Domain 2: Provision of Care

Question 1

Domain 2: Provision of Care

Answer 1

Domain 2: Provision of Care
This domain refers to application of the knowledge, skills, and abilities required to deliver person centred care, which includes recognizing and supporting the unique needs and abilities of the client. Care activities in this domain are directed to supporting, promoting, and maintaining the health and well-being, safety, independence, and comfort of the client. HCAs provide care under the supervision of a regulated professional and follow the client’s care plan.

Question 2

Assisting with Client Mobility

Answer 2

Role and Responsibility Alert!

The HCA must be sure that the mobility aids used for each client are safe and in working order. In addition, only the mobility aids outlined in the care plan are used for the client according to the instructions provided by the regulated health-care professional. If the client’s condition has changed at all and you are concerned she may not have the strength to use the mobility aid outlined in her care plan, you must notify the regulated health-care professional before assisting the client. For example, you may have a client who normally uses a cane but currently is weak and cannot sit alone on the edge of the bed (Government of Alberta, 2013).

Question 3

One-Person Transfers. Two-Person Transfers?

Answer 3

The client should be alert and co-operative during a transfer. Before doing the transfer, always do a micro-assessment of the client’s alertness, strength, and behaviour.

Any splints or positioning devices should be put on properly before the transfer. For example: A leg splint may need to be on the client prior to the transfer to keep the leg in proper alignment during the transfer process.

Ensure that the client’s hearing aids and glasses are worn so the client can hear your instructions during the transfer and see where she is going.

· Footwear with non-skid soles must be worn by the client.

· Have the client actively participate as much as possible to maintain his independence and reduce strain on you.

· Ensure that the environment is free of clutter and there is enough space to perform the transfer safely.

· Use proper body mechanics when completing the transfer. Do not twist or rotate your spine.

· Always communicate with the client and to the other caregiver. The client must know what she is expected to do and where she will be transferred to.

*One-Person Transfers

One health-care worker transfers the client using a transfer belt. The client needs assistance with balance and is able to fully or partially weight-bear (Alberta Health Services, 2015).

Always check the client’s care plan to know which transfer method to use (Alberta Health Services, 2015).

*Two-Person Transfers

Two health-care workers transfer the client using a transfer belt. The client requires more support, but is still able to bear partial weight (Government of Alberta, 2013b; Alberta Health Services, 2015).

Question 4

Manual Wheelchairs and Electric or Power Wheelchairs

Answer 4

Wheelchairs?
A wheelchair may be self-propelled, propelled by a motor or pushed by another individual. Wheelchairs are measured and adjusted specifically for each individual client. As described below, there are two types of wheelchairs (Government of Alberta, 2013).

*Manual wheelchair: A manual wheelchair must be propelled by the client or pushed from behind by another individual.

&Electric or Power Wheelchairs: Power wheelchairs are often used by clients who are physically unable to propel a manual wheelchair and who are able to operate a power wheelchair safely. A power wheelchair allows a client to maintain independence as it doesn’t require someone to push it. Clients can operate the chair using a joystick, chin control, head arrays, or mouth controls. The power wheelchair’s battery needs to be recharged on a regular basis. As a health care aide, you will need to become familiar with the manufacturers’ instructions before assisting a client with a power wheelchair

Question 5

Care and Maintenance of Ambulatory Aids

Answer 5

Regulated health-care professionals, usually the physiotherapist or occupational therapist, assess the client to determine the correct ambulatory aid and set the initial measurements. As a health care aide, you will need to know how to care for the client’s ambulatory aids and recognize when the ambulatory aid is in need of repair or further adjustments. Safety and maintenance checks of ambulation devices should be done on a routine basis.

• Canes: Canes are used to provide support and balance for a client who can weight-bear but who is weak on one side of the body. It is important to regularly check to see it is in good repair and whether the rubber tips are intact.
• Walkers: A walker provides more support than a cane because it has a wider base of support. There are several types of walkers: standard, two-wheeled, and four-wheeled. It is important to regularly check to see whether the rubber tips are intact, and the brakes are working.
• Crutch: Crutches are used for clients with good upper body strength in a variety of situations. It is important to check to see whether the crutches are in good repair and the rubber tips are intact.

*Braces, Splints: A brace or splint is used to support or align weakened body structures during weight-bearing activities. They can also be used to prevent deformities.

*Prostheses: A prosthesis (plural: prostheses) is an artificial body part that is used to replace a natural body part.

Inspect the brace, splint, or prosthetic for wear, damage, or rough edges. Rough edges or a damaged device can cause skin breakdown. Do not use the device on the client until adjustments or repairs have been made. Immediately report your observations to the nurse or regulated health-care professional.

· Remove the device before bathing or showering the client. Soaking in water can cause some devices to warp.

· Using a cloth, wipe the device with mild soapy water and dry well. Hand washes any fabric with soapy water and rinse well. Hang to dry.

• Transfer Belt: A fabric transfer belt is placed around the client’s centre of gravity (usually the waist) and used to assist a weak or unsteady client with standing, walking, or transferring. Transfer belts come in different designs and sizes.

· Inspect the transfer belt for wear, fraying edges, tears, and functioning buckles. The transfer belt is not to be used if it is damaged.

· Machine or hand wash and dry thoroughly. Follow manufacturers’ instructions regarding washing and drying transfer belts.

Question 6

Heel Protectors and Wheelchair Cushions

Answer 6

Pressure ulcers occur when a body part touches a surface for extended periods of time. When too much pressure builds from being in one position for long periods of time blood supply is cut off to that area and breakdown occurs. Some clients are at a high risk to develop pressure ulcers. There are many different types of tools that are used to prevent pressure ulcers from developing.

There are a few different types of heel elevators that are used. One of the most common is called a heel pillow. Heel pillows are padded boots that fit over the calf and keep the foot and leg in a neutral position with the heel open and elevated from the bed.

There are also different types of wheelchair cushions. The cushions depend on function of the wheelchair and the client needs. Typically they are made out of gel, foam, or air cushions.

• Foam: Foam is one of the most common types of wheelchair cushions. Typically foam cushions are a good choice for clients who need a low maintenance, inexpensive, and lightweight surface.
• Gel: Gel cushions are made from a foam base and have a gel layer. Clients find them comfortable and they have a good degree of support and flexibility. However, although they absorb heat very easily, they are not as effective at absorbing shock.
• Air cushions are lightweight and are designed to spread pressure evenly. This allows the client’s skin pressure points to have adequate relief. They are very good at absorbing shock and providing lateral stability. One of the disadvantages is the need to be regularly inflated in order to keep their pressure properly balanced.
• Zero Lift Policy
  In response to reducing the risk of staff and client injuries, many facilities now have a “zero lift policy” or “no-lift policy.” The growing trend shows that clients in care settings are heavier and as such it can be unsafe to lift a client manually. Best practice for caregivers specifies that a “zero lift policy” is the safest approach to client lifting. Clients who cannot weight-bear on either leg, or who are unable to transfer safely, would require a mechanical lift. Check your agency’s policies and procedures prior to lifting or transferring clients. Exceptions are made to this policy in life-threatening situations.

Question 7

Types of Mechanical Lifts: Slings and Sling Placement.

Answer 7

There are various types of mechanical lifts available. It is your responsibility to know the agency’s policies and procedures and the manufacturer’s instructions prior to operating a mechanical lift. You must be properly trained to operate a mechanical lift to ensure the safety of the client and yourself. The three standard types of mechanical lifts are: floor lifts, ceiling track lifts, and sit-to-stand-lifts.

• Floor Lifts: The floor lift is an electrically powered mobile lift. The floor lift can be used in a variety of spaces and rooms, as it is not limited by an overhead track. The caregiver moves the client from one location to another by directing the lift.
• Ceiling Track Lifts: The electrically powered track-lift requires permanent tracks to be installed in the ceiling of the client’s room. The tracks can extend into the adjoining bathroom. The caregiver uses a sling to lift the client and propels her along the track, lowering her at the desired location.
• Sit-to-Stand Lift: The sit-to-stand lift is an electrically powered mobile lift used to transfer clients from one seated position to another seated position. This lift is used for bed-to-chair transfers, toileting and performing perineal care, and changing incontinence briefs. The client must be able to partially weight-bear on at least one leg and have some muscle tone in the trunk. The caregiver moves the client from one location to another by directing the lift.

Slings and Sling Placement: Just as there are many different types of lifts there are also many different types of slings which can be used with each of those lifts. Although you will need to know your site’s equipment, these general tips should assist you.

First, the HCA will need to ensure they are following the care plan for the type of lift used for the client. Clients will have their own slings which are sized differently. The sling size depends on the client’s size, weight, and hip measurement. The choice of sling is based on the manufacturer recommendation for the client’s measurements. If the sling is too large the client may slip out. If the sling is too small, the client may fall out or the sling may worsen the client’s condition. If the client is between sizes, typically it is thought the smaller size may keep the client more secure.

Question 8

Client Grooming and Personal Hygiene Learner Guide

Answer 8

Providing Basic Skin Care: Providing basic skin care is important for both physical and mental health. Healthy skin provides protection and contributes to a sense of well-being. The HCA provides care that keeps skin clean, dry, and moisturized.

Infection Prevention and Control Alert:
Only instruments that can be properly sterilized can be used for more than one client. This includes all tools and instruments used for grooming and nail care. Instruments must be sterilized after use before they are used on another client.

Instruments belonging to a single client (dedicated equipment) must be washed with warm, soapy water, rinsed well, and dried before being stored in a clean place.

Question 9

Bathing the Client and Bed making

Answer 9

Assistive Devices Used for a Client’s Bed: Some clients require special equipment that can be attached to the bed. The equipment is used for a variety of purposes to support the client such as assisting him with transferring, repositioning, and ensuring proper alignment. Many assistive devices give the client greater independence and mobility. As a health care aide, you will be responsible for knowing how to use the assistive devices safely. Always follow agency policy and procedures, and the manufacturer’s instructions.

• Arcorail: The Arcorail attaches to the frame of the bed. It is a bedside handrail that assists clients transferring from the bed to a chair or wheelchair.
• Superpole/Saskapole: The Superpole or Saskapole is designed to assist clients who require support standing, transferring, or moving in bed. It is installed at the side of the bed or the toilet.
• Footboard: A footboard is a padded device placed at the end of the bed. The client’s feet are placed flat against the board. The main purpose of the foot board is to prevent foot drop, which can occur when a client is in bed for long periods of time.
• Bed Cradle: The bed cradle is used to keep the top sheets and blankets off the client’s feet. The weight of the top linens can put pressure on the client’s toes and create pressure ulcers. Bed cradles fit at the end of the bed.

HCA Role and Responsibility Alert! Sheepskins and pressure relief devices such as spanco mats are not to be used between clients. They are single client use only.

Care Plan:
The care plan will outline the specifics of how a client’s bed should be made, whether the client needs to remain in bed during the bed making procedure, and what type of assistive devices, if any, the client uses.

For example, clients who are at a very high risk for skin breakdown may be in a special air bed to help heal or decrease skin breakdown. Check the care plan to identify what kind of linen should be placed on the bed.

Question 10

Assisting with Elimination Learner Guide

Answer 10

Rectal Touch as Related to the HCA Scope of Practice
What is rectal touch? Who decides whether a health care aide can perform this skill? How is it performed?
When a client is suspected of having fecal impaction – the prolonged accumulation of stool in the rectum – the health-care worker may insert a lubricated, gloved finger into the rectum to feel for any hard mass. This is called rectal touch.

If the health-care worker reports feeling a hard mass of stool, the physician will order a laxative or enema to assist in removing the stool. If these methods are not successful in removing the stool from the rectum, the physician or nurse may perform a digital disimpaction.

The Alberta Government Organization Act (GOA) is the legislation that outlines which procedures are considered a restricted activity. In the GOA, it states insertion of a finger or instrument beyond the anal verge is classified as a restricted activity. Restricted activities can only be performed by licensed health-care professionals. In some cases, an HCA may be assigned such a task if it has been determined that the client’s health is stable and that under normal circumstances the client would perform this task for himself or herself if he or she were physically able (an activity of daily living).

Rectal touch is not a task that falls under normal activities of daily living (Government of Alberta, 2013).

If a regulated health-care professional assigns this skill to an unregulated care provider such as an HCA, the following guidelines must be followed:

Role of Adult Incontinence Products
The correct use of adult incontinence products has two parts.

1. Appropriate product
2. Appropriate caregiving when providing incontinence care.

Incontinence products are used to provide dignity and keep the client comfortable and dry. The product’s ability to prevent leakage and odour contribute to a client’s sense of dignity. These products also help to maintain skin health and prevent perineal skin breakdown. The products are designed to absorb several voids and to keep the moisture away from the skin.

The following are different incontinence products clients may use:

• Liners: Used for very light or light urinary incontinence. These are usually a one-size-fits-all and are designed to be worn with regular underwear.
• Bladder control pads: Used in light to heavy urinary incontinence. These are designed to provide comfort, fit, and discretion. They can be worn with regular underwear or reusable briefs.
• Adult briefs: Used in heavy urinary or bowel incontinence. These often contain a cloth-like breathable fabric for more complete protection and improved skin health.
• Skin Creams
  Incontinence products can make skin problems worse. These products may keep the client’s bedding and clothing cleaner however, they allow urine or feces to be in constant contact with the skin. The skin will eventually breakdown over time. The HCA needs to take special care to make sure the skin remains clean and dry.

Wet Wipe/Wash cloth: A non-irritating cleanser which is in convenient, disposable wipes. They gently dissolve irritants (NAFC, n.d.-b).

· Perineal cleanser: A non-soap, non-irritating cleanser which gently dissolves and removes feces and urine. Many of these cleansers contain deodorizers in their formulas. There are many different types which may be for fragile, delicate skin.

· Moisturizing cream or lotion: A protective moisturizer which is specifically formulated for the perineal area.

· Barrier cream or ointment: A barrier cream designed to protect the skin from irritation caused by urine, stool, or excessive moisture.

Antibacterial or Antifungal cream: Creams with a non-prescription strength to topically treat either bacterial or fungal infections.

Question 11

Assist with Nutrition and Mealtimes:

Answer 11

Medical Conditions That Can Cause Dysphagia
There are medical conditions which cause difficulty swallowing (dysphagia). By being aware of these conditions, the HCA will know which clients are at greater risk of having dysphagia. The following is a list of the medical conditions that can cause dysphagia (Government of Alberta, 2013):

· Stroke

· Cancer involving the head and/or neck

· Brain injury

· Parkinson’s disease

· Alzheimer’s disease

· Multiple sclerosis

What Are the Signs of Dysphagia?
Unmanaged dysphagia can lead to dehydration, malnutrition, social isolation, decreased quality of life, respiratory infections, and death. If a client has dysphagia he or she may demonstrate signs of coughing and/or choking while eating. There are other noticeable signs which may occur during or after the meal (Government of Alberta, 2013). They include:

· The client speaks with a wet voice or gargling sound.

· The client makes throat-clearing sounds.

· The client has changes in his breathing pattern.

· The client has a blue colouration around her lips.

· The client has an increased temperature.

· The client drools when eating.

· The client has food particles left in his mouth.

Importance of Following the Care Plan to Meet the Client’s Nutritional Needs
The role of the HCA is to know what nutritional needs mentioned in the client’s care plan. By following the nutritional instructions, client safety is achieved (Government of Alberta, 2013). If instructions are not followed, the client could be harmed and be at risk for the following:

· Aspiration pneumonia

· Choking

· Too many calories

· Not enough calories

· Too much fluid

· Not enough fluid

· Malnourishment

If the HCA has questions or concerns regarding the nutritional instructions on the client’s care plan, the regulated health-care professional in charge should be consulted (Government of Alberta, 2013).

Hand-Under-Hand Feeding
In clients who have dementia, meal time can pose conflicts and responsive behaviours. These responsive behaviours may include being agitated, restless, aggressive, and being combative. Feeding ourselves is one of the first skills we learn as children. In clients with dementia, the ability to feed themselves is one of the last skills to decline.

The most common way of assisting clients to get the nutrition they need is through what is called the direct hand technique. This is when the caregiver holds the utensil and the client is not an active participant. This technique is what people use to feed children. Using the direct hand technique may impact how the client feels about themselves and contribute to increase in responsive behaviours. A better way of increasing effectiveness of feeding clients with less resistive behaviours is the hand-under-hand technique (Dotinga, 2017).

In the hand-under-hand technique the caregiver approaches the client on their dominant side, and holds the utensil. The client’s hand is on top of the caregiver. This engages the client in the eating process.

Texture Modification
To manage dysphagia and meet the client’s nutritional needs, some clients may require their food to have a specific texture and beverages changed in thickness to minimize the risk of choking and aspiration pneumonia. Texture modifications and fluid thicknesses are recommended by qualified health professionals and are described in the client’s care plan.

Texture-modified diets can range in restriction. Often a blender or food processor is required to change a food to the desired texture (Government of Alberta, 2013).

A texture-modified diet provides the following health benefits:

· Safe swallowing to prevent the consequences of dysphagia and aspiration.

Various Types of Texture-Modified Diets

There are different types of diets as outlined in Sorrentino et al. (2018, p. 585). Following are additional diets in more detail as you may see them at your work site (Government of Alberta, 2013).

• Pureed Foods: Foods are pureed to the texture of a pudding or mousse, including pureed bread products.
• Minced Foods

· Foods are minced, grated, or finely mashed.

· Foods are moist and cohesive, and require little chewing with no water separation.

· Regular bread products are allowed, but bread products that are dry or crumbly (e.g., muffins, hard crackers, bagels, crusty buns) should be avoided. In some cases, bread products may need to be pureed.

• Dysphagia Soft Foods

· Foods are soft and moist and served with a gravy or sauce.

· Foods are diced to 1 cm cubed or less on the longest side or can be mashed using a fork in one hand.

·Foods that are dry, crumbly, sticky, gummy, hard, or chewy should be avoided. Examples are crusty buns, bagels, rice, dried fruit, raw hard vegetables and fruits, whole nuts.

• Easy to Chew: This diet is not usually for clients with swallowing difficulties.
  Foods are a softer texture and are easy to chew.
• Finger Foods: This diet is not for clients with chewing or swallowing difficulties.
  Foods are “ready-to-eat” that can be picked up and eaten with fingers. Utensils are not required. Soup is served in a mug.

Regular Foods: This diet is not for clients with chewing or swallowing difficulties.
Foods are served whole and may need to be cut up.

Question 12

Food Safety

Answer 12

Food Protection
Look at this article from the view of working in home care or supportive living where the kitchen is off site.
Growth of Microorganisms

There are six conditions that promote the growth of microorganisms. The key to preventing the growth of microorganisms is to control some or all of those six conditions.
These are six conditions that promote the growth of microorganisms (Government of Alberta, 2013).

• Temperature
  Temperatures between 4 degrees and 60 degrees Celsius create an ideal environment for microorganisms to grow.
• Protein: Bacteria grow quickly in high protein environments, especially fish and poultry.
• Moisture: The higher the moisture level, the better the conditions for growth of microorganisms.
• pH: A neutral pH will promote growth of microorganisms. An acidic or alkaline environment will slow the growth of microorganisms.
• Oxygen: Some microorganisms require oxygen and some require a lack of oxygen.
• Time: Leaving cooked or raw food at room temperature for two hours is long enough to allow pathogens to multiply.

Comparison of Microorganisms

Not all microorganisms are harmful. In fact, some microorganisms can be beneficial to humans, such as the ones used to make yogurt and cheese. However, as a food handler, it is your responsibility to ensure that you are not transferring any microorganisms from the environment onto the food you are preparing or onto the food preparation or storage areas.

There are five common types of microorganisms.

Bacteria: Single-celled microscopic organisms that are the most abundant of all living organisms and that reproduce by division.

Parasites: Organisms that live in or on a host (another living organism) and obtain nourishment from the host without benefiting or killing the host.

Viruses: Microorganisms smaller than bacteria that cannot grow or reproduce apart from a living cell. Viruses cause common human infections.

Moulds: Fungi that are found everywhere – both indoors and outdoors all year round – and that reproduce by producing spores.

Yeasts: Single-celled organisms that are usually larger than bacteria. Individually, yeast cells are invisible to the naked eye but large masses can be easily seen.

It is imperative to ensure that food does not become contaminated with microorganisms. Steps must be taken to protect food from the growth of microorganisms. All food products should be properly protected during storage, preparation, display, and service.

Food may also be contaminated by smoking, coughing, and sneezing; improper handling of foods; insects and other pests; dirty equipment; wastes; and improper storage (Government of Alberta, 2013).

Sanitary Practices: All departments are responsible for maintaining sanitary practices to reduce the risk of food contamination. These practices include the following (Government of Alberta, 2013).

1.Hand washing: Proper hand washing is the number one sanitary practice. Wash your hands when you arrive at work; when you return from a break; after snacking, eating, or smoking; after handling raw food; after handling garbage; after using the toilet; and after using mops and other cleaning equipment.

2. Housekeeping: Housekeeping should have a goal of reducing microorganisms throughout the establishment.

3: Pest Control: Proper pest control helps reduce contamination of food establishments. This is done by: Eliminating all pest nesting areas; Keeping areas clean and uncluttered; Using a good source of light to check for signs of rodents behind and under equipment;

4: Temperature of Food: Failure to monitor temperatures of food from delivery until it served is the cause of most food-borne illness. Both temperature and time need to be controlled to avoid food poisoning. Hot foods must be kept hot and cold foods must be kept cold. Foods are not to be left out between 21 degrees to 60 degrees Celsius for longer than two hours.
The danger zone is the temperature range between 4 and 60 degrees Celsius. Do not allow foods to be left in the danger zone for more than two hours during preparation, cooking, cooling, or serving. Any food left in the danger zone for more than two hours must be discarded

5: Storage Temperatures: Refrigerator temperatures must be kept between 0 and 4 degrees Celsius, and freezers must be kept at –18 degrees Celsius or lower.

6: Safe Defrosting of Food: Hazardous foods should be defrosted in the refrigerator, under cold running water, or in the microwave oven.

7: Cooking Temperatures: The cooking temperature for whole poultry products with or without stuffing is 85° C. The cooking temperature for poultry pieces such as drumsticks and wings, and for ground poultry, is 74° C as well as for food mixtures containing poultry, eggs, meat, and fish. For pork and pork products it is 71° C, and for fish it is 70° C.

8: Heating and Cooling Rates: Reheat foods quickly – do not put them in the steam table to reheat. The safest guideline for re-heating food is to reheat all food to 74 °C for 15 seconds.

9: PH, Oxygen, and Moisture on Food Spoilage: Most microorganisms grow best at a pH of about 7 and cannot grow in an acidic environment. Adding an acid like vinegar or vitamin C (citric acid) will increase the acidity and limit bacterial and fungal growth.

Potentially Hazardous, Non-Hazardous, and Perishable Foods
There are two conditions that make food potentially hazardous. The first condition is that the food itself contains microorganisms that cause food poisoning if allowed to multiply – for example, salmonella in raw eggs, poultry, and fish. The second condition occurs when the food is not properly handled and stored, which provides perfect conditions for microorganisms to grow. Examples include improper storage of milk, cream, custards, salad dressings, and gravies.

• Potentially hazardous food” describes a food that is natural or synthetic and that requires temperature control because it is in a form capable of supporting rapid and progressive growth of infectious or toxigenic microorganisms, growth and toxin production of clostridium botulinum, and the growth of salmonella enteritidis in raw shell eggs. Potentially hazardous foods include raw or cooked animal foods such as meat, fish, poultry, eggs, cut melon, sliced tomatoes, raw bean sprouts, milk and milk products, and custards and gravies.
• Non-hazardous foods” do not require time/temperature control for safety. These foods can be stored at room temperature in dry storage, in a refrigerator, or in a freezer. It is important to read the labels of all canned and pre-packaged foods to determine the safe storage requirements.

Prevention of Food-Borne Illness:
Time and temperature work together to determine whether food is safe to eat. Remember that bacteria can multiply to double their number within 20 minutes in food left in the danger zone. The total amount of time during which a potentially hazardous food can sit at room temperature (danger zone) is two hours.

To prevent the spread of microorganisms, follow the four main principles of safe food handling:

*Cleanliness – Wash hands and surfaces often.
*Separate – Do not cross-contaminate.
*Chill – Refrigerate properly.
*Cook – Cook to proper temperatures.

Hygiene Evidence-Informed Practices When Handling Food
There are some important evidenced-informed practices that need to be adhered to in order to prevent contamination and food-borne illnesses. Several types of communicable diseases can be transmitted through contaminated food. The passing of these diseases can be prevented by good employee hygiene.

Hand washing is the number one defence against contamination of food. In addition, wearing hairnets when in food preparation or storage areas, and wearing gloves when handling raw or ready-to-eat food, are effective ways of preventing the spread of disease through contaminated food. In addition, maintain a clean working surface and change utensils if they become contaminated.

Question 13

Range of Motion Learner Guide

Answer 13

The Purpose of Range of Motion:
Everyday activities, such as walking, dressing, bathing, and eating, provide our joints with full range of motion. Our joints require movement to prevent stiffness, pain, muscle atrophy, and contractures. You will care for clients who are unable to exercise or even move their joints on their own. Complications related to immobility mean that clients have a high risk for joint and muscle problems. Contractures can develop in as little as 48 to 72 hours when a joint is not being exercised. A contracture is a flexed fixation of a joint caused by atrophy and shortening of muscle fibres. This can result in decreased movement called “limited range of motion,” a term meaning that a specific joint or body part cannot move through its normal range of motion. Motion may be limited by a mechanical problem within the joint, swelling of tissue around the joint, spasticity of the muscles, pain, or disease. Contractures are not able to be reversed.

Range-of-motion exercises can help to maintain joint flexibility. You may be required to encourage clients who are at a high risk for joint and muscle complications to actively participate in range-of-motion exercises. You will need to assist clients who are unable to independently complete range of motion activities with the range-of-motion exercises.

Active, Active-Assistive, and Passive Range of Motion:
Range of motion is the act of moving a joint through full range without causing discomfort or pain to the joint. There are three basic ways in which the client can achieve range of motion.

• Active Range of Motion: Active range-of-motion (AROM) exercises are those exercises that the client can perform independently. The client may still need encouragement and direction from the caregiver. Active range-of-motion exercises can be integrated into activities of daily living. For example, the health care aide can encourage the client to do hand exercises while the client is taking a bath.
• Active-Assistive Range of Motion: The range of motion that a client is able to achieve with some assistance from a caregiver is called active-assistive range of motion (AAROM). The assistance provided may be to support the weight of the limb during the range of motion, or to assist with completing the movement. For example, a client may be better able to complete the range of motion while the health care aide supports the weight of the limb.

Clients who benefit from AAROM are those who:
*Are unable to perform the movement because their muscles are not strong
enough
*Are very weak
*Are uncoordinated
*Are in pain when the movement is performed without support.

Passive Range of Motion: When range of motion is performed on the client by a caregiver, it is called passive range of motion. Passive range of motion (PROM) is performed to prevent contractures and maintain normal flexibility. Passive range of motion is often performed on clients who have paralysis of one or more limbs, are unconscious, have weak muscles, and are at risk for developing contractures.

The limitations of passive range of motion are:
●It does not increase muscle tone or strength
●It cannot reduce adipose tissue
●It cannot prevent muscle atrophy.

Ensure Client Comfort, Support, and Safety Related to ROM: Range-of-motion exercises (ROM) can cause injury (muscle strain, joint injury, and pain) therefore it is important to ensure comfort and safety during exercises. As an HCA this can be done by reading and following the client’s care plan. Follow these practices when assisting with ROM exercises:
*Only exercise joints you have been instructed to
*Expose only the body part being exercised
*Support the part being exercised
*Move the joint smoothly and gently
*Never force a joint beyond its present ROM
*Never force a joint to the point of pain
*Review non-pharmacological methods of pain control that could be implemented while performing ROM (e.g., soft music)
-Remember if the client asks you to stop and complains of pain listen and stop.

When you have completed the ROM exercises it is important to document the findings that include
*Date and time
*Which joints were exercised
*How the client tolerated (did they experience pain)
*Any observations on stiffness or spasm
-Note: never perform ROM exercises on the neck unless you are allowed under your employer’s policy.

Assisting with Active, Active-Assistive, and Passive Range of Motion (ROM)
Performing ROM:
*Check the client’s care plan when assisting the client with range of motion.
*Make sure that the client is in proper alignment during ROM.
*Perform ROM for the ordered number of repetitions. Usually each motion is repeated three times for passive ROM.
*Work in a sequence. For example, from shoulder to toe down the client’s body. Start on one side of the body from shoulder to toe and then complete the other side.
*Do not use any quick movements. Perform the motions deliberately and slowly.
*Stop the movement if the client feels pain.
*Know how much ROM the client has. Do not force the joint beyond its normal range.
*Gently grip and give support to the client’s joints, legs, or arms.
*Observe the client during the ROM exercises; report and document your observations appropriately.

*Active ROM: The client can perform the exercises sitting, standing, or lying down. Ensure that the client’s body is in good alignment.

*Passive ROM: The client should be lying in bed and in proper body alignment.

Role and Responsibility Alert!
Passive ROM of the neck is omitted because it is considered high risk due to potential injury to the client’s neck and should be performed only by a health-care professional.

Question 14

Assisting with Wound Care Learner Guide

Answer 14

Integumentary System and Maintaining Skin Integrity
Our skin plays an important role in our overall health. Understanding the structure of the skin and knowing how to identify risk factors that lead to skin breakdown will help you assist your client’s skin integrity and client comfort.

Structure of the Skin:
The skin consists of two layers. The epidermis is the outer, protective, nonvascular layer of the skin. The dermis is the inner layer that is composed of sweat glands, nerve endings, and vessels. Skin ranges in thickness depending on where it is located on the body. The thickest area is on our heels and the thinnest layer of skin is on our eyelids. Our skin is considered the first line of defence against trauma and disease. Skin provides a barrier against:
*Microorganisms
*Chemicals
*Heat and cold
*Pressure
*Friction

The skin also prevents excessive water and fluid loss. It helps the body to regulate temperature through the evaporation of moisture through the sweat glands. Injury to the skin layers puts the client at risk for infection and associated health problems.

-Skin Breakdown Risk Factors

There are many different factors and conditions that can lead to breakdown in skin integrity. By understanding these factors, you play a vital role in preventing wounds and giving assistance with wound healing.

• Aging Skin: The elderly are at a higher risk for skin breakdown because sebaceous glands produce less natural oil and the skin becomes very dry. As people age, the skin becomes thin and fragile due to dermal and subcutaneous tissue loss. This reduces the skin’s strength and elasticity. The elderly are more prone to skin tears.
• To protect intact skin, the client should bathe in warm, not hot, water. Hot water is drying to the skin. In addition, only tub bath or shower a client one to two times a week, as frequent bathing is drying to the skin. Always use a pH-balanced skin cleanser and apply a good quality lubricating lotion.

*Immobility: Clients unable to change their position frequently have an increased risk for pressure breakdown.

-It is the responsibility of the HCA to reposition immobile clients at least every two hours around the clock or as indicated in the client care plan.

• Pressure: A pressure injury (also known as pressure sore, bed sore, decubitus ulcer) is an area of skin that breaks down when you stay in one position for too long without shifting your weight. Pressure ulcers usually develop over bony prominences, the most common areas being the heel, coccyx, head, and elbows (refer to figure 24-1 of the Mosby 4th ed. Textbook). The unrelieved pressure prevents nutrients and oxygen from feeding the affected tissue. As a result, the tissue dies.

The best ways to prevent a pressure injury are as follows.

● Observe for any reddened areas that do not disappear after 15 minutes when a client is repositioned; report the observations to the regulated health-care professional.
●Never rub or massage a reddened area, especially one that appears on a bony prominence.
●Reposition clients frequently – at least every two hours.
Keep the skin clean and dry as accumulation of moisture can cause ulcers.
●Follow the client’s care plan regarding positioning aides and devices. Observe if positioning device is causing any reddened areas on the skin.
●Keep the client well hydrated and monitor dietary intake.
● Ensure that the client is not lying on tubes, wrinkles, or bunched-up linens.
● Use pressure relief devices as indicated in the care plan (National Pressure Ulcer Advisory Panel, 2016).

• Friction: Friction occurs when two surfaces rub together and wear away the outer layers of the skin. This type of wound is often seen on the elbows or heels due to clients rubbing against things like bedsheets. In some cases, when clients are being transferred, the buttocks and back suffer friction wounds from the lift sling.

-When moving a client up in bed or repositioning her from side to side, avoid dragging the client across the sheets.

Shearing Force: Shearing force occurs when the skin remains in a fixed position and the underlying tissue slides in the opposite direction. An example of this occurs when a client slides down in bed when the head-of-bed (HOB) is raised more than 30°. The underlying tissue and blood vessels are stretched and torn resulting in tissue death.

Do not leave a client in an elevated position for prolonged periods of time unless indicated by the care plan. Reposition and change the angle of the head of the bed frequently (Government of Alberta, 2013).

• Moisture and Heat: An excess of heat and moisture can lead to skin breakdown. Perspiration, drooling, incontinence, and wound drainage all have damaging effects on the skin. Moisture and heat promote the growth of microorganisms.

Cleanse and dry the skin as soon as excess moisture is noted (Government of Alberta, 2013).

• Poor Nutrition and Fluid Intake: Proper nutrition and hydration are essential to all aspects of our health, including the prevention and care of wounds. Wound healing requires additional protein and calories. Encouraging clients to drink more fluids helps to keep their skin moist; this can decrease the risk of skin tears. Hydration is important in maintaining blood volume which, in turn, promotes healthy circulation and tissues.

Stages of Pressure Injury
Pressure injuries are classified into four stages of severity. As a health care aide, your role is to observe and report the condition of the client’s wound. Your role is not to assess and stage your client’s pressure injury.

Stage 1 Pressure Injury
In Stage 1, the skin is intact and often red in colour. A red area that won’t go away is the first sign a pressure sore is developing.

Stage 2 Pressure Injury
In Stage 2, the reddened area blisters or forms an open wound. The wound looks like an abrasion, a blister (broken or unbroken), or a shallow crater.

Stage 3 Pressure Injury
In Stage 3, the skin breakdown now looks like a crater and there is damage to the tissue below the skin. The pressure injury has become deeper. Subcutaneous tissue may be visible but bone, tendon, or muscle is not exposed. Discharge may be present, and the client will likely be in pain.

Stage 4 Pressure Injury
In Stage 4, the pressure injury has become so deep that there is damage to the muscle, tendons, joints, and bone. Discharge may be present and it is likely that the client will not be in pain.

-Always follow the care plan carefully for the care of an injury. Pressure injuries in this stage require complex wound dressings that will be applied by a regulated health-care professional.

These are the care goals for an HCA working with a client with a stage four pressure injury:
●Protect the wound; ensure that the dressing is clean and in place.
● Report any odour or increase in discharge from the wound.
●Position the client off the wound.
●Follow the care plan and directions of the regulated health-care professional for bathing clients with a Stage 4 pressure ulcer.

-Non-sterile Dressings
Clean technique and non-sterile dressings are considered the same. Clean technique means using strategies to decrease the number of germs (microorganisms) from being transferred onto a wound. Non-sterile dressings are used to protect open wounds from contamination as well as absorb any drainage that comes from the wound. When performing a non-sterile dressing a clean technique (aseptic technique) is used. If there is more than 1 wound, each wound is considered a separate non-sterile dressing.

Non-sterile dressings can be delegated to HCAs. When performing a non-sterile dressing change using clean technique it is important to perform excellent hand hygiene and maintain a clean area where the dressing change will take place (WOCN, 2011). This means that you will be using clean gloves and instruments.

Generally the equipment that is needed consists of:
*normal saline solution
*gauze pads
*topical agent (prescribed) or special dressing materials
*scissors
*tape
*non-sterile gloves
*trash bag
*linen protector
-Note: Always check to ensure that changing a dressing has been delegated to you prior to doing a dressing change. Always check the clients care plan and follow the instructions exactly. If in doubt always ask prior to undertaking a dressing change.

• Care Plan
  Following the client’s care plan can be the most important step in preventing and caring for wounds. The care plan will outline which interventions to follow when providing client care such as the use of positioning aids, nutrition supplements, and simple dressing applications. The care plan will also assist in providing information to ensure safe care for diverse clients. As a health care aide, it is not within your scope to make the decision as to what type of dressing to apply to your client’s wound; this requires a nursing assessment. Your responsibility is to follow agency policies and procedures and follow the interventions outlined in the care.

Assisting Clients with Diverse Needs during A Dressing Change.
Dressing changes can be scary and intimidating for clients without diverse needs and therefore, you must take into consideration that anxiety may be heightened for those clients who have diverse needs (e.g., dementia or palliative care clients). In all aspects of care it is important to follow the client’s care plan.

-Non-pharmacological ways to assist with pain control during a dressing change
Pain control during a dressing change can often be a part of the care planning when assisting a client with a dressing change. Measures other than medications can assist the client’s overall experience to find comfort throughout the procedure. Non-pharmacological methods can include distraction, relaxation, and guided imagery.

Distraction: Involves directing the client’s attention away from any discomfort with the use of conversation, music, television, games, and other activities or items the client may enjoy.

Relaxation: Involves the elimination of mental and physical stress to reduce anxiety and pain. Ensuring the client is in a comfortable position and quiet space will assist in the promotion of relaxation. Deep breathing exercises and meditation techniques may also assist in achieving a relaxed state for the client.

Guided Imagery: Assist the client to create a pleasant and calming image in their mind and instruct them to focus on that image. Examples may include being outside in the sun with the wind lightly blowing. To enhance this experience, the HCA may choose to use a softer tone, music, a blanket, and lighting to assist the client with the mental picture or image they have chosen.

Question 15

Assisting with Nasogastric and Gastrostomy Care and Tube Feeds Learner Guide

Answer 15

The Digestive System, Nasogastric and Gastrostomy Care, and Tube Feeding:
Our gastrointestinal or digestive system has two major functions. One function is to eliminate waste products through the excretion of stool. The other function is to digest or break down nutrients in food into simple chemicals that can be absorbed into our bloodstream. If a client is unable to take in nutrients orally, but the stomach and intestinal tract are still able to digest, enteral tube feeding is an alternative. Nasogastric tubes are inserted into the nose and down into the stomach or small intestine for feeding. Gastrostomy tubes are surgically inserted into the stomach for continuous or intermittent feeds. For continuous feeds, a jejunostomy tube is surgically inserted into the small intestine. Enteral feedings provide a means for the body to receive nutrients via the digestive tract as well as maintain bowel.

The Importance of the Client’s Care Plan in Tube Feeding
It is critical that you understand your role when providing support and care to a client on a tube feed. Some agencies may permit health care aides to start feeding pumps, administer the formula, and irrigate the feeding tubes. The health care aide will need to be specifically trained for such tasks. It is the health care aide’s responsibility is to know agency policies and procedures for tube-feeding care and to follow the interventions outlined in the care plan. The care plan will outline what equipment to use for tube feeding, the kind of formula required for the client, and specific care for the client on a tube feed. Assist with tube feeding only after you have been trained by a health-care professional in your agency.

Enteral Tube Site Care:
Gastrostomy, jejunostomy tube feed sites are located on the abdomen and require observation and care. It is important to observe the tube exit site and observe the skin around the site for signs of infection, swelling, redness, foul odour, wound drainage, and bleeding. The HCA should report all abnormal signs to the nurse. If the site includes a gauze dressing ensure the dressing is dry, moisture can compromise the integrity of the skin. Note any drainage including colour and consistency, and if odour is present. If it is within the HCA’s role as identified by province/territory, policy/procedure and job description follow evidence-informed practice, along with the care plan for instructions on how to clean the tube site using a prescribed cleaner or mild soap and warm water (Potter, Perry, Stockert, & Hall, 2014).

Compassion for Clients with Diverse Needs Receiving Enteral Nutrition:
Food and water are not only a necessity for life they are a large component in the social and emotional health as well. Clients with Divers needs such as dementia may forget that they have a tube feed. They may become frightened when they see the tube feed. Reassure the client, offer a distraction, use therapeutic touch, and provide a dressing to cover the tube feed if the client is fixated on the tube. Removing the visual may offer enough distraction especially if there is a concern the client may manipulate the tube or the tube causes distress for the client. If a dressing is present when you attempt to observe the tube site, have the client lay down when you remove it so not to upset them.

Some clients may also find it difficult to sit long enough to receive their eternal nutrition. Ensure that the client is positioned correctly and comfortable to assist them to stay seated. Set up an activity such as a puzzle, crafts, or simply engage your client in conversation. Ensure the environment is supportive of your client, it should be a quiet and clam space, which may assist a client with dementia to relax. However, if appropriate offer to set the client up in the dining room for their tube feed if appropriate to meet social and emotional needs.

Preparing the Client for a Tube Feed, Setting up Equipment, and Measuring and Recording Intake
Role and Responsibility Alert!
1.Administering a tube feed is a restricted activity for health care aides. If your agency requires you to perform this task, the following steps must be taken:
2. The client or client’s family must agree to have this task completed by an HCA.
3. The regulated health-care professional must be willing to supervise the HCA.
4.The HCA must receive training for administering the tube feed to a specific client.
5. The client’s condition must be stable and the outcome of the procedure must be predictable.
6.The HCA must be directly supervised by a regulated health-care professional until he or she is competent in the skill and feels confident in his or her ability.
7.Indirect supervision must be available at all times.
8.Any change in the client’s condition must be reported to your supervisor immediately.
9.The client’s care plan must be followed at all times (Government of Alberta, 2013).

Question 16

Assisting with Urinary Catheter and Drainage Systems Learner Guide

Answer 16

Conditions Requiring Urinary Catheters and Drainage Systems
A urinary catheter is used for many reasons:

· To drain urine when the bladder’s muscles or nerves are not working properly. This can be caused by a spinal-cord injury, multiple sclerosis, or other nerve conditions.
·To help to keep the incontinent client dry for the purpose of protecting wounds and pressure ulcers from urine.
· During and shortly after surgery to monitor urinary output.
·For urinary retention. For example, a male client with an enlarged prostate may have the symptoms of straining to urinate or the inability to urinate. The enlarged prostate can put pressure on the urethra and cause urination problems; therefore, a urinary catheter may be required.
·To closely monitor urine output for an ill client.
·To collect a sterile urine specimen. It can be difficult to collect a sterile specimen from a pediatric or incontinent client, and an intermittent or straight catheter may be used.
·A client may have a suprapubic catheter because of an injury to their urethra and urine is no longer able to pass through.

Care of Urinary Catheters and Drainage Systems:
It is critical that you understand your role and limitations as a health care aide when you are caring for a client with a urinary catheter. There is a significant risk to the client who requires this procedure. The risks may include introducing organisms which cause infections in the client’s bladder, and damaging the urethra or bladder when inserting a urinary catheter. If a nursing professional assigns you the task of inserting a catheter, you must be properly trained for the specific client before performing this task. In addition, you must strictly follow any agency policy and procedures when you perform the assigned task.

Reducing the Transmission of Microorganisms during Catheter Care

· Provide good peri-care. Clean the urinary meatus around the catheter. Use a clean washcloth, warm water, and soap to gently wash the urinary meatus. Wash in a circle-like motion, moving away from the meatus.
· Ensure that you use clean technique when cleaning around the suprapubic catheter site. Always cleanse the site in a circular motion wiping outwards away from the tube insertion site.
· Always wear gloves when emptying the urinary drainage bag.
· *Keep the drainage bag below the level of the bladder at all times. If the bag is above the bladder, stagnant and contaminated urine may flow back down the tubing and enter the bladder. This can cause a urinary tract infection.
·Keep the urinary drainage bag off the floor.
·When emptying the urinary drainage bag, ensure that the drainage spout does not touch anything. Wipe the drainage spout with an alcohol swab after draining urine from the drainage bag. The urinary drainage system is a closed system, and opening the system increases the chance of infection for the client.
*Place the catheter tubing so it does not kink or loop. When the client is getting into bed, hang the urine bag beside the bed. Make sure the bag is below the level of the bladder. If you use movable bed rails, do not hang the urine bag on the bed rail. Hang the bag on the frame of the bed instead.

Observe, Measure, and Record Urinary Output
Urinary drainage bags must be emptied when 2/3 full, at the end of every shift or as stated in the client’s care plan. When emptying the urinary drainage bag, you will need to measure the urine output, observe the characteristics of the urine, and record your findings (Government of Alberta, 2013).

Do not use the urinary drainage bag to measure output. The measurement guide on the drainage bag will not provide you with an accurate or reliable measurement. A graduated container is used for measuring output. The graduated container is marked in millilitres.

Once you have drained the urine from the drainage bag into the graduated container, you will need to observe the urine for any abnormalities. You should note the urine for colour, odour, clarity, any particles, and the amount. If anything abnormal is noted, you must document and report your observations to your supervisor

The average human urinates about 1500 millilitres of urine a day. Normally, urine will be pale yellow in colour, clear, with few or no particles, and have a faint odour. Abnormal urine may be brown, dark orange, or red-tinged in colour. The urine may have a foul odour and contain particles.

To obtain an accurate measurement, read the graduated container on a flat surface at eye level. Record the measurement on the intake and output sheet or in the client’s chart.

Question 17

Assisting with Ostomy Care Learner Guide

Answer 17

Conditions Requiring Ostomies:
A client may have a permanent or temporary ostomy. A temporary ostomy is created to divert feces to allow the bowel to heal after an injury or disease. A permanent ostomy may be required when disease or trauma impairs normal bowel function or when the muscles or nerves that control the rectum do not work properly. When part of the urinary tract is not functioning, a urostomy may be required to divert urine flow.
Conditions involving the bowel or the bladder may require an ostomy.

*Bowel
*Colon cancer
*Trauma to the bowel (e.g., serious puncture wound)
*Diverticulitis
*A bowel obstruction
*Crohn’s disease
*Inflammatory bowel disease
*Birth defects
*Bladder; Bladder cancer
*Trauma to the bladder (e.g., crushed in a motor vehicle accident)
Nearly 80% of ostomy procedures are performed because of cancer.

Urostomy Care
Defining a Urostomy:
A urostomy is a surgical procedure in which the surgeon makes an opening in the abdominal wall above the bladder. The bladder is either bypassed or removed. The urine is passed out of the body through an opening called a stoma. The stoma is round or oval in shape, should look pink or light red in colour, and will be moist and shiny in appearance.
There are a number of reasons why a client may have a urostomy. Some of the common reasons are:
*Bladder cancer
*Bladder problems caused by neurological conditions such as multiple sclerosis
*Birth defects
*Inflammation of the bladder

• Reassuring Clients with a Urostomy
  Clients of any age may have a urostomy. Many of them may still be physically or socially active. The client may worry about leaks from his pouch, unsightly bulges under his clothing and/or unpleasant odour.

As an HCA assisting the client to care for his urostomy, providing timely, accurate care can go a long way to helping the client stay active in his community or in the facility. Reassure him that it is normal to have these fears, but that proper care of the urostomy will prevent the problems he fears.

Care of Ostomies
The Ostomy System:
There is an extensive selection of supplies available for ostomy care. As a health care aide, you will not determine which type of ostomy system your client should use; this is often based on the assessment of the nurse or preference of the client. Your role is to assist with applying the system, caring for the skin around the ostomy site, and observing and reporting any abnormalities to your supervisor. It is important that you be familiar with the common types and supplies needed for ostomy care. It is also important that you understand the procedure for changing the ostomy system. Remember to assist only as far as the limits of your role, level of training, and competency allow. Always follow your agency policy and procedures and the client’s care plan.

Ostomy System Types

The system contains two basic parts – a pouch and a skin barrier. The pouches come in a two-piece system or a one -piece system. The pouches can be reusable or disposable. The reusable pouches have an open end and are drainable. A clamp or a secure closure is used to keep drainable pouches closed. A disposable pouch does not have a drainable port and is thrown away after use.

Two-Piece Ostomy System
In a two-piece pouching system, the ostomy pouch and skin barrier are separate. A two-piece system also has a flange. The flange is a plastic ring on both the pouch and skin barrier that allows for a secure attachment. To work, both flanges must be the same product and size. Since the pouch can be removed without removing the skin barrier, it causes less irritation to the skin surrounding the stoma.

One-Piece Ostomy System
The ostomy pouch and skin barrier are joined together permanently in a one-piece pouching system. The pouch and skin barrier are applied and removed together in one piece. Frequent changes can cause skin irritation and skin breakdown around the stoma.

-Ostomy Supplies:
Ostomy accessories are abundant and specific to the needs of the client. It is important that you be familiar with some of the more common supplies used with ostomy care.

• Barrier paste is like a caulking and is not to be used as an adhesive. The barrier paste is used to fill in spaces and irregular surfaces when applying the skin barrier. An example would be a client with an abdominal fold under the skin barrier; the paste fills in that area and decreases the risk of leakage.
• Barrier rings or strips are used to fill uneven areas when applying the skin barrier around the stoma.
  *Barrier powder absorbs moisture on reddened or irritated skin.
  *Barrier wipes are often used on fragile skin. The barrier wipes add a thin layer of sealant to the skin. This helps protect skin against the stripping caused by constant removal of skin barriers and other adhesives.

*Ostomy belts help secure an ostomy pouch. The belts are to be snug but not too tight. Allow two fingers to fit under the belt.

*Pouch deodorizer helps to eliminate odour during pouch changes. Some deodorizers contain a mineral oil to assist with the drainage sliding out of the pouch.

*Charcoal filter is a vent in an ostomy pouch that allows gas to escape and be deodorized. The filter may be integrated into the pouch film, as in a closed pouch, or it may be replaceable, as in a drainable pouch.

Changing an Ostomy System

The client’s care plan will outline when the client’s ostomy should be changed and the supplies required for the ostomy change. A two-piece ostomy system typically stays on for 5 to 7 days (less if the ostomy is new or the client is experiencing diarrhea) or needs to be changed when:
*The client complains of burning or itching under the skin barrier
*The system is leaking or loose
*The system has been on for the length of time specified by the care plan or agency policy.

Emptying an Ostomy Pouch:
When a client has an ileostomy, colostomy, or urostomy, the stool or urine is no longer eliminated through the anus or urethra.

Skin Care:
It is essential that the skin surrounding the stoma (peristomal skin) remain healthy and free of irritation. Each time that you change the ostomy system, observe the peristomal skin for redness, swelling, areas of weeping, or rash.

·*The frequent removal of the skin barrier can cause skin stripping to the peristomal skin. Ensure that you hold the skin taut and carefully ease the skin barrier away from the skin.

Stoma Care:
As a health care aide, observe the stoma for anything abnormal, and document and report any concerns to your supervisor.
*A healthy stoma will be shiny, wet, and red in colour.
*Typically, the stoma will have a round or oval shape and vary in size.
*The stoma is rich in blood vessels and may bleed slightly when rubbed.

Hydration:
Dehydration is a concern for clients with ostomies. Encourage the client with an ostomy to increase their fluid intake to 9-12 glasses a day, to avoid becoming dehydrated. Clients with an ileostomy or urostomy are at a greater risk for dehydration and urinary tract infections and may need to increase their water intake substantially. Please ensure you follow the direction of the clients care plan, along with policy and procedures of your agency.

Care Plan:
Ostomy care is client-specific and is individualized to meet the client’s needs. It is the health care aide’s responsibility to know agency policies and procedures for ostomy care and to follow the interventions outlined in the care plan. The care plan will outline what types of ostomy system the client uses, when the system should be changed, and what supplies are needed and how to apply them. Assist with ostomy care only after you have been trained by a health-care professional in your employing agency

Compassion for Clients with an Ostomy
An ostomy of any kind can be extremely hard for a client. It is important for you to understand that some clients may be experiencing frustration, anger, despair, and anxiety with these conditions. The client may also feel embarrassed as they have no control over their elimination. The client may have concerns related to body image, flatus, leakage, and body image. You will play a large role in listening to your client’s feelings and needs. You will also play a large role in being their advocate if they require additional support.

Question 18

Measuring Vital Signs, Pain, Height, and Weight Learner Guide

Answer 18

Temperature, Pulse, Respiration, Blood Pressure, and Oxygen Saturation Levels
Temperature

Body temperature (T) is the measurement of the amount of heat in the body. Temperature is most commonly measured in Celsius (C). There are different sites on the body where body temperature can be taken.

The most common sites for temperature measurements are listed as follows:

· Mouth (oral temperature): The thermometer is inserted under the tongue and held in place for a few minutes.

· Axillary (under the arm): The thermometer is inserted under the armpit (axilla) of the client. This is the least accurate measure of body temperature.

· Ear (tympanic temperature): A special electronic instrument is inserted into the ear canal and provides a temperature reading within two to five seconds. Tympanic temperatures are very accurate.

· Forehead (temporal artery temperature): The temporal thermometer is non-invasive and is scanned across the temporal artery and forehead. It provides a quick and accurate measurement of body temperature.

· Rectal: This is the most invasive method as it requires a thermometer to be inserted into the client’s rectum and held in place for several minutes. It is also a very accurate measurement.

Role and Responsibility Alert!

Refer to agency policies and procedures to know which sites you will be using when taking the client’s temperature. For example, taking a rectal temperature is considered a restricted activity and is an assigned task. The Government Organizational Act outlines that inserting or removing instruments (such as a rectal thermometer), devices, fingers, or hands beyond the opening of the anal verge is a restricted activity. If you are assigned a restricted activity such as assisting the client with blood glucose monitoring, you must be specifically trained on the task for each client.

Regulated health-care professionals may assign this restricted activity to a health care aide. However, health care aides must be properly trained and the assignment of the task must be appropriate to the client’s needs. The health care aide must be directly supervised by a regulated health-care professional until the health care aide is competent and can perform the skill safely. Every agency has policies and procedures that prescribe the role and responsibilities of health care aides when assisting with vital signs. It is the responsibility of the health care aide to know what is expected in the execution of his or her duties.

Factors That Affect Temperature

You need to know the normal ranges for body temperature for your clients. The normal temperature range for an adult is 35.5°C to 37.5°C.

Many factors can affect body temperature. Body temperature decreases as people age. A reduced metabolism and decreased amounts of subcutaneous tissue cause the elderly to have slightly lower temperatures than those who are younger. For all people, body temperature is lowest in the morning and highest in the late afternoon or the evening.

Other factors affecting body temperature include the following:

*Exercise increases heat production within the body and will temporarily increase body temperature.
*Illness creates fever, which will increase body temperature.
*Emotional states such as stress will increase temperature.
*Environmental temperatures will cause body temperature to increase or decrease.
*Infections will increase a client’s body temperature.
*The menstrual cycle and ovulation will cause a woman’s body temperature to rise.

Pulse:
The pulse (P) can give very important information about the health of a person. Any deviation from normal heart rate may indicate a medical condition. For example, tachycardia may signal the presence of an infection or dehydration.

The normal adult pulse rate is between 60 and 100 beats per minute. The pulse rate is faster in children and slows down with age. However, a client’s pulse rate may be affected by a number of factors:

·*Exercise increases heart rate. Exercise over time will result in a lower resting pulse rate.
*Pain increases heart rate.
*Postural changes will change pulse rate. Pulse rate increases when sitting or standing, and lying down will decrease pulse rate.
*Emotions such as stress will increase heart rate and, of course, relaxation will decrease pulse rate.
*Body temperature will affect pulse rate. If a client has a fever or is hot, the heart rate will be higher, but hypothermia will slow the heart rate.
*Caffeine will increase heart rate.
*Pulmonary conditions such as asthma or COPD will increase pulse rate as the body tries to oxygenate the tissues.

Rhythm is the pattern of the pulsations, and the pauses that occur evenly between them. The pulse is noted to be in a regular or irregular pattern. An abnormal rhythm is called dysrhythmia. The force or quality is the strength of the pulse. Pulse strength may be described as strong, bounding, weak, or thready.

Respiration

Respiration (R) is the process of breathing. One respiration is one cycle of breathing in and out. The health care aide will observe the rate, depth, rhythm, and the sound quality of the client’s respirations for the duration of one minute. Respirations are normally measured by watching the chest of the client rise and fall. The normal respiratory rate for a resting adult is 12 to 20 breaths per minute. Respiration rates vary with age and normally decrease with age. A number of factors can affect respiration:
*Exercise will increase respirations to meet the body’s need for additional oxygen.
*Smoking increases the rate of respirations.
*Body position will affect respiratory depth. Standing or sitting promotes lung expansion while lying flat prevents full lung expansion.
*Pain can cause shallow breathing and increase a client’s respiration rate.
*Anxiety will increase respiration rate and depth.

Blood Pressure: Blood pressure (BP) is the force of the blood pushing against the walls of the arteries. Each time the heart beats, it pumps out blood into the arteries. The pumping action of the heart must create enough force to push blood through the arteries, into the arterioles and, finally, into the tiny capillaries where the porous walls allow fluid exchange between the blood and body tissue.

High blood pressure or hypertension can lead to serious health conditions. A blood pressure that is consistently greater than 140 mm Hg systolic is considered high. Hypertension is the number one risk factor for stroke and a major risk factor for heart disease.

Low blood pressure or hypotension happens when the systolic pressure falls below 90 mm Hg or lower and the diastolic pressure falls below 60 mm Hg. Low blood pressure can cause dizziness and light-headedness in some clients and, consequently, may lead to falls.

Orthostatic hypotension occurs when a client changes position from lying down to a sitting or standing position resulting in reduced blood flow to the brain and dizziness or fainting. When assisting a client up from bed to stand, have the client sit on the edge of the bed for at least two minutes before standing. If the client is independent, encourage the client to rise from the lying position slowly.

Oxygen Saturation Levels:
A pulse oximeter is a non-invasive way to measure the level of oxygen in the blood. The pulse oximeter measures critical changes in the client’s oxygen levels. A sensor is commonly attached to the client’s fingertip or earlobe. The sensor detects changes in oxygen saturation levels by monitoring light wavelengths that are absorbed differently by oxygenated and deoxygenated blood cells. Normal oxygen saturation (SPO2) values are 95% to 100%. Values below 90% indicate the tissues are not receiving enough oxygen. In such cases, you will need to notify the regulated health-care professional immediately.

The Care Plan and Assisting with Vital Signs

As a health care aide, you will need to check the agency’s policies and procedures as well as your job description to determine which vital signs you are permitted to measure. Depending on the agency’s policies, the health care aide may be responsible for taking routine vital signs on stable clients. The care plan will state when routine vitals need to be measured. For example, depending on the need of the client, you may be required to take vital signs daily. It also may be necessary to take a client’s vital signs when you observe abnormal signs and symptoms such as rapid breathing, flushed face, or weakness. They should also be taken when the client complains of pain, dizziness, or nausea. When documenting the measurements, be sure to include the date, the vital sign measurement, and the time that the vital sign was taken, as well as any subjective data from the client.

The Care Plan and Measurement of Height and Weight
The relationship between the client’s height and weight will provide valuable information about the client’s overall health and nutritional status. The client’s weight and height baseline data are taken on admission to a facility. The care plan will indicate how regularly the client’s weight will need to be taken. A client’s weight may need to be checked on a regular basis to evaluate nutritional status. Any changes in the client’s weight can be a sign of a health condition. Many medications are prescribed according to body weight. By comparing the present weight to the baseline weight in the client’s care plan, you may find significant changes. For example, a substantial weight loss may be an indication of a serious medical condition such as cancer. Immediately report any changes in the client’s weight to the regulated health-care professional.

Depending on what unit of measurement is required as per facility policy, you may need to convert the measurement before recording it in the care plan. Most facilities use the metric system.

· 1 kilogram (kg) = 2.2 pounds (lbs)
e.g., 150 lbs ÷ 2.2 = 68 kg

· 1 inch (in) = 2.54 centimetres (cm); 12 inches = 1 foot or 30.48 cm
e.g., 5 feet 3 inches = 160 cm

Types of Pain
Pain is the body’s way of signalling that something is wrong.

Acute Pain

Acute pain is sudden pain due to injury, disease, trauma, or surgery, it generally lasts less than 6 months. You may see the following signs:

· Restlessness or agitation

· Sweating

· Tachycardia (heart rate over 100) or tachypnea (abnormally fast breathing)

· Facial grimaces clearly showing discomfort

· Moaning or crying

· Rubbing, cradling, or guarding the place that hurts

· Tense muscles, or a fear of any movement

Chronic Pain

Chronic pain also known as persistent pain; pain that lasts longer than 6 months, it may be constant or occur off and on. It may be caused by such conditions as arthritis or fibromyalgia, and may be accompanied by emotional symptoms. Symptoms of chronic pain include:

· Frustration

· Anxiety

· Decreased appetite

· Depression

· Irritability

As a caregiver, you have an important responsibility to recognize the signs of pain in the clients that you care for and to report your observations to the regulated health-care professional promptly.

Question 19

Assisting with Specimen Collection Learner Guide

Answer 19

Introduction:
A specimen collection may be ordered for a number of reasons. Specimens can help diagnose the health of a client, give evidence that the client is responding to treatment, or provide baseline data for a client prior to surgery or a medical procedure. As a health care aide, you may be assisting the nurse with specimen collection procedures. The health care aide may be responsible for collecting the following specimens: urine, sputum, and stool.

Equipment Used to Collect Specimens:
You will need to use very specific equipment to collect the ordered specimen to ensure proper stability of the specimen and more accurate test results. Identify which collection method and specimen container to use depends on the type of laboratory test ordered. A variety of collection and transport containers for specimens is available.

*Specimen Pan: A specimen pan (also called a specimen hat) sits on the rim of the toilet and is used to collect either stool or urine specimens. The positioning of the pan on the toilet rim is different for urine than for stool specimen collection. The specimen pan is calibrated for measuring output and some will have a colour chart on the inside of the pan to assist with determining the colour of the client’s urine. A grooved pour spout on the front facilitates emptying.

• Specimen Collection Containers: Collection containers come in a variety of shapes and sizes, with lids that screw or snap on. The specimen collection containers protect health-care workers from exposure to the specimen and protect the specimen from contact with contaminants. Some stool collection containers have an attached spoon to make collection more convenient.
• Stool Occult Blood Test Kit: The stool occult blood testing kit (also called a hemoccult test kit) detects blood in the stool. The presence of blood in the stool may indicate a number of diseases and conditions such as stomach cancer and polyps in the colon.
• Obstetrical Towelettes: These are sanitizing wipes used to cleanse the perineum prior to collecting a midstream urine specimen
• Biohazard Disposable Transport Bags: All specimens are considered to be biohazardous materials and are placed in a specifically marked biohazardous bag for transport to the laboratory. Biohazard specimen bags protect health-care workers from specimen leaks and keep the contents free from contaminants. Each bag has a zipper closure and a separate document pouch. The document pouch keeps client information from being lost or contaminated.

Labelling and Transporting Specimens:
All specimens collected from a client must be properly labelled. Inaccurately labelled specimens can cause diagnosis errors, incorrect treatments, and the need to collect another specimen.

Information that must be on the label includes:
·*The client’s name
*The date
The time that the specimen was collected
*The client’s room number (check agency’s policies and procedures)

The Care Plan and Assisting with Specimen Collection:
It is the health care aide’s responsibility is to know agency policies and procedures for specimen collection and to follow the interventions outlined in the care plan. The client’s care plan will identify the type of specimen to be collected and the time at which the specimen must be collected. The accuracy of the laboratory tests depends on the precision and timing of the health care aide’s collection of the specimen.

The Collection of Urine Specimens
A urine specimen is collected for measuring health and well-being and remains an important test for clinical diagnosis. The information obtained from a urine specimen is influenced by the collection method, timing, and handling.

There are three basic types of urine specimens a health care aide can assist in collecting. They are a routine specimen, a midstream specimen, and the 24-hour urine collection specimen.

The Collection of Sputum Specimens
Sputum is produced by the linings of the respiratory tract. A sputum specimen may be ordered for clients with respiratory conditions. This test is done to determine whether the client has a respiratory infection, cancer of the lung, tuberculosis, or pneumonia.

The Collection of Stool Specimens
A physician may order a stool specimen for a variety of possible conditions, such as bleeding inside the gastrointestinal tract, digestive problems, and the presence of ova and parasites. Depending on the reason for collecting the stool specimen, you will need to use specific supplies and collection containers. Be sure you understand the procedure for collecting and transporting the stool specimen, as some stool specimens must be warm for laboratory testing.

Question 20

Assisting with Respiratory Care and Oral Suctioning Learner Guide

Answer 20

Introduction
Oxygen is the most basic human need to sustain life. If a client is struggling to meet his need for oxygen, we know that this need must be met before any quality of life can be attained.

As a health care aide, you will be providing care and support to clients with respiratory conditions. In this module, you will learn the signs and symptoms of someone in respiratory distress, what your role is when assisting clients who have respiratory problems, and the safety precautions to take when assisting with oxygen therapy and oral suctioning.

Conditions Requiring Oxygen Therapy
Normal room air contains about 21% oxygen. Clients with conditions such as respiratory or cardiovascular disease or clients who have just had surgery may not be getting enough oxygen from the room air alone. In such instances, a doctor will order supplemental oxygen to assist clients with their oxygen needs. Oxygen therapy can supply 22% to 100% oxygen concentration (Potter, Perry, Stockert, & Hall, 2014).

Clients may have the following respiratory conditions or cardiovascular diseases, which might necessitate oxygen therapy (Government of Alberta, 2013).

• Emphysema: Emphysema is a form of chronic obstructive pulmonary disease (COPD). This disease occurs when the walls of the alveoli (air sacs) are damaged and become less elastic. The oxygen-poor air is not fully expelled, and therefore oxygen-rich air has difficulty getting into the lungs. Breathing is very difficult for clients with emphysema.
• Chronic Bronchitis: Chronic bronchitis, also a form of chronic obstructive pulmonary disease (COPD), is inflammation of the bronchi. Large amounts of mucus are produced and the bronchial walls swell up.
• Asthma: Asthma is a chronic inflammatory disease characterized by narrowed airways and shortness of breath. The airways become constricted, making it difficult for air to pass through. The muscles surrounding the airways go into spasms, and the airways begin swelling.
• Pneumonia: Pneumonia is an infection of the lungs. The infection causes the alveoli to fill with fluid. As a result, the gas exchange of oxygen and carbon dioxide is impaired, resulting in decreased amounts of oxygen in the blood. The signs and symptoms of pneumonia include fever, cyanosis, a productive cough, chills, pain when breathing, shortness of breath, and rapid breathing.
• Congestive Heart Failure: Congestive heart failure is a condition in which the heart can’t pump enough blood to the body’s tissues and organs. Because the blood is not travelling to the tissues and organs efficiently, oxygen is poorly exchanged.
• Conditions Requiring Oral Suctioning
  Oral suctioning is performed to remove excess secretions from the mouth and nasal passages. A client may be unconscious, weak, and unable to cough up or swallow secretions. The secretions obstruct air flow and can lead to respiratory distress. Respiratory conditions, injuries, and certain diseases can necessitate the need for oral suctioning.

Clients who have had oral surgery or trauma to the mouth may require oral suctioning to remove secretions to promote an open airway. Dementia, multiple sclerosis, Parkinson’s disease, and cerebral palsy are some of the neurological disorders that impair swallowing and may require the client to receive oral suctioning.

Conditions Requiring Mechanical Ventilation and Non-Invasive Ventilation (NVI)
Mechanical Ventilation
Patients may require mechanical ventilation due to hypoxia, nervous system diseases, injuries affecting the respiratory system and overdoses. It is your responsibility to ensure that assisting with mechanical ventilation is within scope of practice for your province/ territory and agency. Assisting clients requires specific training and considerations for each client. Alarms for ventilators are important as they alert staff if something is wrong. If an alarm is to sounds check to see if the client’s tube is still attached to the ventilator. If it is not, attach the tube to the ventilator. The client can die if not connected to the ventilator. Do not silence the alarm and immediately report to a regulated health-care professional.

Non-Invasive Ventilation (NIV)

Common reasons clients require NIV is due to being diagnosed with COPD (Chronic Obstructive Pulmonary Disease) or Sleep Apnea. NIV is a non-invasive or non-surgical way to assist in delivering oxygen to the upper air ways through a face mask, nasal mask, nasal plugs, or similar device allowing the body to maintain adequate oxygen levels. Examples of NIV devices include a CPAP (constant positive airway pressure) or BIPAP machine (Bi-level positive airway pressure)

You may be caring for a client who requires assistance with a CPAP or BIPAP machine. Ensure you have had proper training as to how to assist in applying the machine, and follow the manufactures guidelines as well as the policies and procedures of your agency to care for and clean the equipment.

Signs and Symptoms of Respiratory Distress
Understanding the signs and symptoms of respiratory distress is a key responsibility for the health care aide in caring for a client with a respiratory condition. The health care aide has to recognize and respond when a client is experiencing respiratory distress including reporting findings immediately to the nurse.

Signs and symptoms of respiratory distress include:
Cyanosis,Pallor,Dizziness,Tachypnea,Wheezing,Dyspnea, Anxiety, Gasping etc..

Notify the nurse immediately if you observe a client in respiratory distress. Reassure the client that you are there to help him or her. If the client is using oxygen therapy, immediately check to make sure the oxygen tubing is not kinked, it is connected to the oxygen source, and the oxygen cylinder is not empty.

The Health Care Aide Role in Assisting with Respiratory Care and Oral Suctioning
Providing safe and competent care is central to your role when assisting with oral suctioning and oxygen therapy. Understand your role as a health care aide and know the policies and procedures at your agency.

Your role and responsibility as a health care aide are to:

· Recognize the signs and symptoms of respiratory distress and immediately notify the nurse

· Assist only as far as the limits of your role, level of training, and competency allow.

· Know the rationale for what you are doing; this ensures the safety and comfort of the client when you are providing respiratory care
· Perform oral suctioning of the client’s mouth as outlined in the client’s care plan.

The Role of the Health Care Aide in Cleaning and Maintaining Suction Equipment Using IPC Guidelines
Respiratory secretions may contain blood and infection-causing microorganisms. Always perform hand hygiene before and after care. Follow routine practices when assisting with oral suctioning. In addition to donning gloves, you may be required to wear a mask and goggles for protection against secretions that may come in contact with your eyes, mouth, and nose. Oral suctioning is not a sterile procedure because the mouth is not a sterile cavity. Clean technique is required when performing oral suctioning and handling equipment. Follow agency policy and procedures when cleaning or disposing of suctioning equipmen.

Care of Oxygen Equipment
There is a wide variety of oxygen therapy equipment available for use. It is important that you become familiar with the type of equipment used within the facility. If a client has oxygen equipment with which you are unfamiliar, it is your responsibility to request training as to how to use the equipment, as well as how to care for the equipment. Make sure that you review the manufacturers’ instructions and trouble-shooting guides about the oxygen equipment. Know your employer’s policies and procedures for changing and cleaning oxygen equipment.

Here are the general guidelines for the care of oxygen equipment (Government of Alberta, 2013).

• Oxygen Concentrator: An oxygen concentrator is a machine that separates oxygen from other gases in room air. The concentrator runs on electricity.
  Clean the cabinet as needed with a damp cloth and wipe dry. Avoid getting water into the internal parts of the unit.
• Oxygen Cylinder: Oxygen cylinders deliver compressed oxygen and store different amounts of oxygen. The cylinders come in different sizes that are appropriate for various uses and settings.

· Ensure that the oxygen cylinder is upright and secured in a storage stand or carrier.

· Turn the cylinder valve off when oxygen is not in use.

· Check the oxygen gauge frequently to ensure that the client has an ample supply of oxygen.

• Liquid Oxygen

Liquid oxygen is typically contained in smaller and lighter cylinders that make it easier for the client to move about. The cylinder can be carried using a strap over the client’s shoulders.

· Ensure that the liquid oxygen base unit is upright.

· Turn the flow control valve off when oxygen is not in use.

· Never touch the frosted fittings or allow the liquid oxygen to come in contact with your skin, as this could cause serious burns.

The Government Organization Act in Relation to the HCA Role in Assisting with Oral Suctioning
Role and Responsibility Alert!

It is crucial that you know your role when assisting with oral suctioning. There are serious risks if oral suctioning is not done correctly.

Oral suctioning puts the client at risk for hypoxia because it removes oxygen from the airway. Suctioning too far back into the client’s airway can cause laryngeal spasms and bradycardia which can cause severe respiratory distress and may even lead to death. A regulated health-care professional performs the task of oral suctioning. Oral suctioning is a restricted activity as outlined in the Government Organization Act.

Inserting or removing instruments, devices, fingers, or hands beyond the pharynx (mouth) or into an artificial opening into the body (e.g., into a tracheostomy) is a restricted activity under the Government Organization Act.

Regulated health-care professionals may assign this restricted activity to a health care aide. However, health care aides must be properly trained and the assignment of the task must be appropriate to the client’s needs. The health care aide must be directly supervised by a regulated health-care professional until the health care aide is competent and performs the skill safely. Every agency has policies and procedures that describe the role and responsibilities of health care aides for oral suctioning and oxygen therapy. It is the responsibility of the health care aide to know what is expected.

Question 21

Medication Assistance Learner Guide (206-m9)

Answer 21

Government Organization Act:
The Alberta Government Organization Act (GOA) permits regulated health-care professionals such as LPNs, RNs, and RPNs to assign “restricted activities” and other health-care-related tasks to unregulated care providers under specific conditions. Restricted activities are ones that are considered invasive and carry risk of injury to the client. They are designated to specific regulated health-care professionals and must be performed with a high degree of competence. Examples of restricted activities are prescribing medications, and entering into one or more body cavities. Medication delivery in itself is not a restricted activity; however, the route of the medication delivery may make it a restricted activity. For example, inserting medication into the rectum or vagina of a client is a restricted activity. Giving injections is also a restricted activity as this activity is often performed by a qualified, regulated, health-care professional.

• The HCA is permitted by legislation to carry out the task.

· The HCA receives appropriate education and training and becomes competent or skilled in the restricted activity or health-care task.

· The client, family, regulated health-care professional, and HCA will have developed a care plan that allows the HCA to assist with the restricted activities or tasks. (In some cases, the family or client signs a document that states they are accepting medication assistance from an HCA within the HCA’s role.)

· The HCA will receive ongoing supervision by a qualified, regulated, health-care professional who agrees to supervise.

Supervision of HCAs by Regulated Health-Care Professionals

Health care aides who are educated and trained, and accept the task of medication assistance, will routinely be supervised by a regulated health-care professional, usually an LPN, RPN, or an RN. This supervision may be direct, which means that the supervisor is physically present and directs the activity as the HCA carries out the task. Indirect supervision occurs when the HCA does the task, but the supervisor is either in the care facility or off-site but available by phone or pager. As the HCA becomes confident and competent with safe medication delivery, the supervision will be more indirect.

• Client Rights in Alberta
  As discussed in the module on legislation (Course One, Module 2), all Canadians have rights and freedoms guaranteed under the Canadian Charter of Rights and Freedoms. Client rights and freedoms extend to health-care decisions and may involve treatments and medications for temporary or ongoing medical conditions. Although some provinces have specific documents that describe client rights in health care such as a bill of rights, the following are basic client rights that health-care workers agree to follow with medication assistance and other procedures:

· Right to be treated with dignity and respect. This right is the basis of the principles of caregiving. Caregivers must always promote and protect a client’s dignity. They must be courteous and respectful, and promote client independence.

· Right to privacy and confidentiality. Persons who receive care from another person have the right to privacy of their bodies. Keeping their health information confidential is a legal requirement.

· Right to decide. After a client receives information from a regulated health-care professional, he or she has a right to decide whether to accept the medication or treatment. The client also has a right to accept or refuse a medication at the time of delivery.

· Right to be involved in care decisions. Clients and their families have a right to be involved in health-care decisions, including decisions about medications

• Medications: Their Purpose, Side Effects, Adverse Effects, and Anaphylaxis
  Medications, both over-the-counter (OTC) and prescribed, are used to treat temporary and ongoing (chronic) health conditions. Some medications are used to prevent disease and illness while others are prescribed to minimize signs and symptoms of a particular medical condition. Some medications are prescribed to minimize side effects of a life-saving medication that a client may be taking.
• PRN Medications

Some medications are taken only when required for a specific medical symptom. These medications are known as PRN medications. HCAs generally do not assist with PRN medications as these medications require that the client be assessed by a regulated health-care professional. Some agencies or facilities, in their policies and procedures, do allow HCAs to assist with low-risk pain medications such as Tylenol or aspirin so long as the PRN medication is given for the condition for which it was prescribed. For example, if a client can take a PRN medication of Tylenol Extra Strength every six hours for a sore left elbow, this same medication cannot be given by an HCA for a client’s headache.

Blood Glucose Monitoring
Blood Glucose monitoring is done by clients in their homes and health-care facilities, both independently and with assistance. Blood Glucose monitoring requires breaking the skin barrier to collect a small amount of blood to apply to a test strip. The test strip is then placed into the glucose monitor or meter and it reads the amount of glucose in the client’s blood. This test is utilized primarily for clients with diabetes. This is a restricted activity for a health care aide. If you are asked to assist with this procedure, check that it is permitted by your province or territory as well as within your job description. Follow your agency policy and guidelines when assisting with the procedure.

Blood Glucose Monitoring
Blood Glucose monitoring is done by clients in their homes and health-care facilities, both independently and with assistance. Blood Glucose monitoring requires breaking the skin barrier to collect a small amount of blood to apply to a test strip. The test strip is then placed into the glucose monitor or meter and it reads the amount of glucose in the client’s blood. This test is utilized primarily for clients with diabetes. This is a restricted activity for a health care aide. If you are asked to assist with this procedure, check that it is permitted by your province or territory as well as within your job description. Follow your agency policy and guidelines when assisting with the procedure.

• Insulin injection Sites
  When assisting a client to give themselves insulin, it is important to know where the client can give the injection for the proper absorption of the insulin their body requires. It is important that the client rotate sites to promote skin integrity and location of the injection site, as repeated injections can create bumps and pits within the skin (Taylor, 2008).

The sites for injection include:

· Abdomen: Injection site cannot be within 5cm or 2 inches from the belly button (umbilicus). The abdomen is the most preferred site and it absorbs insulin most consistently.

· Thighs: The top of the thigh in the fatty tissue.

· Arms: Upper area of the back of the arm in the fatty tissue.

· Buttocks: Top outer corners one the buttocks, in the fatty tissue.

• Role and Responsibility Alert!

The HCA assists only by bringing the insulin to the client and assisting the client to prepare the site for the injection. After the injection, the HCA will assist the client to ensure that the needle has been disposed of in a biohazard sharps container. Clients capable of doing so should place the needle in the biohazard sharps container. HCAs must receive adequate training and supervision from a regulated health-care professional prior to undertaking this activity

• The Client’s Care Plan and Medication Assistance

The client’s care plan may also be called a support plan or nursing care plan. A care plan outlines the care and services a client will receive. It also ensures consistency of care by the health-care team. The care plan has the client’s identifying information and may be written so it can be reviewed and updated regularly by the regulated health-care professional. The care plan contains the client’s diagnosis, the goals of care, the activities or actions (interventions) that will support the goals, and expected outcomes or results of the care. HCAs are front-line care providers who spend much time in health-care activities with their clients and so their input is extremely valuable in the care plan. Care plans have information on personal care, but may also have information on medication assistance. What will be included in the care plan on medication assistance depends on the workplace setting.

The following are some types of information related to medication assistance that may be on the care plan:

• The Nine Rights and Three Safety Checks of assisting with medication delivery
  Employers, whether agencies or facilities, are responsible for ensuring that a safe medication delivery process and system are in place. The nine rights and the three safety checks are put into practice to minimize errors and reduce the possibility of client injury. At each safety check, the regulated health-care professional or the HCA reviews the nine rights.

The appropriate nine rights for HCAs are:

1. Right medication (by name or description)
2. Right client
3. Right dose (amount, number of tablets, or calibrated liquid amount)
4. Right route (way it is given)
5. Right time (of the day)
6. Right Day (day of the week)
7. Right Reason (medication is being given as directed)
8. Right Expiry Date (medication has the correct strength or potency)
9. Right documentation (following agency policy and procedures)

*Discuss these rights with your supervisor and follow agency policy and procedures.

The three safety checks are:

· First safety check. This check is done by the regulated health-care professional who verifies the prescription or the doctor’s order. (The regulated health-care professional is usually an RN, RPN, LPN or pharmacist/technician.)

· Second safety check. This check is done for each medication given. It is done by the HCA just before preparing the medication. The HCA may also be expected check for client allergies. The HCA also prepares the medication according to any special instructions such as “shake well,” “give first,” “to the right eye only,” “do not crush” or other such types of instructions.

· Third safety check. This check is done by the HCA just before giving the medication to the client. Check label before and after pouring the medication, and ensure that it is the right medication being given to the right client, by the right route, at the right time. Also check expiry date.

Note: When the HCA is assigned and begins the medication assistance process, it is assumed that the first safety check has been done. If, however, the HCA has reason to believe that the first safety check has not been completed, he or she must contact the supervisor

Medication Incidents
Even with the best safety procedures in place, medication incidents or errors do occur for a variety of reasons. It is important to report medication errors immediately, as medication errors are very serious and can be very harmful to the client.

Sometimes HCAs may hesitate to report medication errors as they may feel fearful because an error has occurred. It is important to report medication errors immediately so that the client can be assessed by a regulated health-care professional such as a nurse or doctor and follow-up care can be started quickly. More serious harm could occur to the client if there is a delay in follow-up treatment.

When a medication error occurs, under employer policies and procedures an “incident form” is completed or filled out. It may be a general incident form that involves checking off the type of incident which, in this case, would be a medication incident. Other employers may have a specific medication incident form that is filled out. The two main reasons for filling out an incident form are to monitor trends in medication errors and to prevent future occurrences.

Question 22

Assisting with the Care of Infants Learner Guide (207-m1)

Answer 22

Introduction
The arrival of a newborn infant in any family rates as one of life’s astonishing highlights for a variety of reasons. The health care aide will assist newborns in meeting their basic needs. The parents of the newborn may require support in the learning they will undertake to feel comfortable and competent with the care of their new infant. This module will provide the information and learning experiences the health care aide will require when working with infants.

• What Is Shaken Baby Syndrome?
  Shaken baby syndrome is an acquired brain injury due to violent or vigorous shaking of an infant by his arms, legs, chest, or shoulders. The degree of damage to the brain and the rest of the body of the infant depends on the amount and duration of the shaking.

“How does this happen?” one might ask.

Remember the discussion about crying being the only way babies have of telling us when they need something like food, water, or a diaper change? As we know, crying can be quite annoying. If it wasn’t bothersome and irritating, and only manifested as a pleasant little cooing sound, it would be easy to disregard. Then, the poor baby might wait a long time for his needs to be met. Key points to remember are as followed.

• What Is Sudden Infant Death Syndrome (SIDS)?
  Sudden infant death syndrome (or SIDS) occurs when an infant under 12 months old dies suddenly for no apparent reason. When the doctors investigate the infant’s death during an autopsy, they are unable to identify anything that might be seen as a reason or cause.

Sudden infant death syndrome happens without any forewarning. It occurs when the seemingly healthy infant is thought to be sleeping, perhaps in his crib (thus it is sometimes referred to as crib death). Babies can also die of SIDS when they’re sleeping somewhere else, such as in a baby carriage or even their parents’ arms. Thankfully, infants who die of SIDS show no indication of suffering.

• Strategies for Reducing the Risk of SIDS
  ● The number one way to reduce the risk of SIDS is to place the infant on his back to sleep. “Tummy time” is when your infant is awake and alert and has someone to watch him.

● Place the infant on a firm mattress to sleep. Never place the infant on a pillow, waterbed, sheepskin, or other soft surface that may block the baby’s mouth.

● Do not place comforters, stuffed toys, or pillows near the infant’s head and face.

● Prevent creating a small enclosure around the infant’s mouth and thus causing rebreathing of stale, poorly oxygenated air.

● Be sure that the infant does not become too warm while sleeping. It is suggested that you keep the room at a temperature that would feel comfortable to an adult wearing a short-sleeved shirt. If you place your hand on the back of the infant’s neck and find it damp with sweat, you know that the infant is too warm and needs to have some covers removed or the room temperature regulated.

General Observations of the Infant
When approaching an infant that is being cared for by the HCA, there are certain aspects of general well-being that need to be observed and recorded. Always check with the regulated health professional as to any specific observations that need to be made. First, look at the child’s general appearance and behaviour and note whether the child is well fed and developed. When observing an infant start with the head and move towards the feet, this is known as observing in a head-to-toe manner.

Glossary
Taken from (Sorrentino, S.A., Remmert, L., & Wilk, M.J., 2018).

Consciousness: The state of being awake or aware.

Congenital:Present at birth.

Contorted:Twisted or bent out of shape.

Cradle Cap:A skin condition in which yellowish, scaly, or crusty patches, made up largely of oil and dead skin cells, appear on the scalp.

Cyanosis:Bluish-grey colouring of the skin and mucous membranes caused by oxygen deficiency and excess carbon dioxide in the blood.

Flaccid:Limp.

Fontanel:Soft spot of an infant’s skull.

Hernia:The abnormal protrusion of an organ or tissue through the structure usually containing it.

Hydrocephalus:A condition that results in an increase in head size and pressure on the brain. It is due to an increase in intracranial fluid in the brain and is sometimes referred to as water on the brain.

Jaundice:A yellowing of the skin and the white part (sclera) of the eyes.

Meconium:A greenish-black sticky substance in the bowel of a newborn.

Microcephalous:A condition in which an individual has an exceptionally small head.

Postnatal:After birth.

Prenatal:Before birth.

Shaken Baby Syndrome:This term refers to the physical and cognitive impairments caused by violently shaking a baby or young child.

Sudden Infant Death Syndrome:The sudden, unexplained death of an apparently healthy infant under 1 year of age.

Thrush: A common yeast infection that resembles cottage cheese or milk curds and is found on the sides and roof of the baby’s mouth and sometimes the tongue.

Observations of an Infant in Pain
An infant cannot protect themselves and is totally dependent on a parent or caregiver to look out for them. When an infant does need to notify someone that they need help or attention, they have limited ways to communicate their needs other than to cry. Therefore, we can presume a crying infant is trying to tell us something and it is our responsibility to respond and try to figure out what the infant needs. This will ensure that their needs are being met and allows the infant to feel protected and secure.

Babies cry for various reasons. The most common are:

● Hunger or thirst

● Needing to be burped

● Needing a diaper change

● Feeling too hot or cold

● Feeling uncomfortable due to something like needing a change in position, feeling the irritation of a fold in the blanket or scratchy inseams of an outfit

● Feeling the need to be held – a desire for safety and security

● Being overtired or over- or under-stimulated

● Having a fussy time of day (late afternoon or evening is when most babies have their “fussy period”)

Question 23

Course 7 – Module 2: Assisting with the Child

Answer 23

Introduction
In order to work effectively with children from infancy to adolescence, caregivers must have a good understanding not only of children and how they think, but also of children’s normal expected growth and development patterns.

Throughout this module, we will be talking about many aspects of child care, starting at the toddler stage and moving through to adolescence. We will also look at other child care topics such as pain, abuse, discipline, and other issues.

Glossary

Adolescence:Occurs from ages 12-18 years.

Child Abuse:Mistreatment or neglect of a child by a parent, guardian, or caregiver.

Child Neglect:Failure by a child’s parents or other caregivers to meet the child’s basic needs for emotional, psychological, and physical development.

Child Sexual Abuse:The use of a child for sexual purposes by an adult or adolescent. Exposing a child to any sexual activity or behaviour constitutes sexual abuse.

Discipline:The system of rules that governs how we act.

Failure to thrive:A delay in physical growth and weight gain, which can lead to delays in development and maturation; usually caused by environmental and social factors.

Latchkey children:Children who are left unsupervised after school because their parents or caregivers are away from home or at work.

Late Childhood:Occurs from ages 9-12 years.

Menarche:The time when menstruation first begins.

Middle Childhood:Occurs from ages 6-8 years.

Negative reinforcement:Encouraging a behaviour by penalizing the person when that behaviour is not demonstrated.

Obesity:Excess fat accumulation that puts a person’s health at risk.

Positive reinforcement:Encouraging a behaviour by rewarding the desired behaviour after it is demonstrated.

Preschool:Occurs from ages 3-5 years.

Puberty:The period when the reproductive organs begin to function and secondary sex characteristics appear.

Punishment:A harsh response that occurs when a discipline rule is broken.

Separation anxiety:A normal reaction in young children to the actual or prospective separation from a parent or caregiver.

Toddler:Occurs from ages 1-3 years.

Signs That a Child Is in Pain

· Crying

· Making a face or grimacing

· Continuously rubbing the site of the pain, such as an aching ear or leg muscle

· Lying in bed, quiet and still, trying not to move and make the pain worse

Sometimes it is the parent who tells us that this is not normal behaviour for the child. Sometimes we may recognize pain when we look at the child’s vital signs. Pulse, blood pressure, and respiratory changes along with perspiration on the skin can alert us to pain in a child. Sometimes the child simply tells us that he hurts.

Always make sure that you report suspected pain to your supervisor or health-care professional so that he or she can assess and treat the child. Writing it down is not enough. Tell someone who can take measures to help.

Strategies for Helping a Child Deal with Pain

· Whenever possible, have a parent present. Most children will ask for their mom or dad. This allows a feeling of security and comfort like no other.

· Give children accurate information concerning what is about to happen if they are to undergo painful medical procedures. The trust factor very much affects their reaction to pain.

· Encourage children to ask questions, role-play with dolls, and remind them that it is OK to cry or be afraid. These actions show your understanding and help develop a trusting relationship with the child.

· Singing softly, rocking, distraction, and some diversionary activities are often helpful.

· Check the care plan and check with the regulated health-care professional about the application of heat or cold.

· A back rub or simple hand or foot massage may help in some cases.

· Blowing soap bubbles is fun and takes little exertion or movement for a child in pain.

· We all have a right to pain management – adult, child, or infant. Always try your best to follow a high standard of care when looking after children with pain

• Distinguishing Between Discipline and Punishment
  Discipline

The objective of positive discipline is to guide children to make appropriate choices regarding their behaviour, manage their emotions, practise self-control, and learn to function in society. Discipline helps children realize that all actions, behaviours, and choices have consequences, and that these choices they make will determine the consequences they face. This process will allow the child to eventually realize they have control over their life. Key factors of positive discipline include respect, consistency, and firmness (Michigan State University, 2013).

*Punishment

Punishment is using fear to regulate a child’s behaviour. The punishment may be physical- spanking, emotional – belittling or punitive – not allowed a device or playing outside and causes the child to fear the consequence that they will face if the inappropriate behaviour is discovered. Often the interpretation for the child is not that the behaviour is inappropriate but that they need to make sure that they are not caught. The management of the behaviour in this technique is put on the caregiver rather than the choices the child makes

What to Do if Child Abuse is Suspected and What Information Will Need to be Provided in the Report
In the Province of Alberta, under the Child, Youth and Family Enhancement Act any person who has “reasonable and probable grounds” to believe that a child is being harmed or in danger of being harmed by their parent or guardian has an obligation to report it to Child and Family Services.

If it is believed that a child is being neglected, physically injured, emotionally injured or sexually abused, or suspected to be abandoned, the situation must be assessed by the authorities.

If abuse is suspected, the HCA must notify the supervisor and must call the local Child and Family Services office or Delegated First Nations Agency or the Child Abuse Hotline at 1-800-387-KIDS (5437) or the local Police/RCMP office. It is law in Alberta to report suspected cases of abuse (Government of Alberta, 2018).

What Information Will Need to be Provided in the Report
All reports are confidential and the HCA can remain anonymous or provide contact information.

The following information will also need to be provided for the report (Government of Alberta, 2015).

· How long has the HCA known the child/family?

· What is the HCA’s relationship to the child/family?

· What is the HCA’s concern about the child(ren)?

· What has the HCA observed?

· What has the child or others told the HCA in relation to this report?

· Where the child is now?

· What has the HCA has done to support the child/family?

· What supports (formal or informal) are involved with the family?

• Supporting a Child During the Death of a Family Member
  Being able to support a family during the end of life of a loved one is a special role of the HCA. When children are part of this family, there are considerations that are unique to them. Support children in this process by ensuring open and honest communication. Often children have common concerns, referred to by Katherine Murray (2014) as “the three Cs”.

1. Did I cause it?

Ensuring children that nothing they did was responsible for this is essential, even if the child shows no outward signs of this question. Sometimes children will think past behaviour or conversations are responsible for their loved ones’ death.

2. Can I Catch it?

Explaining that not all diseases or conditions can be shared between people is important. Reassure the child that they will not be getting the same condition that is causing their loved one to die.

3. Who will take care of me?

Make sure that the child is aware of who will be caring for them in the future. Have the parents or guardians present to convey this information to the child.

Other considerations to take into account surrounding the support of children whose loved ones are dying:

*Compassionate Caring When Caring for Terminally Ill Children
Compassion is having feelings of deep sympathy for another who is stricken by misfortune, and it is accompanied by a strong desire to alleviate that suffering. Sensitive emotional support is one of the most significant things that health-care workers can provide to their clients.

Compassionate Support for the Family

When a child becomes seriously ill, we feel compassion for the entire family. Imagine the family of a six-year-old boy who has been diagnosed with an illness from which he may not recover. They are devastated.

Applying the HCA Role CARE Principles and Person-Centred Care Approach (Child)

*Compassionate Caring through Competence

The role of the HCA in these situations has many parts. It involves developing positive relationships with all family members, maintaining existing rules of behaviour, maintaining daily routines as much as possible, and reporting any concerns to the supervisor.

• Accurate Observations
  Using these observations, the HCA will be able to make a conclusion in one of the following areas.
• Respond

The HCA should describe what has been observed with precision and accuracy. Provide all the details of what has been seen, smelled, heard, or felt.

• Enhance Quality of Life

Ensuring that the HCA has compassion for the child and the family’s dignity, independence, choices, privacy, and safety is the foundation of this caring approach. Respecting the family’s holistic needs is achieved by applying the knowledge gained within the HCA program. Fostering open communication while implementing the care plan will create a sense of collaboration between the HCA, Sam, George, and Alicia while providing the support this family needs.