HCPro.com - LTC Nursing Assistant Trainer

HCPro celebrates National Nurses Week!

Fri, 04 May 2012 19:22:00 GMT

May 6 through May 12 marks the celebration of National Nurses Week, an annual event to recognize the contributions of nurses throughout the country. In honor of Nurses Week, HCPro will feature a different special offer each day, including discounts, giveaways, and contests.

The celebrations begin on Monday when HCPro is pleased to offer a free white paper on the Image of Nursing-plus free CE credit.

Click here for your Free Image of Nursing White Paper and free CE.

Every day next week, there will be a special Nurses Week promotion. Watch out for discounts on a variety of nursing products, contests with prizes, and more during Nurses Week. Visit The Leader's Lounge blog each day of Nurses Week to learn about the newest offer!

Trainer’s tip: Age-related considerations for intravenous therapy

Thu, 03 May 2012 18:56:00 GMT

The Joint Commission for Accreditation of Healthcare Organizations (JCAHO) requires nurses to be familiar with age-related considerations and possess age-related competencies. The following considerations apply to geriatric residents:

Fragile veins may cause infiltration immediately upon catheter insertion. If the vein is palpable and visible, consider starting the IV without a tourniquet, which increases pressure. A blood pressure cuff inflated to 30 to 40 mm Hg may be effective as a tourniquet replacement.
Skin becomes paper-thin in the elderly. Secure the catheter with hypoallergenic tape, or cover with an IV transparent dressing.
Immobilize the catheter well to prevent movement, which may cause skin tears.
Stabilize the vein well, as veins in the elderly have a tendency to roll upon insertion.
Dehydration, vascular disease, and obesity may limit available sites for intravenous access. Initiate therapy as low on the vein as possible so that sites above it may be used if necessary.
The elderly are at high risk for circulatory overload, making close monitoring essential. Signs and symptoms include:

-Elevated blood pressure
-Rapid respirations
-Coughing and shortness of breath
-Signs and symptoms of pulmonary edema

If you suspect fluid overload, assess body weight, specific gravity, and intake and output. Notify the physician promptly.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Intravenous therapy guidelines

Thu, 03 May 2012 18:49:00 GMT

Before initiating intravenous therapy, perform a focused assessment of the resident’s hydration status. If the resident is receiving the IV for antibiotics, also assess the condition for which antibiotics are being given. At a minimum, assess:

Vital signs
Skin turgor
Mucous membranes
Total body weight; history of recent loss or gain

-Loss or gain of one kilogram of body weight is reflective of a loss or gain of 1 liter of fluid

Signs and symptoms of dehydration:

-1% fluid loss: Thirst
-2%–5% fluid loss: Dry mouth, flushed skin, weakness, impaired physical ability, fatigue, headache
-6% fluid loss: Increased temperature, pulse, respirations, increased weakness, dizziness
-8% fluid loss: Labored respirations on exertion, increased weakness, dizziness
-10% fluid loss: Delirium, swollen tongue, muscle spasms
-11% fluid loss: Failing kidney function, poor blood circulation

Peripheral veins for assessment of plasma volume

-Elevate the hand; the veins should empty within three to six seconds
-Lower the hand; the veins should fill quickly

Fill times as high as 10 seconds suggest sodium depletion
Urine volume and specific gravity

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Notice: Last issue of LTC Nursing Assistant Trainer

Thu, 03 May 2012 18:36:00 GMT

HCPro is sorry to report that this is the last issue of LTC Nursing Assistant Trainer. We thank you for being a loyal subscriber.

You can sign up for any of our other free e-newsletters that cover a variety of topics from infection control to MDS 3.0 updates. Click here to sign up for one of our other e-newsletters.

Trainer’s tip: Nursing assessment for GCS

Thu, 19 Apr 2012 13:51:00 GMT

Before applying compression hosiery initially, consider these safeguards:

Review the physician order.
Clarify hosiery length, if necessary.
GCS are available in light compression, moderate compression, and firm compression. Clarify the compression strength, or follow facility policies. Common strengths are:

--Mild compression (8–15 mmHg)

--Medium compression (23–32 mmHg)

--Firm compression (20–30 mmHg)

--Strong compression (25–35 mmHg)

Systematically assess the resident and each lower extremity for appropriate use of compression.
Review contraindications to hosiery and be sure they do not apply to the resident.
Assess the peripheral circulation, popliteal, posterior tibial, and dorsalis pedis pulses.
Consider the person’s age, dexterity, and ability to apply the hosiery independently, as appropriate. Determine whether a caregiver is needed to assist with application.
Assess the need for an adaptive device or specially modified hosiery (an occupational therapist can assist in obtaining an adaptive application device, or hosiery that fasten with Velcro).
Check the skin condition for potential pressure points, fragile skin, open areas, rashes, signs of infection, healed ulcerations, and areas of possible vulnerability.
Check the patient’s allergies. Although the incidence of allergic reaction is low, some brands contain latex, nylon, Lycra, and other potential allergens.
Review facility policies and procedures for fitting, application, and circulation checks, and follow them.
Initiate a plan of care for the use of GCS.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Graduated compression stockings

Thu, 19 Apr 2012 13:46:00 GMT

Graduated compression stockings (GCS) have been used effectively for years to prevent deep venous thrombosis (DVT) in hospitalized patients. They are also common in long-term care facilities, and are worn by many persons living in the community.

The hosiery provides graduated pressure, and is tightest at the ankle, becoming progressively looser as it extends up the proximal leg. The hosiery increases blood flow velocity and improves valve function. The increased speed reduces the risk of venous stasis and pooling. GCS compress superficial veins and capillaries, which redirects blood to the deeper, larger veins, where it flows effortlessly to the heart. This reduces venous hypertension and decreases the risk of stagnation. The controlled compression of the skin provides additional support for the venous system, reducing edema and promoting venous return from the ankles and calves.
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Although GCS are believed to be a low-tech, low-risk treatment, they are not risk-free. Patients with diabetes, neuropathy, connective tissue diseases, signs of clinical infection in the extremity, and peripheral vascular disease have an increased risk of complications. Contraindications for GCS use include:

Severe arteriosclerosis or other ischemic vascular disease
Pulmonary edema, congestive heart failure
Massive leg edema
Local conditions such as dermatitis, postoperative vein ligation, recent skin graft, and gangrene
Deformity of leg
Circumference greater than 25 inches (63.5 cm) at the gluteal fold, if thigh-high hose are ordered

Potentially serious complications resulting from GCS use include:

Reduced blood flow and tissue oxygenation
Pressure ulcers
Arterial occlusion
Thrombosis
Gangrene

Complications are usually associated with hosiery that do not fit properly, failure to remove the stockings for skin and circulation checks, and folding and bunching up of hosiery, causing a tourniquet effect to the skin.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Notice: Second to last issue of LTC Nursing Assistant Trainer

Thu, 19 Apr 2012 13:39:00 GMT

HCPro is sorry to report that this is the second to last issue of LTC Nursing Assistant Trainer. We thank you for being a loyal subscriber.

You can sign up for any of our other free e-newsletters that cover a variety of topics from infection control to MDS 3.0 updates. Click here to sign up for one of our other e-zines.

Trainer’s tip: Signs and symptoms of dehydration

Thu, 05 Apr 2012 17:39:00 GMT

Signs and symptoms of dehydration include:

Sunken cheeks or eyeballs
Dry, brown tongue and mucous membranes
Furrows or lines in tongue
Dry, inelastic skin
Poor skin turgor (check forehead or over the sternum in the elderly)
Weight loss
Concentrated urine
Constipation and impaction
Nausea and anorexia
Increased time for veins to refill
Abnormal laboratory values (elevated hemoglobin/hematocrit, potassium, chloride, sodium, albumin, transferrin, BUN, urine specific gravity)
Greater than three-pound weight loss within seven days
Delusions, dizziness, delirium
Unsteady gait
Headache
Flushed appearance

Sadly, by the time signs and symptoms appear, most residents are already dehydrated, and aggressive interventions are essential.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Reasons for inadequate fluid intake in the elderly

Thu, 05 Apr 2012 17:33:00 GMT

Unfortunately, normal aging changes increase the risk for fluid imbalance and dehydration. Elderly residents are less capable of maintaining fluid balance compared with younger people. Also, many elderly persons (especially women) deliberately limit fluids to reduce the risk of accidental urination. Some residents may refuse all fluids after the evening meal to avoid having to get up at night to urinate.

Other common reasons for inadequate fluid intake and abnormal loss of fluids include:

Decreased content of body water
Age-related changes in thirst sensation; decreased thirst response
Physical or mental inability to consume fluids independently
Depression, alteration in mood, or cognitive status
Renal changes
Dysphagia
Poor dietary intake (food is up to 80% fluid)
Lack of available fluid
Warm environmental temperature
Delirium
Gastrointestinal distress
Apathy
Bedrest, causing physiological changes and fluid loss
Immobility

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Trainer’s tip: Examining the cognitively impaired resident

Thu, 22 Mar 2012 16:54:00 GMT

When examining a cognitively impaired resident, consider the following:

The resident may be more secure if a family member or regular caregiver is present; honor the resident’s choice.
Keep the resident’s body covered and draped as much as possible.
Allow the resident to be as independent as possible, but provide assistance with dressing and undressing, as needed. Observing how much can be done independently provides useful information about the resident’s abilities and degree of cognitive impairment.
Approach the resident in a warm, assuring manner and recognize him/her by name. Be patient. Cognitively impaired adults are sensitive to the moods of others. Make sure your body language and demeanor do not send a message that you are impatient or irritated.
Speak in simple, concise terms.
Give simple directions one step at a time.
Evaluate the resident’s ability to follow instructions.
Provide reassurance. Respond to the resident’s emotions. For example, if the resident becomes fearful and starts to cry for her mother, reassure her that you understand how she feels and you will do everything you can to make her comfortable. Avoid reminding her that her mother is dead.
Treat the resident with consideration and respect throughout the examination.
Interview a collateral source separately to confirm and gather information.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Physical assessment of the geriatric resident

Thu, 22 Mar 2012 15:30:00 GMT

Physical assessment of elderly individuals can present many challenges. Over time, you will become proficient in adapting the environment and modifying the examination to account for sensory changes, slower response time, acute or chronic diseases, and the resident’s need for assistance. Avoid stereotyping the resident or making assumptions about his or her mental status or physical ability. Individualize the examination to accommodate the resident’s deficits. Anticipate that the process may take longer than it would with a younger resident. If a caregiver or family member is present, privately ask the resident to state his or her wishes regarding whether this person should be asked to leave the room during the examination.

Consider doing the following when examining a resident:

Elderly persons are often very modest and uncomfortable if clothing is removed; arrange for a warm, private area
Provide draping for comfort and warmth
Position the resident in a comfortable position that he or she can maintain during the exam
Provide pillows, props, or other positioning aids as needed
Provide bright, non-glare lighting
Eliminate background noise
Warm instruments before touching the resident with them
Provide a chair with arms and a high seat

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Trainer’s tip: Ways to help a resident perform a task

Thu, 08 Mar 2012 15:40:00 GMT

Residents with dementia have difficulty performing day-to-day tasks. The following steps go a long way in helping dementia residents:

1.Explain each step in simple language, one at a time
2.Demonstrate each step, doing the task while the resident watches
3.Move the person through the steps of the task, placing arms and legs in the right positions
4.If distracted, begin at the beginning

Remember to be patient an unhurried!

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

The effects of dementia

Thu, 08 Mar 2012 15:32:00 GMT

Dementia is a mental disorder involving a general loss of intellectual abilities and changes in personality. Dementia can have the following effects on residents:

1.Memory loss

Affects recent memories the most
Makes it difficult to learn anything new or to follow instructions

2.Language loss (the meaning of words)

Makes it difficult to recognize words and understand complex sentences
Makes it difficult to express ideas

3.Attention loss

Unable to start or stop a task
Easily distracted

4.Judgment loss

Cannot accurately assess circumstances
Unable to see consequences of actions

5.Loss of perception or senses

Unable to recognize things or people
Causes misinterpretation of what is seen, heard, or felt

6.Loss of muscle organization

Unable to perform multiple-step tasks
Require prompts or cues for routine tasks

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Trainer’s tips: Determining calories needed to maintain weight

Thu, 23 Feb 2012 12:32:00 GMT

During a dietary assessment, the dietitian calculates the resident’s basal energy expenditure (BEE)—a measurement that determines how many calories (cal) the resident must consume each day to maintain his or her weight. The information is useful in preventing and managing weight loss, and promoting healing.

The following formulas are helpful on the occasions when the dietician is unavailable and the nurse must calculate the resident’s BEE. Ask the dietitian to recheck the data on his or her next regular visit.

Convert the resident’s height to inches (in), then to centimeters (cm):

1 inch = 2.54 centimeters
Multiply the height in inches by 2.54
Example: A resident is 5 feet 5 inches tall, or 65 inches
Multiply 65 x 2.54 = 165.1 cm

Convert the resident’s weight in pounds (lbs) to kilograms (kg):

1 kg = 2.2 pounds
Divide the weight in lbs by 2.2
Example: A resident weighs 135 lbs
Divide 135 / 2.2 = 61.36 kg
Round this figure to an even number (61 kg)

To calculate BEE for a male resident:

66 + (13.7 x weight in kg) + (5 x height in cm) - (6.8 x age)

To calculate BEE for a female resident:

655 + (9.6 x weight in kg) + (1.8 x height in cm) - (4.7 x age)

The formula to estimate BEE in males is:

1 cal/kg/hour

The formula to estimate BEE in females is:

0.9 cal/kg/hour

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Food intake studies

Thu, 23 Feb 2012 12:24:00 GMT

The physician or dietitian may request food intake studies for residents who are not eating, losing weight, at risk of malnutrition, etc. The resident’s food intake is accurately monitored and documented for a period of time, usually three days. The dietitian will analyze the completed information for nutritional adequacy and number of calories consumed. He or she will plan a diet to meet the resident’s special medical needs and may instruct the dietary department to adjust the resident’s menu, if needed. The dietitian will also make recommendations for adjusting the resident’s diet and nutritional plan of care. When completing a food intake study:

Notify family members so food they bring in to the facility can be documented
Weigh or measure each food item, if that is your facility’s policy
Accurately record the resident’s intake of each food item after meals
Promptly inform the physician of the dietitian’s recommendations once the study has been completed and reviewed

Completing a food intake or calorie count study requires a team effort, good communication, and very accurate documentation.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Trainer's tip: Understand items and conditions problematic to MRI scanning

Thu, 09 Feb 2012 13:19:00 GMT

Other medical conditions, devices, and metallic items that are potentially problematic during MRI scanning are as follows:

Aneurysm clips.
Artificial eyes.
Cardiac pacing wires are sometimes left in place after heart bypass surgery.
Some eye shadow has a metallic base. Avoid eye makeup if a study is being done of the head.
Facial reconstruction surgery may involve implanted metal and wires.
Some heart valves may be scanned, but some cannot. Notify the scheduling secretary if the resident has had open-heart surgery.
Hernia mesh can usually be scanned safely, even if it contains metal. Notify the MRI center if mesh is present.
Metal in the eyes from accidental injury (an eye x -ray must be taken prior to the study as even a tiny fragment can damage the eye).
Prosthesis should be removed before the MRI study.
Shrapnel may cause a problem. Each case is reviewed by the radiologist individually.

Because there are so many variables related to safety of the MRI procedure, listing all contraindicated items here is impossible. Contact your local MRI diagnostic center with questions. A comprehensive listing of 1,300 items that have been safely tested with MRI can be found at www.mrisafety.com/.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Preparing a resident for an MRI

Thu, 09 Feb 2012 13:13:00 GMT

Occasionally, a facility must send a resident to a hospital or diagnostic center for magnetic resonance imaging (MRI). This is an excellent diagnostic tool. Nursing personnel must prepare the resident before the test. Preparation involves making sure that the resident has no contraindications—a condition that causes a treatment or procedure to not be recommended—and checking to make sure that metallic devices do not interfere with the procedure. Some contraindicated items may surprise you. Contraindications for the MRI may vary greatly by the area of the body scanned.

Here are some key points to remember:

The MRI causes a strong magnetic field. Ferromagnetic objects may be pulled into the field at high speed, causing injury to the resident. Because of the potential for injury, metallic jewelry and other items should be removed from the outside of the body before the scan.
Notify the MRI center in advance if the resident has an implanted metallic object from a previous surgery, diagnostic test, treatment, or injury. Some of these items may be safely scanned, but typically, the MRI center must research the resident’s history before scheduling the test.
A pacemaker can never be scanned safely. Contact the attending physician about an alternate type of diagnostic study.
Residents with implanted medication pumps usually can be safely scanned. However, you must notify the MRI center of the type of pump, location, and serial number.
Some transdermal medication patches contain metal and have the potential to cause pain, burns, blisters, and other injuries when exposed to a magnetic field.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Trainer’s tip: Measuring joint mobility

Thu, 26 Jan 2012 13:24:00 GMT

Assess joint range of motion on the initial (admission) assessment and quarterly thereafter. For accuracy, a therapist should measure joint mobility with a goniometer. Some nursing forms have pictures that show degrees of joint mobility. These are used for screening by comparing the resident’s degree of joint mobility to the picture. If the angle is abnormal, the resident is referred to therapy for follow up and possible intervention. If the resident is at risk, a restorative nursing program is developed to prevent or reverse the contractures. Restorative care of the resident involves using pillows, props, and supportive devices, maintaining good body alignment, and providing range of motion exercises two to three times daily.

To determine the degree of impairment, the nurse must know the normal range of motion for each joint:

Neck: Flexion 45 degrees, extension 55 degrees, lateral bending 40 degrees, rotation 70 degrees
Shoulder: Flexion 160 degrees, extension 50 degrees
Elbow: Flexion 160 degrees, extension 160 degrees to 0 degrees
Wrist:Flexion 90 degrees, extension 70 degrees, abduction 55 degrees, adduction 20 degrees
Thumb: Proximal phalange: flexion 70 degrees; Distal phalange: flexion 90 degrees
Fingers: Proximal phalange: flexion 90 degrees, extension 30 degrees; Middle phalange: flexion 120 degrees; Distal phalange: flexion 80 degrees
Hip: Flexion (knee bent) 120 degrees, flexion (knee straight) 90 degrees, abduction 45 degrees, adduction 45 degrees
Knee:Flexion 120 degrees
Ankle:Dorsiflexion 20 degrees, plantar flexion 45 degrees, inversion 30 degrees, eversion 20 degrees
Great toe: Distal phalange: flexion 50 degrees; Proximal phalange: flexion 35 degrees, extension 80 degrees

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Range of motion and contractures

Thu, 26 Jan 2012 13:13:00 GMT

Assessment of joint range of motion is an important part of restorative nursing. You must have some type of baseline knowledge of the resident’s joint motion to show you have maintained or improved function.

Contractures caused by trauma or surgery form scar tissue consisting of thick collagen fibers. These differ from contractures that often develop in the facility, which result from immobility. The contractures are a shortening and deformity of muscles from lack of use. There are no thick collagen fibers. Because of this, treatment differs. Collagen fibers can be surgically released. Contractures resulting from immobility respond best to slow, gentle stretching and massage.

Other contracture facts include:

Residents can begin to develop contractures in as little as four days. Most nurses do not recognize a contracture until it limits joint movement to 45 degrees. Reversing a contracture at this point often takes months but can take years. Most contractures can be reversed if detected before the joint is immobilized completely.
Contractures occlude the capillaries in the joint.
Contractures are often painful, feeling much like cramps that athletes get from overexertion. As a result, contractures make caring for and positioning the resident much more difficult and painful.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.

Trainer's tip: Prevention and treatment of prerenal azotemia

Thu, 12 Jan 2012 14:56:00 GMT

Prerenal azotemia is a very serious condition that can cause permanent renal damage and failure. Being aware of the resident's risk factors, prevention of dehydration, and close monitoring are always best. Regularly monitor the at-risk resident’s laboratory values. Other nursing measures include:

Monitoring intake and output (I&O); never hesitate to order I&O as a nursing measure
Carefully evaluating fluid I&O every 24 hours and comparing with dietitian’s recommended fluid intake
Monitoring weight, vital signs, and level of consciousness
Encouraging fluids

The primary treatment goal of prerenal azotemia is to correct the cause as quickly as possible to prevent permanent kidney damage. Treatment often includes hemodialysis or peritoneal dialysis. The resident will be given IV fluids to increase and restore blood volume. Drugs are used to increase cardiac output. Prerenal azotemia is reversible if the cause is promptly identified and corrected within 24 hours.

This is an excerpt from the HCPro book, The Long-Term Care Nursing Desk Reference, Second Edition, by Barbara Acello, MS, RN.