1. Define important words in the chapter

1. 1. Define important words in the chapter • central venous line • a type of intravenous line (IV) that is inserted into a large vein in the body. • chest tubes • hollow drainage tubes that are inserted into the chest to drain air, blood, pus, or fluid that has collected inside the pleural space/cavity. • gastrostomy • an opening in the stomach and abdomen. • intubation • the method used to insert an artificial airway; involves passing a plastic tube through the mouth or nose and into the trachea or windpipe.

2. 1. Define important words in the chapter • mechanical ventilator • a machine used to inflate and deflate the lungs when a person cannot breathe on his own. • nasogastric tube • a feeding tube that is inserted through the nose and into the stomach. • percutaneous endoscopic gastrostomy (PEG) tube • a tube placed through the skin directly into the stomach to assist with eating. • pulse oximeter • device that measures a person’s blood oxygen level and pulse rate.

3. 1. Define important words in the chapter • sedation • the use of medication to calm a person. • sepsis • a serious illness caused by an infection, usually bacterial, that requires immediate care. • telemetry • application of a cardiac monitoring device that transmits information about the heart rhythm and heart rate to a central monitoring station for assessment. • total parenteral nutrition (TPN) • the intravenous infusion of nutrients in a basic form that is absorbed directly by the cells, bypassing the digestive tract.

4. 2. Discuss the types of residents who are in a subacute setting • Define the following term: • mechanical ventilator • a machine used to inflate and deflate the lungs when a person cannot breathe on his own.

5. 2. Discuss the types of residents who are in a subacute setting • A subacute setting is a special unit or facility that is for people who need more care than most long-term care facilities can provide. Hospitals and long-term care facilities may offer subacute care. • Residents in subacute care settings need a higher level of care than other residents. They will require more direct care and close observation by staff.

6. 2. Discuss the types of residents who are in a subacute setting • Know the types of residents found in subacute units: • Residents who need more care and observation than other residents • Residents having had recent surgery and chronic illnesses, such as AIDS and cancer • Residents on dialysis or with serious burns

7. 3. List care guidelines for pulse oximetry • Define the following term: • pulse oximeter • device that measures a person’s blood oxygen level and pulse rate.

8. 3. List care guidelines for pulse oximetry • Remember these points about the pulse oximeter: • Warns of low blood oxygen level before signs develop • Normal pulse oximeter reading is 95% and 100%, but it can differ. • Report to nurse any change in oxygen levels.

9. 3. List care guidelines for pulse oximetry • Know the care guidelines for pulse oximetry: • Tell the nurse right away if alarm sounds. • Be careful when moving and positioning so oximeter does not move or come off. • Report difficulty breathing. • Report pale, cyanotic, darkening, or grayish skin, or mucous membranes. • Report signs of skin breakdown from the device. • Check vital signs as ordered, and report changes to the nurse.

10. Applying a pulse oximetry device • Equipment: pulse oximetry clip-on sensor probe, nail polish remover, if needed 1. Identify yourself by name. Identify the resident. Greet the resident by name. 2. Wash your hands. 3. Explain procedure to resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 4. Provide for the resident’s privacy with a curtain, screen, or door.

11. Applying a pulse oximetry device 5. Remove nail polish from digits to be used for pulse oximetry, if necessary. 6. Remove sensor probe from package and place clip-on probe on finger, toe, or earlobe. The index finger is usually preferable. The probe must be placed fully onto the finger or toe; it should not be placed just on the tip of the finger or toe.

12. Applying a pulse oximetry device 7. Blood pressure and pulse measurements may be needed prior to placing the device. If device does not seem to be working, make sure wires on pulse oximetry device are in place and that device is plugged in. Turn on the device. The pulse oximetry reading should appear on the screen quickly.

13. Applying a pulse oximetry device 8. Ask resident to not remove or adjust pulse oximetry device. Ask resident to press call signal if the device comes off or dislodges. 9. Make resident comfortable. 10. Remove privacy measures. 11. Leave call light within resident’s reach.

14. Applying a pulse oximetry device 12. Wash your hands. 13. Be courteous and respectful at all times. 14. Report any changes in the resident to the nurse. Document procedure using facility guidelines.

15. 4. Describe telemetry and list care guidelines • Define the following term: • telemetry • application of a cardiac monitoring device that transmits information about the heart rhythm and heart rate to a central monitoring station for assessment.

16. 4. Describe telemetry and list care guidelines • Remember these guidelines for telemetry: • Do not get the unit, wires, pads, or electrodes wet during bathing. • Report to nurse if alarm sounds. • Check vital signs, as ordered. • Report if pads become loose. • Check for signs of skin irritation under or around electrodes. • Remind resident not to leave the monitoring area. • Report change in vital signs, chest pain or discomfort, rapid pulse, sweating, shortness of breath, dyspnea, or dizziness to the nurse.

17. 5. Explain artificial airways and list care guidelines • Define the following term: • intubation • the method used to insert an artificial airway; involves passing a plastic tube through the mouth or nose and into the trachea or windpipe.

18. 5. Explain artificial airways and list care guidelines • An artificial airway is needed when the airway is obstructed due to illness, injury, secretions, or aspiration, and sometimes is needed when a person has surgery. Some residents who are unconscious will need an artificial airway. An artificial airway is inserted during a procedure called intubation.

19. 5. Explain artificial airways and list care guidelines • Remember these guidelines for artificial airways: • Tell nurse if tubing comes out. • Follow orders for positioning. • Check vital signs as ordered. • Perform oral care often, at least every two hours.

20. 5. Explain artificial airways and list care guidelines • Guidelines for artificial airways (cont’d.): • Tell nurse if you see biting and tugging on the tube. • Write notes, draw pictures, and use communication boards and hand and eye signals if resident cannot speak. • Be supportive and reassuring. • Report drainage, change in vital signs, wheezing or difficulty breathing, secretions in tubing, cyanosis, pale, gray, or darkening skin or mucous membranes, or nervousness or anxiety to the nurse.

21. 6. Discuss care for a resident with a tracheostomy • A tracheostomy is a common type of artificial airway. The tracheostomy tube is held in place by a cuff that attaches to the end of the device in the trachea. The cuff prevents the accidental aspiration of food or fluids.

22. 6. Discuss care for a resident with a tracheostomy • Know the reasons why tracheostomies are necessary: • Airway obstruction • Cancer • Infection • Severe injuries • Serious allergic reaction • Coma • Facial burns • Gunshot wounds • To prevent aspiration in an unconscious person

23. 6. Discuss care for a resident with a tracheostomy • Think about this question: • How would it feel to have an artificial airway and be unable to speak?

24. 6. Discuss care for a resident with a tracheostomy • REMEMBER: • Use alternate methods of communication if the resident cannot speak. Answer call lights promptly.

25. 6. Discuss care for a resident with a tracheostomy • Think about this question: • Even though nursing assistants do not perform tracheostomy care or suctioning, why is careful observation and reporting so important?

26. 6. Discuss care for a resident with a tracheostomy • Remember the following guidelines for tracheostomies: • Answer call lights promptly. • Use alternate methods of communication. • Follow orders for positioning. • Inspect ties or tape often. • Report kinks or disconnected tubing.

27. 6. Discuss care for a resident with a tracheostomy • Guidelines for tracheostomies (cont’d.): • Keep the dressing dry, and do not cover the tracheostomy opening. • Provide careful skin care. • Perform oral care often, at least every two hours. • Observe for mouth sores, cracks, breaks or sores on skin. • Observe for pale, bluish, or darkening skin or mucous membranes.

28. 6. Discuss care for a resident with a tracheostomy • Guidelines for tracheostomies (cont’d.): • Check vital signs as ordered. • Do not tire resident. • Do not move spare tracheostomy tubes or bag valve mask. • Report cyanosis, pale, gray, or darkening skin or mucous membranes, mouth sores or discomfort, cracks, breaks, or sores on skin, gurgling sounds, dyspnea or shortness of breath, change in vital signs, disconnected tubing, or loose or wet tape to the nurse.

29. 7. Describe mechanical ventilation and explain care guidelines • Define the following term: • sedation • the use of medication to calm a person.

30. 7. Describe mechanical ventilation and explain care guidelines • Know these points about mechanical ventilators: • Resident will not be able to speak, which can greatly increase anxiety. • Being on a ventilator has been compared to breathing through a straw. • Be supportive. Enter the room so the resident can see you often. • Use other methods of communication. • Act and speak as if resident can understand everything, even if he or she is unconscious or heavily sedated.

31. 7. Describe mechanical ventilation and explain care guidelines • Remember these care guidelines for residents with mechanical ventilators: • Tell nurse right away if alarm sounds. • Report kinks or disconnected tubing right away. • Report biting on the tube. • Answer call lights promptly. • Give oral care often. Report mouth sores or discomfort.

32. 7. Describe mechanical ventilation and explain care guidelines • Care guidelines for residents with mechanical ventilators (cont’d.): • Reposition at least every two hours. Follow positioning orders. • Give regular skin care to prevent pressure ulcers. • Allow time for rest. • Be patient during communication. • Provide emotional support.

33. 7. Describe mechanical ventilation and explain care guidelines • Care guidelines for residents with mechanical ventilators (cont’d.): • Do not move spare artificial airway tubes or bag valve masks. • Report the alarm sounding, a collection of secretions in tubing, mouth sores or discomfort, cracks, breaks, or sores on the skin, change in vital signs, nervousness or anxiety, or depression to the nurse.

34. 7. Describe mechanical ventilation and explain care guidelines • Case Study • Mrs. G is on a mechanical ventilator. She is sedated, but she is conscious. She bites on her tube sometimes and looks anxious when the NA enters the room. • What can the NA do to reassure Mrs. G? • What care can the NA give to help increase Mrs. G’s comfort?

35. 7. Describe mechanical ventilation and explain care guidelines • Define the following term: • sepsis • a serious illness caused by an infection, usually bacterial, that requires immediate care.

36. 7. Describe mechanical ventilation and explain care guidelines • Know the signs of sepsis: • Elevated heart rate and respiratory rate • Slightly elevated temperature or low temperature • Chills • Excessive sweating • Feeling of sickness or weakness

37. 7. Describe mechanical ventilation and explain care guidelines • Signs of sepsis (cont’d.): • Low blood pressure • Decreased urine output • Headache • Skin rash • Shortness of breath • Confusion or change in mental status

38. 7. Describe mechanical ventilation and explain care guidelines • REMEMBER: • You should be familiar with residents’ normal vital signs in order to better recognize changes. This will help you notice the early symptoms of sepsis.

39. 8. Describe suctioning and list signs of respiratory distress • Know these points about suctioning: • Necessary when a person has increased secretions that he cannot expel • Suctioning can be performed orally, nasally, and through the trachea and bronchi. • Nursing assistants do not perform suctioning. • Suction comes from wall or pump and bottle collects suctioned material. • Sterile water or sterile saline is used to rinse suction catheter. • Signs of respiratory distress are gurgling, high respiratory rate, shortness of breath, dyspnea, pallor or cyanosis.

40. 8. Describe suctioning and list signs of respiratory distress • Remember these guidelines for assisting with suctioning: • Follow Standard Precautions. • Follow orders for positioning. • Place pad or towel under chin before suctioning. • Give oral and nasal care after suctioning. • Report signs of respiratory distress immediately.

41. 8. Describe suctioning and list signs of respiratory distress • Guidelines for assisting with suctioning (cont’d.): • Answer call lights promptly. • Observe for pale, bluish, or darkening skin or mucous membranes. • Monitor vital signs closely. • Give emotional support during difficult periods. • Report change in vital signs; gurgling sounds; change in color, amount, or quality of secretions; dyspnea or shortness of breath; cyanosis; pale, gray, or darkening skin or mucous membranes; or nervousness or anxiety to the nurse.

42. 9. Describe chest tubes and explain related care • Define the following term: • chest tubes • hollow drainage tubes that are inserted into the chest to drain air, blood, pus, or fluid that has collected inside the pleural space/cavity.

43. 9. Describe chest tubes and explain related care • Know these points about chest tubes: • Can be inserted at bedside or during surgery • Drain air, blood, pus, or fluid • Allow a full expansion of the lungs • Conditions requiring chest tubes include pneumothorax, hemothorax, empyema, surgery, injuries • Chest tube is connected to bottle of sterile water. • System must be airtight when attached to suction.

44. 9. Describe chest tubes and explain related care • Remember these guidelines for chest tubes: • Be aware of where chest tubes are located. • Check vital signs as directed and report changes. • Report signs of respiratory distress and pain. • Keep drainage system below level of chest. • Keep drainage containers upright and level.

45. 9. Describe chest tubes and explain related care • Guidelines for chest tubes (cont’d.): • Make sure tubing is not kinked. • Report disconnected tubing. • Do not remove equipment in the area. • Observe chest drainage for amount, color, and consistency. • Report clots in tubing. • Observe dressings for drainage, saturation, or bleeding.

46. 9. Describe chest tubes and explain related care • Guidelines for chest tubes (cont’d.): • Follow orders for positioning. • Provide rest periods. • Follow fluid orders and measure I&O carefully. • Encourage deep breathing exercises. • Report complaints of pain, signs of respiratory distress, change in vital signs, change in oxygen levels or if alarm sounds, an increase or decrease in bubbling, disconnected or kinked tubing, clots in the tubing, changes in amount, color, or consistency of chest drainage, wet or loose dressings, or odor to the nurse.

47. 10. Describe alternative feeding methods and related care • Define the following terms: • nasogastric tube • a feeding tube that is inserted through the nose and into the stomach. • percutaneous endoscopic gastrostomy (PEG) tube • a tube placed through the skin directly into the stomach to assist with eating. • gastrostomy • an opening in the stomach and abdomen.

48. 10. Describe alternative feeding methods and related care • When a person is unable to consume food normally due to disease or injury, other methods are used. When a person has difficulty swallowing or is unable to swallow, he may be fed through a tube.

49. 10. Describe alternative feeding methods and related care • One tube is called a nasogastric tube (N/G). A nasogastric tube is inserted into the nose, down the back of the throat through the esophagus and into the stomach. The tube is secured to the nose with dressing tape and to the gown with tape or a clip.

50. 10. Describe alternative feeding methods and related care • An orogastric tube (O/G) is another type of tube. It is used for people who are intubated. It is inserted into the mouth and down the throat, through the esophagus and into the stomach.