CNA. Nursing Assistant Certification Accelerated Edition. Dr. Carrie L. Engelbright RN, CNE, CWP

Transcription

1 CNA Nursing Assistant Certification Accelerated Edition Dr. Carrie L. Engelbright RN, CNE, CWP

2 CNA: Nursing Assistant Certification, Accelerated Edition Dr. Carrie L. Engelbright RN, CNE, CWP 2017, August Learning Solutions Published by August Learning Solutions Cleveland, OH August Learning Solutions concentrates instructor s efforts to create products that provide the best learning experience, streamlining your workload and delivering optimal value for the end user, the student. All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever, including but not limited to photocopying, scanning, digitizing, or any other electronic storage or transmission, without the express written permission of the publisher. ISBN-13: ISBN-10: Printed in the United States of America Textbook activity answers, instructor resources, test bank questions, and workbook answer keys are available to professors via the Instructor Portal at Cover image credits: (left to right): ElenaMedvedeva/iStock/Thinkstock, August Learning Solutions, ElenaMedvedeva/iStock/Thinkstock

3 This book is dedicated to all nursing assistant instructors and students. To my fellow instructors: Your work is so vitally important to our healthcare system. Without nursing assistants the healthcare industry could not function. Nursing assistants are the backbone of nursing care, sharing their roots with nurses in the environmental theory of Florence Nightingale s canons. To my former students: You have taught me so much. To my future students: I am excited to learn even more from you. Nursing assistant programs can lead to a gratifying lifelong career or can be the entry point into any healthcare field that interests you. Please use this text as a platform from which to jump into the exciting world of healthcare.

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5 Brief Contents 1 Healthcare Yesterday and Today 1 2 The Nursing Assistant Role: Where You Fit In! 7 3 Communication 15 4 Professionalism and Ethics 22 5 Body Structures and Functioning Processes 29 6 Common Diseases and Disorders 43 7 Infection Control Practices 56 8 Body Mechanics and Workplace Safety 68 9 Reducing Client Injury and Falls Restraints and Restraint Alternatives Basic First Aid Measures Holistic Care of Clients Client Room Environment Preventing Skin Breakdown Bedmaking Positioning, Moving, and Transporting Clients Ambulation, Restorative Care, and Adaptive Equipment for Clients Vital Signs Bathing Grooming Nutrition Elimination and Specimen Collection Care for the Client with Dementia End-of-Life Care 236 Common Medical Abbreviations and Directional Terminology 243 ISMP s List of Error-Prone Abbreviations, Symbols, and Dose Designations 245 Glossary 249 Index 253

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7 Contents A Note to Nursing Assistant Instructors xvii A Note to the Students xix Visual Walkthrough xx Acknowledgements xxv About the Author xxvii Chapter 1 Healthcare Yesterday and Today A Brief History of Healthcare in the United States The Beginning of Modern Healthcare 2 The Modernization of Medicine The Cost of Healthcare Healthcare Today Who Is Your Client? Consumerism in America Home Healthcare Versus Facility Care Why the Nursing Assistant Needs to Know These Trends 6 Chapter 2 The Nursing Assistant Role: Where You Fit In! Work Settings for the Nursing Assistant 7 Acute Care Settings 7 Subacute or Rehabilitation Facility 8 Long-Term Care 8 Assisted-Living Communities 9 Home Healthcare 10 Hospice Services 10 Respite Services Members of the Healthcare Team Scope of Practice for the Nursing Assistant Chain of Command Delegated Tasks Teaching Versus Reinforcing 14

8 viii Contents Chapter 3 Communication Causes of Medical Errors Subjective Versus Objective Data Oral Reporting Written Documentation and the Nursing Assistant Verbal Versus Nonverbal Communication 18 Verbal Communication 18 Nonverbal Communication Therapeutic Communication Communication Disorders Communication With the Hearing- Impaired Client Communication With the Speech- Impaired Client 20 Chapter 4 Professionalism and Ethics Education and Certification 22 Nurse Aide Registry 23 Continuing Education Acting Like a Professional 23 Dependability 23 Promptness 23 Flexibility 23 Hygiene Employee Rights Employee Responsibilities 24 Following the Care Plan 24 Mandatory Reporting Client Rights 25 Health Insurance Portability and Accountability Act (HIPAA) 25 Informed Consent Client Responsibilities Laws 26 Invasion of Privacy 26 Misappropriation of Funds 26 Negligence 27 Abandonment 27 False Imprisonment 27 Neglect 27 Assault and Battery 27 Abuse Cultural Awareness 28 Chapter 5 Body Structures and Functioning Processes Basic Structures Tissue Types Body Systems 30 Integumentary System 30 Musculoskeletal System 31 Respiratory System 32 Cardiovascular System 34 Nervous System 35 Sensory Organs 36 Endocrine System 38 Digestive System 39 Urinary System 40 Reproductive System 41

9 Contents ix Chapter 6 Common Diseases and Disorders Common Diseases and Disorders 43 Integumentary System 43 Musculoskeletal System 44 Respiratory System 46 Cardiovascular System 47 Nervous System 48 Sensory Organs 51 Endocrine System 52 Digestive System 53 Urinary System 54 Reproductive System 55 Chapter 7 Infection Control Practices Chain of Infection Primary Prevention Hand Hygiene Standard Precautions 58 Personal Protective Equipment (PPE) Specialty Precautions 61 Airborne Precautions 62 Droplet Precautions 62 Contact Precautions 62 Transporting a Client to and From an Isolation Room 62 Blood Spill Kits Drug-Resistant Infections 62 MRSA Infection 62 VRE 63 Chapter 8 Body Mechanics and Workplace Safety Exposure to Blood-Borne Pathogens and Chemicals Injury Prevention 69 Ergonomics 69 Ways to Move Clients 69 Lifestyle Choices to Prevent Back Injuries 70 Slips, Trips, and Falls Fire Safety Natural Disasters Workplace Violence 72 Chapter 9 Reducing Client Injury and Falls Why Falls and Immobility Are Dangerous Risk Factors for Falling Care During a Fall Care After a Fall How to Prevent Fall Injuries Alarm Systems Other Strategies 76

10 x Contents Chapter 10 Restraints and Restraint Alternatives Restraints Ways to Work With Restraints Types of Restraints Risks of Using Restraints Side Rails Restraint Alternatives 83 Chapter 11 Basic First Aid Measures Airway Obstruction Cardiac Arrest Syncope Seizures Hemorrhage Shock Burns Poisoning 90 Chapter 12 Holistic Care of Clients Holistic Care Maslow s Hierarchy of Needs 95 Human Needs 96 Application of Maslow s Hierarchy to Caregiving Growth and Development Quality of Life Meeting the Needs of Loved Ones 100 Chapter 13 Client Room Environment Safety The Physical Environment Individual Room Requirements Noise and Odor Control 103 Noise Control 103 Odor Control and Cleanliness Transfers and Discharges Current Trends 105 Chapter 14 Preventing Skin Breakdown The Importance of Healthy Skin Types of Skin Breakdown 106 Rashes 107 Friction and Shearing 107 Pressure Injuries 107

11 Contents xi 14.3 Stages of Pressure Injuries Risk Factors for Developing Pressure Injuries Interventions for Preventing Skin Breakdown 110 Inspection and Cleanliness 110 Positioning and Turning 111 Pressure-Relieving Devices 111 Positioning Devices 112 Incontinence Care 112 Nutrition and Hydration 113 Reducing the Microclimate 113 Chapter 15 Bedmaking Linens Infection Control Body Mechanics The Closed Versus Open Bed How to Make the Unoccupied and Occupied Bed 117 Unoccupied Bed 117 Occupied Bed 117 Chapter 16 Positioning, Moving, and Transporting Clients Frequency of Repositioning Clients Basic Positions for Clients in Bed Positions to Relieve Pressure Injuries 124 Supine 124 Fowler s Position 124 Prone Position 125 Side-Lying Position 125 Sims s Position 126 Tripod Position Wheelchair Positioning Method to Move a Client in Bed Different Types of Transfers 127 Dangling 127 Footwear 127 Gait Belt 128 One- and Two-Assist Transfers 128 Mechanical Devices Used for Transfers Method to Transfer a Bariatric Client Method to Transport a Client in a Wheelchair 131 Chapter 17 Ambulation, Restorative Care, and Adaptive Equipment for Clients Why We Move 141 Self-Esteem 141 Effects on the Digestive System 141 Effects on the Cardiovascular System 142 Effects on the Integumentary System 142 Effects on the Musculoskeletal System Levels of Assistance Safety Measures Used During Ambulation 143

12 xii Contents 17.4 Assistive Devices for Ambulation Range-of-Motion Exercises Therapy Services Overview 145 Physical Therapy 145 Occupational Therapy 145 Speech Therapy Activities Therapy Restorative Care The Client with a Prosthesis Adaptive Tools 149 Chapter 18 Vital Signs When Vital Signs Are Taken Infection Control How to Accurately Measure Vital Signs 154 Temperature 154 Pulse 156 Respiration 156 Blood Pressure 157 Height 158 Weight 159 Chapter 19 Bathing Routine Bathing Distressed Bathing 168 Alternatives to Tub Bathing and Showering 169 Ways to Ease Distressed Bathing Rinseless Systems Peri-Care Bed Baths 172 Partial Bed Bath 172 Complete Bed Bath Shower and Tub Baths 173 Shower 173 Whirlpool Tub Bath 174 Hair Care Responsibilities on Bath Day 175 Chapter 20 Grooming Promoting Independence Dressing 189 Dressing a Client with One-Sided Weakness 190 Dressing a Client Who Requires Anti-Embolism Stockings Vision and Hearing 190 Glasses 190 Hearing Aids Shaving Oral Care Nail and Foot Care 193 Nail Care 193 Foot Care 193 Chapter 21 Nutrition MyPlate Nutrients Essential for Life 205 Calories 205 Carbohydrates 205 Proteins 205

13 Contents xiii Fats 205 Vitamins and Minerals Water and Fluid Needs Food Groups 208 Grains 208 Fruits 208 Vegetables 208 Dairy Products 208 Protein Types of Diets 209 Specialty Diets 209 Mechanically Altered Diets and Fluids 210 Thickened Fluids How to Feed Dependent Clients 210 Chapter 22 Elimination and Specimen Collection Urinary Elimination via Catheter 214 Types of Catheters 214 The Nursing Assistant s Role in Care of a Client with a Catheter 215 Securing the Catheter 215 Cleaning the Catheter 215 Positioning the Client With a Collection Bag 216 Protecting the Privacy of the Client Who Uses a Catheter 216 Emptying the Collection Bag Incontinence 216 Care of a Client Who Is Incontinent 216 Types of Incontinence Products Bowel Elimination Ostomies Digestive Tract Bleeding Devices Used for Elimination Urine Specimens Fecal Specimens 219 Chapter 23 Care for the Client with Dementia Types of Dementia Treatment of Dementia Ways to Diagnose Dementia 229 Stages of Alzheimer s Dementia 229 Common Signs, Symptoms, and Behaviors Associated With Dementia How to Manage the Behaviors Associated With Dementia 231 Ways to Meet Unmet Needs of the Client 231 Therapeutic Interventions 231 Ways to Maintain Function 232 Approaches to Specific Behaviors 232 Ways to Improve Meal Time 232 Ways to Manage Pain 232 Sleep Disturbances 233 Toileting Interventions 233 Bathing Interventions 234 Wandering and Elopement Safety Measures 234 Ways to Discourage Sexual Inappropriateness Caregiver Strain 235

14 xiv Contents Chapter 24 End-of-Life Care Body System Changes 236 Respiratory Changes 237 Cardiovascular Changes 237 Nervous System and Sensory Organ Changes 237 Digestive Changes 237 Urinary Changes Special Care for the Dying Client Faith and Religion Care for the Family Post-Mortem Care 239 Common Medical Abbreviations and Directional Terminology 243 ISMP s List of Error-Prone Abbreviations, Symbols, and Dose Designations 245 Glossary 249 Index 253

15 Skills Contents Skill 7.1 Hand Washing 63 Skill 7.2 Hand Sanitizing 64 Skill 7.3 Donning Personal Protective Equipment 64 Skill 7.4 Removing Personal Protective Equipment 65 Skill 7.5 Donning and Removing Gloves 66 Skill 7.6 Donning and Removing a Gown 66 Skill 7.7 Donning and Removing a Mask 66 Skill 7.8 Donning and Removing Protective Eyewear 67 Skill 7.9 Using a Blood Spill Kit 67 Skill 9.1 Assisting a Falling Client 77 Skill 9.2 Transferring a Client With a Mechanical Lift Two Assist 77 Skill 10.1 Tying a Quick-Release Knot 84 Skill 11.1 Abdominal Thrusts 91 Skill 11.2 Assisting an Unconscious Adult With an Obstructed Airway 91 Skill 11.3 Assisting a Fainting Client 91 Skill 11.4 Assisting a Client During and After a Seizure 92 Skill 11.5 Assisting a Client Who Is Hemorrhaging 92 Skill 11.6 Caring for a Client in Shock 93 Skill 11.7 Caring for a Client With Second- or Third-Degree Burns 93 Skill 11.8 Caring for a Client Who Has Been Poisoned 94 Skill 15.1 Mitering Corners 119 Skill 15.2 Making an Unoccupied Bed 119 Skill 15.3 Making an Occupied Bed 120 Skill 16.1 Placing the Client in a Supine Position 132 Skill 16.2 Placing a Client in a Fowler s Position 132 Skill 16.3 Placing the Client in a Prone Position 133 Skill 16.4 Placing a Client in a Side-Lying (Lateral) Position 133 Skill 16.5 Placing a Client in Sims s Position 134 Skill 16.6 Moving the Client Up in Bed Two Assist 134 Skill 16.7 Assisting the Client to Dangle One Assist 135 Skill 16.8 Assisting the Client to Dangle Two Assist 135 Skill 16.9 Applying a Gait Belt 136 Skill Moving the Client From the Bed to the Wheelchair One Assist 136 Skill Moving the Client from the Bed to the Wheelchair Two Assist 137 Skill Transferring a Client with a Mechanical Sit-to-Stand Machine One Assist 138

16 xvi Skills Contents Skill Transferring a Client With a Mechanical Lift Two Assist 139 Skill 17.1 Ambulating a Client with One Assist and a Gait Belt 150 Skill 17.2 Ambulating a Client With Two Assist and a Gait Belt 151 Skill 18.1 Taking an Oral Temperature With a Digital Thermometer 160 Skill 18.2 Taking an Axillary Temperature With a Digital Thermometer 161 Skill 18.3 Taking a Tympanic Temperature 162 Skill 18.4 Taking a Temperature With a Professional Model Temporal Artery Scanner 162 Skill 18.5 Counting Heart Rate Radial Pulse 163 Skill 18.6 Counting Respirations 163 Skill 18.7 Taking Blood Pressure With a Stethoscope and a Sphygmomanometer 164 Skill 18.8 Measuring Height 165 Skill 18.9 Measuring Weight on an Upright Scale 166 Skill 19.1 Assisting With Female Perineal Care 176 Skill 19.2 Assisting With Male Perineal Care 178 Skill 19.3 Assisting With a Partial Bed Bath 179 Skill 19.4 Assisting With a Complete Bed Bath 181 Skill 19.5 Assisting With a Shower 183 Skill 19.6 Assisting With a Tub Bath 186 Skill 20.1 Dressing the Client With an Affected or Weak Side 194 Skill 20.2 Applying Anti-Embolism Stockings 196 Skill 20.3 Shaving a Face With an Electric Razor 197 Skill 20.4 Providing Oral Care for a Client with Natural Teeth 197 Skill 20.5 Oral Care for an Unconscious Client 199 Skill 20.6 Oral Care for a Client With Dentures 199 Skill 20.7 Fingernail and Hand Care 201 Skill 20.8 Providing Foot Care 202 Skill 21.1 Feeding a Dependent Client 212 Skill 22.1 Care of an Indwelling Catheter 220 Skill 22.2 Measuring Urine Output From a Collection Bag 221 Skill 22.3 Changing an Incontinence Garment 222 Skill 22.4 Emptying an Ostomy Bag 223 Skill 22.5 Assisting the Client With a Bedpan 224 Skill 22.6 Obtaining a Clean Catch Urine Sample 225 Skill 22.7 Obtaining a Stool Sample 226 Skill 24.1 Post-Mortem Care 240

17 A Note to Nursing Assistant Instructors Adult learners have very specific traits and characteristics that need to be acknowledged by the instructor to optimize the learning process. In this textbook you will see various strategies to engage students and to improve upon the learning process. To address auditory learner needs, your students will rely on your skillful classroom teaching techniques. For the visual learner you will note up-to-date photos and text boxes that incorporate major themes of the content in this textbook. For the kinesthetic learner, I incorporate Get Up and Think exercises throughout the chapters rather than traditional Stop and Think exercise boxes. These boxes encourage dyad learning and creative thinking skills. The exercises ask readers to stand up and walk through different areas of their classroom or school grounds to brainstorm new and creative problem-solving thought processes in relation to the content. The kinesthetic learner will benefit from partnered skill-based activities within the classroom as well. Adult learners need to be challenged with materials yet also need to know why this content is applicable. Throughout the chapters I integrate reflection exercises to stimulate thinking and real-time application of content, and case studies to apply information learned to real-world scenarios to make the information applicable to that unique student. I incorporate prioritization exercises to help the student manage the large amount of information that is needed to function in the nursing assistant role. This book details the care for not just the older adult population, but also populations that are gender specific, age based, and setting specific to address the changing face of our healthcare delivery. Consumers of healthcare want to look at alternative healthcare options, they want their care to be individualized to meet their specific demands and needs, and they want quality in the product they are purchasing. This book addresses these themes in relation to the changing caregiving standards of the nursing assistant. Instructor materials including exercises and case studies are available at solutions.com/cna. xvii

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19 A Note to the Students You will be responsible for many things when working as a nursing assistant. One important aspect of caregiving is promoting independence. I describe in this book how to complete skills for someone who is completely dependent upon you for all care. You must keep in mind, though, that at every step of the way you must factor your client s abilities into their care. This will keep them functioning at their highest capacity for the longest period of time. It will also give them more choices, which in turn will make them feel more in control of their situation and will help maintain their sense of identity and self-esteem. This will take more time, but it is worth it. Stop and think how you would like to be treated in any of these situations. That is how you should be giving care. For each of these skills, common starting-up and finishing-up steps need to be done. I will outline these steps here and just cite starting-up and finishing-up steps within the chapters and each skill page. Starting-Up Steps 1. Knock before entering, identify the client, and introduce yourself. 2. Complete hand hygiene. 3. Provide for privacy. 4. Explain to the client what you will be doing before you start doing it. 5. Assemble your supplies. 6. Ensure that the bed is at a good working height and is locked; or, if the bed is not in use, that you are in an ergonomically correct position to assist the client. Finishing-Up Steps 1. Ensure that all of the client s needs have been met and that the client is positioned as desired. 2. See to safety. Replace any alarms or positioning devices as indicated on the care plan or individual service plan. The bed should be in the low position and locked. 3. Place the call light within easy reach. 4. Clean and replace equipment and return supplies to the designated place in the client s room or facility storage area. 5. Leave the room clean and in order. The bed should be made. Remove trash and dirty linens from the room. 6. Complete hand hygiene. 7. Report and document as required by your facility. xix

20 Visual Walkthrough Whether you re a student or instructor, the walkthrough will guide you through CNA: Nursing Assistant Certification, Accelerated Edition. The purpose of this guide is to serve as a visual reference for the features that you ll encounter throughout the text. Understanding the purpose of each feature and how it works will not only guide your study but also prepare you for the state certification exam. We hope you find this walkthrough useful as you start your journey to becoming a CNA. A note from the author This nursing assistant textbook holistically addresses clients as opposed to teaching narrow caregiving practices that focus on a specific disease process. I collaborated with others around the nation to ensure that the content of this textbook not only is up to date but also offers the most innovative and compassionate caregiving techniques so that we can empower a new generation of nursing assistants to provide exceptional care. Carrie Skills TOC gives quick page references for each critical skill a student will need to learn to become a CNA. Skills Contents Skill 10.1 Donning Personal Protective Equipment 156 Skill 10.2 Removing Personal Protective Equipment 156 Skill 10.3 Hand Washing 158 Skill 10.4 Hand Sanitizing 158 Skill 10.5 Donning and Removing Gloves 159 Skill 10.6 Donning and Removing a Gown 159 Skill 10.7 Donning and Removing a Mask 160 Skill 10.8 Donning and Removing Protective Eyewear 160 Skill 10.9 Using a Blood Spill Kit 160 Skill Double-Bagging Technique for Infectious Waste 161 Skill 12.1 Assisting a Falling Client 189 Skill 13.1 Tying a Quick-Release Knot 199 Skill 14.1 Abdominal Thrusts 212 Skill 14.2 Assisting an Unconscious Adult With an Obstructed Airway 212 Skill 14.3 Assisting a Fainting Client 212 Skill 14.4 Assisting a Client During and After a Seizure 213 Skill 14.5 Assisting a Client Who Is Hemorrhaging 213 Skill 14.6 Caring for a Client in Shock 214 Skill 14.7 Caring for a Client With Second- or Third-Degree Burns 214 Skill 14.8 Caring for a Client Who Has Been Poisoned 215 Skill 15.1 Assisting the Client With Relaxation Breathing 228 Skill 15.2 Assisting the Client With Visualization 228 Skill 19.1 Making an Unoccupied Bed 278 Skill 19.2 Making an Occupied Bed 279 Skill 19.3 Mitering Corners 281 Skill 20.1 Placing the Client in a Supine Position 292 Skill 20.2 Placing a Client in a Fowler s Position 292 Skill 20.3 Placing the Client in a Prone Position 292 Skill 20.4 Placing a Client in a Side-Lying (Lateral) Position 293 Skill 20.5 Placing a Client in Sims s Position 294 Skill 21.1 Moving the Client Up in Bed Two Assist 309 Skill 21.2 Moving a Client in Bed With a Shearing Prevention Device 310 Skill 21.3 Log Rolling a Client 310 Skill 21.4 Moving the Client From Bed to Stretcher 311 Skill 21.5 Assisting the Client to Dangle One Assist 312 Skill 21.6 Assisting the Client to Dangle Two Assist 312 xx

21 15 Bedmaking LEARNING OBJECTIVES At the conclusion of this chapter, the learner will be able to 15.1 Identify the linens necessary to make a bed and the order in which clean linens are collected Identify interventions used while bedmaking to prevent the spread of infection Describe body mechanic techniques of bedmaking to reduce self-injury Describe the difference between an open and a closed bed Identify when to change an occupied bed versus an unoccupied bed Linens No one wants to sleep in a bed that is soiled, wet, or wrinkled. That would be uncomfortable. It is the nursing assistant s responsibility to keep bed linens clean, dry, and wrinkle free. Linens are the bedding that covers the mattress. Clean linens promote healthy skin, control germs from spreading, and promote comfort. Clean and dry linens also help keep the facility smelling clean. To make a clean and comfortable bed, a fitted sheet, draw sheet (sometimes called a lift sheet), a top sheet (sometimes called a flat sheet), pillowcases, a blanket, and a bedspread are needed. The lift sheet is used to move the client up in the bed or over to the side of the bed when positioning her (Figure 15.1). If the client is incontinent, one or two reusable incontinence pads are also used. A reusable incontinence pad is a pad that is placed under the incontinent client to protect bed linens from becoming soiled. If the client uses an alternating-pressure mattress topper or alternating-pressure bed, a disposable incontinence pad should be used instead of the reusable pad. Reusable pads are too thick and hinder the alternating-pressure properties. A mattress pad is used only in a homecare situation or in an assisted-living facility in which the clients bring their beds from Learning Objectives provide an overview of key concepts, serve as a study guide, and are essential tools for passing the state certification exam.

22 Inside the Book 116 Chapter 15 Bedmaking Key Terms are highlighted in the text and defined in the glossary to offer concise and accessible introductions to important topics from each chapter. SKILL 15.1 Learn how to perform this skill on page 119 When making the bed, do not flick or shake out the linens. This action can stir up germs in the room and contaminate clean surfaces. Simply place the linen on the bed and unfold it rather than shaking it. This holds true for putting on a clean pillowcase. Do not shake the pillow into the case. Turn the pillowcase inside out, grab the corners of the pillow with the case corners, and bring the case down over the pillow. Sometimes pillow protectors are used. They are zippered covers that encase the pillow to prevent it from becoming soiled or wet. If a pillow without a protector on it becomes wet and soiled, it should be thrown away because there is no way to properly clean it. Place the pillow on the bed with the opening of the pillowcase facing away from the door. This position will protect the pillow itself from germs. The floor is always considered dirty. If linens fall on the floor, you must place them in the soiled linen bag and replace them with clean linens. If you collected linens that are not needed, those too must go into the soiled linen bag. Linens from one client s room must never be taken into another client s room. That would spread germs from one client to another. You must put on a pair of gloves before you remove linens from the bed. The linens on the bed are considered dirty. Have your soiled linen bag close by as you change the bed. A good place to put this bag is on a chair next to the bed or on the foot of the bed. The linen bag cannot be placed on the floor. That would be a tripping hazard Body Mechanics Always bend with your knees, not at the waist. Work on one side of the bed, and then move to the other side to prevent excessive bending and stretching. Keep items you are using close by. Lower the side rails while you work. If you are changing an occupied bed, keep the side rail up on the side opposite from that where you are working. Always lower the side rails back down after you have finished changing the bed, unless the client s care plan directs you to leave them up. When you are done changing the linens, return the bed to its original position. Place the bed in the low position, put back any alarms or safety devices, and lock the brakes The Closed Versus Open Bed A closed bed is made with all the linens in place over the mattress. The top sheet, blanket, and bedspread are drawn up to the head of the bed (Figure 15.3). A closed bed is made prior to client admission. In a long-term care facility, the bed is closed after the client gets up and out of bed for the day. Maintaining a closed bed keeps the mattress and inner bed linens clean. Mitered corners at the foot of the bed ensure a wrinkle-free, tidy bed (Skill 15.1). Upon admission of a new client, or when the client wants to go to bed, the bed is opened. An open bed invites the client to lie down. Upon admission, or when a client is ready to go to bed, the linens are fanfolded down to the foot of the bed. This placement ensures that the linens do not become Margins include key terms, skills, and ample space for note taking to promote comprehension and retention of learning objectives. Rooms in healthcare facilities are often short on space. Usually, beds are placed against one wall to accommodate space for other furniture and medical equipment. This position can make the task of changing bed linens difficult. Release the brakes on the bed and move it away from the wall and other furniture. This way, you will not have to stretch, twist, or lean over to make the bed. Once the bed is moved to where you can change it easily, raise the bed to a good working height. A good working height is about waist high. This height eliminates the need for bending and stooping. Repeated bending and stooping can hurt your back. Figure 15.3 A closed bed is made with the top sheet, blanket, and bedspread drawn up to the head of the bed. Corners are mitered. Hongqi Zhang/Hemera/Thinkstock Imagery/graphics are incorporated throughout the text to illustrate the skills that are being taught.

23 15.5 How to Make the Unoccupied and Occupied Bed 117 bunched and wrinkled when the client lies down in bed. When a client is transferred from a stretcher to a bed, the linens are fanfolded to one side of the bed, rather than to the foot of the bed. The stretcher must be at the same height as the bed, and wheels on both stretcher and bed are locked. Cover the client with the linens. Tuck the linens back under the foot of the bed and miter the corners. Pull upward on the linens over the client s feet to make a toe pleat. This pleat relieves the pressure from the tucked linens on top of the client s toes, reducing the risk of a pressure injury How to Make the Unoccupied and Occupied Bed Unoccupied Bed An unoccupied bed is changed when the client can get out of the bed. First, assist the client out of bed. She may sit in a chair in the room or in a wheelchair while you perform this task. The bed must be changed completely on every bath day, whenever the linens are heavily soiled or wrinkled, and upon client discharge. Skill 15.2 outlines the procedure for changing an unoccupied bed. Occupied Bed An occupied bed change becomes necessary when a client is unable to get out of bed or when it is uncomfortable for him to do so. This situation arises mainly when clients are bed bound for example, when the client is dying. It also occurs more frequently on the night shift. If bedding becomes soiled when the client is sleeping, it is often more comfortable for the client to stay in bed while the linens are changed. Skill 15.3 details the procedure necessary for changing a bed that is occupied. Soiled linens are removed and replaced with clean linens on one side of the bed first. The client is then asked to roll over, and the process is repeated on the opposite side of the bed. This method limits the amount of walking back and forth that you must do and limits the times the client has to roll back and forth. The client should never lie on a bare mattress during this process. Be careful not to contaminate the clean linens with those that are soiled. Soiled linens should be rolled inward to contain the contamination. Clean linens should be tucked under the rolled soiled linens to prevent contamination. Wrinkles are smoothed in the clean linens before the client rolls back (Figure 15.4). Ensure client safety while changing an occupied bed. Position the bed at a good working height for you, which is high off the floor. When the client rolls over, always have the side rail up in the direction she is rolling. This side rail can help with positioning. The client can grasp the rail, if able, and assist in rolling herself over to the side. The side rail is also used for safety. Raised, it prevents the client from rolling out of bed. The side rail used in this way is not a restraint; it is a temporary positioning aid. Once work is completed on one side of the bed, raise that rail, walk over to the opposite side of the bed and lower that rail back down. The rail should be up on the side where you are not working, and lowered on the side where you are. Remember to lower all side rails at the completion of the task, unless otherwise indicated on the client s care plan or ISP. Some facilities have completely removed all side rails from the beds. If this is the case, you must always roll the client toward you, rather than away. This way, your Figure 15.4 When making an occupied bed, you remove and replace the soiled linens with a clean set on one side of the bed first. You ask the client to roll over, and repeat the process on the opposite side of the bed. August Learning Solutions SKILL 15.2 Learn how to perform this skill on page 119 SKILL 15.3 Learn how to perform this skill on page 120 TEST YOURSELF See workbook page 109 to quiz yourself on the topics covered in this chapter. Skills icons are included throughout the text and end-ofchapter materials for easy reference. Test icons serve as a way to quiz students knowledge and understanding of chapter topics.

24 118 Chapter 15 Bedmaking Skills correspond with icons throughout the chapter for easy reference. These skills are critical for learning how to become a CNA as well as preparing for the certified nursing assistant exam. Skills Starting-Up Steps 1. Knock before entering, identify the client, and introduce yourself. 2. Complete hand hygiene. 3. Provide for privacy. 4. Explain to the client what you will be doing before you start doing it. 5. Assemble your supplies. 6. Ensure that the bed is at a good working height and is locked; or, if the bed is not in use, you are in an ergonomically correct position to assist the client. Finishing-Up Steps 1. Ensure that all of the client s needs have been met and that the client is positioned as desired. 2. See to safety. Replace any alarms or positioning devices, as indicated on the care plan or individual service plan. The bed is in the low position and is locked. 3. Place the call light within easy reach. 4. Clean and replace equipment, and return supplies to the designated place in the client s room or facility storage area. 5. Leave the room clean and in order. Make the bed. Remove trash and dirty linens from the room. 6. Complete hand hygiene. 7. Report and document, as required by your facility. Skill 15.1 Mitering Corners Supplies needed: Fitted sheet Flat sheet 1. Unfold the clean fitted sheet on the mattress. 2. Tuck in the fitted sheet on one side of the mattress, starting at the top of the bed and moving down to the foot of the bed. Move to the other side of the bed and repeat. 3. Unfold the top sheet on the bed with the seams facing upward and the wide hem at the head of the bed. a. Center the middle vertical crease vertically in the center of the mattress. b. The sheet should hang over both sides of the bed evenly. c. The top sheet should be even with the top of the mattress. 4. Tuck in the flat sheet completely under the foot of the mattress. 5. Grab the hanging flat sheet on one side approximately 6 inches from the foot of the bed. 6. Lift up the flat sheet and pull it back over the top of the bed, forming a triangle. 7. While holding the triangular fold in place, tuck the hanging remainder of the flat sheet under the mattress. 8. Bring the triangular fold down over the edge of the mattress, to let the rest of the flat sheet hang freely at the side of the mattress. 9. Repeat Steps 6 9 for the remaining side of the bed.

25 Acknowledgements Writing a textbook is a long and arduous yet rewarding journey. Without the support and understanding of many surrounding me, this monumental task could not have been achieved. First I would like to thank my loving husband and children for always understanding and accepting the immense time commitment required to write this book. I spent many evenings, Fridays, and weekends at a computer screen. Throughout this project, they not only supported me but also cheered me on all the way. To my son, who contributed his creative genius to the text. To my daughter, whose unconditional understanding of missed swim meets and park adventures supported this endeavor. It is with immeasurable gratitude that I give my love and many thanks for their understanding and patience. To my parents and family: you supported me, encouraged me, and believed in me throughout this entire process. It is because of you that I was instilled with the values of hard work and persistence. To Ken Kasee, who had the vision for this project and who believed in me enough to entrust me with this venture. To Jane Velker, who took my words, sentiments, and sometimes even my thoughts and molded them into this beautiful finished product. To August Learning Solutions, who brought this text to life. To the CCHI classes, whose open, honest, eagle eye and noteworthy contributions are immeasurable. Many thanks to the Posey Company, the makers of Bathing Without a Battle; the Wy East Medical Corporation; and the Institute for Safe Medication Practices (ISMP) for allowing their graphics, content, and ideas to be woven into the text. Thank you to the many reviewers who gave feedback throughout this project, and to Cynthia Hintze, who was such an invaluable contributor. Finally I would like to thank those at Mid-State Technical College for their continued support in this venture, including administration and all the nursing assistant faculty who have given me inspiration, support, encouragement, ideas, and feedback throughout this endeavor; and Lisa Whitley and Candace Barth, who stepped outside of their comfort zone to author the accompanying workbook. xxv

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27 About the Author Carrie L. Engelbright is a registered nurse, certified nurse educator, thought leader, and author. She began her career as a nursing assistant and then as a registered nurse in long-term care. She then moved on to work in public health, focusing on children with special healthcare needs, childhood lead poisoning prevention, and prenatal health. In 2006, Carrie started her teaching career as adjunct faculty in the Nursing and Nursing Assistant Programs at Mid-State Technical College (MSTC). In 2007, she became the Lead Nursing Assistant Instructor and Program Director at MSTC and is now the lead faculty in the Gerontology Program and the Health and Wellness Promotion Program. In 2015, Carrie authored Essentials of Certified Nursing Assisting textbook and workbook. She also completed a Doctorate of Nursing Practice in Systems Leadership with a focus on rural food desert conditions from Walden University. xxvii

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29 1 Healthcare Yesterday and Today 1.1 A Brief History of Healthcare in the United States Florence Nightingale is known as the founder of modern nursing (Figure 1.1). After working in a field hospital during the Crimean War, which took place in the 1850s, Nightingale used statistics to show the connection between sanitary conditions and the spread of infectious disease. She helped establish the scientific basis of nursing. She portrayed the art of nursing through her compassionate care of the sick, injured, and poor. As a result, she brought the basics of care to the nursing profession and to public health. Nightingale felt that the nurse s role was to help the individual make the fullest recovery possible. When giving care, she considered not only the person but also the environment. She felt that a healthy environment was important to help the patient regain his health. It is through her work that we have the basics of your training as a nursing assistant! Aspects of the environment that Nightingale regarded as necessary for nursing practice include bedmaking; cleanliness of the patient; activities for physical, intellectual, Learning Objectives At the conclusion of this chapter, the learner will be able to 1.1 Describe the history of healthcare in the United States. 1.2 Paraphrase the beginnings of modern healthcare. 1.3 Describe the causes of the rising cost of healthcare. 1.4 Identify funding sources for healthcare services today. 1.5 Identify who is the consumer in healthcare. 1.6 Describe the trend of client-driven healthcare services (consumerism). 1.7 Generalize why home health services are an important part of healthcare today. 1.8 Describe why the nursing assistant needs to understand healthcare trends. 1

30 2 Chapter 1 Healthcare Yesterday and Today for the services in some way, family members within the home cared for the sick. There were no hospitals during this time either only almshouses. Almshouses were places for the poor, the elderly, the homeless, and the insane to stay. Most often these establishments were operated by donations from the community or religious orders. Illness would easily spread through these almshouses. If a medical school was located in the area, the students worked at the almshouses as part of their training. This training mainly consisted of an apprenticeship with a doctor. 1.2 The Beginning of Modern Healthcare Figure 1.1 Florence Nightingale, the founder of modern nursing. photos.com/photos.com/thinkstock and mental well-being; proper food and water intake; documentation; and cleanliness of the patient s room. These are all the things nursing assistants are responsible for today. By taking care of these needs, you can help the client make the fullest recovery possible. You can also make sure the quality of life for your client is the best it can be. Nursing assistants play a large role in caring for the client! In the early years of the United States, there were no real medical schools as we think of them today. There was no standard training. There were no licensing boards or regulating bodies overseeing medical schools or doctors. There were no tests to pass. Although there were some medical schools, would-be physicians didn t need to attend school of any kind! A doctor, as he called himself, was often the local tailor, clergyman, barman, or barber. Early healthcare practices mostly involved the use of herbal and home remedies. The individual or his family paid for a doctor s services. If the patient could not pay The concept of public health began to take hold in the mid-1800s. The goal of public health is to educate groups of people about healthy ways to live and ways to prevent illness before it starts. Before the start of this idea of public health, it was common for raw sewage to flow in city streets. That raw sewage would then pollute drinking water. An example of public health is to teach communities the importance of a working sewage system and a clean water supply to prevent illness. Public health interventions helped reduce the rate of infectious illness. An infectious illness occurs when a germ enters the body and causes sickness. Before public health, people were more likely to suffer and die from infectious illnesses, such as smallpox or cholera. As the number of people in America dying from infectious illness decreased, people began to live long enough to develop chronic illnesses. Chronic illness is a condition or disease that people live with for a long period of time. Examples of chronic illness include heart disease and arthritis. The trend shifted in the United States from people dying mostly of infectious illness to people dying mostly of chronic illness. The Modernization of Medicine In the early 1900s, scientists began identifying causes of illness, how to prevent illness, and how to better treat patients if they did fall ill. A scientific basis for the practice of medicine

31 1.3 The Cost of Healthcare 3 was therefore established. Medical schools, as we now know them, began to emerge. Medical training was much more demanding. It took a longer time to complete and involved scientific teaching rather than just an apprenticeship. In the late 1900s, medicine became very organized. Doctors now have extensive training. They are also licensed and regulated strictly. There is an increase in specialty healthcare providers. Doctors are furthering their training in areas such as specialty surgery and cancer care. Because of this specialty training, jobs in physical therapy and occupational therapy expanded, and specialty nursing degrees evolved. 1.3 The Cost of Healthcare With the increased complexity of healthcare, the costs increased also. Hospitals are now very organized entities. Some even specialize in treating certain groups of people or specific diseases or injuries. For example, hospitals can specialize in treatment for burn victims, people with cancer, pediatrics, and many more areas (Figure 1.2). Healthcare is now a large part of our economy. It is very costly to access. People often cannot pay for treatment outright. They need help to pay for services. Health insurance became a standard in American life following the Second World War. The model for healthcare insurance was based on the workers Figure 1.2 Many hospitals now specialize in a certain type of care based on the population served, or the disease or injury the patient has. VILevi/iStock/Thinkstock compensation plans. These plans were offered by large manufacturing companies. Originally, workers compensation plans would pay the employee s wages if an injury occurred at work and the employee was unable to come to work for a certain amount of time. Over the years, this type of plan evolved into paying not only for the lost wages but also for the healthcare costs. This system grew into our modern-day group insurance plans. Group insurance provided by the employer became a standard benefit for working people. There was a problem, though. Individuals who did not or could not work did not have access to a group insurance plan. Because they did not work, most could not pay the outof-pocket expenses for healthcare. In 1965, Congress created the Medicare and Medicaid programs. The Medicare plan gives access to health insurance to older adults and to some younger people with certain disabilities. Medicare is funded through federal taxes. The Medicaid plan gives access to health insurance to eligible individuals and families primarily the disabled and people with low incomes. The money for Medicaid comes from both federal and state taxes. Until the 1980s, these methods of providing and paying for healthcare worked well. However, several factors started to increase the costs of healthcare. One reason was the growing use of technology and purchasing those technologies for practice. Another was that paying for specialty services became more frequent. Also, an older population with more chronic illnesses was growing. Finally, research dollars needed to create new technologies, treatments, and drugs made it more expensive. Because of these rising costs, managed care organizations (MCOs) became the insurance providers of choice to better control healthcare costs. MCOs changed the way doctors and other healthcare workers were paid for their services. These large organizations placed limits on how much money healthcare agencies and providers could charge for each service. They also dictated the amount and types of services healthcare consumers could access. There were also financial reasons for providers to treat and discharge patients from hospitals quickly. The payment system initiated by MCOs is very important to understand. It leads us to where we are today in our healthcare system.

32 4 Chapter 1 Healthcare Yesterday and Today This is why we see a great increase in the number of outpatient versus inpatient surgeries. It is also the reason that hospital stays are much shorter than they were in the past. And it is why healthcare consumers have limited choices in where they access healthcare and from which providers they can receive services. In some situations, they are denied eligibility for certain types of care. 1.4 Healthcare Today Today, the rate of healthcare costs is growing faster than that of inflation. It is becoming very expensive for employers to offer insurance as an employee benefit. Healthcare plan premiums may cost too much for a family or an individual to afford. A healthcare premium is the cost that the individual must pay every month toward her healthcare plan. If the individual is employed, the amount of the premium is usually taken out of her paycheck. In addition to the insurance premium that is paid every month, individuals have other insurance-related expenses. To try to keep down the cost of health insurance, people pay more for services used. Most insurance plans have co-pays. A co-pay is a specific dollar amount or percentage that the individual must pay for each healthcare service received. Deductibles are now widely used to control costs too. A deductible is a set amount of money that the individual must pay for healthcare services before the insurance company will start to pay for any services used. This amount is renewed at the start of every year. Often the deductible will be $1,000 or $2,500 or even $5,000. Over the years, the number and types of people covered by national healthcare plans have increased. National healthcare plans now cover military veterans and their families. In some states, families just above the poverty level are now eligible for Medicaid. Services to those on Medicare have also increased. The most popular of these services is the addition of the Medicare prescription drug plan in Some people may not have health insurance. Therefore, everyone pays more healthcare costs. If a person does not have insurance and needs an emergency surgery, most often all or part of the cost of that surgery may go unpaid. That means the price of future surgeries goes up for everyone. This is how the hospital can recoup unpaid costs. 1.5 Who Is Your Client? You can choose from many different settings when working in healthcare. Therefore, you will care for many different types of clients. Often, you will work with a client s family members also. A client is a consumer of healthcare who utilizes the healthcare system. Due to cost-containment strategies in healthcare, nursing assistants are widely employed today. There are more opportunities in hospitals, community settings, and specialty facilities than there were in the past. In your nursing assistant coursework, you will be taught the basics of care for most clients. Once you are hired in a specific setting, you will have more on-the-job training to familiarize you with the specific population you will be caring for. You may prefer to work with older adults, children, infants, or postsurgical clients (Figure 1.3). Wherever you decide to work, you will meet many different people. Each of your contacts has the potential for helping or hurting the facility you work for. 1.6 Consumerism in America Clients also have many choices. In America, healthcare is driven by consumerism. Consumerism is the belief that consumers drive choice and increase the number of choices that are offered to people. You can see this happening everywhere you look. Doctors and hospitals advertise because they want your business. Hospital rooms have pleasant décor. Hospital ads boast new technologies. The environment

33 1.7 Home Healthcare Versus Facility Care 5 is not just available for healthcare professionals anymore. We live in an age of information. Yet, because consumers may have more information, this does not necessarily mean that they have more knowledge. You may have to help clients and their families understand the healthcare system and possibly even dispel incorrect information they may have come across. Clients play an active role in their care. We need to complement that care rather than be indifferent deliverers of care. This means that, as nursing assistants, we need to explain more to our clients. We need to listen more. We need to allow more time for conversation. We need to allow the consumers the right to choose what is best for themselves and their situation. 1.7 Home Healthcare Versus Facility Care Figure 1.3 A nursing assistant works with a pediatric client. michaeljung/istock/thinkstock of healthcare agencies is designed to appeal to the healthcare consumer. Customer service is a key part of your job to ensure that consumers keep coming back. A consumer of healthcare is anyone who accesses healthcare or interacts with a healthcare agency or provider. A consumer of healthcare is your client. We are consumers of healthcare. Clients choose the services provided. They choose when, where, and if they will access those services. With the advent of managed care organizations (MCOs) in the 1980s, some choices have become limited. Usually, however, consumers have a choice of several local providers. Competition occurs when local clinics and hospitals vie for business. This is the root of consumerism in today s healthcare system. Clients now seek healthcare with knowledge about their needs or problems. With the growth of the Internet, healthcare information Historically, sick people were cared for at home, either by a doctor or by their families. It wasn t until the advent of the modern hospital that sick people were placed in one centralized facility. Due to the rising costs of healthcare and the advent of MCOs in the late 1980s, the average hospital stay has decreased. There is also an increase in outpatient, or day, surgeries. Outpatient surgery is a surgical procedure that does not require an overnight stay. It is performed on the same day that the client is admitted and discharged from the surgical center. Outpatient surgery is also called ambulatory, or same-day, surgery. This type of surgery helps control costs for the insurance company and for the client. Long-term care facilities, or nursing homes, offer the same kinds of services that a hospital offers, but for people whose health is more stable. Nursing homes do not cost as much as hospitals. Therefore, clients generally spend only a few nights in the hospital and are then transferred to a long-term care facility for ongoing treatment.

34 6 Chapter 1 Healthcare Yesterday and Today Test yourself See workbook page 1 to quiz yourself on the topics covered in this chapter. Figure 1.4 Home health agencies offer nursing care; personal care; and physical, speech, and occupation therapies in the client s home. Jupiterimages/Stockbyte/ Thinkstock More recently, assisted-living facilities have emerged as another option to nursing homes. Assisted-living facilities usually cost less than long-term care facilities because they do not offer around-the-clock skilled nursing care. Another way costs have been decreased is through home health services, which are less expensive than the inpatient services. Home health agencies offer nursing care; personal care; and physical, speech, and occupation therapies in the client s home (Figure 1.4). This service is reimbursed through Medicare and group insurance plans. It is an option for older adults who cannot travel to a clinic or a hospital for ongoing care. The cost of home healthcare is cheaper because it shifts the daily caregiving away from hospital or nursing home staff to the client or to the client s family members. 1.8 Why the Nursing Assistant Needs to Know These Trends Clients seeking healthcare today are more involved in their care. Generally, they expect more out of the services they receive than clients did in the past. Clients are also more aware of healthcare resources. They also have a greater opportunity to educate themselves about diseases and treatment options. When caring for clients who actively participate in their own care, you must be prepared to adapt the care you give. You must do this even when it means that you must change your routine. You must be respectful of the choices that your clients make. Ensure that you communicate with your supervisor so that she can make updates to the plan of care or intervene when needed. You will need to communicate with and involve the family members if the client requests you to do so. You will need strong customer service skills. Remember, without the client, you would not be employed. As a nursing assistant, you will play a role in controlling costs in healthcare today. You will have many choices with every single client contact that could potentially save healthcare dollars. Use only as many supplies as needed. Try hard not to contaminate items when working. This way, you help prevent new illnesses in other clients and yourself. You also limit how many supplies are thrown away. When bringing supplies into a client s room, label them and put them away in the correct storage area. This way, you prevent the next caregiver from charging the client for a duplicate supply.