1. Define important words in the chapter

1. Define important words in the chapter
central venous line a type of intravenous line (IV) that is inserted into a large vein in the body. chest tubes hollow drainage tubes that are inserted into the chest to drain air, blood, pus, or fluid that has collected inside the pleural space/cavity. gastrostomy an opening in the stomach and abdomen. intubation the method used to insert an artificial airway; involves passing a plastic tube through the mouth or nose and into the trachea or windpipe.

mechanical ventilator a machine used to inflate and deflate the lungs when a person cannot breathe on his own. nasogastric tube a feeding tube that is inserted through the nose and into the stomach. percutaneous endoscopic gastrostomy (PEG) tube a tube placed through the skin directly into the stomach to assist with eating. pulse oximeter device that measures a person’s blood oxygen level and pulse rate.

sedation the use of medication to calm a person. sepsis a serious illness caused by an infection, usually bacterial, that requires immediate care. telemetry application of a cardiac monitoring device that transmits information about the heart rhythm and heart rate to a central monitoring station for assessment. total parenteral nutrition (TPN) the intravenous infusion of nutrients in a basic form that is absorbed directly by the cells, bypassing the digestive tract.

2. Discuss the types of residents who are in a subacute setting
Define the following term: mechanical ventilator a machine used to inflate and deflate the lungs when a person cannot breathe on his own.

A subacute setting is a special unit or facility that is for people who need more care than most long-term care facilities can provide. Hospitals and long-term care facilities may offer subacute care. Residents in subacute care settings need a higher level of care than other residents. They will require more direct care and close observation by staff.

Know the types of residents found in subacute units: Residents who need more care and observation than other residents Residents having had recent surgery and chronic illnesses, such as AIDS and cancer Residents on dialysis or with serious burns

3. List care guidelines for pulse oximetry
Define the following term: pulse oximeter device that measures a person’s blood oxygen level and pulse rate.

Remember these points about the pulse oximeter: Warns of low blood oxygen level before signs develop Normal pulse oximeter reading is 95% and 100%, but it can differ. Report to nurse any change in oxygen levels.

Know the care guidelines for pulse oximetry: Tell the nurse right away if alarm sounds. Be careful when moving and positioning so oximeter does not move or come off. Report difficulty breathing. Report pale, cyanotic, darkening, or grayish skin, or mucous membranes. Report signs of skin breakdown from the device. Check vital signs as ordered, and report changes to the nurse.

Applying a pulse oximetry device
Equipment: pulse oximetry clip- on sensor probe, nail polish remover, if needed 1. Identify yourself by name. Identify the resident. Greet the resident by name. 2. Wash your hands. 3. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 4. Provide for the resident’s privacy with a curtain, screen, or door.

5. Remove nail polish from digits to be used for pulse oximetry, if necessary. 6. Remove sensor probe from package and place clip-on probe on finger, toe, or earlobe. The index finger is usually preferable. The probe must be placed fully onto the finger or toe; it should not be placed just on the tip of the finger or toe.

7. Blood pressure and pulse measurements may be needed prior to placing the device. If device does not seem to be working, make sure wires on pulse oximetry device are in place and that device is plugged in. Turn on the device. The pulse oximetry reading should appear on the screen quickly.

8. Ask resident to not remove or adjust pulse oximetry device. Ask resident to press call signal if the device comes off or dislodges. 9. Make resident comfortable. 10. Remove privacy measures. 11. Leave call light within resident’s reach.

12. Wash your hands. 13. Be courteous and respectful at all times. 14. Report any changes in the resident to the nurse. Document procedure using facility guidelines.

4. Describe telemetry and list care guidelines
Define the following term: telemetry application of a cardiac monitoring device that transmits information about the heart rhythm and heart rate to a central monitoring station for assessment.

4. Describe telemetry and list care guidelines
Remember these guidelines for telemetry: Do not get the unit, wires, pads, or electrodes wet during bathing. Report to nurse if alarm sounds. Check vital signs, as ordered. Report if pads become loose. Check for signs of skin irritation under or around electrodes. Remind resident not to leave the monitoring area. Report change in vital signs, chest pain or discomfort, rapid pulse, sweating, shortness of breath, dyspnea, or dizziness to the nurse.

5. Explain artificial airways and list care guidelines
Define the following term: intubation the method used to insert an artificial airway; involves passing a plastic tube through the mouth or nose and into the trachea or windpipe.

An artificial airway is needed when the airway is obstructed due to illness, injury, secretions, or aspiration, and sometimes is needed when a person has surgery. Some residents who are unconscious will need an artificial airway. An artificial airway is inserted during a procedure called intubation.

Remember these guidelines for artificial airways: Tell nurse if tubing comes out. Follow orders for positioning. Check vital signs as ordered. Perform oral care often, at least every two hours.

Guidelines for artificial airways (cont’d.): Tell nurse if you see biting and tugging on the tube. Write notes, draw pictures, and use communication boards and hand and eye signals if resident cannot speak. Be supportive and reassuring. Report drainage, change in vital signs, wheezing or difficulty breathing, secretions in tubing, cyanosis, pale, gray, or darkening skin or mucous membranes, or nervousness or anxiety to the nurse.

6. Discuss care for a resident with a tracheostomy
A tracheostomy is a common type of artificial airway. The tracheostomy tube is held in place by a cuff that attaches to the end of the device in the trachea. The cuff prevents the accidental aspiration of food or fluids.

Know the reasons why tracheostomies are necessary: Airway obstruction Cancer Infection Severe injuries Serious allergic reaction Coma Facial burns Gunshot wounds To prevent aspiration in an unconscious person

Think about this question: How would it feel to have an artificial airway and be unable to speak?

REMEMBER: Use alternate methods of communication if the resident cannot speak. Answer call lights promptly.

Think about this question: Even though nursing assistants do not perform tracheostomy care or suctioning, why is careful observation and reporting so important?

Remember the following guidelines for tracheostomies: Answer call lights promptly. Use alternate methods of communication. Follow orders for positioning. Inspect ties or tape often. Report kinks or disconnected tubing.

Guidelines for tracheostomies (cont’d.): Keep the dressing dry, and do not cover the tracheostomy opening. Provide careful skin care. Perform oral care often, at least every two hours. Observe for mouth sores, cracks, breaks or sores on skin. Observe for pale, bluish, or darkening skin or mucous membranes.

Guidelines for tracheostomies (cont’d.): Check vital signs as ordered. Do not tire resident. Do not move spare tracheostomy tubes or bag valve mask. Report cyanosis, pale, gray, or darkening skin or mucous membranes, mouth sores or discomfort, cracks, breaks, or sores on skin, gurgling sounds, dyspnea or shortness of breath, change in vital signs, disconnected tubing, or loose or wet tape to the nurse.

7. Describe mechanical ventilation and explain care guidelines
Define the following term: sedation the use of medication to calm a person.

Know these points about mechanical ventilators: Resident will not be able to speak, which can greatly increase anxiety. Being on a ventilator has been compared to breathing through a straw. Be supportive. Enter the room so the resident can see you often. Use other methods of communication. Act and speak as if resident can understand everything, even if he or she is unconscious or heavily sedated.

Remember these care guidelines for residents with mechanical ventilators: Tell nurse right away if alarm sounds. Report kinks or disconnected tubing right away. Report biting on the tube. Answer call lights promptly. Give oral care often. Report mouth sores or discomfort.

Care guidelines for residents with mechanical ventilators (cont’d.): Reposition at least every two hours. Follow positioning orders. Give regular skin care to prevent pressure ulcers. Allow time for rest. Be patient during communication. Provide emotional support.

Care guidelines for residents with mechanical ventilators (cont’d.): Do not move spare artificial airway tubes or bag valve masks. Report the alarm sounding, a collection of secretions in tubing, mouth sores or discomfort, cracks, breaks, or sores on the skin, change in vital signs, nervousness or anxiety, or depression to the nurse.

Case Study Mrs. G is on a mechanical ventilator. She is sedated, but she is conscious. She bites on her tube sometimes and looks anxious when the NA enters the room. What can the NA do to reassure Mrs. G? What care can the NA give to help increase Mrs. G’s comfort?

Define the following term: sepsis a serious illness caused by an infection, usually bacterial, that requires immediate care.

Know the signs of sepsis: Elevated heart rate and respiratory rate Slightly elevated temperature or low temperature Chills Excessive sweating Feeling of sickness or weakness

Signs of sepsis (cont’d.): Low blood pressure Decreased urine output Headache Skin rash Shortness of breath Confusion or change in mental status

REMEMBER: You should be familiar with residents’ normal vital signs in order to better recognize changes. This will help you notice the early symptoms of sepsis.

8. Describe suctioning and list signs of respiratory distress
Know these points about suctioning: Necessary when a person has increased secretions that he cannot expel Suctioning can be performed orally, nasally, and through the trachea and bronchi. Nursing assistants do not perform suctioning. Suction comes from wall or pump and bottle collects suctioned material. Sterile water or sterile saline is used to rinse suction catheter. Signs of respiratory distress are gurgling, high respiratory rate, shortness of breath, dyspnea, pallor or cyanosis.

Remember these guidelines for assisting with suctioning: Follow Standard Precautions. Follow orders for positioning. Place pad or towel under chin before suctioning. Give oral and nasal care after suctioning. Report signs of respiratory distress immediately.

Guidelines for assisting with suctioning (cont’d.): Answer call lights promptly. Observe for pale, bluish, or darkening skin or mucous membranes. Monitor vital signs closely. Give emotional support during difficult periods. Report change in vital signs; gurgling sounds; change in color, amount, or quality of secretions; dyspnea or shortness of breath; cyanosis; pale, gray, or darkening skin or mucous membranes; or nervousness or anxiety to the nurse.

9. Describe chest tubes and explain related care
Define the following term: chest tubes hollow drainage tubes that are inserted into the chest to drain air, blood, pus, or fluid that has collected inside the pleural space/cavity.

Know these points about chest tubes: Can be inserted at bedside or during surgery Drain air, blood, pus, or fluid Allow a full expansion of the lungs Conditions requiring chest tubes include pneumothorax, hemothorax, empyema, surgery, injuries Chest tube is connected to bottle of sterile water. System must be airtight when attached to suction.

Remember these guidelines for chest tubes: Be aware of where chest tubes are located. Check vital signs as directed and report changes. Report signs of respiratory distress and pain. Keep drainage system below level of chest. Keep drainage containers upright and level.

Guidelines for chest tubes (cont’d.): Make sure tubing is not kinked. Report disconnected tubing. Do not remove equipment in the area. Observe chest drainage for amount, color, and consistency. Report clots in tubing. Observe dressings for drainage, saturation, or bleeding.

Guidelines for chest tubes (cont’d.): Follow orders for positioning. Provide rest periods. Follow fluid orders and measure I&O carefully. Encourage deep breathing exercises. Report complaints of pain, signs of respiratory distress, change in vital signs, change in oxygen levels or if alarm sounds, an increase or decrease in bubbling, disconnected or kinked tubing, clots in the tubing, changes in amount, color, or consistency of chest drainage, wet or loose dressings, or odor to the nurse.

10. Describe alternative feeding methods and related care
Define the following terms: nasogastric tube a feeding tube that is inserted through the nose and into the stomach. percutaneous endoscopic gastrostomy (PEG) tube a tube placed through the skin directly into the stomach to assist with eating. gastrostomy an opening in the stomach and abdomen.

When a person is unable to consume food normally due to disease or injury, other methods are used. When a person has difficulty swallowing or is unable to swallow, he may be fed through a tube.

One tube is called a nasogastric tube (N/G). A nasogastric tube is inserted into the nose, down the back of the throat through the esophagus and into the stomach. The tube is secured to the nose with dressing tape and to the gown with tape or a clip.

An orogastric tube (O/G) is another type of tube. It is used for people who are intubated. It is inserted into the mouth and down the throat, through the esophagus and into the stomach.

Another type of tube that is placed through the skin directly into the abdomen is called a percutaneous endoscopic gastrostomy (PEG) tube. The opening in the abdomen and the stomach is called a gastrostomy.

REMEMBER: Nursing assistants do not insert tubes, give the feedings, or clean or suction the tubes. Your role is assisting the nurse and positioning the resident. Careful observation for problems and changes is important.

Transparency 26-1: Tube Feedings
Guidelines for tube feedings include the following: Observe carefully for signs of aspiration. Follow orders for positioning. Be aware of NPO orders. Give frequent mouth and nose care. Do not pull or tug on tubing. Keep tubing free of kinks. Observe for clip falling off. Notify the nurse if the alarm sounds. Make feeding time a social time.

Observe and report the following related to tube feedings: Mouth or nose sores Plugged tubing Kinked, cracked, broken, or disconnected tubing Tubing comes out of abdomen Leaking or empty bag Loose tape Dyspnea or shortness of breath

Observe and report the following related to tube feedings (cont’d.): Cyanosis, pale, gray, or darkening skin or mucous membranes Nausea, vomiting, and cramping Fluid gathering at mouth Signs of infection at the tube site Bleeding or drainage Signs of aspiration Resident pulling on tube Alarm sounds

Define the following terms: total parenteral nutrition (TPN) the intravenous infusion of nutrients in a basic form that is absorbed directly by the cells, bypassing the digestive tract. central venous line a type of intravenous line (IV) that is inserted into a large vein in the body.

If a person’s digestive system does not function properly, he is unable to eat, or his nutritional needs cannot be met by tube feedings, total parenteral nutrition (TPN) may be ordered. When the need for TPN is expected to continue for a while, a central venous line is usually inserted.

Signs to observe and report regarding TPN: Fever Headache Swelling Redness Bleeding Leaking at insertion site

Handout 26-1: Gastrostomies
Another type of enteral feeding is called a gastrostomy. A gastrostomy is a tube placed surgically into the stomach that can bring food, fluids, and medications directly into the stomach by way of the abdomen. This is done for people who are unable to eat in a normal way. A gastrostomy is inserted in people who have swallowing difficulties, tumors of the throat, birth defects, or the tendency to choke or aspirate on food or fluids. It may also be used for a resident who is comatose or unconscious. Percutaneous endoscopic gastrostomy tubes, or PEG tubes, are commonly used because they do not require general anesthesia to insert them. The placement of the PEG tube is done by a physician. The PEG tube procedure includes using an endoscope inserted into the mouth to guide the doctor in the correct placement of the PEG tube into the stomach. There are certain important steps to take to prevent complications with a PEG tube. After any feeding, follow post-feeding directions regarding the length of time to keep the resident upright or in the High-Fowler’s position. Usually, a period of about 30 to 45 minutes in the upright position is required. The head of the bed will be elevated throughout the feeding time and for the time directed after the feeding. If the tubing becomes loose or disconnected, notify the nurse right away.

Handout 26-1: Gastrostomies (cont’d.)
Guidelines for Gastrostomies For a new gastrostomy: Watch for bleeding or drainage at the surgical site. Observe the dressing for saturation. Observe for pain or discomfort. Take vital signs as ordered and report any change, especially fever. Follow instructions from the nurse on additional post-operative signs and symptoms to report. For an established gastrostomy: Wash hands before touching area near insertion site. Listen carefully for the sound of the alarm. Answer the call light promptly. Carefully monitor all vital signs, especially temperature and blood pressure. Be alert for signs of aspiration or choking. Give oral hygiene as needed. Excellent oral care must be performed when a gastrostomy is in place. Apply lubricant to the lips as necessary.

Position as directed during feedings. Generally the person should be in an upright position for enteral feeding. Watch for clogging of the feeding tube. Carefully follow post-feeding positioning order; the resident will need to sit upright or be positioned on the right side with his head slightly elevated for at least 30 to 60 minutes after feeding is completed. Observe skin around insertion site carefully and often. Watch for irritation, redness, or broken skin. Follow skin care instructions around insertion site. The skin should be cleaned at least daily or as often as ordered. Apply special lubricant to skin area around site, as directed. The nurse may apply antibiotic ointment to the area around the insertion site. Never pull, tug, or twist tubing. Inspect dressing and tape often. Observe for bleeding, drainage, or leakage around insertion site. Take great care not to get dressing wet during care. You may need to notify the nurse if cleaning or dressing changes are needed. Provide emotional support.

Notify the nurse if any of the following occurs: Alarm sounds Resident shows signs of choking or aspiration Resident has difficulty breathing or shortness of breath Skin around insertion site or dressing changes, e.g. looks irritated, red, swollen, warm, broken, or has visible sores Resident complains of pain or discomfort Dressing becomes wet or tape comes off Leakage is noted around insertion site Bag or container is dripping or empty Tubing becomes clogged Tubing is kinked, cracked, broken, or disconnected Tube comes out of abdomen Vital signs change, especially fever or respiratory rate Diarrhea or signs of fecal impaction is noted

11. Discuss care guidelines for dialysis
As you learned in Chapter 16, kidney dialysis is a process that cleans the body of wastes that the kidneys cannot remove due to chronic renal failure (CRF).

11. Discuss care guidelines for dialysis
Know these points about dialysis: Can be done via the arm or the neck Follow I&O orders. Report difficulty breathing, shortness of breath, change in vital signs, pain, drainage or bleeding, as well as change in I&O, and edema.

Exam Multiple Choice. Choose the correct answer. 1. Subacute care is for residents who: (A) Are relatively independent and do not need around-the-clock skilled care (B) Need less care than most long-term care facilities provide (C) Need more care than most long-term care facilities provide (D) Need emergency care for an accident or sudden illness 2. A pulse oximeter measures: (A) Blood pressure (B) Body temperature (C) Blood oxygen level (D) Blood glucose level

Exam (cont’d.) 3. Which of the following statements is true of assisting a resident with a telemetry pack? (A) Do not get the unit, pads, or electrodes wet. (B) Vital signs do not need to be monitored. (C) The pads normally cause the skin to crack, so there is no need to report it. (D) The pads should hang loosely from a resident’s chest. 4. What is the function of an artificial airway? (A) To feed a resident who cannot swallow or digest food (B) To keep the airway open for the lungs to perform air exchange (C) To check a resident’s vital signs (D) To prepare a resident for a medical test

Exam (cont’d.) 5. The method used to insert an artificial airway is called: (A) Telemetry (B) Intubation (C) Ventilation Dyspnea 6. Alternate communication methods for a resident with an artificial airway include: (A) Playing charades (B) Shouting at the resident (C) Asking the resident’s family what they think he wants (D) Using communication boards

Exam (cont’d.) 7. What might a nursing assistant do for a resident with a tracheostomy? (A) Provide skin care to the site around the tube (B) Perform suctioning (C) Remove the tube for cleaning (D) Insert the tube 8. Which of the following statements is true of a resident on a ventilator? (A) The resident will be especially relaxed. (B) Clipboards, pads, and communication boards can help with communication. (C) Being on a ventilator is not much different from regular breathing. (D) The resident will be able to speak.

Exam (cont’d.) 9. Symptoms of respiratory distress include: (A) Gurgling (B) Decreased respiratory rate (C) Redness of the skin (D) Apathy 10. Which of the following statements is true of chest tubes? (A) The drainage system must be kept above the level of the resident’s chest. (B) The chest drainage must be observed for amount and color. (C) The tubing should be kinked. (D) Chest tubes will only be in the front of the body.

Exam (cont’d.) 11. A tube that is inserted into the nose, through the esophagus, and into the stomach for feeding is called a(n): (A) Nasogastric tube (B) Orogastric tube (C) Percutaneous endoscopic gastrostomy (PEG) tube (D) Central venous line 12. What is one of the nursing assistant’s responsibilities for tube feedings? (A) Inserting tubes (B) Giving tube feedings (C) Positioning the resident (D) Cleaning or suctioning the tubes

Exam (cont’d.) 13. Care guidelines for dialysis include: (A) Advise the resident to wear tight sleeves (B) Take blood pressure readings on the access arm (C) Follow instructions for I&O measurement carefully (D) Encourage residents to put pressure on the access arm

1. Define important words in the chapter

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