Terminology #1Terminology #1

AxillaAxilla

AspirationAspiration

Perineum/perinealPerineum/perineal

Oral hygieneOral hygiene

PruritusPruritus

NitsNits

Terminology #2Terminology #2

IntegumentaryIntegumentary

DermisDermis

EpidermisEpidermis

AbrasionAbrasion

CyanosisCyanosis

ExcoriationExcoriation

Decubitus ulcerDecubitus ulcer

Terminology #3Terminology #3

NecrosisNecrosis

UrineUrine

ProsthesisProsthesis

UrinalUrinal

UrinationUrination

CatheterCatheter

Terminology #4Terminology #4

FecesFeces

EliminationElimination

Fecal impactionFecal impaction

Anal incontinenceAnal incontinence

FlatulenceFlatulence

ConstipationConstipation

Diarrhea Diarrhea

Terminology #5Terminology #5

OstomyOstomy

ColostomyColostomy

ileostomyileostomy

StoolStool

StomaStoma

DefecationDefecation

Daily routine care/Early MorningDaily routine care/Early Morning

Offer bedpan/urinal or assist to Offer bedpan/urinal or assist to bathroombathroom

Wash face and handsWash face and hands

Offer oral hygieneOffer oral hygiene

Straighten bed and unitStraighten bed and unit

Position resident for breakfastPosition resident for breakfast

Morning care after breakfastMorning care after breakfastOral hygieneOral hygieneOffer bedpan/urinal or assist to Offer bedpan/urinal or assist to bathroombathroomBathingBathingShavingShavingSkin careSkin careDressingDressingHair careHair careChange bed linensChange bed linens

Prepare for mealsPrepare for mealsLunch and dinnerLunch and dinner

Offer bedpan/urinal or assist to Offer bedpan/urinal or assist to bathroombathroom

Wash hands/faceWash hands/face

Straighten bed/unitStraighten bed/unit

Position for mealPosition for meal

Afternoon careAfternoon care

Offer bedpan/urinal or assist to Offer bedpan/urinal or assist to bathroombathroom

Wash face and handsWash face and hands

Oral hygieneOral hygiene

Grooming as necessaryGrooming as necessary

Change soiled linenChange soiled linen

Straighten unitStraighten unit

Evening (HS) careEvening (HS) careOffer bedpan/urinal or assist to Offer bedpan/urinal or assist to bathroombathroomWash face and handsWash face and handsOral hygieneOral hygieneChange soiled linenChange soiled linenDress for bedDress for bedBack massageBack massageStraighten unitStraighten unit

Benefits of bathingBenefits of bathingCleanlinessCleanlinessReduce bacteria and germsReduce bacteria and germsPromote skin integrityPromote skin integrityStimulate circulationStimulate circulationProvide movement and exerciseProvide movement and exerciseRelaxationRelaxationSense of well-beingSense of well-beingOpportunity for communication and Opportunity for communication and observationobservation

Body areas that require bathingBody areas that require bathing

FaceFace

Underarms (axilla)Underarms (axilla)

HandsHands

Perineal areaPerineal area

Any area where skin folds or creasesAny area where skin folds or creases

Types of bathsTypes of baths

ShowerShower

Tub/whirlpool, medicinalTub/whirlpool, medicinal

Complete bed bathComplete bed bath

Partial bed bathPartial bed bath

General guidelines for bathing General guidelines for bathing residentsresidents

Check with nurse regarding type of Check with nurse regarding type of bathbathRefer to procedure manual for Refer to procedure manual for special bathsspecial bathsIdentify skin care products to be Identify skin care products to be usedusedCheck resident’s personal choicesCheck resident’s personal choicesCollect necessary equipmentCollect necessary equipmentProvide privacyProvide privacy

General guidelines for bathing General guidelines for bathing residents #2residents #2

Assure adequate comfortAssure adequate comfortUse comfortably warm water, change Use comfortably warm water, change it when it becomes soapy, dirty or it when it becomes soapy, dirty or coldcoldBathe areas soiled by fecal material Bathe areas soiled by fecal material or urine or urine Wash from cleanest to dirtiest areaWash from cleanest to dirtiest areaRinse off all soapRinse off all soapPat skin dryPat skin dry

Safety Guidelines for bathingSafety Guidelines for bathing

Monitor correct water temperatureMonitor correct water temperature

Use safety equipmentUse safety equipment

Stay with residentStay with resident

Use correct body mechanicsUse correct body mechanics

Privacy during bathingPrivacy during bathing

Close door Close door

Pull curtain around residentPull curtain around resident

Only uncover area being washedOnly uncover area being washed

Observations to be made during Observations to be made during bathing/skinbathing/skin

ColorColor

RashesRashes

DrynessDryness

BruisesBruises

OdorsOdors

SwellingSwelling

Observations/Fingernails,toenails,Observations/Fingernails,toenails,hair,eyes and Mental Status #2hair,eyes and Mental Status #2

Presence of nitsPresence of nits

Color of scleraColor of sclera

Orientation/alertnessOrientation/alertness

MoodMood

AttitudeAttitude

Observations that require reportingObservations that require reportingskinskin

ColorColor

New rashesNew rashes

New bruises, broken skin, bleedingNew bruises, broken skin, bleeding

Unusual odorsUnusual odors

Complaints of painComplaints of pain

Observations that required Observations that required reporting/ Fingernails, hairreporting/ Fingernails, hair

New Yellow, thickened nailsNew Yellow, thickened nails

New significant hair lossNew significant hair loss

FlakingFlaking

Sore scalpSore scalp

NitsNits

Observations that require reportingObservations that require reportingEyes and Mental statusEyes and Mental status

RednessRedness

Yellowing of scleraYellowing of sclera

DisorientationDisorientation

DepressionDepression

Development of unresponsivenessDevelopment of unresponsiveness

Types of medicinal bathsTypes of medicinal bathsBranBranOatmealOatmealStarchStarchSodium bicarbonateSodium bicarbonateEpsom saltsEpsom saltsPine productsPine productsSulfurSulfurSaltSalt

Purposes of medicinal bathsPurposes of medicinal baths

Soothing sedationSoothing sedation

Relief of pruritisRelief of pruritis

Relief of skin disorder (dry skin, Relief of skin disorder (dry skin, irritation, rash)irritation, rash)

Oral hygiene / PurposeOral hygiene / Purpose

Cleanliness of mouth and teethCleanliness of mouth and teeth

Prevent mouth odor and infectionPrevent mouth odor and infection

Prevent tooth lossPrevent tooth loss

ComfortComfort

Pleasant tastePleasant taste

Improve taste of foodImprove taste of food

Oral hygiene / When to performOral hygiene / When to perform

On awakeningOn awakening

After each mealAfter each meal

Bed timeBed time

Oral hygiene / Special Oral hygiene / Special circumstancescircumstances

UnconsciousUnconscious

Mouth breatherMouth breather

O2O2

NG tubeNG tube

Elevated temperatureElevated temperature

Steps of oral hygieneSteps of oral hygiene

Carry out procedure using standard Carry out procedure using standard precautionsprecautions

Examine oral cavity and report Examine oral cavity and report findingsfindings

Steps in cleaning and care of Steps in cleaning and care of denturesdentures

Use standard precautionsUse standard precautions

Examine oral cavity and report Examine oral cavity and report findingsfindings

Nurse assistant role for resident Nurse assistant role for resident nail carenail care

Easier to clean after soaking in Easier to clean after soaking in warm, soapy waterwarm, soapy water

Be cautious to prevent damage to Be cautious to prevent damage to tissuestissues

Report unusual conditions to nurseReport unusual conditions to nurse

Follow facility procedureFollow facility procedure

Nurse assistant role / caring for hairNurse assistant role / caring for hair

Part of daily carePart of daily care

Important for identity and self-Important for identity and self-esteemesteem

Accommodate resident preferences Accommodate resident preferences for style, hair productsfor style, hair products

Nurse assistant role / types Nurse assistant role / types shampooshampoo

Shower / tubShower / tub

SinkSink

BedBed

Nurse assistant role / purpose of Nurse assistant role / purpose of Medicinal ShampooMedicinal Shampoo

Eradicate liceEradicate lice

ScabiesScabies

Soothe / heal irritated skinSoothe / heal irritated skin

Shaving a resident / GuidelinesShaving a resident / Guidelines

Use either electric or safety razorUse either electric or safety razor

Use appropriate safety precautions Use appropriate safety precautions for electrical equipmentfor electrical equipment

Safety razors can cause nicks or cutsSafety razors can cause nicks or cuts

Use standard precautions to prevent Use standard precautions to prevent contact with bloodcontact with blood

Functions of the integumentary Functions of the integumentary systemsystem

Provides protective barrier against Provides protective barrier against microorganismsmicroorganisms

Enables the body to feel pain, Enables the body to feel pain, pressure, and temperaturepressure, and temperature

Shields body tissue from injuryShields body tissue from injury

Insulates against heat and coldInsulates against heat and cold

Eliminates waste productsEliminates waste products

Produces Vitamin D for body useProduces Vitamin D for body use

How to maintain healthy skinHow to maintain healthy skin

Encourage well-balanced diet and Encourage well-balanced diet and fluidsfluids

Maintain skin careMaintain skin care

Observe color and temperatureObserve color and temperature

Give special attention to bony Give special attention to bony prominencesprominences

Age –related changes affecting the Age –related changes affecting the skinskin

Excessively dry areasExcessively dry areas

Elasticity decreased, causing Elasticity decreased, causing wrinkleswrinkles

Thinner layersThinner layers

Residents at risk for skin Residents at risk for skin breakdownbreakdown

Elderly residentsElderly residentsResidents who have no sensation of Residents who have no sensation of painpainParalyzed residentsParalyzed residentsResidents with edemaResidents with edemaThin residentsThin residentsDiabetic, Overweight, in castsDiabetic, Overweight, in castsUnconscious, sedated residentsUnconscious, sedated residents

Conditions which cause decubitus Conditions which cause decubitus ulcersulcers

PressurePressure

Decreased blood flow to an areaDecreased blood flow to an area

Wet skinWet skin

Scratches from fingernailsScratches from fingernails

Dry skinDry skin

Decubitus ulcers #2 / Signs and Decubitus ulcers #2 / Signs and symptoms or stagessymptoms or stages

Stage oneStage one

Stage twoStage two

Stage threeStage three

Decubitus ulcers #3 / Bony Decubitus ulcers #3 / Bony prominencesprominences

SacrumSacrum

HeelsHeels

KneesKnees

ShouldersShoulders

Back of headBack of head

HipsHips

Ankles, Elbows and EarsAnkles, Elbows and Ears

Decubitus ulcers / Preventive Decubitus ulcers / Preventive nursing care measuresnursing care measures

Keep skin clean and dryKeep skin clean and dry

Use only small amounts of powder Use only small amounts of powder and lotionand lotion

Wash after each incontinent episodeWash after each incontinent episode

Keep safety devices, clothing, and Keep safety devices, clothing, and bedding from being too tightbedding from being too tight

Keep edges of casts and braces from Keep edges of casts and braces from pressing against the skinpressing against the skin

Decubitus ulcers / Preventive Decubitus ulcers / Preventive nursing care measures #2nursing care measures #2

Remove crumbsRemove crumbs

Avoid wrinkles in beddingAvoid wrinkles in bedding

Keep tubes from pressing on the skinKeep tubes from pressing on the skin

Remove residents from toilets and Remove residents from toilets and bedpans promptlybedpans promptly

Keep your nails short and smoothKeep your nails short and smooth

Decubitus ulcers / Use of pressure-Decubitus ulcers / Use of pressure-reducing devices # 3reducing devices # 3

Bed cradleBed cradleSheepskinSheepskinHeel and elbow protectorsHeel and elbow protectorsEgg crate mattressEgg crate mattressAlternating pressure matressAlternating pressure matressClinitron bedClinitron bedTrochanter rollsTrochanter rollsFlotation pads or cushionsFlotation pads or cushions

Decubitus ulcers # 4Decubitus ulcers # 4

Turn or change resident’s position Turn or change resident’s position every two hoursevery two hours

Encourage circulation by gentle Encourage circulation by gentle massage around areamassage around area

Teach resident to change position Teach resident to change position frequentlyfrequently

Assist with range of motion exercisesAssist with range of motion exercises

Apply lotion to dry skin areasApply lotion to dry skin areas

Dressing Residents / Types of Dressing Residents / Types of ClothingClothing

CardiganCardigan

PulloverPullover

PantsPants

Disposable briefDisposable brief

Shoes and stockingsShoes and stockings

Accessories Accessories

Physical factors that limit a Physical factors that limit a resident’s ability to dressresident’s ability to dress

Lack of maturationLack of maturationBrain impairmentBrain impairmentWeaknessWeaknessPainPainFracturesFracturesContracturesContracturesParalysisParalysisLack of visionLack of visionPsychological factorsPsychological factors

Caring for resident clothingCaring for resident clothing

Label garmentsLabel garments

Avoid cuttingAvoid cutting

Do not discardDo not discard

Store in the resident’s unitStore in the resident’s unit

Fold neatly or hang in closetFold neatly or hang in closet

Assist resident or family to choose Assist resident or family to choose clothing that meets physical needsclothing that meets physical needs

Purposes for dressing a residentPurposes for dressing a resident

How we look influences the way we How we look influences the way we feel about ourselvesfeel about ourselves

It encourages resident to be It encourages resident to be independentindependent

It discourages incontinenceIt discourages incontinence

Guidelines for dressing and Guidelines for dressing and undressing a residentundressing a resident

Provide for privacyProvide for privacy

Encourage the resident to do as Encourage the resident to do as much as possiblemuch as possible

Allow residents to choose what to Allow residents to choose what to wearwear

Remove clothing from the strong or Remove clothing from the strong or good side firstgood side first

Put clothing on weak side firstPut clothing on weak side first

Ways the body eliminates wasteWays the body eliminates waste

Urinary elimination (Urine)Urinary elimination (Urine)

Bowel elimination (Feces)Bowel elimination (Feces)

Urinary EliminationUrinary Elimination

The body excretes 1000 to 1500 ml The body excretes 1000 to 1500 ml of urine / dayof urine / day

Urine consists of the wastes and Urine consists of the wastes and excess fluidsexcess fluids

Residents have different urination Residents have different urination needsneeds

Keep resident’s routine as normal as Keep resident’s routine as normal as possiblepossible

Characteristics of normal urineCharacteristics of normal urine

ClearClear

Amber ( Medium Yellow) colorAmber ( Medium Yellow) color

Mild odorMild odor

Frequency of urinationFrequency of urination

Amount of fluid ingestedAmount of fluid ingested

Personal habitsPersonal habits

Availability of toilet facilitiesAvailability of toilet facilities

Physical activitiesPhysical activities

IllnessIllness

Ranges from every 2-3 hours to Ranges from every 2-3 hours to every 8-12 hoursevery 8-12 hours

Observations to be made about Observations to be made about urineurine

ColorColor

ClarityClarity

OdorOdor

AmountAmount

Information to report about urineInformation to report about urineCloudyCloudyPinkish or reddish tintPinkish or reddish tintResident complaints burning on Resident complaints burning on urinationurinationDifficulty in urinationDifficulty in urinationFeeling of pressureFeeling of pressureFrequencyFrequencyStrong OdorStrong Odor

Urinary incontinenceUrinary incontinence

Inability to control the passage of Inability to control the passage of urine from the bladderurine from the bladder

Constant dribbleConstant dribble

Occasional dribble when laugh, Occasional dribble when laugh, cough or sneezecough or sneeze

No controlNo control

Urinary incontinence / CausesUrinary incontinence / CausesCentral nervous systemCentral nervous systemSpinal cord injurySpinal cord injuryAging and confusionAging and confusionMedicationsMedicationsWeak pelvic musclesWeak pelvic musclesUrinary tract infectionUrinary tract infectionProstate problemsProstate problemsProlapse of uterus and bladderProlapse of uterus and bladder

Catheter / DefinitionCatheter / Definition

Plastic or rubber tube used to drain Plastic or rubber tube used to drain or inject fluid through a body or inject fluid through a body opening, most commonly used to opening, most commonly used to drain the bladder.drain the bladder.

Catheter TypesCatheter Types

Indwelling CathetersIndwelling Catheters– FoleyFoley– RetentionRetention

Straight CathetersStraight Catheters

Catheter PurposeCatheter Purpose

Complete loss of bladder controlComplete loss of bladder control

Urinary retentionUrinary retention

Before, during and after surgical Before, during and after surgical proceduresprocedures

Catheter CareCatheter CareTubing should not be kinkedTubing should not be kinked

Bag placed below level of the bladderBag placed below level of the bladder

Bag should be attached to the bed Bag should be attached to the bed frame NOT the side table or side railframe NOT the side table or side rail

Should be secured to the inner thighShould be secured to the inner thigh

Catheter Care #2Catheter Care #2Clean the perineal area and around Clean the perineal area and around the catheterthe catheterBag should be emptied and Bag should be emptied and measured each shift ( or more often measured each shift ( or more often if ordered )if ordered )Report complaints promptly to the Report complaints promptly to the nursenurseFollow the rules of asepsis at all Follow the rules of asepsis at all timestimes

Bladder TrainingBladder Training

Goal is voluntary control of bladderGoal is voluntary control of bladder

Two basic methods:Two basic methods:

Scheduled use of bedpan, urinal or Scheduled use of bedpan, urinal or toilettoilet

Clamping of catheter on a schedule Clamping of catheter on a schedule basisbasis

Bowel EliminationBowel Elimination

The excretion of wastes from the gastro-The excretion of wastes from the gastro-intestinal systemintestinal system

Normal StoolNormal StoolBrownBrownSoftSoftFormedFormedCharacteristic odorCharacteristic odor

Bowel Elimination #2Bowel Elimination #2

Pattern: each person is differentPattern: each person is different

Frequency – daily to every 2-3 daysFrequency – daily to every 2-3 days

Time of day – morning or eveningTime of day – morning or evening

Factors influencing bowel Factors influencing bowel movementmovement

PrivacyPrivacy

AgeAge

DietDiet

FluidsFluids

ActivityActivity

MedicationsMedications

Common Problems in eliminationCommon Problems in elimination

ConstipationConstipation

Hard, dry stoolHard, dry stool

Feces that moves too slowly through Feces that moves too slowly through the bodythe body

Caused by decreased fluids, diet, Caused by decreased fluids, diet, inactivity, ignoring the urge to inactivity, ignoring the urge to defecatedefecate

Common Problems in elimination Common Problems in elimination #2#2

Fecal ImpactionFecal Impaction

Stool is unable to pass from the Stool is unable to pass from the rectumrectum

Results from unrelieved constipationResults from unrelieved constipation

Common Problems in elimination Common Problems in elimination #3#3

DiarrheaDiarrhea

Liquid or unformed stoolLiquid or unformed stool

Feces that moves rapidly through the Feces that moves rapidly through the intestinesintestines

Caused by infection, medications, Caused by infection, medications, irritating foodsirritating foods

Common Problems in elimination Common Problems in elimination #4#4

Anal IncontinenceAnal Incontinence

Inability to control the passage of Inability to control the passage of feces and gasfeces and gasPossible cause due to injury or Possible cause due to injury or diseases of the nervous systemdiseases of the nervous systemMay result when residents do not May result when residents do not receive the assistance they need in a receive the assistance they need in a timely mannertimely manner

Common Problems in elimination Common Problems in elimination #5#5

Flatulence ( gas )Flatulence ( gas )

Excessive formation of gas in the Excessive formation of gas in the stomach and intestinesstomach and intestines

Caused by foods, medications, or air-Caused by foods, medications, or air-swallowingswallowing

Maintaining Normal Elimination Maintaining Normal Elimination PatternPattern

Provide the bedpan, urinal or Provide the bedpan, urinal or commodecommode

Assist to get into normal positionAssist to get into normal position

Cover the resident for privacyCover the resident for privacy

Remain nearby if the person is weak Remain nearby if the person is weak or frailor frail

Place signal light and toilet tissue Place signal light and toilet tissue nearbynearby

Maintaining Normal Elimination Maintaining Normal Elimination Pattern #2Pattern #2

Allow the resident enough timeAllow the resident enough time

If resident has difficulty, ask them If resident has difficulty, ask them what kinds of things they did at what kinds of things they did at homehome

Provide perineal care if neededProvide perineal care if needed

Offer opportunity to eliminate at Offer opportunity to eliminate at regular intervalsregular intervals

Bowel TrainingBowel TrainingSuppository at a regular timeSuppository at a regular time

Increase fluidsIncrease fluids

DietDiet

ActivityActivity

PrivacyPrivacy

Purpose of an OstomyPurpose of an Ostomy

Artificial opening most commonly Artificial opening most commonly into colon or small intestineinto colon or small intestine

Allow healing of intestine after Allow healing of intestine after surgery or diseasesurgery or disease

Can be temporary or permanentCan be temporary or permanent

Types of OstomiesTypes of OstomiesCecostomyCecostomyColostomyColostomyIleostomyIleostomyJejunostomyJejunostomyDuodenostomyDuodenostomy

Location depends on the disease or injuryLocation depends on the disease or injuryCharacteristics of stool from different Characteristics of stool from different ostomiesostomies

Ostomy CareOstomy Care

EquipmentEquipment

Emptying the bagEmptying the bag

Skin careSkin care

Odor managementOdor management

Ostomy Care – Role of NAOstomy Care – Role of NA

Assist with personal hygieneAssist with personal hygiene

Provide for privacyProvide for privacy

Changing appliancesChanging appliances

Emptying ostomy bagEmptying ostomy bag

Provide skin careProvide skin care

Use Standard PrecautionsUse Standard Precautions

Measuring weight and heightMeasuring weight and height

On admission and as orderedOn admission and as ordered

Wears gown or pajamasWears gown or pajamas

Urinate before being weighedUrinate before being weighed

Do routine weights at the same time Do routine weights at the same time each dayeach day

Types of prosthetic devices / Types of prosthetic devices / Artificial limbsArtificial limbs

Nursing considerationsNursing considerations

Ask charge nurse for guidelinesAsk charge nurse for guidelines

Observe ability to participate in ADL’sObserve ability to participate in ADL’s

Assist resident to apply brace Assist resident to apply brace

Maintain body alignmentMaintain body alignment

Keep call bell within reachKeep call bell within reach

ROM to affected musclesROM to affected muscles

Nursing considerations #2Nursing considerations #2

Pad bracePad brace

Give constant praise for Give constant praise for rehabilitative effortsrehabilitative efforts

Provide skin careProvide skin care

Observe for complaint of Observe for complaint of pain,numbness, or weaknesspain,numbness, or weakness

Artificial eyesArtificial eyes

Daily removal are not necessaryDaily removal are not necessary

Special concern to prevent infection Special concern to prevent infection of the eye socketof the eye socket

Report redness, drainage, or crusting Report redness, drainage, or crusting of eyelashesof eyelashes

Store the artificial eye in a container Store the artificial eye in a container labeled with the resident’s namelabeled with the resident’s name

Hearing aidsHearing aids

Check the batteryCheck the battery

Do not drop or try to repair the Do not drop or try to repair the devicedevice

Apply to the ear it is designed forApply to the ear it is designed for

Do not allow thr device to get wetDo not allow thr device to get wet

Purposes of a hearing aidPurposes of a hearing aid

Restore hearingRestore hearing

Always face the resident when Always face the resident when talkingtalking

Speak clearlySpeak clearly

Parts of a hearing aidParts of a hearing aid

MicrophoneMicrophone

AmplifierAmplifier

EarmoldEarmold

CordCord

On / off switchOn / off switch

Placement of the hearing aidPlacement of the hearing aid

Turn down the volumeTurn down the volume

It should fit tightly but comfortablyIt should fit tightly but comfortably

Turn it on and adjust volumeTurn it on and adjust volume

Check the placement if the resident Check the placement if the resident complains of an unpleasant whistlecomplains of an unpleasant whistle

Check the batteriesCheck the batteries

Caring for the hearing aidCaring for the hearing aid

Never wash a hearing aidNever wash a hearing aid

Never drop the hearing aidNever drop the hearing aid

Do not expose to heatDo not expose to heat

Do not let moisture get into the Do not let moisture get into the hearing aidhearing aid

Do not use any kind of hair sprayDo not use any kind of hair spray

Talking to a partially deaf personTalking to a partially deaf person

Face the residentFace the resident

Speak slowly and clearlySpeak slowly and clearly

Don’t cover your mouth or chew gumDon’t cover your mouth or chew gum

Sit on the side of the better earSit on the side of the better ear

Use short sentencesUse short sentences

Repeat and rephrase statementsRepeat and rephrase statements

Facial expressions and body languageFacial expressions and body language

Reduce background noiseReduce background noise