet FluidsFluids ActivityActivity MedicationsMedications
  • 78.
    Common Problems ineliminationCommon Problems in elimination ConstipationConstipation Hard, dry stoolHard, dry stool Feces that moves too slowly throughFeces that moves too slowly through the bodythe body Caused by decreased fluids, diet,Caused by decreased fluids, diet, inactivity, ignoring the urge toinactivity, ignoring the urge to defecatedefecate
  • 79.
    Common Problems ineliminationCommon Problems in elimination #2#2 Fecal ImpactionFecal Impaction Stool is unable to pass from theStool is unable to pass from the rectumrectum Results from unrelieved constipationResults from unrelieved constipation
  • 80.
    Common Problems ineliminationCommon Problems in elimination #3#3 DiarrheaDiarrhea Liquid or unformed stoolLiquid or unformed stool Feces that moves rapidly through theFeces that moves rapidly through the intestinesintestines Caused by infection, medications,Caused by infection, medications, irritating foodsirritating foods
  • 81.
    Common Problems ineliminationCommon Problems in elimination #4#4 Anal IncontinenceAnal Incontinence Inability to control the passage ofInability to control the passage of feces and gasfeces and gas Possible cause due to injury orPossible cause due to injury or diseases of the nervous systemdiseases of the nervous system May result when residents do notMay result when residents do not receive the assistance they need in areceive the assistance they need in a timely mannertimely manner
  • 82.
    Common Problems ineliminationCommon Problems in elimination #5#5 Flatulence ( gas )Flatulence ( gas ) Excessive formation of gas in theExcessive formation of gas in the stomach and intestinesstomach and intestines Caused by foods, medications, or air-Caused by foods, medications, or air- swallowingswallowing
  • 83.
    Maintaining Normal EliminationMaintainingNormal Elimination PatternPattern Provide the bedpan, urinal orProvide the bedpan, urinal or commodecommode Assist to get into normal positionAssist to get into normal position Cover the resident for privacyCover the resident for privacy Remain nearby if the person is weakRemain nearby if the person is weak or frailor frail Place signal light and toilet tissuePlace signal light and toilet tissue nearbynearby
  • 84.
    Maintaining Normal EliminationMaintainingNormal Elimination Pattern #2Pattern #2 Allow the resident enough timeAllow the resident enough time If resident has difficulty, ask themIf resident has difficulty, ask them what kinds of things they did atwhat kinds of things they did at homehome Provide perineal care if neededProvide perineal care if needed Offer opportunity to eliminate atOffer opportunity to eliminate at regular intervalsregular intervals
  • 85.
    Bowel TrainingBowel Training Suppositoryat a regular timeSuppository at a regular time Increase fluidsIncrease fluids DietDiet ActivityActivity PrivacyPrivacy
  • 86.
    Purpose of anOstomyPurpose of an Ostomy Artificial opening most commonlyArtificial opening most commonly into colon or small intestineinto colon or small intestine Allow healing of intestine afterAllow healing of intestine after surgery or diseasesurgery or disease Can be temporary or permanentCan be temporary or permanent
  • 87.
    Types of OstomiesTypesof Ostomies CecostomyCecostomy ColostomyColostomy IleostomyIleostomy JejunostomyJejunostomy DuodenostomyDuodenostomy Location depends on the disease or injuryLocation depends on the disease or injury Characteristics of stool from differentCharacteristics of stool from different ostomiesostomies
  • 88.
    Ostomy CareOstomy Care EquipmentEquipment Emptyingthe bagEmptying the bag Skin careSkin care Odor managementOdor management
  • 89.
    Ostomy Care –Role of NAOstomy Care – Role of NA Assist with personal hygieneAssist with personal hygiene Provide for privacyProvide for privacy Changing appliancesChanging appliances Emptying ostomy bagEmptying ostomy bag Provide skin careProvide skin care Use Standard PrecautionsUse Standard Precautions
  • 90.
    Measuring weight andheightMeasuring weight and height On admission and as orderedOn admission and as ordered Wears gown or pajamasWears gown or pajamas Urinate before being weighedUrinate before being weighed Do routine weights at the same timeDo routine weights at the same time each dayeach day
  • 91.
    Types of prostheticdevices /Types of prosthetic devices / Artificial limbsArtificial limbs Nursing considerationsNursing considerations Ask charge nurse for guidelinesAsk charge nurse for guidelines Observe ability to participate in ADL’sObserve ability to participate in ADL’s Assist resident to apply braceAssist resident to apply brace Maintain body alignmentMaintain body alignment Keep call bell within reachKeep call bell within reach ROM to affected musclesROM to affected muscles
  • 92.
    Nursing considerations #2Nursingconsiderations #2 Pad bracePad brace Give constant praise for rehabilitativeGive constant praise for rehabilitative effortsefforts Provide skin careProvide skin care Observe for complaint ofObserve for complaint of pain,numbness, or weaknesspain,numbness, or weakness
  • 93.
    Artificial eyesArtificial eyes Dailyremoval are not necessaryDaily removal are not necessary Special concern to prevent infectionSpecial concern to prevent infection of the eye socketof the eye socket Report redness, drainage, or crustingReport redness, drainage, or crusting of eyelashesof eyelashes Store the artificial eye in a containerStore the artificial eye in a container labeled with the resident’s namelabeled with the resident’s name
  • 94.
    Hearing aidsHearing aids Checkthe batteryCheck the battery Do not drop or try to repair theDo not drop or try to repair the devicedevice Apply to the ear it is designed forApply to the ear it is designed for Do not allow thr device to get wetDo not allow thr device to get wet
  • 95.
    Purposes of ahearing aidPurposes of a hearing aid Restore hearingRestore hearing Always face the resident whenAlways face the resident when talkingtalking Speak clearlySpeak clearly
  • 96.
    Parts of ahearing aidParts of a hearing aid MicrophoneMicrophone AmplifierAmplifier EarmoldEarmold CordCord On / off switchOn / off switch
  • 97.
    Placement of thehearing aidPlacement of the hearing aid Turn down the volumeTurn down the volume It should fit tightly but comfortablyIt should fit tightly but comfortably Turn it on and adjust volumeTurn it on and adjust volume Check the placement if the residentCheck the placement if the resident complains of an unpleasant whistlecomplains of an unpleasant whistle Check the batteriesCheck the batteries
  • 98.
    Caring for thehearing aidCaring for the hearing aid Never wash a hearing aidNever wash a hearing aid Never drop the hearing aidNever drop the hearing aid Do not expose to heatDo not expose to heat Do not let moisture get into theDo not let moisture get into the hearing aidhearing aid Do not use any kind of hair sprayDo not use any kind of hair spray
  • 99.
    Talking to apartially deaf personTalking to a partially deaf person Face the residentFace the resident Speak slowly and clearlySpeak slowly and clearly Don’t cover your mouth or chew gumDon’t cover your mouth or chew gum Sit on the side of the better earSit on the side of the better ear Use short sentencesUse short sentences Repeat and rephrase statementsRepeat and rephrase statements Facial expressions and body languageFacial expressions and body language Reduce background noiseReduce background noise