22 Special Care Skills 1. Understand the types of residents who are in a subacute setting The following types of residents may be found in subacute units:

22 Special Care Skills

1. Understand the types of residents who are in a subacute setting

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


2. Discuss reasons for and types of surgery

Define the following term:anesthesia

the use of medication to block pain during surgery and other medical procedures.



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)



There are three different levels of anesthesia:• Local• Regional• General


3. Discuss preoperative care

Define the following term:preoperative

before surgery.


3. Discuss preoperative care

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.


Transparency 22-1: 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.


4. Describe postoperative care

Define the following term:postoperative

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


Transparency 22-2: 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



Observe and report the following when providing postoperative care (cont’d):• Increased drainage• Swelling at IV site• IV not dripping• Nausea or vomiting• Numbness or tingling• Resident complains of pain


5. List care guidelines for pulse oximetry

Define the following term:pulse oximeter

a noninvasive device that uses a light to determine the amount of oxygen in the blood.


5. List care guidelines for pulse oximetry

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.


Transparency 22-3: 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.


6. Describe telemetry and list care guidelines

Define the following term:telemetry

the application of a cardiac monitoring device that sends information about the heart’s rhythm and rate to a monitoring station.


Transparency 22-4: 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.


7. Explain artificial airways and list care guidelines

Define the following terms:artificial airway

any plastic, metal, or rubber device inserted into the respiratory tract to maintain or promote breathing.

intubationthe passage of a plastic tube through the mouth, nose, or opening in the neck and into the trachea.

tracheostomya surgically-created opening through the neck into the trachea.


Transparency 22-5: 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.


8. Discuss care for a resident with a tracheostomy

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.


9. List care guidelines for residents requiring mechanical ventilation

Define the following terms:mechanical ventilation

the use of a machine to inflate and deflate the lungs when a person is unable to breathe on his own.

sedativean agent or drug that helps calm and soothe a person and may cause sleep.


9. List care guidelines for residents requiring mechanical ventilation

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.


Transparency 22-6: 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.


10. Describe suctioning and list signs of respiratory distressNAs 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.


Transparency 22-7: 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.


11. 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 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.


Transparency 22-8: 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.


ExamMultiple Choice. Choose the correct answer.1. What is one example of emergency surgery?

(A) Having a facelift(B) Coronary artery bypass surgery(C) Surgery to remove a ruptured appendix(D) Surgery to remove the wisdom teeth

2. Which of the following is a task to perform for both preoperative and postoperative care of a resident?(A) Assisting the resident to change into a gown(B) Measuring and recording vital signs(C) Applying anti-embolic hose(D) Removing dentures, eyeglasses, contact lenses, and any other

personal items


Exam3. Which of the following statements is true of residents in a

subacute setting? (A) They need a higher level of care than other residents. (B) They need less care and observation than other residents. (C) The cost for their care is higher than a hospital’s costs. (D) The nursing assistant has less responsibility for residents

in subacute care.

4. A pulse oximeter measures (A) Blood pressure and heart rate (B) Blood pressure and pulse rate (C) Blood oxygen level and pulse rate (D) Blood oxygen level and temperature


Exam5. Which of the following statements is true of assisting a

resident who is being monitored using telemetry? (A) The pads should be kept moist or wet at all times. (B) Once attached, the pads can only be removed via surgery.(C) The pads are usually attached to the person’s legs or feet. (D) The pads should remain dry.

6. The method used to insert an artificial airway is called (A) Telemetry (B) Intubation (C) Ventilation (D) Dyspnea


Exam7. 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

8. What might a nursing assistant do for a resident with a tracheostomy? (A) Keep the stoma clean (B) Perform suctioning (C) Remove the tracheostomy tube for cleaning (D) Insert the tracheostomy tube


Exam9. Which of the following statements is true of a resident on a

mechanical ventilator? (A) The resident will be especially relaxed. (B) The resident might be anxious about not being able to

breathe normally.(C) Being on a ventilator is not much different from regular

breathing. (D) The resident will be able to speak.

10. Signs of respiratory distress include (A) Excessive sleep(B) Fever (C) Lack of interest in surroundings (D) Elevated respiratory rate


Exam11. 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 for better flow of fluids.(D) Chest tubes will only be placed in the front of the body.

12. When might suctioning be needed by a resident in subacute care? (A) After a heart attack (B) When a wound is healing too slowly (C) When secretions have collected in the upper respiratory

system (D) When blood oxygen level is too low


CHAPTER 22 PRACTICE1.What is one example of emergency surgery?

(A) Having a facelift

(B) Coronary artery bypass surgery

(C) Surgery to remove a ruptured appendix

(D) Surgery to remove the wisdom teeth

2. A pulse oximeter measures

(A) Blood pressure and heart rate

(B) Blood pressure and pulse rate • Blood oxygen level and pulse rate • Blood oxygen level and temperature

3. 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 for better flow of fluids.• Chest tubes will only be placed in the front of the body.

4. The method used to insert an artificial airway is called

(A) Telemetry

(B) Intubation

(C) Ventilation

(D) Dyspnea


CHAPTER 22 PRACTICE ANSWERS1. C- SURGERY TO REMOVE A RUPTURED APPENDIX2. C- BLOOD OXYGEN LEVEL AND PULSE RATE3. B- THE CHEST DRAINAGE MUST BE OBSERVED FOR AMOUNT AND COLOR4. A- TELEMETRY

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22 Special Care Skills 1. Understand the types of residents who are in a subacute setting The following types of residents may be found in subacute units: