Chapter 11 Flashcards
1
Q
Residents will need to make many emotional adjustments before
entering a facility.
They may experience any or all the following:
A
- Fear
- Uncertainty
- Anger
- Loss of health, mobility, independence, family, friends, pets,
plants
2
Q
Baseline
A
- an initial value that can be compared to future
measurements. - Baseline vital signs are initial values (Temp, Pulse,
Respiration, BP, Pain Level) that can then be compared
to future measurements.
3
Q
Guidelines for admission:
A
- Prepare the room before the resident arrives.
- When resident arrives, note the time and resident’s
condition. - Introduce yourself. Address the resident by his formal name.
- Do not rush the admission process.
- Make the new resident feel welcome.
- Prepare the room before the resident arrives.
- When resident arrives, note the time and resident’s
condition. - Introduce yourself. Address the resident by his formal name.
- Do not rush the admission process.
- Make the new resident feel welcome.
4
Q
Admitting a resident:
A
Equipment: may include admission paperwork (checklist and inventory form), gloves, and vital signs equipment
- Identify yourself by name. Identify the resident by
name. - Wash your hands.
- Explain procedure to the resident. Speak clearly, slowly,
and directly. Maintain face-to-face contact whenever
possible. - Provide for the
resident’s privacy with
curtain, screen, or door. - If the family is present,
ask them to step
outside until the
admission process is
over. (There are
exceptions to this step.) - Show them where they
can wait and let them
know approximately
how long the process
will take. - If part of facility policy, do
these things:
* Measure the resident’s
height and weight
* Measure the resident’s
baseline vital signs
* Obtain a urine specimen
if required
* Complete the paperwork.
* Take an inventory of all
personal items.
* Help the resident put
personal items away.
* Label personal items
according to facility
policy.
* Provide fresh water. - Show the resident the room and bathroom. Explain
how to work the bed controls and the call light. Show
the resident the telephone, lights, and television
controls. - Introduce the resident to his roommate, if there is one.
- Make sure resident is comfortable. Remove privacy
measures. Bring the family back inside if they were
outside. - Place call light within resident’s reach.
- Wash hands.
- Document procedure
5
Q
Measuring and recording weight of an ambulatory resident:
A
Equipment: standing/upright scale or bathroom scale, pen and paper
- Identify yourself by name. Identify the resident by
name. - Wash your hands.
- Explain procedure to the resident. Speak clearly, slowly,
and directly. Maintain face-to-face contact whenever
possible. - Provide for resident’s privacy with curtain, screen, or
door. - Make sure the resident is wearing nonskid shoes that
are securely fastened before walking to the scale. - Start with scale balanced at zero before weighing the
resident. - Help the resident to step onto the center of the scale.
Be sure she is not holding, touching, or leaning
against anything. This interferes with weight
measurement. Do not force someone to let go. If you
are unable to obtain a weight, notify the nurse. - Determine the resident’s
weight. Balance the
scale by making the
balance bar level.
Move the small and large
weight indicators until
the bar balances. Read
the two numbers shown
(on the small and large
weight indicators) when
the bar is balanced. Add
these two numbers
together. This is the
resident’s weight. - Help the resident to safely step off scale before
recording weight. - Wash hands.
- Record the resident’s weight.
- Remove privacy measures.
- Place call light within resident’s reach.
- Report any changes in resident’s weight (when weighing
resident after admission) to the nurse.
*For residents who can get out of bed, you will measure
height using a standing scale.
Equipment: standing scale, pen and paper
- Identify yourself by name. Identify the resident by name.
- Wash your hands.
- Explain procedure to the resident. Speak clearly, slowly,
and directly. Maintain face-to-face contact whenever
possible. - Provide for resident’s
privacy with curtain,
screen, or door. - Make sure the resident is
wearing nonskid shoes
that are securely fastened
before walking to scale. - Help the resident to step
on to the scale, facing
away from the scale. - Ask the resident to stand
straight if possible. Help
as needed. - Pull up the measuring rod
from the back of the scale
and gently lower the rod
until it rests flat on the
resident’s head - Determine the resident’s height.
- Help the resident to safely step off the scale before
recording height. Make sure that the measuring rod does
not hit the resident in the head while trying to help the
resident off the scale. - Wash hands
- Record the resident’s height.
- Remove privacy measures.
- Place call light within resident’s reach.
- Document procedure using facility guidelines.
5
Q
Physical Exams:
A
- NAs can help lessen residents’ fear and
discomfort during exams. - Listening, being comforting, and answering
questions within their scope of practice may
help.
5
Q
The nurse may discuss the following with a resident who is being discharged: (These are known as discharge instructions)
A
- Future doctor or physical therapy appointments
- Home care or skilled nursing care
- Medications
- Ambulation instructions
- Medical equipment needed
- Medical transportation
- Restrictions on activities
- Special exercises
- Special dietary requirements
- Community resources
5
Q
NAs may have to gather the following equipment:
A
- Sphygmomanometer
- Stethoscope
- Alcohol wipes
- Flashlight
- Thermometer
- Tongue depressor
- Eye chart
- Tuning fork
- Reflex hammer
- Otoscope
- Ophthalmoscope
- Specimen containers
- Lubricant
- Special card to test for blood in stool
- Vaginal speculum
- Gloves
- Drape
6
Q
Discharging a resident:
A
Equipment: may include a wheelchair, cart for belongings,
discharge paperwork, including the inventory list from
admission, the resident’s care items, vital signs equipment
- Identify yourself by name. Identify the resident by name.
- Wash your hands.
- Explain procedure to the resident. Speak clearly, slowly,
and directly. Maintain face-to-face contact whenever
possible. - Provide for resident’s privacy with curtain, screen, or
door. - Measure the resident’s vital signs.
- Compare the inventory checklist to the items there. If
all items are there, ask the resident to sign. - Put the personal items to be taken onto the cart and take
them to pick-up area. - Help the resident dress and then into the wheelchair or
onto the stretcher if used. - Help the resident to say his goodbyes to the staff and
residents. - Take resident to the pick-up area. Help him into the vehicle.
You are responsible for the resident until he is safely in the
car and the door is closed. - Wash your hands.
- Document procedure using facility guidelines. Include the
following:
* The vital signs at discharge
* Time of discharge
* Method of transport
* Who was with the resident
* What items the resident took with him (inventory
checklist)
7
Q
dorsal recumbent position:
A
body position in which a person is flat on her back with her
knees flexed and her feet flat on the bed.
8
Q
lithotomy position:
A
body position in which a person lies on her back with her hips
at the edge of an exam table; legs are flexed, and feet are in
padded stirrups.
9
Q
knee-chest position:
A
body position in which the person is lying on her abdomen
with her knees pulled towards the abdomen and her legs
separated; arms are pulled up and flexed, and the head is
turned to one side.
10
Q
NAs should remember these guidelines for physical exams:
A
- Wash hands before and after.
- Ask resident to urinate and collect urine if needed.
- Provide privacy throughout.
- Listen to and reassure the resident.
- Follow directions.
- Help resident into proper position.
- Protect the resident from falling.
- Provide light to examiner.
- Put instruments in proper places.
- Take and label specimens.
- Follow Standard Precautions.
- Assist with vision screenings as ordered.
- Help resident clean up, get dressed, and return to room.
- Dispose of trash and equipment.
- Clean and store equipment.
- Take labeled specimens to proper place.
