CNA Nursing Assistant Certification Dr. Carrie L. Engelbright RN, CNE, CWP
CNA: Nursing Assistant Certification 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. www.augustlearningsolutions.com 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: 978-1-941626-30-6 ISBN-10: 1-941626-30-0 Printed in the United States of America 21 20 19 18 17 1 2 3 4 5 6 7 8 9 10 Textbook activity answers, instructor resources, test bank questions, and workbook answer keys are available to professors via the Instructor Portal at www.augustlearningsolutions.com/cna Cover image credits: Row 1 (left to right): August Learning Solutions, August Learning Solutions, ElenaMedvedeva/iStock/Thinkstock; Row 2 (left to right): August Learning Solutions, ElenaMedvedeva/iStock/Thinkstock; Row 3 (left to right): August Learning Solutions, ElenaMedvedeva/iStock/Thinkstock, ElenaMedvedeva/iStock/Thinkstock; Row 4 (left to right): August Learning Solutions, August Learning Solutions, ElenaMedvedeva/iStock/Thinkstock
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.
Brief Contents 1 The History of Healthcare in the United States 1 2 Responding to Emerging Trends in Healthcare 10 3 Healthcare Settings and Governance 19 4 The Nursing Assistant Role and Scope of Practice 31 5 Communication 41 6 Professionalism in Healthcare 56 7 Legal and Ethical Issues 69 8 Body Structures and Functioning Processes 82 9 Common Diseases and Disorders 107 10 Infection Control Practices 137 11 Body Mechanics and Workplace Safety 163 12 Reducing Client Injury and Falls 178 13 Restraints and Restraint Alternatives 190 14 Basic First Aid Measures 200 15 Stress Reduction and Management Techniques 216 16 Holistic Care of Clients 229 17 Client Room Environment 242 18 Preventing Skin Breakdown 253 19 Bedmaking 267 20 Positioning Clients 282 21 Moving, Transferring, and Transporting Clients 295 22 Ambulation and Exercises for Clients 322 23 Rehabilitation and Restorative Care 338 24 Adaptive Equipment and Supportive Devices 347 25 Vital Signs 356 26 Bathing 380 27 Grooming 411 28 Nutrition 438 29 Elimination 459 30 Specimen Collection 485 31 Oxygen Therapy and Respiratory Interventions 497 32 Care for the Medical and Surgical Client 510 33 Care for the Client With Communication Disorders 521 34 Care for the Client With Cancer 527 35 Care for the Client With a Positive HIV Status 538 36 Care for the Client With Dementia 546 37 End-of-Life Care 563 38 Common Medications 574 Common Medical Abbreviations and Directional Terminology 585 ISMP s List of Error-Prone Abbreviations, Symbols, and Dose Designations 587 Glossary 591 Index 597
Contents A Note to Nursing Assistant Instructors xxiii A Note to the Students xxv Visual Walkthrough xxvi Acknowledgements xxxiii About the Author xxxv Chapter 1 The History of Healthcare in the United States 1 1.1 A Brief History of Healthcare in the United States 2 1.2 The Beginning of Modern Healthcare 3 The Modernization of Medicine 4 1.3 The Cost of Healthcare 5 1.4 Healthcare Today 6 Summary of Learning Objectives 7 Get Up and Think! 8 Reflect on This! 8 Let s Review! 8 Multiple Choice Questions 8 References 9 Chapter 2 Responding to Emerging Trends in Healthcare 10 2.1 Who Is Your Client? 11 2.2 Consumerism in America 11 2.3 Home Healthcare Versus Facility Care 12 2.4 Alternative Therapies 13 2.5 Why the Nursing Assistant Needs to Know These Trends 14 Summary of Learning Objectives 16 Get Up and Think! 16 Reflect on This! 17 Let s Review! 17 Multiple Choice Questions 17 References 18 Chapter 3 Healthcare Settings and Governance 19 3.1 3.4 Work Settings for the Nursing Assistant 20 Acute Care Settings 20 Subacute or Rehabilitation Facility 22 Long-Term Care 22 Assisted-Living Communities 23 Home Healthcare 25 Hospice Services 26 Respite Services 26 3.5 Advanced Training and Opportunities 27 Summary of Learning Objectives 28 Get Up and Think! 28 Reflect on This! 29
Contents vii Let s Review! 29 Multiple Choice Questions 29 Chapter 4 The Nursing Assistant Role and Scope of Practice 31 4.1 Members of the Healthcare Team 32 4.2 Scope of Practice for the Nursing Assistant 33 4.3 Chain of Command 34 4.4 Delegated Tasks 35 4.5 Teaching Versus Reinforcing 37 4.6 Time Management and Organization 37 Summary of Learning Objectives 38 Get Up and Think! 38 Reflect on This! 39 Let s Review! 39 Multiple Choice Questions 39 Reference 40 Chapter 5 Communication 41 Communication in Healthcare 42 5.1 Causes of Medical Errors 42 5.2 Subjective Versus Objective Data 43 5.3 Oral Reporting 45 5.4 Written Documentation and the Nursing Assistant 46 5.5 Verbal Versus Nonverbal Communication 49 Verbal Communication 49 Nonverbal Communication 50 5.6 Therapeutic Communication 51 5.7 Confrontational Situations 52 Summary of Learning Objectives 53 Get Up and Think! 54 Reflect on This! 54 Let s Review! 54 Multiple Choice Questions 55 Reference 55 Chapter 6 Professionalism in Healthcare 56 6.1 Education and Certification 57 Nurse Aide Registry 57 Continuing Education 57 6.2 Job Searching 58 Applications 58 Resume 60 6.3 Interviewing 62 6.4 Accepting and Resigning From a Position 63 6.5 Acting Like a Professional 64 Dependability 64 Promptness 64 Customer Service 64 Flexibility 64 Hygiene 65 Summary of Learning Objectives 66 Get Up and Think! 66 Reflect on This! 67 Let s Review! 67 Multiple Choice Questions 67 Chapter 7 Legal and Ethical Issues 69 7.1 Client Rights 70 Health Insurance Portability and Accountability Act (HIPAA) 70 Informed Consent 71 7.2 Client Responsibilities 72 7.3 Employee Rights 72 7.4 Employee Responsibilities 73 Following the Care Plan 73 Mandatory Reporting 74
viii Contents 7.5 Laws 75 Invasion of Privacy 75 Misappropriation of Funds 76 Negligence 76 Abandonment 76 False Imprisonment 76 Neglect 77 Assault and Battery 77 Abuse 78 7.6 Cultural Awareness 78 Summary of Learning Objectives 79 Get Up and Think! 80 Reflect on This! 80 Let s Review! 80 Multiple Choice Questions 81 Chapter 8 Body Structures and Functioning Processes 82 8.1 Basic Structures 83 8.2 Tissue Types 83 8.3 Body Systems 83 Integumentary System 83 Musculoskeletal System 85 Respiratory System 87 Cardiovascular System 89 Nervous System 91 Sensory Organs 92 Endocrine System 95 Digestive System 98 Urinary System 100 Reproductive System 101 Summary of Learning Objectives 104 Get Up and Think! 105 Reflect on This! 105 Let s Review! 105 Multiple Choice Questions 106 Chapter 9 Common Diseases and Disorders 107 9.1 Understanding Disease Processes 108 9.2 Risk Factors 108 9.3 Emergency Medical Services 108 9.4 Common Diseases and Disorders 109 Integumentary System 109 Musculoskeletal System 111 Respiratory System 113 Cardiovascular System 115 Nervous System 118 Sensory Organs 122 Endocrine System 123 Digestive System 127 Urinary System 130 Reproductive System 133 Summary of Learning Objectives 134 Get Up and Think! 134 Reflect on This! 135 Let s Review! 135 Multiple Choice Questions 135 References 136 Chapter 10 Infection Control Practices 137 Introduction 138 10.1 The Importance of Hand Washing 138 Germ Theory 138 Global Society and Spread of Disease 139 10.2 Chain of Infection 139 10.3 Primary Prevention 140 10.4 Body Defense Mechanisms 141 10.5 Hand Hygiene 143 10.6 Standard Precautions 146 Personal Protective Equipment (PPE) 147 10.7 Specialty Precautions 149 Airborne Precautions 149 Droplet Precautions 149 Contact Precautions 150 Transporting a Client to and From an Isolation Room 150 Blood Spill Kits 151 Double-Bagging Technique 151
Contents ix 10.8 Drug-Resistant Infections 151 MRSA Infection 151 VRE 152 Summary of Learning Objectives 153 Get Up and Think! 154 Reflect on This! 154 Let s Review! 154 Multiple Choice Questions 155 Skills 155 References 161 Chapter 11 Body Mechanics and Workplace Safety 163 Introduction 164 11.1 Exposure to Blood-Borne Pathogens and Chemicals 164 11.2 Latex Allergies 166 11.3 Injury Prevention 167 Ergonomics 167 Moving Clients 168 Lifestyle Choices to Prevent Back Injuries 169 Slips, Trips, and Falls 170 11.4 Fire Safety 170 11.5 Natural Disasters 172 11.6 Bomb Threats 173 11.7 Workplace Violence 173 Summary of Learning Objectives 175 Get Up and Think! 176 Reflect on This! 176 Let s Review! 176 Multiple Choice Questions 177 Chapter 12 Reducing Client Injury and Falls 178 Introduction 179 12.1 Why Falls and Immobility Are Dangerous 179 12.2 Risk Factors for Falling 180 12.3 Care During a Fall 181 12.4 Care After a Fall 181 12.5 How to Prevent Fall Injuries 183 12.6 Alarm Systems 184 12.7 Other Strategies 185 Summary of Learning Objectives 186 Get Up and Think! 187 Reflect on This! 187 Let s Review! 187 Multiple Choice Questions 188 Skills 188 Chapter 13 Restraints and Restraint Alternatives 190 13.1 Restraints 191 13.2 Working With Restraints 191 13.3 Types of Restraints 192 13.4 Risks of Using Restraints 193 13.5 Instances When Restraints Are Allowed 194 13.6 Side Rails 195 13.7 Restraint Alternatives 195 Summary of Learning Objectives 197 Get Up and Think! 197 Reflect on This! 198 Let s Review! 198 Multiple Choice Questions 198 Reference 199 Skill 199 Chapter 14 Basic First Aid Measures 200 Introduction 201 14.1 Airway Obstruction 201 14.2 Cardiac Arrest 202
x Contents 14.3 Syncope 203 14.4 Seizures 204 14.5 Hemorrhage 205 14.6 Shock 206 14.7 Burns 207 14.8 Poisoning 208 Summary of Learning Objectives 209 Get Up and Think! 210 Reflect on This! 210 Let s Review! 210 Multiple Choice Questions 211 Skills 211 Chapter 15 Stress Reduction and Management Techniques 216 15.1 Why Is Healthcare So Stressful? 217 15.2 Ways to Prevent Stress From Taking Charge 218 15.3 Time-Management Techniques to Reduce Stress While at Work 219 15.4 Preventing Stress and Promoting Job Satisfaction 219 Good General Health 220 Yoga 220 Meditation 220 Pet Therapy 221 Humor 222 Journaling 222 Visualization Techniques 222 Breathing Exercises 223 15.5 Client Stressors 223 Pain 223 Illness 224 Sleep Deprivation 224 Anxiety and Depression 224 Grief 225 Coach Your Clients 225 Summary of Learning Objectives 225 Get Up and Think! 226 Reflect on This! 226 Let s Review! 226 Multiple Choice Questions 227 Skills 227 Chapter 16 Holistic Care of Clients 229 16.1 Holistic Care 230 16.2 Maslow s Hierarchy of Needs 230 Human Needs 230 Application of Maslow s Hierarchy to Caregiving 231 16.3 Growth and Development 233 16.4 Quality of Life 234 16.5 Meeting the Needs of Loved Ones 239 Summary of Learning Objectives 239 Get Up and Think! 240 Reflect on This! 240 Let s Review! 241 Multiple Choice Questions 241 Chapter 17 Client Room Environment 242 Introduction 243 17.1 Safety 243 17.2 The Physical Environment 244 17.3 Individual Room Requirements 245 17.4 Noise and Odor Control 246 Noise Control 246 Odor Control and Cleanliness 247 17.5 Transfers and Discharges 248 17.6 Current Trends 249 Summary of Learning Objectives 250 Get Up and Think! 251
Contents xi Reflect on This! 251 Let s Review! 251 Multiple Choice Questions 252 Reference 252 Chapter 18 Preventing Skin Breakdown 253 18.1 The Importance of Healthy Skin 254 18.2 Types of Skin Breakdown 254 Rashes 254 Friction and Shearing 255 Pressure Injuries 255 18.3 Stages of Pressure Injuries 256 18.4 Risk Factors for Developing Pressure Injuries 258 18.5 Interventions for Preventing Skin Breakdown 260 Inspection and Cleanliness 260 Positioning and Turning 260 Pressure-Relieving Devices 261 Positioning Devices 262 Incontinence Care 262 Nutrition and Hydration 263 Reducing the Microclimate 264 Summary of Learning Objectives 264 Get Up and Think! 265 Reflect on This! 265 Let s Review! 265 Multiple Choice Questions 266 Reference 266 Chapter 19 Bedmaking 267 Introduction 268 19.1 Linens 268 19.2 Infection Control 270 19.3 Body Mechanics 271 19.4 The Closed Versus Open Bed 272 19.5 Making the Unoccupied and Occupied Bed 273 Unoccupied Bed 273 Occupied Bed 273 Summary of Learning Objectives 275 Get Up and Think! 276 Reflect on This! 276 Let s Review! 276 Multiple Choice Questions 277 Skills 277 Chapter 20 Positioning Clients 282 Introduction 283 20.1 Frequency of Repositioning Clients 283 20.2 Basic Positions for Clients in Bed 283 20.3 Position to Relieve Pressure Injuries 284 Supine 284 Fowler s Position 285 Prone Position 286 Side-Lying Position 287 Sims s Position 287 Tripod Position 288 20.4 Wheelchair Positioning 288 Summary of Learning Objectives 289 Get Up and Think! 290 Reflect on This! 290 Let s Review! 290 Multiple Choice Questions 291 Skills 291 References 294 Chapter 21 Moving, Transferring, and Transporting Clients 295 Introduction 296 21.1 Moving a Client in Bed 296
xii Contents 21.2 Preventing Friction and Shearing Injuries 297 21.3 Log Rolling a Client 298 21.4 Moving a Client From Bed to Stretcher 298 21.5 Transferring the Client Using a Oneand a Two-Assist Transfer 299 Dangling 299 Footwear 299 Gait Belt 299 One- and Two-Assist Transfers 300 Mechanical Devices Used for Transfers 302 21.6 Transferring a Bariatric Client 304 21.7 Transporting a Client in a Wheelchair 305 Summary of Learning Objectives 306 Get Up and Think! 307 Reflect on This! 307 Let s Review! 308 Multiple Choice Questions 308 Skills 309 References 321 Chapter 22 Ambulation and Exercises for Clients 322 Introduction 323 22.1 Why We Move 323 Self-Esteem 323 Effects on the Digestive System 323 Effects on the Cardiovascular System 323 Effects on the Integumentary System 324 Effects on the Musculoskeletal System 324 22.2 Levels of Assistance 324 22.3 Safety Measures Used During Ambulation 325 22.4 Assistive Devices for Ambulation 327 22.5 Range-of-Motion Exercises 328 22.6 Soothing Sore Muscles 329 Summary of Learning Objectives 331 Get Up and Think! 332 Reflect on This! 332 Let s Review! 332 Multiple Choice Questions 333 Skills 333 Chapter 23 Rehabilitation and Restorative Care 338 23.1 Therapy Services Overview 339 23.2 Rehabilitation Therapy 339 Physical Therapy 339 Occupational Therapy 340 Speech Therapy 341 23.3 Activities Therapy 342 23.4 Restorative Care 343 Summary of Learning Objectives 345 Get Up and Think! 345 Reflect on This! 345 Let s Review! 346 Multiple Choice Questions 346 Chapter 24 Adaptive Equipment and Supportive Devices 347 Introduction 348 24.1 The Client With a Prosthesis 348 Prosthesis Overview 348 Types of Prostheses 349 Care Measures 350 24.2 The Client With an Orthosis 350 Orthosis Overview 350 Care Measures 351 24.3 Adaptive Tools Used at Meal Times 351 24.4 Adaptive Tools for Grooming and Other ADLs 352
Contents xiii Summary of Learning Objectives 354 Get Up and Think! 354 Reflect on This! 354 Let s Review! 355 Multiple Choice Questions 355 Chapter 25 Vital Signs 356 25.1 Introduction 357 25.2 When Vital Signs Are Taken 357 25.3 Infection Control 358 25.4 Accurately Measuring Vital Signs 358 Temperature 358 Pulse 360 Respiration 361 Pulse Oximetry 362 Blood Pressure 363 Height 365 Weight 365 Summary of Learning Objectives 367 Get Up and Think! 368 Reflect on This! 368 Let s Review! 368 Multiple Choice Questions 369 Skills 369 References 379 Chapter 26 Bathing 380 Introduction 381 26.1 Routine Bathing 381 26.2 Distressed Bathing 382 Alternatives to Tub Bathing and Showering 383 Easing Distressed Bathing 383 26.3 Rinseless Systems 383 26.4 Peri-Care 384 26.5 Bed Baths 388 Partial Bed Bath 388 Complete Bed Bath 389 26.6 Shower and Tub Baths 390 Shower 390 Whirlpool Tub Bath 392 Hair Care 392 26.7 Responsibilities on Bath Day 393 Summary of Learning Objectives 394 Get Up and Think! 394 Reflect on This! 395 Let s Review! 395 Multiple Choice Questions 395 Skills 396 Reference 410 Chapter 27 Grooming 411 27.1 Promoting Independence 412 27.2 Dressing 412 Dressing a Client With One-Sided Weakness 413 27.3 Hair 413 27.4 Vision and Hearing 414 Glasses and Contacts 414 Hearing Aids 415 27.5 Shaving 416 27.6 Oral Care 417 27.7 Nail and Foot Care 420 Nail Care 420 Foot Care 421 Summary of Learning Objectives 423 Get Up and Think! 423 Reflect on This! 424 Let s Review! 424 Multiple Choice Questions 424 Skills 425
xiv Contents Chapter 28 Nutrition 438 Introduction 439 28.1 MyPlate 439 28.2 Nutrients Essential for Life 439 Calories 439 Carbohydrates 440 Proteins 441 Fats 441 Vitamins and Minerals 441 28.3 Water and Fluid Needs 443 28.4 Food Groups 444 Grains 444 Fruits 444 Vegetables 445 Dairy Products 445 Protein 446 28.5 Types of Diets 446 Specialty Diets 446 Mechanically Altered Diets and Fluids 449 Thickened Fluids 449 Diets for the Postsurgical Client 450 Mechanical Feeding 451 28.6 Problems With Digestion 451 Nausea, Vomiting, and Diarrhea 451 Malnutrition and Overeating 452 28.7 Feeding Dependent Clients 453 Summary of Learning Objectives 455 Get Up and Think! 456 Reflect on This! 456 Let s Review! 456 Multiple Choice Questions 457 Skill 457 References 458 Chapter 29 Elimination 459 Introduction 460 29.1 Urinary Elimination via Catheter 460 Types of Catheters 460 The Nursing Assistant s Role in Care of the Client With a Catheter 461 Cleaning the Catheter 462 Changing the Collection Bag to a Leg Bag 462 Positioning the Client With a Collection Bag 463 Protecting the Privacy of the Client Who Uses a Catheter 463 Emptying the Collection or Leg Bag 463 Cleaning Collection and Leg Bags 463 29.2 Urostomy 464 29.3 Incontinence 464 Care of the Client Who Is Incontinent 464 Types of Incontinence Products 465 29.4 Dialysis 465 Hemodialysis 466 Peritoneal Dialysis 466 Care of the Client Who Is on Dialysis 466 29.5 Bowel Elimination 467 29.6 Ostomies 468 29.7 Digestive Tract Bleeding 469 29.8 Devices Used for Elimination 470 Summary of Learning Objectives 472 Get Up and Think! 473 Reflect on This! 473 Let s Review! 473 Multiple Choice Questions 474 Skills 474 Chapter 30 Specimen Collection 485 Introduction 486 30.1 Basic Principles of Collection and Transport 486 30.2 Urine Specimens 487 30.3 Straining for Kidney Stones 488 30.4 Fecal Specimens 488 30.5 Occult Blood 489 Summary of Learning Objectives 490
Contents xv Get Up and Think! 490 Reflect on This! 491 Let s Review! 491 Multiple Choice Questions 491 Skills 492 Chapter 31 Oxygen Therapy and Respiratory Interventions 497 31.1 Why Supplemental Oxygen Is Needed 498 31.2 The Nursing Assistant s Role in Oxygen Therapy 498 31.3 Delivery Routes 499 31.4 Delivery Systems 500 31.5 Interventions to Ease Anxiety Related to Breathing Difficulties 502 31.6 Interventions to Aid Lung Function 502 Coughing and Deep Breathing Exercises 502 Incentive Spirometry 502 Summary of Learning Objectives 504 Get Up and Think! 504 Reflect on This! 505 Let s Review! 505 Multiple Choice Questions 505 Skills 506 Chapter 32 Care for the Medical and Surgical Client 510 Introduction 511 32.1 The Medical Client 511 32.2 The Postsurgical Client 511 32.3 Diet for the Postsurgical Client 512 32.4 Activity for the Postsurgical Client 512 32.5 Weight-Bearing Status 513 32.6 Respiratory Complications 514 32.7 Cardiac Complications 514 32.8 Intravenous Therapy 515 Summary of Learning Objectives 516 Get Up and Think! 517 Reflect on This! 517 Let s Review! 517 Multiple Choice Questions 517 Skills 518 Chapter 33 Care for the Client With Communication Disorders 521 Introduction 522 33.1 Hearing-Impaired Clients 522 33.2 Speech-Impaired Clients 523 33.3 Emotional Communication Deficits 524 Summary of Learning Objectives 525 Get Up and Think! 525 Reflect on This! 525 Let s Review! 526 Multiple Choice Questions 526 Chapter 34 Care for the Client With Cancer 527 Introduction 528 34.1 What Is Cancer? 528 34.2 What Causes Cancer? 529 34.3 How Is Cancer Diagnosed? 531 Staging Cancer 531 34.4 Treatment Options 531 34.5 Common Side Effects of Cancer and Treatment 532 34.6 Palliative Care 534
xvi Contents Summary of Learning Objectives 535 Get Up and Think! 535 Reflect on This! 536 Let s Review! 536 Multiple Choice Questions 536 References 537 Chapter 35 Care for the Client With a Positive HIV Status 538 35.1 HIV Versus AIDS 539 35.2 HIV Transmission 539 35.3 Effects of HIV and AIDS 540 35.4 Testing for HIV 541 35.5 Preventing an HIV Infection 541 35.6 Rights of Individuals With HIV/ AIDS 543 Summary of Learning Objectives 543 Get Up and Think! 544 Reflect on This! 544 Let s Review! 544 Multiple Choice Questions 544 References 545 Chapter 36 Care for the Client With Dementia 546 36.1 Types of Dementia 547 36.2 Risk Factors for Dementia 547 36.3 Treatment of Dementia 547 36.4 Diagnosing Dementia 548 Stages of Alzheimer s Dementia 548 Common Signs, Symptoms, and Behaviors Associated With Dementia 549 36.5 Managing the Behaviors Associated With Dementia 551 Meeting Unmet Needs of the Client 551 Therapeutic Interventions 552 Maintaining Function 553 Approach to Specific Behaviors 554 Improving Meal Time 554 Managing Pain 554 Sleep Disturbances 555 Toileting Interventions 556 Bathing Interventions 556 Wandering and Elopement Safety Measures 557 Discouraging Sexual Inappropriateness 558 36.6 Remember the Families 558 36.7 Caregiver Strain 559 Summary of Learning Objectives 560 Get Up and Think! 560 Reflect on This! 561 Let s Review! 561 Multiple Choice Questions 561 References 562 Chapter 37 End-of-Life Care 563 Introduction 564 37.1 Body System Changes 564 Respiratory Changes 564 Cardiovascular Changes 565 Nervous System and Sensory Organ Changes 565 Digestive Changes 565 Urinary Changes 566 37.2 Special Care for the Dying Client 566 37.3 Faith and Religion 567 37.4 Care for the Family 568 37.5 Post-Mortem Care 568 Summary of Learning Objectives 570 Get Up and Think! 570 Reflect on This! 571 Let s Review! 571 Multiple Choice Questions 571 Skill 572
Contents xvii Chapter 38 Common Medications 574 38.1 Scope of Practice 575 38.2 Drug Names 575 38.3 Actions of Medications 576 Allergic Drug Reactions 576 Drug Interactions 576 38.4 Medication Classifications 577 Analgesics 578 Antibiotics 578 Bronchodilators 579 Antihypertensives 579 Anti-Anginals 580 Cardiotonics 580 Anticoagulants 580 Diuretics 581 Antidiabetics 581 Medications to Relieve Constipation 581 Summary of Learning Objectives 583 Get Up and Think! 583 Reflect on This! 583 Let s Review! 584 Multiple Choice Questions 584 Common Medical Abbreviations and Directional Terminology 585 ISMP s List of Error-Prone Abbreviations, Symbols, and Dose Designations 587 Glossary 591 Index 597
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 10.10 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 Skills Contents Skill 21.7 Applying a Gait Belt 313 Skill 21.8 Moving the Client From the Bed to the Wheelchair One Assist 313 Skill 21.9 Moving the Client From the Bed to the Wheelchair Two Assist 314 Skill 21.10 Transferring a Client With a Mechanical Sit-to-Stand Machine One Assist 315 Skill 21.11 Transferring a Client With a Mechanical Lift Two Assist 316 Skill 21.12 Transferring an Ambulatory Bariatric Client 317 Skill 21.13 Transferring a Non-Weight-Bearing Bariatric Client With a Mechanical Lift 319 Skill 21.14 Transporting the Client via Wheelchair 321 Skill 22.1 Ambulating a Client With One Assist and a Gait Belt 334 Skill 22.2 Ambulating a Client With Two Assist and a Gait Belt 335 Skill 22.3 Applying a Warm Compress 336 Skill 22.4 Applying a Cold Pack 336 Skill 25.1 Taking an Oral Temperature With a Digital Thermometer 370 Skill 25.2 Taking an Axillary Temperature With a Digital Thermometer 370 Skill 25.3 Taking a Rectal Temperature With a Digital Thermometer 371 Skill 25.4 Taking a Tympanic Temperature 372 Skill 25.5 Taking a Temperature With a Professional Model Temporal Artery Scanner 372 Skill 25.6 Counting Heart Rate Radial Pulse 373 Skill 25.7 Counting Respirations 374 Skill 25.8 Obtaining a Pulse Oximetry Reading 374 Skill 25.9 Taking Blood Pressure With a Stethoscope and a Sphygmomanometer 375 Skill 25.10 Taking Blood Pressure With an Electronic Wrist Cuff 376 Skill 25.11 Taking Blood Pressure With an Electronic Arm Cuff 376 Skill 25.12 Obtaining and Recording Orthostatic Blood Pressures 377 Skill 25.13 Measuring Height 378 Skill 25.14 Measuring Weight on an Upright Scale 378 Skill 25.15 Measuring Weight on a Wheelchair Scale 379 Skill 26.1 Assisting With Female Perineal Care 397 Skill 26.2 Assisting With Male Perineal Care 398 Skill 26.3 Assisting With a Partial Bed Bath 400 Skill 26.4 Assisting With a Complete Bed Bath 401 Skill 26.5 Assisting With a Shower 403 Skill 26.6 Assisting With a Tub Bath 406 Skill 26.7 Shampooing Hair in Bed 409 Skill 27.1 Dressing the Client With an Affected or Weak Side 425 Skill 27.2 Assisting With Contact Lenses 427 Skill 27.3 Shaving a Face With an Electric Razor 428 Skill 27.4 Shaving a Face With a Disposable Razor 429 Skill 27.5 Shaving Legs With a Disposable Razor 430 Skill 27.6 Shaving Legs and Underarms With an Electric Razor 431 Skill 27.7 Providing Oral Care for a Client With Natural Teeth 431 Skill 27.8 Oral Care for an Unconscious Client 433 Skill 27.9 Oral Care for a Client With Dentures 433 Skill 27.10 Fingernail and Hand Care 435 Skill 27.11 Providing Foot Care 436 Skill 28.1 Feeding a Dependent Client 458 Skill 29.1 Applying a Condom Catheter 475 Skill 29.2 Care of an Indwelling Catheter 475
Skills Contents xxi Skill 29.3 Changing a Collection Bag to a Leg Bag 476 Skill 29.4 Measuring Urine Output From a Collection Bag 477 Skill 29.5 Emptying a Urostomy Bag 478 Skill 29.6 Changing an Incontinence Garment 479 Skill 29.7 Administration of an Over-the-Counter Enema 479 Skill 29.8 Emptying an Ostomy Bag 480 Skill 29.9 Changing an Ostomy Appliance 481 Skill 29.10 Assisting the Client With a Bedpan 483 Skill 29.11 Assisting the Client With a Urinal 484 Skill 30.1 Obtaining a Clean Catch Urine Sample 492 Skill 30.2 Straining Urine for Kidney Stones 493 Skill 30.3 Obtaining a Stool Sample 494 Skill 30.4 Checking for Fecal Occult Blood 495 Skill 31.1 Assisting With the Delivery of Oxygen via Nasal Cannula 506 Skill 31.2 Assisting With the Delivery of Oxygen via Mask 507 Skill 31.3 Use of an Oxygen Concentrator 507 Skill 31.4 Routine Maintenance of an Oxygen Concentrator 508 Skill 31.5 Assisting With Coughing and Deep Breathing 508 Skill 31.6 Assisting With Incentive Spirometry 508 Skill 32.1 Splinting for Coughing and Deep Breathing 518 Skill 32.2 Applying Anti-Embolism Stockings 519 Skill 32.3 Applying Sequential Stockings 519 Skill 32.4 Dressing a Client With an IV 520 Skill 37.1 Post-Mortem Care 572
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. xxiii
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. xxv
Visual Walkthrough Whether you re a student or instructor, the walkthrough will guide you through CNA: Nursing Assistant Certification. 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 10.10 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 xxvi
bedmaking Jupiterimages/BananaStock/Thinkstock szefei/istock/thinkstock Bea is an older woman in the assisted-living facility where you work. Normally, she is active. Today she was complaining of feeling ill. She had a slight fever on the day shift, and refused her supper on the evening shift. You are working the night shift. You answer her call light, which usually she never uses. Upon entering her room, you find her crying. She is upset and tells you that she had an accident in her bed. She needs you to help her clean up, but she feels too weak to get to the bathroom. How can you help Bea? Learning Objectives At the conclusion of this chapter, the learner will be able to: 19.1 Identify the linens necessary to make a bed and the order in which clean linens are collected. 19.2 Identify interventions used while bedmaking to prevent the spread of infection. 19.3 Describe body mechanic techniques of bedmaking to reduce self-injury. 19.4 Describe the difference between an open and a closed bed. 19.5 Identify when to change an occupied bed versus unoccupied bed. Learning Objectives provide an overview of key concepts, serve as a study guide, and are essential tools for passing the state certification exam. 267 Personas are applied to learning objectives throughout each chapter to assist with critical thinking skills as well as provide examples of clients that CNAs might encounter on the job.
Inside the Book 272 Chapter 19 Bedmaking Key terms offer concise and accessible introductions to important topics from each chapter. Focus Questions are designed to motivate students to think about various learning objectives throughout each chapter. Closed bed A bed made with all of the linens in place over the mattress, and the top sheet, blanket, and bedspread drawn up to the head of the bed Open bed A bed made with the top sheet, blanket, and bedspread fanfolded down to the foot of the bed, or to the side of the bed for the surgical client, to allow the client access into bed SKILL 19.3 Learn how to perform this skill on page 281 Figure 19.6 The bed should be pulled away from the wall and raised to a good working height for bedmaking. August Learning Solutions To reduce the risk of injury, release the brakes on the bed and move it away from the wall and other furniture. Raise the bed to a good working height. Always bend at the knees, not at the waist. Do not stretch, twist, and lean down or over to make the bed. Keep items close by your body. Lower the side rails while you work. Reflect on Choices! Keep yourself free from injury and illness while bedmaking by using correct body mechanics and maintaining proper infection-control practices. 19.4 The Closed Versus Open Bed What is the difference between an open and a closed 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 19.7). 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. This keeps the mattress and inner bed linens clean. Mitered corners at the foot of the bed ensure a wrinkle-free, tidy bed (Skill 19.3). Upon admission of a new client, or when the client wants to go to bed, the bed is opened. Reflect on Professionalism! Part of your job as a nursing assistant is to ensure that the client s room is tidy. Always make the bed after getting the client up and ready in the morning. An open bed invites the client to lie down. Upon hospital admission, or when the client is ready to go to bed, the linens are fanfolded down to the foot of the bed. It ensures that the linens do not become 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 Margins include key terms, skills, and ample space for note taking to promote comprehension and retention of learning objectives. Reflect on Settings! Private homes and assisted-living facilities are unlikely to have hospital-type beds, which raise and lower. Body mechanics become especially important then. Always bend at the knees. Do not twist and bend at the same time. If making an occupied bed, ask your client to help you as much as possible when rolling to prevent injuring yourself. Figure 19.7 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 Reflect on scenarios develop critical thinking and encourage students to solve real world situations that they will encounter on the job. Imagery/graphics are incorporated throughout the text to illustrate the skills that are being taught.
19.5 Making the Unoccupied and Occupied Bed 273 height as the bed, and wheels on both stretcher and bed are locked. The client is transferred as reviewed in Skill 21.4. 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 relieves the pressure from the tucked linens on top of the client s toes, reducing the risk of a pressure injury. A closed bed is made with all the linens in place over the mattress, with the top sheet, blanket, and bedspread drawn up to the head of the bed. In an open bed, the linens are fanfolded down to the foot of the bed, or, if the client is transferred from the stretcher to the bed, the linens are fanfolded to one side of the bed. Reflect on Bea! How can you help Bea? How would you change her bed linens so that she remains comfortable? An occupied bed may be changed when the client is unable to get out of bed or when it is uncomfortable for him to do so. Reflect on Privacy! Always pull the privacy curtain when performing an occupied bed change, even if the client s roommate is sleeping. Occupied bed change A change of bed linens when the client is not able to get out of bed or when it is uncomfortable for the client to get out of bed Reflect on Personas correspond with Personas at the beginning of each chapter and help develop the critical thinking skills needed to provide caregiver excellence. 19.5 Making 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 the wheelchair while you perform this task. Changing the bed completely must be done on every bath day, whenever the linens are heavily soiled or wrinkled, and upon client discharge. Skill 19.1 outlines the procedure for changing an unoccupied bed. Occupied Bed What are two reasons the caregiver may have to complete an occupied bed change? An occupied bed change becomes necessary when the 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 19.2 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 rolling back and forth for the client. 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 19.8). Take Time-Management Action! Tip! If It you may suspect be more that time your effective client to has perform suffered a an spinal occupied injury, bed report change, it immediately rather than to the transfer nurse! the Do client not out move of bed the and client make until an the unoccupied nurse has bed. assessed Offer the him choice and given to your permission client. for movement. Why should a side rail be used during an occupied bed change? Why is the side rail not considered a restraint during this procedure? What is the alternative to using the side rail if one is not present? SKILL 19.1 Learn how to perform this skill on page 278 TeST yourself See workbook page 143 to quiz yourself on the topics covered in this chapter. Focus Answers are designed to assist with comprehension by providing solutions to the Focus Questions. Skills icons are included throughout the text and end-ofchapter materials for easy reference. Take Action! provides advice for how best to deal with a variety of scenarios that students will encounter on the job. Test icons serve as a way to quiz students knowledge and understanding of chapter topics.
Chapter Summary 198 Chapter Summary Summaries provide an overview of the learning objectives covered throughout the chapter. Summary of Learning Objectives 13.1 Paraphrase what a restraint is and identify two main categories of restraints as defined by CMS. 13.2 Describe the responsibilities of the nursing assistant when caring for the client who is restrained. 13.3 Identify six common types of restraints. 13.4 Paraphrase the risks associated with restraint use. 13.5 Generalize when restraint use is allowed. 13.6 Contrast the use of a side rail as a restraint and as a positioning device. 13.7 Identify a key primary prevention strategy to reduce the use of restraints. A restraint is anything that prevents the client from freely moving about her environment. A restraint can be either chemical or physical. Check on the client every 15 minutes. When checking the client, look at the restraint itself and the extremity it affects. Look for color, sensation, warmth, function, and circulation, and ask if the client has any pain. Restraints must be released every 2 hours. Assist the client to the toilet or with changing the incontinence product, ambulate the client, or perform ROM activities if she is unable to walk. Reposition her to prevent pressure injuries. Offer food and fluids and socialize with the client. The six most common types of restraints used include wrist, ankle, vest, mitt, roll belt, and a belt restraint for wheelchair use. Risks associated with restraint use are plentiful and include a decrease in mobility, increased dependency, behavioral problems, loss of dignity, depression, pressure injuries, muscle soreness and atrophy, decreased self-worth, incontinence, impaction, falls, and even death. The only appropriate reason to use a restraint is to ensure safety. A restraint must be ordered by the physician, and it must be listed on the client s care plan or ISP. The facility must consistently try to reduce or eliminate the use of the restraint. A side rail is always considered to be a restraint unless it is used for purposeful movement by the client while in bed. Informed consent is always needed, as side rails can be life threatening. A key strategy to prevent the use of restraints is to attend to basic human needs in a consistent and timely manner, which includes attending to toileting, food, fluid, exercise, and social needs. Get Up and Think! encourages students to work together and brainstorm answers to scenarios they may face on the job. Get Up and Think! Find a partner, and both of you get up and think. Take along a piece of paper and pencil. Jot down your brainstorming thoughts to these questions as you walk. Bring back your thoughts to the class. Every time you let Alma roam freely about the unit in her wheelchair, she immediately goes to Fred and starts screaming at him and kicking him. She thinks he is her late husband, who cheated on her many years ago. When this happens, Fred gets very upset, as does his family. They are threatening to move him to a different facility because of this. Today you lock Alma s wheelchair brakes and put her in front of the television to distract her. She is very calm and does not even notice when Fred comes into the room. The day goes by without incidence. Was this an appropriate action to take? Is keeping Fred safe and happy an appropriate reason for locking the brakes on Alma s wheelchair? Is keeping Fred safe and happy the ultimate goal in this scenario? Would you get in trouble for locking Alma s brakes? If so, why; if not, why not? Alma was much more calm and relaxed while watching television. Do you think this intervention will work every day?
Chapter Summary 199 Reflect on This! 1. Clarence is continuously trying to walk out the front door. He has dementia and is always very confused. He tells you repeatedly that he needs to go home; his mother will be looking for him. It is very cold outside, and you worry that if he did get out, even for a few minutes, it would not be safe. What can you do to help Clarence? How can you decrease his agitation? Is a restraint needed in this scenario? If so, why; if not, why not? 2. Devin scratches himself a lot. Every time you help him into bed, he scratches his buttocks so fiercely that the skin begins to bleed. Devin is incontinent and you fear he will get fecal matter in his wounds. What could be the reason(s) that he is scratching so fiercely? How can you help prevent infection? What are some interventions you could try prior to applying a restraint? If none of the interventions work, would a restraint be appropriate? If so, what type of restraint would be the least restrictive and most effective? Let s Review! Prioritize these action items. MaryAnn has a wrist restraint on her left hand while in bed. 1. You take the restraint off because it has been on for 2 hours. 2. You tie a quick-release knot. 3. You check on her every 15 minutes and note the color and temperature of her left hand and ask her about any sensation in the hand. 4. You ambulate her so she can stretch her legs, and you take her to the bathroom. 5. You reapply the restraint to the wrist. Multiple Choice Questions 1. The goal of restraining an individual is to (13.1): a. keep the client safe. b. keep others around the client safe. c. prevent falls. d. a and b. 2. Before a client can be restrained, the nurse must obtain (13.5): a. consent. b. a physician s order. c. a report from the nursing assistant that the client is acting out. d. none of the above. 3. A physical restraint must be released (13.4): a. every 15 minutes. b. every 30 minutes. c. every hour. d. every 2 hours. 4. When checking on a client who has a mitt restraint, the nursing assistant should (13.4): a. check the color of the client s hand. b. check the warmth of the client s hand. c. ask the client to wiggle his fingers. d. all of the above. 5. Restraining clients (13.1): a. prevents falls. b. prevents clients from wandering off. c. prevents outbursts. d. none of the above. Reflect on This! provides examples of potential clients and encourages students to figure out how to address clients unique needs. Let s Review! helps with mastering key concepts and learning objectives. Multiple Choice Questions help students assess their understanding of learning objectives.
200 Chapter Summary Reference Centers for Medicaid and Medicare Services. (2005). Clarification of nursing home reporting requirements for alleged violations of mistreatment, neglect, and abuse, including injuries of unknown source, and misappropriation of resident property. Baltimore, MD: Center for Medicaid and State Operations/Survey and Certification Group, Department of Health & Human Services. CMS, 42: 483.13; https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r12som.pdf. 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. Skill Skill 13.1 Tying a Quick-Release Knot When: A quick-release knot is used every time a restraint is applied. *Apply a restraint only when ordered by a physician and only when required to treat the resident s medical symptoms. Check the client every 15 minutes while a restraint is in use. Remove the restraint every 2 hours. Remove the restraint at meal times. Why: All restraints must be fastened with a quick-release knot. The quick-release knot is a safety measure. In case of a fire or other emergency, the restraint can be untied quickly, and the client can be helped to a safe place. What: Supplies needed for this skill include: A restraint How: 1. Wrap the strap once around a movable part of the bed frame leaving at least an 8-inch (20 cm) tail. 2. Fold the loose end in half to create a loop and cross it over the other end. 3. Insert the folded strap where the straps cross over each other, as if tying a shoelace. Pull on the loop to tighten. 4. Fold the loose end in half to create a second loop. 5. Insert the second loop into the first loop. 6. Pull on the loop to tighten. Test to make sure strap is secure and will not slide in any direction. 7. Repeat on other side. 8. Practice quick-release ties to ensure the knot releases with one pull on the loose end of the strap. Images and accompanying text provided courtesy of Posey Company, Arcadia, California.
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 2017 18 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. xxxiii
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. xxxv
The History of Healthcare in the United States Hemera Technologies/PhotoObjects.net/Thinkstock Digital Vision/DigitalVision/Thinkstock Jennifer, a 32-year-old woman, presents to the after-hours urgent-care clinic complaining of severe shortness of breath. She has a history of asthma. The shortness of breath has been a problem for about a week now but has progressively gotten worse. She tells you she didn t come in right away because she really can t afford the deductible on her insurance plan. She didn t go to her normal doctor or clinic during the week because she can t afford to miss any work. That time would be unpaid. Because of this she tried treating her problems at home with an herbal remedy she read about on the Internet. The doctor orders a breathing treatment while Jennifer is at the clinic and gives her two new prescriptions to fill at the pharmacy. Her insurance doesn t cover much for prescription medications. When leaving, she says to you, You may as well throw these prescriptions away; I can t afford to fill them. I ll probably see you in a few days again for another breathing treatment. What do you do? 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
2 Chapter 1 The History of Healthcare in the United States 1.1 A Brief History of Healthcare in the United States What did Florence Nightingale feel was important in caregiving? How does that relate to nursing assistant work today? 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. In doing so, she helped establish the scientific basis of nursing. She portrayed the art of nursing through her compassionate care of the sick, injured, and poor, without regard to background, class, or wealth. 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 person s environment. She felt that a stable and healthy environment was an essential part of care 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 basic nursing practice, and for which today s nursing assistants are responsible, include bedmaking; cleanliness of the patient; activities for physical, intellectual, and mental well-being; proper food and water intake; documentation; and cleanliness of the patient s room. By taking care of these needs, in addition to addressing the illness itself, we can help the client make the fullest recovery possible. We can also make sure the quality of life for our client is the best it can be. Nursing assistants play a very large role in caring for the client! Florence Nightingale s nursing, infection control, and compassionate caregiving principles lay the foundation for many nursing assistant tasks today, including bedmaking; cleanliness of the patient; activities for physical, intellectual, and mental well-being; proper food and water intake; documentation; and cleanliness of the patient s room. Reflect on Jennifer! How would Florence Nightingale help Jennifer? What was healthcare delivery in the United States like before the formation of regulated medical colleges? Figure 1 1. Florence Nightingale, the founder of modern nursing. photos.com/photos.com/thinkstock 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, and there were no licensing boards or regulating bodies overseeing medical schools or doctors. There were no tests to pass. Although some medical schools were established, would-be physicians didn t need to attend school of any kind not even high school! Doctors, as they called themselves, were often the local tailor, clergyman, barman, or barber (Figure 1 2). Early healthcare practices mostly involved the use of herbal and home remedies. Practices were quite basic at this time. Payment for a doctor s services was completely paid for by the individual or his family.
1.2 The Beginning of Modern Healthcare 3 If there was no community doctor, or if the patient could not pay for the services in some way, the sick were simply cared for by family members within the home. There were no hospitals during this time either only almshouses. Almshouses were places for the poor, older adults, the homeless, and the insane to stay. Most often these establishments were operated by donations from the community or religious orders. As you might expect, illness would easily spread through these almshouses. If there was a medical school in the area, often the students worked at the almshouses as part of their training. The training mainly consisted of an apprenticeship with a doctor, who usually had no formal training himself. Almshouses Places for the poor, older adults, the homeless, and the insane to stay; early form of a hospital Infectious illness Occurs when a germ enters the body and causes sickness Doctors had very little training. Many were community barbers, clergymen, or tailors. There were very few medical schools or hospitals. Most people were cared for at home by family members or in almshouses. Reflect on Settings! Figure 1 2. In the early years of the United States no formal training was required to be a physician. Many were barbers, clergymen, or tailors. photos.com/photos.com/thinkstock Imagine how care would be different in an almshouse compared to the patient s home. Who would be caring for the patient? What if an emergency happened? Would a patient be safer in his home or in an almshouse? Would there be access to more care and supplies in an almshouse or in the patient s home? 1.2 The Beginning of Modern Healthcare What changes occurred in the U.S. healthcare system that led to the prevalence of chronic illness versus infectious illness? The concept of public health began to take hold in the mid-1800s (Figure 1 3). The goal of public health is to educate groups of people (not simply an individual) about healthy ways to live and how to prevent illness before it starts. Before the start of public health, it was common for raw sewage to flow in city streets. That raw sewage would then flow on to streams and rivers and pollute drinking water. An example of public health is to teach communities the Figure 1 3. Public health efforts began in the mid- 1800s. stocksnapper/istock/thinkstock importance of a working sewage system and a clean water supply to prevent illness. What is infectious illness, and what are some examples of infectious illness? Public health interventions helped to reduce the prevalence of infectious illness, which was the type of disease that most often affected Americans. An infectious illness occurs when a germ enters the body and causes sickness. Before public health plans were put into place, people were more likely to suffer and die from infectious illnesses, like smallpox or cholera.
4 Chapter 1 The History of Healthcare in the United States Chronic illness A condition or disease that people live with for a long period of time Infectious illness occurs when a germ enters the body and causes sickness. Examples of infectious illness include smallpox, cholera, strep throat, the common cold, tuberculosis (TB), and HIV. What is chronic illness, and what are some examples of chronic illness? As the number of individuals 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, asthma, and arthritis. The trend shifted in the United States from people dying primarily of infectious illness to people dying primarily of chronic illness (Table 1.1). Chronic illness is a condition or disease that people live with for a long period of time. Examples of chronic illness can include heart disease, asthma, arthritis, diabetes, osteoporosis, and epilepsy. Public health interventions helped reduce the occurrence of infectious illness. As the number of individuals dying from infectious illnesses at an early age decreased, people began to live long enough to develop chronic illnesses. Reflect on Jennifer! Have you thought about exposure to other germs at the clinic that might make Jennifer even sicker? Explain what the risks are to her. What could you do to limit those risks? The Modernization of Medicine In the early 1900s, scientists were identifying causes of illness, how to keep people from becoming ill, and how to better treat them if they did fall ill. A scientific basis for the practice of medicine became established. Medical schools, as we now know them, began to emerge. Medical training was much more demanding, took longer amounts of time to complete, and involved scientific instruction 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 a rise in specialty healthcare providers. Doctors are furthering their training in areas such as specialty surgery and cancer care. Because of the specialty training, jobs in physical therapy and occupational therapy expanded, and specialty nursing degrees evolved. Reflect on Professionalism! What would healthcare look like today if we did not have formal schooling and education for healthcare professionals? What would happen if you were a nursing assistant without any formal training? Do you think being certified as a nursing assistant will encourage your clients to trust you more? How does being certified raise the standard of care for your clients? Should nursing assistants have to continue their education once training has been complete? If so, how much continuing education do you think would be appropriate? Table 1.1 Examples of Infectious and Chronic Illnesses Examples of Infectious Illness Smallpox Cholera Strep throat The common cold Tuberculosis (TB) HIV Examples of Chronic Illness Heart disease Asthma Arthritis Diabetes Osteoporosis Epilepsy
1.3 The Cost of Healthcare 5 1.3 The Cost of Healthcare What made healthcare become so costly in the United States? With the increased complexity of healthcare, the fees for accessing healthcare services greatly 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 4). What sources of funding help pay for healthcare? Healthcare is now a large part of our economy. It is very costly to access. People cannot pay for treatment outright; they need help to pay the mounting costs. Health insurance became a standard in American life following the Second World War. The model for healthcare insurance was based on the workers compensation plans 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 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, however. 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 out-of-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. Figure 1 4. 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 During this time, however, there were several factors that started to increase the costs of healthcare. These included the growing use of technology and purchasing those technologies for practice; paying for specialty services; a growing older population with more chronic illnesses; and research dollars needed to create new technologies, treatments, and drugs. Healthcare has become so costly due to the growing use of technology and purchasing those technologies for practice; paying for specialty services; a growing older population with more chronic illnesses; and research dollars needed to create new technologies, treatments, and drugs. How did managed care organizations (MCOs) keep healthcare costs down? Because of these rising costs, managed care organizations (MCOs) became the insurance provider 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 and dictated the amount and type of services healthcare consumers enrolled in these plans could access. There were also financial incentives 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 at today in our healthcare system. This is why we see a great increase in the number of outpatient versus inpatient surgeries. It is also why hospital stays are much Medicare Health insurance plan for older adults and, in certain situations, the disabled, funded through federal taxes Medicaid Health insurance plan for low-income people and the disabled, funded through federal and state taxes Managed care organizations (MCOs) Insurance programs that worked to reduce the rising healthcare costs in the United States in the late 1980s
6 Chapter 1 The History of Healthcare in the United States Healthcare premium The cost that the individual must pay every month toward her healthcare plan; when the individual is employed, this amount is usually taken out of the employee s paycheck Co-pay A specific dollar amount or percentage that must be paid by the individual for each healthcare service received Deductible A certain amount of money that the individual must pay for healthcare services before the insurance company will start to pay for any services used; this is renewed at the start of every year shorter than they were in the past. And it is why consumers of healthcare in America 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. MCOs placed limits on how much money healthcare agencies and providers could charge for each service and dictated the amount and type of services healthcare consumers enrolled in these plans could access. There were also financial incentives for providers to treat and discharge patients from hospitals quickly. 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 insurancerelated expenses. To try and keep the cost of the health insurance down, people pay more for services used (Figure 1 5). Most insurance plans have co-pays. A co-pay is a specific dollar amount Figure 1 5. Insurance helps the consumer of health care afford medical services. An individual often purchases insurance through an employer and pays a premium every month for coverage. alexskopje/istock/ Thinkstock or percentage that must be paid by the individual for each healthcare service received. Deductibles are now widely used to control costs paid to the insurance company 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 is renewed at the start of every year. Often the deductible will be $1,000 or $2,500, or even $5,000. Reflect on Jennifer! What is preventing Jennifer from seeking medical care? Is she noncompliant, meaning that she just doesn t follow the doctor s orders? Or is there another reason? Reflect on Choices! Imagine you had a $1,000 deductible to meet. Would you miss work and go to the doctor if you knew you would not only lose your wages for the day but would also end up with a $300 bill? Or would you just go to work sick and potentially infect your coworkers and clients with the illness? 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 2006. 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 and the associated care goes unpaid. That means the price of future surgeries goes up for everyone. This is how the hospital can recoup unpaid costs. The Affordable Care Act* was passed by Congress and signed into law in 2010. The Supreme Court upheld this law in 2012. The Affordable Care Act aims to increase access to insurance. Instead of needing a job to get health insurance, individuals were able to