biots - rapid and deep followed by 30 seconds apnea. nervous system disorder
cheyne stokes - gradually increase in rate and depth then become shallow and slow and then apnea for 10-20 seconds
Describe Oxygen therapy?
Oxygen is a drug and must be ordered by MD
Nursing Assistant can only administer at predetermined and preset rate
Check care plan for correct flow rate and delivery method
What are the side effects of Oxygen?
Retinopathy of the newborn
Bronchial Pulmonary Dysplasia of the newborn (BPD)
Drying of respiratory tract mucosa
Skin breakdown under tubing and edges of delivery devices
Hypoventilation (breathing at slow rate. high CO2 in blood) in COPD patients
In what ways can lack of oxygen alter our functioning?
Alteration in pulmonary function
Alteration in cardiac function
Alteration in neurological function
Alteration in musculoskeletal function
What is a pulse oximetry?
measures concentration of o2 in arterial blood
What is orthopedic position?
being placed in fowlers or semi fowlers to breath easier.
What is atelectasis?
collapse of a portion of the lung.
What will lack of oxygen ultimately mean?
alteration in alveolar perfusion (passage of fluid thru vessels)
alteration in cellular respiration
cell death
Describe Oxygen Therapy?
Delivery of oxygen from an extrinsic source
Controlled oxygen therapy will benefit any patients with impaired tissue oxygenation
When is controlled oxygen therapy used?
Used to prevent or relieve hypoxia (deficiency in the amount of o2 reaching tissues)
Not a substitute for other treatments
Treatment of underlying cause
Restorative treatments
Adjunct treatments
Incentive Spirometry
TCDB - turn, cough, deep breath
Correct Positioning
Describe Incentive Spirometry?
encourages people to inhale to a preset volume of air and then hold the breath for 3 seconds
Will benefit all post op patients
Requires teaching and coaching
Difficult for some people to follow instructions
Increases inspiratory volume
Prevents atelectasis (collapse of the lung)
What are some oxygen sources?
wall outlet, oxygen tank, oxygen concentrator (uses oxygen from air), liquid oxygen system (8 hours of use)
How do you perform a TCDB?
Sit with your head slightly forward and your feet flat on the floor.
Turn head away from nurse
Breathe in deeply while splinting abdomen.
Hold your breath for a few seconds.
Cough twice, first to loosen mucus, then to bring it up.
Breathe in by sniffing gently.
Use strong tissues or paper towels to dispose of the mucus.
What is therapeutic positioning for people with oxygen deficiencies?
Either High Fowlers or fowlers
Buttocks firmly into gatch of bed.
Spine is straight
Expands chest cavity
Often improves O2 saturations without supplemental oxygen
use of a foot board to keep but in gatch of bed
What are some oxygen regulators?
Cylinder
Pressurized O2 Oxygen
Handle with care
Can achieve high flow rates of O2
What is an oxygen concentrator?
Concentrates atmospheric oxygen
Patient receives greater concentration than room air would deliver
What are some oxygen delivery systems?
Nasal Cannula
Face Mask
Non-Re-breather Mask
Describe nasal cannulas?
Most frequently used O2 delivery device - looks like snake teeth in nose and tubing wraps around ears and fastened under chin
Delivery range from 24% @ 1L/min to 44% @ 6L/min
Patient preference
Simple to use
Comfortable at low flow rate
Over 4 liters / min may cause drying of mucosa
May be used orally for mouth breathers
Describe a simple face mask?
Short term oxygen therapy - covers whole nose and mouth
Delivers from 30% up to 60% @ 6 L/mn � 8 L/mn
May be uncomfortable
Contraindicated (should not be used) for CO2 retainers
Suitable for mouth breathers
Must remove mask to eat
May switch to NC for meals
Describe a non-rebreather mask?
Delivers high concentrations of O2 - covers nose and mouth with a bag hanging off of it containing O2
80% to 90% at 10L/min
Must frequently check bag to insure inflation
Must remove mask to eat
NC will not deliver high concentrations
Describe a Venturi Mask?
Precise delivery of high flow O2 rates - face mask with pointed end in all colors to show the amount of O2 given.
Flow device calibrates delivery
24% @ 2L/mn up to 55% @ 14L/mn
May be used for carbon dioxide retainers
How do you know if O2 is needed?
look for bluish skin and nail color
look for pallor and cyanosis (bluish discoloration of the skin)
look for an injury like broken ribs (side will be very bruised) or injury of the spine
Check for proper circulation in the feet
look for rib retractions during breathing to gage the amount of effort the patient is using to breath
look for the tripod position as it eases breathing
look for deformities that could labor breathing like scoliosis
look at body mass�those too thin or too big
The person needs to rest after?
pulmonary function tests
CH 3: Ethics and Laws: What are is the function of ethics and laws?
to protect patients and residents from harm
What do Nurse practice acts involve?
Authorized duties (scope of practice)
Your training and job description
Safe delegation
A complex set of rules and standards of conduct
Define Ethics?
Knowledge of what is right conduct and wrong conduct.
Professional groups have codes of ethics.
Morals are involved.
Ethical problems involve making choices.
Ethical behavior involves choices or judgments about what should or should not be done.
Ethical behavior involves not being prejudiced or biased.
Define Boundaries?
A boundary limits or separates something.
Helping relationships with patients, residents, and families have professional boundaries.
Professional boundaries separate helpful behaviors from behaviors that are not helpful.
What is a boundary crossing?
a brief act or behavior outside of the helpful zone.
Over-involved or under-involved with person that you are caring for
What is a boundary violation?
an act or behavior that meets the caregivers needs, not the person�s. act is unethical.
What are boundary signs?
acts, behaviors, or thoughts that warn of a boundary crossing or violation.
What are some boundary violations?
Abuse of any kind
Sexual
Physical
Financial
Emotional
Giving a lot of personal information about yourself
Keeping secrets with the person
Are boundary violations and professional sexual misconduct a crime?
yes
Describe professional sexual misconduct?
An act, behavior, or comment that is sexual in nature.
Telling off color jokes
Making comments with a sexual message
Having more physical contact with a certain resident than with others
Touching a resident inappropriately
Flirting with, kissing or having a sexual relationship with a resident or family member
Suggesting a romantic relationship with a resident or family member
Define laws?
Laws tell you what you can and cannot do.
A law is a rule of conduct made by a government body.
What are criminal laws?
concerned with offenses against the public and society in general.
What are civil laws?
concerned with relationships between people.
Torts are part of civil law.
Define Ethics?
Ethic concerned with what you should or should not do
Often addressed in law
What is a tort?
a wrong committed against a person or their property
What are unintentional torts?
Acts in which harm was not intended.
Negligence: like giving someone a bath in too hot water which burns them
Malpractice: Negligence by a professional (licensed) person.
What are intentional torts?
Acts of malice like�done knowingly
What are some examples of intentional torts?
Defamation: Injuring a person�s name & reputation by making false statements to a 3rd party
Libel: Making a false statement in print, writing or through pictures or drawings that harms a person
Slander: Spoken false statement that harms a person
False imprisonment: Unlawful restraint of a person and Restriction of freedom of movement
Invasion of privacy: Violating a persons right to privacy
HIPAA violation (protects patients privacy of health information)
Name or private affairs made public
Photograph published without consent
Fraud: Tricking, deceiving or fooling a person with the result of harming a person or their property
Assault and battery
Define Assault?
Intentionally attempting or threatening to touch a person�s body with consent
The person fears bodily harm
�I�m going to tie you in that wheel chair if you try to get up again�
Define Battery?
Touching a person without their consent
Person must consent to any procedure, treatment or other act that involves touching the body
Person have right to withdraw consent at any time
Define Consent?
May be verbal �yes� or �okay�
May be a gesture: a nod or turning to the side for a back rub
What is a person's right in regards to their body?
the right to decide what will be done to his or her body
Who can touch his or her body
What treatment may be given
If the person is unable to give consent, a responsible party or a legal representative gives informed consent.
What is informed consent?
implies that the person clearly understands:
The reason for a treatment, procedure, or care measure
What will be done
How it will be done
Who will do it
The expected outcomes
Other treatment, procedure, or care options
The effects of not having the treatment, procedure, or care measure
Can the nursing assistant be responsible for obtaining consent?
no, but May witness signed consent in some agencies
Can a CNA be present a will signing?
You can ethically and legally witness the signing of a will.
You can refuse to witness the signing of a will.
You must politely refuse to prepare a will.
Know your agency�s policy before you agree to witness a will.
If you are named in a will, don't witness it.
If you have questions, ask the nurse.
What is abuse?
intentional mistreatment or harm of a person
Is reporting abuse mandatory?
yes, Abuse is a crime.
What are the elements of abuse?
Willful causing of injury
Unreasonable confinement
Intimidation
Punishment
Depriving the person of the goods or services needed for physical, mental, or psychosocial well-being
What is the role of health care workers in abuse?
it is their duty to protect against abuse of patients
Extends to persons in a coma.
The abuser is usually a family member or caregiver.
Both men and women are abusers.
Both men and women are abused.
Persons convicted of abuse, neglect, or mistreatment May not be allowed to be employed in long term care
Law of states, accrediting agencies & OBRA
What is the nursing assistant registry?
it tells of base, neglect or mistreatment done by any nursing assistant.
Who are vulnerable populations of people who cant protect themselves from harm?
All children under 18 years of age
Persons 18 years old or older who have:
Disabilities or conditions that make them at risk to be wounded, attacked, or damaged.
Problems caring for or protecting themselves
Mental illnesses
Brain damage
Emotional disabilities
Physical disabilities
Developmental disability
Changes from aging
Describe elder abuse?
Physical abuse
Neglect
Verbal abuse
Involuntary seclusion
Financial exploitation or misappropriation
Emotional abuse
Sexual abuse
Abandonment
What federal or state laws require the reporting of elder abuse?
State Ombudsman
Senior & Disabled Services Division (SDSD)
Contact information must be posted in clear view of general public
What does child abuse and neglect involve?
A child 18 years old or younger
Any recent act or failure to act in the best interest of the child on the part of a parent or caregiver
The act or failure to act results in:
Death
Serious physical injury
Emotional harm
Sexual abuse
Sexual exploitation
The act or failure to act presents a likely or immediate risk for harm
What are the types of child abuse and neglect?
Physical abuse
Physical or emotional neglect
Sexual abuse
Rape
Molestation
Incest
Child pornography
Child prostitution
Emotional abuse
Substance abuse
Abandonment
Where is child abuse/neglect seen?
at every social level
The abuser usually is a household member.
Usually an abuser is someone the family knows.
All states require the reporting of suspected child abuse.
AS a CNA what is your duty in regards to child abuse?
If you suspect child abuse, share your concerns with the nurse.
Give as much detail as you can.
What is intimate partner abuse?
domestic abuse/violence
Occurs in relationships
One partner has power and control over the other through abuse.
Heterosexual
Male on female
Female on male
Both parties may be involved
Homosexual
Female partners
Male partners
Abuse may be physical, sexual, verbal, economic, or social.
Usually more than one type of abuse is present.
Patients and residents can suffer from domestic abuse.
State laws vary about reporting domestic abuse.
If you suspect domestic abuse, share your concerns with the nurse.
What is self-neglect?
when a person's behavior puts him or her at risk for harm
Who is at risk for being wounded, attacked or damaged?
all patients and residents
CH 12: Preventing Falls - who are at risk for falls?
Fall risk increases with age.
A history of falls increases the risk of falling again.
What are the most common nursing center accidents?
Falls
What are the causes of falls?
Most falls occur in patient and resident rooms and in bathrooms.
Causes include:
Poor lighting
Cluttered floors
Throw rugs
Out-of-place furniture
Wet and slippery floors, bathtubs, and showers
Urge to urinate is a major cause of falling.
Most falls occur between 1800 and 2100.
They also are more likely to occur during shift changes.
Are there fall prevention programs?
Agencies have fall prevention programs
Common sense and simple safety measures can prevent many falls.
Identifies people at high risk for falls
The health team works with the person and family to reduce the risk of falls.
The goal is to prevent falls without decreasing the person�s quality of life.
What is the role of bed rails?
Bed rails are raised and lowered.
Bed rails lock in place with levers, latches, or buttons.
They are half, three quarters, or the full length of the bed.
The nurse and care plan tell you when to raise bed rails.
When are Bed rails needed?
Persons who are unconscious or sedated with drugs
Some confused or disoriented people
What are the hazards of bed rails?
Entrapment is a risk.
May increase risk for falls
May increase injury from falls
When are bed rails considered restraints?
The person cannot get out of bed.
The person cannot lower them without help.
What standards affect bed rail use?
Accrediting agency standards and federal and state laws
What should a CNA do if a person uses bed rails?
Check the person often.
Report to the nurse that you checked the person.
If you are allowed to chart, record when you checked the person and your observations.
What are some assistive devices?
Hand rails and grab bars
Bed wheels are locked at all times except when moving the bed.
Wheelchair and stretcher wheels also are locked during transfers.
What are hand rails?
Hand rails are in hallways and stairways.
They give support to persons who are weak or unsteady when walking.
What are grab bars?
Grab bars are in bathrooms and in shower/tub rooms.
They provide support for sitting down or getting up from a toilet.
They are used for getting in and out of the shower or tub.
What is the function of transfer/gait belts?
A device used to support a person who is unsteady or disabled.
It helps prevent falls and injuries.
A transfer belt is always applied over clothing.
The belt buckle is never positioned over the person�s spine.
What causes a person to fall?
Weakness, light-headedness, or dizziness
Fainting
Slipping or sliding on spills, waxed floors, throw rugs, or improper shoes
If someone falls, what should you never do?
Do not try to prevent the fall.
Helps to prevent injury to care giver
If a person starts to fall, ease him or her to the floor.
Do not let the person move or get up before the nurse checks for injuries
May get a set of vital signs
Ch 39: Nervous System Disorders - What is a reflex arc?
The reflex arc is the body's rapid response to painful / dangerous stimuli. This also looks at sensory and motor pathways helping you to understand why paralyzed people or stroke patients with a hemiplegia may still be able to feel pain. IT happens in the spinal cord with brain processing occurring after the reflex
What affect does nervous system disorders have on a person?
Can affect mental and physical function
Some Mental effects are...
Depression
Impulsiveness
Dementia and cognition
Some Physical effects are..
Paralysis
Hemiplegia (total paralysis on one half of body)
Paresthesia (numbness of tingling on the skin)
Dysphagia (difficulty swallowing)
Incontinence
Blindness
Deafness
Define Stroke?
(aka: brain attack or cerebrovascular accident: CVA)
Disease affecting arteries that supply blood to the brain.
Stroke occurs when one of the following happens:
A blood vessel in the brain bursts.
Bleeding occurs in the brain (cerebral hemorrhage).
A blood clot blocks blood flow to an area of the brain.
Stroke is the 3rd leading cause of death in the United States.
It is a leading cause of disability in adults.
Emergency care needed promptly
Brain function can be saved. Time is Brain!
3 hour window for help
Define a heomorrhagic stroke?
when blood leaks into brain tissue
Define Ischemic Stroke?
clot prevents perfusion to an area of the brain so brain cells die (large holes in brain)
Define Transient ischemic attack?
Symptoms last less than 24 hour
No residual - No lasting affect with full recovery
Predictive of stroke within a 5 year period
Many �mini strokes� over time may lead to dementia
Sometimes warning signs last a few minutes to a few hours.
What are some stroke symptoms?
Sudden numbness or weakness
Often unilateral (one side of the body) - hemiplegia
Face: May affect one side of tongue and May affect ability to swallowing - dysphagia
Arms
Legs
Sudden confusion
Trouble speaking (expressive aphasia)
Trouble understanding speech (receptive aphasia)
-or- both (global aphasia)
Sudden trouble seeing in one or both eyes
Sudden trouble walking
Dizziness
Loss of balance or coordination
Sudden severe headache with no known cause
urge to throw up
What are some controllable risk factors for stroke?
Hypertension
Heart disease
Smoking
Diabetes
High blood cholesterol
Obesity
Previous stroke or TIA (mini-strokes: transient ischemic attack)
What are uncontrollable risk factors for stroke?
Age: Older people are at greater risk than younger people
Family history: risk increases if a parent or sibling had a stroke
Gender: Men and women are affected equally
Race: Blacks are at greater risk than other groups
What are the disabilities that arise from stroke?
brain damage
Functional loss dependent on the area of brain damage
What is the goal of rehab for a stroke victim?
Goal is to help person regain the highest possible level of function
CNAs and all members of health care team involved
Describe Parkinson's disease?
Disorder of dopamine in brain
Slow, progressive disorder with no cure.
Dopamine affects smooth & skeletal muscle
which affects Voluntary movement, B/P and Peristalsis (intestinal contractions)
Who is at risk for parkinsons?
Persons over the age of 50
What are the signs and symptoms of parkinsons?
Tremors
Rigid, stiff muscles in the arms, legs, neck, and trunk
Slow movements
Stooped posture and impaired balance
Mask-like expression - fixed stare cannot blink or smile
What are some characteristics of dopamine deficit?
Mask like facial expression
Forward tilt
Reduced arm swing
Rigid, trembling extremities
Shuffling gait with short steps
Pill rolling tremor of hands
Difficulty swallowing
Depression
Chronic constipation
What is the treatment of parkinsons?
Drugs to treat and control the disease
Carbidopa / levodopa
Exercise and physical therapy to improve strength, posture, balance, and mobility
Therapy for speech and swallowing problems
What are ways CNA's can help parkinson patients?
The person may need help with eating and self-care.
Normal elimination is a goal.
Safety measures are needed to prevent falls and injury.
Help with communication
Safety is high priority!
Describe Multiple SClerosis?
Chronic disease of myelin sheath
The myelin, which covers nerve fibers in the brain and spinal cord, is destroyed.
Nerve impulses are not sent to and from the brain in a normal manner.
There is no cure.
Symptoms usually start between the ages of 20 and 40.
More women are affected than men.
Whites are at greater risk than other groups.
A person�s risk increases if a family member has MS
affects both voluntary and involuntary muscles.
What causes MS?
Demyelinating disease of nervous system
Likely autoimmune
Immune system erodes hole in myelin sheath of nerves
Affects only nerves coated with myelin
Any body system may be affected
�Hole� in myelin may slow nerve conduction �or-
Short circuit nerve conduction (analogous to hole in insulating cover on an electrical cord)
How does MS progress?
May present as on of the following
Relapsing-remitting: Periods of remission and relapses
Primary progressive: No periods of remission
Secondary progressive: Periods of remission cease and disease progresses
Progressive-relapsing: Periods of remission decrease in onset and length of time
Other signs and symptoms of MS?
Vision problems- May be first symptom of MS, Feature in majority of MS patients
Peripheral (arms & legs) muscle weakness
Balance problems that affect standing and walking
Tingling, prickling, or numb sensations
Partial or complete paralysis
Pain
Tremors
Dizziness
Problems
Concentration
Attention
Memory
Judgment
Depression
Bowel & bladder
Constipation
Diarrhea
Incontinence
Problems with sexual function
Hearing loss
Fatigue
Coordination problems and clumsiness
What is the treatment of MS?
Medication - Steroids
MS drugs targeting neuron pumps
Physical therapy, speech therapy
Persons with MS are kept active as long as possible with as much independence as possible.
The care plan reflects the person�s changing needs.
Describe ALS (Lou Gherig's Disease)?
Attacks the nerve cells that control voluntary (skeletal) muscles.
Rapidly progressive and fatal
Death within 3 � 5 years of symptom onset
Muscles weaken, atrophy & twitch (fasciculation)
Affects more men than women.
It usually strikes between 40 and 60 years of age.
Motor nerve cells in the brain, brainstem, and spinal cord are affected.
What does ALS stand for?
Amyotrophic Lateral Sclerosis
What causes ALS?
Motor nerve deterioration
Brain cannot start or control voluntary movements as disease progresses
What you hear - Apical pulse is 120 bpm and irregular
What you see-The skin ulcer is 1 mm in depth x 4 cm in diameter & erythematous
What you smell-The stool has an odor of blood
What you feel-The lump feels hard with a nodular texture
What are the different types of subjective data?
�Symptoms� - Difficult to measure or quantify
Things the patient (or patient�s family) tells you that cannot be observed
Nausea, Pain, Fear, Fatigue, Sadness
What are some basic observations?
Ability to respond
Movement
Pain / discomfort
Skin
Eyes, Ears, Nose & Mouth
Respirations
Bowels & Bladder
Appetite
Activities of daily living (ADLs)
Other: Bleeding / discharge and Anything out of the ordinary for an individual
Can CNA's asses a patient?
No, only a nurse can do that. CNAs can only observe and report.
When should a CNA report and observation at once?
Altered mental status (AMS) / Change in level of consciousness (LOC)
Responsive person no longer responding
Unresponsive person now responding
Abnormal response in formerly normal person
A change in mobility
Loss of function in a body part
Ability to move a non-functional body part
Onset of sudden severe pain anywhere
A sore or reddened area on skin
Sudden change in vision
Complaints of pain or difficulty breathing
Abnormal respirations
Complaints of or signs of difficulty swallowing
Vomiting
Bleeding
Vital signs outside of normal range
What does a nursing diagnosis deal with?
a health problem that can be treated by nursing measures
whole person & expressed as �needs�
Physical
Emotional
Social
Spiritual
Change as assessment changes
What is a medical diagnosis?
Identification of disease or condition
Physician orders drugs, therapies, surgery for cure or healing
Describe the nursing planning process?
Nursing interventions chosen to help meet goals in conjunction with others
Patient, Family and Interdisciplinary team
Priorities :What is most important? To whom?
Maslow�s Hierarchy of Needs
Goals: What is desired in or by a person as a result of nursing care
Interventions: An action or measure Chosen to meet specific goals
Nursing intervention: Provider�s order not required and May originate in the provider�s order
What is the nursing care plan?
Written plan that guides care
Consists of: Nursing Diagnosis, Goals and measures and actions for each goal
Communication tool
Consistency of care
What cares needed
Individualized to each patient
Will change as nursing diagnosis changes
How is a care plan implemented?
Nurse delegates cares
Simple cares: Cares within nurse assistant scope of practice
Complex care: Assist licensed nurse with cares
Report & record:Always after care has been given
Assignment sheet:Used to record patient assignment, observed data, patient�s care, unit tasks
Describe the evaluation process?
Measurement
Were goals met: Met, Partially met or Not met
Assessment information used May result in changes to:
Nursing diagnosis, Goals and Care plan
What is the CNA role in the evaluation process?
Nursing diagnosis
Planning: Observation
Implementation: Nursing actions and Measurements
Evaluation: Observation
Details of recording observations?
Must record pertinent data
VS
Observations:May be directed by facility policy
Indelible black ink must be used
Corrections must be made appropriately
Cannot scribble out
Cannot white out
Cannot erase
An error is corrected with a single line through the error, initial and date
Do not leave blank spaces when you are through with an entry
Always sign your appropriate title
Details of charting?
Charting must be dated and timed for the time that you are doing the charting. Not when action took place!
If charting is forgotten do the following, make the date, the date that charting is taking place. in the progress notes, say "charting for 1/12/11 at 1015. Mr. Gordon transported via wheelchair. Maria Buagas CNA ---------
CH 13: Restraints: Who issued new rules in regards to restraints for medicaid and medicare funds?
CMS - centers for medicare and medicaid services
What are the rules instituted from CMS in regard to restraints?
all patients have the right to be free from restraints or seclusion. They can only be used for immediate physical safety of the person, staff members or others and only as a last resort. They should be discontinued at the earliest possible moment.
What other agencies have rules for restraints?
FDA, state agencies and joint commissions don't forbid their use but all other alternatives must be tried first.
What is an alternative to restraint?
diversions like tv provided, extra visitor time, knob guards used on doors, exercise program provided if person is restless.
What is a restraint?
any manual method either equipment or drugs that restricts freedom of movement
What is seclusion?
involuntary confinement of a person
Are bed rails considered restraints?
yes, in long term care
and if The person cannot get out of bed because of the rails or The person cannot lower them without help
Bed rails must be ordered on care plan before use
Bed rails may be needed by:Persons who are unconscious or sedated with drugs and Some confused or disoriented people
Bed rails are kept up at all times when ordered, except when giving bedside
nursing care
What are some hazards of bed rails?
Person can fall when trying to climb over them
Person may become stuck in rails
if a person uses bed rails, you need to?
Check the person every 15 minutes
Must provide toileting and exercise every 2 hours
Report to the nurse that you checked the person
Record when you checked the person, what cares were done and your observations
How many entrapment zones do hospital beds have?
7
What is zone 1 entrapment?
within bed rail
What is zone 2 entrapment?
Between the top of the compressed mattress and the bottom of the bed rail and between the rail supports
What is zone 3 entrapment?
Between the bed rail and the mattress
What is zone 4 entrapment?
Between the top of the compressed mattress and the bottom of the bed rail and at the end of the bed rail
What is zone 5 entrapment?
between the split bed rails
What is zone 6 entrapment?
Between the end of the bed rail and the side edge of the headboard or footboard
What is zone 7 entrapment?
Between the headboard or footboard and the end of the mattress
Define freedom of movement?
Any change in place or position of body or any part of the body
Person is physically able to control movement.
What is the history of restraint use?
Restraints thought to prevent falls
What is the reality of restrain use?
Late 1980s nursing research show that:
Restraints cause falls
Injuries are more serious from falls involving restrained persons
Restraints can cause serious harm, even death.
When can a restraint be used?
A doctor�s order is required.
Reason for the restraint must be for protection of resident or others
What body part to restrain
What restraint to use
How long to use it: Must be least restrictive method
Restraints are used only after other measures fail
Attempts must be documented
Unnecessary restraint is false imprisonment
Informed consent is required
Person or legal representative must be counseled about restraint
Person or legal representative must give consent before a restraint can be used
What are the legal aspects of restraints?
Laws applying to restraint use must be followed.
Restraints must protect the person.
Not for staff convenience
A restraint is used only when necessary to treat a person's medical symptom.
Not to discipline a person.
Restraints are not used to punish or penalize uncooperative persons.
The person must give consent for restraint use
How to apply restraints?
Leather restraints are applied to the wrists and ankles
Wrist restraints (limb holders) - Limit arm movement.
Hands are placed in mitt restraints: Prevent finger use if patient is taking out IV or picking at sutures in a wound
The belt restraint is used When there is risk of injury from falls or For positioning during medical treatment
How are vest and jacket restraints used?
Vest and jacket restraints are applied to the chest.
A jacket restraint is applied with the opening in the back.
The straps of vest and jacket restraints always cross in the front.
Vest and jacket restraints are never worn backward.
The restraint is always applied over a garment.
Vest and jacket restraints have life-threatening risks.
You are advised to only assist the nurse in applying them.
The nurse should assume full responsibility for applying a vest or jacket restraint.
Never use force to apply a restraint.
What are the safety guidelines for restraints?
Observe the person at least every 15 minutes
May be more often as required by the care plan.
Observe for increased confusion and agitation.
Must protect person�s quality of life.
Restraints are used for shortest time needed.
Follow the manufacturer�s instructions for restraint application
Apply restraints with enough help to protect the person and staff from injury.
Remove or release the restraint for at least 10 min, reposition the person, and meet basic needs at least every 2 hours.
Follow the care plan.
What are the main pressure areas when using restraints for wheelchair?
back, lumbar region, butt, back of knees, heels
To minimize the skin breakdown as a result of restraints, you should?
Must release restraint every 2 hours & prn
Must exercise person every 2 hours & prn
Must toilet person every 2 hours & prn
Must offer nourishment every 2 hours & prn
When using restraints what should be documented?
The type of restraint applied
The body part or parts restrained
The reason for the application
Safety measures taken
The time you applied the restraint
The time you removed or released the restraint and for how long
The person�s vital signs
The care given when the restraint was removed or released
Skin color and condition
Condition of the limbs
The pulse felt in the restrained part
Changes in the person�s behavior
Complaints of discomfort
A tight restraint
Difficulty breathing
Pain, numbness, or tingling in the restrained part
Report these at once
What are the behaviors that result in restraint use?
Behaviors often a result of unmet needs
Knowing and treating the cause can prevent restraint use.
Restraint alternatives for the person are identified
They become part of the care plan.
If restraint alternatives do not protect the person, the doctor may need to order restraints.
What are some restraint complications?
injury occurs when Person tries to get free of the restraint.
The wrong restraint is used
The restraint is applied incorrectly
The restraint is kept on too long
-death from strangulation
-can affect dignity and self-esteem causing depression, anger, agitation, embarrassment, humiliation and mistrust
When a death occurs of someone who was restrained, when should it be reported to the CMS?
while a person was in a restraint
within 24 hours after restraint was removed
within 1 week after a restraint was removed
Restraint alternatives fail to protect a person. You can apply a restraint. T/F - FALSE
A device is a restraint only if it is attached to the person's body. T/F
FALSE -it can be a tv tray or pushing a wheelchair up against a wall
A belt restraint is applied to a person in bed. Where should you tie the straps?
to the movable part of the bed frame
CH 11: Safety - Is it a human need?
yes!
What can prevent most accidents?
common sense and simple safety measures
What does a safe setting offer?
Little risk of illness or injury.
Offers physical & mental safety/security
Low risk of infection, falls, burns, poisoning, and other injuries
Comfortable temperature and noise levels are
Pleasant smells
Enough room and light to move about safely
Safety from are safe from fire and intruders- Both person and property are safe
What are some oxygen safety concerns?
o2 is a medication that is also a fire hazard, so one must Avoid open flame / smoking around O2 and Avoid petroleum based skin creams on patients using O2
What can CNAs do in regards to giving oxygen?
may turn oxygen on and off at pre-established flow rates set by the nurse
Only the physician or RN can make changes to the amount of oxygen to be given
Sensory impairment: Vision and hearing loss and Impaired smell and touch
Multiple medications: Medications affecting heart or nervous system
When giving care, what are some ways to ID the patient?
Carefully compare identifying information on the assignment sheet with that on the ID bracelet.
Use at least two identifiers
Follow agency policy.
Call the person by name when checking the ID bracelet
May ask name & BD in some settings
When is equipment unsafe?
Broken
Not used correctly
Not working properly
What if equipment isn't in good repair?
Remove all malfunctioning items from circulation
Do not use or give damaged items to patients or residents.
Describe Wheelchair safety?
Position the person�s feet on the footplates.
Make sure the person�s feet are on the footplates before moving the chair.
Wheel the chair correctly
Push the chair forward when transporting the person
You may pull the chair backward when going through a doorway which requires opening the door -or- when going into an elevator
Make sure removable parts are locked in place
Keep the wheels locked when not moving
Lock both wheels before: Transferring a person to or from the chair
Do not stand on the footplates
Swing footplates out of the way when transferring a person to or from the chair
Do not let the footplates fall back onto the person�s legs
Always support dependent limbs
What part should you remove in the wheelchair when transferring patients?
remove armrest, swing front rigging out of the way or detach. once patient is in the chair, make sure movable parts are locked in place and that patients fingers, toes, skin not pinched by parts
Describe stretcher transfers?
Never transfer a person to or from stretcher by yourself
Always ask for help
Use a transfer sheet or slip �n� slide
Lock the stretcher wheels before the transfer
Fasten the safety straps when the person is properly positioned on the stretcher.
Ask a co-worker to help with the transport.
Always raise the side rails when transporting a person
Keep them up during the transport.
Properly position person
Make sure the person�s arms, hands, legs, and feet do not dangle through the side rail bars
Stand at the head of the stretcher
Your co-worker stands at the foot of the stretcher
Move the stretcher feet first.
Never, ever leave a person alone on a stretcher
What are the OSHA requirements for Hazardous substances?
Understand the risks of hazardous substances
Understand safe handling
OSHA requires employers to provide hazardous substance training
container labeling, and MSDS material safety data sheets (contains info about the chemical)
What are physical hazards?
can cause fires or explosions
What are health hazards?
chemicals that can cause health problems
When can exposure to hazardous substances occur?
Under normal working conditions
During certain emergencies
What needs to be on hazardous substances?
Warning labels identify:
Physical and health hazards
Precaution measures
What personal protective equipment to wear
How to use the substance safely
Storage and disposal information
What If a warning label is removed or damaged?
Do not use the substance.
Take the container to the nurse and explain the problem.
Do not leave the container unattended.
What are MSDSs?
Material Safety Data Sheets.
Describe MSDS uses?
Every hazardous substance has an MSDS
Employees must have ready access to MSDSs.
When do you check for MSDS?
Using a hazardous substance
Cleaning up a leak or spill
Disposing of the substance
What if you see a leak or spill?
Do not leave it unattended and tell the nurse about it immediately.
Define Bloodborne pathogens?
Infectious materials in blood that can cause disease in humans
Hepatitis B and C
Human immunodeficiency virus or HIV
Workers exposed to these pathogens risk serious illness
What is the OSHA requirements for bloodborne pathogens?
OSHA requires employers to provide bloodborne pathogen training to their employees yearly
Facilities must have policies & procedures to prevent employee exposure
What are the standard precautions for bloodborne pathogens?
PPE must be provided
Use it only once
Never reuse equipment that has been exposed to pathogens
Red biohazard bags are used to contain contaminated material.
it needs to be double bagged
What are the fire prevention responsibilities?
The entire health team must:
Prevent fires
Act quickly and responsibly during a fire
What are the 3 things needed for a fire?
A spark or flame
A material that will burn
Oxygen:Safety measures are needed where oxygen is used and stored and Turn oxygen off in a fire
When was the Smoke Free Workplace Law passed?
2009
Agencies have no-smoking policies and smoke-free areas
Good fire safety knowledge?
know where Fire alarms, Fire extinguishers and Emergency exits are
Keep emergency exits clear of barriers
Do not use elevators if there is a fire
What is the word RACE for fire safety?
R is for rescue
A is for alarm
C is for confine
E is for extinguish
How to use a fire extinguisher?
PASS
P-pull safety pin
A-aim low
S-squeeze the lever
S-sweep back and forth
Define disaster?
A sudden catastrophic event.
May be human made or natural
Many people are injured and killed.
Property and infrastructure is destroyed.
What do you do if there is a disaster in your area?
follow agency procedures
What about for bomb threats?
follow agency procedures
look for items that look or sound strange
Define Workplace Violence?
Any violent act directed toward persons at work or while on duty.
Workplace violence can occur in any place where an employee performs a work-related duty.
It can be a permanent or temporary place.
Where does workplace violence most often occur?
It occurs most often in mental health units, emergency departments, waiting rooms, and geriatric units.
What is risk management?
Identifying and controlling risks and safety hazards affecting an agency.
What is the intent of risk management?
Protect everyone in the agency
Protect agency property from harm or danger
Protect the person�s valuables
Prevent accidents and injuries
Who are risk managers?
People who look for patterns and trends in
Incident reports
Patient and resident complaints
Staff complaints
Accident and injury investigations
What should you do if there is an accident?
report it at once for any accidents involving patients or residents, visitors or staff
Define Errors in care?
Giving the wrong care
Giving care to the wrong person
Not giving care
What about a person's belongings?
Belongings must be kept safe
A personal belongings list is completed
A valuables envelope is used for jewelry and money
Personal items kept at the bedside are listed in the person�s record
What if a person's property goes missing?
report theft or property damage promptly
Broken or missing items owned by the person
Missing money or clothing
What need to be done if workplace violence occurs?
an incident report needs to be completed as soon as possible
Before shaving a resident with an electric shaver?
the maintenance staff must do a safety check
Resident brings a radio from home, what prevents property loss?
putting the residents name on the radio
How to clean eyeglasses?
wash hands, take them off patient by grasping the stems, rinse under warm water, lather with liquid soap, rinse, dry with soft cloth, replace on face of patient or put in eyeglass case
What should you not do when cleaning glasses?
Use only the stems when handling eyeglasses.
Never use hot water to clean lenses; they may warp.
Use liquid soaps without conditioners.
Never use a paper product to clean or dry lenses.
Glasses are not on the face, should be in a case.
CH 37: hearing, speech, vision - what do these senses allow?
Allows communication, learning, and navigation
Important for self-care, work, and most activities
Critical for safety and security needs
What are some common causes of hearing or vision loss?
Birth defects
Hereditary factors
Accidents
Infections
Diseases
Aging
What is Otitis media?
an infection of the middle ear
Viruses, fungi and bacteria are causes.
Otitis media is acute or chronic.
What are some signs or symptoms of otitis media?
Pain (earache) and hearing loss
Fever
Tinnitus: a ringing, roaring, hissing, or buzzing sound in the ears or head
What is treatment of otitis media?
Antibiotics
Drugs for pain relief
Drugs to relieve congestion
What is meniere's disease?
Common cause of low frequency hearing loss
Idiopathic disease of inner ear
Endolymphatic hydrops creates increased fluid in middle ear
Usually one ear is affected
Symptoms occur suddenly
Attack can last several hour
What are symptoms of meniere's disease?
Vertigo (dizziness)
Tinnitus
Hearing loss
Pain or pressure in the affected ear
What is the treatment of meniere's disease?
Drugs: Antihistamines
Fluid restriction
A low-salt diet
No alcohol or caffeine
What are some safety measures that are needed for people with meniere's disease?
Bed rest during attack
Falls are prevented.
The person�s head is kept still.
Sudden movements are avoided.
Bright or glaring lights are avoided.
The person should not walk alone.
Define hearing loss?
Inability to hear the normal range of sounds associated with normal hearing
Hearing loss occurs in all age-groups
Losses are mild to severe
Define Deafness?
Hearing loss in which speech is not comprehensible
What are some common causes for hearing loss?
Damage to the outer, middle, or inner ear
Damage to the auditory nerve
What are some risk factors that can damage the ear structures?
High decibel sound exposure
Drugs- Antibiotics - Neomycin: Inner ear damage
Too much aspirin- Tinnitus
Infections
Reduced blood flow to the ear: High blood pressure, Heart and vascular diseases and Diabetes
Aging
Stroke
Head injuries
Tumors
Heredity
Birth defects
What are some causes of temporary hearing loss?
Cerumen impaction (earwax)
Cerumen removal restores hearing
What are signs of hearing loss?
Hearing loss may result in slurred speech.
Words may be pronounced wrong.
Some have monotone speech or drop word endings.
It may be hard to understand what the person says.
Others notice it before the person does
Treatment for hearing loss?
Wear hearing aids or lip-read (speech-read)
Watch facial expressions, gestures, and body language
Learn American Sign Language (ASL)
Some people have hearing assistance dogs (hearing dogs).
What are hearing aids?
Electronic devices that fit inside or behind the ear.
They make sounds louder
Background noise and speech are louder.
They do not correct, restore, or cure hearing problems.
What are the measure to fix a nonfunctioning hearing aid?
Check if the hearing aid is on
It has an on and off switch.
Check the battery position.
Insert a new battery if needed.
Clean the hearing aid.
Define speech disorders?
Impaired or ineffective oral communication
What are some common causes of speech disorders?
Hearing loss
Developmental disabilities
Brain injury
Define Apraxia?
Inability to use the speech muscles to produce understandable speech.
What causes Apraxia?
caused by damage to the motor speech area in the brain.
The person understands speech and knows what to say.
The brain cannot coordinate the speech muscles to make the words.
What is Dysarthria?
difficult or poor speech
What causes Dysarthria?
caused by damage to the nervous system.
Mouth and face muscles are affected.
What is Aphasia?
Partial or total loss of the ability to use or understand language.
What is Expressive Aphasia?
(motor aphasia, Broca�s aphasia)
Relates to difficulty expressing or sending out thoughts.
What is receptive aphasia?
(Wernicke�s aphasia)
Relates to difficulty understanding language
What is expressive-receptive aphasia?
when you have both types aka global aphasia or mixed aphasia
What are the causes of aphasia?
Stroke
Head injury
Brain infections
Cancer
Alcoholism
What is the goal of speech rehabilitation?
Improve communication ability
The amount of improvement possible depends on many factors.
Cause, amount, and area of brain damage
Age and health
Willingness and ability to learn
What do speech language pathologists and health team members help?
Improve affected language skills
Use remaining abilities
Restore language abilities to the extent possible
Learn other methods of communicating
Strengthen the muscles of speech
What are eye disorders?
Vision loss occurs at all ages.
Problems range from mild vision loss to complete blindness.
Vision loss may be sudden or gradual in onset.
One or both eyes are affected.
What is blindness?
Blind is the absence of sight.
What is glaucoma?
Damage to the optic nerve.
Problem or aqueous humor build up, trabecular network or both
Pressure from build up of optic fluid
Vision loss with eventual blindness occurs.
can be in one or both eyes
Onset may be sudden or gradual.
Peripheral vision (side vision) is lost.
Who is high risk for glaucoma?
African-Americans over 40 years of age
Everyone over 60 years of age
Those with a family history of the disease
Those who have diabetes, high blood pressure, or heart disease
Those who have eye diseases or eye injuries
Those who have had eye surgery
How is glaucoma treated?
Glaucoma has no cure.
Prior damage cannot be reversed.
Drugs and surgery can control glaucoma and prevent further damage to the optic nerve.
Pilocarpine drops
Timoptic drops
What is cataract?
Clouding of the lens in the eye.
A cataract can occur in one or both eyes
What are the signs of cataract?
Cloudy, blurry, or dimmed vision
Colors seem faded
Blues and purples are hard to see
Sensitivity to light and glares
Poor vision at night
Halos around lights
Double vision in one eye
What are risk factors for cataracts?
Aging (Most cataracts are caused by aging.)
Diabetes
Smoking
Alcohol use
Prolonged exposure to sunlight
Everybody should be wearing sunglasses with UVA/UVB protection
Family history of cataracts
What is the treatment of cataract?
Surgery is the only treatment
Diseased lens removed and replaced with plastic or cadaver lens
What is AMD?
age-related macular degeneration
Disease that blurs central vision.
Damage to the macula located in the center of the retina.
The disease is usually gradual in onset.
Painless
Leading cause of blindness in persons 60 years of age and older.
What are the two types of AMD?
Wet: More severe and rapidly progressive
Dry: More common, May convert to wet AMD
What are the risk factors for AMD?
Aging
Smoking
Obesity
Race (Whites are at greater risk than any other group.)
Family history
Gender (Women are at greater risk than men.)
Light-colored eyes
Exposure to sunlight
Cardiovascular disease
What can reduce the risk of AMD?
Eating a healthy diet high in green leafy vegetables and fish
Not smoking
Maintaining a normal blood pressure
Managing cardiovascular diseases
Maintaining a normal weight
Exercising
Wearing sunglasses
Regular eye exams
What is diabetic retinopathy?
Tiny blood vessels in the retina are damaged
Floaters common sign
Leading cause of blindness in U.S.
Usually both eyes are affected
Everyone with diabetes is at risk
What is the treatment of diabetic retinopathy?
Tight control or diabetes, hypertension, hypercholesterolemia
Advanced retinopathy is treated with laser surgery.
Another surgery involves removing blood from the center of the eye.
The person with diabetic retinopathy may need low vision services.
What is low version?
Eyesight that cannot be corrected with:
Corrective lenses, Drugs and Surgery
What person is at risk for low vision?
Eye diseases
Glaucoma
Cataracts
Age-related macular degeneration
Eye injuries
What diseases affect vision?
Diabetes
Birth defects
What is the treatment for low vision?
May need one or more visual and adaptive devices.
Devices used depend on the person�s needs.
How many americans are legally blind?
1.3 million
How many older persons are blind or visually impaired?
5.5 million
What are the causes of impaired vision or blindness?
Birth defects
Accidents
Eye diseases
Complications of some diseases
How far can the legally blind person see?
The legally blind person sees at 20 feet what a person with normal vision sees at 200 feet
How can rehab help vision loss?
Adjust to the vision loss
Learn to be independent.
What is braille?
A touch reading and writing system
Raised dots for each letter of the alphabet.
The first 10 letters also represent the numbers 0 through 9.
What can help a visually impaired person get around?
A long cane with a red tip
A dog guide - Universal mobility aids for the visually impaired
What can help correct many vision problems?
eyeglasses and contact lenses for near sightedness, Far sightedness and Presbyopia (aka: �old eye�)
When would an eyeball be removed?
if injured or diseased
The person is fitted with an ocular prosthesis.
Some prostheses are permanent implants.
If removable, the person may be taught to remove, clean, and insert it.
You need to protect the person�s prosthesis from loss or damage.
CH 15: Body Mechanics - What is good body mechanics?
Using the body in an efficient and careful way
Low center of gravity
Broad base of support
Using strongest and largest muscles for work.
Good posture
Balance
What are the principals of body mechanics?
body alignment - posture
base of support is the area on which an object rests
use your strongest and largest muscles
What is good body alignment?
Head, trunk, arms, legs align.
Allows body to move and function with strength and efficiency.
What is good base of support?
Feet are base of support when standing
A good base of support is needed for balance.
What are your strongest and largest muscles?
Hips and thighs
Shoulders and upper arms
Describe good body mechanics?
Bend your knees and squat - Do not bend from your waist, Keep back flat and Tighten abdominal muscles
Hold items close to your body and base of support -This involves upper arm and shoulder muscles.10 lbs held away from body translates to 100lbs
Define Ergonomics?
Science of designing a job to fit the worker.
WHat is the goal of ergonomics?
Eliminate serious and disabling work-related musculoskeletal disorder (WMSD)
WMSDs are injuries and disorders of the muscles, tendons, ligaments, joints, and cartilage.
May involve the nervous system.
What are some risk factors for WMSD identified by OSHA?
Force: Amount of physical effort needed to perform a task.
Repeating action: Performing the same motion or series of motions continually or frequently.
Awkward postures: Positions that place stress on the body.
Heaving lifting: Manually lifting patients and residents who cannot move themselves.
What are the OSHA requirements for safe work setting?
The setting must be free of recognized hazards that are causing or likely to cause death or serious physical harm to employees.
The employer must make reasonable attempts to prevent or reduce the hazard.
What is the most common injury for nurses?
back injuries
What are some signs for back injuries?
Pain when trying to assume a normal posture
Decreased mobility
Pain when standing or rising from a seated position
What are the advantages for proper positioning of the patient?
Promote comfort and well-being
Promote breathing
Promote circulation
Help prevent pressure ulcers and contractures
All levels of ability for patients in regards to positioning?
Move and turn when in bed or a chair without assistance
Need reminding to adjust their positions
Need help with position changes
Depend entirely on the nursing team for position changes
When does repositioning need to occur in bed or chair?
every 2 hours or PRN
follow the nurses instructions and the care plan
What are the guidelines to safely position a person?
Use good body mechanics.
Ask a co-worker to help you if needed.
Explain the procedure to the person.
Be gentle when moving the person.
Provide for privacy.
Use pillows as directed by the nurse for support and alignment.
Provide for comfort after positioning.
Place the signal light within reach after positioning.
Complete a safety check before leaving the room
What is fowlers positioning?
Semi-sitting position.
Head of the bed is raised 45 to 60 degrees.
Knees may be slightly elevated.
What is supine position?
Back-lying position.
What is prone position?
Lying on abdomen with the head turned to one side.
What is lateral position?
The person lies on left or right side.
What is Sims' position?
This is a left side-lying position.
When can a patient sit in a chair?
must be able to hold their upper bodies and heads erect
What is the best way to have a patient in a chair?
Feet are flat on the floor or wheelchair footplates.
Backs of the knees and calves are slightly away from the edge of the seat.
A pillow can be put between the person's lower back and chair but not if restraints are used
postural supports sometimes required if they can't keep upper bodies erect.
Which action is easier? Pushing, pulling, sliding or lifting?
pushing!
Ch 16: safe patient handling - When is safe body mechanics required?
Turning and repositioning persons
Moving persons in bed
Transferring persons to and from Beds, Chairs, Wheelchairs, Stretchers, Toilets
Define transfer?
moving the person from one place to another.
What does OSHA recommend for safe movement?
manual lifting be minimized or eliminated when possible
Who determines a patient's level of assistance?
the nurse and health team determines the amount of assistance needed, what procedure to use and what equipment is needed and this is based on the person's dependence level, amount of assistance needed (1 -4 people) and what procedure or equipment to use
What is OSHA's dependence level of code 4?
total dependence, use mechanical lift or friction reducing device. at least 2 staff members needed
What is OSHA's dependence level of code 3
extensive assistance, use mechanical lift or friction reducing device, at least 2 staff needed. if less than 200 lbs, 2-3 staff needed and friction reducing device. if more than 200 lbs, 3 staff + friction reducing device
What is dependence level Code 2?
limited assistance, stand assist devises may be mended like walkers or gait belts or slide boards
What is dependence level Code 1?
staff just needs to supervise and cue the person. some assist devices may be needed
What is a Code 0?
independent, very limited assistance needed
What do you need to do when moving someone in bed?
protect the skin, reduce friction and shearing
What is friction?
rubbing of one surface against another
What is shearing?
skin sticks to a surface while muscles slide in the direction the body is moving
How to reduce friction and shearing?
rolling the person, using friction reducing devices
How to raise the person's head and shoulders?
safely lock arms with person, Do not pull on the person's arm or shoulder
When to get help with lifting a person?
with older people, those who are heavy or hard to move alone
When do you move a person up in bed?
for good alignment and comfort
When can you move a person in bed by yourself?
for children, and lightweight adults with the use of a trapeze
When do you need two or more members to move someone?
if they are heavy, weak or very old
What are some assistive devices for moving?
turn sheets
"geri" pads
slip n slide
When are the assistive moving devices used?
for most patients, following OSHA recommendations, for people recovering from spinal cord surgery or injuries and for older persons
How do you move a person to the side of the bed?
3 segment move
Why do you move a person to the side of the bed?
for repositioning and care
before turning
to limit the need to reach over the person
When using a mechanical lift or asset device always?
follow OSHA recommendations
for older persons
for people with arthritis
for persons recovering from spinal cord surgery or injuries
What are the advantages of right or left side lying position?
prevents complications of bed rest
used to relieve pressure
used for comfort
What is the combination of movement?
left, back, right, and back
What is logrolling?
turning a person as a unit in alignment so spine is kept straight
Who needs to be logrolled?
older people with arthritis, people with hip fractures, spinal cord injuries or recovering from spinal surgery
For a safe transfer to/from bed what is needed?
room but be arranged so there is enough space and equipment be placed correctly.
When are gait belts useD?
to support patients and residents during transfers
to reposition persons in chairs and wheelchairs
When can stand and pivot transfers be used?
when persons leg strong enough to bear weight, can follow directions, and can help you
When are mechanical lifts used?
when a person cant help themselves, are too heavy for the staff to transfer
When are slings used?
depends on the person's size, condition and other needs
follow agency policy and manufacturers instructions
Before using a mechanical lift?
you must be trained on its use
it must be in working order and good repair
weight of patients must not exceed the lifts capacity
need 2 staff members
What is a bathing sling?
used to transfer a person using a lift from bed into bathtub
What is a toileting sling?
open on the bottom so they can use toilet, each resident should have their own to avoid infection
When can a slide board be used in transfers to toilet?
if they wheelchair armrests are removable
the person has upper body strength
has good sitting balance
and when there is enough room to position the wheelchair next to the toilet
When is a stretcher used?
when person cant sit up
must stay in lying position
are seriously ill
What is placed on a stretcher?
folded flat sheet or bath blanket
a draw sheet
large incontinence under pad
slide sheet
slide board if 2-3 people needed for safe transfer
What safety precautions are used for stretcher transfers?
safety straps used
side rails kept up during transfer
moved feet first
2 staff members used for transport
person at heard watches breathing and color of patient
never leave person alone on stretcher
What are the OSHA recommendations for moving a person?
If the person weighs less than 100 pounds, use a
lateral slide aid and 2 staff members.
2.If the person weighs 100 to 200 pounds, use a lateral sliding aid or a friction-reducing device and 2 staff members.
3.If the person weighs more than 200 pounds, use one of the following:
a)A lateral sliding aid and 3 staff members b) A friction-reducing device or lateral transfer device and 2 staff members
c)A mechanical lateral transfer device with a built-in slide board
What is good wheelchair positioning?
persons back and buttocks against back of chair
positioning devices used for dependent limbs
don't pull up person under arms from behind the wheelchair
You are using a drawsheet as an assist device. It is placed so that�
it is nude the person from the head to above the knees.
CH 8 and 39 - Skeleton: how many bones do we have?
206
What is tensile strength?
Bends but resists breaking
Proteins provide flexibility
Ca++ & PO4 provide rigidity
Constant building & breaking down
Osteoclasts and osteoblasts
Form in proportion to task required
Heals with little scarring
What are the 4 bone types?
long bones: weight bearing like legs and bones
short bones: bones of fingers and toes for skill and ease of move
flat bones: protective like bones of chest, skull and pelvis
irregular bones: vertebrae for mov't and flexibility
What are bones covered by?
periosteum which have vessels that supply bone with o2 and food
What are the sections of the spine?
cervical (7), thoracic (12), lumbar (5), sacrum and coccyx
What is the function of the skeleton?
support, movement, protection, storage of minerals and fat soluble vitamins, hematopoesis
What are the 2 major divisions of the skeleton?
axial skeleton of central core: skull, spine, rib cage
appendicular skeleton: arms, legs, shoulder girdles and pelvic
What is a joint?
where bone meets bone
What lines joints?
synovial membrane which secretes synovial fluid that lubricates the joint for smooth movement
What is cartilage?
the connective tissue at the end of long bones, cushions so bones don't rub together
What is a ligament?
attach bone to bone at joint
What is a tendon?
attach muscle at bone
What are the types of joints?
sutures - fused by 8 months
pivot-rotation atlas/axis
ellipsoidal-limited move carpal and tarsals
hinge- elbow
gliding-
saddle- thumb
ball and socket-shoulder
How many muscles do we have?
more than 500
What are the muscle types?
skeletal (voluntary/striated), cardiac (involuntary/striated) and smooth (involuntary)
Function of muscles?
mov't of body parts, maintenance of posture, production of heat
what are the 2 parts of the nervous system?
the cns - brain and spinal cord
and pns - contains 12 cranial nerves and 31 spinal nerves
What does the myelin sheath do?
conducts faster impulses and insulates nerve fiber
What are the 3 main parts of the brain?
cerebrum contains cerebral cortex (highest brain functions) cerebellum (body move) and brainstem (midbrain, pons and medulla which controls heart rate, breathing, blood vessel size)
What covers the spinal cord?
3 layers of meninges.
dura mater (outer), arachnoid and the pia mater (inner)
middle ear-eustachian tubes from ear to throat and ossicles amplify sound
inner ear-semicircular canals for balance and cochlea containing fluid which carries sound waves to auditory nerve
What are the structures and functions of the circulatory system?
blood, heart and vessels
carries nutrients and oxygen to cells
removes waste products from cells
regulate body temp
carry cells that function in immunity
What are the 3 layers of the heart?
pericardium (outer), myocardium (2nd muscular layer) and endocardium (inner)
What is respiration?
process of supplying the cells with oxygen and removal of CO2
What is a fracture?
a broken bone
What is a closed fracture?
bone is broken but skin intact
What is an open fracture?
bone has come through the skin
What are causes of bone fracture?
Falls and accidents
Bone tumors
Metastatic cancer
Osteoporosis
What is a closed reduction?
bones ends brought into alignment to fix fracture
held in place with traction, cast or external fixator
What is open reduction Internal fixation?
a surgical procedure where bone is exposed and moved into alignment
held in place with screw, plates, cast or external fixator
Signs and symptoms of fractures?
Pain
Swelling
Loss of function
Limited or no movement of the part
Movement where motion should not occur
Deformity
Bruising and skin color changes at the fracture site
Bleeding internal or external
What is a cast?
Plaster of paris, plastic, or fiberglass
What is traction?
Reduces & immobilizes joints & fractures
System of weights, ropes, and pulleys
Used to treat muscle spasms and to correct deformities or contractures
Traction is applied to the neck, arms, legs, or pelvis
Skin traction is applied to the skin
Skeletal traction is applied directly to the bone
For cervical traction, tongs are applied to the skull.
When are hip fractures common?
in older persons, specifically older women
very poor outcome for people over 65 with hip fracture
How are hip fractures treated?
The fracture requires internal fixation or joint replacement
Post-op avoid the following
Adduction
Internal rotation
External rotation
Severe hip flexion
Rehabilitation is usually needed after a hip fracture
What are some postoperative problems?
immobility can cause
Thrombi (blood clots) in the leg veins - Pulmonary embolus
Pressure ulcers
Constipation
Confusion, depression, anxiety, delirium
Atelectasis (collapse of a part of a lung) - Pneumonia
Dehydration - Urinary tract infections
What is arthritis?
joint inflammation - most common joint disease
What causes arthritis?
Aging
Being overweight
Joint injury
Stress
Muscle weakness
heredity
what are the 3 types of arthritis?
osteoarthritis, gout and rheumatoid
What is Osteoarthritis?
Degenerative disease
Wear & tear injury
More common in women
What is Gout?
Excess uric acid in blood
Hereditary
More common in men
Generally affects large toe joint
Can affect any joint or organ
What is Rheumatoid
Inflammatory connective tissue disease
Autoimmune
May affect children
Systemic
What are the signs and symptoms of Arthritis?
Joint stiffness occurs with rest and lack of motion.
Pain occurs with weight-bearing and joint motion.
Swelling is common after using the joint.
Is there a cure for arthritis?
no
When does rheumatoid arthritis develop?
Develops between the ages of 20 and 50
RA is more common in women than in men
RA occurs on both sides of the body.
What are the symptoms of rheumatoid?
Symptomatic for years prior to diagnosis
Varies from person to person
Fatigue and fever are common.
Joint pain
Tender, swollen and warm
Swelling
Stiffness
Loss of function
Other body parts may be affected.
What is the treatment of arthritis?
Drugs to decrease swelling and inflammation and relieve pain
Heat - Sometimes cold applications
Exercise -Physical therapy and Massage
Rest and joint care
Weight control
Healthy life-style
Joint replacement surgery - arthroplasty
What are the goals of arthritic treatment?
Relieve pain
Reduce inflammation - Slow down or stop joint damage and Preserve function
Improve the person�s quality of life
What is osteoporosis?
brittle porous bones that are fragile and easily broken
older men and women are at risk, for women increase after menopause
all ethnic gropes are at risk
What are other risk factors for osteoporosis?
A family history of the disease
Being thin or having a small frame
Eating disorders
Tobacco use
Alcoholism
Lack of exercise
Bedrest
Immobility
What are these signs of osteoporosis?
Back pain
Gradual loss of height
Stooped posture
Fractures
What are some preventive measure of osteoporosis?
Calcium and vitamin supplements
Estrogen for some women
Exercising weight-bearing joints
Strength-training
Not smoking
Limiting alcohol and caffeine
Back supports or corsets if needed for good posture
Walking aids if needed
Safety measures to prevent falls and accidents
Good body mechanics
Safe handling, moving, transfer, and turning and positioning procedures
CH 1: Health Care Agency - What is the purpose of an agency?
health promotion (diet/exercise), disease prevention (immunizations), detection and treatment of disease and rehab and restorative care. the person is the focus of care
What is primary care?
Goal to reduce the risk of illnesses
Teaching and counseling about healthy living
What is secondary care?
Early warning signs of disease
Diagnostic tests, exams, surgery, emergency care, medications
What is tertiary care?
rehab and restorative care - return patients to highest possible level of functioning
When does rehab start?
when person first seeks health care
What are the different types of agencies?
Hospitals
Other agencies free standing or in hospital
Rehabilitation and sub-acute care agencies
Long-term care centers: Skilled nursing facilities (SNFs), Assisted living and Residential care
Mental health centers
Home care agencies
Hospices
Health care systems
What is actor illness?
sudden and expected to recover
What is chronic illness?
ongoing, slow onset, no cure
What is terminal illness?
no reasonable expectation of recovery. death.
What is the chain of command in an agency?
Board of trustees or board of directors. They make policies.
Administrator manages the agency
Directors or department heads manage certain areas
The interdisciplinary health care team can include PT/OT/ST, nursing, dietary, lab, radiology
What is a health team?
all the health care workers that focus on the person's total care
What is the goal of an agency?
to provide quality care
What is the responsibility for the Director of Nursing - RN?
for the entire nursing staff, and nursing/staff education
Who assists that DON?
nurse managers where each nursing area is headed up by a charge nurse
Who do staff RNs report to?
charge nurse, LPNs/LVNs
Who can provide direct nursing care?
registered nurses: phd, msn, ban, asn
LPN or LVNs
Nursing Assistants
What is patient-focused care?
when services are moved from departments to the bedside. nurses do jobs usually done by other members of health care team. reduces cost.
What determines a nursing care pattern?
How many patients / residents need care
Health care needs of patients / residents
The staff available
Care costs
What is functional nursing?
focus on tasks and jobs. one nurse is the drug nurse, another is showers
What is team nursing?
team of nursing staff lead by an RN
What is primary nursing?
total care provided by registered nurse
What is case management?
similar to primary nursing except a case manager RN coordinates a person's care. communicates with whole care team even insurance. good for cancer or heart disease patients
What is private insurance?
bought by individuals and families
What is group insurance?
bought by groups and organizations for individuals
Who ends up paying for the uninsured?
the insured do, about an extra $1000 per year
What is medicare?
Federal health insurance program for persons 65 years of age or older.
Part A: Automatic
Part B: Voluntary with monthly premium
Some younger people with certain disabilities are covered.
What is medicaid?
Health care payment program
Operated by the states
Sponsored by the federal government
What is the prospective payment systems?
they limit the amount paid by insurers, medicare or medicaid. if treatment coos are less than the amount paid, the agency keeps the extra money.
What are DRGs?
Diagnosis-related groups are for hospital costs
What are RUGs?
resource utilization groups are for SNF (skilled nursing facilities) payments
What are case mix groups?
they are used for rehab centers
What are HHRGs?
home health resource groups are for home health care
What are HMOs?
Managed care deals with health care delivery and payment.
Approval for health care must be approved by many insurers
Insurer pays for the services if need is approved
Person pays if the need is not approved
What are managed care limits?
Choice of where to go for health care
Choice of provider
Care provided
insurers contact docs and hospitals to get reduced rates. if you don't go to their preferred docs or hospitals, then they don't cover it, so the insured will have to cover more out of pocket costs.
Who sets the standards of care?
Set by Federal and state governments
Accrediting agencies - JCAHO and OSBN
What standards must an agency meet?
State issued licensure - License for operation and care provision
Agency receives a license, certification, or accreditation if standards are met.
Agency can lose its license, certification, or accreditation if deficiencies are found.
The agency is given time to correct deficiencies.
The agency can be fined for uncorrected or serious deficiencies.
The agency may not admit new residents until state survey is passed.
Students may not practice clinical in a setting which has been found deficient.
What is a CNAs role in the survey process?
Following agency policies and procedures
Meeting cleanliness and safety standards
Conducting yourself in a professional manner
Providing quality care
Protecting the person�s rights
Providing for the person�s safety
Providing for your own safety
Having good work ethics
Answering questions honestly and completely
CH 4: work ethic - What does professionalism involve?
Following laws
Being ethical
Having good work ethics
Having the skills to do your work
What do work ethics involve?
How you look
What you say
How you behave
How you treat others
How you work with others
What parts of health, hygiene and appearance is involved in professionalism?
diet, 7 hours of sleep, exercise, wear corrective lenses, bathe daily, brush teeth, foot and nail care, body mechanics, don't smoke or drink or do drugs
What are employers looking for?
dependable, well groomed, have needed skill/training and have values and attitudes that fit with agency
For a job interview, what should you do?
greet interviews in polite manner
stand until asked to take a seat
keep your mind on the interview
avoid overly short or long answers
What questions should yo ask in an interview?
Pay rate
Work hours
Benefits
Tuition reimbursement and scholarship programs
Uniform requirements
The new employee orientation program
What happens during new employee orientation?
agency's policy and procedure manual is reviewed and skills are checked
What is a preceptor?
a staff member that helps new staff learn the agency's layout, introduce to patients, answers questions about policy
How to avoid gossiping?
remove yourself from a gossiping group
don't repeat anything that can hurt a person
don't repeat anything that you know isn't true
don't talk about anything from work at home or in social settings
What is a courtesy?
polite, considerate or helpful comment or act
What is harassment?
Trouble, torment, offend, or worry a person by one�s behavior or comments.
Harassment can be sexual.
Harassment can involve: Age, Race, Ethnic background, Religion and Disability.
What is sexual harassment?
involved unwanted sexual behaviors by another
How to resign from a job?
Give a written notice.
Giving 2-weeks notice is a good practice.
Do not leave a job without notice.
An exit interview is common practice
Can you lose your job for not wearing the dress code?
yes
Ch 26: Describe nursing process and activity?
Used to promote exercise and activity in all persons to the extent possible. Care plan will include person�s activity level and needed exercises
Why is bed rest ordered?
Reduce physical activity
Reduce pain
Encourage rest
Regain strength
Promote healing
What is strict bed rest?
everything is done for the person - no activities are allowed
What is bed rest?
some activities of daily living (ADL) are allowed
What are other types of bed rest?
bed rest with bedside commode privileges
bed rest with bathroom privileges
What can bed rest promote?
Pressure ulcers
Constipation and fecal impaction
Urinary tract infections and renal calculi (kidney stones)
Blood clots (thrombi)
Pneumonia (inflammation and infection of the lung)
Contractures
Muscle atrophy
Orthostatic hypotension (postural hypotension)
Syncope (fainting)
What is a contractor?
lack of joint mobility caused by abnormal shortening of a muscle.
person becomes permanently deformed or disabled.
How can nursing care prevent complications from bed rest?
Good alignment
Range-of-motion exercises
Frequent position changes
These are part of the care plan.
What supportive devices are used?
Bed boards prevent the mattress from sagging.
Foot boards prevent plantar flexion (footdrop �foot falls down at ankle) and serve as bed cradles.
Trochanter rolls prevent the hips and legs from external rotation/turning inward.
Hip abduction wedges keep the hips abducted.
Handrolls or handgrips prevent contractures of the thumb, fingers, and wrist.
Splints keep the elbows, wrists, thumbs, fingers, ankles, and knees in normal position.
Bed cradles keep the weight of top linens off the feet and toes.
What does exercise prevent?
Contractures
Muscle atrophy
Other complications of bedrest
When is a trapeze used?
For exercises to strengthen arm muscles
To move up and turn in bed
What is range of motion exercises?
movement of joint through complete range to the extent possible without pain or to point of resistance
What is active range of motion?
exercises are done by the person
What is passive range of motion?
exercises done by someone else moving the limbs
What is active-assistive range of motion?
exercise is done by the person with some help
After prolonged bed rest, activity increases in what steps?
Sit at side of bed with pedaling of feet and ankles
Stand at side of bed and march
Walk across room to chair
Walk in hallway
What should you look for when getting people up after bed rest?
Profuse sweating
Nausea and salivation
Increased heart rate
Pallor
In order to achieve the goal of walking, you nee to make sure that?
Contractures and muscle atrophy must be prevented.
Proper positioning and exercises are needed during bed rest.
Walking regularly helps prevent de-conditioning.
What is the purpose of walking aids?
Walking aids support the body.
The type ordered depends on:
The person�s condition
The amount of support needed
The type of disability
May be temporary or permanent
PT or RN teaches the person to use the device and fits patient
When are crutches are used?
The person cannot use one leg
When one or both legs need to gain strength.
What are the safety measures for crutches?
Check the crutch tips.
Check crutches for flaws.
Tighten all bolts.
Make sure the person wears street shoes with flat, non-skid soles.
Make sure clothes fit well.
Practice safety rules to prevent falls
Path is clear of obstacles or spills
Keep crutches within the person�s reach.
Know which crutch gait the person uses.
What is a four point gait?
both legs used. right crutch moves forward and then left foot moves. the left crutch moves forward followed by the right foot.
What is a three point gait?
only one leg is used. both crutches move forward and then the good foot is moved forward
What is a two point gait?
left crutch and right foot moved forward at same time followed by the right crutch and left foot moving forward together
What is a swing to gait?
both crutches moved forward and then the person swings both legs to the crutches
What is a swing through gait.
both crutches move forward and then both legs are swung through the crutches at once.
When are canes used?
for weakness on one side of the body
provide balance and support
held on strong side of body
What is a walker?
a four point walking aid, gives more support, sometime come with attachments of trays
What is a brace?
support weak body parts, prevent or correct deformities, prevent joint movement
What is an AFO?
ankle foot orthosis is a brace placed in the shoe over ankle and food
When using braces what do you need to do?
Keep skin / bony points under braces clean / dry.
Report redness & signs of skin breakdown at once.
Report complaints of pain & discomfort.
Follow the care plan for brace use
What activities are required by OBRA?
activity programs required for residents so as to improve quality of loofa
What do recreational activities promote?
Important for physical and mental well-being
Exercises joints and muscles
Stimulates circulation
Provide social outlet
Provide mental stimulation
CH 27: Comfort rest sleep - what can arise from deficits of comfort rest and sleep?
injury, illness, pain may be physical or emotional which disrupts sleep and if left untreated can decrease function and quality of life
What is comfort?
a state of well-being
The person has no physical or emotional pain.
Person is calm and at peace.
What is comfort affected by?
Age, illness, stress and activity
Environmental factors like Temperature, Ventilation, Noise, Odors and Lighting
What is pain?
Subjective, personal and individual experience
You must rely on what the person says: Ache, Hurt, Sore
Pain is a warning from the body.
It signals tissue damage.
Pain often causes the person to seek health care.
What are the types of pain?
acute, chronic, radiating, phantom
What is acute pain?
felt suddenly from injury, disease, trauma, or surgery.
What is chronic pain?
pain lasts longer than 6 months.
Chronic pain may result from inadequate pain control during the acute phase.
What is radiating pain?
felt at the site of tissue damage and in nearby areas.
What is phantom pain?
Phantom pain is felt in a body part that is no longer there.
What factors affect pain?
Past experience: Knowing what to expect can help or hinder how the person handles pain.
Anxiety: Pain can cause anxiety. Anxiety increases pain.
Anxiety reduction may be needed to adequately control pain.
Rest and sleep:Rest and sleep restore energy and increase healing. May seem worse when tired or restless.
Attention: Pain is reported more frequently at night with greater pain levels. Fewer distractors at night. Night time pain control is paramount for promoting sleep and rest
Personal and family duties: deal with pain in order to take care of kids.
The value or meaning of pain: Culture, experience, religion, societal expectations Give value or meaning to how a person experiences & responds to pain. showing pain is a sign of weakness.
Support from others: Comfort and support from family & friends increases coping.
Illness: May increase or decrease pain sensation
What needs to be reported about pain?
OLDCARTS need to be reported immediately. anytime pain level gets to 2.
o-onet
l-location
d-duration
c-characeter
a-aggravators
r-relievers
t-treatments
plus vital signs and any other signs or symptoms
What are the nursing measures to deal with pain control?
The nurse uses the nursing process to promote comfort and relieve pain.
Other measures
Distraction: To change the person�s center of attention
Relaxation: Free from mental and physical stress
Guided imagery: Creating and focusing on an image
Medications are ordered to control or relieve pain.
May cause orthostatic hypotension, drowsiness, dizziness, and coordination problems.
Be alert to needed safety measures.
What does rest mean?
to be calm at ease and relaxed
How can rest be promoted?
Meet basic needs
positioning
quiet setting, neat room
How to Help relieve pain or discomfort so as to promote rest?
Providing a comfortable position and good alignment
Providing a quiet setting
Providing a clean, dry, and wrinkle-free bed
Providing a clean, neat, and uncluttered room
Release tight clothing and remove shoes
How to meet higher needs in order to promote rest?
Meeting safety and security needs: Keeping the signal light within reach
Explaining the reasons for care, Explaining how care is given
Following routines and rituals whenever possible
Meeting love and belonging needs: Promoting visits or calls from caring family and friends, Reading cards and letters
Meeting self-esteem needs: Promoting personal choice in sleepwear and Assisting with hygiene and grooming measures as needed
Why is sleep necessary?
it is a basic need. A state of unconsciousness, reduced muscle activity & lowered metabolism
It lets the mind and body rest.
The body saves energy.
Body functions slow.
Vital signs are lower than when awake.
Tissue healing and repair occur.
Sleep lowers stress, tension, and anxiety.
The person regains energy and mental alertness.
What is a circadian rhythm?
a daily rhythm based on a 24-hour cycle.
It affects functioning.
Circadian rhythm includes a sleep-wake cycle.
How many phases of sleep are there?
Two phases of sleep with 4 stages.
NREM sleep (non-REM sleep) is the phase of sleep where there is no rapid eye movement. has 4 stages that go from light to deep sleep.
The rapid eye movement phase is called REM sleep. Important for mental restoration.
Sleep needs vary for each age-group.
What are the average sleep needs for an adult?
Average adult needs 7 � 9 hours of sleep daily. this requirement changes as a person ages, need less sleep.
What factors affect sleep quality?
illness and nutrition (sleep needs increase with weight gain)
exercise, environment, drugs, life style changes, emotional problems.
Details about illness affecting sleep?
Signs and symptoms of illness interfere with sleep.
Treatments and therapies interfere with sleep.
Care devices can cause uncomfortable positions.
The emotional effects of illness can affect sleep.
Details about nutrition affecting sleep?
Sleep needs increase with weight gain and decrease with weight loss.
Foods with caffeine prevent sleep.
The protein tryptophan tends to help sleep.
What can disrupt sleep in daily life?
Exercise improves health and fitness but Exercise before bedtime interferes with sleep.
Environment: People adjust to their usual sleep settings.
Medication and other substances
Caffeine, amphetamines interfere with sleep
Hypnotics, narcotics, muscle relaxers, antidepressants & anxiolytics promote sleep but shorten REM sleep
Alcohol interferes with REM sleep.
Life-style changes can affect sleep.
Emotional problems
What are sleep disorders?
repeated sleep problems - amount and quality are affected
What is insomnia?
a chronic condition in which the person: Cannot fall asleep, Cannot stay asleep and Awakens early and cannot fall back asleep
What is sleep deprivation?
Amount and quality of sleep are decreased. Sleep is interrupted.
What is sleepwalking?
Person leaves the bed and walks about.
Usually does not remember episode, High risk for injury
What needs to be reported or done about sleep?
Report signs and symptoms of sleep disorders.
Follow the care plan for measures to promote sleep.
Report your observations about how the person slept.
CH 30: sputum specimens: define sputum?
mucus from the respiratory system when expelled through the month. it is coughed up from the bronchi and teaches.
When is the best time to collect it?
in the morning
What should the patient do before collecting it?
rinse mouth with water to decrease saliva and remove food particles
