BAY AREA COLLEGE OF NURSING

Module 8: Resident Care Skills

I. Terminology A. Abrasion B. Aspiration C. Axilla D. Catheter E. Colostomy F. Constipation G. Cyanosis H. Decubitus Ulcer I. Defection J. Dermis K. Diarrhea L. Elimination M. Epidermis N. Erythema O. Eschar P. Excoriation Q. Fecal R. Feces S. Flatulence T. Integumentary U. Necrosis V. Nits W. Oral Hygiene X. Ostomy Y. Perineum/perineal Z. Prosthesis AA. Pruritus BB. Impaction CC. Incontinence DD. Stoma EE.Stool FF. Urinal GG. Urinal Incontinence HH. Urination II. Urine II. Identify daily routine care for resident.

A. Each facility has specific policies and procedures related to AM care,

morning care and PM care. The following outline is an example:

1. Early morning (AM) care 2. Morning care after breakfast 3. Prepare for meals (lunch and dinner) III. Benefits of bathing and the five areas of the body that requires bathing daily A. Benefits of Bathing 1. Cleanliness 2. Reduce bacteria and germs 3. Promote skin integrity 4. Stimulate circulation 5. Provide movement and exercise 6. Relaxation 7. Sense of well-being 8. Opportunity for communication and observation B. Body areas that require bathing: 1. Face 2. Underarms (axilla) 3. Hands 4. Perineal area 5. Any area where skin folds or creases, e.g. under breast IV. General and safety guidelines for bathing residents A. General guidelines 1. Check with nurse regarding type of bath. 2. Refer to procedure manual, if necessary, for special baths. 3. Identify skin care products to be used. 4. Check residents personal choices. 5. Collect necessary equipment. 6. Provide privacy. 7. Assure adequate comfort, such as room temperature, freedom from drafts and adequately covered. 8. Use comfortable warm water; change it when it becomes soapy, dirty or cold. 9. Bath areas soiled by fecal material or urine with soap and water. 10.Wash from cleanest to dirtiest area. 11.Rinse off all soap. 12.Pat skin dry. B. Safety guidelines: 1. Monitor correct water temperature. 2. Use safety equipment, such as grab bars, nonskid surfaces, emergency call buttons and safety belts. 3. Stay with resident. 4. Use correct body mechanics. V. Providing privacy for residents during bathing A. Providing privacy during bathing: 1. Close door. 2. Pull curtain around resident.

3. Uncover only area being washed.

B. Facility policy may vary VI. Purposes and schedule for oral hygiene. A. Purpose of oral hygiene 1. Cleanliness of mouth and teeth 2. Prevention of mouth odor and infection 3. Prevention of tooth loss 4. Comfort 5. Pleasant taste 6. Improve taste of food B. When 1. 2. 3. to perform oral hygiene: On awakening After each meal At bedtime

C. Special circumstances 1. Unconscious 2. Mouth breather 3. O2 4. NG tube 5. Elevated temperature VII. Procedure for oral hygiene for a resident needing assistance and the unconscious individual

A.

Assisting with oral hygiene and mouth care of the unconscious resident (Refer to manual skills handout Assisting with Oral Hygiene (p.8.45) and Mouth Care of the Unconscious Resident (pp. 8.46 -8.47) B. Standard precautions while performing oral hygiene 1. Contact with mucous membranes 2. Gums may bleed 3. Pathogens may exist in the mouth. Examine oral cavity and report findings: 1. Report dry, cracked, swollen or blistered lips. 2. Report redness, swelling, sores or white patches in the mouth or on the tongue. 3. Report redness, swelling or bleeding of gums. 4. Report any observed damage to dentures.

C.

VIII. Cleaning and care of dentures

A. Steps denture care (Refer to manual skills handout Denture Care

(pp. 8.48 8.49) B. Carrying out the procedure using standard precautions. C. Examining oral cavity and reporting findings.

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The CNAs role and responsibility for resident nail care

A. Procedures for nail care (Refer to manual skills handout Nail Care
(pp. 8.50 8.51) B. Preventing infection, injury and odors. C. Guidelines: 1. Nails are easier to clean after soaking in warm, soapy water. 2. When trimming fingernails, be cautious to prevent damage to tissues. 3. Do not cut or trim toenails. 4. Report unusual conditions to RN such as redness or tenderness of finger tips, cuticles or toes. 5. Follow facility procedure. X. The CNAs role and responsibility for resident hair care

A.

Procedures for hair care (Refer to manual skills handout Combing the Residents Hair (p. 8.52) B. Shampoo (Refer to manual skills handout Shampoo of Bedridden Resident and Shampoo with Shower or Tub Bath (pp. 8.53 8.53) 1. Shower/tub, sink or bed 2. Procedures in shampooing bedridden residents 3. Procedures in shampooing in the shower or bath tub C. Medicinal shampoo 1. Purposes a. Eradicate lice, scabies or similar organisms b. Soothe/heal irritated skin/pruritus 2. Procedures a. Verify order for medicinal shampoo. b. Review and clarify manufacturers procedure for application. c. Follow universal precautions. d. Follow manufacturers directions for procedure. XI. Procedures for shaving a resident

A. Procedures for shaving a resident (Refer to manual skills handout

Shaving the Resident (pp. 8.56 8.57) B. Important for feeling of comfort and self-esteem. C. Guidelines: 1. Use either electric razor or safety razor (patient choice or facility policy).

2. If using an electric razor, use appropriate safety precautions for electrical equipment. 3. Safety razors can cause nicks and cuts use standard precautions to prevent contact with blood. XII. Functions of the integumentary system

A. Functions of the integumentary system (skin) 1. Provides protective barrier against microorganisms and infection. 2. Provides for sensory function to enable the body to feel pain and temperature. 3. Shields body tissue from injury. 4. Temperature regulation of heat and cold. 5. Eliminates waste products. 6. Produces Vitamin D for body use. 7. Helps maintain fluid balance by preventing fluid loss and perspiration. 8. It is the largest organ of the body. B. Epidermis is the top surface layer. C. Dermis is the second layer. D. Subcutaneous tissues are deeper tissues beneath the skin. XIII. Things the CNA can do to help maintain healthy skin A. B. C. D. Maintain skin health Maintain skin care Observe high-risk residents for potential problems Give special attention to bony prominences.

XIV. Three common age-related changes affecting the skin A. Excessively dry areas due to decrease in oil gland production B. Elasticity decreased, causing wrinkles C. Thinner layers with loss of fatty tissues for padding XV. Residents at risk for skin breakdown A. Factors that place residents at high risk for skin breakdown: 1. Mobility/sensory problems 2. Elimination 3. Fluid status 4. Nutrition/body fluid 5. Other predisposing factors XVI. Causes, signs and symptoms and areas of the body prone to decubitis ulcers. A. Three common conditions which can lead to decubitis ulcers:

1. Pressure leads to decreased blood flow and nutrition of an area resulting in tissue loss. 2. Excessively wet or dry skin. 3. Moving patients causing a shearing force. B. Signs and symptoms or stages: 1. Stage I a. Skin is not broken. The epidermis and dermis are intact. b. Erythema (redness) which does not resolve within 30 minutes.

2. Stage II a. Skin is not intact. The epidermis is damaged and part of the dermis can be involved. b. Skin can be blistered, cracked and open with erythema. c. No necrotic or dead tissue is present. d. Wound bed is moist, pink and painful. 3. Stage III a. Have a full-thickness skin loss with both epidermis and dermis gone. May not be painful. b. Can have part of dermis left with necrotic tissue. c. May or may not have necrotic tissue in deeper stage III. 4. Stage IV a. Involves subcutaneous tissues possible fatty tissue, muscle and/or bone. b. Can see pink healthy cells, necrotic tissue and eschar. c. Wound can tunnel or have undermining in skin surrounding wound. d. Risk that bone may become infected (osteomyelitis) XVII. General nursing measures to prevent and treat decubitis ulcers A. Nursing measures to prevent and treat decubitis ulcers: 1. Mobility/sensory 2. Elimination 3. Fluid status 4. Nutrition status/body fluid 5. Others B. Use of pressure-reducing devices 1. Nothing replaces basic nursing care. Still must turn, position and keep dry. 2. Types of pressure reducing devices a. Bed cradle b. Sheepskin c. Heel and elbow protectors shearing effect. d. Egg crate mattress e. Alternating pressure mattress f. Air fluidization bed g. Trochanter rolls h. Flotation pads or cushions

C. Legal and TQI issues XVIII. Clothing for the resident

A. Guidelines in selecting clothing for the resident:

1. 2. 3. 4. 5. Fits well Comfortable Easy to put on and off Neat In good condition

B. Factors that limit a residents ability to dress self 1. Limitation of body movement 2. Other factors 1. 2. 3. 4. 5. C. Guidelines on caring for residents clothing Label clothes with residents name and write on personal belongings list. Avoid cutting or tearing. Do not discard. Store in the residents unit. Fold neatly or hang on hangers in closet. 6. Find out whether family or facility will clean soiled clothing and put into dirty clothes container. 7. Assist resident or family to choose clothing that meets physical needs and looks good. 8. Do not use residents clothing or personal items for another resident. D. Purposes of encouraging a resident to dress in street clothes 1. How a resident looks has an effect and influence on dignity and self-esteem as well as how others perceive them. 2. Encourages independence in the residents activities in daily living (ADL). 3. Discourages incontinence. E. Guidelines for dressing and undressing a resident. 1. Provide for privacy. 2. Encourage the resident to do as much as possible. 3. Allow resident to choose what to wear. 4. Remove clothing from the strong or good side first. 5. Put clothing on weak side first. 6. Follow residents individual choices in the use of make-up, jewelry, perfume, etc. 7. While assisting resident, be gentle and pay attention to how you hold them. F. Procedures in dressing and undressing the resident (Refer to skills manual handout Dressing and Undressing the Resident (pp. 8.58 8.59) Two main ways the body eliminates waste A. Excreting bodily waste:

a. b.

Urinary elimination (urine) Bowel elimination (feces)

XX. Urinary elimination A. Urinary elimination 1. The body excretes 1000 to 15000 ml of urine/day. 2. Urine consists of the wastes and excess fluids which are filtered out of the blood stream by the kidneys and stored in the bladder. 3. Each resident has different urination needs. 4. It is important to keep the residents routine as normal as possible. B. Characteristics of normal urine 1. Clear 2. Amber (medium yellow color) 3. Mild odor

C. Usual frequency pattern for urination 1. Frequency for urination depends on: a. Amount of fluid ingested b. Personal habits c. Availability of toilet facilities d. Physical activities e. Illness/infection D. Frequency of urination ranges from every 2-3 hours to every 8-12 hours. E. Assist in the use of bedpan/urinal (Refer to skills manual handout Assist in the Use of Bedpan/Urinal (pp 8.60 8.62) F. Observations to be made about urine: 1. Color 2. Clarity 3. Odor 4. Amount G. Information that should be reported to the R.N. 1. Urine which appears abnormal: a. Cloudy b. Pinkish or reddish tint

2. Resident complaints: a. Urgency b. Burning on urination c. Difficulty in urinating d. Feeling of pressure in area of bladder e. Frequency f. Strong odor

XXI. Urinary incontinence and the need for immediate care A. Urinary incontinence 1. Definition: inability to control the passage of urine from the bladder a. Constant dribble b. Occasional dribble when laughing, coughing or sneezing c. No control 2. Causes: a. Central nervous system b. Spinal cord injury c. Aging d. Confusion e. Medications f. Weak pelvic muscles g. Urinary tract infection h. Prostate problems (male) i. Prolapsed uterus and bladder (female)

B. Immediate care is important because: 1. Embarrassment to the person 2. Development of odors 3. Resident is uncomfortable 4. Major cause for skin breakdown: a. Infection b. Irritation, redness or rashes 5. Diapering is to be avoided as it may cause low selfesteem and skin irritation and encourage incontinence. 6. Perineal care (Refer to skills manual handout Perineal Care (pp. 8.64 8.65) XXII. Definition and purpose of a catheter A. A catheter is a plastic or rubber tube used to drain or inject fluid through a body opening, most commonly used to drain the bladder; one end is placed in the bladder and the other end is attached by tubing to a drainage bag. B. Types: 1. Indwelling catheters: a. Foley b. Retention c. Suprapubic 2. Straight catheter C. Purpose is to drain bladder in the following situations: 1. Complete loss of bladder control 2. Urinary retention (inability to urinate) 3. Before, during and after surgical procedures

XXIII. Major complications resulting from catheters and the general rules of catheter care. 1. 2. A. Complication resulting from catheters: Bladder infection Blockage 3. Emptying urinary drainage bags (Refer to skills manual handout Empty Urinal Drainage Bags (p. 8.67) XXIV. Bladder training, goals and methods 1. 2. A. Bladder training Goal is voluntary control of bladder Two basic methods: a. Scheduled use of bedpan, urinal or toilet b. Clamping of catheter on a scheduled basis XXV. Normal stool and normal pattern of bowel movements A. Bowel Elimination the excretion of waste from the gastrointestinal system

1. Foods and fluids are taken through the mouth and partially digested. Waste products pass into the large intestine and are concentrated into feces for storage in the rectum. Defecation is the process of excreting feces (stool). 2. Normal stool: a. Brown b. Soft c. Formed d. Characteristic odor B. Pattern: each person is different and has own pattern 1. Frequency daily to every 2 to 3 days 2. Time of day morning or evening 3. The CNA should note stool shape, size, frequency, color, consistency, complaints of pain with defecation, etc. and report. C. Factors influencing bowel movements: 1. Privacy fear of others, hear or smell 2. Age more problems are encountered as one ages 3. Diet need balanced diet with regular meals; food stimulate bowel movement 4. Fluids adequate fluid intake 5. Activity 6. Medication most tend to cause constipation D. Common problems in elimination 1. Constipation 2. Fecal impaction

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3. Diarrhea 4. Anal incontinence 5. Flatulence E. General rules for maintaining normal elimination patterns of the resident 1. Provide bedpan, urinal or commode or help the resident to the bathroom when the request is made and do promptly. 2. Assist the resident to get into normal position (as much as possible or safe). 3. Cover the resident for privacy and warmth. 4. Remain nearby if the person is weak or frail. 5. Place the signal light and toilet tissue nearby. 6. Allow the person time to carry out the elimination process. 7. If resident has difficulty, ask them what kinds of things they did at home to assist them, i.e., running water, reading or looking at a magazine. 8. Provide perineal care if needed. 9. Offer the opportunity to eliminate at regular intervals. F. Assisting resident to commode/toilet. G. Bowel Training 1. Important aspects a. Control b. Regular pattern 2. Methods a. Suppository at a regular time b. Increase fluids c. Diet d. Activity e. Privacy XXVI. Purpose and type of ostomy and care of residents with ostomies A. Purpose of Ostomy 1. Artificial opening most commonly into colon or small intestine (some ostomies are for urinary drainage, i.e. nephrostomy, unreterostomy) 2. Urine, feces and flatus pass through opening 3. Allow healing of intestine after surgery or disease 4. Can be temporary or permanent B. Terms used with ostomy residents: 1. Stoma a piece of the intestine brought to the surface of the abdomen to allow for drainage a. Pink and moist b. Size and shape are different depending on area of intestine and resident. c. Can bleed when cleaned 2. Peistomal skin the skin around the stoma; it should be clean, intact and dry

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3. Appliance the wafer and pouch or bag which protects the residents skin and collects the drainage C. Brief review of small and large intestine anatomy and function 1. Small intestine a. About 20 feet long and - 1 1/2 wide b. Produces 1,500 3,000 cc digestive juices; very acidic and receives bile and pancreatic juices c. Has three sections: 1) duodenum 10 inch area 2) jejunum about 8 feet 3) ileum about 12 feet long *** jejunum and ileum are where most absorption take place 2. Large bowel or colon a. About 8 feet long and 1 - 2 wide b. Produces mucus to help bind stool and finish absorption of water and electrolytes. c. Has seven areas: 1) cecum pouch right after ileum 2) ascending up right side 3) transverse across top abdomen 4) descending down left side 5. sigmoid S curved area 6. rectum last 7 inches 7. anus

D. Type of stool drainage varies by area of colon 1. Names according to location: a) Colostemy 1) Ascending and transverse are like pureed liquid with slightly acidic content a. must wear pouch all the time b. chew food well with a lot of fluid 2) Descending and sigmoid a. stool formed and in low descending and sigmoid look normal b. pattern stool drainage every day or every other day c. may irrigate (enema) d. regular diet e. may wear small patch, not pouch b) Ileostomy on ileum 1) continuous puree stool with large acidic content; will become liquid if resident does not eat three meals a day 2) about 1000 1500 cc out everyday 3) empty pouch 2-4 hours or when half full 4) watch skin for irritation if there is leakage 5) very special diet, fluid and electrolyte problems c) Jejunostomy

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1) like ileostomy; only liquid output which drains 2000 3000 cc a day 2) hook pouch up to a Foley cath bag to help drainage 3) need IV nutrition to meet nutritional needs, as very little absorption takes place 2. Location depends on the disease or injury E. Ostomy care 1. Equipment: a) Soap and water b) Bag or pouch c) Wafer d) Wash cloth or paper towels e) Gloves f) Different types of appliances: 1) one piece a wafer and pouch together and cannot be reused 2) two piece a wafer that lasts 5-7 days and cannot be reused; the pouch can be taken off, emptied, cleansed and reused multiple times 2. Emptying of pouch: a) Check pouch every 2-4 hours and do not let the pouch get more than half full. b) If the pouch is reusable, empty and rinse over toilet with water, dry and reapply. c) Make sure seal is tight.

3. Skin care: a) Wash skin well with soap and water and dry well. b) Shave hair. 4. Odor management a) Everyones stool smells; ostomy residents are no different. b) There are sprays, tables, etc. to reduce the odor on the market. F. CNAs role in caring for residents with ostomy 1. CNAs role: a. Assist with personal hygiene. b. Provide for privacy. c. Change appliances. d. Emptying ostomy bag. e. Provide skin care. f. Use universal precautions. g. Encourage resident to assist in the care. h. Reinforce the teaching plan and material shared by the RN. i. Be aware of cultural differences in attitude about ostomies and their care. 1) Privacy

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2) Shame 3) Body Image 2. Refer to manual skills procedure handout Colostomy Care (pp. 8.67 8.68) XXVII. Measuring the residents weight and height A. Measuring weight: 1. Measured on admission and as ordered. 2. Wears gown or pajamas. 3. Should urinate before being weighed. 4. Do routine weights at the same time each day if ordered by physician. B. Refer to skills procedures handout for the following: 1. Weighing the resident using an upright scale (pp.8.69 8.70) 2. Weighing the resident in bed (pp. 8.71 8.72) 3. Measuring weight of resident in wheelchair (p. 8.73) 1. 2. C. Refer to skills procedure handout for measuring residents height: Measuring the residents height using an upright scale (p. 8.74) Measuring height of resident in bed (p. 8.75) XXVIII.Common prosthetic devices and their care (artificial limbs, hearing aids, contact lenses, eye glasses and dentures) A. Types of prosthetic devices cosmetic, adaptive and restorative; 1. Artificial limbs: arms and legs a. Specially fitted to the individual resident b. Nursing considerations: 1) Ask charge nurse for guidelines. 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) Observe residents ability to participate in ADLs, body positing and ambulation. Assist resident to apply brace as ordered. Maintain body alignment when in chair or bed. Keep call bell and personal items within reach. Assist resident with ROM to affected muscles. Assist resident with aids to foster ADL and independence. Pad brace, if necessary. Stump sock to reduce swelling. Give constant praise for rehabilitative efforts. Provide skin care at pressure points of device to prevent skin breakdown. Observe for complaint of arm/leg pain or numbness, or weakness with use of prosthetic device. Physical strengthening exercises are important for the non-involved extremities.

2. Contact lenses: a. Daily cleansing of contact lenses as directed. b. Special caution due to fragile nature of contact lenses.

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c. Store according to package directions. 3. Eyeglasses: a. Clean daily or as needed. b. Check for intact parts, such as temples and screws. c. Encourage resident to wear eyeglasses. d. Store with caution. e. Check food trays and bed linens for hidden eyeglasses. f. Label eyeglasses with residents identification. 4. Dentures: (Refer to the handout Oral Hygiene section (p.8.45)) a. Label denture storage container with residents name. b. Label dentures with residents identification. c. Encourage resident to wear dentures. d. Examine dentures for rough surfaces, breaks or cracks. Report findings to charge nurse. e. Handle with care and clean thoroughly before storing. 5. Hearing aids: a. Check the battery periodically. b. Do not drop or try to repair the device. c. Be sure to apply the device to the ear for which it is designated. d. Do not allow the device to get wet. B. Prosthetic devices help maintain independent functioning and resident self-esteem. XXIX. Hearing aid A. Guidelines: 1. The purpose of the hearing aid is to restore hearing. 2. Even the best hearing aid cannot restore full, normal hearing ability. The resident may still have trouble hearing. 3. Always face the resident when talking to him or her and speak clearly. B. Parts of a hearing aid: Microphone - changes sound waves into electric signals and transmits sound Amplifier uses battery energy to make the sound signals strong 3. Earmold channels the sound through the external ear canal to the ear drum (tympanic membrane) 4. Cord connects the amplifier to the earmold 5. On/off switch controls volume C. Placement of the hearing aid: 1. Turn down the volume before placing the hearing aid in the external ear canal. It should fit tightly but comfortably. After the hearing aid is in place, turn it on and adjust the volume so that resident can hear in a normal tone. The resident will tell you when he or she can hear comfortably.

1. 2.

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2. If the resident complains of an unpleasant whistle or squeal, check the placement in the ear and for a crack or break in the earmold or wire. D. Checking the batteries: 1. Before applying a hearing aid, check the batteries. Be sure they are the right size for the hearing aid. The battery case must close easily or something is wrong. 2. To test the batteries, place the control switch to turn on and turn up the volume control. Cup your hand over the hearing aid and you should hear a whistle. If you do not hear the whistle, change the batteries. 3. If the resident complains the he or she cannot hear any sound, first remove the hearing aid and check the batteries for freshness. If the batteries are fresh, then check to see if the hearing aid is broken. 4. If the resident complains of hearing only intermittent sound, remove and check the batteries.

E. Refer to manual skills procedure Removing a Behind-the-Ear

Hearing Aid and Applying a Behind-the-Ear Hearing Aid (pp.8.76 8.77) F. Caring for the hearing aid 1. Caution: Never wash a hearing aid. This should be sent to the dealer for cleaning. 2. Never drop the hearing aid. 3. Do not expose the hearing aid to heat. 4. Do not let moisture get into the hearing aid. 5. Do not use any kind of hair spray or medical spray on a resident while he/she is wearing the hearing aid. The spray can clog the microphone opening. 6. Check food trays and bed linens for lost hearing aids. 1. G. Storage of a hearing aid: Turn the hearing aid off when not in use. 2. Remove the battery from the battery case when not in use and leave the case open. 3. Store hearing aid in a well-marked container labeled with residents name and room number. 4. Label hearing aid with residents name.

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