Oermacc.edc.org



& Contents TOC \o "1-1" \f \h \z \t "Overview,1" Module 1: Overview of the Field PAGEREF _Toc397709874 \h 2Module 2: Communication PAGEREF _Toc397709875 \h 16Module 3: Documentation and Reporting PAGEREF _Toc397709876 \h 20Module 4: Infection Control PAGEREF _Toc397709877 \h 27Module 5: Safety and Emergencies PAGEREF _Toc397709878 \h 44Module 6: Human Growth and Development PAGEREF _Toc397709879 \h 61Module 7: Rights and Abuse Reporting PAGEREF _Toc397709880 \h 71Module 8: Cardio-Respiratory System PAGEREF _Toc397709881 \h 82Module 9: Taking and Recording Vital Signs PAGEREF _Toc397709882 \h 90Module 10: Digestion and Nutrition PAGEREF _Toc397709883 \h 95Module 11: Integumentary System PAGEREF _Toc397709884 \h 110Module 12: Musculoskeletal System PAGEREF _Toc397709885 \h 115Module 13: Body Mechanics and Assisting With Transfers PAGEREF _Toc397709886 \h 122Module 14: Nervous System and Disorders PAGEREF _Toc397709887 \h 127Module 15: Dementia PAGEREF _Toc397709888 \h 141Module 16: Urinary System PAGEREF _Toc397709889 \h 149Module 17: Death and Dying PAGEREF _Toc397709890 \h 155This work is licensed under a Creative Commons 3.0 License workforce solution is 100% funded by a grant awarded by the U.S. Department of Labor, Employment and Training Administration, TAACCCT grant agreement # TC-22505-11-60-A-25.The solution was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including, but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership. Massachusetts Community Colleges are equal opportunity employers. Adaptive equipment available upon request for persons with disabilities.Module 1Overview of the Field TOC \b module1\h \z \t "Title,1" The Main Ingredient PAGEREF _Toc397770508 \h 3The Purposes, People and Places of Health Care PAGEREF _Toc397770509 \h 4Essential Skills for Providing Care PAGEREF _Toc397770510 \h 5Overview of O.B.R.A. PAGEREF _Toc397770511 \h 6Nurse Practice Act PAGEREF _Toc397770512 \h 7Legal And Ethical Behavior PAGEREF _Toc397770513 \h 8Medicare and Medicaid PAGEREF _Toc397770514 \h 9The Rights and Responsibilities of People Receiving Care PAGEREF _Toc397770515 \h 10Confidentiality PAGEREF _Toc397770516 \h 11Greenfield Community College C.N.A. and H.H.A program Confidentiality Certification PAGEREF _Toc397770517 \h 12Professional Boundaries PAGEREF _Toc397770518 \h 13Sue’s Caregiver Creed PAGEREF _Toc397770519 \h 14Guidelines for Personal Safety: PAGEREF _Toc397770520 \h 151428750218440The Main Ingredient0The Main Ingredient Water makes up about the same percentage of the human body as it does of the planet, about 70%Water is needed for every bodily processIt carries nutrients and oxygen to the cells. It regulates body temperature, lubricates the joints, protects vital organs, helps with digestion and to prevent constipation, keeps skin looking young. It even helps to prevent bad breath.Water is vital to mental performance! Just a 2% drop in water in the body can cause mental confusion. Lack of water is the #1 cause of daytime fatigue. Our bodies are constantly using/losing waterEven inhaling and exhaling uses waterThirst lags behind our body’s water need.Don’t wait to be thirsty –Drink Water!The Purposes, People and Places of Health CareThe focus of health care should always be on the person receiving care. The goal of health care should always be to help the person receiving care be as involved in their own care as possible and to achieve and maintain the highest possible level of function and independence.There are many disciplines within the health care profession. Nurses, Doctors, Therapists, Social Workers, Dietitians, CNAs, HHAs and many others are all members of the health care team.People Seek Assistance from Health Care Providers for:Traumatic Injury or Emergency Care = UrgentTreatment of Acute illness = sudden and severe Management of Chronic illness/condition = long term or progressiveRehabilitation = to restore health/function after illness, injury, surgeryCare for Terminal illness = ending in deathThe Places People Receive Health CareHospitals treat emergencies and acute illness Rehabilitation takes place at Rehab Centers & Nursing HomesNursing Homes/Skilled Nursing Facilities provide management of chronic health care conditions and support with Activities of Daily Living = ADLsHospice provides care at the end of lifePeople also receive health care in their own homes, assisted living and other community living As-HHAs are important members of the health care team. They assist the nurse by performing tasks and procedures that support a person with ADLs: Hygiene, Grooming, Nutrition, Mobility, Elimination, Comfort and Socialization.They also play an important role in the management of health care conditions.This includes observation/monitoring of health conditions and reporting changes. Culture influences people’s beliefs and approach to health care. Many individuals seek alternative sources of health care. Acupuncture, herbal medicine, chiropractic, reflexology, massage therapy, Reiki, and homeopathy are just a few examples. Health care providers must always be respectful of cultural differences.Essential Skills for Providing CareAs a Nursing Assistant/Home Health Aide student you will learn many techniques and skills for providing care and assisting a person with all of their activities of daily living.You will gain knowledge about the function and disorders of each body system as well as procedures to assist people with the management of health conditions and disease.You will learn how to observe, monitor, measure and report signs and symptoms in order to support the health and well-being of the people for whom you provide care.Embedded in every task that a caregiver performs are 3 very essential skill areas:SAFETY - This includes infection control, back safety, environmental safety and emotional safety – for both the consumer and the caregiver. COMMUNICATION - Effective communication skills help to engage the person and promote their highest level of involvement. RIGHTS - Respect for the right of the person to be treated with dignity and respect.Overview of O.B.R.A.In 1987 Congress passed health care reform into law. This was due largely to the work of the Citizens’ Coalition for Nursing Home Reform. The law is known as OBRA, the Omnibus Budgetary Reconciliation Act. The purpose of OBRA was to improve the quality of health care, especially in nursing homes. Standards of practice and systems for clinical oversight were established to insure quality care and to promote the person’s highest level of function. The philosophy of OBRA is to approach care from a holistic prospective, which means to consider the whole person: Physical, Mental, Social, Emotional and Spiritual. The goal is to support the individual resident’s right to choice and to be treated with dignity and respect. The state has a process for evaluating quality of care and compliance with the federal OBRA standards/regulations. Annually a team of state surveyors visit each facility to determine if they are meeting all requirements and following all the rules, to see that:The environment is home like, clean, neat and odor free.The food taste good is nutritious and served in a timely manner.The residents’ medical needs are being met and managed well.To evaluate the staff and their treatment of residents.To ensure residents have access to meaningful activities.Before OBRA there were no accepted training standards for nursing assistants. Now individuals must:Complete a 75 hour training programPass a competency exam, including both written and skills testsRenew certification every two yearsWork under the supervision of nurse at least 8 plete 12 hours of in-service education a year. O.B.R.A. requires each state to maintain a Nurse Aide Registry, an official record of each person that completes the program.O.B.R.A. defines what a Nursing Assistant can do and what they can’t. Each state has a nurse practice act that determines the scope of practice.Nurse Practice ActEach state has a Nurse Practice Act to determine the scope of practice and level of education required for nurses.A Registered Nurse (RN) must have, at least, an Associate's degree, which requires 2 years of training/education. They may have a Bachelor or Master's degree.An RN has advanced knowledge about body systems and related disorders, clinical practices and medication. The RN is generally responsible for assessment and admission of clients and residents.Licensed Practical Nurse (LPN) has from 10 to 15 months of training/education. An LPN can administer most medications and preform most skilled nursing tasks. They always work under the supervision of the RN. Even when an RN is not right in the room, or even the building, the LPN is working under the RN license.Nursing Assistants are not licensed. They are certified. They must complete a minimum of 75 hours of training in order to be eligible to take the certification exam. Certified Nursing Assistants (CNA) and Home Health Aides (HHA) are considered Dependent Practitioners. This means that they are allowed to perform certain nursing tasks, under the supervision of a licensed nurse. When a nurse gives an assignment to a CNA or HHA it is called a delegation, which means they have authorized them to perform the task. The nurse always shares responsibility for the task and for the health and safety of the person receiving care.The Five Rights of DelegationThe Right Task - Is the task within the CNA/HHA role limits and job description?The Right Circumstances - Consider the person's situation, condition, mood, needs and desires at the time.The Right Person - The CNA/HHA must have the training and experience to safely and effectively perform the task.The Right Direction and Communication - The nurse gives clear instructions, which should include what to observe and report helps to set priorities and allows time for questions.The Right Supervision - The nurse guides, directs and evaluates the care, provides additional supervisor and demonstrates task as needed.Legal And Ethical BehaviorLaws = Rules set by government to help people to live safely and peacefully together.Nursing Assistants have to follow the laws related to the legal limits of their role.Role Limits of CNA and HHADo not administer medication – Only cue, remind, or assist with pre-poured medicationDo not insert or remove tubes or other objects in to body openings. The exception to this is feeding a person. Do not take Doctors’ orders. Only a nurse can do this.Do not perform procedures that require sterile technique.Do not diagnose or prescribe treatment. Only Doctors can do this.Do not tell the person or family the diagnosis. Refer them to the nurse/Doctor. Do not ignore a delegation from a nurse. You may decline a delegation that is beyond your scope, or that you are not familiar with. You may ask to be shown.Do not supervise another nursing assistant. You may mentor or orient another CNA/HHA, but you do not have the authority to supervise. Ethics = principles and values governing conduct.Nursing Assistants and all medical professionals must follow a code of conduct to guide them in making right decisions and to protect the people that they are caring for.Guidelines for Ethical BehaviorBe honest. If you make a mistake report it.Protect the privacy of residents/clients. Share information only on a need to know basis. Also respect the privacy of coworkers.Report abuse or suspected abuse. Assist residents/clients to report abuse.Follow the care plan. Report/document observations and incidents promptly and accurately.Do not perform tasks beyond your role limits.Follow all rules on safety and infection control. Report violations to nurse. Do not accept gifts or tips.Maintain professional boundaries. Do not get personally involved with residents/clients or their family members. Talk to a supervisor when this becomes challenging.Medicare and MedicaidMedicare is the federally funded health care (entitlement) for:People who have paid in to social security for a certain period.People age 65 or olderPeople under 65 with certain disabilities Medicare is run by the US Department of Health and Human Services. It has many options for types of plans and coverage.Medicare will pay for Skilled Nursing and Rehabilitation services at home and in nursing homes for a limited period of time.Medicaid Medicaid is the federal health care program for certain low income people. It is funded jointly by state and federal government and managed by each state. In Massachusetts the program is called MassHealth. About 60% of long term nursing home residents are paid for by Medicaid. There are also programs within MassHealth for children’s health and social service programs. There are home care options for elders and adults with disabilities under Medicaid as well.The US Department of Health and Human Services sets standards of practice for Medicare and Medicaid. Any health care provider that accepts payment from Medicare or Medicaid must meet the standards and follow the conditions of participation. For example, the C in CNA stands for certified. That means that the nursing assistant has met the federal standards for training and testing. Some states require more training and/or additional testing.The Rights and Responsibilities of People Receiving Care If you have Medicare you have certain guaranteed rights. People who have Medicare have the right to:Appeal denied servicesReceive information about their careReceive emergency room servicesSee doctors, specialists, and women’s health specialists Go to Medicare Certified hospitalsParticipate in treatment decisionsBe informed of treatment decisionsGet information in a culturally competent mannerFile complaints Non discriminationPrivacy/ Confidentiality Medicare guarantees these rights through standards and regulations. All providers that accept Medicare payments (Medicare Certified providers) must adhere to Medicare standards, regulations, and oversight. This includes Nursing Assistance. INFORMED CONSENTEvery person has the right to decide what will be done to his or her body and who can touch his or her body. Consent is “informed” when the person clearly understands:The reason for the treatmentWhat will be doneHow it will be doneWho will do itThe expected outcomeOther treatment options The effects of not having the treatment People who are under 18 years of age or have been declared mentally incompetent must have a designated “Responsible Person” give consent. Everyone should have a Health Care Proxy, a person designated to make health care choices in the event that he or she is unable to give consent.ConfidentialityConfidentiality = A conscious effort by all healthcare professionals to keep private all personal information related to the person who is receiving care and their families. This may include:* Identity – Name, address, phone number, E-mail, any personal information.* Physical and Psychological Condition. - Diagnosis, signs, symptoms.* Emotional Status – Mood, behaviors, attitude.* Financial Circumstances – Any information related to the person’s finances, or method of payment for services.* Personal/Family History – Any personal information, where they grew up, went to school, which they are related to, what they do/did for work, where they vacation or do for leisure activities. Privacy is a basic right in our society. Safeguarding that right is an ethical and legal responsibility of all health care professional. In addition to monitoring their own behavior in regards to confidentiality, a CNA/ HHA may need to remind coworkers, visitors, volunteers, etc. of the importance of privacy and confidentiality. In some cases violations may need to be reported. Guidelines for Confidentiality* Information should be shared only with those that have a need to know in order to deliver safe and effective care.* Never share confidential information without prior consent from the person receiving care, even with close family members or friends.* Be aware of surroundings and environment. Never discuss private information where it may be overheard by others. * Do not use client/resident’s full name when discussing them with others.Congress passed HIPAA – Health Insurance Portability and Accountability Act - in 1996. Under this law, health care organizations must take special steps to protect health information. Organizations and their employees can be fined or imprisoned if they break the rules. In certain circumstances, when a client/resident’s health is at risk, the CNA/HHA may not be able to honor the client/resident’s wish for privacy. Greenfield Community College C.N.A. and H.H.A programDue to the nature and content of this training, personal experience is often shared during class discussion. You are learning how to care for people’s needs and you are a person with needs. You have experienced loss of loved ones, challenges brought on by illness or chronic health conditions, the difficulties of holding it all together when you feel like falling apart -- and at times you have experienced falling apart. You will be learning how to help individuals and their families cope with the very same issues you yourself face.You can enrich your learning experience when you share your stories, and you can learn a lot from one another’s learned lessons.As a caregiver you must protect your client’s privacy. You must keep confidential any personal information you learn while providing care. This class is an opportunity for you to practice the skill of confidentiality by extending it to your classmates. If you agree, please sign the following. I, ______________________________________, agree to keep confidential all personal information I may learn about any of my classmates during the course of this program. Signature: ___________________________________________Date: ______________________________________________Professional BoundariesAs a Nursing Assistant you will develop relationships with the people for whom you provide care. Nursing Assistants are guided by ethics and laws that set limits for their relationships with clients/residents. These limits are called Professional Boundaries. Boundaries help to support a healthy therapeutic relationship. Therapeutic = Serving to cure, or to heal, or to preserve health. To develop and maintain therapeutic relationships with the people you are caring for, it is best to give them unconditional positive regard. Unconditional Positive Regard = Basic acceptance and support of the person no matter what they say or do. Humanist Carl Rogers felt that positive regard is essential to healthy human development.It is easy to have positive regard for someone who is nice and cooperative, but not everyone is. Some people can’t control their behavior; others are simply not very nice. Receiving care can be stressful. Stress, illness, pain, fear, etc., can make a person irritable. You may not be able to control or change a client/resident’s behavior, but you should be able to control your response. You must maintain a boundary between your needs and feelings and the needs and feelings of the person for whom you are providing care. Get support from a supervisor when your boundaries are challenged.Psychologist Abraham Maslow believed that the ability to be completely open and honest with at least one or two other people is essential to healthy growth toward full human potential. He called this self-disclosure. Self-Disclosure = the process of revealing authentic personal information, thoughts and feelings.As a caregiver you may be the one person that the person you are caring for relates to. You will want to encourage self-disclosure from them in order to foster their fulfillment; however you must be careful not to disclose too much of your personal information to them, in order to maintain a therapeutic relationship. Some helpful rules:Do not share your personal problems or your own life concerns.Do not share information about other people for whom you provide care.Never complain about your work, your job or co-workers.Always present a positive attitude.Always stay focused on the health and well-being of the client/resident. Sue’s Caregiver CreedI will be mindful of my own needs and I will take care of myself, which will enable me to better care for others. My own safety and well-being comes first, not only in emergency situations, but in all care procedures. Care is a reciprocal process. I must be mindful of myself as part of the equation. Self–awareness is an essential tool of a caregiver. I encourage the people for whom I provide care to do as much of their own care as they can, and I help them to determine how much they can safely and effectively do. When assisting a person with their activities of daily living, my actions and approach always support the highest level of involvement of the person for whom I am caring. If a person has no other ability to participate, I involve them by verbalizing/explaining what I am doing. As a caregiver I am an extension of the individual I am assisting. I do for them only what they cannot do for themselves. I develop and maintain relationships that are therapeutic to the people for whom I provide care.As a caregiver it is my responsibility to establish healthy connections with the individuals for whom I provide care. It is essential for me to be sensitive, accountable and to hold the person I am caring for in unconditional positive regard. I must create and maintain a clear boundary between their needs and mine and I must be consistent and realistic in what I can and cannot do. I acknowledge and respect the whole person.I approach each person and task holistically, taking into consideration any factors that may impact or influence the person’s ability to receive or participate in care. I will always strive to protect the individual’s dignity and to support their right to privacy and self determination. I am grateful to be of service and I believe that care giving is sacred work. I consider it a privilege to be allowed in to a person’s vulnerability. As a caregiver I have opportunities to interact at a level of deep humanity. I find these interactions very spiritually and emotionally satisfying and rewarding and at times transformative. Guidelines for Personal SafetyMaintain good hydration. Drink plenty of water.Get enough rest and nourishment.Perform only tasks that are within your job description.Accept only the tasks you feel confident performing. Request assistance with any task you are unsure of. Always follow the care plan.Don’t rush.Ask question to clarify anything you don’t understand.Use proper body mechanics.Request assistance with care or transfer as needed.Observe standard precautions and blood borne pathogen standard and use any personal safety equipment properly. Maintain professional boundaries. Follow all agency and facility policies.Don’t bring a lot of personal items in to a consumer’s home.Lock personal items in the truck of your car.If you have broken skin, cover all open areas with a band-aid. Let office or emergency contact know if your schedule changes.If the elder lives in an unsafe area, you may need to change your visit time. Car should be in good working condition. Keep gas tank above ? full.Module 2Communication TOC \b Module2 \h \z \t "Title,1" Communication – An Exchange of Information PAGEREF _Toc397761823 \h 17Listening to Understand PAGEREF _Toc397761824 \h 18Non–Verbal Communication PAGEREF _Toc397761825 \h 19Communication – An Exchange of InformationAn Exchange of InformationHaving effective communication skills is a job requirement of Direct Care munication is an essential aspect of every task a caregiver performs. You need to know of any communication problems the person may have. The care plan should have information regarding techniques that work best, or about the individual’s special communication needs. Verbal CommunicationVerbal communication includes both what we say and how we say it. How information is received and how a message is interpreted is affected by: Tone of voice – Volume of voice - Speed of speech - Choice of wordsOpen and Closed QuestionsClosed questions, also known as direct questions, can be answered with yes or no. This is a good approach for people with speech problems such as aphasia, or during acute distress. (“Did you eat today?”)Open questions encourage further communication. (“What did you eat today?”) Open questions can draw the person out and give you an opportunity to make important observations about the person’s level of orientation.The I StatementCommunication can break down easily at any point in the process, often due to misunderstandings or hurt feelings. The way something is said can have more impact than what is being said. The “I” statement is a very effective communication tool. It allows the receiver to be clear about how she is understanding and affected by what is being communicated. For example, “I feel angry when you say that,” rather than “You make me angry when you say that.” The fact is no one makes us feel anything. We cannot control what another says or does, but we can control our reaction/response. Using the “I” statement also helps to keep the communication on the subject that is being discussed, rather than feelings which can cause us to get off topic.Subjective and Objective informationSubjective = something that is reported, not observed. Objective = something you can see, hear, touch, smell.Listening to UnderstandListening is not simply hearing and more than just being quiet or not interrupting. “Listening to understand” means that the goal is to really get what the person is trying to convey. The following are things you can do to help achieve that goal:Listening TechniquesListening ExamplesListen and repeatAs you listen, repeat back or paraphrase what you have heard. This trains you to listen closely and shows the speaker that you are paying attention. Speaker: “I had my interview today”Response: “Oh, you had your interview today”EncourageOne or two word prompts encourage the speaker to continue to speak.Response: “Oh” or “Yes?” or “Um-hmm” “Go on”Ask for more Ask open–ended questions to encourage further discussion of the topic Ask: “What were some of the questions they asked you in the interview?” Direct/Closed Questions Ask closed questions that can be answered with yes, no, or other single word answers, to clarify what you are hearing or encourage further thought and discussion Ask: “How many people were there asking questions?” Clarify/Verify UnderstandingClarify your understanding. Speaker: “I’m glad I practiced before the interview”Response: “So it sounds like the practice helped.” Summarize Summarize any agreements or commitments that have been mentioned, in order to clarify and verifyStatement: “So you want to meet before the next interview and practice again.”Non-verbal cues Use positive body language, smile, lean in, affirmative head nod, and provide other positive non-verbal cues. Non–Verbal CommunicationWe communicate, even before we speak a word. Our Perception Influences Our Reception! Perception = understanding of a situation through the senses, insight or intuition. Aspects of Non Verbal Communication: Attitude/Intention Posture/AttentivenessFacial Expressions General Appearance Eye Contact Hand Movement/Gestures Awareness of Personal SpaceTouching Body Language = positive non-verbal messages can get across good feelings, and encourage trust and more communication. A smile, nod, head tilt, gentle touch, leaning toward the person, or eye contact, can send the message that you care and want to listen. Behavior is communication. A person with impaired memory may not be able to express themselves verbally, but their behavior can tell us a lot. Written Communication = the use of words or symbols to convey information.Factors that affect written communication: Neatness – Legibility – Spelling - Choice of words – Length. Too much information can decrease understanding. The reader may lose track of the main point or lose interest altogether.Reporting Signs and Symptoms:SIGNS: (Objective) Data that can be seen, heard, felt, smelled and measured.SYMPTOMS: (Subjective) Data that is reported, not observed, by your senses.Signs of a UTI might include small or large amounts of dark, strong smelling urine. Symptom might include reported urgency, burning or pain with urination. Symptoms are best reported in quotations: “She stated that…”How we do something is as important as what we do. There are 3 indirect skills which are part of every task that we perform: *Safety – Infection control, body mechanics, awareness of what is around you.*Client/Resident Rights – respecting privacy, supporting dignity, allowing choice. *Communication – How you address the client/resident and how you interact.Module 3Documentation and Reporting TOC \b Module3 \h \z \t "Title,1" The Care Planning Process For Skilled Nursing Facility PAGEREF _Toc397762759 \h 21The Care Plan PAGEREF _Toc397762760 \h 22RECORD/DAILY FLOW SHEET PAGEREF _Toc397762761 \h 24Accident/Incident Report Form PAGEREF _Toc397762762 \h 26The Care Planning Process For Skilled Nursing FacilityThe AssessmentThe Federal Nursing Home Reform Law mandates that a nursing home must help each resident to “attain or maintain” his/her highest level of well being – physically, mentally and emotionally. The first step in fulfilling this mandate is to perform a holistic, comprehensive and interdisciplinary resident assessment. The Minimum Data Set (MDS) is an assessment tool that nursing homes use to gather information about a resident. The assessment is completed within 14 days of admission (7 days for Medicare residents) and at least once a year thereafter. The MDS is reviewed every three months to monitor the residents condition and to identify any changes The purpose of the MDS is to gather information about the resident’s health, functional status and ability to perform activities of daily living (ADLs). This in turn helps to determine the kind of help he/she will need and also to better understand the reason for the difficulties a resident is having. The MDS process also examines the resident’s routines, habits, activity preference and significant relationships. This information helps nursing home staff to assist the resident to live more comfortably and to feel more at home in the facility. Ultimately the MDS assists staff to set realistic goals for the resident and to develop a comprehensive plan of care. The Care PlanThe plan should be specific, stating what will be done, who will do it and when or how often it will be done. When the assessment is completed, the information is analyzed and a plan of care is developed to address all of the needs and concerns of the resident. The initial care plan must be completed within 7 days after the MDS. The care plan will identify and address all of the needs/problems of the resident and establish goals (measurable every three months by all disciplines or more often if there is a significant status change). The Care ConferenceAn interdisciplinary care conference will be scheduled every three months or more often if needs/goals change. The resident and/or family members are invited to attend. The purpose of the conference is to review the plan of care and the progress that has been made toward the established goals. Another purpose of the meeting is to provide opportunity for the resident and/or family members to voice any concerns and/or to ask any questions related to care or life at the facility. CNAs should be involved in the review of the care plan and ideally invited to attend. The Care PlanThe planning of care is an on-going activity, not a one-time event. The care plan must be regularly reviewed and up dated as needed to reflect the changing needs of the people for whom we are providing care. The care plan is developed by the interdisciplinary team, which means that all members of the heath care team participate in the planning of care. The health care team includes:Doctors - Nurses – Physical, Occupational, Speech Therapist - Social WorkerNutritionist – Dietitian - Pharmacist – Psychologist – CNA/HHA – Family The care planning process has five steps:ASSESS – the person’s current condition, level of function and specific needs.Establish a baseline. What is the status? What is needed? What is and what is not working.PLAN – Set goals to promote improvement, prevent decline and provide for comfort. Determine what can be done to maintain or improve the condition. How will it get done? Who will do it? When and how often? The goals should be clear and measurable and the plan should include a time line for measuring progress. IMPLEMENT – Putting the plan into action. Monitoring, reporting and documenting progress toward goals.EVALUATE – Check in. What is the status now? How is the plan working? Revisit the goal/s, measure the progress. Is the goal still realistic?MODIFY – Adjust or change the plan. Set new goals, or new timelines. When you fail to plan, you plan to fail.Documentation and Medical RecordObserving, reporting and recording are an important part of a direct care workers job in any care setting. Each facility, agency group or private home will have its own specific rules and routines for documentation, including the abbreviations that are allowed.In all cases documentation should be considered as a formal communication. In many cases the record is considered a legal document. Information should reflect what really happened and when, in order to give an accurate accounting of the person's condition and needs as well as the care given.Documentation also serves as a tool for reimbursement/billing. Medicare, Medicaid and private insurers rely on documentation to justify payment for services. In accurate information may be considered fraud.There is an saying in health care, "If it isn't documented, it hasn't been done"A few guidelines to follow:Timeliness:It is generally best to document at the end of a shift.Don't assume that you will remember later. You may want to carry a small pad of paper to make notes as you go along.Never chart "in advance":Always date, initial or sign anything that you add to the record.Always report any urgent concerns immediately.Accuracy:Maintain accurate and truthful records by recording only factual information and observationsStick to the facts. Objective information is best.Only document your own actions, not othersWhen recording statements made by another person, including the care recipient, use quotation marks.Don't use pencil or something that can be smudged easily. Permanent ink pen is best.Make entries short and concise, but not so short that you don't mention something important or useful.Errors and Legalities:If after completing an entry you feel the need to add information, or clarify a point, write the date and the additional comments with the word "addendum".Any changes or mistakes on an entry must be clearly noted. Never erase, scribble over, or use white out. A single line through an incorrect entry with date, and initials is most widely used.Don't alter anyone else's documentation. If you think it's wrong, see your supervisor or the responsible person about it.RECORD/DAILY FLOW SHEETResident Name: ______________________________________________________________________________Write correct code (I = Independent; A = Assisted; D = Dependent) in the box for the day and skill you performed.Place your initials at the bottom of the sheet in the box for the date and shift you performed the skills. Initial each page where you performed a skill.Date12345678910111213141516171819202122232425262728293031TemperaturePulseRespirationWeightDIET - % consumedI – Independent 11-7A – Assisted 7-3D – Dependent 3-11POSITIONINGI – Independent 11-7A – Assisted 7-3D – Dependent 3-11TRANSFERI – Independent 11-7A – Assisted 7-3D – Dependent 3-11NAIL CARE I – Independent 11-7A – Assisted 7-3D – Dependent 3-11BATHING I – Independent 11-7A – Assisted 7-3D – Dependent 3-11HAIR CARE I – Independent 11-7A – Assisted 7-3D – Dependent 3-11ROM EXERCISES I – Independent 11-7A – Assisted 7-3D – Dependent 3-11INITIALS 11-7 7-3 3-11RECORD/DAILY FLOW SHEETResident Name: ______________________________________________________________________________Write correct code (I = Independent; A = Assisted; D = Dependent) in the box for the day and skill you performed.Place your initials at the bottom of the sheet in the box for the date and shift you performed the skills. Initial each page where you performed a skill.Date12345678910111213141516171819202122232425262728293031ORAL HYGIENEI – Independent 11-7A – Assisted 7-3D – Dependent 3-11DRESSINGI – Independent 11-7A – Assisted 7-3D – Dependent 3-11COMMODEI – Independent 11-7A – Assisted 7-3D – Dependent 3-11PERINEAL CARE I – Independent 11-7A – Assisted 7-3D – Dependent 3-11SKIN CARE I – Independent 11-7A – Assisted 7-3D – Dependent 3-11BED PAN I – Independent 11-7A – Assisted 7-3D – Dependent 3-11INITIALS 11-7 7-3 3-11Nurse Aide Signature and Initials: _________________________________________________________Accident/Incident Report Form(Complete this form as soon after incident/accident as possible)Date of incident: _______________Time: ________ AM/PMName of person reporting: Phone Number(s):Was anyone other than reporter involved? (Circle one) YES NOName of others involved: _______________________________________________________________________________________________________Phone Number(s):________________________________________________Details of incident/accident: (If more space is needed continue on back)Was medical attention required/received? (Circle one) YES NO Explain treatment received: Physician/hospital Name: Signature of reporter: _____________________________Date____________Module 4Infection Control TOC \b Module4 \h \z \t "Title,1" Hand Washing PAGEREF _Toc397764943 \h 28Introduction to Infection Control PAGEREF _Toc397764944 \h 29Signs And Symptoms Of Infection PAGEREF _Toc397764945 \h 30Precautions PAGEREF _Toc397764946 \h 31Basic Rules of Bed-Making PAGEREF _Toc397764947 \h 32Public Health Fact Sheet: Clostridium difficile PAGEREF _Toc397764948 \h 33Public Health Fact Sheet: MRSA PAGEREF _Toc397764949 \h 36Public Health Fact Sheet: HIV PAGEREF _Toc397764950 \h 391752600-6657975Hand WashingHand Washing2571751905000Introduction to Infection ControlPreventing the spread of infection is an important job responsibility of a direct care worker. Infection control is embedded in every task that a direct caregiver performs. Following infection control standards protects both the person receiving care and the caregiver. Micro-organisms (Microbes) = Small organism that are everywhere, but seen only under a microscope. Common types of microbes include: Bacteria, Fungi, Viruses and Normal Flora, which grows in the respiratory tract, intestines and on skin.Pathogen = Microbes that cause infection.Non-Pathogen = Microbes that do not cause infection.Infection = A disease caused by the invasion and growth of microbes in the body.Types of Infection* Local Infection = In a certain location of the body.* Systemic Infection = Travels through the bloodstream, throughout the body.* Nosocomial = Healthcare Associated (HAIs) Infection = Infection acquired in a health care setting.Source = A pathogen that causes disease.Reservoir = A place for a pathogen to grow – a warm, dark, moist place is best.Portal of Exit = Any body opening that allows the pathogen to leave.Mode of Transmission = How the pathogen travels.Portal of Entrance = Any body opening that allows pathogens to enter. Susceptible Host = A person at risk for infection.Signs And Symptoms Of InfectionThe immune system helps the body to fight infection. When a harmful pathogen enters the body, the immune system will go to work to attack the pathogen. Sometimes the pathogens grow too fast, or are too strong for the immune system and an infection will grow.Local infections are in a specific location, such as an ear infection, an infected tooth, or an infected cut. An infection can spread through the blood. This is called a systemic infection (blood poisoning). A systemic infection is very serious and can be life threatening. Common signs and symptoms of infection include:*Unsteady/Falls – Poor balance*TIRED – low energy, fatigue, sleepy, weakness*FEVER – can be low or can spike high*CHILLS – can’t get warm.*PAIN – burning, aching, tenderness*LOSS OF APPETITE – not hungry, food does not sit well.*NAUSEA – could include vomiting*SKIN REDNESS – rash, itching, hot to the touch*SWELLING – puffy, stiffness*PUS – yellowish thick, mucus drainage*CONGESTION – runny nose, cough * BEHAVIOR CHANGE – irritability, agitation, confused, weepy, disorientation* CONFUSION – foggy, unfocused Elders are at higher risk for infection. They may only have moderate symptoms. Even minor changes should be closely monitored and reported.PrecautionsMedical Asepsis = clean technique is the practice used to maintain a clean environment. Sterile technique is used to keep an area free of all microbes.Precautions are used by health care workers to prevent the spread of infections and to protect workers against exposure to contagious conditions. Standard Precautions = guidelines set by the (CDC) Center for Disease Control for the proper use of Personal Protective Equipment (PPE) to protect against exposure to body fluids, also known as Bloodborne Pathogens. Standard precautions are used with everyone, regardless of their health status, whenever exposure is possible. The guidelines include proper handwashing before and after use of PPE and proper disposal of any contaminated linens, supplies and waste.There are additional types of precautions that may be used. These are called: Modes of Transmission:Airborne – Germs that travel through the air Droplet – Coughing, sneezing, talking; droplets only stay in the air a few minutes. Contact - Direct touch Indirect – Touching contaminated surfaces Vector – Transmitted by animals PPE includes Gloves, Gowns, Masks, goggles and face shields. There are proper ways to put on (Don) and take off (Doff) PPE and a specific order and techique for donning and doffing each item in order to prevent contamination/exposure. Always discard PPE in appropriate trash receptacle. DONNING PPEREMOVING PPEGownGlovesMaskEye-wear/gogglesEye-wear/gogglesGownGlovesMaskOSHA = Occupation Safety and Health Administration sets and enforces workplace safety and health standards. Under OSHA, employers are required to provide their employees with a safe work place and where there is occupational exposure, the employer shall provide, at no cost to the employee, appropriate PPE and having for the proper use. People with dementia may not or cannot protect themselves from germs.We must do it for them.1562100220345Basic Rules of Bed-Making0Basic Rules of Bed-Making Beds should be made every day and changed at least weeklyA clean, dry, wrinkle-free bed helps prevent skin problemsHandle soiled linen according to care plan. Follow standard precautions Do not shake linens in the airHold clean and dirty linens away from your bodyGather all clean linens before you beginRemove soiled linen one piece at a time, rolling linen away from youLaunder soiled linen promptly Wash hands after handling soiled linens and before handling clean linens Do not lean over bed. Make bed one side at a time CLOSED BED - When the person is up for the day, linens are pulled up to the top of the bed. OPEN BED - When the person is out of bed, and expected to get back in to bed. Linens are fan-folded to the bottom of the bed in order to allow the person to pull covers up independently.Public Health Fact Sheet: Clostridium difficileWhat is Clostridium difficile infection? Clostridium difficile infection also known as “C. diff”, is a diarrheal illness caused by the germ (a bacterium) Clostridium difficile. C. difficile can be found in the soil but it is also commonly found in the hospital environment. It can be found in the stool of people with infection and also in the stool of people without symptoms (carriers). Most cases of C. difficile happen in patients who are taking or have taken antibiotics and who have been exposed to healthcare settings. Antibiotics can destroy the “good” bacteria in the intestines allowing C. difficile to grow. What are the symptoms of infection? The most common symptoms are watery diarrhea (usually 10 or more bowel movements per day which can contain blood or mucous), fever, loss of appetite, nausea, and abdominal (stomach) pain and tenderness. It is also possible to carry C. difficile in the bowel and have no symptoms. How is C. difficile spread? C. difficile can form spores which can exist and remain infectious for a very long time. These spores are not killed by temperatures or other things that kill bacteria that do not form spores. C. difficile is spread from person-to-person. Spores from C. difficile can be found in many environments, especially in healthcare facilities on bed rails, light switches, and medical equipment. They can also be carried on the hands of healthcare providers after caring for a patient who has C. difficile. Improper hand washing and incomplete environmental cleaning of hospital rooms and bathrooms can put individuals in these settings at risk of getting the infection. Who is most at risk of C. difficile infection? Since spores from this germ can live outside the body for a very long time, nursing homes and hospitals have become common places for the elderly and patients taking antibiotics to get this infection. Child care facilities have also become places where C. difficile can be a problem. This germ can be found in the stools of healthy newborns and young infants without causing infection. People with prolonged exposure in any of these settings or in contact with a person with C. difficile infection are at higher risk of getting C. difficile. It mostly affects people taking antibiotics, but is also more likely to affect the elderly and people with bowel disease or other medical conditions. It is less likely to be a problem in children. How is C. difficile diagnosed? Your healthcare provider must examine you and send your stool sample to a laboratory. The laboratory then tests the sample for the presence of C. difficile or the toxins (poisons) the bacteria produce. It is the toxins that cause the damage in the intestines. How is C. difficile infection treated? In most cases infection with C. difficile can be treated with certain antibiotics. C. difficile can recur, however, after treatment ends. In very rare cases serious infection can result and surgery may be required to remove part of the intestines. How can you prevent C. difficile infection?Soap and water works the best against C. difficile. Always wash your hands thoroughly with soap and water before eating or handling food and after using the bathroom. Make sure all doctors, nurses, and other healthcare providers wash their hands with soap and water or with an alcohol-based hand sanitizer before and after caring for you. If you do not believe your healthcare provider has washed their hands, please ask them to do so. Only take antibiotics as prescribed by your healthcare provider. If you are taking care of someone who has C. difficile or any kind of diarrhea, scrub your hands with plenty of soap and water after cleaning the bathroom, helping the person use the toilet, or changing diapers, soiled clothes or soiled sheets. Disinfect surfaces that may have been contaminated by an individual with diarrhea or any other symptoms of C. difficile. Use a disinfectant with “sporicidal” on its label or a fresh 1:10 dilution of household bleach and water. These will kill C. difficile spores. However, keep in mind that bleach solutions must be handled with care as they can irritate your skin, eyes, nose and respiratory secretions. Use them in a well ventilated area.What are hospitals and other facilities doing to prevent the spread of C. difficile?To prevent transmission of C. difficile, hospitals and long-term care facilities have infection control measures in place. Doctors, nurses, and other healthcare providers should regularly wash their hands with soap and water before and after caring for every patient. They may also wear medical gowns and gloves while caring for patients with C. difficile. All rooms and bathrooms in hospitals and long term care facilities should be thoroughly cleaned on a regular basis and all waste should always be properly handled and disposed of. Contact with infected patients should be limited. Whenever possible, patients with C. difficile should have their own room or only share a room if the other patient also is infected with C. difficile. Hospitalized patients with C. difficile should avoid common areas in the facility as much as possible. Visitors may be asked to wear protective gowns and gloves. Children in daycare who are infected with C. difficile may also be excluded while they have active diarrhea in order to reduce transmission to the other children. Where can you get more information?Your doctor, nurse or health care clinic. The Centers for Disease Control and Prevention (CDC) website at: local board of health (listed in the telephone directory under “government”).The Massachusetts Department of Public Health (MDPH), Division of Epidemiology and Immunization at (617) 983-6800 or toll-free at (888) 658-2850, or on the MDPH website at Public Health Fact Sheet: MRSA HYPERLINK "" \l "page=1" \o "Page 1" What is MRSA? MRSA (methicillin-resistant Staphylococcus aureus) is a kind of bacteria that is resistant to some kinds of antibiotics. To understand MRSA it is helpful to learn about Staphylococcus aureus bacteria, often called “staph,” because MRSA is a kind of staph.What are staph?Staph are bacteria commonly carried on the skin or in the nose of healthy people. About 25-30% of the U.S. population carry staph on their bodies at any time. Do staph always make people sick?No. Many people carry staph in their nose or on their skin for a period of time and do not know they are carrying them. They do not have skin infections. They do not have any other signs or symptoms of illness. This is called “colonization.” Sometimes, though, staph can cause an infection, especially pimples, boils and other problems with the skin. These infections often contain pus, and may feel itchy and warm. Occasionally, staph cause more serious infections. How are staph spread? Staph are spread by direct skin-to-skin contact, such as shaking hands, wrestling, or direct contact with the skin of another person. Staph are also spread by contact with items that have been touched by people with staph, like towels shared after bathing and drying off, or shared athletic equipment in the gym or on the field. Staph infections start when staph get into a cut, scrape or other break in the skin. People who have skin infections—painful, swollen pimples, boils, and rashes, for example—should be very careful to avoid spreading their infection to others. Is MRSA different from other staph? Yes. MRSA is different from other staph because it cannot be treated with some antibiotics. When antibiotics are needed to treat a MRSA infection, the right antibiotic must be used. If the right antibiotic is not used, the treatment may not work. MRSA is just like other staph in almost every other way: ? MRSA can be carried on the skin or in the nose of healthy people, and usually not cause an infection or make them sick. ? It can cause minor skin infections that go away without any special medical treatment. ? It is spread the same way as other staph.? The symptoms are the same as other staph infections. What are the symptoms of an infection caused by staph? Pimples, rashes, pus-filled boils, especially when warm, painful, red or swollen, can mean that you have a staph or MRSA skin infection. Occasionally, staph can also cause more serious problems such as surgical wound infections, bloodstream infections and pneumonia. The symptoms could include high fever, swelling, heat and pain around a wound, headache, fatigue and others. What should I do if I think I have a staph skin infection? Keep the area clean and dry. See your doctor, especially if the infection is large, painful, warm to the touch, or does not heal by itself.How will my doctor know if I have a MRSA infection? The only way to tell the difference between MRSA and other staph infections is with lab tests. Lab tests will also help your doctor decide which antibiotic should be used for treatment, if antibiotic treatment is necessary. Your doctor will usually take a sample on a swab (like a Q-tip) from the infected area. The sample will be sent to a laboratory to see if the infection is caused by staph. Blood and other body fluids can also be tested for staph. How are MRSA infections treated? Most MRSA skin infections are treated by good wound and skin care: keeping the area clean and dry, washing your hands after caring for the area, carefully disposing of any bandages, and allowing your body to heal. Sometimes treatment requires the use of antibiotics. Lab tests help your doctor decide which antibiotic should be used for treatment, if antibiotic treatment is necessary. If antibiotics are prescribed, it is important to use the medication as directed unless your doctor tells you to stop. If the infection has not improved within a few days after seeing your doctor, contact your doctor again. How can I prevent a staph infection? ? Regular handwashing is the best way to prevent getting and spreading staph, including MRSA. Keep your hands clean by washing them frequently with soap and warm water or use an alcohol-based hand sanitizer, especially after direct contact with another person’s skin. ? Keep cuts and scrapes clean and covered with a bandage until they have healed. ? Avoid contact with other people’s wounds or bandages. ? Avoid sharing personal items such as towels, washcloths, toothbrushes and razors. Sharing these items may transfer staph from one person to another. ? Keep your skin healthy, and avoid getting dry, cracked skin, especially during the winter. Healthy skin helps to keep the staph on the surface of your skin from causing an infection underneath your skin. ? Contact your doctor if you have a skin infection that does not improve. For more information about MRSA, visit the MDPH website at dph Public Health Fact Sheet: HIVWhat is HIV?HIV (Human Immunodeficiency Virus) is caused by a virus that attacks your body and makes it hard for you to fight off other infections. HIV is the virus that causes AIDS (Acquired Immune Deficiency Syndrome), a condition where your body becomes unable to protect itself from certain kinds of infections. This means that people with AIDS can get diseases which a healthy person's body would normally fight off easily. Once you have the HIV virus in your body, it becomes easier for you to get sick from other things. A health care provider can tell from testing your blood how much virus you have in your body and how hard it may be for your body to protect itself from other germs. When your body gets too weak to fight off other infections, a health care provider may say that you have AIDS. How do you get HIV?If you have anal sex, vaginal sex, or oral sex without a condom with someone who has it, you can get it. Some kinds of sex may be riskier than others (e.g. oral sex is lower risk). You can also get it from sharing needles or works with someone who has the virus. It is passed through body fluids (like blood, vaginal fluid or semen). It can also be passed from mother to baby during birth or breastfeeding. You can’t get it from: ? insect bites ? kissing or hugging ? shaking hands ? sharing food or using the same dish ? sitting on public toilets How do you know you have it?Many people don’t know they have HIV. You may not have symptoms until your body gets so weak that you get sick from something else. You may have: ? small sores, blisters, bumps or a rash? a sore throat ? chills or sweats ? diarrhea ? a fever or swollen glands ? weight loss The only way to know if you have HIV is to get tested. What is the test like?A doctor, nurse or testing counselor will usually take a sample of blood from your fingeror from your arm or they may swab the inside of your mouth. How is HIV treated?There is no cure for HIV or AIDS. Medicines can help reduce the amount of virus in the body. If you have HIV, talk with your health care provider about how you can stay healthy and live longer with the disease. What can you do to protect yourself? ? You can choose not to have sex ? You can reduce your number of partners if you choose to have sex ? You can use condoms when you have sex ? You can talk with your partner(s) about STDs ? You can avoid sharing needles or other works when using drugs ? You can talk with your health care provider and get tested To find out more about HIV or AIDS or for information about where you can go to get tested, call (800) 235-2331 or visit dph/aids QUESTIONS AND ANSWERS ABOUT Methicillin-resistant Staphylococcus aureus (MRSA)What is MRSA? MRSA is a kind of bacteria that is resistant to some kinds of antibiotics. To understand MRSA it is helpful to learn about Staphylococcus aureus bacteria, often called “staph,” because MRSA is a kind of staph.What is staph?Staph is a bacteria commonly carried on the skin or in the nose of healthy people. About 25-30% of the U.S. population carries staph on their bodies at any time. Does staph always make people sick?No. Many people carry staph in their nose or on their skin for a period of time and do not know they are carrying them. They do not have skin infections. They do not have any other signs or symptoms of illness. This is called “colonization.” Sometimes, though, staph can cause an infection, especially pimples, boils and other problems with the skin. These infections often contain pus, and may feel itchy and warm. Occasionally, staph cause more serious infections. How is staph spread? Staph are spread by direct skin-to-skin contact, such as shaking hands, wrestling, or other direct contact with the skin of another person. Staph are also spread by contact with items that have been touched by people with staph, like towels shared after bathing and drying off, or shared athletic equipment in the gym or on the field. Staph infections start when staph gets into a cut, scrape or other break in the skin. People who have skin infections—painful, swollen pimples, boils, and rashes, for example—should be very careful to avoid spreading their infection to others. Is MRSA different from other staph? Yes. MRSA is different from other staph because it cannot be treated with some antibiotics. When antibiotics are needed to treat a MRSA infection, the right antibiotic must be used. If the right antibiotic is not used, the treatment may not work. MRSA is just like other staph in almost every other way: ? MRSA can be carried on the skin or in the nose of healthy people, and usually not cause an infection or make them sick. ? It can cause minor skin infections that go away without any special medical treatment. ? It is spread the same way as other staph.? The symptoms are the same as other staph infections. What are the symptoms of an infection caused by staph? Pimples, rashes, pus-filled boils, especially when warm, painful, red or swollen, can mean that you have a staph or MRSA skin infection. Occasionally, staph can also cause more serious problems such as surgical wound infections, bloodstream infections and pneumonia. The symptoms could include high fever, swelling, heat and pain around a wound, headache, fatigue and others. What should I do if I think I have a staph skin infection? Keep the area clean and dry. See your doctor, especially if the infection is large, painful, warm to the touch, or does not heal by itself.How will my doctor know if I have a MRSA infection? The only way to tell the difference between MRSA and other staph infections is with lab tests. Lab tests will also help your doctor decide which antibiotic should be used for treatment, if antibiotic treatment is necessary.Your doctor will usually take a sample on a swab (like a Q-tip) from the infected area. The sample will be sent to a laboratory to see if the infection is caused by staph. Blood and other body fluids can also be tested for staph. How are MRSA infections treated? Most MRSA skin infections are treated by good wound and skin care: keeping the area clean and dry, washing your hands after caring for the area, carefully disposing of any bandages, and allowing your body to heal. Sometimes treatment requires the use of antibiotics. Lab tests help your doctor decide which antibiotic should be used for treatment, if antibiotic treatment is necessary. If antibiotics are prescribed, it is important to use the medication as directed unless your doctor tells you to stop. If the infection has not improved within a few days after seeing your doctor, contact your doctor again. How can I prevent a staph infection? ? Regular hand washing is the best way to prevent getting and spreading staph, including MRSA. Keep your hands clean by washing them frequently with soap and warm water or use an alcohol-based hand sanitizer, especially after direct contact with another person’s skin.? Keep cuts and scrapes clean and covered with a bandage until they have healed. ? Avoid contact with other people’s wounds or bandages. ? Avoid sharing personal items such as towels, washcloths, toothbrushes and razors. Sharing these items may transfer staph from one person to another. ? Keep your skin healthy, and avoid getting dry, cracked skin, especially during the winter. Healthy skin helps to keep the staph on the surface of your skin from causing an infection underneath your skin. ? Contact your doctor if you have a skin infection that does not improve. For more information about MRSA, visit the MDPH website at: dph Module 5Safety and Emergencies TOC \b Module5 \h \z \t "Title,1" Situations That Are Considered to be Emergencies PAGEREF _Toc397765365 \h 52Responding To An Emergency PAGEREF _Toc397765366 \h 56What To Do In A Fire PAGEREF _Toc397765367 \h 59Handling Hazardous Substances PAGEREF _Toc397765368 \h 60SafetyAs a Nursing Assistant you have a great deal of responsibility for the health and well-being of the people for whom you provide care. However, your first responsibility is always to your own well-being. You can’t give water from a dry well. An important key to safety is the understanding and management of the risk factors involved. Risk factor = something that is likely to increase the chances that a certain event or condition will happen.Two Aspects of Safety:Prevention: To keep from happening, to stop Preparedness: To anticipate, to plan, to make readyFive Areas of Safety:Personal SafetySafety of the Person Receiving CareEnvironmental SafetySafe use of Equipment, Devices, Appliances Emergency Preparedness In order to provide safe and effective care, it is important to understand:The goals of the Care Plan The consumer’s Baseline = current condition, abilities, disabilities.Risk factors involved Cultural factors NOTE: Home Care Aides do not make any changes in a consumer’s home, diet routine or lifestyle without direction from, consumer, supervisor, responsible person or emergency contact.Every individual has the right to live the way they choose; this includes taking risks.Identifying and reporting any situations or conditions that seem less than safe is an important job responsibility of an HHA. Always be clear about who to report to and how to contact that person. Remember that your own safety comes first!Guidelines for Personal Safety:Maintain good hydration. Drink plenty of water.Get enough rest and nourishment.Perform only tasks that are within your job description.Accept only the tasks you feel confident performing. Request assistance with any task you are unsure of. Always follow the care plan.Don’t rush.Ask question to clarify anything you don’t understand.Use proper body mechanics.Request assistance with care or transfer as needed.Observe standard precautions and blood borne pathogen standard and use any personal safety equipment properly. Maintain professional boundaries. Follow all agency and facility policies.Don’t bring a lot of personal items in to a consumer’s home.Lock personal items in the trunk of your car.If you have broken skin, cover all open areas with a band-aid. Let office or emergency contact know if your schedule changes.If the elder lives in an unsafe area, you may need to change your visit time. Car should be in good working condition. Keep gas tank above ? municating Concerns in Home CareAs a Home Care Aide, you will see many different types of clients in a variety of home settings. Generally you will be working unsupervised in the client's home. You may be the only person aware of a health or safety concern.Many factors contribute to safety in the home, for example the time of year. Snow removal/ lawn care. Older homes generally have more safety concerns than a newer home. Location of the home may also be an munication (documentation and reporting) is an important responsibility of a Home Care Aide. It is essential that you know what to communicate, in what form and to whom you should report.Things that you need to know prior to starting a case:Who is the emergency Contact/who to report to?Who is responsible for medications/care planWho else is involved in the caseWhen to call 911What health concerns are being monitoringWhat is the backup planSome Situations Require Immediate Attention.If any of these situations occur during your visit call your supervisor or the client's responsible person immediately:Witnessed/un-witnessed fallsNo food or money to buy food or MedicationsEMT's could not fit a stretcher in their homeClient doesn't answer the door or is not home at a scheduled visitClient asks you to leave earlyClient expressing suicidal thoughtClient refuses personal careClient has no cleaning suppliesClient asks you to complete a task that's beyond your job descriptionSuspected sexual, emotional, spiritual, physical or financial abusePersonal Response System not workingChange in physical/mental statusInappropriate home temperatureNo electricityEnvironmental safety concernHome Safety Check ListAs a health care worker, you encounter potentially hazardous situations every day. Because you are working in the homes of patients, you have less control over the working environment. You should be aware of potential hazards and know how to handle and avoid them. This safety check list will help to identify home hazards.OutdoorsBe aware of uneven sidewalks entering the home.Have handrails on both sides of stairs.Keep all walk ways and stairs free of clutter; rock, ice and snow.Have adequate outside lighting.Is the snow removed from the drive way, and walk way.Could an ambulance enter the drive way.KitchenMaintain well lit roomRemove scatter rugsWipe up spills immediatelyHave an A-B-C fire extinguisher in kitchen.Keep stove free of grease and have pot holders within easy reach,Appliances unplugged when not in use.BasementAre the cellar stairs stable (in good working order)., are there railings in placeRemove clutter from stairs.Are there carbon monoxide detectors in the home. They will need to be installed 5feet from the floor.Keep area well lit.BathroomMaintain a well it roomAre grab bars hand rails needed or in need of repair.Non-skid surface in the tubRaised toilet seat or need one, bed side commode needed for night use.Water temperature less than 120 degrees.Non-skid mat beside the tubBathroomDoes the person need a tub bench.Does the person need a hand held shower.Have a night light in use.Living Room, Dining RoomMaintain a well lit room.Be careful of area rugs, may need to tape down.Keep electrical and cords away from the walk ways.Use high couches or chairs for easy sitting and standing.Avoid clutter around inside walk ways.Smoke DetectorsMinimum one per floor. Need to be on the ceiling NOT WALLS.Replace batteries 2x a year.Test each one monthly.Carbon Monoxide detector should be installed on every floor of your home. These can be installed on the wall 5 feet above from the floor.Bed RoomMake sure bed is not too high, can the persons feet touch the floor. Does the person need a hospital bed.Utilize night light or monitor.Keep phone or health watch button near the bed during the night.May need a bedside commode or urinal for night use.Miscellaneous InformationWatch out for cats and dogs and their toys.Visit your MD regularly.See podiatrist regularly. Sore feet can cause you to fall.To avoid dizziness when first getting out of bed, have the person sit on the edge of the bed for 1-2 minutes before standing.Keep an updated File of Life on your fridge-Review person’s medications every 6 months.Safety Measures for Tub Baths and ShowersClean the tub/shower before and after use.Check all safety equipment, hand rails, grab bars, lifts, tub bench, rubber mat. Report any malfunctions. — body alarmsFollow the care planWipe up spills promptly.Cover the person for warmth and privacy. The person may want to remain covered during bathing.Place needed items within persons reach.Be sure persons use grab bars or hand rails for entering and exiting the bath. Towel bars are made to hold towel not people. Report if grab bars are needed.Turn cold water on first; then hot water. Turn hot water off first; then cold water.When adjusting water temperature, always direct water away for the person.Fill the tub before the person gets into it.Drain the tub before the person gets out of the tub. Cover them for privacy and warmth.Keep the water on the person during the entire shower. You can wet towels and keep them over the person shoulders during tub baths and showers to ensure their warmth.AVOID BATH OILS! They make bathroom surfaces slippery.DO NOT leave weak or unsteady persons unattended.Stay within hearing distance if the person can be left alone. Can give them a bell if at home or the call bell in facility.Household water temperature should be less than 120 degrees.Situations That Are Considered to be EmergenciesALLERGIC REACTIONS - Can be to food or bee stings. You may observe: Trouble breathingFeeling of tightness in the chest and throatSwelling of the face, neck, and tongueRash, hives, dizziness, or confusionPeople who know that they are allergic may have a special kit.WHAT TO DO: If the person has trouble breathing - call 911. If they have a kit, use the kit CHEST PAIN OR PRESSURE - Most people who die of a heart attack die within 2 hours of onset of symptoms. Recognizing the signs of potential heart attack and getting prompt help can save lives! You may observe:Chest pain, heaviness (“an elephant sitting on the chest”) not relieved by rest, changed position, or medication. Pain may radiate to arm, neck, or jawShortness of breathNausea and/or vomitingSweating or change in skin appearanceDizziness or unconsciousnessACHE, HEARTBURN or INDIGESTION - may occur more in women, elderly and diabetics.WHAT TO DO: Call 911, stay with client, make comfortable - adjust position, prop up head, loosen clothing, stay calm. HEAD, NECK, AND BACK INJURIES - Injuries to the head, neck, or back account for only a small percentage of all injuries (according to the Red Cross), but they are the cause of more than half of injury-related deaths. SIGNS OF HEAD, NECK AND BACK INJURIES ARE OFTEN SLOW TO DEVELOP AND ARE NOT ALWAYS OBVIOUIS AT FIRST. Always suspect a head, neck, or back injury if:There’s been a fall greater than the person’s height or if elderly A diving injuryA person is found unconscious for unknown reasonsAny injury where a person’s helmet is broken Any known lightning strikeSigns of this type of injury:Changes in consciousness, loss of balance, seizuresSever pain to head, neck, or backTingling or loss of sensation anywhere on bodyLoss of mobility of a body partUnusual bumps or depressions on head or spineBlood or other fluids draining from earsHeavy external bleedingImpaired breathing or visionNausea or vomiting or persistent headacheWHAT TO DO: Call 911! Do NOT move person unless absolutely necessary. Stay with the person until help arrives SUDDEN ILLNESS - Many types of sudden illnesses often have similar signs. Usually you will not know what exactly is going on, but you can still help. Call 911 when: There is a chance in consciousness or losing consciousnessDifficulty breathingChest pains or pressureAbdominal pain or pressurePerson is vomiting or passing bloodSlurring speech, severe headache or seizuresSome causes of sudden illness: Diabetic ReactionsCardiac EpisodesSeizures DisordersAcute AbdomenStrokeFaintingFIRST AID Animal Bites - if bleeding is minor, WEAR GLOVES - wash wound with soap and water, control bleeding, and apply antibiotic ointment and dressing. Get medical attention if the wound bleeds severely, appears to require sutures, or the animal is suspected of having rabies. May need to contact Animal Control.Burns - are caused by heat, chemicals, electricity, or radiation. Superficial burns (first degree) - cool burn with lots of cool water. DO NOT USE ICE OR ICE WATER on small superficial burns. Can apply soaked towel or cloth. Keep cloth cool by adding more cool water. Cover burn with sterile dressing to prevent infection. CALL 911 FOR BURNS WHEN: There’s trouble breathing Burns covers more than one body part or are on head, neck, feet or genitalsChildren or elderly unless they are very minorBurns result from chemicals, explosions, or electricityMinor wounds - A wound is an injury to the skin and soft tissue beneath it. Damage to blood vessels cause bleeding. USE GLOVES WHEN CARING FOR WOUNDS TO PREVENT DISEASE TRANSMISSION!!! For abrasions and minor cuts - wash wound gently with soap and water. Control bleeding and apply antibiotic ointment and clean dressing. CALL 911 or SEEK MEDICAL ATTENTION FOR WOUNDS WHEN:Bleeding can’t be stopped - apply additional dressings. DO NOT TAKE OFF EXISTING DRESSINGSApply pressure to nearby artery until help arrivesWounds that show muscle or bone, or involve joints are deep and require suture, or involve hands and feet Human bitesAny wound that looks like it might leave a scar – especially on the faceSkin or body parts have been partially or completely torn awayBruises - apply ice or cold pack to the bruise to control pain and swelling. Place a cloth between the person’s skin and the cold source to prevent injury to the tissue.Nosebleed - have person lean slightly forward, pinch the nose shut for approximately 10 minutes. Apply ice pack. If still bleeding, apply pressure on upper lip just beneath the nose. If it STILL doesn’t stop, seek medical attention. Dislocations/broken bones - Only a trained professional can tell the difference between a sprain, fracture, or dislocation. You do not need to know what kind of injury it is to help. SIGNS: Pain, bruising, and swellingApply ice or cold pack with cloth between the cold source and the skinAVOID MOVEMENT or activity that causes painIF SERIOUS INJURY IS SUSPECTED: CALL 911 If an imbedded object - call 911. Keep person still. DO NOT MOVE OBJECT!!! Place bulky dressing around object to support staying in place. Seizures - Protect person from injury. DO NOT restrain or attempt to place anything in the person’s mouth. DO NOT leave person alone. Check for breathing, and call 911.Fainting - May indicate a more serious condition. CALL 911. Elevate legs 8-12 inches if injury is not suspected. Loosen any tight clothing. CHECK breathing. DO NOT give anything to eat or drink. Choking Adult (Conscious) - Clutching throat. Unable to speak, cough forcefully, or breathe. High pitched wheeze. CALL 911!!! Place thumb side of fist against middle of abdomen just above the navel. Grasp fist with other hand. Give quick upward thrusts. Repeat until object is coughed up and person breathes on own or becomes unconscious. Choking Adult (Unconscious) - If person becomes unconscious, look for object in mouth. If seen, remove with your fingers. IF trained in CPR, begin CPR. If not, wait with person until help arrives. Choking Small Child (Conscious) - Turn small child upside down to dislodge object. Give 4 sharp blows between shoulder blades. Repeat if necessary. CALL 911Electric shock - Shut off source of electricity. If not possible, separate person from electrical source using loop of rubber, cloth, dry wood, or leather belt. CALL 911 and stay with person until help arrives.Heat Exhaustion - If person is conscious, move person to cool place. Give cool fluids. Loosen or remove perspiration soaked clothing. Apply cool, wet clothes to skin. Poison Ingested- CALL 911 or call Poison Control (1-888-222-1222), stay with person until help arrives.Responding To An EmergencyEmergencies can’t always be avoided. It is likely that at some time during your life or your work that you will be witness to an emergency or be required to provide first aid. It can be frightening or confusing. STAY CALM!! You can help!!Getting help quickly is often the single most important thing you can do. Call 911 when: The person is unconsciousHas trouble breathing or is breathing in a strange wayHas chest pain or pressureIs bleeding severelyHas severe pain or pressure in the abdomen and it doesn’t go awayIs vomiting or passing bloodHas injuries to the head, neck, or backHas possible broken bones Has fallen and can’t get upShows signs of having had a strokeALSO CALL FOR: fire, downed electrical wires, vehicle collision, presence of poisonous gas, or when a person suddenly becomes disoriented.Use a land line whenever possible to call 911.IF THE PERSON DOES NOT WANT 911 TO BE CALLED? CALL ANYWAY!! Tell the person that they can refuse treatment, and will not have to pay for the ambulance if they don’t go in it. The EMS workers will be able to assess the situation and often convince the person to accept treatment. Always complete an Incident/Accident form or report.The Recovery PositionThis position is used after an emergency such as fainting, seizure or fall. The recovery position is a side lying position which keeps the airway open and prevents aspiration.HAND SUPPORTS HEAD804545347472000KNEE STOPS BODY FROM ROLLING ONTO STOMACHThe person is positioned on their left side, to allow any fluids, mucus, and vomitus to drain from the mouth and to keeps the head, neck and spine in proper alignment.The recovery position is used when the person is breathing and has a pulse but is NOT responding. DO NOT USE the recovery position if you suspect head/neck/back injury. It may be necessary to activate the EMS system or follow the agency's emergency policy.What To Do In A FireR- RescueRescue person in immediate danger. Assist them to a safe place A- AlarmCall 911. Pull building alarm if there is one.C- ConfineClose doors and windows to confine the fire. Turn off oxygen and electrical appliances. E- Extinguish If you can, put the fire out. For small fires, use a fire extinguisher if you have one Handling Hazardous SubstancesA hazardous substance is any chemical that can cause harm. Substances that CNAs and HHAs commonly handle -- such as household cleaners and personal hygiene products -- are perfectly safe when used properly. However, the same products may become hazardous under certain circumstances such as: * When ingested * When inhaled * If it gets in the eye * When mixed with other substances * When stored improperly * When expiredBy law all hazardous substances must have important safety information on the label and a phone number to call for more information about the contents of the product.Every hazardous substance must have a MSDS (Material Safety Data Sheet). That can be available upon request. The MSDS provides detailed information about the hazards of the substance.The Occupational Safety and Health Administration (OSHA) mandates that all employees have a right to know about the hazardous substances that they may come in to contact with in the course of their work. OSHA requires that all employers have a Hazard Communication program that includes: * Container labeling * MSDSs * Employee trainingThis is not true of home care. In home care you are in a client’s home and you will be using products that they have. However, you still have the right to know.White vinegar mixed with water makes a good, safe household disinfectant.Use a 3 to 1 ratio: 1 cup white vinegar with 3 cups of water.Bleach also can be mixed with water to make a disinfectant.1 part bleach and 10 parts water.Module 6Human Growth and Development TOC \b Module6 \h \z \t "Title,1" Culture PAGEREF _Toc397765988 \h 62Basic Human Needs – Maslow’s Hierarchy PAGEREF _Toc397765989 \h 63Human Growth and Development PAGEREF _Toc397765990 \h 64Stages of Growth and Development PAGEREF _Toc397765991 \h 65Erik Erikson’s Stages of Psychosocial Development PAGEREF _Toc397765992 \h 66The Aging Process PAGEREF _Toc397765993 \h 66Physical Changes Common to the Aging Process PAGEREF _Toc397765994 \h 67The Stages of Grief PAGEREF _Toc397765995 \h 69CultureCulture = the distinct way that people live. Culture influences what a person perceives as “normal” or “the right way” to do things.Cultural influences can come from the ethnic background or country a person is from, their religion, a group that they are a part of, where they work, go to school, or even their interest and hobbies. Culture can affect:Life styleBeliefsLanguageTraditionsCustomsFoodFamily roles and interactionsSocial behaviorsReligionBeliefs about health careCulture can affect communication. For example, in some cultures making eye contact with an elder is considered to be disrespectful; in ours it is a sign of respect. As a caregiver it is good to learn about the culture of the person you are caring for. Be open and curious and always hold the person and their culture in positive regard.When cultural differences create challenges, speak with your supervisor. Maslow referred to basic physical needs as deficiency needs (D needs) and higher needs as being needs (B needs). His theory is that D needs must be meant before a person will be motivated to focus on B needs. Behavior and choices are also motivated by needs. Physical Eating, drinking, elimination, rest, shelter, etc. Safety & Security Safe from harm and sense of security for person and property (including money)Love & Belonging Support love and affection, from relationships and roles with family, friends and society.Experiencing personal potential, living to the limit of one’s capacity.Self ActualizationEsteemTo see oneself as valuable and useful to others.-474345-582930 Basic Human Needs Described by Abraham Maslow as a Hierarchy Basic Human Needs Described by Abraham Maslow as a Hierarchy Human Growth and DevelopmentGrowth= Measurable physical changes Human Growth and DevelopmentDevelopment= Changes in mental, emotional and social functionsGrowth and development occurs in stagesEach stage is the basis for the nextEach stage has its own developmental tasksEvery stage affects the whole personHolistic = A concept that considers the whole person Physical HealthMental Health Emotional StabilitySocial/Spiritual Well-being Many factors such as the following can influence and effect the growth and development of a person: Environmental Factors HealthRelationships Past experiences Culture Beliefs Economics Each stage of growth and development relates to and depends upon the stage before. No developmental task can be skipped.Stages of Growth and DevelopmentInfancy (Birth to 1 year)Learning to walkLearning to eat solid foodBeginning to talk and communicate with others Beginning to have emotional relationships with parents and siblingsDeveloping stable sleep and feeding patterns. Toddlerhood (1 to 3 years) Tolerating separation from primary caregiverGaining control of bowel and bladder functionUsing words to communicate Becoming less dependent on the primary caregiver Preschool (3 to 6 years) Increasing ability to communicate and understand others Performing self-care activitiesLearning gender differences and developing sexual modesty Learning right from wrong and good from badLearning to play with othersDeveloping family relationships School Age (6 to 9 or 10 Years)Developing the social and physical skills needed for playing gamesLearning to get along with children of the same age and backgroundLearning gender appropriate behaviors and attitudes Learning basic reading, writing, and arithmetic skillsDeveloping a conscience and moralsDeveloping a good feeling and attitude about oneselfEntering the world of peer groups, games, and learning Adolescence (12 to 18 Years) Accepting changes in the body and appearanceDeveloping appropriate relationships with peersAccepting the male or female role appropriate for one’s age Becoming independent from parents and adultsDeveloping morals, attitudes, and values needed to function in society rapid growth and physical and social maturitypubertyYoung Adulthood (18 to 40 Years)Choosing an education and careerSelecting and learning to live with a partnerBecoming a parent and raising childrenBecoming self sufficient Middle Adulthood (40 to 65 Years)Adjusting to physical changesHaving grown childrenDeveloping leisure-time activitiesAdjusting to aging parentsLate Adulthood (65 Years and Older)Adjusting to decreasing strength and loss of healthAdjust to retirement and reduced incomeCoping with partner’s death Developing new friends and relationshipsPreparing for one’s own death Erik Erikson’s Stages of Psychosocial DevelopmentErikson’s theory is that at each stage of life, we are faced with developmental tasks or challenges. Successful completion of each task/challenge leads to continued growth and a healthy personality. Challenges/tasks not successfully completed may reappear as problems later in life. For example, someone whose needs were not well attended to in the 1st year of life may be fearful in later life.In his 90s, Mr. Erikson added the achievement of wisdom as the ultimate stage of emotional maturation.StageIssueChallengeFavorable OutcomeUnfavorable Outcome1st Year of Life HopeTrust Vs. Mistrust Faith in the environment and future events Suspicion, fear of future events 2nd Year WillAutonomy Vs. DoubtA sense of self-control and adequacyFeelings of shame and self-doubt3 – 5 years PurposeInitiative Vs. Guilt Ability to be a self-starter, to initiate one’s own activities A sense of guilt and inadequacy to be on one’s own 6 year to pubertyCompetenceIndustry Vs. Inferiority Ability to learn how things work, to understand and organize A sense of inferiority at understanding and organizingAdolescence FidelityIdentity Vs. ConfusionSeeing oneself as a unique and integrated person Confusion over who and what one really is Early AdulthoodLoveIntimacy Vs. IsolationAbility to make commitments to others, to love Inability to form affectionate relationshipsMiddle AgeCareGeneratively Vs. Self-absorption Concern for family and society in generalConcern only for self, one’s own well-being and prosperityAging Years WisdomIntegrity Vs. Despair A sense of integrity and fulfillment, willing to face death Dissatisfaction with life, despair over prospect of death The Aging ProcessIf given a choice, growing to old age is the option most of us would choose, but few of us look forward to it. Abraham Joshua-Heschel put it this way: “Old age is something we all want to attain. However, once attained we consider it a defeat, a form of capital punishment. In enabling us to reach old age, medical science may think that it gave us a blessing; however we continue to act as if it were a disease.”We are a very youth oriented culture, but that is changing; this is due to the post- World War II baby boom = Between 1946 and 1964, 78.3 million babies were born. The baby boomers are aging. Currently the fastest growing segment of the population is over 80 years old. People are living longer than ever before. In 1930 human life expectancy was 59 years old. In 1965 it was 70. Today 80% of people in this country can expect to live 80 years. The baby boomers are aging. As a result of these changes, we now have new age group definitions: the “young old” are people ages 65-80. People over 80 are the “old-old” No two individuals age alike. There is a wide range of “normal” aging characteristics. A person’s physical, psycho–social, environmental, and family histories influence how they age. Although people often develop chronic health conditions, disabilities or disease as they age, disease is not a normal part of aging. This means that if all goes well one will die healthy. There are common functional changes that occur with age. How we adjust to the body system’s decline and psychosocial changes impacts how we age. Our own attitudes towards aging may be the biggest influence in how well we age. Healthy aging requires adjusting to declining abilities and decreased independence, dealing with change and losses, and accepting support. Physical Changes Common to the Aging ProcessAging is a very individual process. No two people age exactly the same. Genetics, personal health history, life style, diet, activity, stress level, environment and attitude toward aging are important factors in how a body ages.People are staying healthy and living longer than ever before. However, even in the healthiest of people, body system functions slow down, energy level and body efficiency declines as the body ages. Generally these changes occur slowly and gradually over time. People adapt, adjust and make changes in their lifestyle and activities of daily living to accommodate these changes, often without conscious awareness of the decline.The following is a list, by body system, of common age related changes. Not all people experience all of the below-listed changes: CARDIOVASCULAR SYSTEM:Heart muscle weakens, pumps with less force, increase fatigue may occurArteries narrow and are less elastic Less blood flows through narrowed arteries Weakened heart works harder to pump blood through narrowed vessels Fluid retention may occurINTEGUMENTARY (SKIN) SYSTEM:Skin becomes less elastic and loses its strengthBrown spots (age spots or liver spots) Fewer blood vessels Fewer nerve endings can result in decreased sensitivity to painFatty tissue layer is lostSkin thins and sags, becomes fragile, and wrinkles appear Decreased secretion of oil and sweat glands may result in dry skin and itching Decreased sensitivity to heat and cold Nails become thick and toughWhitening/graying, loss/thinning, drier hair - Facial hair for some women DIGESTION SYSTEM:Decreased saliva production may result in diminished swallowing capacityLoss of teethDecreased appetite may result in decreased nutritional intakeSlower digestion due to decreased secretion of digestive juices Difficulty digesting fried and fatty foodsDecreased peristalsis causing flatulence and constipation.Physical Changes Common to the Aging Process – ContinuedNERVOUS SYSTEM:Slower nerve conduction Reduced blood flow to brainReflexes and response time slow Decrease in short term memory, which may result in forgetfulness Sleep patterns change, sleep periods are shorter Smell and taste decreases Less tear secretions Pupils less responsive to light Decreased vision especially at night or dark rooms Problems seeing green and blue colors Eardrums atrophy resulting in changes in auditory nerve and hearing lossDecreased ear wax secretionReduced sensitivity to hot, cold and/or painMUSCULOSKELETAL SYSTEM:Muscle atrophy resulting in decreased range of motion, flexibility and strengthBone mass and strength decreases Bones may become brittle; can break easily Vertebrae shorten resulting in gradual loss of height Joints may become flexed, stiff and/or painfulRESPIRATORY SYSTEM:Respiratory muscles weaken, resulting in decreased strength for coughingLung tissue become less elasticShortness of breath with exercise may occurHigher risk for respiratory infectionURINARY SYSTEM:Reduced blood supply to kidneys Kidney atrophy Bladder muscles weakenUrinary frequency and/or urgency may occur Urinary incontinence may occur Nighttime urination may occur The Stages of GriefElisabeth Kubler-Ross was a pioneer in the field of hospice care. She identified five different stages of grief, a process by which people cope when diagnosed with a terminal illness. Today we use these stages as a guideline to understand the grieving process. The grieving process is highly personal and should not be rushed or judged. Certainly the Five Stages are not an exact science. They are simply a guide to understanding a person’s behavior. Some people reach acceptance very easily, while others struggle with depression or anger for a long time. It is also important to note that the Five Stages are not always a linear process. Often individuals coping with loss have good days, not so good days, and bad days. They may move back and forth between these Stages:Denial- Often an initial feeling. Shock, disbelief, unable to grasp the reality of the situation/diagnosis. Sometimes unwillingness to believe: “This can’t be happening” “Everything will be fine” “The Doctor is wrong”Anger- This reaction can be very intense. Anger may come in sharp emotional outbursts, rage, or in sustained dark moods. The person may blame or resent others, a situation, him/herself or even God. “Why me” “It’s not fair” Bargaining- For some this may be bargaining with God for a little more time or another chance or with the doctor for more test or treatment. This process is usually private. “I’ll do anything, if only …”Depression- This reaction is marked by a deep sadness. Sometimes a very flat affect and withdrawal from others. The person mourns things that are lost. “I don’t care about anything”Acceptance- The person who has reached acceptance is generally calm and at peace. They no longer fight the reality of their situation. They may be planning their funeral, or writing their will.Module 7Elder Rights and Abuse Reporting TOC \b Module7 \h \z \t "Title,1" Rights of Nursing and Rest Home Residents PAGEREF _Toc397767092 \h 72What Do You See? – a poem PAGEREF _Toc397767093 \h 73Reflections on the Importance of Stuff PAGEREF _Toc397767094 \h 74Elder Abuse Law PAGEREF _Toc397767095 \h 75Types of Abuse PAGEREF _Toc397767096 \h 77Frequently Asked Questions About the Elder Abuse Law PAGEREF _Toc397767097 \h 78Self-Neglect Identifiers PAGEREF _Toc397767098 \h 79Western Mass Elder Abuse Information PAGEREF _Toc397767099 \h 80Agency/Town List PAGEREF _Toc397767100 \h 81Rights of Nursing and Rest Home ResidentsResidents of nursing and rest homes have rights. The following is a list of some of those rights: To be treated with dignity and respectTo privacy and to confidentialityTo be free from physical and chemical restraintsTo send and to receive their mail unopened To participate in arranging their personal care plansTo refuse treatment of medicationTo manage their personal and financial affairs To present grievances to facility staffTo have choices regarding menu and meal timeTo present concerns to an Ombudsman To participate in meaningful activities For more information about residents’ rights contact your local Ombudsman:Franklin County – (413) 773-5555Hampshire County Highland Valley Elder Services – (413) 586-2000 Department of Public Health - Elder Abuse Hotline - 1-800-922-2275Disabled Person Protection Commission - 1-800-426-9009Office of Elder Affairs State Long Term Care Ombudsman ProgramOne Ashburton Place, Room #517, Boston, MA 02108(617) 727-7750 or Toll Free: 1-800-882-2003What Do You See?A poem written by an anonymous nursing home residentWhat do you see; tell me what do you see? What are you thinking when you’re looking at me? A crabby old woman, with faraway eyes? Who seem not to notice things that you do, and forever is losing a stocking or shoe? Is that what you’re thinking? Is that what you see? Then open your eyes, for you’re not seeing me.I’ll tell you who I am as I sit here so still, as I rise at your bidding and eat at your will. I’m a small child of ten, with a father and mother, brothers and sister, who love one another.A young girl of sixteen, with wings on her feet, dreaming that soon her true sweetheart she’ll meet.A bride at just twenty – my heart gives a leap, remembering the vows that I promised to keepAt twenty-five now, I have babies of my own, who need me to build a secure happy homeA woman of thirty, my children grow fast, at forty, my young sons have grown and are gone, but my man’s beside me to see I don’t mournAt fifty once more, babies play round my knee, again we know children, my loved ones and meDark days are upon me, my husband is dead; I look at the future, I shudder with dreadFor my children are busy with lives of their own, and I think of the years and the love that I’ve knownI’m an old woman now – grace and vigor depart, but thousands of memories still live in my heart. Inside it you see a young girl still dwells, and now and again my tired heart swellsI remember the joys, I remember the pain, and I’m loving and living all over again. So open your eyes please open and see, not a crabby old woman, look close … and see me!!Remember this poem next time that you meet an older person. Reflections on the Importance of StuffMany of our belongings have meaning to us beyond their monetary value or use. Our possessions are a big part of our identity. Some things have sentimental value to us. In some cases where we got it is more important than what it is. “One person’s trash is another person’s treasure.”In this culture, most of us love stuff. We engage in retail therapy to lift our spirits when we’re down, to celebrate something wonderful, or to treat ourselves for a job well done. We devote a large amount of our time to decorating and caring for our homes. The clothing and accessories we wear can communicate our individuality and help us to express our identity to the world. Take a few minutes to complete this Personal Belongings InventoryHow many pairs of shoes do you own? ______ Which is your favorite?_____________________Do you have a favorite set of sheets? _____Why do you like them?_______________________Which room in your home do you like the best? ______________ Why?___________________Do you have a favorite sweater?___________________ How old is it? ___________________Where did you get it? ________________________________________________________Name something that you keep because someone special gave it to you: ____________________Do you collect anything? ____ What?_____________________________________________ How many do you have? _________________What is the item you have had the longest? _________________________________________Do you own anything valuable? ___________________________________________________If you had to select only ten items to keep safe how would you decide? 1. _________________________________ 6. ___________________________________2. ________________________________ 7. ___________________________________ 3. _________________________________ 8.____________________________________4. _________________________________ 9. ___________________________________5. _________________________________ 10.___________________________________Elder Abuse LawThe Elder Abuse Law:Massachusetts General Law, Chapter 19A: Sets forth definition of elder abuse and the provisions governing the Elder Protective Services Program.The Executive Office of Elder Affairs is responsible for coordinating the development of a statewide system for Elder Abuse Reporting and the Elder Abuse Protective Services Program. The Executive Office has developed regulations for the Protective Services Program to carry out the law. The following agencies investigate reports of elder abuse in your area, so that you can make a Protective Service Report to the appropriate local agency: Franklin County Home Care, 330 Montague City Road, Turners Falls (413) 773-5555Greater Springfield Senior Services, 66 Industry Ave., Suite 9, Springfield. (413) 781-8800Highland Valley Elder Services, 320 Riverside Drive, Suite B, Northampton. (413) 586-2000The state Elder Abuse Hotline will take reports of abuse on a 24 hour per day, seven-day per week basis. The hotline number is 1-800-922-7725. For purpose of the law:Act or Omission, which results in serious physical or emotional injury of an elder or financial exploitation of an elder. Also includes self-neglect. Elder is defined as an individual who is 60 years of age or older.Elder Protective ServicesProgram PhilosophiesThe Elder Protective Services Program embodies the three principles articulated below:The overall program philosophy recognizes the elder’s right to self-determination thereby balancing individual autonomy with its mandate to provide protection. Protective Services aim to involve the older to the greatest feasible extent in decisions which affect them, providing services only with the consent of the elder and with the least possible intrusion into their life.-18415233680Least Restrictive Intervention00Least Restrictive Intervention-104775328930EPS seeks to provide services which will have the least disruption and intrusion into the elder’s life while still alleviating the abuse.0EPS seeks to provide services which will have the least disruption and intrusion into the elder’s life while still alleviating the abuse.-1841573025Self-Determination00Self-Determination-104775274320EPS aims to serve the best interests of the elder. The elder is in charge of decision-making unless they delegate this responsibility or court-authorizes another to do so.00EPS aims to serve the best interests of the elder. The elder is in charge of decision-making unless they delegate this responsibility or court-authorizes another to do so.-18415292735Freedom Over Safety00Freedom Over Safety-104775278130Freedom is more important than safety. This means elders can choose to live in harm or even self-destructively provided they are competent to choose, do not harm others and commit no crime.00Freedom is more important than safety. This means elders can choose to live in harm or even self-destructively provided they are competent to choose, do not harm others and commit no crime.Types of AbuseSelf-Neglect: Failure, inability or resistance to provide for oneself, or one or more of the necessities essential for physical & emotional well-being. Elder may not be safe to remain in the community without addressing these needs. Physical Abuse: Non-accidental infliction of serious physical injury or threat of serious physical injury. Sexual Abuse: Sexual assault, rape, sexual misuse, or sexual exploitation or threats of sexual abuse. Emotional Abuse: Non-accidental infliction of serious emotional injury to elder.Neglect: Failure or refusal by caretaker to provide one or more of the necessities essential for the physical well-being of elder which has resulted in or where there is substantial reason to believe that such failure or refusal will immediately results in serious physical harm to an elder.Financial Exploitation: Non-accidental act or omission by another person without the consent of the elder causing substantial monetary or property loss to elder or substantial monetary or property gain to the other person which gain would observe benefit the elder. Financial exploitation may result from consent obtained as a result of misrepresentation, undue influence, coercion or threat of force by another person. You should report if there is reasonable cause to believe that an abusive act probably took place or an abusive condition probably exists, that an elder is being neglected by a caregiver or is neglectful of their own needs and if you believe that an elder may have died as a result of a reportable condition.All persons are encouraged to make a report if they have a reasonable suspicion that abuse or neglect has occurred. Home Health Aides are mandated reporters of elder abuse, which means you are required to report it if you think an abusive act or condition. To report suspected abuse of persons with disabilities, call:Disabled Persons Protection Commission (DPPC) 1-800-426-9009Frequently Asked Questions About the Elder Abuse LawHow long will it take Elder Protective Services to see an elder?All referrals are evaluated based on information provided to the agency. If it appears that the elder has an acute situation which needs immediate attention, the situation will be assessed on the day of the report. In situations where there is no apparent immediate serious risk to the elder, she/he will be contacted within 5 calendar days. I made a report and nothing has been done! Can’t you get the elder out of there? When a report is made, the Protective Service Worker will attempt to investigate all allegations. If a report of abuse or self-neglect is sustained, Protective Services will be offered to the elder. Services include but are not limited to the following: referral to various services, assistance with other living arrangements, safety planning, family intervention and legal assistance. Services provided do not always offer an immediate solution, but do reflect the speed at which an elder feels he or she can attempt change. Elders, if mentally competent, retain the right to refuse services and sometimes they may choose to do so. What if an elder is not competent and cannot make decisions on his/her own?Competency is a legal term which is determined by a court of law. If there are concerns about an elder’s competency, the following is the process that is reviewed:Is the Elder at serious risk of further abuse, neglect or self-neglect?What is the elder’s ability to understand his/her situation?Is the elder refusing protective service intervention?After assessing the questions listed the Protective Service Program will:First try to enlist the cooperation and support of family, professionals and others in providing assistance to alleviate the problem or concern. If the elder remains at serious risk and clearly is not understanding his/her situation, the Elder Protective Service Program may pursue a formal competency evaluation and legal intervention, in the form of a guardianship or conservatorship, to bring about change in the elder’s situation in order to alleviate the abuse or self neglect. Self-Neglect IdentifiersPresenting ProblemsContributing FactorsHousing: (Shelter):Behavior problems jeopardize housing or there are threats to evict Eviction in process or current living situation is short term or inappropriate Elder is homeless or eviction is imminent with appropriate shelter available I. Mental Health:Elder displays symptoms of mental illness (diagnosed or not) which have occasional impact of functioning level Elder displays symptoms on mental illness which have regular impact on functioning Elder displays symptoms of mental illness which pose a immediate threat or risk of harm to self or others Housing (physical environment)Home is extremely cluttered and poses some ambulation problems; some level of disrepair Serious disrepair; unsanitary condition/infestation No heat/utilities, fire hazards, property is condemnable J. Dementia:Elder has some memory loss of confusion which has a slight impact on daily functioning, but usually meets basic needs Elder has regular periods of memory loss or confusion which has a significant impact on daily functioning; ability to meet or obtain assistance for basic need is inconsistent Elder has severe memory loss or confusion and demonstrates little or no ability to function independently or meet basic needsNutrition Inadequate diet or the diet poses a threat to elder’s healthNot eating regularly or appropriately with significant impact on health Dehydrated/malnourished; indicators or diagnosis of failure to thrive K. Cognition/Judgment Elder displays little or no awareness of risks, choice and possible consequences, which has had minimal impact on functioning level or on safety of self or others Elder displays little or no awareness of risk, choices and possible consequence, with significant impact on functioning level or on safety to self and others Elder displays little or no awareness of risks, choices and possible consequences, with severe and/or immediate impact on functioning level on safety of self or others Financial:Difficulty managing finances Inadequate income, failure to appropriately use resources, or unable to manage finances consistently Essential bills are not paid, elder threatened with impoverishment L. Cultural/Ethnic/Linguistic:C/E/L issues pose an intermittent or minor problem for elder in accessing assistance C/E/L issues pose a regular problem for elder in accessing assistance C/E/L issues pose a serious problem for elder in accessing assistanceMedical Noncompliance: Elder does not receive medical care for chronic, non-life threatening condition with minimal impact Elder does not follow through with medical care/ medications with significant impact Elder does not seek or accept medical care for acute of life threatening conditions M. Social Isolation:Social contacts are very limited; elder experiences discomfort with social settings Social contacts are inconsistent and/or have negative impact on elder Social contacts are nonexistent or inappropriate & have negative impact on elders Personal Care:Elder does not bathe or change clothes consistently Elder is dirty with offensive odor, and/or inappropriately dressed Elder has skin breakdown or infections N. Medical/Physical:Medical/physical limitations pose an intermittent or minor problem for elder in meeting needs M/PL pose a regular problem for elder in accessing assistance M/PL pose a serious problem for elder in accessing assistance Personal Safety:Behavior is potential threat to health and/or safety Behavior presents significant threat to health and/or safety with some impact having occurred Behavior has had a severe impact on elder, requiring immediate intervention by others O. Sensory Disabilities:Hearing/vision/speech impairment pose an intermittent or minor problem for elder in meeting needs H/V/S pose a regular problem for elder in accessing assistance H/V/S pose a serious problem for elder in accessing assistance H. Substance Abuse:1. Elder’s use of drugs or alcohol has slight impact on functioning levelElder’s use of drugs or alcohol has significant impact on functioning levelElder’s use of drugs or alcohol has severe impact on functioning levelP. Variability Issues Time of day, month, or year creates an intermittent or minor problem for elder in meeting needs Time of day, month or year creates a serious problem for elder in accessing assistance Western MassElder Abuse LawMandated ReportingHighland Valley Elder Services, Inc.320 Riverside DriveNorthampton, MA 01060(413) 586-2000 Elder Services of Berkshire County, Inc.66 Wendell Avenue Pittsfield, MA 01201(413) 499-0524Franklin County Home Care330 Montague City RoadTurners Falls, MA 01376(413) 773-5555Greater Springfield Senior Services, Inc.66 Industry AvenueSpringfield, MA 01104(413) 781-8800In 1983, Massachusetts mandatory reporting law went into effect. This law required certain professionals to report suspected serious occurrences of elder abuse, neglect and financial exploitation. The law provides for cases of elder abuse to be handled by social service professionals and not the criminal justice system. Protective services staff are sensitive to the needs of the elderly and make every effort to maintain the elders in their own homes with appropriate services, support and with respect for the elder’s rights to accept or reject services as he/she chooses. In addition to the local protective services agencies for each area, there is a state-wide Elder Abuse Hotline (1-800-922-2275) for emergencies outside of normal office hours. Under the elder abuse statue, the following individuals are mandated to report if there is reasonable cause to believe that an elderly person is suffering from, or has died as a result of a reportable condition: any physician, medical intern, dentist, nurse, family counselor, probation officer, police officer, social worker, firefighter, EMT, licensed psychologist, registered therapist and occupational therapist, osteopath, pediatrician, coroner, and directors of licensed home health aide or homemaker provider agencies. How to Report Suspected AbuseIf you have a reasonable cause to believe that an elder is being abused or exploited:Make a VERBAL report to the locally designated agency of to the Elder Abuse Hotline (nights, holidays, weekends) 1-800-922-2275 A written report must be forwarded to the protective service agency within 48 hours of the verbal report Information necessary: Name of elderPermanent address and current location of elderPhone NumberExact age of elder Identity and address/location of alleged perpetratorDetailed description of nature of abuseOthers who may have knowledge of elder How best to contact elder Agency/Town ListFranklin County Home Care330 Montague City Road Turners Falls, MA(413) 773-5555Greater Springfield Senior Services 66 Industry Ave., Suite 9Springfield, MA(413) 781-8800Highland Valley Elder Services320 Riverside Dr, Suite BNorthampton, MA(413) 586-2000AshfieldAtholBernardstonBucklandCharlemontColrain ConwayDeerfieldErvingGillGreenfieldHawleyLeverettLeydenMonroe Montague New SalemNorthfieldOrangePetershamPhilipstonRoweRoyalstonShelburneShutesburySunderlandWarwickWendellWhately AgawamBelchertownBrimfieldChicopeeEast LongmeadowFeeding hillsGranbyHampdenHollandHolyokeLongmeadowLudlowMonsonPalmerSouth HadleySpringfieldWalesWareWest SpringfieldWilbraham Amherst BlandfordChesterChesterfieldCummingtonEasthamptonFlorence GoshenGranvilleHadleyHuntingtonMiddlefieldMontgomeryNorthampton PelhamPlainfield RussellSouthamptonSouthwickTollandWestfieldWesthamptonWilliamsburgWorthington Module 8Cardio-Respiratory System TOC \b Module8 \h \z \t "Title,1" The Circulatory System PAGEREF _Toc397767600 \h 83Pulse Chart PAGEREF _Toc397767601 \h 84Cardiovascular Disorders PAGEREF _Toc397767602 \h 85Signs and Symptoms of a Heart Attack PAGEREF _Toc397767603 \h 86Cholesterol: What do the Numbers Mean? PAGEREF _Toc397767604 \h 87The Respiratory System PAGEREF _Toc397767605 \h 88Disorders Of The Respiratory System PAGEREF _Toc397767606 \h 89The Circulatory SystemThe circulatory system is made up of the heart, blood and blood vessels.The functions of the system are:Blood carries food, oxygen and other substances to the cells.Blood removes waste products from cells.The system produces and carries cells that defend the body from microbes that cause disease.Blood helps regulate body temperature. Blood carries heat from muscles to other body parts. Blood vessels in skin dilate to cool the body and they constrict to retain heat.The heart is a muscle. It has four chambers. The heart pumps blood to the lungs for fresh oxygen, delivers the freshly oxygenated blood throughout the body to the tissues and cells, carries carbon dioxide and waste products out of the cells and returns to the heart for fresh oxygen. The heart has two actions:Systole – The heart contracts and pumps blood through the vessels.Diastole – The resting phase. The heart chamber fills with blood.Blood flows through three groups of blood vessels:Arteries – carry oxygen-rich blood away from the heart.Capillaries – are very tiny vessels. Food, oxygen and other substances pass through the capillaries in to the cells.Veins – return blood to the heart. Venous blood is dark red because it has little oxygen and lots of carbon dioxide.The blood consists of blood cells, plasma and platelets:Red blood cells contain hemoglobin, which gives it the red color. As the blood circulates through the lungs, the hemoglobin picks up oxygen and carries it to the cells.Plasma is mostly water. It carries substances that the body needs to function (proteins, fats, carbohydrates, hormones and other chemicals).White blood cells have no color. They are produced by the bone marrow. At the first sign of infection, white blood cells rush to the site and multiply rapidly to help fight the infection.Platelets are needed for blood clotting. They are also produced in the bone marrow.1647825-7229475Pulse ChartPulse Chartcentertop00Cardiovascular DisordersHypertension = High Blood Pressure can lead to heart disease, stroke, kidney failure and blindness. Signs and symptoms such as headaches, dizziness, blurred vision, nose bleeds develop over time. Historically men are at greater risk of high blood pressure. However, women are catching up, primarily due to their increase of other risk factors. The older we get the higher our risk. African-Americans are at higher risk than whites, and individuals with a family history of cardiovascular disorders are at greater risk than someone without. In many cases hypertension can be managed with medication. The following risk factors can be controlled and decreased through life style changes, such as low fat/low sodium diet, exercise, stress management and decreased use of alcohol, tobacco and caffeine:Family historyBeing overweightStressSmokingHigh sodium dietExcessive alcohol consumptionLack of exerciseAtherosclerosisCoronary Artery Disease (CAD) occurs when one or more of the coronary arteries narrow, causing the heart muscle to get less blood. The most common cause is atherosclerosis, also known as hardening of the arteries, which is a buildup of fatty deposits on the artery walls. The risk factors are the same as hypertension, but also include diabetes. One major complication of CAD is Peripheral Artery Disease (PAD), a narrowing of arteries in the leg, which results in decreased blood flow. Signs and symptoms include pain or cramping in the leg when exercising, a marked decrease in temperature in the foot of one leg and pale or purplish color of the foot. Generally symptoms do not arise until an artery is 60% blocked. Another complication of CAD is Angina Pectoris, which is pain, tightness or pressure in the chest that occurs when the heart needs more oxygen, generally caused by stress, exertion, over eating, over excitement or exposure to hot or cold temperatures. People with angina commonly carry nitroglycerin tablets. This very small tablet is placed under the tongue where it is quickly absorbed in to the blood stream. If chest pain is not relieved by nitroglycerine the person may be having a Myocardial Infarction, commonly known as a heart attack, which means that blood flow to the heart is suddenly blocked and part of the heart muscle will die without immediate emergency medical care.Signs and Symptoms of a Heart Attack Include:Sudden severe chest pain (generally on the left side)Pain radiates to arm, neck, or jaw Severe indigestion or nauseaApprehension or feeling of doomPerspiration and cold clammy skinDizzinessLow blood pressurePale or grayish skin colorShortness of breathCongestive Heart FailureCongestive Heart Failure (CHF) is a common chronic health problem of the elderly. CHF occurs when the right or left side of the heart cannot pump blood normally, generally due to a weakened or damaged heart muscle or valve. With CHF the blood backs up and tissue congestion occurs.When the left side of the heart cannot pump normally the blood backs up in to the lungs causing congestion, coughing, gurgling sounds and shortness of breath. When the right side of the heart cannot pump normally the blood backs up into the venous system causing feet and ankles to swell, as well as liver and abdominal congestion. With CHF all of the body’s organs receive less blood flow. Signs and symptoms occur from the effects of decreased blood flow to the organs. Poor blood flow to the:Brain may cause dizziness, confusion and fainting.Kidneys will produce less urineLiver will not function properlySkin will become pale or purplishHeart may drop the blood pressure Cholesterol: What do the Numbers Mean?Cholesterol and triglyceride levels are measured as milligrams (mg) per deciliter (dL) of blood. Below are the levels that the National Heart Lung & Blood Institute deems as too high, too low, borderline, and good. Total CholesterolLess than 200 mg/dLGood240 mg/dL and aboveHigh200-239 mg/dLBorderline HighLDL CholesterolLess than 100 mg/dLGood160-189 mg/dLHigh100-129 mg/dLNear Optimal190 mg/dL and aboveVery High130-159 mg/dLBorderline HighHDL CholesterolLess than 40 mg/dLToo Low60 mg/dL and aboveGoodTriglyceridesLess than 150 mg/dLOptimal200 mg/dL and aboveHigh150-199 mg/dLBorderline HighThe Respiratory SystemThe function of the respiratory system is to bring oxygen in to the body, to distribute oxygen in the body and to rid the body of carbon dioxide by inhalation and exhalation.RespiratoryTract Nose – Air entersPharynx – throatEpiglottis - lid over the esophagus. During inhalation, it lifts up to let air pass. Trachea divides into: Right bronchus, Left bronchus Bronchi enter the lungs and branch, dividing many times to create bronchiolesBronchioles subdivide into alveoliRespiration= Inhalation and exhalation. Air enters the nose and winds up in the alveoli, where oxygen and carbon dioxide are exchanged between the alveoli and capillaries. The lungs are separated from the abdomen by the diaphragm, a muscle that aids in breathing.Pleura cover each lung. It’s a double sac in which one is attached to the lung, the other to the chest wall. They secrete a fluid that keeps the pleura from rubbing together.Ribs, sternum and vertebrae protect the lungs. Disorders Of The Respiratory SystemCOPD: Chronic Obstruction Pulmonary Disease Chronic Bronchitis: an inflammation of the bronchi. Symptoms include frequent infections with coughing, excess mucus production, shortness of breath. The inflammation causes irritation, which obstructs the flow of oxygen to the lungs. RX Treatment = Removing the irritant (usually smoking), oxygen, inhaled medications, and breathing exercises. Asthma: an allergic reaction where the airways narrow causing shortness of breath. Allergies and emotional stress can trigger episode and they can become life threatening. Symptoms include wheezing and coughing, rapid pulse and, sweating. Treatment = inhaled medication. Emphysema: affects the alveoli. They enlarge and become less elastic. They don’t expand and shrink normally with inhalation and exhalation. Air gets trapped there and is not exhaled. Breathing is easier when the person is sitting upright and slightly forward. Cause is usually smoking. 20% of smokers get it. The first sign occurs with exhalation, but over time it occurs at rest too. Treatment = oxygen, exercise (pulmonary rehab) breathing exercises, and meds.Pneumonia: inflammation and infection of the lung tissue. Types: aspiration, viral, bacterial. Symptoms are fever, chills, painful cough, chest pain on breathing, and rapid pulse. Mucus is thick and colored green, yellow, or rust. Treatment = antibiotics, antiviral, increased fluids to thin mucus and to prevent dehydration. Oxygen may be ordered. Position in semi-fowlers to ease breathing. Precautions must be taken to prevent spread. Tuberculosis (TB): is a bacterial infection in the lungs. It is spread by airborne droplets by coughing, sneezing and singing. Person nearby can inhale the bacteria. Symptoms include fatigue, loss of appetite, weight loss, fever, and night sweats, gradual increase in cough and sputum production over time. Chest pain occurs. Treatment = medication, oxygen Module 9Taking and Recording Vital Signs TOC \b Module9 \h \z \t "Title,1" Taking and Recording Pulse and Respiration PAGEREF _Toc397767810 \h 91Blood Pressure PAGEREF _Toc397767811 \h 92Taking and Recording Blood Pressure PAGEREF _Toc397767812 \h 93Measuring and Reporting Vital Signs PAGEREF _Toc397767813 \h 94Taking and Recording PulseThe Pulse Rate = the number of heartbeats measured in 1 minute. Generally pulse is taken for 30 seconds and multiplied by 2. The normal adult pulse rate is between 60 and 100 beats per minute.Any pulse below 60 or above 100 should be reported to the nurse or a responsible person promptly. The apical pulse is taken with a stethoscope for 1 minute. Generally apical pulse is taken when there are irregularities. The rhythm of the pulse should be regular. Irregular pulse should be reported.A pulse may be reported as strong or weak depending on the force of the beat felt when taking the pulse.Taking and Recording RespirationsEach respiration involves one inhalation and one exhalation. The chest rises during inhalation and falls during exhalation.In normal/healthy respiration both sides of the chest rise and fall equally.The healthy adult has 12 to 20 respirations per minute.Count respiration for 30 seconds and multiply by 2, unless irregular. When respiration is irregular, measure for full minute, and report irregularity.It is best to measure respirations when the person does not know you are doing it, in order to measure a natural and accurate rate. Blood PressureBlood pressure is the amount of force exerted against the walls of an artery by the blood. Systolic pressure: (recorded as the top number) Measures the amount of force needed to pump blood out of the heart into the arterial circulation. Diastolic Pressure: (recorded as bottom number) Measures the pressure in the arteries when the heart is at rest. Average Blood Pressure 120/80High Blood Pressure Hypertension Low Blood Pressure Hypotension Stethoscope Sphygmomanometer There are two additional types of blood pressure equipment, a column of mercury in a calibrated tube and electronic, which shows a digital reading. Taking and Recording Blood PressureEquipment:Sphygmomanometer (blood pressure cuff) - select appropriate size cuff. StethoscopeSafety:Too much inflation can alter one’s blood pressureAsk the nurse of any specific considerations needed before taking a blood pressure Blood Pressure Steps:Deflate the bladder of the cuff and place it around the upper arm, one inch above the fold of the elbow, so it fits snug but not too tight. Feel for the brachial artery.Put the head of the stethoscope just under the edge of the cuff, a little above the crease of the person’s elbow. Hold it there firmly with the thumb, or with a few fingers. Put the ear pieces of the stethoscope in your ears.Inflate the cuff with brisk squeezes of the bulb. Watch the pressure gage as you do it. For most you shouldn’t go over 160 (the markings indicate “pressure” in Hg or mercury.)If at 160 Hg you hear the pulse/beat, inflate another 20Hg of mercury. Slightly open the valve on the air pump (this takes practice). It’s important that you don’t let the air out too suddenly (approximately 2-3 Hg per second).Pay attention *Very Carefully* to what you hear through the stethoscope as the needle on the pressure gauge falls. You will be listening to the pulse beat. The first time you hear the sound, note what the reading was on the pressure gauge. This value/number represents the systolic blood pressure. The sounds should continue and become louder in intensity, then softer. Note the pressure reading when you hear the sound for the last time. This value/number represents the diastolic blood pressure. Remember even number are needed for an accurate blood pressure and don’t forget to write them down. A normal blood pressure at this time is 120/80When inflated, the cuff is tight on the arm, this is uncomfortable and can be painful. Do not leave cuff inflated for more than a minute; if unable to get a good reading deflate and try again. Only try twice on one arm.Measuring and Reporting Vital SignsVital signs reflect the functions of the body processes essential to life. They can show how even minor changes in a person’s condition and they may signal life-threatening events. The Four Measurements of Vital Signs of Body Functions are: Temperature PulseRespirationBlood PressureVital signs are part of the nursing assessment process. They are taken at the time of admission and measured regularly as part of the ongoing monitoring of a person’s condition. Each facility/agency has its own policy and protocols related to vital signs. Generally vital signs are taken while the person is at rest in a lying or sitting position. When completed, vital signs are reported on a graphic or flow sheet. Abnormal vital signs must be reported to the nurse or responsible person promptly.TemperatureSite Normal RangeRectal 98.6 to 100.6 F -- 37.0 to 38.1 COral97.6 to 99.6 F -- 36.5 to 37.5 CTympanic Membrane 98.6 F -- 37 cAxillary 96.6 to 98.6 F -- 35.9 to 37.0 C Glass thermometers are now illegal and will need to be properly disposed of. You can dispose of them at local pharmacies or call your town offices. Module 10Digestion and Nutrition TOC \b Module10 \h \z \t "Title,1" The Digestive System PAGEREF _Toc397768399 \h 98Dysphasia PAGEREF _Toc397768400 \h 99Nutrition PAGEREF _Toc397768401 \h 100Factors Affecting Eating and Nutrition PAGEREF _Toc397768402 \h 101Food Groups PAGEREF _Toc397768403 \h 102How The Body Uses Vitamins And Minerals PAGEREF _Toc397768404 \h 103Understanding Nutrition Labels PAGEREF _Toc397768405 \h 104Understanding and Managing Diabetes PAGEREF _Toc397768406 \h 105Special Diets PAGEREF _Toc397768407 \h 107Preventing Constipation in the Older AdultConstipation is a common problem for older people. Expect constipation to occur when a pain medication is prescribed, or when mobility is decreased due to illness, injury or significant change in routine.Constipation is often relieved by adequate hydration, (at least one quart of water a day) increased mobility (Walking is excellent) and fiber supplementation (wheat or oat bran, fruits, vegetables or nuts) Nuts can be ground in a coffee grinder to make digestion easier.Many older people don't drink enough because they don't want to have an increased, need to urinate, especially at night. Encourage intake early in the day.When fiber intake is increased excessive gas may initially present, but generally resolves as the body becomes accustomed to the change. It is recommended to increase fiber slowly, approximately 5 gA bran mixture that significantly reduces laxative use for older people includes:3 cups unsweetened applesauce2 cups course wheat bran59537609015730001 ? cups unsweetened prune juice or 1 cup stewed prunesAdminister 4 tablespoons a day(Two before breakfast and two before super)Monitoring bowel elimination is a very important aspect of elder care. Using a tracking sheet is very helpful.The Digestive SystemThe digestive system is the group of organs that work together to gain fuel from the food we eat and discard the unwanted waste. This system breaks down food into simple substances your body’s cells can use. It then absorbs these substances into the bloodstream and any leftover waste is eliminated. This path is called the alimentary canal. The alimentary canal is folded back and forth, like a fan, in your body so that it fits.Teeth tear and grind food and moistened by saliva (1 minute)Esophagus carries food to stomach (4-8 seconds)Stomach mixes food with acid to further break it down (2-4 hours)Pancreas makes food small enough to mix with blood stream Liver cleanses food and mixes it with bloodBroken down food is sent into bloodstream and the rest of the bodySmall intestine further break down food (3-5 hours)Large intestine water and minerals are added (10 hours to several days)Bladder and rectum food is passed as waste10.) Gallbladder stores bile produced by liver and sends it to small intestine DysphasiaDysphasiaDifficulty swallowing. This condition is most commonly caused by stroke. Often the Doctor will order that liquid be thickened or food consistency be changed to meet the person’s swallowing needs. The condition is generally managed by a speech therapist/pathologist. Exercise may be ordered to strengthen the muscles involved in swallowing. Slow SwallowThe person has difficulty getting enough food and fluids to maintain adequate nutrition and fluid balance. PocketingFood may accumulate in the back of mouth, between the gums and teethAspirationBreathing fluids or food/object into lungs. This may cause pneumoniaUnsafe SwallowThe person is at risk for food or fluid entering the airway NPOThe Doctor has ordered that the person take nothing by mouth. In some cases a feeding tube may be used to provide nourishment When eating, the individual with dysphasia must always be in a sitting (Fowler’s) position and must remain focused on chewing and swallowing. Talking should take place between mouthfuls and only after swallowing. It is important that food is chewed well before swallowing and that the person eats slowly and mindfully. The person should remain in the Fowler’s position for at least 30 minutes after eating. Signs and SymptomsChanges in eating habits – Coughing – Water, Gurgley Voice – Drooling - FeverFood Residue in Back of Mouth - Feeling a “lump in throat”NutritionThe process involved in the ingestion, digestion, absorption, and use of foods and fluids in the body. Nutrients: The elements in food that the body uses as fuel: Carbohydrates – Fats –Minerals – Protein – Vitamins. Carbohydrates, fats and protein give the body energy. The amount of energy provided by a nutrient is measured in calories. A calorie is the amount of energy produced when the body burns food. Carbohydrate – 1 gram = 4 calories Fat - 1 gram = 9 caloriesProtein - 1 gram = 4 calories Vitamins- There are 2 kinds of vitamins, fat soluble and water soluble. Fat soluble vitamins can be stored in the body. Water soluble vitamins are not stored in the body; they must be ingested daily. Vitamins are essential to health. They are used for many body processes and functions. Fat soluble vitamins are A, D, E, and K. Water soluble vitamins are C and B complex which includes: Thiamine – Riboflavin – Niacin – Biotin - Folic Acid - Pantothenic AcidMinerals are needed for strong bones and teeth, for nerves and muscle function, fluid balance and many other body processes. There are nine minerals the body requires: Calcium – Chromium – Copper – Magnesium – Manganese – Phosphorus - Potassium – Selenium - ZincIt is necessary to know the content of foods in order to plan a healthy diet. Most foods have labels that list the ingredients and nutrition facts such as, calories, fat and the percent of daily value (DV) of the food item. The daily value is set by the US Food and Drug Administration’s recommendations as to how much of that food item a day a person needs to have. The DV is generally based on a 2000 calorie a day diet. It is important to note the serving size, which is also listed on the label. Factors Affecting Eating and NutritionAge Culture and ReligionFinances Physical and Mental HelpAppetitePersonal Choice Physical ConditionWhat You Need to Know to Prepare Food at Home Need to understand the food pyramid Need to understand basic nutrition Need to understand food labels Need to understand people’s personal choice Need to understand any religious constraints Need to know if there are any dietary restrictions or special diet(s) ordered by doctor Need to understand any dietary habits or religious rituals Go over to the grocery list with the person you are shopping for before going to the store. It is important to know brand preferences and amounts needed. When planning menus, check to make sure that you have all of the needed ingredients. SAVE ALL RECEIPTS FOR THE PERSON OR FAMILY MEMBER Food GroupGood Source OfBread, Cereal, Rice and Pasta GroupComplex Carbohydrates, Fiber, Riboflavin, Niacin, Thiamin, Folate and IronVegetable GroupComplex Carbohydrates, Fiber, Vitamins A, B-6 and C, Folate, Potassium, Iron, MagnesiumFruit GroupCarbohydrate, Fiber, Potassium, Folate, Vitamins A and CMeat, Poultry, Fish, Dry Beans, Eggs and Nuts GroupProtein, Iron, Phosphorus, Potassium, B Vitamins (Meat, Poultry, Fish, Eggs may contain saturated fat and cholesterol)Milk, Yogurt, and Cheese GroupProtein, Carbohydrate, Calcium, Vitamins A, B-12 and D, Riboflavin, Phosphorus(Most contain fat, saturated fat and cholesterol)How The Body Uses Vitamins And MineralsVitamins and minerals are needed for many body functions and processes. There are two types of vitamins: fat-soluble and water-soluble. Fat-soluble vitamins can be stored in the body. Water-soluble vitamins are not stored in the body and must be ingested daily.Fat Soluble VitaminsVitamin A – Retinal – maintains healthy skin, hair and mucous membranes, aids in cell development and vision, especially night vision.Vitamin D – regulates the absorption and use of calcium and phosphorus, which aids in bone and muscle function. We can get Vitamin D from the sun.Vitamin E – anti-oxidant, which helps to maintain healthy cells and to prevent cardiovascular disease and cancer.Vitamin K – promotes blood clotting.Water Soluble VitaminsVitamin B – actually, 8 vitamins including thiamine, riboflavin, niacin, biotin, folic acid and pantothenic acid. These vitamins are important for metabolism, healthy cell growth – including red blood cells – and they support nervous system function.Vitamin C – promotes iron absorption and the immune system.MineralsCalcium – important to formation of bones and teeth. Supports muscle and nerve function and aids in blood clotting.Chromium – works in conjunction with insulin to maintain normal blood sugar metabolism.Copper – works with enzymes that maintain bone, blood vessel and lung cells.Magnesium – helps maintain stable levels of calcium and phosphorus.Manganese – involved with protein metabolism.Phosphorus – works with calcium to promote proper bone and tooth mineralization.Potassium – required for normal nerve transmission, muscle contraction and to maintain blood pressure within normal range.Selenium – preserves tissue elasticity, slows down the aging and hardening of tissue.Zinc – helps with digestion, wound healing and reproductive health.Understanding Nutrition LabelsServing SizeCompare your serving to the one on the label. If you eat double the serving listed, you will need to double the nutritional valuesCalories and Calories from FatCalories are a measure of how much energy a serving of this food provides. Try to limit your calories from fat. Choose foods that have less than one third of the calories from fat.Total Fat: 45-55g. per day or lessSaturated Fat: as little as possibleSaturated fat increases LDL (“bad”) cholesterol and increases your risk of heart disease.Trans Fat: Less than 2-3g Per dayToo much Trans Fat has been linked to heart disease and diabetes. Trans fat is also listed on the ingredients list on food labels as ‘hydrogenated’ or ‘partially hydrogenated’ oilCholesterol: 300 mg. per day or lessCholesterol is only found in animal foods like meat, fish, cheese, and butter. Too much cholesterol is not healthy for your heart.Sodium: 2400hm. per day or lessToo much salt can lead to high blood pressure in some people. Examples of high sodium food include pre-packaged, convenience, and fast foods.Total Carbohydrates: 45-0g. per meal (women), 60-75g. per meal (men), 15-30g. per snackCarbohydrates (starch and sugar), are found in breads, potatoes, rice, cereals, fruits and juices, milk, sweets, and sweetened drinks. Carbohydrates are our most important source of energy, but too many carbohydrates raise the blood sugar too high.Fiber: 25-35g. per dayChoose whole grain breads and cereals and at least 5 servings of fruit and vegetables per day. If the word ‘whole’ is first in the ingredient list, the food is a whole grain product and high in fiber. When you are counting carbohydrates, dietary fiber grams (g) can be subtracted from the Total Carbohydrate g.Sugar:It’s okay to have a little sugar once in a while, but it can make those total carb grams add up quickly! Other names for sugar include: corn syrup, high fructose corn syrup, fruit juice concentrate, maltose, dextrose, sucrose, honey, and maple syrup.Protein: 6-8 ounces of meat, fish, poultry, or pork dailyMost adults get more protein than they need. Some meat is high in fat. Use skim or low-fat milk, yogurt, and cheese. Choose lean meats. Try to get some of your protein from high fiber plants like beans and vegetables. Understanding and Managing DiabetesDiabetes is a disorder of the Endocrine system. Diabetes occurs when the pancreas does not produce enough insulin to turn glucose/sugar into energy, or the body does not use insulin in the right way (abnormal metabolism). Sugar/glucose builds up in the blood and cells do not have enough sugar/glucose for energy and they cannot perform their functions. Almost 20% of people over the age of 65 have diabetes. There are three types of diabetes: Type 1- Occurs in children and young adults. The pancreas produces little or not enough insulin. Generally onset is rapid and the condition is treated with insulin injections 2 to 3 times daily. Type 2- Occurs in adults most commonly over 40. With this type the pancreas produces insulin, but the body cannot use it well. High blood pressure and obesity are risk factors. Onset is slow and the condition can often be treated with diet, oral medication or, in severe cases, insulin injections. Gestational Diabetes- Occurs during pregnancy and generally goes away after pregnancy. Symptoms of diabetes include: Increase in thirst and urination, blurred vision, weight loss, frequent infections, slow wound healing, tingling or numbness in feet, and fatigue. All types of diabetes require monitoring of blood sugar/glucose levels. The normal range is 70-110. There are two types of acute complications:Hypoglycemia, when levels fall too low, caused by too much insulin or diabetic drugs in the blood, or by eating too little food. Signs and symptoms include: Shakiness, low blood pressure, sweating, confusion, rapid pulse, headache, cold/clammy skin, dizziness, seizure and unconsciousness. This is a potentially fatal condition. Treatment: If alert and able, ingest orange juice, sugar in water, or other high carbohydrate item such as glucose paste. Hyperglycemia, when levels are too high, caused by not enough insulin in blood, eating too much, too little exercise, stress. Signs and symptoms include: weakness, drowsiness, excessive thirst, sweet breath odor, dry skin, frequent urination, nausea or vomiting, flushed face, leg cramps.Treatment: Fluid replacement.The long- term effects of high blood sugar include vascular and nerve damage. Unmanaged diabetes can cause permanent cell damage resulting in amputations, heart attack, or stroke. Meal PlanningMost important is the total carbohydrate count. As a general rule:Protein should account for 10 to 20 percent of calories.Fat no more than 30 of calories.Carbohydrates should make up the rest. Carbohydrates are more slowly digested and provide the body with other needed nutrients.Consistency is key: it is important to consider the person’s food preferences, likes, dislikes, eating habits, meal times, culture and life-style. It may be necessary to limit the amount of food or prepare it in a different way.Calories needed (determined by doctor): The same amount of carbohydrates, protein and fats eaten each day. Meal times and snacks are eaten at regular times. The person eats at the same time each day to maintain a stable blood sugar. If food is left on the plate at the meal, a between meal snack is needed. If person is taking insulin, it is very important that they eat all meals and snacks to prevent the blood sugar from dropping dangerously low. Special DietsDoctors order special diets for many reasons. Often there are specific guidelines or limits; for example, number of calories or grams of protein, fat, or carbohydrates. Regular diets or House diet - means that there are no dietary restrictions.Types of Special Diets:Clear Liquid: Water, tea or coffee (without cream or milk); jello; clear broths; clear fruit juices; and popsicles. Full Liquid: Foods liquid at room temperature or melt at body temperature. Foods on clear-liquids; plus custard, eggnog, strained soups, strained fruits and vegetable juices; milk and milk shakes; strained cooked cereals; plain ice cream and sherbet; pudding and yogurt.Mechanical Soft: All liquids; eggs (not fried); broiled or roasted meat, fish or poultry that is chopped or ground; mild cheese; strained fruit juices; refined breads and crackers; cooked cereal; cooked or pureed vegetables; cooked or canned fruit without skin or seeds; pudding; plain cakes and soft cookies without fruit or nuts. Bland: Foods that are mechanically and chemically nonirritating and low in roughage; foods served at moderate temperatures; no strong spices or condiments; lean meats; white bread; creamed and refined cereals; cream or cottage cheese; gelatin; plain puddings, cakes, and seeds; strained fruit juices; potatoes (not fried); pasta and rice; strained or soft cooked vegetables; creamed soups; no fried food. High Calorie: Calorie intake is increased to about 3000 to 4000; includes 3 full meals and between meal snacks. Dietary increases with all foods, large portions of a regular diet, 3 between meal snacks.Calorie controlled: Provides adequate nutrients while controlling calories to promote weight loss and reduction of body fat. Food low in fats and carbohydrates; lean meats; avoid butter; cream; rice; gravies; salad oils, noodles, cakes, pastries, carbonated and alcoholic beverages; candy; potato chips; and similar foods.High Iron: Foods that are high in iron: liver and other organ meats; lean meats; egg yolks; shellfish; dried fruits; dried beans; green leafy vegetables; lima beans; peanut butter; enriched breads and cereals.Fat Controlled (Low cholesterol): Foods low in fat and foods prepared without adding fat; egg whites, skim milk or buttermilk; cottage cheese (no other cheeses allowed); gelatin; soups made with skim milk; margarine; rice; pasta; breads and cereals; vegetables; potatoes; olive and canola oil.High Protein: Meat, milk, eggs, cheese, fish poultry; breads and cereals; vegetables; potatoes Low Sodium/No added salt: High sodium foods are omitted. Module 11Integumentary System TOC \b Module11 \h \z \t "Title,1" The Integumentary System = Skin PAGEREF _Toc397768548 \h 111Maintaining Skin Integrity PAGEREF _Toc397768549 \h 112Risk Factors for Skin Breakdown PAGEREF _Toc397768550 \h 113The Integumentary System - SkinThe skin is the body’s largest organ. It has two major layers -- the epidermis and the dermis -- and includes the nails and hair.The Epidermis: is the outer layer of skin. It has pores, very few nerve endings, and no blood vessels and contains the pigment, which gives the skin color. The cells of the epidermis are constantly dying, flaking off and being replaced by new cells. The Dermis: is the inner layer. It is made of connective tissue, blood vessels, nerves, sweat and oil glands and hair roots. The integumentary system has many functions:It is the body’s first defense against germs, by keeping bacteria and other substances out. It holds and releases water through the pores, which helps to regulate body temperature. Nerve endings in the skin sense both pleasant and unpleasant sensation, such as touch, pressure, pain, heat and cold. It cushions, protects and insulates the body.The hair acts as a filtering screen to keep unwanted particles from entering the body. Eyebrows prevent sweat from falling into eyes. Hair also provides insulation. A quarter size piece of skin contains: 1 yard of blood vessels, 4 yards of nerves, 25 nerve endings, 100 sweat glands and more than 300 cells.Maintaining Skin IntegrityNormal age-related skin changes -- such as, loss of fatty tissue, decreased secretion of oil glands resulting in dry skin, thinning of skin and decreased sensitivity due to fewer nerve endings -- cause elders to be at a higher risk for skin break down. Preventing skin breakdown is much easier than trying to heal it. Good nursing care is essential to the prevention of skin breakdown. The most common causes are:Pressure Ulcers: also known as Bedsores, Decubitus Ulcers, and Pressure Sores. They are caused by unrelieved pressure over a bony prominence, preventing blood flow to the skin and underlying tissue. In most cases, pressure ulcers can be prevented by regularly repositioning (every two hours is the standard). There are 4 stages of pressure ulcers, beginning with a reddened area over a bony prominence that does not go away within a few minutes after pressure is relieved, and advancing to serious wounds that can be very painful and are excellent portals of entry for infection. Friction is caused by two surfaces rubbing together resulting in heat and injury to the skin. This can happen if dragging the person’s skin on the sheets below when repositioning. Proper repositioning technique is very important to prevent friction and/or shearing.Shearing is caused by separation of tissue below surface. Several layers of skin move in different directions causing capillaries to bleed and a deep wound may result. Proper repositioning technique is very important to prevent friction and/or shearing. Skin to Skin Contact, especially under breast and under folds of fat on people who are overweight can cause skin irritation and create a perfect environment for infection. It is very important to clean and dry these areas very well. Ulcers may also be caused by poor circulation. Decreased blood flow to an area can cause tissue death. This type of ulcer is most common to the lower extremities. Frequent and careful observation and timely reporting of skin changes is very important for people with impaired circulation. Risk Factors for Skin BreakdownIt is essential to have knowledge of a person’s condition and ability to function. A person with any of the following conditions is at greater risk for skin breakdown: Bed bound or limited mobility - Unable to reposition independently - Poor nutritional or fluid intake - Impaired circulation – Diabetes - Cognitively impaired - Dry or sensitive skin - Overweight with skin folds – Under weight. Stages of Pressure UlcersStage 1. Persistent red, pale, or dark skin (generally over a bony prominence). The color does not return to normal after pressure is relieved.Stage 2. The skin cracks, blisters, or peels. There may be a shallow crater, indicating that skin breakdown has reached the inner tissue. Stage 3. The skin is gone. Underlying tissues are exposed. The exposed tissue is damaged. There may be drainage from the area.Stage 4. A deep crater that extends to expose the muscle and/or bone. Drainage or crust formations usually present. There is a high risk of infection. Techniques for Preventing Skin Breakdown* Frequent observation of skin, especially at pressure points, under breasts and skin folds.* Immediately report any changes in skin condition to the nurse.* Keep skin clean, wash, rinse and dry the person’s skin thoroughly (pat dry, do not rub). Apply moisturizers and/or powder per nurse’s instructions.* Reposition the person every two hours.* Get help when moving a person in bed, make sure to lift rather than slide the person.* Encourage the person to drink an adequate amount of fluid daily. * Encourage high protein intake, including beverages and snacks. * Use assistive devices, such as sheepskin, egg crate mattresses, cushions, heel and/ or elbow protectors to reduce pressure and friction. * Keep the bed linens clean and as wrinkle free as possible.* Keep the person out of bed as much as possible. Assist with exercises to promote circulation. Module 12Musculoskeletal System TOC \b Module12 \h \z \t "Title,1" The Musculoskeletal System PAGEREF _Toc397768766 \h 116Disorders of Musculoskeletal System PAGEREF _Toc397768767 \h 117Musculoskeletal System - Diagram PAGEREF _Toc397768768 \h 118Bones of the Body PAGEREF _Toc397768769 \h 119Types of Joints PAGEREF _Toc397768771 \h 120Range of Motion PAGEREF _Toc397768772 \h 121The Musculoskeletal SystemThe musculoskeletal system is the framework for the body. It provides protection, allows our bodies to move and gives us our shape. The system has three components:1) Bones, which are hard and rigid. Inside the hollow center of bones is a substance called bone marrow, which is where blood cells are made. There are four types of bones:Long bones bear the body’s weight. Leg bones are long bones.Short bones allow ease in movement, such as wrist, ankles and fingers.Flat bones protect the organs. Examples are ribs, pelvic bones, the skull, and shoulder blades.Irregular bones are the vertebrae in the spinal column.2) Joints are the point where two or more bones meet. They allow movement. Joints are held together by cartilage and lubricated by synovial fluid. Bones are held together at the joint by strong bands of muscle called ligaments.3) Muscles, which have three functions. They help the body to move, to maintain posture and produce body heat. Strong connective tissues called tendons connect muscles to bones, which help with movement. When muscles contract (shorten) they burn food for energy and heat is produced. Shivering, which is a form of rapid general muscle contraction, is how the body produces heat when exposed to cold. There are two types of muscles: Voluntary muscles can be consciously controlled. They do not move unless you will them to move.Involuntary muscles work automatically. You cannot control them. The heart is an involuntary muscle.The CNA role in musculoskeletal health:Encourage balanced diet and vitamin/mineral supplements as ordered by Physician.Encourage activity which is weight bearing to strengthen/tone muscles and support bone density. Assist with braces, canes, walkers, wheelchair use. Observe and report red areas that may be caused by these devices.Ambulate consumer as instructed on care plan. Use gait belt for safety. Assist with ROM exercises.Care provider can prevent injury to themselves by keeping muscles toned, eating balanced diet, getting plenty of rest, staying well hydrated (drinking plenty of water), and balancing stresses.Disorders of Musculoskeletal SystemAtrophy is the most common disorder of the musculoskeletal system. It is the decrease in size or wasting away of muscle tissue due to inactivity. Some atrophy is normal to the aging process. Severe atrophy can seriously limit range of motion and mobility. It is commonly a result of extended inactivity or bed rest after an illness or medical episode. In many cases muscle tissue can be regained with exercise.Contracture is the lack of joint mobility due to severe shortening of a muscle. The contracted muscle is fixed in position, deformed and cannot stretch.Arthritis is inflammation of one or more joints or part of the spinal column. This occurs with aging, excessive weight, and joint injuries. Joint stiffness occurs with lack of motion. Pain occurs with weight bearing or joint motion. Cold weather and dampness seem to increase symptoms. Severe pain affects rest and mobility. The two most common types are:Osteoarthritis (Degenerative Joint Disease)(DJD) is the most common type of arthritis. It is caused from general wear and tear and generally occurs late in life. Treatment involves pain management, which includes medication, heat and/or cold application, exercise and rest. Weight loss is stressed for individuals who are overweight.Rheumatoid Arthritis (RA) is a chronic inflammatory autoimmune disease most common in women. It can occur at any age, but generally onset is between 40 and 60 years old. With RA both sides of the body are affected; for example, it will affect both wrists or both knees. The wrist and finger are the most commonly affected. In addition to pain and stiffness, joint swelling occurs; also bone erosion and joint deformity. In addition to pain management, treatment goals are to slow down or stop joint damage, or possibly joint replacement.Osteoporosis is when the bones become brittle, fragile and break easily. Elderly women are at risk due to the lack of estrogen after menopause. Inactivity is also a risk factor. Back pain, loss of height and stooped shoulders are common signs. Fractures can occur very easily; turning in bed, twisting, even coughing or getting up from a chair can cause a fracture. Preventing falls is very important for someone with osteoporosis.Fracture is a broken bone. There are several types of fractures:Closed Fracture (Simple Fracture) - The bone is broken, but the skin is intact.Open fracture (Compound Fracture) - The bone has come through the skin.For healing, bones are brought back into alignment. Sometimes, nails, rods, pins, plates or screws are used to keep the bones in place. Movement is prevented with a cast or traction.Hip fractures are common in the elderly, generally from falls. After surgery rehabilitation is needed, and can take several weeks in a facility.10668001600200Musculoskeletal System - DiagramMusculoskeletal System - DiagramBones of the BodyTypes of JointsRange of MotionRange of motion (ROM) = the amount of movement possible in a joint, or how far a person can move a joint comfortably.R.O.M. exercises can be:Active: Which means done by the personActive assisted- by the person with assistance Passive: Done for the person by anotherAbduction Abduction is movement away from the midline, or to abduct. Adduction Adduction is movement toward the midline, or to add. 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Extension Extension is to straighten at a joint, or to increase the angle, for example, from 90 degrees to 180 degrees. 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Lateral Rotation Lateral rotation is to turn outward. 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Use your legs, not your back!Keep the weight you’re lifting close to your body.Assisting With TransfersTransfer = assisting a person to move from one surface to another; for example, a bed to chair transfer. Body mechanics = the position of the person performing the transfer. To help a patient transfer safely, you must understand body mechanics. This is the way you move your trunk, legs, and arms for the best leverage with the least stress and fatigue.Rules for Transferring a PatientCommunicate -- tell the person what you are going to do. Speak slowly and clearlyTransfer on the count of 3 -- count out loud, with person if they canLock the wheelchair at an angleMove the person’s hips to the front edge of the chair/bedInstruct/assist person to lean shoulders forwardPlace the person’s knees between your knees, or place your feet in front of their feetHold on to the gait beltHave patient rock back and forth before transferSpecial ConsiderationsTransfer toward the patient’s strong sideIf the patient is heavy, get help or use a sliding boardIf patient is anxious, reassure and be sure that they feel safeRules That Protect You When Transferring a PatientKeep your back straightTighten your stomach musclesBend your kneesKeeping a good base of supportKeep your feet apartTurn, don’t twist your back during the transferWhen appropriate, use a gait beltHold patient close to youDon’t reach a long distanceNever let the patient hold you around your neck during the transfer53340057150Proper Use of Gait00Proper Use of GaitModule 14Nervous System andNervous Disorders TOC \b Module14 \h \z \t "Title,1" The Nervous System PAGEREF _Toc397769292 \h 128Understanding Cognitive Functioning PAGEREF _Toc397769293 \h 129Common Disorders of the Nervous System PAGEREF _Toc397769294 \h 130Signs and Symptoms of Stress PAGEREF _Toc397769295 \h 132Fight or Flight PAGEREF _Toc397769296 \h 134Beck Depression Inventory PAGEREF _Toc397769297 \h 137Alcohol and Medication Issues Among Older Adults PAGEREF _Toc397769298 \h 139The Nervous SystemThe nervous system controls all body functions. It has two main divisions:The Central Nervous System: Consisting of the brain and spinal cord.The Peripheral Nervous System: Consisting of the nerves throughout the body. The Central Nervous System: The brain weighs about 3 pounds, is 90% water and has 4 main parts:The Cerebrum: The largest part of the brain, controls the highest functions such as conscious thought, memory, speech and voluntary muscle movement. It processes sensory information from the outside world through vision, hearing, smell and sensation. Our personal individuality is developed through this part of the brain. The cerebrum has two hemispheres. The right hemisphere controls movement on the left side of the body while the left hemisphere controls movement on the right.The cerebellum- Controls balance and coordination. It sends instructions through the spinal cord to the muscles, promoting smooth movement and mobility. The Spinal Cord is another part of the central nervous system. It lies within the spinal column and is approximately 18 inches long. It contains pathways which conduct messages to and from the brain. The Brain Stem- connects the spinal cord with the rest of the brain. It controls the functions that happen automatically such as heart rate and breathing. It also controls sleeping and dreamingThe Peripheral Nervous System: is a network of nerves that carry impulses back and forth from the body to the brain. Some peripheral nerves form the autonomic nervous system, which controls involuntary muscle/body functions. This system contains the sympathetic nervous system, which increases the function needed for exercise, and the parasympathetic nervous system, which slow functions to allow for relaxations. They balance each other out. Understanding Cognitive FunctioningCognition is the process by which we learn, store, and use information.Cognitive Functions Include:Intelligence- The ability to deal with symbols, abstract ideas and to comprehend new information.Learning- The means by which new information is stored in the brainMemory- The process of recalling (recognizing) information stored in the brain.Cognitive development continues throughout life. The process of fulfilling basic human needs at every stage of life influences the development and function of cognitive faculties. Other factors include:Stress- A Condition or feeling experienced when a person perceives that external and or internal demands may exceed the resources the person is able to mobilize. Maturity- A state of being encompassing a person’s experience, ability for self reflection, mastery over the emotions, interaction with the environment and a use of reasoning. Creativity- The ability of a person to apply unique and practical solutions to new situations, to come up with original ideas and to communicate these in an effective ways.All cognitive processes take place in the brain. The brain is part of the body’s central nervous system.Frontal Lobe: Intellectual function, smell, and speech. Motor area of the Frontal Lobe: Initiation of skilled and postural movement. Parietal lobe: Awareness and distinction of taste and touch, pressure, temperature, muscle and sense of body position. Occipital Lobe: VisionTemporal Lobe: Hearing, language, smell, and emotional behavior.Corpus Callosum: A bundle of nerve fibers connecting the left and right cerebral hemisphere. Cerebellum: Equilibrium, muscle tone and postural control, coordination of voluntary movement. Common Disorders of the Nervous SystemStroke/CVA (Cerebrovascular Accident): The third leading cause of death in this country and the leading cause of disability. A stroke affects the blood supply to the brain. The two main causes are:A ruptured blood vessel in the brain, resulting in bleeding swelling, pressure and ultimately damage in the brain.A blood clot that blocks the flow of the blood to the brain. Functions controlled by the affected part of the brain, such as speech, swallowing and muscle control, may be temporarily or permanently impaired or lost. Strokes occur in the right or left hemisphere of the brain and affect function or cause paralysis on the opposite side of the body; this is known as hemiplegia.Warning Signs of StrokeSudden numbness or weakness of the face, arm, or leg, especially on one side of the bodySudden confusion, trouble speaking, or understanding.Sudden trouble seeing in one or both eyes.Sudden trouble walking, dizziness or loss of balance or coordinationSudden severe headache with no known causeTIA= Transient Ischemic Attack- A short episode of muscle weakness, confusion, memory loss, slurred speech or other, stroke like symptoms from which the person recovers in a few minutes. A TIA may be an early warning of an impending stroke. Risk factors for stroke include: age, male gender, hypertension/high blood pressure, family history, cardiovascular disease, diabetes, high cholesterol, obesity, alcoholism, and inactivity. People who have suffered a stroke often experience frustration, emotional instability, and impulsive behavior. These behaviors are commonly related to the difficulty with communication, called Aphasia. There are two types of aphasia; one or both can be present. Expressive Aphasia = Difficulty sending messages. Speech may be slurred or the person may not be able to form words at all. They may think one thing but say another. They may shout or cry without reason, or they may not be able to speak, write or signal at all due to paralysis. Receptive Aphasia = Difficulty receiving messages. The person has trouble understanding what is said; a person may not recognize familiar objects, people or words (written or spoken). Recovery from stroke depends on the type and extent of damage to the brain and the ability of the person to participate in rehabilitation. Parkinson’s Disease- A progressive degeneration of specific parts of the brain. There is no known cause for this disease. Symptoms include: lack of facial expression, muscle stiffness, rigidity, tremors, shuffling gait, shaking, or repetitive movements, especially of the hands, (pill rolling = rubbing of the thumb and index finger), a slumping posture, or forward tilt of the trunk. Symptoms worsen as the disease progresses and may include problems with speech, swallowing, elimination, memory and sleep. As with all disorders of the nervous system, emotional/behavioral symptoms, such as frustration, anger, depression, or anxiety may occur. While symptoms of this disease can be treated there is no cure. People over 50 are at risk. Multiple Sclerosis (MS): is a chronic disease resulting in the destruction of the myelin (the coating of the nerves in the spinal cord and brain), causing a disruption in the nerves impulses/messages to and from the brain. Functions controlled by the damaged area of the brain or spinal cord is impaired or lost. There are several types of MS. Some types involve acute attacks or flare ups, following remissions when the symptoms lessen or disappear. In other cases the losses are permanent and progressive. The disease may progress rapidly or in a slow, gradual decline. Symptoms may include: poor coordination, tremors, numbness, tingling or loss of feelings, vision problems, speech problems, or problems with elimination, impaired concentration, memory, judgment and behavioral instability. Respiratory muscle weakness is also common in people with M.S. The disease generally begins between the ages of 20 and 40, but can be hard to diagnose because the symptoms often come and go. There is no cure. Head and Spinal Cord Injuries: Temporary or permanent damage to the brain and spinal cord, generally caused by falls, car accidents or sports injuries. The damage can range from temporary loss of consciousness, confusion and impaired nerve or muscle function to permanent brain damage or paralysis depending on the location and extent of the injury. Cervical injuries high up on the spinal column cause damage from the neck down. Quadriplegia = paralysis from the neck down. Lumbar or thoracic level (lower down the spinal column) injuries cause paraplegia = paralysis from the waist down. As with all nervous system disorders emotional instability and behavioral symptoms are common. Seizures are sudden and sometimes violent contractions of muscle groups caused by electrical misfiring in the brain. There are a number of types of seizures. Safety is the first concern of the care provider. Remove furniture or other objects that may cause injury to your resident. Turn the person on their side to prevent aspiration, time the length of the seizure and describe what you are seeing so you can report this to the nurse or charge person. Reassure the resident. The person may be incontinent or be very drowsy after the event.Signs and Symptoms of StressStress = the body’s response to demands. Distress = when the demands are perceived by the person to exceed personal resources. What is stressful for one person might not be stressful for another. People respond to stress differently. Some people blush or eat more, while others grow pale or eat less. Prolonged stress is not good for physical or mental health. Identifying personal signs and sources of stress can help in the management of stress. The following are some common signs and symptoms of stress:Frequent headaches, jaw clenching or painGritting, grinding teethStuttering or stammeringTremors, trembling lips, hands Neck ache, back pain, muscle spasmsLight headedness, faintness, dizzinessRinging, buzzing, or “popping sounds”Frequent blushing, sweating Cold or sweaty hands, feet Dry mouth, problems swallowingFrequent colds, infections, herpes soresRashes, itching, hives, “goose bumps”Unexplained or frequent “allergy” attacks Heartburn, stomach pain, nausea Excess belching, flatulence Constipation, diarrheaDifficulty breathing, sighing Sudden attacks of panic Chest pain, palpitations Frequent urinationPoor sexual desire or performance Excess anxiety, worry, guilt, nervousnessIncreased anger, frustration, hostilityDepression, frequent or wild mood swings Increased or decreased appetite Insomnia, nightmares disturbing dreamsDifficulty concentrating, racing thoughts Trouble learning new informationForgetfulness, disorganization, confusionDifficulty in making decisions Feeling overloaded or overwhelmedFrequent crying spells or suicidal thoughtsFeelings of loneliness or worthlessnessLittle interest in appearance, punctuality Nervous habits, fidgeting, feet tapping Frustration, irritability, edginessOverreaction to petty annoyancesIncreased number of minor accidents Obsessive or compulsive behavior Reduced work efficiency or productivity Lies or excuses to cover up poor workRapid or mumbled speechExcessive defensiveness or suspiciousnessProblems in communication, and sharingSocial withdrawal and isolationConstant tiredness, weakness, fatigue Frequent use of over-the-counter drugsWeight gain or loss without diet Increased smoking, alcohol or drug useExcessive gambling or impulse buyingFight or FlightThe General Adaptation Syndrome (GAS), also known as the “Fight or Flight” response, is our biological coping mechanism. When confronted by a threat or stressor, the body responds by preparing to fight or flee from danger. Stressor = an activity, event or stimulus that causes stress. The body automatically responds to all threats, or stressors the same way. The brain sends a message to the pituitary gland to release hormones. This triggers the adrenal glands to pour out adrenaline. Adrenaline increases the heartbeat and rate of respiration, raises the blood sugar level, increases perspiration, and dilates the pupils. Digestion slows to allow oxygen to be more readily available to the muscles, muscles contract to increase strength and blood-flow to the extremities is decreased to slow bleeding if injured. This response helped ancient humans to survive, but today it is often counter -productive. The spurt of adrenaline, bracing muscles, quickening pulse and shutting down of digestion we experience may leave us feeling anxious and unable to relax. We may feel exhausted and foggy. Chronic unrelieved or unexpressed tension can build up and can lead to a variety of long-term health issues such as high blood pressure, heart disease and diabetes. The symptoms of unrelieved tension are many and they differ for different people. Commonly we feel exhausted after a bout of G.A.S. Some other common symptoms include: headaches, body aches, loss or increase of appetite, irritability, confusion, inability to focus, hyperfocus with inability to think of anything else, general feeling of anxiety, muscle weakness and digestive distress. We treat the symptoms with pain relievers, anti-anxiety, anti-depression and other drugs. We self medicate with comfort food, alcohol, caffeine and diversional activities. These methods help us to achieve temporary relief, but often cause other problems.We can learn to minimize the effects of G.A.S. and help our body systems to return to normal more quickly by controlling our reactions and our thoughts. We can also intentionally relax. It is not possible to be both tense and relaxed at the same time. When we can pay attention to what we are thinking and feeling, we can maintain better control of our reactions and prevent a bout or G.A.S. Physical exercise also helps us to express and release tension. Good nutritional intake is essential to counter the effect stress has on the cells and organs of the body. Sequencing - Being able to do things in a logical order.DEMENTIAAn UmbrellaThat Covers Multiple SymptomsMemory - Loss of memory is the most common symptom of dementia.Short Term loss is more common in the early stages.Concentration - Decreased ability to focus attention and stay on task.Orientation - The awareness of who, where and when is affected. This may be referred to as oriented x 3 Person, Place and Time.Language - Problems finding, using and understanding words.Judgment - Decreased ability to make decisions, to understand consequences of actions.Visuospatial - The ability to make sense of what is seen. And how objects relate to one another.Mental HealthMental health involves the mind and thought processes: According to most definitions, a mentally healthy person is someone who copes with and adjusts to everyday stresses in a socially acceptable way. Mentally healthy people also can control or adapt their behavior as needed to cope with increased stress.Mental Illness is defined as a disturbance in the ability to cope or adjust to stress, resulting in impaired function, judgment and/or abnormal behavior. Mental illnesses, just like physical illness, can be mild or severe, short term, acute or chronic. There are many different kinds of mental illness that fall in to three categories:Mental Disorders - Emotional Illness - Psychiatric DisordersCauses of mental illness include:Inability to cope or adjust to stress. Example- Depression Chemical imbalance - Example - Bipolar DisorderGenetics - Example - SchizophreniaSubstance abuse or side effects - Example - IntoxicationSocial or cultural factors - Example - Eating disorder The signs and symptoms of mental illness vary depending on the type and severity of the illness and may be physical as well as behavioral. The following is a list of common disorders/symptoms and definitions.Anxiety - Vague, uneasy feeling of distress.Depression - Persistent feelings of pulsion - Repeated act.Delirium - Acute confusion.Delusion - False believe.Disorientation - Confusion related to person, place, or time.Hallucination - Seeing, hearing feeling something that is no real. Panic - Intense, sudden feeling of fear.Paranoia - Suspicious beliefs.Phobia - Fear of object or situation.Psychosis - Inability to view the real or unreal correctly. Obsession - Recurrent, unwanted thoughts.Beck Depression InventoryChoose one statement from among the group of four statements in each question the best describes how you have been feeling during the past few days. Circle the number beside your choice. 1.0 – I do not feel sad 1 – I feel sad2 – I am sad all the time and I can’t snap out of it3 – I am so sad and unhappy I can’t stand it2.0 – I don’t feel I am any worse than anybody else 1 – I am critical of myself for my weaknesses or mistakes 2 – I blame myself all the time for my faults 3 – I would kill myself if I had the chance 3.0 – I am not particularly discouraged about the future 1 – I feel discouraged about the future2 – I feel I have nothing to look forward to3 – I feel that the future is hopeless and that things cannot improve 4.0 – I don’t have any thoughts of killing myself 1 – I have thoughts of killing myself, but I would not carry them out 2 – I would like to kill myself 3 – I would kill myself if I had the chance5.0 – I do not feel like a failure 1 – I feel I have failed more than the average person 2 – As I look back on my life, all I can see is a lot of failure 3 – I feel I am a complete failure as a person 60 – I don’t cry any more than usual1 – I cry more now than I used to 2 – I cry all the time now 3 – I used to be able to cry, but now I can’t cry even though I want to 7.0 – I get as much satisfaction out of things as I used to 1 – I don’t enjoy things the way I used to 2 – I don’t get any real satisfaction out of things anymore 3 – I am dissatisfied or bored with everything 80 – I am no more irritated by things than I ever am1 – I am slightly more irritated now than usual2 – I am quite annoyed or irritated a god deal of the time3 – I feel irritated all the time now 9. 0 – I don’t feel particularly guilty 1 – I feel guilty a good part of the time 2 – I feel quite guilty most of the time 3 – I feel guilty all of the time 100 – I have not lost interest in other people 1 – I am less interested in other people than I used to be 2 – I have lost most of my interest on other people 3 – I have lost all of my interest in other people 11.0 – I don’t feel I am being punished 1 – I feel I may be punished 2 – I expect to be punished 3 – I feel I am being punished 120 – I make decisions about as well as I ever could 1 – I put off making decisions more than I used to2 – I have greater difficulty in making decisions than before 3 – I can’t make decisions at all anymore 13. 0 – I don’t feel disappointed in myself 1 – I am disappointed in myself 2 – I am disgusted with myself 3 – I hate myself 140 – I don’t feel that I look any worse than I used to 1 – I am worried that I am looking old or unattractive 2 – I feel that there are permanent changes in my appearance that make me look unattractive 3 – I believe I look ugly 150 – I can work about as well as before 1 – It takes an extra effort to get started at doing something 2 – I have to push myself very hard to do anything 3 – I can’t do any work at all 160 – I haven’t lost much weight, if any lately1 – I have lost more than five pounds 2 – I have lost more than ten pounds 3 – I have lost more than fifteen pounds (score 0 if you have been purposely trying to lose weight) 170 – I can sleep as well as usual1 – I don’t sleep as well as I used to 2 – I wake up 1-2 hours earlier than usual and find it hard to get back to sleep 3 – I wake up several hours earlier than I used to and cannot get back to sleep 180 – I am no more worried about my health than usual1 – I am worried about physical problems such as aches and pains, or upset stomach, or constipation 2 – I am very worried about physical problems, and it’s hard to think of much else 3 – I am so worried about my physical problems that I cannot think about anything else 210 – I don’t get more tired than usual1 – I get tired more easily than I used to 2 – I get tired from doing almost anything 3 – I am too tired to do anything 220 – I have not noticed any recent change in my interest in sex1 – I am less interested in sex than I used to be 2 – I am much less interested in sex now 3 – I have lost interest in sex completely Scoring: 1-10: These ups and downs are normal; 11-16: Mild mood disturbance; 17-20: Borderline clinical depression; 21-30: Moderate depression; 31-40: Severe depression; Over 40: Extreme depression Alcohol and Medication Issues Among Older Adults As a home care aide, you help keep your clients healthy. You are the eyes and ears of the home care team and may be the first to notice if a client has a health problem. Some older clients may have problems with medications or alcohol. You can help by sharing your concerns about these and other health problems with your supervisor. You can make the difference.WHAT YOU NEED TO KNOW Signs of a ProblemSome signs of a medication or alcohol problem, which may also be signs of other health conditions, include:Missing pills, confusion about medicationEmpty alcohol containers or a large supply of alcoholDrinking more than recommended by one’s health care providers Blackouts, problems with memory, speech, or visionGetting hurt, including falls Sleep problems Feeling depressed, anxious, confused, or moodyNot caring for oneselfBeing mean to loved one/caregivers Spending a lot of time aloneOther signs like weight loss, upset stomach, or shakingIf a client shows these signs or other major changes all of a sudden, speak with your supervisor. You can help your clients get the support they may need for any of their health problems. Medications Older adults can feel the effects of medications more than younger adults do.Some prescription drugs, over-the-counter drugs, and supplements --, like vitamins and herbs -- can interact with one another. Some older adults take their medication in the wrong way, which can be harmful. They may take too many, too few, or forget to take them at all.AlcoholOlder adults can feel the effects of alcohol more than younger adults do.Alcohol can interact with some prescription and over-the-counter drugs and supplementsAlcohol can cause health problems, falls, and sleeping troubles in older adults. It can also make their health problems worse. WHAT YOU CAN DO TO HELPKnow the Signs To help your clients, it is important for you to know the signs of a possible medication or alcohol problem. Learn the signs listed on the front of this sheet. Watch for changes in how your clients look, feel, and act.Do not try and diagnose a problem. Your very important role is to observe and report to your supervisor. Report the ProblemTell your supervisor if you see any signs of a problem or changes in your clients that concern you. It is your job to report anything that may harm your clients, even if they ask you not to. Sharing what you see or hear with your supervisor may help your clients get the support they need.Report anything that might put you or your client in immediate danger, like falls, as soon as you can. Report less dangerous situations once you have left the client’s home When you contact your supervisor, you will talk aboutwhat you have noticed and what concerns you, confidentiality issues, and safety issues for you client and you (including whether you feel unsafe at work or about reporting your client’s problem)You Make the Difference It has been shown that many older adults who get help for their problems can improve their health and quality of life. You can assist your clients to get this help. You can make all the difference.Resources To learn more about alcohol, medications, and other adults, you can contact: Massachusetts Substance Abuse Information & Education Helpline (800) 327-5050 helpline- Bureau of Substance Abuse Services Massachusetts Department of Public Health state.ma.us/dph/bsas/bsas.htmMassachusetts Health Promotion Clearinghouse (800) 952-6637 National Clearinghouse for Alcohol & Drug Information (800) 729-6686 Massachusetts Council for Home Care Aide Services, Inc. (617) 224-4141 Module 15Dementia TOC \b Module15 \h \z \t "Title,1" Dementia PAGEREF _Toc397769579 \h 142Stages of Alzheimer’s Disease PAGEREF _Toc397769580 \h 144Caregiver’s Techniques for Communicating With the Memory Impaired PAGEREF _Toc397769581 \h 147The Principles of Validation PAGEREF _Toc397769582 \h 148DementiaDementia = Loss of social and cognitive function. Not all people with dementia have Alzheimer’s Disease, but all people with Alzheimer’s Disease have dementia. Alzheimer’s Disease is a chronic-progressive condition. Many older people have short-term memory problems, or lapses of memory. This does not mean that they have dementia or Alzheimer’s Disease. Dementia can be an important symptom of many health problems. There are many other disorders, some very treatable, that can cause dementia. These include: Strokes are not always a big medical crisis; some are mini-strokes (TIAs) that happen recurrently and may not be identified by the person. A series of these tiny infarcts can bring on symptoms that look like Alzheimer’s. Brain Injuries. Symptoms similar to Alzheimer’s are found in persons who have repeated head injuries. A blow to the head can cause a blood clot under the skin which puts pressure on the brain. With an elderly person the injury can be a very simple one; it does not have to be a severe blow. Alcoholism. Some elderly people have a history of frequent use of alcohol. This problem can be treated and the result is a reverse of the symptoms. Endocrine disorders. For instance, a disturbance in the thyroid gland is very easily treated and can reverse the symptoms of dementia. There are other endocrine system imbalances that effect cognition and reasoning. Syphilis. This is a sexually transmitted disease that can affect the brain and cause behavioral problems. It, too, is treatable when diagnosed early. Brain tumors. Surgery can remove a tumor that has caused changes in behavior and personality. Malnutrition. Elderly people don’t always eat enough of the right foods and are consequently they may develop vitamin and nutritional deficiencies. We see poor nutrition in older people who are having financial problems or who are taking medications that depress appetite. Some people may not have anyone who can help them with food shopping or preparing appropriate meals. Addressing the nutritional needs of the elderly person can reverse the signs of cognitive impairment. Medications. Medications can affect the behavior of all of us. When we suspect that someone is having memory loss or other problems, we must identify what medications the patient has been taking. Multiple medications are often taken by elderly people and not always on time or in the right dosage. Depression. Depression is seen in elderly people, sometimes to such an extent that Alzheimer’s is suspected. Changes in personality, sleeping patterns, behavior, and sociability are not only symptoms associated with depression, but also a major problem for the elderly population. This is particularly true when family members no longer live near the person and are not available for assistance or support. Depression is treatable. Respiratory. Respiratory problems can cause anxiety and disorientation that mimic the anxiety found in Alzheimer’s. Infections. Infections such as urinary tract infection or pneumonia can manifest in signs of noticeable confusion or hyperactivity or even hallucinations or delusions. Infections are easily treatable. Metabolic disturbances. Metabolic disturbances are easily treated when identified. These disturbances are seen in adults suspected of having Alzheimer’s because of altered attention span, depression, and physical tremors. (One third to one half of people referred to gerontologists and Alzheimer’s specialists have some other illness or problem)Stages of Alzheimer’s DiseaseAlzheimer’s Disease is a chronic-progressive condition. People with A.D. live an average of 8 years after diagnosis, but may have been coping with signs and symptoms for several years prior to diagnosis. The following is a guideline for the progression of A.D. However, it is important to note that no two people with A.D. progress in the same exact way. Not everyone will experience every symptom. For some the progression is slow, for others more rapid. The Early StageThe person may have some or all of the problems listed below. Initially the problems may not be very evident to others. The person will often deny -- or cover up -- the problems in order to pass as “normal.”Awareness that she/he is forgetting more often, having memory lapses Problems with sequencing; may forget how to begin or complete tasks May be unable to think back chronologically Forgetting familiar words and namesMay check and recheck their watch/calendar Household tasks may be left undone May become more withdrawn in social situations Becomes socially isolated, and may seem self-absorbed Experiences anxiety Loses things and may become paranoid that things are moved or stolenDeclining ability to plan and organize day to day activitiesDecreased memory of recent activities and current eventsDecreased attention to hygiene and groomingDresses inappropriately, sometimes in layers Interruptions in sleep patterns Repetitive behavior begins (asking questions over and over again) Has problem remembering to eat, or may eat too much Inability to reason appropriately Role of Caregiver in Early StageValidate feelings - try to address the feelings behind the questionsRe-assure that support is availableProvide positive messagingPay attention to ADL needs, Provide cues, reminders, notes, check insGently suggest rather than instructBe responsive rather than directive Encourage routineReorient as toleratedIt is all about maintaining the person’s dignity.Persons in the early stage of A.D. need someone to perform tasks with them rather than for them. Supporting the independence of the person is extremely important at this stage, because it helps to preserve their sense of self-worth. Let the person have as much choice as they can tolerate. Be flexible about schedules and agenda.Be sensitive to the fears and worries of the person in regard to the future.Middle Stage - This is generally the longest stageStage one problems are more evident Shorter attention spanLess able to learn new information; long term memory is still possible Less able to recognize familiar faces Ability to speak in words that can be understood is gradually disappearing Loses the ability to write, may be able to write only their nameLosing ability to readCannot remember names of family and friendsEventually will not recognize family and friendsMay identify self as younger, may not recognize self in mirrorRestlessness, wanderingSundowning = Increased agitation at sunset Motor problems might occur, such as jerking and twitching movements Mood instability - may laugh or cry inappropriately, or switch between the two Hallucinations are possible May express insecurity or discomfort by asking to go home or for motherEating may become a problem, may grab food from others foodMay lose interest in eating May have visual problems, depth perception is impairedUnable to understand and answer questionsUnable to manage ADLs independentlyBecomes incontinentUnable to express needsMay lose sense of socially acceptable behavior Role of Caregiver in Middle StageDon’t correct - redirectLimit decisions, keep choices simple Give information only as tolerated – Monitor for frustration (yours and theirs)Take it one step at a time - Transitions become difficultDo keep good notes about client. Look for a patternAvoid phrases like “I told you this before” Always speak calmly and maintain positive demeanor Validate: go where they areCaregiver will need to assist with bathing and dressing at this time If “sundowning” occurs use high voltage bulbs towards the end of the day Client may be suspicious of what you are doing Little fiblets may be necessaryFinal Stage -Usually lasts 1 – 3 years Gradual loss of all bodily functions Weight lossLoss of interest in food, must be fedCan no longer communicate verballyIncontinent Potential seizures Requires total care Atrophy and contractures occurSpends much time sleeping High risk for secondary infections (UTI, pneumonia) Role of Caregiver in Final Stage Provide for all ADLs.Monitor for any physical changes, including painAdvocate for the person’s needsCommunicate verbally while providing care.Provide comfortCaregiver’s Techniques for Communicating With the Memory ImpairedThe ability to communicate with a person with dementia changes with the progression of the disease. In the mild/early stages names of objects, persons, and places may be difficult for the individual to recall. Words such as “this,” “that,” and “there” may replace the word the person is unable to find. When you listen carefully, the context of the conversation often gives you clues to the missing words. At this stage, closed questions, cues and reminders may munication becomes increasingly difficult as the disease progresses. Language becomes confused and harder to understand. Persons with mid to later stage dementia may have difficulty understanding what others tell them. Words lose meaning; they may not be able to understand or answer questions or instructions. They may ask the same question repeatedly. Pay attention to the emotion or need behind the question. Trying to reason with the person is not helpful. Validation of the feeling is generally more comforting.The following are some techniques to foster positive communication and avoid frustration: Eliminate distraction: confusion is likely to increase with extra noise and activity. Pay attention, watch for signs of frustration. Behavior is communication. If the person is getting frustrated or agitated, pull back.Do not correct, redirect.Establish eye contact at a face to face level.Identify yourself by name and call the person by their name.Use non-verbal communication skill: smile, nod, touch, to convey positive regard. Speak in a gentle tone. Break down tasks: give brief one-step directions, as tolerated.Keep choices simple. Ask closed questions, requiring yes or no answers. Emphasize the positive and be reassuring. Validate feelings.Allow plenty of time for response; if needed, repeat the question again exactly as it was phrased the first time. If there is still no response, do not force the person to respond or comply: pull back and try again in a few minutes. The Principles of ValidationBy Naomi Feil INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET All people are unique and must be treated as individualsAll people are valuable, no matter how disoriented they areThere is a reason behind the behavior of disoriented old-old peopleBehavior in old-old age is not merely a function of anatomic changes in the brain, but reflects a combination of physical, social, and psychological changes that take place over the lifespan.Old-old people cannot be forced to change their behavior. Behaviors can be changed only if the person wants to change them.Old-old people must be accepted non-judgmentallyParticular life tasks are associated with each stage of life. Failure to complete a task at an appropriate stage of life may lead to psychological problemsWhen more recent memory fails, older adults try to restore the balance to their life by retrieving earlier memories.When eyesight fails, they use the mind’s eye to see. When hearing goes, they listen to sounds from the pastPainful feelings that are expressed, acknowledged, and validated by a trusted listener will diminish. Painful feelings that are ignored or suppressed will gain strength.Module 16Urinary System TOC \b Module16 \h \z \t "Title,1" The Urinary System and Common Disorders PAGEREF _Toc397769793 \h 150Appliances that Elders may need to Support Incontinence PAGEREF _Toc397769794 \h 152Approximate CCs of Food and Drink Served PAGEREF _Toc397769795 \h 153The Urinary System and Common DisordersThe Urinary system is the filtering system for the body. It helps to maintain fluid and chemical balance. It consists of 2 kidneys, ureters, bladder, and the urethra. The kidneys are located in the back of the upper abdomen on either side of the spine. Blood is filtered through the kidneys. Waste, in the form of urine, passes through the ureters to the bladder where it is stored, until it is expelled out the urethra. A normal/healthy adult urinates between 4 to 7 times a day and produces approximately 3 pints or 1500 milliliters (ml)For persons who require assistance with urination or bladder retraining program, the standard is every 2 hours. Output depends on fluid intake and the strength of the bladder muscles. Males with enlarged prostates may urinate more frequently. The urethra is a portal of entry/exit for bacteria. Always wipe from front to back.Normal urine should be pale yellow or amber. It is clear with no particles and has only a faint odor. Urine stored in the bladder is sterile.Many factors effect urinary production and elimination. Some substances, such as coffee (any caffeinated beverage), alcohol will increase urine production. A doctor may prescribe a diuretic=medication to increase urine production. This will cause a person to urinate more frequently. Decreased circulation can cause reduced urinary output, which can result in edema = swelling, Most commonly in the ankles and feet. Common Problems of the Urinary SystemIncontinence – the inability to hold urine. An incontinence product will be needed and changed when it becomes soiled to prevent UTIs (Urinary Tract Infection). Caregivers will need to provide peri care after every incontinent episode if the elder is unable to care for themselves.* Stress Incontinence - Urine is expelled when one coughs, sneezes, laughs, or in severe cases, even moves.* Urinary Urgency and Frequency when one feels the urge to urinate often.* UTI’s/Urinary Tract Infection/Cystitis – Causes inflammation of the bladder and ureters, generally caused by bacteria. More common in women than men because of the size of the urethra. Individuals who have incontinence or are bedbound are at increased risk for a UTI. Women should wipe themselves front to back after using the bathroom. * Kidney stones/Renal Calculi - Small stones that are passed through the urethra. Individuals that are on bed rest, have a poor fluid intake and are immobile can be at risk for “stones.”When caring for someone that has urinary incontinence, it’s important to prepare in advance for issues that may arise. Here are some important tips that may help you: * During outings bring a change of clothes, extra incontinence products, and hand sanitizer. * Protect furniture and mattress by covering with plastic; chuck pads are available in pharmacies, water proof quilted pads are available in medical supply stores. (Only wash 1 quilted pad at a time.) * Assess the need for urinary appliance or product. * Remember dementia patients will need to reminded and assisted with hand washing after toileting. * Elders with poor circulation will retain fluid. They may have swollen ankles and may be advised to elevate their feet above their waste for 20 to 30 minutes 2 or 3 times a day; they may need to use the bathroom shortly after. * A daily weight may be advised. Generally a 3 lb weight gain in one day should be reported to the nurse or responsible person. * Low salt diet may be recommended. * Observe amount, color, odor and report changes to the nurse or responsible person. * Provide peri care after every incontinent episode. * Ensure soiled clothes are changed and washed promptly and appropriately * Take temperature if any signs of an infection. Report elevated temperature to nurse or responsible person.Appliances that Elders may need to Support IncontinenceThere are many types of appliances that will support client/residents with bladder incontinence. Most can be bought in pharmacies and medical supply stores; some will need to be ordered through the physician. Here is a list that may help: * Bed pans/Fracture pans - Used for bed bound patients, will need to be covered and cleaned after every use. * Bed side commodes - Portable toilets, helpful during night, or if the bathroom is on a different floor. Some like to keep cleaner in bottom of the commode to help eliminate odors. * Raised Toilet Seats - Helpful for patients with low toilets, or may have mobility issues. * Grab bars - Mounted on the wall beside the toilet may help with bathroom independence. * Urinals - Male and Female. Useful especially for night time. They should be cleaned and disinfected regularly. When empting a urinal use Universal Precaution. When emptying urine in toilet, put toilet lid down, and then flush. This will help eliminate bad “pathogens” into the air. * Incontinence Products - There are many types of briefs and pads to choose from. Caregivers will need to ensure incontinence products are being used and changed often. Measuring Intake and OutputThe doctor may order that all fluids consumed and eliminated be measured. This is called I and O. Documentation of I and O is required, usually on a tracking or log sheet, generally at the end of shift. Fluids measured in ounces (oz) must be converted to cubic centimeters (cc) 1 oz = 30 cc. For example: 8 oz glass of water = 240 cc, because 8 x 30 = 240.For a person that is incontinent, exact measurement of output is not possible. In that case, the amount of output is recorded by estimation of amount and number of incontinent episodes. The weight of the brief is heavier when there is a large amount of urine and less weight when there is only a small amount of urine. This could be recorded as follows: “Incontinent of large amount of urine, or Incontinent of small amount of urine x 3”Approximate CCs of Food and Drink ServedMain Dining RoomWater240Juice Glass180Milk180Coffee Cup150Milk Pitcher or Cereal240Units7 oz Coffee2107 oz Juice Glass2104 oz Orange Juice1206 oz Resource Juice180Small Milk Carton120Large Milk Carton2405 oz Med Cup1202 Handled Cup180Foods? C Pudding120? C Jello120? C Custard120? C Ice Cream1206 oz Soup1806 oz Italian Ice18012 oz Styro Cup360Supplements4 oz Health Shake1208 oz Resource Plus240Ensure240Ensure Pudding150CNA/HHA Catheter CareYour observations are important when it comes to caring for an elder with a catheter bag. Here are several observations and steps required of CAN/HHA.(Rule of Thumb) patient has a catheter always record intake and output. Even if your nurse hasn’t delegated it to you. Total up at the end of your shift and give to your nurse.Make sure catheter tubing is not kinked or looped.Keep catheter drainage bag below patient’s waist at all times.Provide pericare 2x a day and after a bowel movement. Be sure to ALWAYS wipe patient from front to back.You may need to assist patient with securing the catheter. Tape may be irritating to the skin, ask your nurse for catheter tube holder if needed.Reprtable Situation When Caring for a CatheterComplains of pain (and or burning) and fullness in the abdomen.Urinary leakage from catheter.A small/scant amount of urine output.Blood or thick sediment in the urine bag.Crusting around the catheter site.Dark urine.Urine May Contain Microbes and Blood. Remember to Follow Standard Precautions for Bloodborne PathogensModule 17Death and Dying TOC \b Module17 \h \z \t "Title,1" Advanced Directives PAGEREF _Toc397769974 \h 156Hospice and Palliative Care Programs PAGEREF _Toc397769975 \h 157Communicating with the Dying Client PAGEREF _Toc397769976 \h 158Common Signs of Impending Death PAGEREF _Toc397769977 \h 159Signs and Symptoms of Pain PAGEREF _Toc397769978 \h 161Water Bugs & Dragonflies PAGEREF _Toc397769979 \h 162Advanced Directives An Advance Directive is a document stating a person’s wishes about health care procedures to be used in the event that the person cannot speak for her/himself. It is wise for everyone to designate a Health Care Proxy: a friend or family member that can make medical/health care decisions in the event that the person cannot communicate her/his own wishes. This is a form that can be obtained at any Doctor’s office. The person assigned as Health Care Proxy should have a copy to present if needed. Advanced Directives generally forbid certain life sustaining procedures when there is no hope of recovery.A Living Will is a document a person completes about measures that support or prolong life, such as feeding tubes or ventilator use, generally to direct not to start such measures or to remove them if started. DNR/Comfort Care Order means that a person will not be resuscitated if their heart stops. A person must consult with her/his Doctor to get this order written. The original Doctor’s order must be available to EMS personnel in order for it to be honored. If they cannot see the actual order they must begin resuscitation measures, such as CPR. A common place to keep the DNR is on the refrigerator. A DNR is also available in a wrist band that looks very much like a hospital name band. Hospice and Palliative Care ProgramsPalliative care = care that improves the quality of life of patients and their families facing life-threatening illness. The focus is on comfort rather than cure. Special attention is given to recognizing, preventing and managing pain and to psychological, emotional and spiritual support. Hospice = a program of palliative care for persons with a terminal illness. Hospice has a holistic philosophy of care. The focus is not just on the medical needs of the person receiving care. Much attention is given to the emotional and spiritual needs as well. Services and care plan often address the needs of the caregivers as well as the person receiving care. Hospice programs in the U.S. have been focused on caring for the terminally ill since the early 1970s. Care may be provided in a person’s home or in a hospital, nursing home or a free standing hospice facility.Palliative/hospice care programs aim to serve patients throughout their illness. If a hospice program wishes to have its services paid for under the Medicare Hospice Benefit, the hospice program must meet federal regulations. Most hospice programs and their patients and families rely on this payment option. The United States Medicare Hospice Benefit limits care to patients who:Agree to therapy with a palliative intentHave less than 6 months to live if the disease runs its usual course, in the judgment of the patient’s attending physician and the hospice medical director Elect the Medicare Hospice Benefit for coverage of all services related to their terminal illnessCommunicating with the Dying ClientTalking with a dying person is less about building a relationship and more about deepening our human connection. Validate the individual’s experience. Avoid sharing your point of view or personal experience. Ask simple questions. Listen with all of your senses. When working with a nonverbal client whose death is pending, it is generally wise to make emotional contact before you make physical contact. You can do this by stilling your mind, opening your inner senses and directing your attention and focus to the person. Slowly enter the client’s energy field. Silently ask permission to touch, and trust what you sense as a response. Always allow silence, don’t push for communication -- this signals your acceptance of the person just as they are and your willingness to be with them, to listen or to simply sit in silent companionship. Ask the person if they want to talk. Ask them if they would like to be alone, or if they want you to stay with them. Ask before you touch. The dying person’s work includes de-indentifying with their life and their body. Talk and touch can distract them. You may want to reassure them that it is okay to let go, and that you will be the steward of their body while they make their passage out of the physical world. Dying people often perform a life review. They may want to tell stories or they may remark that they remember things that they haven’t thought of for years. They may express regrets. Simply listen and validate. Symbolic language – Talk of travel, a trip or a passage -- for example, waiting to board a bus or plane, needing to pack a suitcase or purchase tickets for a trip, needing to go home and closed or opened doors -- are commonly used by individuals who are getting close to death. Caregivers should always reassure the person that they can go when they need to and that they will help them to make a safe passage. Visitations - Another common experience of dying people is visits and talks with dead friends and family members. It is common for the dying person to see beings or light in the room that cannot be seen by others. They may report that someone who has passed is coming for them. They may say that they are waiting for them or that they are going with them. These occurrences are often reported after sleeping, but are perceived as real, rather than dreams. This can be a little unsettling for a caregiver. Don’t worry, these beings are not there for you. Generally the person is comforted by these visits. In the event that the person is frightened or upset by these visitations, report this to the nurse or responsible person. Always observe for signs and symptoms of pain or mon Signs of Impending DeathAs in every stage of life, no two people are exactly the same. Some persons will exhibit all of the signs, while others will exhibit only some – or perhaps none -- of them.As a person enters the final stage of the dying process, there are certain signs that are commonly present that you can see. These are signs that the body’s systems are shutting down. Some people linger in the final stage for weeks, while others pass very quickly. There are many factors involved, including the type and length of the illness that led to this stage. The person’s spiritual beliefs and how they’ve prepared for death emotionally will also influence their dying experience.The following are signs and symptoms that commonly occur when death is near:*A decreased interest in food. Food is the way the body nourishes, energizes and maintains health. Body systems that are shutting down don’t need food any more. There may be a gradual or sudden loss of interest in eating. Cravings may come and go. When there are no swallowing or digestive issues, you can honor requests for food, but it is not necessary to encourage food.* Liquids may be desired as long as the person is conscious. As with food, it is alright to give -- but not encourage -- fluids, as long as there are no prohibitive health conditions. The symptoms of dehydration such as headache, cramping, nausea, which generally occur in a healthy body, most commonly do not occur at this stage. In fact dehydration is believed to have pain-relieving properties. As a comfort measure ice chips may be helpful, or you can use swabs to moisten the mouths, tongue and lips.* The person sleeps a good deal of the time. They may wake confused and less able to focus, respond and participate in the world around them. They may be less interested in life. They may see and talk with loved ones who have died or other beings you cannot see. They are often comforted by these interactions. Simply validate their experience and reassure them that all is well. * The person may seem restless due to lack of oxygen in the blood. They may pick at bedclothes, move limbs aimlessly or seem to be reaching for something. Monitor for signs and symptoms of pain, such as moaning, stiffening or grimacing. Pain management is a very important part of the caregiver role at this stage. * Generally urinary and fecal output will decrease with diminished intake. The person may lose control of their bladder or bowels. Urine may become very dark in color. * Temperature goes up and down. The person may sweat, or be cold and clammy.* Skin color changes occur as circulation decreases. Nail beds, hands and feet are often pale or bluish. Very close to the end the underside of the body becomes blotchy and purplish. *Breathing becomes irregular, often stopping for ten or fifteen seconds before resuming. Fluid pooling in the back of the throat can cause a rattling, congested sound. Positioning on the side can help. Eyes be may open or semi open. The sense of hearing remains intact until death. Signs and Symptoms of PainBehaviors:CryingGaspingGrimacingGroaningGruntingHolding or rubbing the affected body part (splinting)IrritabilityMaintaining one position; refusing to moveMoaningQuietnessRestlessnessChanges in speech: slow or rapid; loud or quietScreaming Body Responses: Increased pulse, respirations, and blood pressureNauseaPale skin (pallor)Sweating VomitingWater Bugs & DragonfliesBy Doris Stickney Down below the surface of a quiet pond lived a little colony of water bugs. They were a happy colony, living far away from the sun. For many months they were very busy, scurrying over the soft mud on the bottom of the pond. They did notice that every once in a while one of their colony seemed to lose interest in going about with friends. Climbing the stem of the pond lily, it gradually moved out of sight and was seen no more. “Look”, said one of the water bugs to another. “One of our colonies is climbing up the lily stalk. Where do you suppose she is going?” Up, up, up she went slowly. Even as they watched, the water bug disappeared from sight. Her friends waited and waited but she didn’t return. “That’s funny!” said one water bug to another. “Where do you suppose she went?” wondered a third. No one had an answer. They were greatly puzzled. Finally, one of the water bugs, a leader in the colony, gathered his friends together. “I have an idea. The next one of us who climbs up the lily stalk must promise to come back and tell us where he or she went and why.” “We promise”, they said solemnly. One spring day not long after, the very water bug who had suggested the plan found himself climbing up the lily stalk. Up, up, up he went. Before he knew what was happening he had broken through the surface of the water and fallen onto the broad, green lily pad above. Weary from his journey, he slept. When he awoke, he looked about with surprise. He couldn’t believe what he saw. A startling change had come to his old body. His movements revealed four silver wings and a long tail. Even as he struggled, he felt an impulse to move his wings. The warmth of the sun soon dried the moisture from the new body. He moved his wings again and suddenly found himself up above the water. He had become a dragonfly. Swooping and dipping in great curves, he flew through the air. He felt exhilarated in the new atmosphere. By and by, the new dragonfly lighted happily on a lily pad to rest. Then it was that he chanced to look below to the bottom of the pond. Why, he was right above his old friends, the water bugs! There they were, scurrying about, just as he had been doing some time before. Then the dragonfly remembered his promise: “The next one of us who climbs up the lily stalk will come back and tell where he or she went and why.” Without thinking, the dragonfly darted down. Suddenly he hit the surface of the water and bounced away. Now that he was a dragonfly, he could no longer go into the water. “I can’t return!” he said in dismay. “I tried, but I can’t keep my promise. Even if I could go back, not one of the water bugs would know me in my new body. I guess I’ll just have to wait until they become dragonflies too. Then they’ll understand where I went.”Then the dragonfly winged off happily into its wonderful new world of sun and air. ................
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