BAY AREA COLLEGE OF NURSING

Resident Care Procedures

I. Terminology A. Admission B. Anti-embolic Stockings (T.E.D. Hose) C. Bandage D. Binders E. Clean Catch F. Defecate G. Discharge H. Drawsheet I. Edema J. Elastic Bandage K. Electric Bed L. Evacuation M. Excoriated N. Expectorate O. Fanfold P. Fluid Q. Gastronomy Tube R. Hives S. Intake T. Integumentary System U. Intravenous V. Lesions W. Manual Bed X. Mitered Corner Y. Mucous Z. Nasogastric Tube AA. Non-prescription BB. Occupied Bed CC. Ointment DD. Output EE.Pruritus FF. Reverse Trendelenberg GG. Scaly HH. Semi-Fowlers Position II. Side Rails JJ. Specimen KK.Suppository LL. Transfer MM. Trendelenberg NN. Unoccupied Bed

II. Sputum specimens A. Collecting sputum specimens: 1. Respiratory disorders cause the secretion of mucous from: Lungs Bronchi Trachea 2. Mucous secretion Called sputum (not related to saliva) Expectorated from mouth 3. Reasons to study sputum: a. Blood b. Microorganism c. Abnormal cells 4. Assisting the resident in raising sputum for a specimen: a. Secretions are usually coughed up after the resident wakes up in early a.m. b. Allow the resident to rinse their mouth with water, as this reduces the amount of saliva in the mouth. c. Do not use mouthwash, as this may destroy dome of the organisms. d. Coughing up sputum may be embarrassing to the resident. e. The specimen itself may be perceived as unpleasant. 5. Specimen needs to be labeled and refrigerated as soon as possible. B. Refer to manual skills procedure Collect and Identify Specimens, Sputum Specimen (pp.9.35 9.38) III. Role of CNA in collecting urine specimens A. Purpose: to collect urine for a laboratory examination or testing in the unit to help the physician diagnose a problem or evaluate treatment. B. Methods for collecting urine specimen 1. Mid-stream 2. Clean catheter urine specimen 3. 24-hour urine specimen C. Rules to follow in collecting urine specimen: 1. Wash hands before and after collecting a specimen. 2. Use standard precautions. 3. Use the correct and clean container for each specimen. 4. Label the container accurately. 5. Collect specimen direction into container. 6. Do not touch the inside of the container or lid. 7. Ask the resident not to have bowel movement while the specimen is being collected. 8. Ask the resident to place toilet tissue in the toilet or wastebasket. 9. Take the specimen and the requisition slip to the designated lab pick-up station.

10. Document that the specimen was obtained and where it was taken in the resident record. D. Refer to manual skills procedure Collect and Identify Specimens, Urine Specimens (pp. 9.35 9.38) IV. Role of CNA in collecting stool specimens A. Purpose: collect for laboratory test to check for the presence of: 1. Blood 2. Fat 3. Micro-organisms 4. Worms 5. Any abnormal contents B. General rules: 1. Maintain residents privacy. 2. Use standard precautions. 3. Give the resident clear instruction on how to defecate for the specimen. 4. Label the container accurately. 5. Clarify if the specimen must be kept at room temperature or refrigerated (check on specific lab test). 6. Take specimen and requisition slip to the designated lab pick-up station. C. Refer to manual skills procedure Collect and Identify Specimens, Stool Specimen (pp. 9.35 9.38) V. Principles of bed making A. Bed making is an important part of the CNAs role. A clean, neat bed makes the resident more comfortable. B. Bed linen can act as an irritant to resident skin. C. Aseptic technique is important when handling bed linen. D. Encourage resident independence. VI. Manual and electric hospital beds A. The functions and structures of a hospital bed: 1. Manually operated beds have hand cranks at the foot of the bed which raise or lower the head, foot or total bed. 2. Electric beds have electric controls located on the side for the resident and CNA or located at the foot of the bed for CNA use. 3. Side rails are used to: a. Prevent resident from falling out of bed. b. Provide security c. Give resident support to hold or grasp when moving or turning while in bed. B. Bed positions: 1. High position encourages the staff to use good body mechanics when giving care to residents, moving residents to stretchers or when making the bed.

2. Low position is used to encourage ambulatory resident to get in and out of bed with ease and safety. 3. Fowlers position (backrest raised 50o to 90o ) is used to give resident comfort while eating meals and to help breath more easily in certain respiratory and cardiac conditions. 4. Semi-Fowlers position (backrest 15o to 50o with knees raised 15o) is used for comfort and to keep the resident from sliding down in bed). C. Proper body mechanics while completing the bed making procedure. Good body mechanics is required in making beds to prevent injury and fatigue. D. Refer to manual skills procedures Occupied Bed Making (pp. 9.31 9.33) and Unoccupied Bed Making (pp. 9.45 9.46). VII. Maintaining residents environment A. Residents spend a lot of time in their rooms. 1. Rooms should be comfortable. 2. Rooms should be safe. General rules for maintaining the residents unit: 1. Make sure resident can reach bedside stand and overbed table. 2. Arrange personal belonging according to the residents preferences. 3. Keep call bell within residents reach. 4. Make sure resident can reach telephone, television, call bell and light controls. 5. Provide the resident with tissues, toilet paper and waste container.

B.

VIII. Enema A. An enema is the introduction of fluids into the rectum and lower colon; ordered by the doctor. B. Purpose of an enema is to: 1. Stimulate a bowel movement. 2. Cleanse a bowel movement. 3. Remove flatus (gas). C. Types of enemas: 1.Cleansing enemas to remove feces from colon and rectum (i.e., tap water, soap suds, saline) 2. Oil retention enema; given for constipation or fecal impaction for lubrication of feces. 3.Commercial mixtures; given for constipation (i.e., Fleets) D. General rules to follow when giving an enema: 1. Temperature of solution should be 105oF 2. Amount of solution is 750-1000 ml for adults. 3. Resident positioned in left Sims position.

4. Height of enema bag is no more than 18 above the mattress. 5. Depth of tube insertion is about 2 to 4 into rectum. 6. Administer solution slowly over ten to fifteen minutes (solution is usually held in rectum for a variable length of time until urge to defecate occurs). 7. Hold enema tube in place while administering. 8. Make sure toilet facility is nearby and available. 9. Observe the results of the enema. 10.Use standard precautions. E. Refer to manual skills procedures Administering the Commercially Prepared Enema and Cleansing Enema (pp. 9.39 9.42).

IX.

The CNAs role in giving a suppository A. A rectal suppository is used to: 1. Stimulate one to empty the bowel. 2. Lubricate the stool to ease evacuation. B. CNAs role: 1. Facility policy dictates if the CNA may insert a suppository. 2. General rules to follow when inserting a suppository. a. Identify the resident by checking the arm band. b. Remove wrapper for the suppository (if wrapped). c. Place suppository 1 to 1-1/2 inches past anal sphincter using gloved hand and index finger. d. Instruct the resident to hold the suppository in rectum as long as possible. e. Observe for results of the suppository. f. Report the result to the RN. C. Refer to manual skills procedure Rectal Suppository-Laxative (pp. 9.43 9.44).

X.

Types and uses of gastrointestinal (GI) tubes

A.

Nasogastric tubes are inserted through nose into stomach or intestine to: 1. Drain the GI tract by means of suction to prevent post-operative vomiting, obstruction or gas formation. 2. Diagnose a disease. 3. Wash out stomach contents. 4. Provide a route for feeding when one is unable to take food by mouth. B. Gastrotomy tube is surgically inserted through abdominal wall into the stomach for the purpose of feeding the resident.

C. Nursing care activities for residents with nasogastric and gastrotomy tubes 1. Maintain a residents physical comfort by: a. Giving frequent oral hygiene and keeping the lips and mouth moist, since the mouth becomes very dry and may taste bad. b. Increasing freedom of movement by securing tubing with clamp or tape to the residents clothing to permit maximum activity. c. Checking to see that the resident does not sit or lie on tubing (tubing must be free of kinks) d. Checking to see if the suction machine is operating satisfactorily and reporting at once if it is not working (if suction is ordered) e. Permitting the resident (if allowed) to suck on ice chips, throat lozenges, or hard candy to keep throat slightly moist. f. Positioning the resident with head of bed elevated at 45 degrees during the feeding and for 30 degrees after the feeding for residents with nasogastric tubes. g. Positioning the resident with head of bed elevated at all times 20 degrees to 30 degrees to prevent reflux for residents with gastrotomy tubes. h. For residents with gastrotomy tubes: remove dressing from Gtube; clean and dry area, replace according to care plan. i. Reporting any unusual conditions observed during the procedure. 2. Maintain a residents mental and emotional comfort by: a. Keeping the environment clean, tidy and well-ventilated, as the resident is often very sensitive to odors which can cause nausea and vomiting. b. Answering call lights promptly. c. Checking frequently and giving emotional support. d. Giving an extra back rub. e. Straightening or changing bed linen p.r.n. f. Asking resident to express concerns about the tube. g. Encouraging the resident to be up, dress in day clothes, and join in activities as tolerated. h. Assist resident to attend family and group activities. 3. Observe, report and record routine care and any unusual events. XI. Using Intravenous (I.V.) therapy A. Intravenous (I.V.) therapy provides the body with needed elements which cannot be given as rapidly or efficiently by other means. These elements may be: 1. Blood, plasma 2. Nutritional requirements for water, salt, sugar, etc. 3. Medications B. Rate of flow is often controlled by an infusion pump.

C. Nursing care activities for a resident with an I.V.

responsibilities include: 1. Maintaining a constant flow by: a. Keeping tubing free of twisting or kinking.

Nursing

b. Observing position of tubing and condition of injection site for any infiltration. An infiltrated I.V. is one which the needle has come out of the vein and the I.V. leaks into the tissue, causing swelling. Report this condition immediately to the charge nurse. c. Checking restraints or soft protective devices to be sure that they are not blocking the vein. Follow your agencys policy regarding restraints and soft protective measure.

2. Maintaining a residents physical comfort: a. Bathe the resident according to daily routine. 1) Wash gently around the area where needle is inserted. 2) Do not loosen the tape that holds needle in place. 3) When drying, do not rub over area, pat gently to avoid dislodging the needle. b. Assist the resident with eating by cutting food, preparing liquids, and arranging utensils conveniently. Assist the resident with feeding as little as possible to encourage selfcare. c. Assist the resident to ambulate: 1) Provide a portable I.V. stand 2) Assist out of bed. 3) Observe closely for weakness. 4) Support the I.V. arm to ensure continuous flow; a sling may be used to rest the arm. 5) Residents may grasp the I.V. pole for support (with I.V. hand). This provides support for the arm and lets them move at their own pace, leaving other hand free for balance by holding onto railings. 3. 4. Refer to manual skills procedure Changing Clothing of Resident with an I.V. (p. 9.34). To maintain a residents mental and emotional comfort: a. Keeping the environment clean, tidy and well-ventilated as the resident is often very sensitive to odors which can cause nausea and vomiting. b. Answering call lights promptly. c. Checking frequently and giving emotional support. d. Giving an extra back rub. e. Straightening or changing bed linen p.r.n. f. Asking resident to express concerns about the tube. g. Encouraging the resident to be up, dress in day clothes and join in activities as tolerated. h. Assist resident to attend family and group activities. XII. Importance of maintaining fluid body balance. A. Next to oxygen, water is the most important physical need. 1. Death can result from taking in inadequate fluids or from losing too much fluid.

a. Water enters body through food and fluid. b. Water is lost through urine, sweat, feces and lungs. 2. Balance between amount of fluid taken in and the amount of fluid lost is necessary to maintain health. B. Amount of fluid taken in and the amount of fluid lost must be equal. 1. Edema fluid intake exceeds fluid output, tissues swell with water. 2. Dehydration fluid output exceeds fluid intake, decrease in the amount of fluid in tissues. C. An adult needs about 2000 ml of fluid a day. Residents depend on nursing personnel to meet part or all of their food and fluid needs. D. Subcutaneous tissues are deeper tissues beneath the skin. XIII. Meaning of force fluids and ways to encourage a resident to increase fluid intake A. When physicians order force fluids it means to have the resident drink an increased amount of fluid. 1. May order specific amount of fluid for 24-hour period. 2. Maintains fluid balance. 3. May be for general or specific amount of fluid. B. CNAs responsibilities: 1. Keep record of amount taken in. 2. Provide variety of fluids. 3. Place within residents reach. 4. Offer fluids frequently to residents who cannot feed themselves.

XIV. Meaning of restrict fluids and ways to restrict a residents fluid intake A. When physicians order restrict fluids it means fluids are restricted to a specific amount. B. CNAs responsibilities: 1. A sign posted above the bed. 2. Water is offered in small amounts. 3. Keep water in pitcher out of sight. 4. Keep accurate intake and output record. 5. Provide resident with frequent oral hygiene. 6. Explain to the resident and family the reason for limiting fluid, removing water pitcher, etc. XV. Nothing by Mouth (NPO) and the CNAs role A. NPO 1. 2. 3. Nothing by mouth is ordered Before and after surgery Before certain lab tests and x-rays In the treatment of some illnesses

B. CNAs responsibilities:

1. 2. 3. 4.

NPO sign above bed. Remove water pitcher and glass. Offer frequent oral hygiene. No swallowing of any fluid.

XVI. Intake and Output A. Purpose of intake and output: 1. The doctor or nurse may want to keep track of a residents fluid intake and output to evaluate fluid balance and kidney function, or medical treatment. 2. Intake and output record. B. Procedure for measuring the amount of fluid taken in by the resident: 1. Measurement of residents intake is done in milliliters (ml) or cubic centimeters (cc). (Review metric and household systems of measurements in handout, Module 7, p. 7.10) a. Determine the fluid capacity of bowls, dishes, cups, pitchers, glasses and other containers used to serve fluids. b. Count as intake: 1) Water, milk, coffee, juice, soup, etc. 2) All food in liquid form when eaten or those that later revert to liquid (i.e. Jello, ice cream) 3) A conversion table is provided on the intake and output record used to chart intake. 4) A container called a graduated cylinder is used to measure fluid. 2. Refer to manual skills procedure, Measuring Urinary Output (p. 9.48). C. Methods for recording and reporting intake and output: 1. Recording intake and output: a. I&O record at bedside, document amounts when fluid is taken or excreted. b. Amounts are totaled at end of shift and entered in the patients record. c. Other special forms as required by facility. 2. Reporting intake and output report any unusual occurrences: a. Refusing to drink fluid. b. Special fluid likes or dislikes. c. Blood in urine. XVII. Bandages and binders A. Bandages and binders are used for the following purposes to: 1. Apply pressure (compression) in order to stop bleeding or swelling, and to assist in absorbing tissue fluids. 2. Provide for immobilization of an injured part, such as a fractured (broken) arm. 3. Hold dressings in place. 4. Protect open wounds from contaminants.

5. Apply warmth to a joint, as for persons suffering from painful joints due to arthritis. 6. Provide support and aid in venous (return blood flow) circulation, as when bandaging the leg of a resident suffering from varicose veins or limited circulation in the extremities (arms or legs). B. Bandages are ordered by the physician and initially applied by the RN. C. Materials used for dressings and bandages: 1. Dressings are made from a variety of materials, mainly gauze which comes in 2, 3 and 4 squares. The size depends on the area of the body involved and the purpose of the dressing. 2. Bandages and binders made from muslin, gauze, flannel, rubber and elastic fiber. 3. Dressings are held in place with hypoallergenic tape, plastic tape, paper tape, silk tape, adhesive tape and binders and bandages. The type depends on the purpose and the resident. D. Principles of bandaging: 1. Apply bandage so pressure is evenly distributed to area. 2. If joint is involved in bandaging, support it in a comfortable position with a slight flexion of the joint. 3. Attach bandage securely to avoid friction and rubbing of underlying tissue which could cause irritation.

E. Observations related to bandages and dressing that should be reported to the nurse: 1. Swelling 2. Pain 3. Change in color 4. Decreased temperature F. Elastic bandages should be removed every eight hours, unless ordered more frequently, to allow for inspection of underlying skin.

XVIII. Use and method of applying anti-embolic hose/elastic stockings (T.E.D. hose) A. Anti-embolic hose/elastic stockings are used to increase circulation by improving venous return from the legs to the heart. B. Things to remember when applying elastic stockings: 1. Always apply before resident gets out of bed. 2. Check frequently for wrinkles. 3. Check circulation in feet frequently. 4. Check popliteal pulse. C. Refer to manual skills procedure Applying Anti-embolic Hose/Elastic Stockings (p. 9.30) Skin conditions

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A. Review objective 15, Module 8 on integumentary system B. Symptoms of skin disease: 1. Pruritus 2. Swelling (edema) 3. Scaling 4. Lesions 5. Hives C. The CNAs role in applying non-prescription ointment, lotions or powders - The CNA applies non-prescription ointments, lotions or powders to prevent skin irritation and breakdown. 1. Provide emotional support to the resident. 2. Apply non-prescription ointments, lotions or powders to intact skin surface only. 3. The CNA does not apply ointments, lotions or powders to irritated skin surfaces or open lesions. D. Distinguish between skin conditions that the CNA can care for and those that must be referred to the RN. 1. The CNA can provide care to residents with the following intact skin conditions: a) Foot care b) Dandruff c) Dry Skin 2. The CNA reports the following existing skin conditions to the RN: a) Acne b) Minor burn c) Diaper rash or prickly heat d) Eczema or psoriasis e) Poison ivy or poison oak f) Minor wounds g) Insect bites or stings E. List of over-the-counter ointments, lotions or powders that the CNA may apply to intact skin. 1. Over-the-counter ointments: a) Zinc oxide b) A and D ointment 2. Over-the-counter lotions: a) Clearasil b) Stri-dex medicated pads c) Selsun Blue d) Keri Lotion e) Corn Huskers 3. Over-the-counter powders: a) Johnsons Medicated Powder b) Tinactin Foot Powder

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F. General rules the CNA should follow in applying an ointment, lotion or powder: 1. Prepare the resident. 2. Position the resident. 3. Cleanse the skin. 4. Protect the surrounding skin. 5. Applying ointments, lotions or powders. a. Apply as directed. b. Creams or liniments are rubbed in by hand. c. Lotions are patted on with a cotton ball. d. Ointments are applied with a wooded tongue blade or a cotton swab. e. Always use gloves in applying lotion or ointment. 6. Chart and report observations. a. Make a note of the appearance of the skin. b. Describe any changes in the appearance. c. Identify any signs of irritation. XX. Admission of a resident to the facility A. Role of the CNA in the admission of a resident to the facility 1. Admission to a long-term facility is stressful to both the resident and family. a. First impression of the facility is important for the adjustment of the resident to the facility. b. The new resident may have many feelings of loss (i.e., home, possessions, independence, family, freedom, privacy, control over ones life). 2. Welcome the resident. 3. Collect base line information about the resident: a. Measure residents height and weight. b. Measure residents vital signs. c. Observe the residents: 1) Grooming 2) Condition of hair and nails 3) Condition of skin 4) Mental alertness 5) Sight and hearing 6) Presence of any prosthesis 7) Ability to move around 4. Report all questions and concerns of the resident or family to the RN. 5. Orient the resident and family to the facility. 6. Care for personal belongings: a. Residents must know they have control over their possessions and can decide where to put items. b. Fill out the facility list of possessions. c. Label items with residents name. B. Role of the CNA in transferring a resident from one area to another within the facility

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1. Tell the resident in advance about the transfer and explain the reason for moving. 2. Collect all the residents belongings and take them to the new room. 3. Introduce resident to new roommates. C. Role of the CNA in the discharge of a resident. 1. Collect all personal belongings of the resident. 2. Assist the resident to his or her vehicle or designated mode of transportation.

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