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1. Each training entity shall have a qualified Program Director, who possesses, at minimum, the following:
   1. A current Indiana Registered Nurse license (IC 25-23-1-1).
   2. A minimum of two years of licensed nurse's experience, of which at least one year must be in the provision of long term care services.
   3. Documentation of completion in a course in teaching adults.
   4. Have a completed application for approval as a program director on file at the ISDH with all the required documentation.
   5. Be approved by the ISDH Division of Long Term Care Training Section as a program director.
   6. A vocational teacher's license will substitute for the required training in teaching adults.

2. The program director is to be directly accountable for the program development and is also accountable for the classroom instruction and clinical training provided to the students.

3. In a facility based program, the Director of Nursing may be the program director, and the Director of Nursing in these cases is prohibited from doing any of the classroom and clinical training. If the Director of Nursing is the program director, a delegated instructor must teach the entire nurse aide training course and will conduct the supervision of the clinical experience.

4. A delegated instructor must meet all of the following minimal requirements:
   1. Be a Registered Nurse or Licensed Practical Nurse licensed and in good standing in the State of Indiana.
   2. Have a minimum of one year of licensed nurse experience.
   3. Have completed a course in teaching adults.
   4. A vocational teacher's license will substitute for the required training in teaching adults.

5. Other qualified personnel that may participate in the training of nurse aides may include individuals that are qualified either through education or certification. These individuals must have at least one year of experience in their chosen field, and cannot exceed their scope of practice. Examples of these personnel are, but not limited to:
   1. Pharmacist
   2. Dietician
   3. Social Worker
   4. Sanitarian
   5. Gerontologist
   6. Psychologist
   7. Nursing home administrator
   8. Therapist:
      1. Physical
      2. Occupational
      3. Speech and language
      4. Activity

STANDARD 2. SITE APPROVAL

1. Each training entity providing the certified nurse aide training program must meet all of the following minimal requirements:
   1. Have on file a completed Application for Approval 105 Hour Nurse Aide Training (state form 629) at the ISDH.
   2. Have written approval from the ISDH to offer the nurse aide training programs.
   3. Must be in compliance with 42 CFR 483.151 regarding nurse aide training.
   4. Be a licensed long term care facility as required by 410 IAC 16.2 or
   5. An Indiana Vocational School governed by the Department of Education or an accrediting board of a school of nursing or
   6. Be a non-facility based program not participating in Medicare or Medicaid or
   7. A state hospital licensed under 410 IAC 16.2.
   8. Meet all the requirements in Standard 2C of this document.

2. All training entities offering the 105 hour nurse aide training program must have a designated classroom which meets all of the following requirements:
   1. Be in a quiet area that is conducive to adult learning.
   2. Be well illuminated and ventilated.
   3. Have sufficient space to meet the educational needs of the student.
   4. Have necessary supplies and equipment to train nurse aides.
   5. Cannot interfere with normal resident activities.
   6. If the classroom is held in another location, other than the facility, the training entity will ensure the classroom meets the above requirements.
   7. No classroom will be held in a facility that does not meet the requirements of 42 CFR 483.151 and 483.152 or has had its ability to train nurse aides revoked for any reason.

3. An approved training entity must have one or more approved clinical sites which meet all of the following minimal requirements:
   1. Be in a licensed long term care facility under 410 IAC 16.2 or state hospital.
   2. Meet the requirements of 42 CFR 483.151 and 483.152.
   3. The clinical site(s) must not have had their ability to train nurse aides revoked for any reason.
   4. In the event the ability to train nurse aides is revoked during a clinical rotation, that rotation may be completed; however, no other classes or clinical rotations may be initiated for a minimum of two (2) years.

STANDARD 3. CLASSROOM INSTRUCTION

1. All classroom instruction must be held in accordance with Section 11B of this document and meet all of the following minimal requirements:
   1. Be at least thirty hours classroom instruction, of which a minimum of sixteen (16) hours must be conducted prior to any resident contact as outlined in 410 IAC, and
   2. Must meet the course content standards.
   3. Must be provided in accordance with Standard 1 of this document.

2. Students must meet the following minimal requirements:
   1. Be able to add and subtract simple equations.
   2. Be able to read and write English.
   3. It is encouraged, but not mandated, that the student be a high school graduate, or have a GED.
   4. In cases of students who are enrolled in a Health Occupation Educational (HOE) program, the program must be approved by the ISDH as an approved nurse aide training entity.

STANDARD 4. CLINICAL INSTRUCTION

All students completing the 30 hours of classroom and seeking placement on the Nurse Aide Registry, must complete a clinical rotation which:

1. Is in accordance with Section II B and C of this document.
2. Is in accordance with 410 IAC 16.2.1.14.
3. Is completed in its entirety in an approved clinical site of the training entity where the classroom was conducted.
4. Is conducted utilizing the Resident Care Procedures (RCP) checklists.
5. Consists of no less than 75 hours in length.
6. Must be under the general supervision of the program director that is responsible for the development of the clinical skills used by the students during the clinical rotation.
7. Must be supervised by a licensed nurse.
8. Meets the requirements for PPD administration as set forth in 10 IAC 16.2.1.14.t.

STANDARD 5. STUDENT FILES

Each student trained as a nurse aide by an approved training entity will have an organized, individualized student file. These files will be kept for a minimum of five (5) years, or three (3) years beyond the employment of the nurse aide, whichever is greater. The files will contain, at minimum, the following:

1. Individualized documentation of the actual time frames for the classroom training.
2. Any and all assessment tools utilized during the classroom portion of the course.
3. PPD and physical examinations.
4. Individualized documents of the actual time frames of the clinical experience, including procedures and activities completed during the clinical experience. Time cards are not acceptable.
5. The student's completed "RCP" checklists.
6. A copy of the application submitted for testing.
7. All testing data, including pass/fail documentation. If the training entity tests their own students, the actual answer sheet and skills final examination documentation will be kept in the file.
8. Copies of certificates or letters of completion, confirming the student has Successfully completed the Indiana State Department of Health 105 hour Nurse Aide Training Program, signed and dated by the program director. This certificate or letter must bear the name and address of the training entity.
9. Nurse Aide Registry verification, including out-of-state verification, if appropriate.
10. Proof of placement on the Nurse Aide Registry.

STANDARD 6. TESTING REQUIREMENTS

All long term care facilities governed by 410 IAC 16.2 and state hospitals must utilize the state approved testing entity for all final testing. All students must have their testing applications submitted to the testing entity within 30 days after completion of the classroom and clinical experience.

Non-facility and vocational schools may administer the ISDH final examinations as long as the school/entity meets the requirements of the ISDH and 42 CFR 483.154.

STANDARD 7. TESTING PROCEDURES FOR SPECIAL CONSIDERATIONS

After completion of the course, students who choose not to work as a nurse aide and take the final examinations immediately, will be given their application for testing. These students may have up to 24 months after completion of the course to sit for the final examinations and be placed on the Nurse Aide Registry upon successful completion of the final examinations.

Out-of-state nurse aides who are current and in good standing on another state's Nurse Aide Registry may be permitted to challenge the ISDH nurse aide training program through reciprocity. These individuals will be required to take the 100 question written examination, and the optional skills final examination, at the discretion of the hiring facility.

Student nurses that do not pass the state nursing boards may be placed on the Nurse Aide Registry after successfully completing both the written and skills final examinations.

Student nurses currently enrolled in nursing school, who have successfully completed the Fundamentals of Nursing with a "C" or above, may be placed on the Nurse Aide Registry, after successfully completing the written final examination, and the optional skills final examination, at the discretion of the hiring facility.

STANDARD 8. FEE ASSESSMENT

All training entities will abide with the prohibition of charging for training of nurse aides as set forth in 42 CFR 483.158.

STANDARD 9. REGISTRY PLACEMENT

Immediately following successful testing, the testing entity shall submit the application for registry placement to the ISDH as described in CFR 483.154.

STANDARD 10. REVOCATION OF APPROVAL TO TRAIN NURSE AIDES

The state must remove the approval to train nurse aides from any training entity that does not meet the requirements of 42 CFR 483.151.

The state may revoke the training approval from any training entity that refuses unannounced visits by the ISDH.

The state may revoke the training approval from any training entity that refuses to submit an acceptable plan of correction to an ISDH survey.

The state may revoke the training approval from any program/instructor in which training improprieties are validated. In addition, the state may revoke the training approval for program directors/instructors and or sites where there has been a pattern of excessive failure rates established.

The state may revoke the training approval from any entity, program director and/or instructor where falsification of any documents pertaining to the nurse aide training is validated.

The state may revoke the testing and/or training approval from any training entity where an issue of breach of test security is validated. All training entities testing their own students must abide by the test security policies set by the ISDH.

STANDARD 11. PROGRAM APPROVAL

The state will require all training entities requesting initial approval and any changes in program director(s), instructor(s), or clinical sites prior to the actual change submit an application for Approval 105 Nurse Aide Training (state form 629). The training entity must have written approval before any changes in the training program can occur. Students that are trained in training entities that have not notified the ISDH of the changes in the program will not be allowed to sit for the final testing and will have to be retrained as a nurse aide.

The state will approve training programs and changes as set forth in 42 CFR 483.151.

STANDARD 12. MASTER SCHEDULE

All non-facility based programs must submit an ISDH Basic Nurse Assistant Training Program Master Schedule of all classes ten (10) days prior to the beginning of each class.

STANDARD 13. TEST SECURITY

All testing entities will abide by the testing agreement and test security procedures set forth by the ISDH.

STANDARD 14. NURSE AIDE SCOPE OF PRACTICE

The nurse aide will perform only the tasks in the course standards and Resident Care Procedures manual.

The nurse aide will not perform any invasive procedures, including enemas and rectal temperatures, checking for and/or removing fecal impactions, instillation of any fluids, through any tubing, administering vaginal or rectal installations.

The nurse aide will not administer any medications, perform treatments, or apply or remove any dressings.

    (2) Reviewing, evaluating, and implementing resident care policies 
        and procedures and to guide the director of nursing services in matters 
        related to resident care policies and services.
    (3) Reviewing incidents and accidents that occur on the premises to 
        identify hazards to health and safety.
    (4) Reviewing employees preemployment physicals and health reports, 
        and monitoring employees health status.
    (5) The coordination of medical care in the facility.
    (w)For purposes of IC 16-28-5-1, a breach of:
    (1) subsection (a), (c), (g), (r), (t), (u), or (v) is a deficiency;
    (2) subsection (b), (d), (e), (f), (i), (l), (p), (q), or (s) is a  
        noncompliance; and
    (3) subsection (h), (j), (k), (m), (n), or (o) is a nonconformance.
(Indiana State Department of Health; 410 IAC 16.2-3.1-13)

410 IAC 16.2-3.1-14 Personnel
  Authority: IC 16-28-1-7; IC 16-28-1-12
  Affected: IC 16-28-5-1; IC 16-28-13-3

  Sec. 14. (a) Each facility shall have specific procedures written and 
implemented for the screening of prospective employees.  Specific inquiries shall  
be made for prospective employees. The facility shall have a personnel policy that 
considers references and any convictions in accordance with IC 16-28-13-3.
  (b) A facility must not use any individual working in the facility as a nurse 
aide for more than four (4) months on a full time, part time, temporary, per diem,  
or other basis unless that individual:
  (1) is competent to provide nursing and nursing-related services; and
  (2) has completed a training and competency evaluation program 
      approved by the division or a competency evaluation program
      approved by the division.
  (c) Each nurse aide who is hired to work in a facility shall have successfully 
completed a nurse aide training program approved by the division or shall enroll  
in the first available approved training program scheduled to commence within 
sixty (60) days of the date of the nurse aide's employment. The program may be 
established by the facility or by an organization or institution. The training 
program shall consist of at least the following:
  (1) Thirty (30) hours of classroom instruction within one hundred twenty 
      (120) days of employment. At least sixteen (16) of those hours shall be 
      in the following areas prior to any direct contact with a resident:
      (A)      Communication and interpersonal skills.
      (B)      Infection control.
      (C)      Safety/emergency procedures, including the Heimlich 
               maneuver.
      (D)      Promoting resident's independence.
      (E)      Respecting residents' rights.
  (2) The remainder of the thirty (30) hours of instruction shall include the 
      following:
      (A) Basic nursing skills as follows:
          (i)     Taking and recording vital signs.
          (ii)    Measuring and recording height and weight.
          (iii)   Caring for residents' environment.
          (iv)    Recognizing abnormal changes in body functioning and 
                  the importance of reporting such changes to a supervisor.
          (v)     Caring for residents when death is imminent.
      (B) Personal care skills, including, but not limited to, the following:
          (i)     Bathing.
          (ii)    Grooming, including mouth care.
          (iii)   Dressing.
          (iv)    Toileting.
          (v)     Assisting with eating and hydration.
          (vi)    Proper feeding techniques.
          (vii)   Skin care.
          (viii)  Transfers, positioning, and turning.
      (C) Mental health and social service needs as follows:
          (i)     Modifying aides' behavior in response to residents' 
                  behavior.
          (ii)    Awareness of developmental tasks associated with the 
                  aging process.
          (iii)   How to respond to residents' behavior.
          (iv)    Allowing the resident to make personal choices, 
                  providing and reinforcing other behavior consistent with 
                  the resident's dignity.
          (v)     Using the resident's family as a source of emotional 
                  support.
      (D) Care of cognitively impaired residents as follows:
          (i)     Techniques for addressing the unique needs and 
                  behaviors of individuals with dementia (Alzheimer's and 
                  others).
          (ii)    Communicating with cognitively impaired residents.
          (iii)   Understanding the behavior of cognitively impaired 
                  residents.
          (iv)    Appropriate responses to the behavior of cognitively 
                  impaired residents.
          (v)     Methods of reducing the effects of cognitive impairments.
      (E) Basic restorative services as follows:
          (i)     Training the resident in self-care according to the 
                  resident's abilities.
          (ii)    Use of assistive devices in transferring, ambulation, 
                  eating, and dressing.
          (iii)   Maintenance of range of motion.
          (iv)    Proper turning and positioning in bed and chair.
          (v)     Bowel and bladder training.
          (vi)    Care and use of prosthetic and orthotic devices.
      (F) Residents' rights as follows:
          (i)     Providing privacy and maintenance of confidentiality.
          (ii)    Promoting residents' right to make personal choices to 
                  accommodate their needs.
          (iii)   Giving assistance in resolving grievances and disputes.
          (iv)    Providing needed assistance in getting to and 
                  participating in resident and family groups and other 
                  activities.
          (v)     Maintaining care and security of residents' personal 
                  possessions.
          (vi)    Promoting residents' right to be free from abuse, 
                  mistreatment, and neglect, and the need to report any 
                  instances of such treatment to appropriate facility staff.
          (vii)   Avoiding the need for restraints in accordance with 
                  current professional standards.
    (3)  The thirty (30) hours may not be counted toward the facility's 
         required staffing.
    (4)  Seventy-five (75) hours of supervised clinical experience, at least 
         sixteen (16) hours of which must be in directly supervised practical 
         training. As used in this subdivision, "directly supervised practical 
         training" means training in a laboratory or other setting in which the 
         trainee demonstrates knowledge while performing tasks on an 
         individual under direct supervision of a registered nurse or a licensed 
         practical nurse. These hours shall consist of normal employment as a 
         nurse aide under the supervision of a licensed nurse. The seventy-five 
         (75) hours shall be counted toward the facility's required staffing.
    (5)  Training that ensures the following:
      (A)   Students do not perform any services for which they have not 
            trained and been found proficient by the instructor.
      (B)   Students who are providing services to residents are under the 
            general supervision of a licensed nurse.
    (d) A facility must arrange for individuals used as nurse aides as of the 
effective date of this rule, to participate in a competency evaluation program 
approved by the division, and preparation necessary for the individual to 
complete the program.
    (e) Before allowing an individual to serve as a nurse aide, a facility must 
receive registry verification that the individual has met competency evaluation 
requirements unless:
    (1)  the individual is a full-time employee in a training and competency 
         evaluation program approved by the division; or
    (2)  the individual can prove that he or she has recently successfully 
         completed a training and competency evaluation program approved 
         by the division and has not yet been included in the registry.
Facilities must follow up to ensure that such individual actually becomes 
registered.
    (f) A facility must check with all state nurse aide registries it has reason 
to believe contain information on an individual before using that individual 
as a nurse aide.
    (g) If, since an individual's most recent completion of a training and 
competency evaluation program, there has been a continuous period of twenty-four 
(24) consecutive months during none of which the individual provided nursing or 
nursing-related services for monetary compensation, the individual must complete 
a new training and competency evaluation program or a new competency evaluation 
program.
    (h) The facility must complete a performance review of every nurse aide at 
least once every twelve (12) months, and must provide regular in-service 
education based on the outcome of these reviews. The in-service training must 
be as follows:
    (1)    Sufficient to ensure the continuing competence of nurse aides, but 
           must be no less than twelve (12) hours per year.
    (2)    Address areas of weakness as determined in nurse aides' performance 
           reviews and may address the special needs of residents as determined 
           by the facility staff.
    (3)    For nurse aides providing services to individuals with cognitive 
           impairments, also address the care of the cognitively impaired.
    (i) The facility must ensure that nurse aides and qualified medication 
aides are able to demonstrate competency in skills and techniques necessary to 
care for residents' needs, as identified through resident assessments, and 
described in the care plan.
    (j) Medication shall be administered by licensed nursing personnel or 
qualified medication aides. If medication aides handle or administer drugs or 
perform treatments requiring medications, the facility shall ensure that the 
persons have been properly qualified in medication administration by a state-
approved course. Injectable medications shall be given only by licensed 
personnel.
    (k) There shall be an organized ongoing in-service education and training 
program planned in advance for all personnel. This training shall include, but  
not be limited to, the following:
    (1)    Resident rights.
    (2)    Prevention and control of infection.
    (3)    Fire prevention.
    (4)    Safety and accident prevention.
    (5)    Needs of specialized populations served.
    (l) The frequency and content of in-service education and training programs 
shall be in accordance with the skills and knowledge of the facility personnel 
as follows. For nursing personnel, this shall include at least twelve (12) hours 
of in-services per calendar year and six (6) hours of in-service per calendar 
year for nonnursing personnel.
    (m) In-service programs for items required under subsection (k) shall 
contain a means to assess learning by participants.
    (n) The administrator may approve attendance at outside workshops and 
continuing education programs related to that individual's responsibilities in  
the facility. Documented attendance at these workshops and programs meets the 
requirements for in-service training.
    (o) In-service records shall be maintained and shall indicate the following:
    (1)    The time, date, and location.
    (2)    Name of the instructor.
    (3)    The title of the instructor.
    (4)    The name of the participants.
    (5)    The program content of in-service.
The employee will acknowledge attendance by written signature.
    (p) Initial orientation of all staff must be conducted and documented and 
shall include the following:
    (1)    Instructions on the needs of the specialized population(s) served in 
           the facility, for example, aged, developmentally disabled, mentally 
           ill, or children.
    (2)    A review of residents' rights and other pertinent portions of the 
           facility's policy manual.
    (3)    Instruction in first aid, emergency procedures, and fire and disaster 
           preparedness, including evacuation procedures and universal 
           precautions.
    (4)    A detailed review of the appropriate job description, including a 
           demonstration of equipment and procedures required of the specific 
           position to which the employee will be assigned.
    (5)    Review of ethical considerations and confidentiality in resident care 
           and records.
    (6)    For direct care staff, instruction in the particular needs of each 
           resident to whom the employee will be providing care.
    (q) Each facility shall maintain current and accurate personnel records for 
all employees. The personnel records for all employees shall include the 
following:
    (1)    Name and address of employee.
    (2)    Social Security number.
    (3)    Date of beginning employment.
    (4)    Past employment, experience, and education if applicable.
    (5)    Professional licensure, certification, or registration number if 
           applicable.
    (6)    Position in the facility and job description.
    (7)    Documentation of orientation to the facility and to the specific  
           job skills.
    (8)    Signed acknowledgment of orientation to resident rights.
    (9)    Performance evaluations in accordance with the facility's policy.
    (10)   Date and reason for separation.
    (r) The employee's personnel record shall be retained for at least three 
(3) years following termination or separation of the employee from employment.
    (s) Professional staff must be licensed, certified, or registered in 
accordance with applicable state laws or rules.
    (t) A physical examination shall be required for each employee of a facility 
at the time of employment. The examination shall include a tuberculin skin test, 
using the Mantoux method (5 TU PPD), administered by persons having documentation 
of training from a department-approved course of instruction in intradermal 
tuberculin skin testing, reading, and recording unless a previously positive 
reaction can be documented. The result shall be recorded in millimeters of 
induration with the date given, date read, and by whom administered. The 
facility must assure the following:
    (1)    At the time of employment, and at least annually thereafter, 
           employees and nonpaid personnel of facilities shall be screened for 
           tuberculosis. For health care workers who have not had a documented 
           negative tuberculin skin test result during the preceding twelve (12) 
           months, the baseline tuberculin skin testing should employ the two-
           step method. If the first step is negative, a second test should be 
           performed one (1) to three (3) weeks after the first step. The 
           frequency of repeat testing will depend on the risk of infection with 
           tuberculosis.
    (2)    All employees who have a positive reaction to the skin test shall be 
           required to have a chest x-ray and other physical and laboratory 
           examinations in order to complete a diagnosis.
    (3)    The facility shall maintain a health record of each employee that 
           includes:
           (A)  a report of the preemployment physical examination; and
           (B)  reports of all employment-related health examinations.
    (4)    An employee with symptoms or signs of active disease, (symptoms 
           suggestive of active tuberculosis, including, but not limited to cough, 
           fever, night sweats, and weight loss) shall not be permitted to work 
           until tuberculosis is ruled out.
    (u) For purposes of IC 16-28-5-1, a breach of:
    (1)    subsection (c), (e), (f), (g), (i), (j), or (s) is a deficiency;
    (2)    subsection (a), (b), (d), (h), (k), (l), (m), (n), (o), (p), or 
           (t) is a noncompliance; and
    (3)    subsection (q) or (r) is a nonconformance.
(Indiana State Department of Health; 410 IAC 16.2-3.1-14)

48918  Federal Register / Vol. 56, No. 187 / Thursday, September 26, 1991 / Rules and Regulations
2. A new § 431.120 is added to subpart C to read as follows: § 431.120 State requirements with respect to nursing facilities.   (a) State plan requirements. A State plan must—   (1) Provide that the requirements of subpart D of part 483 of this chapter are met; and   (2) Specify the procedures and rules that the State follows in carrying out the specified requirements, including review and approval of State-operated programs.   (b) Basis and scope of requirements. The requirements set forth in part 483 of this chapter pertain to the following aspects of nursing facility services and are required by the indicated sections of the Act.   (1) Nurse aide training and competency programs, and evaluation of nurse aide competency (1919(e)(1) of the Act).   (2) Nurse aide registry (1919(e)(2) of the Act). PART 433--STATE FISCAL ADMINISTRATION   B. Part 433 is amended as follows:   1. The authority citation for part 433 is revised to read as follows:   Authority: Secs. 1102, 1137, 1902(a)(4), 1902(a)(25), 1902(a)(45), 1903(a)(3), 1903(d)(2), 1903(d)(5), 1903(o), 1903(p), 1903(r), 1912 and 1919(e) of the Social Security Act; 42 U.S.C. 1302, 1320b-7, 1396a(a)(4), 1396a(a)(25), 1396a(a)(45), 1396b(a)(3), 1396b(d)(2), 1396b(d)(5), 1396b(o), 1396b(p), 1396b(r) and 1396k, unless otherwise noted.   2. Section 433.15 is amended by adding a new paragraph (b)(8) to read as follows: § 433.15 Rates of FFP for administration. * * * * *   (b) * * *   (8) Nurse aide training and competency evaluation programs and competency evaluation programs described in 1919(e)(1) of the Act: for calendar quarters beginning on or after July 1, 1988 and before July 1, 1990: The lesser of 90% or the Federal medical assistance percentage plus 25 percentage points; for calendar quarters beginning on or after October 1, 1990: 50%. (Section 1903(a)(2)(B) of the Act.) PART 483-Requirements for States And Long Term Care Facilities     C. Part 483 is amended as follows:	1. The heading of part 483 is revised to read as set forth above.   1a. The authority citation for part 483 is revised to read as follows:   Authority: Secs. 1102, 1819(a)-(f), 1905(c) and (d), and 1919(a)-(f) of the Social Security Act (42 U.S.C. 1302, 1395i(3)(a)-(f), 1396d (c) and (d), and 1396r(a)-(f)).   2. The table of contents for part 483 is amended by redesignating existing subpart D (consisiting of §§ 483.400- 483.480), Conditions of Participation for Intermediate Care Facilities for the Mentally Retarded, as subpart I, and adding a new subpart D containing §§ 483.150 through 483.158 to read as follows: * * * * * Subpart D-Requirements That Must Be Met by States and State Agencies: Nurse Aide Training and Competency Evaluation Sec. 483.150 Deemed meeting of requirements,    waiver of requirements. 483.151 State review and approval of nurse    aide training and competency evaluation    programs. 483.152 Requirements for approval of a    nurse aide training and competency    evaluation program. 483.154 Nurse aide competency evaluation. 483.156 Registry of nurse aides. 483.158 FFp for nurse aide training and    competency evaluation. Subpart B--Requirements for Long Term Care Facilities   3. In subpart B, the heading of § 483.75 is revised, the introductory text is republished and paragraph (e) is revised to read as follows: § 483.75 Administration.   A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psycho-social well-being of each resident. * * * * *   (e) Required training of nursing aides— (1) Definitions.   Licensed health professional means a physician; physician assistant; nurse practitioner; physical, speech, or occupational therapist; physical or occupational therapy assistant; registered professional nurse; licensed practical nurse; or licensed or certified social worker.   Nurse aide means any individual providing nursing or nursing-related services to residents in a facility who is not a licensed health professional, a registered	dietitian, or someone who volunteers to provide such services without pay.   (2) General rule. A facility must not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless:   (i) That individual is competent to provide nursing and nursing related services; and   (ii)(A) That individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State as meeting the requirements of §§ 483.151– 483.154 of this part; or   (B) That individual has been deemed or determined competent as provided in § 483.150 (a) and (b).   (3) Non-permanent employees. A facility must not use on a temporary, per diem, leased, or any basis other than a permanent employee any individual who does not meet the requirements in paragraphs (e)(2) (i) and (ii) of this section.   (4) Competency. A facility must not use any individual who has worked less than 4 months as a nurse aide in that facility unless the individual—   (i) Is a full-time employee in a State- approved training and competency evaluation program;   (ii) Has demonstrated competence through satisfactory participation in a State-approved nurse aide training and competency evaluation program or competency evaluation program; or   (iii) Has been deemed or determined competent as provided in § 483.150 (a) and (b).   (5) Registry verification. Before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met competency evaluation requirements unless—   (i) The individual is a full-time employee in a training and competency evaluation program approved by the State; or   (ii) The individual can prove that he or she has recently successfully completed a training and competency evaluation program or competency evaluation program approved by the State and has not yet been included in the registry. Facilities must follow up to ensure that such an individual actually becomes registered.   (6) Multi-State registry verification. Before allowing an individual to serve as a nurse aide, a facility must seek information from every State registry established under sections 1819(e)(2)(A) or 1919(e)(2)(A) of the Act the facility believes will include information on the individual.   (7) Required retraining. If, since an individual's most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual provided nursing or nursing-related services for

 

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monetary compensation, the individual must complete a new training and competency evaluation program or a new competency evaluation program.   (8) Regular in-service education. The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. The in-service training must—   (i) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year;   (ii) Address areas of weakness as determined in nurse aides' performance reviews and may address the special needs of residents as determined by the facility staff; and   (iii) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.   4. Subpart D of part 483 is redesignated as subpart I and a new subpart D (§§ 483.150 through 483.156) is added to read as follows: Subpart D—Requirements That Must Be Met by States and State Agencies: Nurse Aide Training and Competency Evaluation § 483.150 Statutory basis; Deemed meeting or waiver of requirements.   (a) A nurse aide is deemed to satisfy the requirement of completing a training and competency evaluation approved by the State if he or she successfully completed a training and competency evaluation program before July 1, 1989 if—   (1) The aide would have satisfied this requirement if—   (i) At least 60 hours were substituted for 75 hours in sections 1819(f)(2) and 1919(f)(2) of the Act, and   (ii) The individual has made up at least the difference in the number of hours in the program he or she completed and 75 hours in supervised practical nurse aide training or in regular in-service nurse aide education; or   (2) The individual was found to be competent (whether or not by the State) after the completion of nurse aide training of at least 100 hours duration.   (b) Waiver of requirements. A State may—   (1) Waive the requirement for an individual to complete a competency evaluation program approved by the State for any individual who can demonstrate to the satisfaction of the State that he or she has served as a nurse aide at one or more facilities of the same employer in the state for at	least 24 consecutive months before December 19, 1989; or   (2) Deem an individual to have completed a nurse aide training and competency evaluation program approved by the State if the individual completed, before July 1, 1989, such a program that the State determines would have met the requirements for approval at the time it was offered.   § 483.151 State review and approval of nurse aide training and competency evaluation programs and com-petency evaluation programs.   (a) State review and administration. (1) The State—   (i) Must specify any nurse aide training and competency evaluation pro-grams that the State approves as meeting the requirements of § 483.152 and/or competency evaluations programs that the State approves as meeting the requirements of § 483.154; and   (ii) May choose to offer a nurse aide training and competency evaluation program that meets the requirements of § 483.152 and/or a competency evaluation program that meets the requirements of § 483.154.   (2) If the State does not choose to offer a nurse aide training and competency evaluation program or competency evaluation program, the State must review and approve or disapprove nurse aide training and competency evaluation programs and nurse aide competency evaluation programs upon request.   (3) The State survey agency must in the course of all surveys, determine whether the nurse aide training and competency evaluation requirements of § 483.75(e) are met.   (b) Requirements for approval of programs. (1) Before the State approves a nurse aide training and competency evaluation program or competency evaluation program, the State must—   (i) Determine whether the nurse aide training and competency evaluation program meets the course requirements of §§ 483.152:   (ii) Determine whether the nurse aide competency evaluation program meets the requirements of § 483.154; and   (iii) In all reviews other than the initial review, visit the entity providing the program.   (2) The State may not approve a nurse aide training and competency evaluation program or competency evaluation program offered by or in a facility which, in the previous two years—   (i) In the case of a skilled nursing facility, has operated under a waiver under section 1819(b)(4)(C)(ii)(II) of the Act;	(ii) In the case of a nursing facility, has operated under a waiver under section 1919(b)(4)(C)(ii) of the Act that was granted on the basis of a demonstration that the facility is unable to provide nursing care required under section 1919(b)(4)(C)(i) of the Act for a period in excess of 48 hours per week;   (iii) Has been subject to an extended (or partial extended) survey under sections 1819(g)(2)(B)(i) or 1919(g)(2)(B)(i) of the Act;   (iv) Has been assessed a civil money penalty described in section 1819(h)(2)(B)(ii) of 1919(h)(2)(A)(ii) of the Act of not less than $5,000; or   (v) Has been subject to a remedy described in sections 1819(h)(2)(B) (i) or (iii), 1819(h)(4), 1919(h)(1)(B)(i), or 1919(h)(2)(A) (i), (iii) or (iv) of the Act.   (3) A State may not, until two years since the assessment of the penalty (or penalties) has elapsed, approve a nurse aide training and competency evaluation program or competency evalua-tion program offered by or in a facility that, within the two-year period beginning October 1, 1988—   (i) Had its participation terminated under title XVIII of the Act or under the State plan under title XIX of the Act;   (ii) Was subject to a denial of payment under title XVIII or title XIX;   (iii) Was assessed a civil money penalty of not less than $5,000 for deficiencies in nursing facility standards;   (iv) Operated under temporary management appointed to oversee the operation of the facility and to ensure the health and safety of its residents; or   (v) Pursuant to State action, was closed or had its residents transferred.   (c) Time frame for acting on a request for approval. The State must, within 90 days of the date of a request under paragraph (a)(3) of this section or receipt of additional information from the requester—   (1) Advise the requester whether or not the program has been approved; or   (2) Request additional information form the requesting entity.   (d) Duration of approval. The State may not grant approval of a nurse aide training and competency evaluation program for a period longer than 2 years. A program must notify the State and the State must review that program when there are substantive changes made to that program within the 2-year period.   (e) Withdrawal of approval. (1) The State must withdraw approval of a nurse aide training and competency evaluation program or nurse aide competency evaluation program offered by

 

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or in a facility described in paragraph (b)(2) of this section.   (2) The State may withdraw approval of a nurse aide training and com- petency evaluation program or nurse aide competency evaluation program if the State determines that any of the applicable requirements of §§ 483.152 or 483.154 are not met by the program.   (3) The State must withdraw approval of a nurse aide training and competency evaluation program or a nurse aide competency evaluation program if the entity providing the program refuses to permit unannounced visits by the State.   (4) If a State withdraws approval of a nurse aide training and competency evaluation program or competency evaluation program—   (i) The State must notify the program in writing, indicating the reason(s) for withdrawal of approval of the program.   (ii) Students who have started a training and competency evaluation program from which approval has been withdrawn must be allowed to complete the course. § 483.152 Requirements for approval of a nurse aide training and com-petency evaluation program.   (a) For a nurse aide training and competency evaluation program to be approved by the State, it must, at a minimum—   (1) Consist of no less than 75 clock hours of training;   (2) Include at least the subjects specified in paragraph (b) of this section;   (3) Include at least 16 hours of supervised practical training. Supervised practical training means training in a laboratory or other setting in which the trainee demonstrates knowledge while performing tasks on an individual under the direct supervision of a registered nurse or a licensed practical nurse;   (4) Ensure that—   (i) Students do not perform any services for which they have not trained and been found proficient by the instructor; and   (ii) Students who are providing services to residents are under the general supervision of a licensed nurse or a registered nurse;   (5) Meet the following requirements for instructors who train nurse aides;   (i) The training of nurse aides must be performed by or under the general supervision of a registered nurse who possesses a minimum of 2 years of nursing experience, at least 1 year of	which must be in the provision of long term care facility services;   (ii) Instructors must have completed a course in teaching adults or have experience in teaching adults or supervising nurse aides;   (iii) In a facility-based program, the training of nurse aides may be performed under the general supervision of the director of nursing for the facility who is prohibited from performing the actual training; and   (iv) Other personnel from the health professions may supplement the instructor, including, but not limited to, registered nurses, licensed practical/vocational nurses, pharmacists, dietitians, social workers, sanitarians, fire safety experts, nursing home administrators, gerontologists, psychologists, physical and occupational therapists, activities specialists, speech/language/ hearing therapists, and resident rights experts. Supplemental personnel must have at least 1 year of experience in their fields;   (6) Contain competency evaluation procedures specified in § 483.154.   (b) The curriculum of the nurse aide training program must include—   (1) At least a total of 16 hours of training in the following areas prior to any direct contact with a resident:   (i) Communication and interpersonal skills;   (ii) Infection control;   (iii) Safety/emergency procedures, including the Heimlich maneuver;   (iv) Promoting residents' independence; and   (v) Respecting residents' rights.   (2) Basic nursing skills;   (i) Taking and recording vital signs;   (ii) Measuring and recording height and weight;   (iii) Caring for the residents' environment;   (iv) Recognizing abnormal changes in body functioning and the importance of reporting such changes to a supervisor; and   (v) Caring for residents when death is imminent.   (3) Personal care skills, including, but not limited to—   (i) Bathing;   (ii) Grooming, including mouth care;   (iii) Dressing;   (iv) Toileting;   (v) Assisting with eating and hydration;   (vi) Proper feeding techniques;   (vii) Skin care; and   (viii) Transfers, positioning, and turning.   (4) Mental health and social service needs:   (i) Modifying aide's behavior in response to residents' behavior;   (ii) Awareness of developmental	tasks associated with the aging process;   (iii) How to respond to resident behavior;   (iv) Allowing the resident to make personal choices, providing and reinforcing other behavior consistent with the resident's dignity; and   (v) Using the resident's family as a source of emotional support.   (5) Care of cognitively impaired residents:   (i) Techniques for addressing the unique needs and behaviors of individual with dementia (Alzheimer's and others);   (ii) Communicating with cognitively impaired residents;   (iii) Understanding the behavior of cognitively impaired residents;   (iv) Appropriate responses to the behavior of cognitively impaired resi-dents; and   (v) Methods of reducing the effects of cognitive impairments.   (6) Basic restorative services:   (i) Training the resident in self care according to the resident's abilities;   (ii) Use of assistive devices in transferring, ambulation, eating, and dress-ing;   (iii) Maintenance of range of motion;   (iv) Proper turning and positioning in bed and chair;   (v) Bowel and bladder training; and   (vi) Care and use of prosthetic and orthotic devices.   (7) Residents' Rights.   (i) Providing privacy and maintenance of confidentiality;   (ii) Promoting the residents' right to make personal choices to accommodate their needs;   (iii) Giving assistance in resolving grievances and disputes;   (iv) Providing needed assistance in getting to and participating in resident and family groups and other activities;   (v) Maintaining care and security of residents' personal possessions;   (vi) Promoting the resident's right to be free from abuse, mistreatment, and neglect and the need to report any instances of such treatment to appropriate facility staff;   (vii) Avoiding the need for restraints in accordance with current professional standards.   (c) Prohibition of charges. (1) No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide training and competency evaluation program may be charged for any portion of the program (including any fees for text-books or other required course materials).   (2) If an individual who is not employed, or does not have an offer to be employed, as a nurse aide becomes employed by, or receives an offer of employment from, a facility not later

 

48921  Federal Register / Vol. 56, No. 187 / Thursday, September 26, 1991 / Rules and Regulations
than 12 months after completing a nurse aide training and competency evaluation program, the State must provide for the reimbursement of costs incurred in completing the program on a pro rata basis during the period in which the individual is employed as a nurse aide.   § 483.154 Nurse aide competency evaluation.   (a) Notification to Individual. The State must advise in advance any individual who takes the competency evaluation that a record of the successful completion of the evaluation will be included in the State's nurse aid registry.   (b) Content of the competency evaluation program—(1) Written or oral examinations. The competency evaluation must—   (i) Allow an aide to choose between a written and an oral examination;   (ii) Address each course requirement specified in § 483.152(b);   (iii) Be developed from a pool of test questions, only a portion of which is used in any one examination;   (iv) Use a system that prevents disclosure of both the pool of questions and the individual competency evaluations; and   (v) If oral, must be read from a prepared text in a neutral manner.   (2) Demonstration of skills. The skills demonstration must consist of a demonstration of randomly selected items drawn from a pool consisting of the tasks generally performed by nurse aides. This pool of skills must include all of the personal care skills listed in § 483.152(b)(3).   (c) Administration of the competency evaluation. (1) The competency examination must be administered and evaluated only by—   (i) The State directly; or   (ii) A State approved entity which is neither a skilled nursing facility that participates in Medicare nor a nursing facility that participates in Medicaid.   (2) No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide competency evaluation program may be charged for any portion of the program.   (3) If an individual who is not employed, or does not have an offer to be employed, as a nurse aide becomes employed by, or receives an offer of employment from, a facility not later than 12 months after completing a nurse aide competency evaluation program, the State must provide for the reimbursement of costs incurred in completing the program on a pro rata	basis during the period in which the individual is employed as a nurse aide.   (4) The skills demonstration part of the evaluation must be—   (i) Performed in a facility or laboratory setting comparable to the setting in which the individual will function as a nurse aide; and   (ii) Administered and evaluated by a registered nurse with at least one year's experience in providing care for the elderly or the chronically ill of any age.   (d) Facility proctoring of the competency evaluation. (1) The competency evaluation may, at the nurse aide's option, be conducted at the facility in which the nurse aide is or will be employed unless the facility is described in § 483.151(b)(2).   (2) The State may permit the competency evaluation to be proctored by facility personnel if the State finds that the procedure adopted by the facility assures that the competency evaluation program—   (i) Is secure from tampering;   (ii) Is standardized and scored by a testing, educational, or other organization approved by the State; and   (iii) Requires no scoring by facility personnel.   (3) The State must retract the right to proctor nurse aide competency evaluations from facilities in which the State finds any evidence of impropriety, including evidence of tampering by facility staff.   (e) Successful completion of the competency evaluation program. (1) The State must establish a standard for satisfactory completion of the competency evaluation. To complete the competency evaluation successfully an individual must pass both the written or oral examination and the skills demonstration.   (2) A record of successful completion of the competency evaluation must be included in the nurse aide registry provided in § 483.156 within 30 days of the date if the individual is found to be competent.   (f) Unsuccessful completion of the competency evaluation program. (1) If the individual does not complete the evaluation satisfactorily, the individual must be advised—   (i) Of the areas which he or she; did not pass; and   (ii) That he or she has at least three opportunities to take the evaluation.   (2) The State may impose a maximum upon the number of times an individual upon the number of times an individual may attempt to complete the competency evaluation successfully, but the maximum may be no less	than three. § 483.156 Registry of nurse aides.   (a) Establishment of registry. The State must establish and maintain a registry of nurse aides that meets the requirement of this section. The registry—   (1) Must include as a minimum the information contained in paragraph (c) of this section:   (2) Must be sufficiently accessible to meet the needs of the public and health care providers promptly;   (3) May include home health aides who have successfully completed a home health aide competency evaluation program approved by the State if home health aides are differentiated from nurse aides; and   (4) Must provide that any response to an inquiry that includes a finding of abuse, neglect, or misappropriation of property also include any statement disputing the finding made by the nurse aide, as provided under paragraph (c)(1)(ix) of this section.   (b) Registry operation. (1) The State may contract the daily operation and maintenance of the registry to a non-State entity. However, the State must maintain accountability for overall operation of the registry and compliance with these regulations.   (2) Only the State survey and certification agency may place on the reg-istry findings of abuse, neglect, or misappropriation of property.   (3) The State must determine which individuals who (i) have successfully completed a nurse aide training and competency evaluation program or nurse aide competency evaluation program; (ii) have been deemed as meeting these requirements; or (iii) have had these requirements waived by the State do not qualify to remain on the registry because they have performed no nursing or nursing-related services for a period of 24 consecutive months.   (4) The State may not impose any charges related to registration on individuals listed in the registry.   (5) The State must provide information on the registry promptly.   (c) Registry Content. (1) The registry must contain at least the following information on each individual who has successfully completed a nurse aide training and competency evaluation program which meets the requirements of § 483.152 or a competency evaluation which meets the requirements of § 483.154 and has been found by the State to be competent to function as a nurse aide or who may function as a nurse aide because of meeting criteria in § 483.150:   (i) The individual's full name.

 

48922  Federal Register / Vol. 56, No. 187 / Thursday, September 26, 1991 / Rules and Regulations
(ii) Information necessary to identify each individual;   (iii) The date the individual became eligible for placement in the registry through successfully completing a nurse aide training and competency evaluation program or competency evaluation program or by meeting the requirements of § 483.150; and   (iv) The following information on any finding by the State survey agency of abuse, neglect, or misappropriation of property by the individual:   (A) Documentation of the State's investigation, including the nature of the allegation and the evidence that led the State to conclude that the allegation was valid;   (B) The date of the hearing, if the individual chose to have one, and its out-come; and   (C) A statement by the individual disputing the allegation, if he or she chooses to make one; and   (D) This information must be included in the registry within 10 working days of the finding and must remain in the registry permanently, unless the finding was made in error, the individual was found not guilty in a court of law, or the State is notified of the individual's death.	(2) The registry must remove entries for individuals who have performed no nursing or nursing-related services for a period of 24 consecutive months, unless the individual's registry entry includes documented findings of abuse, neglect, or misappropriation of property.   (d) Disclosure of information. The State must—   (1) Disclose all of the information in § 483.156(c)(1) (iii) and (iv) to all requesters and may disclose additional information it deems necessary; and   (2) Promptly provide individuals with all information contained in the registry on them when adverse findings are placed on the registry and upon request. Individuals on the registry must have sufficient opportunity to correct any misstatements or inaccuracies contained in the registry.   § 483.158 FFP for nurse aide training and competency evaluation.   (a) State expenditures for nurse aide training and competency evaluation programs and competency evaluation programs are administrative costs. They are matched as indicated in § 433.15(b)(8) of this chapter.   (b) FFP is available for State expenditures associated with nurse aide training	and competency evaluation programs and competency evaluation programs only for—   (1) Nurse aides employed by a facility;   (2) Nurse aides who have an offer of employment from a facility;   (3) Nurse aides who become employed by a facility not later than 12 months after completing a nurse aide training and competency evaluation program or competency evaluation program; or   (4) Nurse aides who receive an offer of employment from a facility not later than 12 months after completing a nurse aide training and competency evaluation program or competency evaluation program.   (Catalog of Federal Domestic Assistance Program No. 93.714, Medical Assistance Program No. 93.774, Medicare- Supplementary Medical Insurance Program)   Dated: January 7, 1991 Gail R. Wilensky, Administrator, Health Care Financing Administration.   Approved: March 26, 1991, Louis W. Sullivan, Secretary. [FR Doc. 91-22275 Filed 9-25-91 8:45 am] BILLING CODE 4120-01-M

 

AUTHORIZED BY:
INDIANA STATE DEPARTMENT OF HEALTH
2 NORTH MERIDIAN STREET INDIANAPOLIS, INDIANA 46204 317-233-7442	STATE HEALTH COMMISSIONER: DR. RICHARD FELDMAN, M.D. ASSISTANT HEALTH COMMISSIONER: GERALD COLEMAN DIRECTOR LONG TERM CARE: SUZANNE HORNSTEIN PROGRAM COORDINATOR: MARY WASSEL, RN, TRAINING DIRECTOR DEVELOPMENT SUPERVISOR: DAVID MILLER, RN, TRAINING OFFICER

 

PREPARED BY:
PROFESSIONAL RESOURCES 206 ELM STREET VALPARAISO, INDIANA 46383 219-462-7760	Eileen Heinze, Executive Director Pamela Davis, Associate Director Irene Lawson, Research and Development Coordinator Jaynee Strycker, RN, Program Director     Vicki Gust, RN, Program Director Tamara Harbison, RN, Program Director     Kristine DeYoung, Research Consultant Donna Ragsdale, RN, Program Director     Julie Gannon, Intake Officer

 

CONTRIBUTORS:
Mary Blauser, RN, BSN	Inservice Director, Towne House Retirement Community, Fort Wayne
Peggy L. Booe, RN	Staff Development Coordinator, The Lakeview Nursing and Rehabilitation Center, Terre Haute
Cheryl Burton, RN	Inservice Director, Clifty Falls Health & Rehabilitation, Madison
Norma Jean Brady, RN, BSN	Education Coordinator, Miller's Merry Manor, Hartford City
Stephanie C. Colston, RN, BSN	Director of Staff Development, Rosewood Terrace, Elkhart
Karalee Eltzroth, RN	Human Resources Coordinator of Nursing Relation, Holy Cross Care Services, South Bend
Mary Lou Fewell, RN	Program Director, Holy Cross Care Services, South Bend
Dorothy Ball, RN	Program Director, Holy Cross Care Services, South Bend
Pat Yehle, RN	Quality Improvement Program Coordinator, Holy Cross Care Services, South Bend
Margaret Nan Floyd, LPN	Behavior Management Coordinator, Meadow View Health Care and Rehabilitation Center, Salem
Sandra Frick, RN	Inservice Director, Huntingburg Convalescent Center, Huntingburg
Judy Gunning, RN	Director of Staff Development, Lakeview Manor, Indianapolis
Kim Haan, RN	Program Director, Mulberry Lutheran Home, Mulberry
Sue Hook, RN	CNA Instructor, Health Occupations Education, Four County Area Vocational Cooperative, Garrett
Susan Jesop, RN	Regional Training Programs Director, Extendicare Training Center, Evansville
Diane Johnson, RNC	Program Director, Christian Care Retirement Community, Bluffton
Dorothy Jordan, RN	Staff Development Coordinator, Beverly Healthcare and Rehabilitation Center, Tell City
Nancy Leising, RNC, BS	Director of Education, Miller's Merry Manor, Rushville
Penny Busald, RN	Assistant Director of Education, Miller's Merry Manor, Rushville
Leslie Levell, RN	Consultant, First Health Corporation, Muncie
Paula Lynch, RN	Staff Development Coordinator, Lincoln Hills Health Care of New Albany, New Albany
Charlene Mantock, MA, RNC	Director of Continuing Education, University of St. Francies, Fairfield Camputs, Fort Wayne
Diane Sargent, BSN, MS	Instructor, University of St. Francies, Fairfield Camputs, Fort Wayne
Carol Schweitzer, RN	Program Director, Dillsboro/Ross Manor, Dillsboro
Pauls M. Pribble, RN	Certified Nurse Aide Program Coordinator, Houston Companies: Ben Hur Home, Crawfordsville
Penne Reed, RN, BSN	Staff Development Coordinator, Green Valley Care Center, New Albany
Peggy Roehm, RN	Program Director, Covington Manor Nursing Center, Fort Wayne
Kay Sisk, LPN	Assistant Director of Nursing, Lyons Convalescent Center, Lyons
Connie Temple, RN, BSN	Assistant Director of Nursing, Monticello Healthcare Center, Monticello
Lana Turell, RN	Staff Coordinator, Kennedy Living Center, Martinsville
Brian C. Wilson, RN	Director of Staff Development, Southlake Nursing and Rehabilitation Center, Merrillville
Lois Zuercher, RN	Staff Development Coordinator, Ossian Health & Rehabilitation Center, Ossian

 

SOURCES
Glenco, Nursing Assistant Fundamentals, 1998	Medline Industries
Brady, The Nursing Assistant, 1998	Skill-Care, Yonkers, New York
Mosby, AHCA, How To Be A Nurse Assistant, 1995	Center For Disease Control, Atlanta, Georgia
Mosby, Long Term Care Assistants, 1994	United States Federal Register
First Class Books, Inc., Nursing Assistants, 1992	US Department of Labor, OSHA
Delmar, Nursing Assistant, 1992	Omnibus Budget Reconciliation Act, OBRA
Becton Dickinson and Company, Rochelle Park, New Jersey	National Council of State Boards of Nursing, NACEP
Posey Co., Arcadia, California	Indiana State Department of Health: Health Facilities Rules
Risk Management C.P., Inc., Steven H. Conkle, P.E., CSP, President	State Emergency Management Agency
William Shideler, DDS	Civil Defense, Ron Stevens

 

DISCLAIMER: The procedures set forth herein reflect current practices intended to meet federal, state, local and facility regulations and guidelines in effect at the time of publication, and are subject to change upon a change in the law.  

TOPIC 1: HEALTH CARE DELIVERY

1. The Health Care System is composed of different parts designed to work together to make health care accessible to everyone. The health care system includes:
   1. Hospitals – provide acute care (treatment for illnesses which come on suddenly and are usually of short duration) and either general or specialized care (children’s, cancer, psychiatric, AIDS).
   2. Doctor’s offices and Clinics – provide maintenance and preventative care.
   3. Rehabilitation/Convalescent Care Facilities – provide subacute care (treatment for illnesses after acute phase).
   4. Long Term Care Facilities – provide long term care (treatment for chronic illnesses that may develop slowly and continue for long periods of time). Many residents are elderly but an increasing number of residents are younger.
   5. Home Health Agencies – provide care within the person’s home.
   6. Hospices – provide terminal care (treatment for the dying person to improve comfort and quality of life).

2. Long Term Care is provided in nursing facilities, psychiatric facilities and facilities for persons with special needs. Long term care facilities:
   1. Provide a home-like and safe living environment with daily routines designed to meet the resident’s specific needs.
   2. Coordinate resident care through the efforts of the health care team.
   3. Provide health care, restorative care, and maintenance care.
   4. Provide activities and entertainment for the residents.
   5. Are subject to inspections by the federal government, the state department of health, and local health and fire departments.

3. The Health Care Team is a group of professionals and non-professionals with special skills who work together to meet a resident’s needs. The team approach creates the highest quality of care because information is shared, care is coordinated, and a comprehensive care plan is developed for each resident. Team members may include some or all of the following depending on each resident’s needs:
   1. Resident – efforts made to meet needs and maintain quality of life.
   2. Resident’s Family – provides information about resident to staff; may make decisions if resident is unable with durable power of attorney.
   3. Physician – responsible for treatment of disease and illness.
   4. Nursing Staff – monitors and promotes health of the resident, identifies needs, assists with activities of daily living (ADL’s). Staff includes registered nurses, licensed practical nurses, certified nurse aides (CNAs) and qualified medication aides (QMAs).
   5. Ombudsman – resident advocate who investigates complaints and helps achieve agreement between parties.
   6. Social Worker – counsels resident, family and staff and obtains needed services.
   7. Activity Coordinator – plans and carries out appropriate activities for the resident.
   8. Physical Therapist – works with muscle groups to maintain and increase the resident’s physical abilities.
   9. Occupational Therapist – works with fine motor skills to improve the resident’s use of hands for all activities and communication.
   10. Speech Therapist – works with resident who has difficulty with speech, communication and swallowing.
   11. Dietician – plans menus, special diets, and monitors nutritional needs of the resident.
   12. Spiritual Counselor – provides guidance and coordinates religious services for the resident.
   13. Administrator – manages all departments within the facility and sets policies.
   14. Building Maintenance – keeps buildings and grounds in good repair.
   15. Laundry – cleans resident’s clothing and maintains linens.
   16. Dentist – provides routine and emergency dental care for the resident.
   17. Podiatrist – provides foot care for the resident.
   18. Optometrist – provides eye care for the resident.
   19. Respiratory Therapist – provides breathing treatment and special equipment for respiratory conditions.
   20. Housekeeping – keeps the facility clean and sanitary.
   21. Qualified Mental Retardation Professional (QMRP) – person who is trained and experienced in treating the mentally retarded.
   22. Power of Attorney/Health Care Representative or Guardian – makes decisions regarding care if resident is unable.

4. Observations made by all members of the health care team provide the nurse with the information necessary to complete the Minimum Data Set (MDS) which is a form used to identify the physical, mental, and psychological status of each resident. The MDS provides the guidelines that help develop the comprehensive care plan.

5. The Comprehensive Care Plan (care plan) is a written plan of action developed by the Health Care Team to meet each resident’s highest functional, medical, nursing, mental and psychosocial needs. The plan includes the identification of the cause and nature of a resident’s needs, the short term and long term goals for the resident, the individualized approaches to reach those goals, and the disciplines responsible for monitoring those goals. The comprehensive care plan fosters Continuity of Care.

6. CNA’s role:
   1. Provide care according to the resident’s comprehensive care plan.
   2. Actively listen and communicate with the resident, the family and the health care team.
   3. Observe and report any changes in the resident’s appearance, behavior or mood to the nurse.
   4. Participate in care planning when asked.

What is the difference between an acute care facility and a long-term care facility?
What is the purpose of the Comprehensive Care Plan?
How does the CNA contribute to the Comprehensive Care Plan?

ADDITIONAL DEFINITIONS:

Maintenance Care – care that preserves function
Preventative Care – care that stops disease or injury from happening
Restorative Care – care aimed at regaining health and strength
Activities of Daily Living (ADL) – physical activities of everyday life (bathing, grooming, dressing, positioning, toileting, eating)
Advocate – one who defends the rights of another
Spiritual – the search for meaning in life usually through religion
Psychosocial Needs – need for independence, a supportive environment, recognition as an individual, spiritual fulfillment, and social interaction
Continuity of Care – getting everyone from every department on all shifts working towards the same goals using compatible methods
Actively Listen – paying attention to what is said in a conversation
Communicate – exchange information

1. The role of the Certified Nurse Aide is to provide for the daily care, comfort, safety and health needs of the residents. The CNA is an important member of the health care team and the nursing team.
   1. To provide for the resident’s daily care, the CNA assists the resident with:
   1. Bathing, dressing and grooming (Topics 17, 18, 19, 20, 21).
   2. Eating (Topic 24).
   3. Elimination (Topic 25).
   4. Transferring and ambulating (Topics 6, 15, 22, 23).
   5. Communication (Topic 4).
   2. To provide for the resident’s comfort, the CNA should:
   1. Create a positive home-like environment (Topic 14).
   2. Help the resident develop trust (Topic 9).
   3. Offer emotional support and work with the family (Topic 13).
   4. Communicate and actively listen.
   3. To provide for the resident’s safety, the CNA must:
   1. Follow infection control practices (Topic 5).
   2. Maintain a clean, safe environment and report safety problems immediately (Topic 7).
   3. Perform procedures correctly (as taught and mandated by ISDH).
   4. To provide for the resident’s health needs, the CNA should:
   1. Observe and report any changes in the resident’s appearance, behavior, or mood to the nurse (Topics 3, 10, 11, 12, 26).
   2. Determine measurements accurately (temperature, pulse, respirations, blood pressure, weight, intake, output and food consumption) (Topic 16).
   3. Assist the nurse during treatments, medical procedures and emergencies (Topic 8).
   4. Respond to any call light immediately.

2. A person who chooses to become a CNA must:
   1. Understand that, by law, a criminal history check will be done.
   2. Have Mantoux testing or chest X-ray and a physical examination.
   3. Complete an Indiana State Department of Health (ISDH) approved training program that includes at least 30 hours of classroom training, at least 75 hours of clinical experience, and successfully pass both a written and skills competency evaluation.

3. The CNA must exhibit ethical behavior. All health care employees are expected to behave ethically.
   1. Perform to the best of your ability.
   2. Be loyal to your employer, co-workers, residents, and their families.
   3. Be accountable for your actions.
   4. Carry out your supervisor’s instructions.
   5. Perform only duties legally permitted.
   6. Respect the people and environment around you.
   7. Maintain confidentiality.
   8. Safeguard the resident’s right to privacy.
   9. Keep residents free from abuse or neglect. Report suspected abuse or neglect to the nurse immediately.
   10. Safeguard the resident’s property.
   11. Report incidents or errors to the nurse immediately.

4. The CNA must be aware of and abide by the legal considerations or rules of conduct enacted by a governmental body. All facilities have standards of care based on federal, state and local laws and rules, facility policies, and current nursing practices.

5. CNA’s must understand their job description. The job description should list the tasks that a CNA is expected to perform.

6. The CNA is expected to present a positive personal image. Take care of yourself before you care for others. Because of the physical and emotional demands of the job, the CNA must maintain:
   1. Personal Health – eat a balanced diet, get adequate rest, use good body mechanics.
   2. Personal Hygiene – bathe daily, use deodorant, practice good oral hygiene.
   3. Personal Appearance – dress professionally including clean uniform and shoes, limited jewelry, ID tag, moderate makeup, simple hair style, little or no perfume, nails that are smooth, clean and trimmed.
   4. Personal State of Mind - since the job is stressful, talk about feelings and emotions, identify what is stressful, feel sad when appropriate, set priorities. Personal behavior on personal time is still a reflection on the employer.

7. To maintain certification, the CNA must:
   1. Be offered at least 12 hours of inservice education per year.
   2. Work for a health care provider at least one eight hour shift every twenty-four months.
   3. Never have a verified complaint against them on the registry. If a complaint of abuse or misappropriation of resident’s property or funds is found to be valid, the CNA will loose their certification in all 50 states permanently. If found guilty of neglect the CNA will not be allowed to work as a CNA for two to five years.
   4. Be evaluated yearly and offered inservice education on their weaknesses.

QUESTIONS:

ADDITIONAL DEFINITIONS:

Environment – surroundings
Trust – to have confidence and faith in, to rely on
Call Light – a means of communicating with staff to get help
Ethical Behavior – doing what is right according to the rules of conduct of a particular group
Accountable – being responsible for your own choices (words and actions)
Respect – to treat with courtesy and consideration
Confidentiality – keeping information secret
Privacy – freedom from outsiders entering and watching without your consent
Abuse – an act that causes harm
Neglect – failure to act in a reasonable and caring manner.
Incident – any unusual event (falls, theft, errors) that occurs in the health care facility
Current Nursing Practices – up-to-date, proven and accepted ways of providing nursing care
Stress - pressure or strain that disturbs a person’s mental or physical well being
Inservice Education – opportunities for learning offered by an employer
Verified Complaint – wrong doing that has been proven

TOPIC 3: OBSERVING AND REPORTING

1. Observing and reporting is the most important way the CNA assists the nurse and other members of the health care team to identify the needs of the residents.
   1. Observing is the gathering of bits of information about a resident through the use of the senses and feelings. The information provides knowledge about the resident’s condition and response to care. Methods of observation include:
      1. Objective observation includes data available through the senses.
         Sight - rash, swelling, diarrhea, skin color change, unconsciousness.
         Sound - cough, irregular heartbeat, moans of pain.
         Smell - foul odor from a wound, bad breath, unusual odors from urination or defecation.
         Touch - fever, change in pulse, swelling or lump under the skin.
      2. Subjective observation includes information reported by a resident about how he or she is feeling. Statements such as "I’m tired," "I’m dizzy," "I can’t see," "My ears are ringing".
      3. Accurate observations include detailed information and improve the quality of care.
      4. Observations that indicate an acute condition requiring immediate attention from the nurse include but are not limited to :
         

         severe pain	anxiety	mood swings	any sudden change in condition
         fall or accident	confusion	depression	skin tears or bruises
         signs of shock	odor	loss of control	loss of consciousness
         seizures	swelling	hemorrhage	difficulty breathing

   2. Reporting means verbally informing the person in authority (the nurse) about resident care and what has been observed. Telling another CNA or a QMA about an observation is not reporting.
      1. Report should include the resident’s name, room and bed number and detailed descriptions of the observation. Reporting may be:
         1. Objective-stating what is seen, smelled, heard or felt including exactly what the resident says.
         2. Subjective – stating what cannot be observed by the senses but rather a feeling about something that doesn’t seem right ("Mrs. Jones seems uncomfortable.").
      2. Routine reporting is usually done at the end of the shift. Routine information is not of immediate importance. Include information about the resident and the care given. Before reporting, ask:
         1. Did I meet each resident’s needs?
         2. Was there anything new or changed?
         3. What did I see, hear, smell, or touch?
      3. Immediate reporting must be done at the time the observation is made and includes:
         1. Dangerous situations (i. e., frayed cord, loose handrails, broken equipment).
         2. Unusual observations (i. e., high temperature, skin changes especially any red or open areas).
         3. Unusual incidents (i. e., falls, signs or suspicions of abuse).
         4. Resident complaints of ill health (i. e., dizziness pain).

2. Documentation is the written account of a resident’s condition. Documentation can include charts, worksheets and facility records. Documentation is considered a permanent legal record of the resident’s condition and the care given. The CNA is legally responsible for recording complete and accurate details of the care given. If it isn’t documented, legally it wasn’t done.
   1. Guidelines for Documentation:
      1. Resident’s name must be on each page before anything else is written.
      2. Write all entries in ink - not pencil or felt tip - neatly and legibly.
      3. Make sure all entries are accurate. Use quotation marks when reporting what the resident said. Document only what you observe and perform.
      4. Documentation must be in chronological order.
      5. Never document before a procedure is completed.
      6. Do not leave spaces or skip lines between entries to prevent altering of document.
      7. Use standard medical terminology and standard abbreviations - no ditto marks.
      8. Time and date all entries, and sign with your name and title.
      9. Never document for someone else.
   2. Guidelines for Correcting Documentation.
   1. Draw a single line through error. What was written should remain readable. Never use correction fluid.
   2. Print word "error". Initial and date the correction.
3. CNA’s Role:
   1. Use your senses to observe physical changes.
   2. Use your active listening skills to observe any changes the resident may say they are experiencing.
   3. Report any unusual findings to the nurse immediately.
   4. Always document according to current nursing practices.

QUESTIONS:

ADDITIONAL DEFINITIONS:

TOPIC 4: COMMUNICATION AND INTERPERSONAL SKILLS

1. Communication is the exchange of information and messages. Communicating with residents, families and co-workers is the responsibility of every member of the health care team. Effective communication completes a cycle between two people. Four elements necessary for successful communication include:
   1. Sending the message through:
      1. Verbal communication - written or spoken words.
      2. Nonverbal communication – facial expressions, tone of voice, posture, gestures, touch (body language) or call light.
   2. Formulating the message – must be organized, complete and understandable.
   3. Receiving the message – listener must prepare to receive the message, concentrate on the content and actively listen.
   4. Observing the feedback – sender must interpret the verbal and nonverbal response of the listener. What is observed may be more important than what is heard.

2. To make it easier for others to understand what is being communicated:
   1. Speak clearly and slowly using a gentle tone.
   2. Be at eye level looking directly at the person with whom you are speaking.
   3. Use appropriate nonverbal communication.
   4. Use language with which the listener is familiar. Use words with only one meaning. Allow time for the listener to process the information.
   5. Give facts, not opinions, unless specifically requested.
   6. Make messages logical and brief.
   7. Repeat a message, using exactly the same words, if necessary.

3. Good listening skills allow you to learn more about the people around you. Active listening promotes good relationships. To actively listen:
   1. Use body language that shows interest and concern (eye contact, lean forward).
   2. Avoid interrupting the speaker. Let the person finish his thought.
   3. Give the speaker feedback, both verbal and nonverbal, to show that you are actively listening.
   4. Avoid judging the other person based on your own personal opinions and beliefs.

4. Barriers to communication include:
   1. Cultural differences - beliefs, values, habits, diet and health practices that relate to a person’s culture or religion.
   2. Age - people of different ages and eras with different values and communication styles.
   3. Impairments – physical and/or mental limitations requiring special considerations when communicating.
   1. A person who is blind relies on verbal cues, including words and tone of voice.
   1. State your name before beginning a conversation.
   2. Describe persons, things and environment.
   3. Tell the resident when you are entering or leaving the room.
   4. Explain in detail what you are doing and ask the resident what he would like to do for himself.
   5. Touch the resident if appropriate.
   6. Read resident’s mail or personal documents if asked.
   7. Sit where resident can easily see you if resident has partial vision.
   2. A person who is hearing impaired relies on nonverbal cues including body language, sign language, and writing.
   1. Speak slowly and distinctly.
   2. Use short sentences.
   3. Face the resident.
   4. Be certain that the light source is on you and behind the resident.
   5. Use facial expressions and gestures.
   6. Reduce outside distractions.
   7. Use sign language and message boards if appropriate.
   8. Be certain that the resident’s hearing aid is in and working properly, if applicable.
   3. A person who is cognitively impaired relies on both verbal and nonverbal cues and may need messages repeated frequently, using short sentences and simple words.

5. Interpersonal skills needed to form positive relationships between people include:
   1. Patience - the capacity to be even-tempered and calm.
   2. Courtesy - the capacity to have respect and consideration for others.
   3. Tact – a sense of what to do or say in order to maintain good relations with others and avoid offense.
   4. Empathy - the ability to understand another’s point of view and share in another’s feelings or emotions.

6. CNA’s role:
   1. Always use tact.
   2. Use gestures and posture to show you care.
   3. Use touch to communicate comfort, caring, and understanding.
   4. Practice active listening.
   5. Be patient with residents who have difficulty communicating.
   6. Develop positive relationships with residents and coworkers.
   7. Never say, "I know how you feel" because you don’t!
   8. Always include the resident in conversation if more that one CNA is assisting in care.
   9. Verbally communicate with an unconscious resident.
   10. Always offer choices.
   11. Be supportive when a resident is transferred or discharged.

QUESTIONS:

What are the four elements necessary for successful communication?
Explain verbal and nonverbal communication.
Define active listening.
What are three barriers to good communication?
List factors affecting communication with residents who are impaired.
Explain interpersonal skills.

ADDITIONAL DEFINITIONS:

1. Infection Control means preventing the spread of microorganisms by following certain practices and procedures. Microorganisms:
   1. Compose the largest population of life forms on earth.
   2. Are everywhere – water, air, soil, plants, animals, minerals, humans.
   3. Cannot be seen with the naked eye.
   4. May be harmful – harmful microorganisms that may cause infection are called pathogens (germs) and include bacteria, viruses, fungi, protozoa.

2. The "infection chain" explains how pathogens move from one place to another. The six links which make up the chain include the:
   1. Pathogen – the causative agent: bacteria, viruses, fungi, and protozoa.
   2. Reservoir – the place where pathogens live and multiply (especially places that are warm, dark and moist): on linen, medical equipment, surfaces, animals and humans.
   3. Portal of exit – the way pathogens leave the body: in urine, feces, saliva, tears, drainage from wounds, sores, blood, excretion from respiratory tract or genitals.
   4. Route of transmission – how pathogens travel: through the air, in contaminated soil and water, on objects (dirty linen, your uniform, equipment), by insects (flies, mosquitoes, maggots), and on people, especially on hands.
   5. Portal of entry – the way pathogens get into the body: mouth, nose, skin breaks, urinary tract and anus.
   6. Susceptible host – the person who can be infected: the very young, the elderly, persons who are not in good health, people who are exposed to large numbers of pathogens, and people who do not follow proper infection control practices.

3. Breaking the chain of infection controls the spread of infection. To prevent the spread of infection at work:
   1. Use good handwashing technique. Handwashing is the best way to prevent the spread of infection.
   2. Follow employee health policies - stay home when ill, take advantage of vaccines such as flu and Hepatitis Vaccine, have a Mantoux test or chest X- ray as indicated, know the facility’s exposure plan.
   3. Take care of yourself - good personal hygiene, good nutrition, adequate fluid, rest and exercise.
   4. Practice medical asepsis - keep clean away from dirty, handle linen properly, remove and clean dirty articles and equipment quickly, handle food and food tray properly.
   5. Follow rules for disposal of medical waste - handle and dispose of sharps safely according to current nursing practices and local and state laws.
   6. Separate persons with infections from others, which helps prevent nosocomial infection.
   7. Kill germs - disinfect or sterilize equipment, surfaces, dishes and utensils.
   8. Use Standard Precautions.

4. Standard Precautions are guidelines developed by the Center for Disease Control (CDC) to reduce the risk of transmission of pathogens from both known and unknown sources of infection in a health care setting. Every person is treated as potentially infectious. Sources of infection include: blood, all body fluids, secretions and excretions (except sweat) regardless of whether or not they contain visible blood, non- intact skin, and mucous membranes. Standard Precautions include:
   1. Wearing gloves when indicated for resident care.
   2. Wearing a gown, apron, mask and protective eyewear in situations or during procedures where indicated.
   3. Washing your hands at appropriate times.
   4. Transporting infected residents using indicated safeguards.
   5. Cleaning common use equipment between residents.

5. Isolation (Transmission Based) precautions may be ordered to prevent the transmission of pathogens.
   1. Airborne precautions – pathogens are transmitted on dust particles in air currents. Examples include tuberculosis, chickenpox and measles.
   2. Droplet precautions – pathogens are transmitted in droplets when a person coughs, sneezes or talks. Examples include pneumonia, influenza and scarlet fever.
   3. Contact precautions – pathogens are transmitted by direct contact (skin to skin) with the resident or indirect contact with surfaces or care items in the resident’s environment. Examples include conjunctivitis, scabies, and impetigo.

6. Some infections of concern in Long Term Care include:
   1. Hepatitis - contagious disease of the liver caused by a virus and spread by exposure to infected blood, sexual contact and fecal/oral contact. Symptoms are flu-like. Severe infection can cause permanent liver damage and death.
   2. Scabies – skin infection caused by a mite and spread by direct contact. Symptoms include itching, skin irritation in the form of a rash. All contacts, bedding and clothing must be treated to prevent spread and re-infestation.
   3. Tuberculosis (TB) – chronic bacterial infection that usually affects the lungs but may affect other parts of the body such as the kidneys, bones and brain. TB is spread through air in droplets from sputum of persons with active disease. Symptoms include fever, loss of appetite, fatigue, productive cough and night sweats.
   4. Acquired Immune Deficiency Syndrome (AIDS ) – results from infection with Human Immunodeficiency Virus (HIV) which destroys the body’s ability to fight infection. The virus is spread through infected blood and body fluid. Early symptoms are flu-like followed by a symptom free period which can last many years (one to ten or more). No cure is known, however new drugs and treatments show promise.
   5. Methicillin Resistant Staphlococcus Aureus (MRSA) – bacteria that no longer responds to antibiotics normally used to treat staphlococcal infections. It is spread on the hands of health care workers. To prevent the spread follow Standard Precautions.

7. CNA’s role:
   1. Wash your hands before and after performing procedures, using the bathroom, eating, serving food or feeding a resident.
   2. Clean spills quickly.
   3. Follow standard precautions.
   4. Remove gloves immediately after completing a procedure and wash your hands.
   5. Never wear gloves in the hallway unless you have a rash, open sore, or are transporting an infected person.
   6. Keep the environment clean.
   7. Use isolation techniques when ordered and follow directions on posted signs.
   8. Keep linen away from uniform.
   9. Consider all blood, body fluids and excrement contaminated.

QUESTIONS:

Define pathogens and give examples.
Explain infection control.
What is the best and easiest way to prevent the spread of infection?
What is a nosocomial infection?
What are Standard Precautions?
When should gloves be worn during resident care?
What is the purpose of isolation precautions?

ADDITIONAL DEFININTIONS:

Microorganism –a tiny living thing which can only be seen with a microscope
Pathogen – microorganism capable of producing disease
Vaccine – weakened or killed disease-producing organism taken orally or by injection to protect against disease
Mantoux Test – skin test to determine past or present exposure to Tuberculosis
Personal Hygiene – cleanliness including bathing, using deodorant, mouth care and wearing clean clothing
Sharps – any piece of medical equipment that has the potential to cut or puncture the skin
Nosocomial Infection – an infection acquired during a stay at a health care facility
Disinfect – using chemicals or boiling water to reduce the number of microorganisms
Sterilize – process of killing all microorganisms (done by steam or chemical solutions)

1. Body mechanics means using the body properly to coordinate balance and movement. Using proper body mechanics:
   1. Maximizes strength and minimizes stress allowing the CNA’s body to be used efficiently.
   2. Prevents injury to the CNA when bending, moving and lifting.
   3. Reduces fatigue for the CNA at the end of the workday.
   4. Promotes safety for the CNA and the resident during moves.

2. Mechanisms that affect moving include:
   1. Center of gravity - the pelvis is the center of gravity and maintains balance and stability.
   2. Base of support - the feet are the base of support and should be approximately 18 inches or shoulder width apart to support the body during the move.
   3. Friction- affects the amount of effort needed to move something. More friction under the feet increases stability. Less friction under what is being moved decreases the effort needed to move it. Avoid lifting objects. Push, pull, or slide objects if possible.

3. General principles include:
   1. Bend the knees, keep the back straight.
   2. Keep the load close to you.
   3. Lift smoothly using leg muscles. Don’t jerk.
   4. Never lift and twist at the same time.

4. What to consider before lifting and moving:
   1. Survey the area: remove clutter to reduce the chance of accident and injury. Adjust height of bed up for care, down for transfer. Lock wheelchair and bed brakes for safety.
   2. Assess the load to be lifted: assess both weight and height. If unsure of your ability or resident’s ability talk with the nurse and review the plan of care.
   3. Plan and think through the move: prepare the move. Bring the resident close to you by moving the resident to edge of the bed with feet on the floor.
   4. Communicate: explain what you are going to do and always move on a count of one, two, three.

5. What to consider during the lift:
   1. Take a deep breath before lifting and exhale during the lift which helps pump blood to the lungs and oxygen to the muscles.
   2. Tighten the abdominal muscles. Pull in the stomach to support the spine.
   3. Move smoothly. Counting to three allows the CNA and the resident to move at the same time. Jerking could injure both the CNA and the resident. Stop if any team member is not ready for the lift.
   4. Don’t lift and twist at the same time. Once you straighten your knees, pivot around by repositioning your feet as you turn.

6. CNA’s role:
   1. Always tell the resident what you are doing.
   2. Always move the resident on the count of three.
   3. If in doubt, get help. Offer to help others.
   4. Report injuries to the nurse immediately.

QUESTIONS:

ADDITIONAL DEFINITIONS:

1. Providing an environment in which the resident feels safe and secure is an important goal of every member of the health care team.

2. To promote safety:
   1. Be aware of the environment:
   1. Keep the traffic patterns clear in residents’ rooms and hallways.
   2. Walk. Never run. Stay to the right.
   3. Clean up spills immediately. Use "Wet Floor" signs if necessary.
   4. Check for frayed electrical cords but do not attempt repairs.
   5. Check that equipment is working properly before using.
   6. Use equipment safely and according to manufacturer’s guidelines.
   7. Never use electrical equipment near water or oxygen.
   8. Approach swinging doors with care.
   9. Report potentially hazardous conditions to the nurse immediately.
   2. Visit all residents frequently:
   1. Be certain the call light is on resident’s unaffected side and within reach.
   2. Answer any call light immediately.
   3. Follow good infection control practices:
   1. Wash hands properly.
   2. Use Standard Precautions at all times during the workday.
   3. Handle linen and equipment according to proper infection control practices.
   4. Be aware of your body and the resident’s body when moving a resident:
   1. Use good body mechanics.
   2. Never turn a resident toward the side of the bed with the side rail down. Raise the side rail, walk to the other side of the bed and assist the resident to turn toward the raised side rail.
   3. Never lean over a resident in bed to do any procedure. Discomfort and injury to both the CNA and the resident can result. The linen and your uniform can cross contaminate.
   4. Be certain the resident is wearing shoes or slippers with rubber soles when getting out of bed.
   5. Have resident sit on the side of the bed with feet flat on the floor 10-15 seconds and check for dizziness before moving.
   6. Never move a resident by grabbing him under the arm.
   7. Place pillow against headboard when moving a resident up in bed.
   8. Ask resident to help as much as possible.
   9. Move resident on a count of "one, two, three".
   5. Understand that side rails can be considered:
   1. A safety aid and must be up if bed is elevated to working height.
   2. A self help device to assist the resident to move independently.
   3. A restraint if used for the sole purpose of confining the resident in bed and requires a doctor’s order.
   6. Use protective devices (restraints, safety devices) only under the following rules:
   1. A specific doctor’s order is required.
   2. A protective device must be used according to the manufacturer’s guidelines including a quick release knot.
   3. A restraint must be checked for proper fit and comfort by placing the open hand flat between the resident and the restraint.
   4. Residents in restraint must be visited at least every hour and the restraint released at least every two hours with some type of activity provided.
   7. Use extreme caution when oxygen is in use.
   1. Oxygen is highly flammable. Never use electrical appliances near oxygen.
   2. Keep open flames (matches, lighter, cigarettes) away from oxygen.
   3. "No Smoking, Oxygen In Use" signs must be posted on the inside and outside of the resident’s door.
   8. Before beginning any procedure, check the resident’s identity.
   1. Call resident by name and observe for a response.
   2. Check identification bracelet, and/or photo ID, if applicable.

3. CNA’s Role:
   1. Be aware of safety at all times.
   2. Observe and report unsafe situations to the nurse immediately.
   3. Always practice proper infection control.
   4. Use proper body mechanics.
   5. Use side rails as directed by the nurse.
   6. Identify each resident before beginning a procedure.
   7. Understand that safety is an important consideration for the CNA and the resident.
   8. Document the release and activity of resident in restraint according to current nursing practices.

QUESTIONS:

DEFINITIONS:

RELATED PROCEDURES:

1. An emergency is a sudden, unexpected severe problem that endangers people. Emergencies can occur anywhere at anytime. Remain calm and know what to do.

2. Fire is a major concern in any building where large numbers of people live and work. Three things necessary to start a fire are fuel (anything that will burn, i.e. paper, cloth, or grease), heat (a spark or flame), and oxygen (air). If all three are present at the same time, in the same place, a fire will result.
   1. Common causes of fire in a health care facility are: faulty electrical wiring or equipment (overloaded circuits and plugs not properly grounded), and careless or unsupervised smoking.
   2. To prevent fires:
   1. Follow precautions for oxygen use:
   1. Post "No Smoking, Oxygen In Use" signs on the inside and outside of the room door.
   2. Do not allow any smoking or open flames near oxygen.
   3. Do not use electrical appliances such as electric razors, hair dryers.
   4. Remove flammable liquids from the room.
   5. Use cotton instead of wool or synthetics that can cause static electricity.
   2. Follow smoking regulations:
   1. Smoke only in designated areas.
   2. Never leave smoking materials at the bedside of confused or sedated residents.
   3. Provide ashtrays and dispose of contents into approved containers (metal with sand or water).
   4. Supervise smoking of residents who cannot protect themselves.
   3. Actions necessary in the event of a fire include:
   1. R=remove residents from the immediate fire area to safety.
      A=activate the alarm.
      C=contain the fire by closing all doors and windows.
      E=extinguish the fire.
   2. Know how to use the facility fire extinguishers:
   1. Extinguishers are rated A, B or C according to the type of fire they put out:
      A=paper, wood, cloth    B=oil, grease    C=electrical
      Most extinguishers in health care facilities are ABC (good for any type of fire).
   2. To use an extinguisher:
      P=pull pin  A=aim nozzle  S=squeeze handle  S=sweep from side to side
   3. Additional points to remember include:
   1. Never use an elevator in the event of a fire.
   2. Avoid smoke inhalation. Stay low and cover your mouth with a wet cloth.
   3. If your clothing catches on fire, STOP, DROP and ROLL to smother the flames.

3. Resident emergencies such as choking, falls, shock, burns, seizures, fainting, hemorrhage or cardiac arrest require immediate action:
   1. Know your limitations. Do not perform any procedure for which you have not been trained.
   2. Call for assistance immediately.
   3. Remain calm and reassure the resident.
   4. Observe the resident for life threatening problems (breathing, pulse, bleeding).
   5. Keep the resident in the same position. Movement could cause further injury.
   6. Keep the resident warm.
   7. Do not give the resident any food or fluids.
   8. Follow the nurse’s instructions.

4. Points to remember when responding to specific resident emergencies:
   1. Choking – a complete blockage of the airway requiring immediate action.
   1. The resident cannot breathe, speak or cough and has no chest movement.
   2. The resident gasps or clutches at the throat (the universal sign for choking).
   3. The procedure used on an adult is the "Heimlich procedure" or abdominal thrust. Knowing this procedure is required of all CNAs.
   2. Falls – preventing falls is the best way to avoid serious injury. If a resident begins to fall, never try to
   stop the fall. Gently ease the resident to the floor and :
   1. Call for help immediately. Keep the resident in the same position until the nurse examines the resident.
   2. Be calm, reassure the resident and follow nurse’s instructions.
   3. Shock – occurs when vital parts of the body (brain, heart, and lungs) do not get enough blood.
   1. Call for help immediately.
   2. Keep the resident lying down.
   3. If bleeding is external, apply direct pressure to the bleeding site using Standard Precautions.
   4. Keep the resident warm and reassure her/him.
   4. Burns – smoking, spilled hot liquids and bath water that is too hot are some causes of burns.
   1. Call for help immediately.
   2. Follow nurse’s instructions.
   5. Seizures (convulsions) – are sudden contractions of muscles due to a disturbance in brain activity.
   1. Call for help and stay with the resident.
   2. Protect the resident from injury.
   3. Never restrain the resident or place anything in the mouth.
   4. Loosen clothing, especially around the neck.
   5. After the seizure, turn the resident to the side to prevent choking and allow the resident to rest.
   6. Observe and report (time and duration of seizure).
   6. Poisoning – many products in a health care facility are dangerous if used improperly.
   1. Never use anything from an unlabeled container.
   2. In case of suspected poisoning, take container to the nurse immediately.
   3. Keep toxic substances and cleaning supplies locked and out of reach of the resident.
   4. Call for help and report observations to the nurse.
   7. Fainting – sudden loss of consciousness because of inadequate blood supply to the brain. Causes
   include hunger, fatigue, pain, fear. Dizziness, and perspiration are symptoms.
   1. Call for help.
   2. Have resident sit or lie down before fainting occurs. If sitting, have resident bend forward and place head between knees. If lying down slightly elevate resident’s legs.
   3. Loosen tight clothing.
   4. Keep resident lying down until checked by the nurse.
   8. Hemorrhage – excessive loss of blood from a blood vessel.
   1. Use Standard Precautions.
   2. Apply direct pressure over the area with a sterile dressing or a clean piece of linen.
   3. Stay with resident and follow the nurse’s instruction.
   9. Cardiac Arrest – heart function and circulation stop. Resident is unresponsive, no chest movement or pulse, pupils dilated and fixed, skin may be cyanotic.
      1. Touch or tap collar bones and ask the resident "Are you okay?"
      2. Check breathing. If breathing has stopped, call for the nurse.

5. A disaster is a sudden event in which property is destroyed and many people may be killed or injured. Floods, tornadoes, earthquakes, hurricanes and blizzards are natural disasters. Fires, explosions, train and air accidents are considered man-made disasters.
   1. Know the community and facility disaster plans.
   2. Know and follow specific facility policies and procedures relating to disasters.
   3. Know the facility evacuation plan.
   4. Remain calm.
   5. Remove residents from immediate danger.
   6. Follow the nurse’s instructions.
   7. Remove records for safekeeping as directed.

6. CNA’s Role:
   1. Know where the facility pull boxes and fire extinguishers are located.
   2. Be informed about facility procedures regarding fire and other emergencies.
   3. Remain calm in any emergency.
   4. Always talk to the resident to reassure him.
   5. Call for help as soon as you notice an emergency.

QUESTIONS:

ADDITIONAL DEFINITIONS:

RELATED PROCEDURES:

PROCEDURE 45: CHOKING
STEP	RATIONALE
1. CALL FOR NURSE AND STAY WITH RESIDENT	1. Allows you to get help yet continuously provide for resident’s safety and comfort
2. ASK IF RESIDENT CAN SPEAK OR COUGH	2. Identifies sign of a blocked airway (not being able to speak or cough)
3. IF NOT, MOVE BEHIND RESIDENT AND SLIDE ARMS UNDER RESIDENT’S ARMPITS	3. Puts you in correct position to perform procedure
4. PLACE YOUR FIST WITH THUMBSIDE AGAINST ABDOMEN MIDWAY BETWEEN WAIST AND RIBCAGE	4. Positions fist for maximum pressure with least chance of injury to resident
5. GRASP YOUR FIST WITH YOUR OTHER HAND	5. Allows you to stabilize resident and apply balanced pressure
6. PRESS YOUR FIST INTO ABDOMEN WITH QUICK INWARD AND UPWARD THRUSTS	6. Forces air from lungs to dislodge object
7. REPEAT UNTIL OBJECT IS EXPELLED
8. DO FINAL STEPS
9. ASSIST WITH DOCUMENTATION ACCORDING TO CURRENT NURSING PRACTICES	9. Accuracy is necessary because decisions regarding resident’s care may be based on your report. What you write is a legal record of what you did. If you don't document it, legally it didn’t happen

1. Rights are both human privileges and legal protections. Residents have the legal rights of all United States citizens. Residents also have rights relating to their everyday lives and care in a nursing facility. A facility must inform residents of their rights and post the "Residents Bill of Rights" in writing in the facility. CNAs must read and sign a document stating that they understand the resident’s rights.

2. Resident’s rights include but are not limited to:
   1. The resident has the right to confidentiality. Personal information, medical records, written and telephone communications, medical treatment, personal care, behavior and meetings with family are not discussed unless appropriate. To maintain confidentiality, the CNA should:
   1. Never discuss a resident’s personal or medical information with friends, news media, and family.
   2. Only discuss resident information with appropriate staff in a private place.
   2. The resident has a right to privacy. To provide privacy, the CNA should:
   1. Knock on door, announce yourself, pull curtains, close door and drape resident.
   2. Ask visitors to leave when providing care, if appropriate.
   3. Never open mail or go through resident’s belongings unless requested.
   4. Provide privacy for visits.
   3. The resident has the right to information, including the right to see personal and medical records within 24 hours and a copy within two days, if requested; right to be fully informed of total health status in a language they can understand; right to be informed of any change in service that they are charged for and that they are not charged for, and to see financial records; right to be informed of advocacy groups and ombudsman program; right to read recent facility survey. The State survey and advocacy groups phone numbers and the most recent survey must be posted in the facility. To help residents be informed, the CNA should:
   1. Know where to find the information and who to go to for answers.
   2. Actively help residents find the answers.
   3. Go with residents to areas where information is posted and read to them if necessary.
   4. Inform the nurse about a resident’s specific concerns regarding medical condition or treatment.
   4. The resident has the right to choose. The resident has the right to refuse treatment and self administer medication, if deemed safe; to choose a personal physician; to participate in their care planning; to perform voluntary or paid services; to keep and use personal possessions as space permits; to participate in activities in and out of facility; to have space available for private family meetings. To encourage choice the, CNA should:
   1. Make sure residents are aware of choices.
   2. Inform residents about activities.
   3. Find out the resident’s interests and encourage participation.
   5. The resident has the right to dispute services and file grievances. The resident can voice complaints without fear of retaliation, get prompt action on complaints, have the ombudsman program investigate complaints from resident and family. To support the resident’s right to complain, the CNA should:
   1. Tell the nurse if the resident or family voices a complaint.
   2. Never let a complaint negatively affect how you care for the resident.
   3. Understand that if the resident complains about you, staff must investigate.
   6. The resident has the right to be free of restraint and abuse, including physical and chemical restraint for discipline or convenience, verbal, mental, sexual, physical abuse, corporal punishment, or seclusion. Violations must be reported according to state laws and facilities must investigate thoroughly. Facilities must have written policies to prohibit abuse. To protect the resident from abuse, the CNA should:
   1. Report any suspected abuse to the nurse immediately.
   2. Ask for help if resident becomes aggressive or uncooperative.
   3. Never use a protective device without the nurse’s permission.

3. CNA’s Role:
   1. Understand that violating the resident’s rights is against the law.
   2. You are the resident’s advocate.
   3. Encourage the resident to exercise their rights.
   4. Report immediately anyone who abuses the resident’s rights.
   5. Always treat residents the way you would expect to be treated if you were in the their situation.
   6. Remember that privacy and confidentiality promote dignity and self-esteem.
   7. Understand that when you talk about some one else’s negative behavior or personal problems, you are the one who ends up looking bad.

QUESTIONS:

ADDITIONAL DEFINITIONS:

1. The human body is composed of:
   1. Cells - the basic structural unit of all living things. Cell function, size and shape may be different but each cell takes in food, water and oxygen, and eliminates waste to live and perform functions.
   2. Tissues - groups of similar cells that combine to perform a particular function.
   3. Organs - group of tissues forming a distinct unit that carries out one or more specific functions.
   4. Systems - groups of organs that work together to carry out a primary body function.

2. Integumentary System structure and function:
   1. Skin-prevents germs from entering body and is the first line of defense against infection.
   2. Hair-provides protection to skin and organs.
   3. Nails-protect tips of fingers and toes.
   4. Oil glands-help skin remain moist and smooth.
   5. Sweat glands-cool body.

3. Musculoskeletal System structure and function:
   1. Bones - provide the frame for the body. Joints are the point where two bones come together and allow movement.
   2. Muscles - tissue that contracts (shortens) and relaxes (lengthens) to make motion possible.
   3. Ligaments - connect bone to bone and support joints.
   4. Tendons - connect muscles to bones.
   5. Cartilage - cushions joints.

4. Nervous System structure and function:
   1. Brain – sends, receives and interprets messages to make sense of the outside world.
   2. Spinal cord – carries messages between nerves and brain.
   3. Nerves - carry messages between brain and the point of stimulation.

5. Endocrine System includes glands that produce hormones and secretions to regulate bodily functions.

6. Reproductive System structure and function:
   1. In males:
   1. Testes – glands that produce testosterone and sperm.
   2. Scrotum – sac containing testes.
   3. Prostrate – gland producing fluid for sperm.
   4. Penis – external sex organ through which males ejaculate and urinate.
   2. In females:
   1. Ovaries – produce estrogen, progesterone and ova.
   2. Fallopian tubes – carry ova from ovaries to uterus.
   3. Uterus – muscular sac where ova can develop.
   4. Vagina – muscular canal leading out of body.
   5. Breasts – produce nutrients for infants.

7. Urinary System structure and function:
   1. Kidneys - filter waste products from blood and produce urine.
   2. Ureters - carry urine from kidneys to bladder.
   3. Urinary bladder - stores urine.
   4. Urethra - carries urine from bladder out of body.

8. Gastrointestinal System structure and function:
   1. Mouth - takes in and masticates food and fluid.
   2. Esophagus – tube that transports masticated food from mouth to stomach.
   3. Stomach - sac that mixes food and fluid with digestive juices.
   4. Small intestine – tube that absorbs nutrients from food.
   5. Large intestine – tube that absorbs water from waste.
   6. Rectum – sac at end of large intestine which stores waste.
   7. Anus – opening at end of rectum through which waste is expelled.
   8. Other organs which aid in digestion include - gall bladder, liver.

9. Circulatory System structure and function:
   1. Heart – pumps blood through the body.
   2. Blood - body fluid.
   3. Blood vessels - tubes (arteries, veins, capillaries) through which the blood is transported.

10. Respiratory System structure and function:
    1. Mouth and nose - take in air.
    2. Trachea - tube connecting mouth and nose to lungs.
    3. Lungs - move oxygen from air into blood and remove carbon dioxide (gaseous waste product).

11. CNA’s Role:
    1. Understand the body and how it functions.
    2. Think about the body and how it functions whenever performing procedures.

QUESTIONS:

ADDITIONAL DEFINITIONS:

1. The aging process is a series of physical, sensory and psychosocial changes that occur over many years.

2. Physical changes occur in all body systems causing body processes to slow down:
   1. Respiratory system - lung capacity decreases as chest wall and lungs become more rigid. Deep breathing is more difficult. Air exchange decreases causing person to breathe faster to get enough air when exercising, ill, or stressed.
   2. Circulatory system – blood vessels become more rigid and narrow. Heart muscle has to work harder which may result in high blood pressure and poor circulation.
   3. Gastrointestinal system - taste buds loose sensitivity causing decreased appetite. Tooth and gum problems result in inability to eat properly. Digestive secretions decrease causing constipation and food intolerance.
   4. Urinary system - kidney function decreases slowing removal of waste. Bladder tone decreases resulting in more frequent urination, incontinence, bladder infections and urinary retention.
   5. Endrocine system - insulin production decreases possibly causing excess sugar in blood. Adrenal secretions decrease reducing ability to handle stress. Thyroid secretions decrease slowing metabolism.
   6. Reproductive system – hormone production decreases. Decreased estrogen in females causes menopause. Decreased testosterone in males slows sexual response. Prostate gland may become enlarged causing difficulty when urinating.
   7. Integumentary system - loss of fat and water in skin causes increased sensitivity to cold, dehydration, wrinkling and sagging. Decrease in oil production causes dry skin and hair. Decrease in sweat gland function causes loss of ability to regulate body temperature. Changes in pigmentation causes gray hair and liver spots. Loss of capillary function causes yellowing of skin, thickening of nails, and thinning hair.
   8. Musculoskeletal system – bones become more brittle and porous and may fracture more easily. Loss of muscle strength and tone causes weakness and feeling tired. Less flexible joints make moving more difficult. Changes in spine and feet result in height loss, postural changes and difficulty walking.
   9. Nervous system - decreased blood flow to certain areas of brain causes decreased short-term memory.
      Nerve cells die causing decreased perception of sensory stimuli and less awareness of pain and injury.

3. Sensory changes affect how the older person perceives the environment. All information about the environment is sent to the brain through the senses:
   1. Sight – changes in the eye affect visual perception. The lens becomes flattened and rigid and the small muscles lose elasticity, decreasing the ability to focus on things that are close (presbyopia). The lens becomes more yellow, therefore, greens and blues are difficult to see. Reds and oranges are easier to see. Pupil size becomes smaller, less light reaches the inner eye making it more difficult to see in low light.
   2. Hearing - structures within the ear become stiff causing the loss of hearing of high frequency sounds (presbycusis). Soft wax production decreases and hard, dry wax builds up causing hearing loss.
   3. Smell – ability to smell decreases causing decreased appetite. Identifying smells becomes more difficult, (i.e. body odors, smoke, chemicals).
   4. Taste – taste buds are less perceptive, especially salty and sweet. More seasoning may be needed on food.
   5. Touch - decreased sensitivity in the skin results in less information from touch. Hot items are difficult to detect causing burns. Injuries from bumping are not readily felt and treated. Person may drop things more often.

4. Psychosocial changes that occur with aging affect how people perceive themselves as individuals and as a part of society:
   1. Social changes - loss of friends and relatives, loss of ability to participate in social functions.
   2. Status changes - changes in the individual’s role within a group (family, community, or workplace) may result in feelings of being less productive and less respected.
   3. Economic changes – changes in income and ownership. The person may have given up their home, car, or possessions.
   4. Positive self-esteem - becomes difficult to maintain.

5. CNA’s role:
   1. Help each resident be as independent as possible. Avoid taking over tasks that resident’s can accomplish for themselves.
   2. Be patient. Be a good listener.
   3. Be very aware of resident safety and potential hazards.
   4. Allow the resident as much freedom as possible.
   5. Help resident feel comfortable in his surroundings.
   6. Have empathy for the resident, his family and visitors.
   7. Touch can be an important means of reducing loneliness but understand and respect that some residents do not like to be touched.
   8. Help to create, but do not force, new relationships for the resident.
   9. Encourage a resident to set new goals as their needs change.
   10. Do not pass judgment on resident’s preferences.
   11. Treat each resident as an adult. Address residents by the name and title they prefer.

QUESTIONS:

ADDITIONAL DEFINITIONS:

1. Cognitive impairment is a temporary or permanent change within the brain which affects a person’s ability to think, reason and learn. Temporary causes may include stress, medication, depression, vitamin deficiency, thyroid disease, alcohol, and head trauma. Permanent causes include severe head trauma, illness, brain disease and brain damage at birth.
2. Some disorders which may cause cognitive impairment include:
1. Depression - emotional sadness and withdrawal, usually caused by loss (of person, possession, health, choice, self-esteem).
2. Anxiety – persistent feelings of fear and nervousness.
3. Suspiciousness - distrust of others.
4. Delusion - false belief not supported by reality.
5. Paranoia – irrational feeling of being persecuted, suspiciousness, hostility.
6. Schizophrenia - suspiciousness, paranoia, and delusion resulting in inappropriate behavior.
7. Mental retardation – process which slows or stops a child’s brain from maturing. Most common causes include difficult birth, Down’s Syndrome, high fever, drug or alcohol abuse during pregnancy.
8. Dementia – progressive mental deterioration due to organic brain disease which causes structural changes within the brain. Alzheimer’s Disease is the most common.
3. Dementia causes progressive deterioration of memory, judgment, orientation, physical skills, language and communication.
1. Behaviors common to residents with advanced dementia include sundowning, catastrophic reactions, wandering, pacing, pillaging, hoarding, agitation, anxiety, hallucinations, and delusions.
2. Techniques used to reduce the effects of advanced dementia and initiated only upon instruction from the nurse include:
1. Reality orientation - helps resident remain aware of their environment, of time and of themselves.
2. Validation therapy - helps resident improve dignity and self-worth by having their feelings and memories acknowledged.
3. Reminiscing - allows resident to talk about past experiences, especially pleasant ones.
3. Difficult behavior may result from too much stimulation, change in routine or environment, physical pain or discomfort, reactions to medications, and fatigue. Responses to difficult behavior:
1. Remain calm. Speak slowly and clearly.
2. Avoid approaching the resident from side or back.
3. Try to calm the resident by holding hands, patting, singing, if appropriate.
4. Try to distract the resident’s attention and redirect behavior.
5. Allow resident to express feelings if talking reduces agitation.
4. Dementia resident needs assistance in the following areas:
1. Safety
1. Monitor movement (wandering).
2. Do not move things around in room.
3. Watch for inappropriate use of objects (knives, forks, throwing things).
4. Check that clothing is worn properly (shoes tied, pants buttoned).
2. Nutrition
1. Assist resident to dining area when food is being served.
2. Have food ready to eat when placed in front of resident (seasoned, opened, cut, and buttered).
3. Allow resident more time to swallow and tell resident to swallow, if necessary.
4. Serve only one food at a time or serve finger foods, if appropriate.
5. Monitor food intake according to current nursing practices to assure adequate nutrition.
6. Check if resident is hiding food.
3. Hydration
1. Offer fluids more often and in smaller amounts to assure adequate hydration, if appropriate.
2. Listen for spoken cues that resident may be thirsty (using words like water, ocean, rain).
3. Watch for nonverbal signs that resident is thirsty (dry mouth, searching, smacking lips).
4. Dressing
1. Assist resident to choose appropriate clothing. Offer the resident a choice of two outfits.
2. Assist resident to dress properly.
3. Simplify dressing according to needs (snaps or Velcro instead of buttons).
5. Bathing
1. Prepare bathing area before bringing resident into room.
2. Explain procedure and allow resident to feel water to reduce anxiety.
3. Assist resident to bathe, as necessary, and check water temperature frequently since resident may be unable to tell you if water turns too hot or too cold.
6. Elimination
1. Take resident to bathroom frequently.
2. Provide perineal care as needed.
4. CNA’s role:
   1. Focus on what the resident can do. Do "with" and not "for" the resident.
   2. Treat each resident as an adult, with respect and dignity.
   3. Speak and move slowly. Never rush the resident.
   4. Be consistent in approach, do not force care. Remain calm and speak softly if a resident becomes agitated. If resident is agitated, stop and try again later. Never argue with the resident.
   5. Check resident frequently and always explain who you are and what you are doing.
   6. Encourage daily exercise.
   7. Give resident only one short, simple direction at a time and give resident extra time to process information and to respond.
   8. Use eye contact and appropriate body language. The resident can sense impatience.
   9. Watch resident’s facial expressions and body language for feelings and moods.
   10. Learn each resident’s past routines and patterns.
   11. Understand that all behavior has meaning. Try to discover that meaning.
   12. Understand that wandering may be necessary for some residents.

QUESTIONS:
What is depression?
List the types of deterioration that occur with dementia.
List the behaviors that are common with advanced dementia.
How should the CNA respond to a resident who is exhibiting difficult behaviors?
What techniques can be used to reduce the effects of dementia?

ADDITIONAL DEFININTIONS:
Orientation – being aware of person, place and time
Sundowning - increased confusion and restlessness in late afternoon, evening, and night
Catastrophic Reactions – being abnormally overwhelmed by stimuli; easily startled
Pillage – take what does not belong to you
Hoard – to accumulate and hide
Agitation – being overly excited
Anxiety – worry or uneasiness about what may happen
Hallucination – hearing, smelling or seeing things that are not there

TOPIC 13: RESIDENT’S FAMILY

1. The family is an extension of the resident. Family may include relatives, friends, neighbors, former co- workers, and/or guardian with durable power of attorney. Family members are a valuable part of the health care team and important to the resident, because the family:
   1. Is familiar to the resident in a facility that is unfamiliar.
   2. Can bring comfort to the resident.
   3. Offers knowledge about the resident to the health care team.
   4. Can provide assistance in caring for resident.

2. The family must adjust to life in the facility with the resident. Some emotions expressed by the family during the adjustment process are:
   1. Guilt – family may feel like they are abandoning a resident, or have broken a promise to take care of the loved one at home.
   2. Anger – family may feel anger about losing control and responsibility for the care of the resident. They may feel they are being replaced. Anger may be directed toward staff.
   3. Uncertainty – family may feel uncertain about their decision to place a loved one in a facility. They may be emotional when visiting and seem afraid, worried, nervous and tense.
   4. Sadness – family may have difficulty coping with the separation from the resident and the increased dependency of the resident.
   5. Relief – family may feel relieved, since sole responsibility for the resident’s care has been removed.

3. Communication and interpersonal skills are important when relating to the family. How the CNA relates to the resident’s family reflects both care giving and the facility as a whole:
   1. Let the family know who you are and get to know the family.
   2. Create a positive and trusting relationship.
   3. Be available to talk to the family in a quiet atmosphere.
   4. Become a resource and support for the family as their loved one’s primary caregiver.
   5. Wear a name tag and identify yourself by name and position.

4. Encourage visits between the resident and the family:
   1. Have the room ready for a family visit.
   2. Remind a resident with memory loss of the names of family members to make the visit more comfortable.
   3. Assist the resident with grooming and dressing for the visit.
   4. The resident has a right to visit with family and friends in private without unnecessary interruptions.
   5. If care is necessary during the visit, remember the resident has a right to privacy.

5. CNA’s role:
   1. Greet each family member with warmth, courtesy, kindness and respect.
   2. Refer family members requesting information about a resident to the nurse.
   3. Report to the nurse if you notice a visit is stressful or tiring to a resident.
   4. Listen to family members’ suggestions, complaints and comments, and direct the family to the nurse.
   5. Be objective. Do not judge decisions made by the family. Do not agree or disagree or take sides.
   6. Include the family in the care of the resident whenever possible but never make the family feel that they are responsible for the care. Encourage the family to participate in the comprehensive care plan conference.

QUESTIONS:

ADDITIONAL DEFINITIONS:

1. The resident environment includes the facility, the grounds and especially the resident’s room. When a resident enters a long-term care facility, he or she experiences the loss of home and belongings. The staff’s goal is to help each resident make the room his or her own. Familiar things create a positive environment.

2. The resident’s room contains all of the things necessary to make the resident feel safe and comfortable and usually includes the:
   1. Bed - types of beds may vary in each facility. Most beds have controls to raise, lower and adjust positions. Some facilities may allow the resident to bring a bed from home.
   2. Side rails - half or full rails attached to the sides of the bed considered:
   1. A self-help aid to assist the resident with mobility.
   2. A safety device, and should be up if the bed is raised.
   3. A restraint if used for the sole purpose of confining the resident in bed and requires a doctor’s order.
   3. Overbed Table – narrow table on wheels with adjustable height, which can be pushed over the bed and used for eating, writing and other activities.
   4. Bedside Stand - storage area for personal care items and personal belongings.
   5. Cushioned comfortable chair - for use by visitors or residents.
   6. Curtains or Screens - can be pulled around bed as needed to provide for a resident’s right to privacy.
   7. Personal Care Items – may include a wash basin, emesis basin, soap dish, bedpan and/or urinal.
   8. Call System – used by the resident to request assistance - must be on the resident’s unaffected side and within reach whenever the resident is alone in the room or the bathroom.

3. A comfortable environment may positively affect how the resident feels physically and emotionally and improve the resident’s sense of well being:
   1. Temperature - the resident’s condition and preferences should determine the appropriate temperature.
   2. Light - indirect lighting is preferable because glare causes fatigue. If more light is needed for a procedure, turn the added light off when the procedure is completed.
   3. Ventilation - good air circulation helps control odors and reduce pathogens. Promptly remove odor-causing waste.
   4. Floors - wipe up spills immediately. Keep floors clean and free from clutter to provide for safety.
   5. Noise - interferes with rest, which is important for health and recovery. Keep equipment in good condition and handle equipment quietly.
   6. Water - fresh water should be placed on the resident’s unaffected side and within reach to ensure adequate hydration unless contraindicated by the resident’s care plan.
   7. Equipment - Always report unsafe equipment and conditions to the nurse immediately.

4. The Resident needs a clean, neat, wrinkle-free bed for comfort and dignity and to prevent skin irritation and skin breakdown.
   1. When making a bed:
   1. Carry clean or dirty linens away from your uniform. Place clean linen on a clean surface. Never place dirty linens on the floor, which can spread infection and pose a safety hazard.
   2. Use good body mechanics.
   3. Dispose of soiled linens properly.
   4. Make sure bottom layers of linen are wrinkle-free.
   5. Make one side of the bed at a time. It is quicker, more efficient and conserves energy.
   2. An unoccupied bed can be either closed or open:
   1. A closed bed is made when a resident gets out of bed for the day. The spread is pulled over the pillow.
   2. An open bed is made for the resident who is getting out of bed for a short time. The top linens are fanfolded so the resident can safely get into bed.
   3. An occupied bed is made when a resident is unable to get out of bed.
   1. Respect and provide for the resident’s privacy while changing the linens. Close the curtains and door. Keep the resident covered.
   2. Plan the procedure so the resident is turned the least number of times possible for the resident’s comfort and safety.
   3. Turn the resident toward the raised side rail for safety and support.
   4. Make sure linen is smooth and stretched tightly under resident for comfort.

5. CNA’s Role:
   1. Help arrange the resident’s belongings as the resident wants them.
   2. Label the resident’s clothing and other personal items so that the name does not show and store appropriately when not in use.
   3. Treat the resident’s belongings with respect. Clothing is an important part of the resident’s self-esteem.
   4. Encourage residents to use their personal items.
   5. Help safeguard the resident’s personal belongings.
   6. Ask residents’ permission before handling their belongings.

QUESTIONS:

ADDITIONAL DEFINITIONS:

RELATED PROCEDURES:  

PROCEDURE 21: UNOCCUPIED BED
STEP	RATIONALE
1. Collect clean linen in order of use	1. Organizing linen allows procedure to be completed faster
2. CARRY LINEN AWAY FROM YOUR UNIFORM	2. If linen touches your uniform, it becomes contaminated
3. DO INITIAL STEPS
4. PLACE LINEN ON CLEAN SURFACE (bedside stand, overbed table or back of chair)	4. Prevents contamination of linen
5. Put bed in flattest position	5. Allows you to make a neat, wrinkle-free bed
6. REMOVE PILLOWCASE
7. LOOSEN SOILED LINEN. ROLL LINEN FROM HEAD TO FOOT OF BED AND PLACE IN HAMPER/BAG, AT FOOT OF BED OR IN CHAIR	7. Always work from cleanest (head of bed) to dirtiest (foot of bed) to prevent spread of infection. Rolling puts dirtiest surface of linen inward, lessening contamination
8. FANFOLD BOTTOM SHEET TO CENTER OF BED AND FIT CORNERS	8. Shaking linen spreads infection
9. FANFOLD TOP SHEET TO CENTER OF BED
10. Fanfold blanket over top sheet
11. TUCK TOP LINEN UNDER FOOT OF MATTRESS AND MITER CORNER	11. Mitering prevents resident’s feet from being restricted by or tangled in linen when getting in or out of bed
12. MOVE TO OTHER SIDE OF BED	12. Completing one side of bed at a time allows procedure to be completed faster and reduces strain on you
13. FIT CORNERS OF BOTTOM SHEET, UNFOLD TOP LINEN, TUCK IT UNDER FOOT OF MATTRESS, AND MITER CORNER
14. Fold top of sheet over blanket to make cuff
15. PUT ON PILLOWCASE AND PLACE AT HEAD OF BED WITH OPEN END AWAY FROM DOOR
16. FOR OPEN BED: MAKE TOEPLEAT AND FANFOLD TOP LINEN TO FOOT OF BED WITH TOP EDGE CLOSEST TO CENTER OF BED	16. Top edge of top linen must be closest to head of bed so resident can easily reach covers
17. FOR CLOSED BED: PULL BEDSPREAD OVER PILLOW AND TUCK BEDSPREAD UNDER LOWER EDGE OF PILLOW. MAKE TOEPLEAT	17. Toepleat automatically reduces pressure of top linen on feet when resident returns to bed
18. DO FINAL STEPS

 

PROCEDURE 22: OCCUPIED BED
STEP	RATIONALE
1. Collect clean linen in order of use	1. Organizing linen allows procedure to be completed faster
2. CARRY LINEN AWAY FROM YOUR UNIFORM	2. If linen touches your uniform, it becomes contaminated
3. DO INITIAL STEPS
4. PLACE LINEN ON CLEAN SURFACE (bedside stand, overbed table or back of chair)	4. Prevents contamination of linen
5. Lower head of bed	5. When bed is flat, resident can be moved without working against gravity
6. DRAPE RESIDENT (according to procedure 14)	6. Maintains resident’s dignity and right to privacy by not exposing body. Keeps resident warm
7. Turn resident away from you toward side rail
8. LOOSEN BOTTOM LINENS AND ROLL LINEN TOWARD RESIDENT TUCKING IT SNUGLY AGAINST RESIDENT’S BACK	8. Rolling puts dirtiest surface of linen inward, lessening contamination. The closer the linen is rolled to resident, the easier it is to remove from the other side
9. FANFOLD BOTTOM SHEET TO CENTER OF BED AND FIT CORNERS OVER MATTRESS	9. Shaking linen spreads infection
10. TURN RESIDENT ONTO BACK, RAISE SIDE RAIL, MOVE TO OTHER SIDE OF BED AND LOWER SIDE RAIL
11. Turn resident away from you toward side rail
12. LOOSEN SOILED LINEN. ROLL LINEN FROM HEAD TO FOOT OF BED AND PLACE IN HAMPER/BAG, AT FOOT OF BED OR IN CHAIR	12. Always work from cleanest (head of bed) to dirtiest (foot of bed) to prevent spread of infection. Rolling puts dirtiest surface of linen inward, lessening contamination
13. UNFOLD BOTTOM SHEET AND FIT CORNERS OVER MATTRESS
14. Place resident in supine position and raise side rail
15. REMOVE PILLOW, CHANGE PILLOWCASE AND PLACE PILLOW UNDER RESIDENT’S HEAD WITH OPEN END AWAY FROM DOOR
16. PLACE CLEAN TOP SHEET OVER RESIDENT AND REMOVE DRAPE (according to procedure 14)	16. Maintains resident’s dignity and right to privacy by not exposing body
17. Unfold blanket over top sheet and make cuff
18. TUCK TOP LINENS UNDER FOOT OF MATTRESS AND MITER CORNERS	18. Mitering prevents resident’s feet from being restricted by or tangled in linen when getting in and out of bed
19. LOOSEN TOP LINENS OVER RESIDENT’S FEET	19. Prevents pressure on feet which can cause pressure sores
20. DO FINAL STEPS

 

1. Positioning is the placement and alignment of the resident’s body when assisting the resident to sit, lie down or turn. If a resident has trouble moving or forgets to change position, the CNA must change the resident’s position at least every two hours (ISDH regulation) or more often as indicated in the resident’s care plan. Always check body alignment. Shoulders should be directly above hips, head and neck straight, arms and legs in a natural position. Proper positioning and good body alignment:
1. Improves physical comfort and general well being.
2. Relieves strain on the resident’s body.
3. Promotes good blood flow.
4. Helps the body function more efficiently.
5. Prevents deformities and complications including contractures and pressure sores.
2. Frequent position changes prevent:
1. Musculoskeletal deformities.
2. Development of pressure sores.
3. Respiratory complications.
4. Decreased circulation.
3. Commonly used positions include:
   1. Semi-Fowler’s position – head elevated 30-45 degrees helps breathing, puts less pressure on coccyx than sitting up and allows resident to better view environment.
   2. Fowler’s position – head elevated 45-60 degrees helps breathing and is comfortable for grooming, oral care, and eating but puts more pressure on coccyx.
   3. Supine position – flat on back; maybe necessary during some procedures including bedmaking, bed bath, and perineal care.
   4. Lateral position – lying on either right or left side reduces pressure on one side of body.

4. CNA’s role:
   1. Use good body mechanics.
   2. Keep resident’s body in good alignment. Support affected limbs during repositioning. Recheck alignment after the position change.
   3. Pay special attention to equipment such as oxygen tubing, urinary catheters and IV’s during moves.
   4. Encourage resident to assist with positioning.
   5. Be patient and never rush the resident. Speak calmly and reassuringly because resident may feel anxious.
   6. Be gentle with the resident to prevent pain and injury.
   7. Be informed of what positions are safe for each resident.
   8. Position urinary catheter over (not under) the leg to prevent pressure sores.
   9. Prevent skin tears by never sliding or dragging a resident on the bed.
   10. Use side rails while moving resident in bed.
   11. Reposition a resident who is sitting in a chair every hour.

QUESTIONS:

ADDITIONAL DEFINITIONS:

Alignment – to put in a straight line
Deformities – abnormally formed parts of the body
Coccyx – triangular bone at the base of the spine

RELATED PROCEDURES:

1. Vital signs include temperature, pulse, respiration and blood pressure. Vital signs provide important information about:
   1. How the body is functioning.
   2. How the resident is responding to treatment.
   3. How the resident’s condition is changing.

2. Temperature is a measurement of heat in the body. Temperature is affected by time of day, age, exercise, emotional state, environmental temperature, medication, pregnancy, illness, and menstruation.
   1. Methods used to measure temperature include:
   1. Oral (by mouth) – normal range is 97.6° F to 99.6° F.
   2. Axillary (placed in the armpit) – normal range is 96.6° F to 98.6° F.
   3. Aural (placed in the ear) – normal range is 98.6° F to 100.6° F.
   2. Types of thermometers include:
   1. Glass - a hollow tube (stem) filled with a liquid metal (mercury) that expands and contracts with changes in temperature. One end is the tip (often red for rectal and blue for oral). The other end is the bulb (short and round for rectal and longer and slender for oral). To read, measure the mercury level against marks on the stem of the thermometer.
   2. Electronic - a probe is covered by a plastic disposable sheath and placed under the tongue. The result is displayed on a screen.
   3. Paper or plastic tape - placed on the forehead or abdomen. Changes in color indicate temperature.
   4. Aural (tympanic) – a covered probe is placed in the ear to measure temperature at the eardrum and is considered as accurate as a rectal temperature.

3. Pulse rate is the measurement of the number of heartbeats per minute. Pulse rate is affected by age, sex, emotions, body position, medication, illness, fever, physical activity and fitness level. The pulse can be felt at many locations on the body.
   1. The pulse points most often used are:
   1. Carotid - located on either side of the neck and used during CPR.
   2. Apical - located on the left side of the chest under the breastbone, and taken with a stethoscope.
   3. Radial - located on the thumb side of the wrist and used for standard pulse rate.
   4. Brachial – located at the bend of the elbow and used for blood pressure measurement.
   2. When taking a pulse, note three things:
      1. Rate – number of beats per minute (normal rate is 60 to 100 per minute).
      2. Rhythm – the regularity or skipping of beats.
      3. Force – strength or weakness of beats.

4. Respiration rate is the measurement of the number of times a person inhales per minute. Respirations are affected by age, sex, emotional stress, medication, lung disease, heat and cold, heart disease, and physical activity.
   1. When taking respirations, note three things:
   1. Rate – number of respirations per minute (normal rate is 12 to 20 per minute).
   2. Rhythm – the regularity or irregularity of breathing.
   3. Character – the type of breathing (shallow, deep, labored).
   2. Special considerations when taking respirations:
   1. Count respirations after finishing the pulse, without taking your fingers off the wrist or the stethoscope from the chest so that the resident is unaware you are checking his respirations.
   2. If resident is agitated, place hand on resident’s chest and feel chest rise and fall during breathing.

5. Blood pressure is a measurement of the force the blood exerts against the walls of the arteries. In addition to the factors affecting other vital signs, heredity, diet, condition of vessels and volume of blood in the system affect blood pressure. Abnormally high blood pressure is called hypertension. Abnormally low blood pressure is called hypotension.
   1. Two measurements are taken:
   1. Systolic – first beat heard; upper number.
   2. Diastolic – last beat heard; lower number.
   2. In order to ensure accurate readings:
   1. Take blood pressure only if the resident is lying or sitting unless otherwise instructed.
   2. Correctly apply the proper sized cuff and keep resident’s arm at or below the level of the heart.
   3. Place diaphragm of the stethoscope over brachial artery and read the sphygmomanometer gauge accurately.

6. The resident’s height and weight are other important measurements.
   1. The resident’s height is measured at the time of admission or at significant change.
   2. The resident’s weight is recorded at the time admission and at least monthly according to the resident’s care plan. Different types of scales include: standard, chair, and bed scales.
   1. Weight must be checked at least every month to:
   1. Assist physician to determine medication dosage.
   2. Assess fluid balance, kidney and heart function.
   3. Determine changes in nutritional status.
   2. To weigh resident:
   1. Have resident wear the same type of clothing each time they are weighed.
   2. Have resident empty bladder before being weighed.
   3. Schedule daily weights at the same time each day.
   4. Follow manufacturer’s guidelines for use of the scale.

7. CNA’s role:
   1. Be certain measurements are accurate. Document measurements and report unusual readings to the nurse immediately. If unsure of measurements, tell the nurse.
   2. Provide for resident’s privacy when taking measurements.
   3. Never leave the resident unattended with a thermometer inserted.
   4. Never take the oral temperature of a resident who is unconscious or has seizures.
   5. Never leave resident standing or sitting on the scale.
   6. Wait 15 minutes after smoking or drinking to take an oral temperature.

QUESTIONS:

ADDITIONAL DEFINITIONS:
Diaphragm – piece at the end of the stethoscope which magnifies sound
Stethoscope – instrument used to convey to the ear sounds produced in the body
Sphygmomanometer – instrument for determining arterial pressure

STEP

PROCEDURE 40: WEIGHT
RATIONALE
1. DO INITIAL STEPS
2. BALANCE SCALE	2. Scale must be balanced on zero for weight to be accurate
3. DEPENDING ON SCALE USED, ASSIST RESIDENT TO STAND ON PLATFORM OR SIT IN CHAIR WITH FEET ON FOOTREST OR TRANSPORT WHEELCHAIR ONTO SCALE AND LOCK BRAKES	3. When using chair scale, if resident has feet on floor, weight will not be accurate. Wheel locks prevent chair from moving when using a wheelchair scale
4. WHEN USING A STANDARD SCALE - MOVE LOWER WEIGHT TO FIFTY POUND MARK THAT CAUSES ARM TO DROP. MOVE IT BACK TO PREVIOUS MARK. MOVE UPPER WEIGHT TO POUND MARK THAT BALANCES POINTER IN MIDDLE OF SQUARE. ADD LOWER AND UPPER MARKS WHEN USING A DIGITAL SCALE - PRESS WEIGH BUTTON. WAIT UNTIL NUMBERS REMAIN CONSTANT	4. When arm drops, weight is too high When pointer is suspended, weight is accurate Total gives accurate weight
5. SUBTRACT WEIGHT OF WHEELCHAIR FROM TOTAL WEIGHT, IF APPLICABLE
6. ACCURATELY RECORD RESIDENT’S WEIGHT ACCORDING TO CURRENT NURSING PRACTICES.	6. Record weight immediately so you won't forget. Weight changes are an indicator of resident condition. Accuracy is necessary because decisions regarding resident's care may be based on your report. What you write is a legal record of what you did. If you don't document it, legally it didn't happen
7. DO FINAL STEPS
8. REPORT UNUSUAL READING TO NURSE	8. Provides nurse with information to assess resident’s condition and needs

PROCEDURE 41: PULSE AND RESPIRATION
STEP	RATIONALE
1. DO INITIAL STEPS
2. Place resident’s hand on comfortable surface
3. FEEL FOR PULSE ABOVE WRIST ON THUMB SIDE WITH TIPS OF FIRST THREE FINGERS	3. Because of artery in your thumb, pulse would not be accurate if you use your thumb
4. COUNT BEATS FOR 60 SECONDS, NOTING RATE, RHYTHM AND FORCE	4. Ensures accurate count. Rate is number of beats. Rhythm is regularity of beats. Force is strength of beats
5. CONTINUE POSITION AS IF FEELING FOR PULSE	5. Resident could alter breathing pattern if aware that respirations are being taken
6. COUNT EACH RISE AND FALL OF CHEST AS ONE RESPIRATION
7. COUNT RESPIRATION FOR 60 SECONDS NOTING RATE, REGULARITY AND SOUND	7. Ensures accurate count. Rate is number of breaths. Regularity is pattern of breathing. Sound is shallowness or depth of breathing
8. RECORD PULSE AND RESPIRATION RATES ACCORDING TO CURRENT NURSING PRACTICES	8. Record pulse and respirations immediately so you won’t forget. Accuracy is necessary because decisions regarding resident’s care may be based on your report. What you write is a legal record of what you did. If you don't document it, legally it didn’t happen
9. DO FINAL STEPS
10. REPORT UNUSUAL FINDINGS TO NURSE	10. Provides nurse with information to assess resident’s condition and needs

PROCEDURE 42: ORAL TEMPERATURE
STEP	RATIONALE
1. DO INITIAL STEPS
2. Position resident comfortably in bed or chair
3. Rinse thermometer in cool water and dry with clean tissue, if necessary
4. HOLD THERMOMETER AT STEM END AND SHAKE DOWN TO BELOW THE LOWEST NUMBER	4. Holding the stem end prevents contamination of the bulb end. The thermometer reading must be below the resident’s actual temperature
5. Put on disposable sheath, if applicable	5. Equipment used incorrectly may cause discomfort and injury to resident
6. PLACE BULB END OF THERMOMETER UNDER RESIDENT’S TONGUE	6. The thermometer measures heat from blood vessels under the tongue
7. Ask resident to close lips	7. The lips hold the thermometer in position. If broken, injury to the mouth and mercury poisoning may occur
8. LEAVE IN PLACE FOR AT LEAST 3 MINUTES OR LONGER BASED ON THE NEEDS OF THE INDIVIDUAL RESIDENT	8. More time may be required if resident opens mouth to breathe or talk
9. REMOVE THERMOMETER, WIPE WITH TISSUE FROM STEM TO BULB OR REMOVE SHEATH . DISPOSE OF TISSUE OR SHEATH	9. Reduces contamination
10. HOLDING THERMOMETER AT EYE LEVEL, SLOWLY ROTATE UNTIL LINE APPEARS. ACCURATELY READ AND RECORD TEMPERATURE ACCORDING TO CURRENT NURSING PRACTICES	10. Record temperature immediately so you won’t forget. Accuracy is necessary because decisions regarding resident’s care may be based on your report. What you write is a legal record of what you did. If you don’t document it, legally it didn’t happen
11. Shake down thermometer, clean and return thermometer according to current nursing practices	11. Facilities have different methods of sanitation. You need to carry out the policies of your facility
12. DO FINAL STEPS
13. REPORT UNUSUAL READINGS TO NURSE	13. Provides nurse with necessary information to properly assess resident’s condition and needs

PROCEDURE 44: BLOOD PRESSURE
STEP	RATIONALE
1. DO INITIAL STEPS
2. CLEAN EARPIECES AND DIAPHRAGM OF STETHOSCOPE WITH ANTISEPTIC WIPE	2. Reduces pathogens, prevents ear infections and prevents spread of infection
3. Uncover resident’s arm to shoulder
4. REST RESIDENT’S ARM, LEVEL WITH HEART, PALM UPWARD ON COMFORTABLE SURFACE	4. A false low reading is possible if arm is above heart level
5. WRAP SPHYGMOMANOMETER CUFF AROUND UPPER UNAFFECTED ARM APPROXIMATELY 1-2 INCHES ABOVE ELBOW	5. Cuff must be proper size and put on arm correctly so amount of pressure on artery is correct. If not, reading will be falsely high or low
6. PUT EARPIECES OF STETHOSCOPE IN EARS	6. Earpieces should fit into ears snugly to make hearing easier
7. PLACE DIAPHRAGM OF STETHOSCOPE OVER BRACHIAL ARTERY AT ELBOW
8. CLOSE VALVE ON BULB. IF BLOOD PRESSURE IS KNOWN, INFLATE CUFF TO 20 mm/hg ABOVE THE USUAL READING. IF BLOOD PRESSURE IS UNKNOWN, INFLATE CUFF TO 160 mm/hg	8. Inflating cuff too high is painful and may damage small blood vessels
9. Slowly open valve on bulb	9. Releasing valve slowly allows you to hear beats accurately
10. Watch gauge and listen for sound of pulse
11. NOTE GAUGE READING AT FIRST PULSE SOUND	11. First sound is systolic pressure
12. NOTE GAUGE READING WHEN PULSE SOUND DISAPPEARS	12. Last sound is diastolic pressure
13. Completely deflate and remove cuff	13. An inflated cuff left on resident’s arm can cause numbness and tingling. If you must take blood pressure again, completely deflate cuff and wait 30 seconds. Never partially deflate a cuff and then pump it up again. Blood vessels will be damaged and reading will be falsely high or low
14. ACCURATELY RECORD SYSTOLIC AND DIASTOLIC READINGS ACCORDING TO CURRENT NURSING PRACTICE	14. Record readings immediately so you won't forget. Accuracy is necessary because decisions regarding resident's care may be based on your report. What you write is a legal record of what you did. If you don't document it, legally it didn't happen
15. DO FINAL STEPS
16. REPORT UNUSUAL READINGS TO NURSE	16. Provides nurse with information to properly assess resident’s condition

 

1. Bathing helps keep skin healthy and prevents skin problems. State regulations say that a "resident shall be bathed or assisted to bathe as frequently as is necessary, but at least twice weekly." Bathing:
   1. Cleanses the skin of perspiration, dirt and germs.
   2. Increases circulation to the skin.
   3. Promotes resident comfort and well being.

2. Consideration is given to a resident’s preferences and condition when determining the type, time and frequency of bathing. Residents may choose to bathe before bedtime or in the morning, according to their habits before entering the long term care facility. Types of baths include:
   1. Complete Bed Bath - given to a resident who is weak or unable to leave the bed and includes washing the resident’s entire body.
   2. Partial Bath - bathing certain parts of the body between complete baths or to provide comfort; involves washing the face, hands, underarms, and then perineal area.
   3. Tub Bath - relaxing method of bathing for a resident who can tolerate sitting in water.
   4. Shower - taken by a resident who is strong enough to move or be moved. Residents may prefer to use a shower chair in the shower.

3. During bathing, observe and report any of the following:
   1. Color changes of the lips, skin, nail beds and whites of the eyes.
   2. Rashes, dry skin, bruises, broken skin, reddened areas, abnormal skin temperature.
   3. Drainage, bleeding, complaints of pain or itching.
   4. Excessive hair loss.

4. Perineal care means cleaning the genital and anal area to prevent infection and odor and improve the resident’s comfort. Perineal care is a routine part of a complete bed bath. Perineal care may be necessary between baths, especially for incontinent residents, residents with diarrhea and residents with skin irritation and/or discharge. When performing perineal care:
   1. Provide privacy and dignity. Drape resident.
   2. Follow Standard Precautions. Clean from front to back.
   3. Clean catheter from meatus out.
   4. Retract and clean foreskin of uncircumcised male.
   5. Separate and wash labia of female.
   6. Provide for comfort (warm water, handle genitals carefully, rinse well).

5. Back rubs should be offered after a bath and before bedtime to keep skin healthy and prevent skin breakdown. Back rubs stimulate circulation and relieve tension. Bedridden residents need back rubs more often to stimulate circulation.
   1. Use lotion to reduce friction. Warm lotion in hands before applying to resident’s skin.
   2. Keep your nails short to prevent injury.
   3. Check skin for unusual findings before beginning back rub.
   4. Use good body mechanics.
   5. Use long, smooth strokes up spine from lower back to shoulders to relax muscles.
   6. Use short, circular strokes down sides of back from shoulders to lower back to stimulate circulation.

6. CNA’s role:
   1. Provide for the resident’s privacy and encourage the resident to do as much as possible to promote independence.
   2. Check water temperature before resident checks it. ISDH regulations state that the water temperature at the point of use must be maintained between 100 – 120^o F. Recommended bath temperature is approximately 105^o F.
   3. Follow Standard Precautions when performing perineal care or when bathing a resident with skin lesions or rashes.
   4. Always help a resident in and out of a tub or shower to prevent falls.
   5. Dry resident’s skin by patting with a towel which decreases friction and prevents skin breakdown.
   6. Never leave a resident unattended in a bathing room.
   7. Wash from cleanest to dirtiest.
   8. Observe and report unusual findings to the nurse.
   9. Clean incontinent residents every time urine and/or feces touch the skin.
   10. Offer resident backrub after bathing and at bedtime to stimulate circulation and relieve stress.
   11. Apply lotion to dry skin if requested.
   12. Clean tub, shower and shower chair before and after each use.
   13. Always check each resident’s skin during bathing.

QUESTIONS:

ADDITIONAL DEFINITIONS:

RELATED PROCEDURES:

PROCEDURE 32: SHOWER
STEP	RATIONALE
1. DO INITIAL STEPS
2. Clean shower area and shower chair	2. Reduces pathogens and prevents spread of infection
3. Help resident remove clothing. Drape resident with bath blanket	3. Maintains resident’s dignity and right to privacy by not exposing body. Keeps resident warm
4. Turn on water AND HAVE RESIDENT CHECK WATER TEMPERATURE	4. Resident’s sense of touch may be different than yours, therefore, resident is best able to identify a comfortable water temperature
5. ASSIST RESIDENT INTO SHOWER AND LOCK WHEELS OF SHOWER CHAIR	5. Chair may slide if resident attempts to get up
6. LET RESIDENT WASH AS MUCH AS POSSIBLE, STARTING WITH FACE	6. Encourages resident to be independent
7. Help resident shampoo and rinse hair
8. STAY WITH RESIDENT DURING PROCEDURE	8. Provides for resident’s safety
9. GIVE RESIDENT TOWEL AND ASSIST TO PAT DRY	9. Patting dry prevents skin tears and reduces chaffing
10. Assist resident out of shower
11. Help resident dress, comb hair and return to room	11. Combing hair in shower room allows resident to maintain dignity when returning to room
12. DO FINAL STEPS

PROCEDURE 33: BED BATH
STEP	RATIONALE
1. DO INITIAL STEPS
2. Offer resident urinal or bedpan	2. Reduces chance of urination during procedure which may cause discomfort and embarrassment
3. DRAPE RESIDENT (according to procedure 14 )	3. Maintains resident’s dignity and right to privacy by not exposing body. Keeps resident warm
4. FILL BATH BASIN WITH WARM WATER AND HAVE RESIDENT CHECK WATER TEMPERATURE	4. Resident’s sense of touch may be different than yours, therefore, resident is best able to identify a comfortable water temperature
5. If resident has open lesions or wounds, put on gloves (procedure 2)	5. Protects you from contamination by bodily fluids
6. Fold washcloth and wet
7. GENTLY WASH EYE FROM INNER CORNER OUT. USING A DIFFERENT PART OF CLOTH WASH OTHER EYE	7. Helps prevent eye infections. Always wash from cleanest to dirtiest. Using separate area of cloth reduces contamination
8. WET WASHCLOTH AND APPLY SOAP, IF REQUESTED. WASH, RINSE AND PAT DRY FACE, NECK, EARS AND BEHIND EARS	8. Patting dry prevents skin tears and reduces chaffing
9. Remove resident’s gown
10. Place towel under far arm	10. Prevents linen from getting wet
11. WASH, RINSE AND PAT DRY HAND, ARM, SHOULDER AND UNDERARM	11. Soap left on the skin may cause itching and irritation
12. REPEAT STEPS 10 AND 11 WITH OTHER ARM
13. PLACE TOWEL OVER CHEST AND ABDOMEN. LOWER BATH BLANKET TO WAIST	13. Maintains resident’s right to privacy
14. LIFT TOWEL AND WASH, RINSE AND PAT DRY CHEST AND ABDOMEN	14. Exposing only the area of the body necessary to do the procedure maintains resident’s dignity and right to privacy
15. Pull up bath blanket and remove towel
16. PLACE TOWEL UNDER FAR LEG	16. Prevents linen from getting wet
17. WASH, RINSE AND PAT DRY LEG AND FOOT	17. Soap left on the skin may cause itching and irritation
18. REPEAT STEPS 16 AND 17 WITH OTHER LEG AND FOOT
19. CHANGE BATH WATER	19. Water is contaminated after washing feet. Clean water should be used for neck and back
20. Turn resident
21. WASH, RINSE AND PAT DRY FROM NECK TO BUTTOCKS INCLUDING ANAL AREA	21. Always wash from cleanest to dirtiest
22. CHANGE BATH WATER AND GLOVES. USE CLEAN WASHCLOTH AND TOWEL	22. Water and linen are contaminated after washing anal area
23. PROVIDE PERINEAL CARE (according to procedure 34, steps 8 through 13)
24. Help resident put on clean gown
25. DO FINAL STEPS

PROCEDURE 34: PERINEAL CARE
STEP	RATIONALE
1. DO INITIAL STEPS
2. Offer resident urinal or bedpan	2. Reduces chance of urination during procedure which may cause discomfort and embarrassment
3. ASSIST RESIDENT TO SUPINE POSITION (according to procedure 3)	3. Prepares resident for procedure
4. Place waterproof pad under resident’s hips	4. Prevents linen from getting wet
5. DRAPE RESIDENT (according to procedure 14)	5. Maintains resident’s right to privacy by not exposing body. Keeps resident warm
6. FILL WASH BASIN WITH WARM WATER AND HAVE RESIDENT CHECK WATER TEMPERATURE	6. Resident’s sense of touch may be different than yours, therefore, resident is best able to identify a comfortable water temperature
7. PUT ON GLOVES (according to procedure 2)	7. Protects you from contamination by bodily fluids
8. ASSIST RESIDENT SPREAD LEGS AND LIFT KNEES IF POSSIBLE	8. Exposes perineal area
9. WET AND SOAP FOLDED WASHCLOTH	9. Folding creates separate areas on cloth to reduce contamination
10. IF RESIDENT HAS CATHETER, CHECK FOR LEAKAGE, SECRETIONS OR IRRITATIONS. GENTLY WIPE FOUR INCHES OF CATHETER FROM MEATUS OUT	10. Washes pathogens away from the meatus
11. WIPE FROM FRONT TO BACK AND FROM CENTER OF PERINEUM TO THIGHS. CHANGE WASHCLOTH AS NECESSARY FOR FEMALES: A. SEPARATE LABIA. WASH URETHRAL AREA FIRST B. WASH BETWEEN AND OUTSIDE LABIA IN DOWNWARD STROKES, ALTERNATING FROM SIDE TO SIDE AND MOVING OUTWARD TO THIGHS. USE DIFFERENT PART OF WASHCLOTH FOR EACH STROKE FOR MALES: A. PULL BACK FORESKIN IF MALE IS UNCIRCUMCISED. WASH AND RINSE THE TIP OF PENIS USING CIRCULAR MOTION BEGINNING AT URETHRA B. CONTINUE WASHING DOWN THE PENIS TO THE SCROTUM AND INNER THIGHS	11. Prevents spread of infection Females: Removes secretions in skin folds which may cause infection and odor Males: Removes secretions from beneath foreskin which may cause infection and odor
12. CHANGE WATER IN BASIN. WITH A CLEAN WASHCLOTH, RINSE AREA THOROUGHLY IN THE SAME DIRECTION AS WHEN WASHING	12. Water used during washing contains soap and pathogens. Soap left on the body can cause irritation and discomfort
13. GENTLY PAT AREA DRY IN SAME DIRECTION AS WHEN WASHING	13. If area is left wet, pathogens can grow more quickly. Patting dry prevents skin tears and reduces chaffing
14. Assist resident to turn onto side away from you
15. WET AND SOAP WASHCLOTH
16. CLEAN ANAL AREA FROM FRONT TO BACK. RINSE AND PAT DRY THOROUGHLY	16. Prevents spread of infection
17. REMOVE PAD, Assist resident to turn onto back AND UNDRAPE RESIDENT (according to procedure 14)
18. REMOVE GLOVES (according to procedure 2)
19. DO FINAL STEPS

 

1. Skin is the body’s largest organ. Skin helps control body temperature and is the first line of defense against infection because it prevents pathogens from entering the body. As people age, the skin becomes thinner, less elastic and easier to damage. The skin can tear and bruise more easily.

2. The resident’s skin should be closely observed for any sign of:
   1. Rashes.
   2. Abrasions.
   3. Dryness.
   4. Changes in color.
   5. Pressure areas.
   6. Temperature.
   7. Bruising.
   8. Swelling.

3. Pressure sores (decubitus ulcers, bedsores) are areas where the skin has been damaged due to excessive pressure or friction. Factors contributing to skin breakdown include mobility, nutrition and hydration. Residents who are at risk for developing pressure sores include those who are the:
   1. elderly,
   2. very thin,
   3. obese,
   4. paralyzed,
   5. diabetic,
   6. unconscious,
   7. chair-bound or bedridden.

4. Pressure sores occur most frequently at:
   1. Pressure points - any area on the body that bears the body’s weight when lying or sitting and where bones are close to the skin’s surface (toes, heels, ankles hips and knees; coccyx, spine and shoulder blades; elbow, ears and back of the head).
   2. Friction areas – places where skin rubs on skin (beneath breasts and abdominal folds; between buttocks and legs; under arms, in groin area and around any tubing sight (nasogastric or feeding tubes, catheters).

5. CNA’s role:
   1. Keep resident’s skin clean and dry. Check and clean incontinent resident frequently.
   2. Reposition resident at least every two hours or more often if necessary. Prevent shearing (sliding) of skin against linens.
   3. Pat resident’s skin dry instead of rubbing and use lotion on dry areas of skin.
   4. Check that clothing and shoes fit properly.
   5. Keep linens dry, wrinkle-free, and free of objects to avoid irritation.
   6. Encourage resident to get adequate nourishment and fluids.
   7. Give backrubs to increase comfort and circulation.
   8. Cushion pressure areas with heel and elbow protectors, pillows or foam pads to prevent irritation.
   9. Use Standard Precautions if resident’s skin is damaged in any way.
   10. Observe skin carefully for any changes and report unusual findings to nurse immediately.
   11. Reposition a chair-bound resident frequently.
   12. Be certain incontinence briefs are not too tight and plastic is away from the skin.
   13. Be aware of safety hazards to prevent residents from injuring skin.

QUESTIONS:

ADDITIONAL DEFINITIONS:

RELATED PROCEDURES:

1. Oral care includes cleaning the teeth, gums, tongue, inside of mouth and dentures and must be performed at least daily according to ISDH regulations. Oral care:
   1. Reduces the number of pathogens in the mouth.
   2. Helps prevent bad breath, gum disease, caries (cavities) and infections.
   3. Improves a resident’s sense of well being and appearance.
   4. Improves a resident’s sense of taste and helps improve appetite.
   5. Eliminates particles from beneath dentures, preventing gum injuries and improving the ability to chew.

2. When assisting with oral care, observe the condition of the teeth, gums, tongue and lips.
   1. Excessively bad breath - a sign of decay, infection or gastrointestinal problems.
   2. Bleeding - a sign of decay or infection.
   3. Bright red or pale gums – a sign of a disease process.
   4. Decayed, broken or loose teeth – can cause pain, infection and inability to eat.
   5. Swelling – a sign of irritation.
   6. Any sore - a sign of infection, injury, improperly fitted dentures.
   7. Coated tongue - a sign of a disease process.

3. Dentures are removable false teeth. Full dentures replace a resident’s entire upper and lower teeth. Partial dentures replace some of the resident’s teeth. When performing oral care for a resident with dentures:
   1. Provide privacy. Dentures are a very personal and private item.
   2. Handle dentures carefully. Dentures are expensive to replace.
   3. When not in use, store dentures in cool water in a denture cup labeled with the resident’s name.
   4. Observe for signs that dentures do not fit properly. Report unusual findings to the nurse.
   5. Encourage residents to wear their dentures to prevent gum shrinkage, improve speech, allow for proper chewing and improve self-image and appearance.

4. More frequent oral care is needed by residents who:

   a. Are unconscious.		f. Breathe through the mouth
   b. Have been vomiting.		g. Are being given oxygen.
   c. Have a high temperature.		h. Are dying.
   d. Are taking certain medications.		i. Have a history of mouth, tooth and gum problems.
   e. Are dehydrated.

5. CNA’s Role:
   1. Provide for privacy and encourage the resident to do as much as possible to promote independence.
   2. Use Standard Precautions when performing or assisting with oral care.
   3. Report any unusual findings and complaints of pain or discomfort to the nurse immediately.
   4. Perform mouth care gently to prevent injuries.
   5. Rinse toothpaste from mouth thoroughly.

RELATED PROCEDURES:

PROCEDURE 27: ORAL CARE
STEP	RATIONALE
1. DO INITIAL STEPS
2. RAISE HEAD OF BED SO RESIDENT IS SITTING UP	2. Prevents fluids from running down resident’s throat, causing choking
3. PUT ON GLOVES (according to procedure 2)	3. Brushing may cause gums to bleed
4. Drape towel below resident’s chin	4. Protects resident’s clothing and bed linen
5. Wet brush and put on small amount of toothpaste	5. Water helps distribute toothpaste
6. FIRST BRUSH UPPER TEETH AND THEN LOWER TEETH	6. Brushing upper teeth first minimizes production of saliva in lower part of mouth
7. Hold emesis basin under resident’s chin
8. HAVE RESIDENT RINSE MOUTH WITH WATER AND SPIT INTO EMESIS BASIN	8. Removes food particles and toothpaste
9. If requested, give resident mouthwash diluted with half water	9. Full strength mouthwash may irritate resident’s mouth
10. CHECK TEETH, MOUTH, TONGUE, AND LIPS FOR ODOR, CRACKING, SORES, BLEEDING AND DISCOLORATION. CHECK FOR LOOSE TEETH REPORT UNUSUAL FINDINGS TO NURSE	10. Provides nurse with necessary information to properly assess resident’s condition and needs
11. Remove towel and wipe resident’s mouth
12. REMOVE GLOVES (according to procedure 2)
13. DO FINAL STEPS

 

1. Care of the hair, facial hair, fingernails and toenails is an important part of the resident’s daily grooming. Cultural, ethnic, religious and personal choices influence each resident’s needs and practices.

2. Daily hair care improves appearance, self-esteem and a sense of well being.
   1. Brushing and combing hair increases circulation and promotes healthy scalp and hair.
   2. Hair is shampooed at least once per week or more often, if necessary, according to ISDH regulations.
   3. Hair should be styled according to the resident’s preference.
   4. Remove tangles by dividing hair into small sections and gently combing out from ends of hair to scalp.
   5. Hair preparations are a personal choice and should be used at the resident’s request.

3. Shaving is part of daily routine, especially for men and occasionally for women. The resident has the right to grow facial hair and to choose the preferred method of shaving if not medically contraindicated.
   1. When using a safety razor (manual razor):
      1. Soften hair with damp warm washcloth, apply shaving cream and lather well.
      2. Shave in direction of hair growth (downward on face, upward on neck).
      3. Rinse skin thoroughly to prevent irritation and use after-shave lotion as resident requests.
   2. When using an electric razor (plug in or battery operated):
      1. Do not use near water source, oxygen or if resident has certain type of pacemaker.
      2. Use pre-shave and after-shave lotions as resident requests.
      3. Shave with back and forth motion (foil head razor) or circular motion (three-head razor).
      4. Clean razor after each use.
   3. Check with the charge nurse before trimming a woman’s facial hair.

4. Nails require daily attention. Clean, trimmed and smooth nails prevent infection, injuries and odor.
   1. To provide fingernail care clean under and around nails to keep skin healthy, intact and infection free. Soak nails to soften and trim nails straight across, then file smooth, gently rounding corners.
   2. To provide toenail care clean under and around nails to keep skin healthy, intact and infection free. Never cut toenails if resident is diabetic or circulation impaired. A podiatrist provides the best care. If instructed by nurse, cut toenails straight across to prevent ingrowths and file smooth.

5. CNA’s role:
   1. Provide privacy and encourage resident to do as much as possible to promote independence.
   2. Show resident how they look when you have finished.
   3. Use Standard Precautions when shaving or cutting nails.
   4. Observe and report signs of dryness, tenderness, color changes in nails (cyanosis or redness), swelling, drainage, cuts or splits in skin.
   5. Be familiar with facility policy since some facilities do not allow the CNA to cut toenails.
   6. Never cut a resident’s hair unless specifically instructed by the nurse.

QUESTIONS:

ADDITIONAL DEFINITIONS:

PROCEDURE 24: SAFETY RAZOR
STEP	RATIONALE
1. DO INITIAL STEPS
2. Raise head of bed so resident is sitting up	2. Puts resident in more natural position
3. FILL BATH BASIN HALFWAY WITH WARM WATER	3. Hot water opens pores and causes irritation
4. Drape towel under resident’s chin	4. Protects resident’s clothing and bed linen
5. PUT ON GLOVES (according to procedure 2)	5. Shaving may cause bleeding
6. MOISTEN BEARD WITH WASHCLOTH AND PUT SHAVING CREAM OVER AREA	6. Softens skin and hair
7. HOLD SKIN TAUT AND SHAVE BEARD IN DOWNWARD STROKES ON FACE AND UPWARD STROKES ON NECK	7. Maximizes hair removal by shaving in the direction of hair growth
8. RINSE RESIDENT’S FACE AND NECK	8. Removes soap which may cause irritation
9. Apply after-shave lotion as requested	9. Improves resident’s self-esteem
10. Remove towel
11. REMOVE GLOVES (according to procedure 2)
12. DO FINAL STEPS

PROCEDURE 25: ELECTRIC RAZOR
STEP	RATIONALE
1. DO INITIAL STEPS
2. Raise head of bed so resident is sitting up	2. Puts resident in more natural position
3. DO NOT USE ELECTRIC RAZOR NEAR ANY WATER SOURCE, WHEN OXYGEN IS IN USE OR IF RESIDENT HAS PACEMAKER	3. Electricity near water may cause electrocution. Electricity near oxygen may cause explosion. Electricity near some pacemakers may cause an irregular heartbeat
4. Drape towel under resident’s chin	4. Protects resident’s clothing and bed linen
5. PUT ON GLOVES (according to procedure 2)	5. Shaving may cause bleeding
6. Apply pre-shave lotion as resident wishes
7. HOLD SKIN TAUT AND SHAVE RESIDENT’S FACE AND NECK ACCORDING TO MANUFACTURER’S GUIDELINES	7. Smoothes out skin. Shave beard with back and forth motion in direction of beard growth with foil shaver. Shave beard in circular motion with three head shaver
8. Apply after-shave lotion as resident wishes	8. Improves resident’s self-esteem
9. Remove towel from resident	9. Restores resident’s dignity
10. REMOVE GLOVES (according to procedure 2)
11. DO FINAL STEPS

1. Clothing is an expression of each resident’s personality and individuality. Residents have their own style and preferences. When residents like the way they look outside, they feel good inside. Most residents dress in their own street clothes each day.

2. Each piece of the resident’s clothing should be:
   1. Inventoried according to facility policy, adding new items and deleting discarded items as necessary.
   2. Labeled with the resident’s name in an inconspicuous place.
   3. Neatly folded in drawers or hung in the closet.
   4. Kept clean and in good repair.

3. When assisting the resident to dress:
   1. Affected limbs should be dressed first and undressed last.
   2. Avoid pullover garments if the resident has an affected side or difficulty with the neck or shoulders unless requested by the resident.
   3. Simplify dressing for residents with dementia (one-piece dresses, Velcro instead of buttons).
   4. Understand that the resident’s perception of room temperature may differ from yours.

4. CNA’s role:
   1. Provide for privacy and encourage the resident to do as much as possible to promote independence.
   2. Assist the resident to choose clothing and accessories appropriate for the weather, season, and event. If confused, offer the resident a choice of two outfits.
   3. Inventory and label clothing as necessary.
   4. Encourage resident to use napkins or clothes protectors to help keep clothing clean when eating.
   5. Report clothing in need of repair to the nurse.
   6. Assist resident to change clothing if soiled and put soiled clothing in appropriate container.
   7. Check that shoes and slippers have non-skid soles and fit properly to prevent falls.
   8. When using incontinence briefs, be certain plastic is away from skin and check for proper fit.

QUESTIONS:

ADDITIONAL DEFINITIONS:

RELATED PROCEDURES:

1. Moving or transferring a resident to and from a bed, wheelchair, or stationary chair requires the use of proper body mechanics with emphasis on planning and safety. A safe transfer for the resident and CNA is the primary goal. Refer to the resident’s care plan before moving the resident. To prepare for a move:
   1. Gather all equipment. Be certain it is safe and in good working order.
   2. Provide for privacy. Observe resident for tubing, catheters or other devices that indicate a special need. Clear the immediate area and position furniture for safety.
   3. Assess the resident’s size and ability to assist. Determine if you need help to move the resident safely.

2. Moving the resident from a lying to a sitting position can cause dizziness and fainting. To avoid falls and injuries, residents should be moved into a sitting position at the edge of the bed with their feet flat on the floor for at least 10-15 seconds prior to the move. When transferring a resident:
   1. Be sure the resident is wearing shoes or slippers with nonskid soles.
   2. Ask for assistance if the resident is too heavy or cannot help in the transfer.
   3. Determine if the resident has an affected (weak) side. Place the chair on the resident’s unaffected side and transfer toward the unaffected side.
   4. If the chair has wheels, set the brakes before transferring resident.
   5. Communicate with the resident. Count to three to let the resident know when to move.
   6. Ask resident to put his hands on your upper arms, never around your neck (which could injure you).
   7. Frequently encourage the resident to help as much as possible and be alert for any sign of a problem.

3. A stretcher is a cart with wheels used to move a resident from one place to another.
   1. If the resident is dependent, place a sheet or bath blanket under the resident for transfer to the stretcher.
   2. Have at least two co-workers assist when transferring to a stretcher.
   3. Lock wheels of bed and stretcher before transfer and raise bed to same height as stretcher.
   4. Once resident is on the stretcher, use safety straps and side rails.
   5. Elevate head of stretcher as directed by the charge nurse.

4. A mechanical lift is a hydraulic or electric device used to transfer dependent or obese residents in and out of bed, wheelchair, or tub. Most lifts include a sling that is placed under the resident. Have at least one co- worker assist when using a mechanical lift. Follow manufacturer’s guidelines for use of a mechanical lift.

5. Transporting residents to therapies, activities, and meals is a common task in a health care facility.
   1. Approach the resident from the front and explain what is going to happen.
   2. Observe for special equipment. Protect tubing to avoid resident discomfort.
   3. Transport only one resident at a time.
   4. Always push forward except when moving on and off an elevator, down a ramp, or up to a closed door. Turn the wheelchair or stretcher around and back on and off elevators and down ramps. When approaching a closed door, open door, and back through the door after checking for traffic.
   5. Be certain resident’s legs, arms, and hands are inside the framework of the wheelchair or stretcher.
   6. Set brakes at the destination.

6. CNA’s role:
   1. Provide for privacy and encourage the resident to help as much as possible to promote independence.
   2. Use proper body mechanics and check that equipment is safe and in good repair before use.
   3. Check the resident’s care plan before moving the resident.
   4. Be patient and give the resident time to adjust to changes in position.
   5. Be very aware of the position and location of the resident’s arms and legs when transferring and transporting and keep safety first. If unsure, get help.

QUESTIONS:

ADDITIONAL DEFINITIONS:

RELATED PROCEDURES:

1. Physical movement is important for mental and physical well being. Residents who walk should be encouraged and/or assisted to walk frequently throughout the day. Residents in wheelchairs should be encouraged to transport themselves if possible.

2. Residents with assistive devices should be encouraged to use the devices when ambulating. Assistive devices are ordered by the doctor and fitted specifically to the resident. Assistive devices should never be borrowed or shared. Some assistive devices include:
   1. Brace – supports a specific part of the body.
   2. Cane – used by the resident with weakness on one side.
   3. Crutches – used when weight-bearing ability is reduced.
   4. Walker – used for support and steadiness.

3. Range of motion exercises (ROM) are exercises that move each joint in the body to the fullest extent possible without causing pain. Each movement is different based on the structure of the joint. Residents should be encouraged to actively do range of motion exercises each day. Residents who have difficulty moving by themselves will require assistance to exercise (passive range of motion).
   1. Check joints for redness and swelling. Report unusual findings to the nurse immediately and do not continue with procedure.
   2. Remove obstacles that may block motion.
   3. Support above and below the joint being exercised.
   4. Perform ROM exercises according to resident’s care plan.
   5. Frequently ask resident if he is uncomfortable or in pain. Watch facial expression and response if a resident is unable to verbalize pain. Stop ROM immediately if resident experiences pain and report to nurse immediately.

4. CNA’s role:
   1. Notice when a resident is using a piece of equipment improperly; help the resident to a safe place; report to the nurse immediately.
   2. Check equipment to see that it is in good condition.
   3. Help resident use assistive devices properly.
   4. Watch for signs of discomfort or fatigue.
   5. Make sure resident is wearing well-fitted nonskid shoes or slippers.
   6. Use proper body mechanics to prevent injury to both you and the resident.
   7. Provide for privacy and encourage the resident to do as much as possible to promote independence.
   8. When assisting the resident to walk with cane, stand on the resident’s affected side.

QUESTIONS:

ADDITIONAL DEFINITIONS:

Assistive Devices – equipment used to help resident increase independence
Ambulate – to walk
Obstacle – anything that stands in the way
Verbalize – expresses in words

RELATED PROCEDURES:

1. Nutrition is the process by which the body takes in food to maintain health. Good nutrition is important because it promotes physical and mental health, increases energy level and resistance to illness, and aids in the healing process. A balanced diet is necessary for good nutrition and health.
   1. Nutrients include:
   1. Carbohydrates – provide energy and fiber.
   2. Proteins – promote growth and repair of tissue.
   3. Fats – help the body use certain vitamins; provide a concentrated form of energy.
   4. Vitamins – help the body function.
   5. Minerals – build body tissue, regulate body fluids, promote bone and tooth formation, affect nerve and muscle function.
   2. The energy potential of food is measured in calories. The amount of calories needed depends on age, illness, activity, climate, and sleep. More calories are needed if a resident has an illness, infection, or pressure sore. Individual food choices are affected by:
      1. Culture – dietary content and cooking methods differ greatly throughout the world.
      2. Religion – some religions have food restrictions and periods of fasting.
      3. Illness – pain, medication, and treatment such as chemotherapy affect the ability to eat.
      4. Finances – a limited food budget influences the types of foods in a person’s diet.
      5. Personal preferences – everyone has likes and dislikes.
   3. Most residents are on a basic diet. Some residents need special diets, which may:
   1. Restrict, eliminate or change the proportions of specific foods (sodium restricted, low fat, low cholesterol, diabetic).
   2. Be modified in consistency (clear liquids, full liquids, pureed, mechanical soft).
   4. When serving food, the CNA should:
   1. Prepare the dining area by being certain it is clean and free of unpleasant odors.
   2. Assist resident with elimination before the meal. Incontinent residents should be clean and dry.
   3. Assist resident with oral hygiene needs and handwashing.
   4. Identify the resident and position resident for comfort and safety.
   5. Check the resident’s menu card for name, diet, restrictions, likes and dislikes and be certain that the tray is complete and correct.
   6. Be certain that hot foods are not too hot to eat. Stir hot foods to cool them. If food is cold, return to dietary and request a replacement.
   7. Allow resident time to pray before the meal to show respect and caring.
   8. Encourage resident to do as much as possible for themselves. Offer to help cut meats, open packages and pour liquids.
   9. Assist resident with visual impairment by using the numbers on a clock to describe location of the foods on the plate.
   5. When feeding residents who cannot feed themselves because of weakness, paralysis, casts, or confusion:
   1. Sit at eye level with the resident.
   2. Protect resident’s clothing with covering.
   3. Identify the food with each bite.
   4. Feed slowly and in small amounts to prevent choking and aspiration.
   5. Place spoon on unaffected side of mouth.
   6. Offer fluids at regular intervals.
   7. Be patient, empathetic and encouraging.
   8. Record food intake according to current nursing practices.
   6. Supplements and in-between meal snacks increase protein and calories and can be ordered mid morning, mid afternoon and at bedtime for some residents.

2. Approximately 2000-2500cc of fluid should be taken into the body each day (liquids include water and some foods like gelatin, soup, and ice cream). Approximately the same amount of fluid should be excreted from the body through urine, feces, lungs (breathing) and skin (perspiration). This is called "fluid balance".
   1. Intake and Output (I&O) is the measurement of the amount of fluid the resident takes into the body and the amount of fluid leaving the body.
   1. Determine the resident’s total fluid intake. Include liquids taken with meals and between meals and foods which are considered liquid (gelatin, soup, ice cream).
   2. Use metric measurements. 1 oz = 30cc.
   3. Use a graduated measuring container to measure output including urine and emesis.
   4. Record results immediately according to current nursing practices.
   2. Understand that:
   1. Fluid requirements change in hot weather, with exercise, fever and illness.
   2. The elderly may have a decreased sense of thirst.
   3. Fresh water must be available for each resident unless otherwise instructed by the nurse.
   4. Some residents will have special orders to restrict fluids.

3. Residents unable to take in food and fluid in a normal manner may require:
   1. Nasogastric tube - inserted into the nose and throat into the stomach.
   2. Gastrostomy tube - inserted through an opening in the abdomen directly into the stomach.
   3. Intravenous (IV) infusion – needle inserted into a vein.
   4. Report to the nurse immediately:
   1. Resident complaints of discomfort related to feeding.
   2. Redness, swelling, drainage or complaint of pain at needle or tube site.
   3. Tension or pulling on the tube, loose tape, difficulty breathing or choking.
   5. Provide frequent oral care to resident with a nasogastric tube feeding.

4. CNA’s role:
   1. Encourage the resident to eat as much of the meal as possible.
   2. Note the foods the resident avoids and report to the nurse.
   3. Be patient when feeding or assisting the resident to eat.
   4. Create a positive environment during meals.
   5. Encourage socialization during meals.
   6. Offer fluids to the resident according to their care plan.
   7. Measure Intake and Output accurately.
   8. Observe and report any problems with tubing.
   9. Check with nurse before offering residents additional foods.

QUESTIONS:
Why is adequate nutrition especially important for the elderly?
What are the basic nutrients?
On what factors does a person’s caloric need depend?
List the factors that influence a person’s food choices.
Other than orally, what methods are used to provide nutrition and fluid to certain residents and what observations should the CNA make?

ADDITIONAL DEFINITIONS:
Nutrient - chemical substances contained in food
Basic Diet - a regular or general well balanced diet
Special Diet – therapeutic or modified
Aspiration – inhaling a foreign object or substance (food, liquids)
Supplement – to add

RELATED PROCEDURES: