Chapter 7 Flashcards
NAs should know the resident’s _______ at the time of discharge
Condition
Vital signs order
Temp
Pulse
Resp
BP
Pain
O2 sat
Pulse ox
What are vital signs?
Show how well organs are working
Which changes in vitals require nurse attention
1.Temp outside of normal range
- Too rapid or too slow resp rate
- Abnormal pulse
- Changes in BP
Ranges: mouth (oral) temp
97.6-99.6
Temp rectum (rectal)
98.6-100.6
Temp Armpit (axillary)
96.6-98.6
Temp ear (tympanic)
96.6-99.7
Temporal artery (forehead) temp
97.2-100.1
Normal pulse rate
60-100 bpm
Normal resp rate
12-20
Blood pressure normal systolic
90-119 systolic
Body temperature is normally very close to ___
98.6
Body temperature is a balance between
The heat created by the body, and the heat lost to the environment
Factors that affect body temperature
Age
Illness
Stress
Environment
Excercise
Circadian rythym
What should you do if a resident has just done done something with their mouth, eating, drinking, smoking EXCERCISED etc
Wait 20 minutes and come back
True or false: body temperature fluctuates?
True
When is body temperature lower?
Morning
Increases in body temperature may indicate an ___or____
Infection or disease
Which is the most common way of taking body temperature
Oral
Which is the most accurate way of taking body temperature
Anal
Places where you can take temperature
Oral
Rectal
Axillary
Tympanic
Temporal artery
Types of thermometers
Digital
Electronic
Tympanic
Temporal artery
Mercury-free
What color is a rectal thermometer
Red
What color is an oral thermometer?
Blue or green
Which temperature is least accurate
Axillary
Who should not have an oral temperature recorded?
- Unconscious
- Had facial surgery
- Is younger than 5
- Is confused or disoriented
- Is heavily sedated
- Is likely to have a seizure
- Is coughing
- Is using oxygen
- Has facial paralysis
- Has a nano gastric tube
- Has soreness, redness, swelling or pain
- Has injury to face or neck
Rectal temp should be a last resort?
Yes
1.oral
2. Axillary
3. Rectal
How to use a digital thermometer
- Put on sheath
- Turn on thermometer
- Wait until ready sign appears
How to use electronic thermometer?
Remove probe from base unit.
Put on probe cover
Mercury free thermometer
- Hold thermometer by stem
- Shake thermometer before inserting it in resident’s mouth. Shake thermometer down to lowest #. Below 96 f
- Hold it at end opposite with bulb with thumb and 2 fingers. Stand away from furniture and walls.
Digital thermometer
Insert end of the thermometer into the resident’s mouth, under the tongue and to one side.
Electronic thermometer
Insert the end of the thermometer into the resident’s mouth, under the tongue and to one side.
Hold thermometer in until it
Beeps
How long should a mercury free thermometer stay in?
At least 3 minutes
How should residents breathe while getting oral temp taken?
Through nose
Should resident talk while getting temp checked
No
Should resident bite on thermometer?
No
Why should you never let go of a thermometer during rectal temperature?
It can get lost or puncture the colon
On what side should a resident lie for a rectal temperature assessment?
Left side
How far does the thermometer go in for rectal temperatures?
1/2 inch to 1 inch
What should you do if you feel resistance during rectal temperature?
Stop
In what direction should you pull an ear for adult when taking tympanic temp
Up
In what direction should you pull an ear when taking tympanic temp for child?
Down
Pulse
Number of heartbeats per minute
Beat
Wave of blood moving through artery as result of heart pumping
When do you add a superscript to a temperature
Rectal or axillary
Superscript R for rectal
Superscript Ax for axillary
Radial pulse
Inside of wrist, using radial artery
Brachial pulse
Pulse inside the elbow. 1- 1&1/2 inches above the elbow
Normal Pulse range for children
100-120 bpm
Newborn pulse rate
120-180 bpm
What affects pulse rate
Excercise,
Fear
Anger
Anxiety
Heat
Infection
Illness
Medications
Pain
A rapid pulse could indicate
Fever
Dehydration
Heart failure
Slow, weak pulse could indicate
Infection
Respiration
One inhale one exhale
Inspiration
Breathe in
Expiration
Breathe out
Infant respiratory rate
30-40
Should you report irregular pulse rythym even if the bpm are normal?
Yes you also should if breathing is irregular
Blood pressure
Pressure of blood in heart. Input/output rate. Pressure on walls and arteries
How is BP recorded?
Fraction mmHg
Systolic
Heart contractions. Filling the bucket.
Top number.
Pushes blood from left ventricle
Diastolic
Heart relaxes.
Blood leaves bucket.
Hypertensive
Blood pressure is constantly high
Sphygmomanometer
Used alongside stethoscope to take BP
Systolic pressure is the ____ sound
First
Diastolic pressure sound
Last sound. Soft muffled thump
On which arms shouldn’t you take BP
IV
Dialysis shunt
Arms with medical equipment
Cast
Recent burns
Trauma or mastectomy
Pulse oximeter
Measures percentage of oxygen in blood. Uses light. Also measures pulse.
Less than ___% O2 saturation must be reported
95%, but re check first
Is pain a vital sign?
No it isn’t, but some refer to it as the fifth vital sign
Is pain a normal part of aging?
No
What should an NA ask about pain?
Where is the pain?
When did the pain start?
How long does the pain last?
How often does it happen?
Rate it on 1-10
Can you describe pain?
Use resident’s exact words
What makes pain better?
What makes pain worse?
What were you doing when you started?
Which changes in weight must be reported?
All of them
Restraint
Physical or chemical way to restrict voluntary movement or behavior
Physical restraints
Anything that restricts a person’s freedom of movement
Chemical restraints
Medications that control someone’s mood or behavior
Enabler
Equipment that promotes safety, comfort, independence and mobility.
Person must be able to remove it independently
LTCs are prohibited from using restraints unless they are ___ _______
Medically necessary
NAs can’t use physical restraints unless
- Doctor ordered it in care plan and they have been trained in the restraint’s use
Restraint free care
Restraints are not kept or used for any reason
Restraint alternatives
Measures in place instead of using restraints
How often must a restrained resident be checked on
At least every 15 minutes
Output
Urine, feces, vomit, sweat, perspiration, moisture that a person exhales and wound drainage
Fluid balance
Maintaining equal input an output. Taking in and eliminating an equal amount of fluids
Specimen
Sample that’s used for analysis
Routine urine specimen
Collected every time resident voids
Void
Urinate
Hat
Container that’s sometimes used to measure urine or stool
Seal must be ____ before specimen collection
Intact
Clean catch specimen
Mid stream specimen.
Does not include first and last urine voided in the sample
Purpose of a clean catch specimen
Detect bacteria in the urine
True or false: you shouldn’t touch the inside of the container or the inside of the lid when collecting specimens
True
Should you clean perineal area first when collecting a clean catch?
Yes
Why can’t residents also urinate when you’re taking a stool sample?
It ruins it
When is the best time to collect sputum?
Early morning
How much sputum should an NA collect?
1 teaspoon
Catheter
Thin tube inserted into bodies used to drain or inject fluids
Urinary catheter
Drains urine from bladder
Oxygen therapy
Administering oxygen to increase the supply of oxygen to the lungs
Do nursing assistants stop, adjust or administer oxygen?
No, they never stop, adjust or administer oxygen
Water temperature should be no higher than ___ when providing catheter care?
105
Indwelling catheter
Remains in bladder for periods of time
Indwelling catheter is also known as
Foley catheter
Condom catheter is also called
Texas catheter
Condom catheter.
External, goes on penis. Fastened with special tape. Has leg bag.
Should bag hang above catheter opening
No! Can cause infection. Bag should never flow back into water
Drainage bag must be ___ the floor
Off
Is it okay for catheter tubing to touch the floor?
No! Catheter tubing should never touch the floor
How do you prevent accidentally dislodging the catheter tube?
Keep it as straight as possible. No kinks
Things to report about catheters
-blood or unusual urine
-cathether bag doesn’t fill after several hours
-cathether bag fills suddenly
-cathether is not in place
-urine leaks from catheter
-resident reports pain or pressure
-odor is present
Should the spout and clamp touch the graduated container?
No
Oxygen therapy
Administering oxygen to increase the supply of oxygen to lungs
Combustion
Burning
Can you use oil based lubricants on resident or any part of the cannula or mask?
No
IV therapy
Giving medication, nutrition or fluids through a vein
Port
Permanent IV opening
Closed bed
Bed completely made with the bedspread and blankets in place.
Who is a closed bed made for?
Residents who will be out of bed most of the day
Open bed
Folding linen down to foot of bed. Bed ready to receive a resident
Sterile dressings
Cover new, open or draining wounds. Nurse changes these
Non sterile dressings
Applied to dried, closed wounds that have less chance of infection. Depending on state regulations
Which changes in weight should NAs report?
NAs must report every change in weight, no matter how small
1 lb is equal to ___ oz
16
1 kg is equal to ___ grams
1000
1 kg equals ___ lbs
2.2
Can you put your hand on a resident’s back while weighing?
No, resident must be able to fully hold themselves up on scale without any help
Can a resident hold, touch or lean on something while weighing?
No
What kind of shoes should a resident wear before walking on the scale?
Nonskid
Which things should stay the same when weighing a resident?
- Amount of clothes
- Time of day
- Scale used
Residents shouldn’t gain more than __ lbs per day
3
Which scale is the least accurate
Bed scale
How often are height and weight measured
Height: once
Weight: at least monthly
What should you do if a resident can’t stretch out to be measured?
Get the nurse
Examples of restraints
belt restraints, vest restraints, wrist/ankle restraints
Examples of enablers
Wheelchairs, geriatric chairs, cushions and pillows, assistive devices
Are side rails restraints?
Sometimes
Are geriatric chairs restraints?
Sometimes
Doctor’s note for restraints has to be signed within __ to __ hrs
24-48
Does family have to be notified if their resident is restrained?
Yes
Why is it important to document what you did to prevent using restraints
Because restraints are a last resort! Document everything you did to keep from putting on restraints. Offered backrub. Document everything done to patient
How often do residents have to be released from restraints?
Every 2 hours for 10 minutes
Restraints can easily cause
Pneumonia
Incontinence
Pressure sores
Constipation
Blood clots
What is a good way to distract a resident instead of restraining them?
Giving them a repetitive task
An NA cannot use a restraint unless the _______ ______ has approved it &
Charge nurse
NA has been trained to use it properly
How do you give a restrained resident proper care
- Help with elimination often. Check for incontinence and give skin care
- Offer fluids and food
- Measure vital signs
- Check for irritation, bruising or odd marks
- Check for swelling
- Reposition the resident
- Ambulate resident
1 oz= ___ml
30
How much water should we drink a day
64 oz
1/4 cup= __oz
2
1/2 cup = __ oz
4
Older women should drink
Just over 1.5 quarts /1.6 liters
Older men should drink
2 L about 2 quarts
Specimen
Sample that is used for analysis to make a diagnosis
Urine breaks down after ___ seconds
15
You should make sure hats and pans have been ____ before getting resident to go again
Cleaned
Where should you label a specimen?
On the side of the cup
Can you get a urine sample from a diaper
No
Can you get a stool sample from a diaper?
Sometimes. Not for worms. Just for blood
Anything that comes from the body should go in a
Biohazard bag
What does rusty sputum sometimes indicate
TB
Is sputum spit?
No
The NA should ask ___ to find out a resident’s personal preferences and ___
Questions
Routines
The NA should always call the resident by their _____ name
Formal
The NA should not____ the admission process or the resident
Rush
New residents must be given a copy of their _____
Rights
It is important for the NA to ___ the resident in case something important was missed
Observe
T/F the resident will pack their own belongings for a transfer
False
T/F an NA writes discharge order for resident
False
What may changes in vital signs indicate
Issues with health
Worsening condition
What changes should be immediately reported to the nurse
- Fever
- Abnormal pulse/resp
- Changes in BP
- Pain is worse
Apical pulse
Pulse on chest, most accurate
Femoral pulse
Groin
Pedal pulse
Foot
8 things you can do to reduce resident’s backpain?
- Backrub
- Comfortable position
- Distract them
- Notify nurse
- Align pillows
- Help resident to restroom
- Calm, quiet environment
- Ask if they want bath
Why must an NA report weight losses
Could indicate health problems
Restraint free care means that
Restraints are never used for any reason
What 8 care tasks need to happen every 2 hours when resident is restrained
- Moving around
- Bathroom/incontinence/skin
3.bruises - Measure vitals
- Offer fluids &food
- Swelling
- Check for bruising and signs of irritation
- Reposition resident
7 things that can disrupt resident’s sleep
- Other residents
- Fear/anxiety
- Stress
- Diet
- Noise
6.medication
7.Illness
Things affected by lack of sleep
Decreased mental function
Reduced reaction time
Irritability
Compromised immune system function
T/f: urinals and bedpans are normally stored on the over bed table
False
When a resident cannot get out of bed,
The bed should be raised to a safe height before making it
A bed made with the bedspread and blankets in place is called a
Closed bed
Sterile dressings cover
Open or draining wounds
Elastic bandages are also known as
Non sterile bandages
ACE bandages
ACE wraps
How soon should an NA check on a resident after applying a bandage?
10 minutes
T/f: Soiled linens should be placed on the over bed table when changing a resident’s bed
False
How many inches down should you clean a catheter
At least 4
Can NAs turn off oxygen in case of fire?
Yes, but they can’t adjust setting or dose
Can you use oil based lubricants on resident or on cannula?
No
Which fabrics can cause electric discharges ?
Nylon and wool
Can oxygen tubing or cords for under rugs or furniture?
No
Can you use an extension with an oxygen concentrator?
No
Examples of fire hazards
Electric equipment
Electric razors
Hair dryers
Cigs
Flammable liquids
Alcohol and nail polish remover
Intravenous Therapy
Delivery of medication, nutrition or fluids through a vein
What is the NAs responsibility in regards to IV
Report and document problems with the IV line
What should you report about IV therapy
1.Tube/needle falls out
2. Tubing disconnects
3. Dressing around IV is loose or not intact
4. Blood is in tubing or around IV site
5. Site is swollen or discolored
6. Bag is broken
7. Amount of fluid doesn’t decrease
8. IV fluid doesn’t drip or leak
9. IV fluid is almost out
10. Pump beeps indicating a problem
11. Pump is dropped
12. Resident complains or has trouble breathing
Can you wet an IV site?
No
Can you catch IV tube on anything?
No
Can an NA lower an IV bag below the IV site?
No, it should be at least 3 ft above heart so the fluid has enough pressure to infuse
Why shouldn’t an NA disconnect the IV pump or turn off the alarm?
Will hurt resident’s treatment
Why shouldn’t you touch the IV clamp
It controls the flow rate
What goes on top of bedside stand?
Water pitcher, cup
Phone, radio, photos, other items
What is the over bed table used for
Meals,
Personal care,
Must be kept clean
Uncluttered
(No contaminated items)
Do privacy curtains block sound?
No
What should an NA do when she doesn’t know how to use equipment?
Ask for help
When should over bed table be cleaned?
After each use.
Where should over bed table be before leaving?
Within resident’s reach
Temperature range required by obra
71-81f
When should meal trays be removed?
Right after meals
Check for bread crumbs
Do wrinkled linens have to be changed?
Yes
Why should you check to see if resident can lift pitcher and cup
So they always have access to water
Who cleans bathrooms?
Housekeeping
Is it okay to move a resident’s belongings?
No
What should be reported about sleep issues
1.Sleeping too much
2.Eating or drinking caffeinated items late in day
3. Wearing night clothes during day
4. Eating heavy meals late at night
5. Refusing to take sleep meds
6. Taking new meds
7. Having TV, radio, computer on late at night
8. Having pain
Linens should be changed after:
1.Bedbath
2. Personal care
3. Damp sheets/soiled/need straightening
Sheets that don’t lie flat increase the risk of
Pressure injuries
Bag soiled linen at:
Point of origin
When making the bed the NA should
Use a wide stance and bend her knees. Bending at the waist should be avoided. Especially when tucking sheets under mattress
Always work from _____ to ____ area of bed
Cleanest
Dirtiest
Hospital corners prevent
Residents feet from getting tangled when getting in and out of bed
Should resident see soiled side of dressing?
No
What should you note when changing a dressing
Color
Odor
Drainage
What do ace bandages do?
Help decrease swelling
Hold dressings in place
Secure splints
Support and protect body parts
How should bandage be wrapped?
In figure 8 pattern
So no part of wrapped area is pinched
Why shouldn’t you tie a bandage?
Cuts off circulation
Signs and symptoms of poor circulation
- Swelling
- Pale gray cyanotic skin
- Shiny, tight skin
- Skin that is cold to touch
- Sores
- Numbness
- Tingling
- Pain or discomfort
What should do in case of poor circulation?
Loosen bandage and notify nurse
Normal diastolic BP
60-79 diastolic
What is sims position
Resident lying on left side to straighten colon for rectal temp
