Quiz Content

Improve conditions for all people in long-term care facilities

Protect the resident’s confidentiality

Focuses on the degree of assistance / skilled care the resident needs, including:

• weight

• bowel & bladder habits

• ability to care for themselves

admit clearly that she does not know the answer

inform the nurse that this duty is beyond their scope of practice

• When they haven’t received adequate training about the task and the directions are not clear

• When the task is outside of their scop eof practice

Neglect

Poor personal hygeine, weight loss, unexplained bruises, chafing or discharge from the genital area

Transfers the decision-making power to another person (often family or friend)

a violation of civil law (tort) that occurs when someone causes harm/injury to another person without the intent to cause harm

False

A file that contains condensed versions of each patient/resident’s medical record

provided for ppl who have recently required some type of acute care for an illness or injury

provides care for ppl who are chronically ill and require assistance with activities of daily living (ADLs)

separate areas of the facility designed to meet the needs of residents with specific types of disorders (eg. Alzheimer’s)

Each resident’s personal history is used as the basis for an individualized plan of care. Staff members are permanently assigned to residents to foster this individualized knowledge and understanding.

Omnibus Budget Reconciliation Act (OBRA)

Activities of Daily Living

hot, red swollen, and painful

1. Shoe Coverings

2. Gloves

3. Gown

4. Hair Covering

5. Eye Protection

6. Face / Breathing Mask

Hep B, Hep C

considered normal (resident) flora when they are in or on one part of the body, but can cause infection if they move out of that area into another part of the body

non-living object that has been contaminated (soiled) by pathogens

Alignment, Balance and Coordinated Movement

• face drooping

• arm weakness

• speech difficulty

• loss of consciousness or a coma

• pain, pressure or tightness in the chest, which may extend to the neck, back or arm

• pale or grayish skin

• excessive sweating

• trouble breathing

• nausea or heartburn-like pain

• fatigue

have the person lie down, and raise the person’s head to make breathing easier, and call the nurse / activate emergency response system immediately

Semi-Fowler’s (30-45 degrees)

• Semi (30-45 degrees - for person who has trouble breathing when lying flat, hernias with reflux, tube feedings, visiting with guests)

• High (60-90 degrees - for eating a meal and during grooming)

• allowing the person to sit upright on the side of the bed a few minutes before standing so they can adjust to an upright position

• dizzyness / fainting / risk of falling due to low blood pressure when they stand

• decreased blood flow to the skin (dermis)

• pressure ulcers

• contractures

• 
  

labored or difficule breathing

sudden decrease in BP when a person stands up from a lying position

• aka tube feeding

  • nasogastric tube, nasointestinal tube, gastronomy tube, jejunostomy tube, percutaneous endoscopic gastronomy (PEG) tube

• high risk for aspiration (inhalation of foreign material into the lungs) if they regurgitate the feeding formula

• prevention: raise head of bed during feeding + 1 hr after feeding

nothing by mouth

• Stage 1 Pressure Ulcer: reddened skin that does not return to normal color after pressure is removed (w/in a few min)

• Reddened area may become very pale or white and develop a shiny appearance

• if it stays red, feels hot to the touch, or is painful, report to nurse!

coughing up blood

call the nurse - they could be getting inadequate oxygen!

• blod clot that moves from one place to another (eg. leg to lungs = pulmonary embolism)

• can be prevented by using TED (antiembolism) stockings

• symptoms of DVT = pain, rednes, swelling, warmth in the lower leg

• ppl with DVT are at high risk for pulmonary embolism - symptoms could include shortness of breath and chest pain

• cool, clammy skin

• sweating

• feeling “shaky”

• confusion / difficulty concentrating

• rapid heart rate & rapid breathing

• headache

• blurry / double vision

• restlessness and irritability

• trembling

• tingling sensation in mouth / tongue

• hunger

• loss of consciousness

• excessive urination

• excessive thirst

• extreme hunger

• unplanned weight loss

• fatigue

• blurry / double vision

• headache

• irritability

• dry, flushed skin

• sweet-smelling breath

• dehydration

• seizures

• loss of consciousness (diabetic coma)

has a medical condition that causes them to sweat a lot

as-needed

• polyuria - aka diuresis - excessive urine output

• oliguria - voiding small amt of urine (100-400mL) over 24 hrs

• anuria - voiding less than 100mL in 24 hrs

FAST

• F - face drooping or numb on one side

• A - arm weakness or numbness on one side - ask them to raise both arms - does one arm drift down?

• S - speech difficulty

• T - time to call 911

a person with medical conditions that cause them to sweat a lot

place pt. in side-lying position or turns pt. head to side to prevent aspiration

1. face (use clean part of wash cloth for each eye)

2. neck & torso

3. perineal care last (it’s the most dirty part)

No - elderly person’s toenails are thick and hard, and if an injury occurs to the foot it takes a long time to heal. The Nurse or Podiatrist does this care. CNAs may be permitted to file toenails.

Periodic clamping and unclamping of the catheter tubing

Unclamps the emptying spout on the urine drainage bag and allows all of the urine to drain into a graduate that has been placed on a paper towel on the floor underneath the urine drainage bag.

The patient is incontinent of urine and has wounds or pressure ulcers that would be made worse by contact with urine.

NEVER for the convenience of nursing staff!

Keeping the patient's legs in correct alignment. (through use of pillows or bolsters like an abduction pillow)

Being aware of specific ambulation and transfer techniques that are used with the person

• shuffling, leaning gait

• hard to stop once they begin walking

• speaking slowly, in a voice that does not vary in tone

• loss of ability to move small muscles in the face, giving them a “mask-like” appearance

Episode of temporary decreased bloodflow to the brain lasting only a few minutes to a few hours

condition of person who is no longer able to understand the meaning of words following a stroke

condition of person who is no longer able to find the words to express themselves following a stroke (they may construct non-sensical sentences)

pain or burning, cloudy urine

Ask her questions about each of her children.

Do NOT bring them back to the present / tell her she’s wrong! Join her in her reailty!

Dementia patients become more agitated, restless, and confused in the late afternoon and evening.

Irregular, shallow breaths in an alternating fast-slow pattern.

Often accompanied by a “death rattle” - noisy, rattling breathing that often occurs in ppl when death is near

• cyanosis

• Cheyne-Stokes respirations

• rapid and weak pulse

• decreased urinary output

Approach the patient cautiously and initiate a conversation.

(Try to pull them out of the hallucination)

• change in bowel habits

• a sore that doesn’t go away

• every 15-min for first hour

• every 30-min for next 1-2 hrs

• every hour for the next 4 hrs

• every 4 hrs thereafter