Beginning And Ending Steps In Care Procedures Flashcards
Beginning steps of a care procedure
1) identify yourself by name. Identify the resident by name.
2) wash your hands
3) explain the procedure to the resident
4) provide for the residence privacy with a curtain, screen, or door
5) adjust the bed to a safe level, usually waste high. Lock the bed wheels.
Ending steps of a care procedure
1) Return bed to lowest position. Remove privacy measures.
2) place call light within residence reach
3) wash your hands
4) report any changes in resident to the nurse. Document procedure using facility guidelines.
Why should you identify yourself and the resident by name?
Residents have a legal right to privacy.
1) knock and wait for permission to enter the residence room
2) upon entering identify yourself and state your title.
3) identify and greet the resident showing courtesy and respect. (This prevents care from being performed on the wrong person)
Explaining procedures to the resident
1) speak clearly, slowly and directly
2) maintain face-to-face contact whenever possible
3) residents have a legal right to know exactly what care is being provided
4) residents are able to do more for themselves if they know what needs to happen
Reporting changes in resident to the nurse
1) document procedure using facility guidelines
A) every time you provide care, observe the residents physical and mental capabilities as well as the condition of his or her body.
B) do not record care before it is given. If you do not document the care you gave, legally it did not happen
Long-term care (LTC)
Is given in long-term care facilities for people who need 24-hour skilled care
Skilled care
Care that is medically necessary given by a skilled nurse or therapist
A) ordered by a doctor and involves a treatment plan
B) given to people who need a high level of care for ongoing conditions
Other names for long-term care facilities
1) skilled nursing facilities
2) rehabilitation centers
3) extended Care facilities
Chronic conditions
A patient’s condition lasting a long period of time, even a lifetime. They include…
Physical disabilities
Heart disease
Dementia
Diagnosis
Medical condition determined by a doctor
Home Health Care
Care provided in a person’s home. Generally given to people who are older and chronically ill, but who are able and wish to remain at home.
May also be given when a person is weak after a recent hospital stay.
Assisted living facilities
Residences for people who need some help with daily tasks such as showering, eating and dressing. People who live in these facilities do not need 24-hour skilled care.
Help with medications may also be given.
ALF allow for more independent living in a home like environment
Adult Day services
Are for people who need some help and supervision during certain hours, but who do not live in the facility where care is provided.
They are for people who need some help, but are not seriously ill or disabled.
They often provide a break for spouses, family members and Friends
Subacute care
Is care given in hospitals or long-term care facilities. It is used for people who need less care than for an acute (sudden onset, short-term) illness, but more care than for a chronic (long-term) illness.
Treatment usually ends when the condition is stabilized or after the set time for treatment has been completed.
Outpatient Care
Is usually given to people who have had treatments, procedures, or surgeries and need short-term skilled care.
They do not require an overnight stay in a hospital or other Care facility
Rehabilitation
Is caregiving by specialists.
Physical, occupational and speech therapists help restore or improve function after an illness or injury.
Hospice care
Is given in facilities or homes for people who have about 6 months or less to live.
Hospice workers give physical and emotional care and comfort until a person dies.
They also support families during this process.
Personal care
also known as Activities of Daily Living or ADLs
These include:
Bathing Skin, nail and hair care Mouth care Assistance with walking Assistance with eating and drinking Assistance dressing, transferring and elimination
Common services offered at long-term care facilities
ADL’s
Physical, occupational and speech therapy
Wound care
Tube care
Such as catheters (tubes inserted into the body to drain/inject fluids)
Nutrition therapy
Management of chronic diseases including:
Alzheimer’s
Acquired immunodeficiency syndrome (AIDS)
Diabetes
Chronic obstructive pulmonary disease (COPD)
Cancer
Congestive heart failure (CHF)
Culture change
Culture change is a term given to the process of transforming services for elders so that they are based on the values and practices of the person receiving care. It involves respecting both elders and those working with them. Core values are promoting choice, dignity, respect, self-determination and purposeful living. This may result in organizations changing their practices, physical environments and relationships.
Person-centered care
Emphasizes the individuality of the person who needs care, recognizing and developing his or her capabilities.
It promotes the residents individual preferences, choices, dignity and interests.
Each person’s background, culture, language, beliefs and traditions are respected.
CMS
The centers for Medicare and Medicaid services is a federal agency within the US Department of Health and human services
Medicare
Is a federal health insurance program covering people of any age with permanent kidney failure or certain disabilities.
The four parts of Medicare
A) helps pay for care in a hospital or skilled nursing facility or for care from home Health agency or hospice
B) helps pay for Doctor services and other medical services and equipment
C) allows Private health insurance companies to provide Medicare benefits
D) helps pay for medications prescribed for treatment.
Medicaid
A medical assistance program for people who have a low-income, as well as for people with disabilities. It is funded by both the federal government and each state. Eligibility is determined by income and special circumstances.
Nursing Assistant titles
Nurse aide
Certified nurse aide
Patient care
Certified nursing assistant
The role of a nursing assistant
Provides personal care and also promotes Independence and self-care
They act as the “eyes and ears” of the team.
Observing/reporting changes in a residents condition
Charting (documenting)
Nursing assistant duties
Bathing residents
Assisting with elimination needs
Assisting with range of motion exercises and ambulation
Transferring residents from a bed to a chair or wheelchair
Measuring vital signs (temperature, pulse rate, respiratory rate, and blood pressure)
Assisting with meals
Helping residents dress and undress
Giving back rubs
Helping with mouth care
Making and changing beds
Keeping residents living area neat and clean
Caring for supplies and equipment
Nursing assistants are not allowed to
Insert or remove tubes
Give tube feedings
Change sterile dressings
Nursing assistants and administering medication
Some states allow nursing assistants to give medications if they have completed an additional, specialized course for medications and meet the requirements of the individual facility.
Responsibility for ALL residents
A nursing assistant should provide care for all residents who are in need even if they are not on their personal assignment sheet
Chain of command
Doctor (or other member of the care team)
Nurse (acts on the instructions of the doctor)
Nursing assistant (C/NA)
The line of authority ensures that residents get proper Health Care while protecting employees and employers from liability.
Scope of practice
Defines the tasks that healthcare providers are legally allowed to do as permitted by state or federal laws
Laws and regulations about what NA’s can and do vary from state to state
It is imperative that NA’s know which tasks are outside their scope of practice and not perform them
Care plan
Tasks that the team members, including NA’s must perform.
The care plan States how often these tasks should be performed and how they should be carried out
It should involve input from the resident (person-centered care) and/or the family, as well as from health professionals
Policy
A course of action that should be taken every time a certain situation occurs
Ex: HIPPA
Procedure
A method, or way of doing something.
Ex: what form to complete, when and how often to complete it and to whom it is given
Common policies
All resident information must remain confidential (HIPPA)
Always follow the care plan and do not execute tasks that are not listed in the care plan or approved by the nurse
A Nursing assistant should not do tasks that are not included in their job description
A Nursing assistant must report important events or changes in residents to a nurse
A Nursing assistant should not discuss their personal problems with residents or residents families
A Nursing assistance should not take money or gifts from residents or their families
A Nursing assistant must be on time for work and must be dependable
Nursing assistant professionalism
Follow the care plan
Make careful observations
Report/chart accurately
A professional relationship with residents includes:
Providing person-centered care
Keeping a positive attitude
Doing only the assigned tasks that are in the care plan and that the nursing assistant is trained to do
Keeping all residents information confidential
Always being polite and cheerful
Never discussing personal problems
Not using personal phones in a residents room or in any resident care area
Not using profanity, even if a resident does
Listening to the resident
Calling a resident Mr, Mrs, Ms, or Miss and his or her last name, or by the name he or she prefers.. do not use terms such as sweetie or honey, etc
Never giving or accepting gifts
Always explaining care before providing it
Following practices such as hand-washing to protect oneself and residents
Professional relationship with employers includes:
Completing tasks efficiently
Always following all policies and procedures
Documenting and reporting carefully and correctly
Reporting problems with residents or tasks
Reporting anything that keeps a nursing assistant from completing duties
Asking questions when you do not know or understand something
Being available to direction or feedback without becoming upset
Being clean and neatly dressed and groomed
Always be on time
Notify the employer if you cannot report for work
Following the chain of command
Participating in education programs
Being a positive role model for the facility
Residents rights include:
Quality of life
Services and activities to maintain a high level of wellness
The right to be fully informed about rights and services
The right to participate in their own care
The right to make independent choices
The right to privacy and confidentiality
The right to dignity, respect and freedom
The right to security of possessions
Rights during transfers and discharges
The right to complain
The right to visits
Rights with regard to social services
The right to quality of life
The facility must give equal access to quality Care regardless of a resident’s condition, diagnosis or payment source ensuring that the residents dignity, choice and Independence are integral
The right to services and activities in order to maintain a high level of wellness
The baseline care plan which includes instructions for providing person-centered care must be developed within 48 hours of admission. Residents Health should not decline as a direct result of the caregiving at the facility
The right to be fully informed about rights and services
Residents must be told what services are available to them. They must be told the fee for each service and informed of charges both verbally and in writing. Residents must be given a written copy of their legal rights, along with the facilities rules. Residents must be provided with contact information for state agencies relating to quality of care (ombudsman program). Residents have the right to be notified about any change of room or roommate. They have the right to communicate with someone who speaks their language. They have the right to assistance for any sensory impairment, such as vision loss.
The right to participate in their own care
Residents have the right to participate in planning their treatment, care and discharge. Residents have the right to see and sign their care plans after all significant changes. The right to refuse and/or discontinue treatment and care. The right to refuse restraints. The right to refuse participation in experimental research.
Informed consent
Process by which a person with the help of a doctor, makes informed decisions about his or her health care
The right to make independent choices
Residents can make choices about their doctors, care and treatments. They can make choices as to how to spend their time. They have a right to reasonable accommodation of their needs and preferences. They have the right to participate in resident or family groups, such as a resident council
The right to privacy and confidentiality
The residents medical, personal and financial information cannot be shared with anyone but the care team
The right to dignity, respect and freedom
Residents must not be abused, mistreated or neglected in any way
The right to security of possessions
Residents’ personal possessions must be safe at all times. Facilities must make an effort to protect residents property from loss or theft. Residents have the right to manage their own finances or choose someone else to do it for them. Residents can request that the facility handle their money.
Rights during transfers and discharges
The facility must develop an effective discharge plan for residents that involves each residents goals and preferences. If the resident is planning to stay at the facility long-term, discharge planning still needs to occur, keeping the residents preferences in mind.
The right to complain
Residents have the right to make complaints and voice grievances without fear for their safety or care. Facilities must work quickly to address their concerns
The right to visits
Residents have the right to visits which cannot be restricted, limited or denied in any manner
Rights with regards to social services
The facility must provide residents with access to social services including counseling, assistance in solving problems with others and help contacting legal and financial professionals
False imprisonment
Not allowing a resident to leave the facility
Involuntary seclusion
Is the separation of a person from others against that person’s will. An example is an NA confining a resident to his room
Negligence
Actions, or the failure to act or provide the proper care for a resident, resulting in unintended injury.
Ex: An NA forgetting to lock a residents wheelchair before transferring them. The resident falls and is injured.
Malpractice
Is what occurs when a person is injured due to professional misconduct through negligence, carelessness, or lack of skill
Observing and reporting: abuse and neglect
The Following injuries are considered suspicious and should be reported:
Poisoning or traumatic injury
Teeth marks
Belt buckle or strap marks
Bruises, contusions or welts
Scars
Fractures or dislocations
Burns of unusual shape and in unusual locations, or cigarette Burns
Scalding Burns
Scratches or puncture wounds
Scalp tenderness or patches of missing hair
Swelling in the face, broken teeth or nasal discharge
Bruises, bleeding, or discharge from the vaginal area
Signs that could indicate abuse
Yelling obscenities
Fear, apprehension or fear of being alone
Poor self control
Constant pain
Threatening to hurt others
Withdrawal or apathy
Alcohol or drug abuse
Agitation, anxiety or signs of stress
Low self-esteem
Mood changes, confusion or disorientation
Private conversations are not allowed, or the family member/caregiver is present during all conversations
Reports of questionable Care by the resident or their family
Signs that could indicate neglect
Pressure injuries
Unclean body
Body lice
needs relating to hearing aids, eyeglasses, etc
Weight loss or poor appetite
Uneaten food
Dehydration
Freshwater or beverages not being offered regularly
Reports of not receiving prescribed medication by the resident or their family
Reporting abuse or neglect
Observe for signs of abuse and report suspected cases to the proper person. Follow the chain of command. If action is not taken, the NA should keep reporting up the chain of command until action is taken. If no action is taken at the facility level they can call the state abuse hotline or contact the proper state agency. Abuse can be reported anonymously. If a life or death situation is witnessed the NA should remove the resident to a safe place if possible. The NA should get help immediately or have someone go for help. The resident should not be left alone.
If abuse is suspected or observed
The NA should give the nurse as much information as possible. If a resident wants to make a complaint of abuse, the NA must help them in every way. This includes telling the resident about the process of their rights. If an NA observes someone being cruel or abusive to a resident who made a complaint they must report it.
Ombudsman
Is assigned by law as the legal advocate for residents. They monitor care and conditions at LTC facilities. They help resolve conflicts and settle disputes concerning residents health, safety, welfare and rights.
Health Insurance Portability and Accountability Act (HIPPA)
A law that keeps a person’s health information private and secure.
Protected Health Information (PHI)
Information that identifies a person and relates to the patient’s condition, any healthcare that person has had, and payment for that healthcare.
PHI must be kept confidential
Examples of PHI include a person’s name, address, telephone number, social security number, email address and medical record number.
Guidelines to protecting privacy
Make sure you are in a private area when you listen to or read your messages
Know with whom you are speaking on the phone. If you’re not sure, get a name and number. Call back after you find out it is all right to share information with this person.
Do not talk about residents in public areas
Use confidential rooms for reports to other care team members
If you see a residents family member or a former resident in public, be careful with your greeting. They may not want others to know about the family member or that he or she has been a resident
Do not bring family or friends to the facility to meet residents
Make sure nobody can see PHI or personal information on your computer screen. Log out and/or exit the browser when finished with any computer work.
Do not give confidential information in emails.
Do not share resident information, photos, or videos on any social media
Make sure fax numbers are correct before faxing information. Use a cover sheet with a confidentiality statement.
Do not leave documents where others may see them
Store, file or shred documents according to facility policy. If you find documents with a resident’s information, give them to the nurse
Careful charting is important for these reasons:
If it was not documented, legally it was not done
It is the only way to guarantee clear and complete communication among all the members of The Care team
Documentation is a legal record of every part of a resident’s treatment. Medical charts can be used in court as legal evidence
Documentation helps protect nursing assistants and their employees from liability by proving what they did when caring for residents
Documentation gives an up-to-date record of the status and care of each resident
Guidelines to careful documentation
Document care immediately after it is given. This makes details easier to remember. DO NOT RECORD ANY CARE BEFORE IT HAS BEEN DONE.
Think about what you want to say before documenting. Be as brief and clear as possible.
Use facts, not opinions.
Use Black ink when documenting by hand. Right as neatly as possible
If you make a mistake, draw one line through it. Write the correct information. Put your initials and the date. Do not erase what you have written. Do not use correction fluid. Documentation done on a computer is time stamped; it can only be changed by entering another notation
Sign your full name and title. write the correct date
Document as specified in the care plan.
Guidelines for computer documentation
Do not share your login information with anyone
Don’t have someone else enter information for you, even if it is more convenient.
Double check to make sure you are logged into the correct residents chart before beginning documentation.
Double check to make sure autofill entries are accurate.
Recheck your entries before exiting a residents chart
Do not use the facilities computers or tablets to browse the internet or access any personal accounts
Minimum Data Set (MDS)
A detailed form with guidelines for assessing residents. It also lists what to do if resident problems are identified.
Nurses must complete the MDS for each resident within 14 days of admission and again each year.
The MDS for each resident must be reviewed every 3 months
A new MDS must be done when there is any major change in the residents condition
NA’s contribute to the MDS by reporting changes in residents promptly and by documenting accurately. Doing this means a new MDS can be completed when needed
When to file an incident report
When there is an accident, problem or unexpected event during the course of care. It documents the incident and the response to it.
Examples of when to file a report:
Feeding resident from the wrong meal tray
A resident fall or injury (even if they report they are fine)
Accusations made by residents against staff
Employee injuries
An NA or resident breaks or damages something
An NA makes a mistake in care
A resident or a family member makes a request that is outside the NA’s scope of practice
A resident or a family member makes sexual advances or remarks
Anything that happens to make an NA feel uncomfortable, threatened or unsafe
An NA gets injured on the job
An NA gets exposed to blood or body fluids
Guidelines to filing an incident report
Report any incident immediately to the charge nurse.
Complete the report as soon as possible and give it to the charge nurse
If a resident falls and the NA did not see it, they should not document “Mr G fell”. Instead they should document “Found Mr G on the floor” or “Mr G states that he fell”
Do not place blame or liability within the report
Tell what happened. State the time and the mental and physical condition of the person
Describe the person’s reaction to the incident
State the facts; do not give opinions
Do not document that an incident report was completed on the medical record
Describe the action taken to give care
