1. Chapter 22: Special care skills

2. Learning objectives
Understand the types of residents who are in a subacute setting
Discuss reasons for and types of surgery
Discuss preoperative care
Describe postoperative care
List care guidelines for pulse oximetry
Describe telemetry and related guidelines
Explain artificial airways and related guidelines
Discuss care for a resident with a tracheostomy
List care guidelines for residents requiring mechanical ventilation
Describe suctioning and list signs of respiratory distress
Describe chest tubes and related care

3. Types of residents in a subacute setting
Residents who may be found in subacute units
The following types of residents may be found in subacute units:
Residents who need more treatment, monitoring, and services than other residents
Residents who have had recent surgery and chronic illnesses, such as AIDS
Residents who require complex wound care, dialysis, or a mechanical ventilator

4. Reasons for and types of surgery
Reasons for surgery
Any of the following may be a reason for surgery:
Relieve symptoms of a disease
Repair or remove problem tissues or structures
Improve appearance or correct function of damaged tissues
Diagnose disease
Cure disease
There are several different types of surgery:
Elective surgery (e.g., facelift)
Urgent surgery (e.g., coronary artery bypass surgery)
Emergency surgery (e.g., repairing damage from a gunshot wound)
Anesthesia is the use of medication to block pain during surgery and other medical procedures.
There are three different levels of anesthesia:
Local
Regional
General

5. Preoperative care Points to remember Guidelines for preoperative care
Preoperative means before surgery.
NAs should remember this information about preoperative care:
Includes both physical and psychological preparation
Doctor will explain the procedure.
Patient can ask questions, give opinions, and must give consent for surgery.
Patient often experiences anxiety, fear, worry, sadness, and other emotions.
NA can listen to residents’ concerns and report concerns and questions to nurse.
Guidelines for preoperative care:
Follow nothing by mouth (NPO) order by removing water pitcher, glass, and any food or fluids from the immediate area. Explain to the resident why you are doing this.
Assist resident with urinating before surgery.
Assist with enemas or suppositories as trained, ordered, and allowed. Provide privacy.
Assist with bathing as needed.
Make sure call light is within reach every time you leave the room.
Measure and record vital signs as ordered.
Remove and store dentures, eyeglasses, contact lenses, hearing aids, jewelry, hairpieces, hairpins, and any other personal items. (For local or regional anesthetic, hearing aids and dentures may be needed for better communication.)
Assist resident to change into gown if required.
Transfer to gurney/stretcher if necessary.
Make sure identification bracelet is accurate prior to transport.

6. Postoperative care Points to remember about postoperative care
Equipment for postoperative care
Guidelines for postoperative care
Things to observe and report
Postoperative means after surgery.
NAs should remember this information about postoperative care:
Goals are to prevent infections, promote healing, and return person to state of health.
Immediate concerns: problems with breathing, mental status, pain, and wound healing
Complications can include urinary retention or infections, constipation, BP variances, and blood clots.
Careful monitoring is critical.
The following equipment may be needed for postoperative care:
Bed protector
Towels and washcloths
Vital signs equipment
Emesis basin
Pillows and other positioning devices
Warming blankets
IV pole
Oxygen and suction equipment
Guidelines for postoperative care:
Move furniture as needed to allow room for the stretcher.
Assist with transferring resident back into bed (see Chapter 10).
Return personal items to resident.
Measure and record vital signs as directed.
Reposition resident every one to two hours, or as ordered. Elevate extremities as ordered.
Assist with deep breathing and coughing exercises.
Apply anti-embolic hose if ordered. Assist with sequential compression device as ordered. Assist with leg exercises.
Apply binders as ordered.
Observe amount and appearance of drainage from surgical drains.
Encourage residents to follow diet orders.
Assist with elimination.
Help with bathing and grooming.
Assist with ambulation as needed/ordered. Be encouraging and positive.
NAs should observe and report the following when providing postoperative care:
Changes in vital signs
Difficulty breathing
Mental changes (e.g., confusion, disorientation)
Changes in consciousness
Pale or bluish skin
Cold or clammy skin
Increased drainage
Swelling at IV site
IV not dripping
Nausea or vomiting
Numbness or tingling
Resident complains of pain

7. Care guidelines for pulse oximetry
Points to remember
Guidelines for pulse oximetry
A pulse oximeter is a noninvasive device that uses a light to determine the amount of oxygen in the blood.
NAs should remember these points about pulse oximetry:
Warns if blood oxygen level is less than optimal
Normal blood oxygen is between 95% and 100%, but it can differ.
Report any increase or decrease in oxygen levels to nurse.
Guidelines for pulse oximetry:
Report to the nurse immediately if alarm sounds.
Tell the nurse if pulse oximeter falls off or resident requests that you remove it.
Check the skin around device often. Report any of the following:
Swelling
Bluish, or cyanotic, skin
Shiny, tight skin
Skin that is cold to the touch
Sores, redness, or irritation
Numbness or tingling
Pain or discomfort
Check vital signs as ordered and report changes to the nurse.

8. Telemetry and related care guidelines
Care guidelines for telemetry
Telemetry is the application of a cardiac monitoring device that sends information about the heart’s rhythm and rate to a monitoring station.
Guidelines for telemetry:
Report to nurse if the pads become wet or soiled or if they are loose or fall off.
Report if alarm sounds.
Check the skin around the pads often and report the following:
Swelling
Sores, redness, irritation
Fluid or blood draining from skin
Broken skin
Report resident complaints of chest pain or discomfort, or difficulty breathing
Check vital signs as ordered, reporting changes to nurse.

9. Artificial airways and related guidelines
Guidelines for artificial airways
An artificial airway is any plastic, metal, or rubber device inserted into the respiratory tract to maintain or promote breathing.
Guidelines for artificial airways:
Check resident regularly. Tell nurse if tubing falls out.
Monitor vital signs as ordered. Report changes to the nurse.
Perform oral care often as directed.
Watch for biting and tugging on tube. Tell the nurse if resident is doing this.
Use other methods of communication if person cannot speak.
Be supportive and reassuring.

10. Care for a resident with a tracheostomy
Reasons for tracheostomies
Points to remember about tracheostomies
Things to observe and report
Tracheostomies may be necessary for these reasons:
Tumors/cancer
Infection
Severe neck or mouth injuries
Facial surgery and facial burns
Long-term unconsciousness or coma
Airway obstruction
Paralysis of muscles relating to breathing
Aspiration related to muscle or sensory problems in throat
Severe allergic reaction
Gunshot wound
NAs should remember these points about tracheostomies:
Be supportive and responsive.
Resident may be unable to speak. Use other methods of communication.
Answer call lights promptly.
NA responsibilities will mostly include observing and reporting.
NAs should observe and report the following:
Shortness of breath
Trouble breathing
Gurgling sounds
Signs of skin breakdown
Type and amount of discharge coughed up through tracheostomy
Any increase in discharge
Thick, yellow, green, or bloody discharge, or discharge with an odor
Mouth sores or discomfort
Disconnected tubing
Remember: It is very important to prevent infection when caring for residents with tracheostomies. NAs should wash hands often, wear gloves when indicated, and keep equipment clean.

11. Care guidelines for residents requiring mechanical ventilation
Points to remember about mechanical ventilators
Guidelines for mechanical ventilation
Mechanical ventilation is the use of a machine to inflate and deflate the lungs when a person is unable to breathe on his own.
NAs should know these points about mechanical ventilators:
May be required due to cardiac or respiratory arrest, lung injuries or diseases, or head and spinal cord injuries
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.
Guidelines for mechanical ventilation:
Wash hands often.
Tell nurse right away if alarm sounds.
Report disconnected or loose tubing right away.
Answer call lights promptly.
Follow care plan for repositioning instructions. The head of the bed may need to be elevated.
Give regular, careful skin care, and report any of the following:
Swelling
Sores, redness, irritation
Fluid or blood draining from skin
Broken skin
Report if resident is pulling on or biting tube. Report resident anxiety, fear, or distress.
Be patient during communication.
Check on resident often so resident can see you. Be supportive.

12. Suctioning and respiratory distress
Points to remember about suctioning
Guidelines for suctioning
NAs should know these points about suctioning:
Necessary when a person has collected secretions in upper respiratory system.
Suction comes from a pump and bottle or canister collects suctioned material.
Signs of respiratory distress are gurgling, difficulty breathing, elevated respiratory rate, pale skin, bluish skin, nostrils flaring, chest retracting (sinking in below the neck with each breath), sweating, and wheezing.
Guidelines for suctioning:
Report signs of respiratory distress immediately.
Monitor vital signs closely, especially respiratory rate.
Follow Standard Precautions.
Assist nurse as needed. You may be asked to have a towel or washcloth ready for resident after suctioning. Perform oral care as ordered.
Report resident complaints of pain or difficulty breathing.

13. Chest tubes and related care
Points about chest tubes
Guidelines for chest tubes
Chest tubes are hollow drainage tubes that are inserted into the chest to drain air, blood or other fluid, or pus that has collected inside the pleural cavity or space.
NAs should know these points about chest tubes:
Can be inserted at bedside or during surgery
Drain air, blood, or fluid
Allow a full expansion of the lungs
Conditions requiring chest tubes include pneumothorax, hemothorax, empyema, surgery, and injuries.
Chest tube is connected to bottle of sterile water.
System must be airtight when attached to suction.
Guidelines for chest tubes:
Be aware of where chest tubes are.
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.
Make sure tubing is not kinked.
Report disconnected tubing.
Do not remove equipment in the area.
Observe chest drainage for amount and color.
Report if there is increase or decrease in bubbling.
Report clots in tubing.
Be gentle and careful with repositioning.
Report odor.
Provide rest periods.
Measure I&O carefully.
Encourage deep breathing exercises.
Remember: Other residents who require more direct care and observation include those with IVs and those who receive tube feedings.

14. Review Understand the types of residents who are in a subacute setting
Discuss reasons for and types of surgery
Discuss preoperative care
Describe postoperative care
List care guidelines for pulse oximetry
Describe telemetry and related guidelines
Explain artificial airways and related guidelines
Discuss care for a resident with a tracheostomy
List care guidelines for residents requiring mechanical ventilation
Describe suctioning and list signs of respiratory distress
Describe chest tubes and related care
In this chapter, we discussed the types of residents who are in a subacute setting. Reasons for and types of surgery were discussed. Preoperative and postoperative care were described. Guidelines were outlined for pulse oximetry, telemetry, artificial airways, tracheostomy, mechanical ventilation. Signs of respiratory distress were described and chest tube care was explained.