The CNA Study Guide – Health Maintenance and Restoration
Section 2 – Health Maintenance and Restoration
Improving and Promoting Healthy Circulation and Skincare (with the help of chair cushions, proper positioning, and mattresses)
Some patients will stand at greater risks for potentially developing pressure sores. These particular patients will need to reduce the amount of pressure on their skin when seating, which can often be done with the aid of egg crate mattress tops, either on top of or in place of a traditional mattress. Air mattresses can also prove helpful in reducing the amount of pressure placed on bony areas of the body. Seating props, like wedges and cushions, may be needed when helping a patient up from their current position to a seated position in order to maintain a level of comfort within the patient.
When fluid builds up within tissue of the body, it is known as Edema. This can cause immobility or portions of the body to retain excessive amounts of fluid. In general, edema first appears in extremities of the body. That is why it is so important to continually inspect patients in both the morning and prior to going to bed. This helps identify edema or the development of new skin conditions. Those patients with the ability to move on their own should do so regularly as this will reduce the potential of developing edema. Those who are not able to do freely move on their own need to receive assistance from nursing assistants in order to perform regular movements and motion exercises. Whenever possible, elevating areas of the body that experience edema will help reduce fluid buildup and improve to the overall health and comfort of the patient.
Proper Hydration and Nutrition
General Hydration and Nutritional Needs
It is important for patients to remain both properly hydrated and well nourished throughout the day. This will both help maintain and often improve their physical health. If a patient does not receive proper hydration and nourishments on a daily basis, they will not heal properly (or may deteriorate) from surgery, accidents or infecting diseases. The diet needs to remain balanced including proteins, whole grains, fruits, vegetables and healthy fats (like those found in olive oil, nuts, and avocados). Nursing assistants need to monitor patients during meal time, assist when needed and report any changes in his or her eating habits. If a patient suddenly becomes unable or uninterested in eating their food, the nursing aide needs to inform the nurse on staff.
At the same time, patients need to remain properly hydrated in order to avoid dehydration. If a patient does not replenish fluids he or she loses, they can become dehydrated. Should this occur, it could lead to vomiting, diarrhea, fever and other physical problems. Other signs of dehydration include dry skin, feeling thirsty, a dry mouth, headaches, low blood pressure, feeling lightheaded or dizzy and an accelerated heart rate. Their urinary output may become concentrated (brighter/darker yellow), decrease all together and they may also become constipated.
If any of these symptoms appear in a patient, the nursing aide needs to inform the nurse right away. Now, it is possible for a patient to experience dehydration without immediately showing any of the mentioned symptoms. This is why it is so important to always monitor fluid intakes and output levels. Whenever the output far outreaches that of the input, it puts the patient in potential danger of becoming dehydrated.
Should a patient demonstrate significant weight changes (both gaining or losing two plus pounds) form one day to the next, it is a clear demonstration that there is a problem with their nutritional levels and hydration. There can be serious health problems related to sudden weight loss or gain. Patients with congestive heart failure who put on sudden weight (usually overnight) may indicate fluid overload within the body. Additionally, some side effects may lead to death if not identified and treated right away.
What Affects Dietary Preferences?
Patients do have a say on some of their dietary preferences. This can be influenced by the religion, cultural heritage and specific values (such as if they are a practicing vegan). There are some religions that require food to be prepped in specific ways, served in a certain way or prevent the consumption of certain foods (such as shellfish or pork). Whenever possible, it is extremely important to adhere to the dietary requirements and preferences of a patient.
What Affects Dietary Intake?
There are generally many factors at play when it comes to the dietary intake of a patient. Current health conditions, injuries and simply aging can all play a role in how, when and what a patient is able to eat. If a patient recently suffered a stroke, they may have trouble swallowing (dysphasia). Because of this, they are at a greater risk of aspiration. In these cases, it is necessary for their food to be made up of thickened liquids. This makes it easier to swallow and not block airways while chewing. In other situations, a patient may be missing teeth, making it difficult to chew. In these cases, the patient should be offered soft food. There may also be patients who simply are not able to consume food by their mouth (either temporarily or permanently) and consume food through the use of a feeding tube.
When a patient is unable to eat their food as they once did, it is common to see some patients lose their desire to eat at all. However, it is very important for a nursing assistant to promote proper nutrition and to make sure the patients are consuming the food. They also need to make eating time as pleasant an experience as possible. All patients should be monitored to ensure they are in fact eating all of their food.
Special Nutritional Care and Hydration
There will be times when a patient must receive special nutritional and hydration care. Some of the most common specialized diets required include:
NPO (nothing by mouth). In this case, patients are not able to eat or drink anything by way of the mouth (often prior to surgery).
RD (regular diet). This means there are no restrictions or requirements on the patient’s diet
Mechanical Soft Diet. In this case, patients should only be served pureed food
Clear Liquid Diet. This is when a patient can only consume non-thickened liquids. This can mean water, juice (without pulp), popsicles, clear broth, gelatin, coffee and tea (without cream or milk).
Full Liquid Diet. In this instance, a patient needs to follow the requirements of a clear liquid diet, on top of anything that can pass through a straw, such as pureed soups, meal shakes and some ice creams.
There are other specially designed food diets that are based specifically on the needs of the patient and their nutritional needs. Some of these diets can include heart healthy, low cholesterol, diabetic, lactose-free, low sodium, gluten-free, low residue or high residue.
Elimination of the Bladder and Bowel
Patients will typically develop a pattern for which they need to use the restroom. Nursing assistants need to understand the bathroom needs of patients and be around for them in order to provide assistance.
There should always be an output from the patient whenever taking in nutrients and fluids throughout the day. When helping a patient with their toileting needs, it is important to document what the patient outputs. Any kind of elimination of fluids should be counted toward an output. This includes stool, emesis, and urine. All stools are counted and recorded into a daily stool count. Additional remarks should be noted (odd color or smell, dryness or extremely watery). In the event of any different than normal characteristics, it is important to report the change to the nurse.
When measuring urine output, noting changes in color, consistency or odor should be noted. Any changes might indicate a change in the patient’s overall condition (and it also may be connected to a change in diet or medication). If the patient’s urine is pink or red, it may mean there is blood in the urine. If it is cloudy there might be an infection. A fruity aroma to the urine indicates high blood sugar. Ideally, the urine should be clear or a light yellow color.
When assistance is needed but delayed, or if the patient’s general routine is altered in any way, it can lead to problems in eliminating the bladder and bowel. That is why it is very important for nursing aides to work with patients on a regular basis and at regular intervals. Whenever working with a patient, the nursing aide needs to provide privacy and as much time as necessary.
If a patient uses a bladder and bowel program, it is designed to establish a set routine that will help avoid incontinence. This is done by providing a patient help with their individual toileting needs and offering assistance whenever needed. This includes following a specific schedule of meal times and consuming fluids. The nursing assistant should note all intakes. All of this is designed to help create a set routine that will improve bladder and bowel training. This can help the staff be prepared for the bathroom needs of a patient.
One of the most important elements in maintaining and building health is sleep. Some patients may have trouble sleeping. In these situations, establishing a specific care routine that fits around when patients are awake. Additionally, it is important to not disturb a patient during restful periods as they may struggle to get back to sleep. Adequate sleep is important, but when awake it is important to encourage a patient to get out of bed and to take part in physical activities whenever possible. Physical activities will help tire out the body and improve the quality of sleep. If a patient is unable to leave their bed, helping a patient take part in the range of motion exercises is important.
Whenever a patient is new to a particular facility, it can make it difficult to sleep. From the new surroundings to change in lighting and strange noises, all of this may initially lead to sleep problems and disorientation. Due to this, it is important to implement as many environmental cues to nighttime as possible. This includes keeping the noise down to as low a level as possible at night and to dim lighting or to completely turn lights off. In the morning, opening curtains help bring in natural light, which helps the body naturally wake up. Additionally, offering physical activities throughout the day will help a patient become better acquainted with the new surroundings.
Mobility and Bed Mobility
It is crucial for patients to remain mobile as this helps improve blood flow throughout the body. Nursing assistants will often need to work with patients in order to offer help with mobility. This all begins with proper positioning for the patient in order to help improve both safety and comfort. The most common positions a nursing assistant needs to know includes:
Prone. The patient lays on their stomach with their head turned to one side
Supine. The patient lays on their back
Lateral. The patient lays on either side
Fowler’s Position. The patient’s head is raised between 45 and 60 degrees
High Fowler’s Position. The patient’s head is raised between 60 and 90 degrees. The knees are either held out straight or flexed
Semi-Fowler’s Position. The patient’s head is raised between 30 and 45 degrees.
Whenever a nursing assistant helps position a patient in their bed, it is important to raise the bed high enough in order to avoid any bending over. This reduces the potential of injuring an aide’s back. Prior to positioning the patient, it is important to lower the bed’s head to its lowest possible position.
There will be times where a nursing assistant needs to help patients become as mobile as possible. The patient may require corrective and assistive devices (including walkers and canes). Some patients will have prosthetic limbs and require help with using and accessing the devices. It is important to note any irritation or redness that occurs with the prosthetic’s contact point with the skin.
Whenever moving a patient, the nursing assistant needs to focus on safety. Improperly transferring the patient can lead to injuries to both the aide and the patient, so maintaining proper technique including a straight back, bending with the knees and not turning with the waist is crucial.
When a nursing assistant helps patients out of bed, they need to lower the bed to it’s lowest setting. The aide can help the patient sit up along the side of the bed and position both feet onto the floor. While the patient is seated, it is necessary to check to see if they are lightheaded or dizzy from the movement. If the patient still struggles with these movements, assistive devices might prove necessary.
When helping a patient stand, the nursing aide needs to stand in front of the patient and position their knees in front of the knees of the patient. From there the aide should hug the patient right under the arms to help with lifting and then inform the patient what they need to do and what will be taking place. The back of the patient’s knees should remain touching the seat or bed before being lowered down.
Prior to moving a patient, the bed and wheels need to be locked to avoid shifting.
Using Mobility Devices
If a patient uses mobility assistive devices a nursing assistant needs to encourage the patient to actively use the devices. Whenever leaving the patient’s room, the nursing assistant should position the assistive devices within reach of the patient. Patients with low lower body strength but proper upper body strength might have a trapeze, which is an assistive bar that hangs over their head to allow them to pull themselves up and shift their position.
Devices such as a gait belt (also referred to as a transfer belt) help both the nursing assistant and the patient. Whenever helping a patient move from one device to the next or when walking alongside a patient who require help, the gait belt will help prevent falling. The belt is connected around the waist of the patient. The nursing assistant then holds it with both their hands while standing to either side of the patient. Should the patient lose their balance, it’s important to never reach out and try to catch them while using the belt. Instead, but holding onto the gait belt, it will help correct the patient’s position. When a patient does begin to slip though the aide needs to bend at their knees and lower the patient to the floor slowly in order to avoid injury to both patient and aide.
Techniques for Range of Motion
It is important for patients to exercise proper range of motion as this helps improve blood flow and keep joints flexible and healthy. Proper range of motion techniques should be executed with patients independently. However, for patients who are unable to perform the active moves on their own should partake in passive motion exercises. It is very important for nursing assistants to never force the patient’s body to move as it may lead to injury.
When a patient is in a supine position, the nursing aide needs to take each joint through a set range of motions. This includes adduction, which is moving the limbs toward the middle line of the body.
Abduction then consists of moving the limb away from the body’s middle line:
Flexion is the bending of a joint. The extension is straightening the joint (of a limb).
Immobility Effects on the Body
With poor (or no) mobility, the body will experience problems with blood circulation and the integrity of the skin itself. Nursing assistants need to help patients reposition at least once every two hours. This prevents sores and improves circulation through the body.
Pressure sores (which are also referred to as pressure ulcers or bedsores) are parts of the skin that break down due to pressure and poor circulation in the area. This happens usually around body areas, like the elbow, knee, hip, ankle or coccyx. Patients with pressure sores generally have poor (or no) mobility and are not able to move. There are four stages of these bedsores.
Stage I: Skin is not broken, but red and warm to touch. Discoloration can remain even after being repositioned to reduce pressure. Associated pain with the spot may also exist. This might be difficult to identify on individuals with a darker complexion.
Stage II: Loss of skin or damage to several layers with shallow abrasions or blistering.
Stage III: Epidermal and dermal layer of skin damage. Maybe deep enough to expose fatty tissue (bones, muscles, and tendons are not visible). Tunneling may appear at this stage.
Stage IV: Epidermis, dermis and underlying tissue damage. Tunneling may occur. Muscle, bones, and tendons can be visible, along with deep ulceration.
In order to prevent these pressure sores, a patient’s skin must remain clean and dry. They should be repositioned every two hours. Assistive devices like wedges and pillows should be placed under bony areas of the body to reduce pressure. Bony areas should not be massaged as it might break down the skin. Bedding and clothing should be straightened around the areas to avoid wrinkles. All incidents of skin damage and breakdowns need to be reported to the nurse on staff.
DVT (Deep Vein Thrombosis) is a blood clot in the deep veins of the patient. This is most common in the leg. Swelling, pain, and redness are common signs of DVT. Patients at the highest risk of DVT are also at risk of PE (pulmonary embolism). This takes place with the blood clots breaks off and travels to the lungs, cutting off blood flow. Swollen and red areas in extremities should not be massaged. This may cause the clots breaking off.
Patients unable to move are at a greater risk for DVT. Due to this, encouraging patients to engage in movement is important. When patients are not able to move on their own, help with motion exercises is needed. TED hose (anti-embolism stockings) and SCDs (sequential compression devices) are common for bed-confined patients. Both can help improve circulation and prevent blood pooling in the legs.
Bowel and Bladder Elimination For Immobility
Patients who are not able to control their bladders or make it to the bathroom on their own are at an elevated risk for incontinence. Nursing assistants must be mindful of a patient’s bathroom needs and work on creating a routine. The inability to move leads to constipation. Patients at a greater risk of constipation should consume more fluids. Patients who are unable to control toileting needs may be less likely to increase their fluid intake, so promoting the added intake is important.
Sleep and Rest For Immobility
Patients who are unable to move on their own may struggle with sleep patterns, as their body does not tire from exertion. Other reasons a patient doesn’t sleep is medication, pain, anxiety, and stress. Older patients and those healing from surgery (or illness) need longer periods of sleep for the body to repair itself. When awake, the patients should remain active (unless otherwise instructed). Establishing daily routines for activity is important. This can be anything from sitting in a chair to eat (instead of laying in a bed). Patients in need of assistance may want to move from bedpan to bedside toilet. It is important to not overtire a patient. The nurse on staff should be told of any trouble sleeping.
Activity Ability For Immobility
Encouraging patients who struggle with mobility to remain active is important, but it’s important to not overdo it. Their routine should be planned based on their mobility level and should provide the opportunity to both participate and rest.
Improving Strength and Endurance For Immobility
Those with mobility issues will likely lose muscle strength and endurance. When not cared for correctly, muscles will weaken, joints will stiffen and the muscles will shorten (contractures). Nursing assistants need to help perform passive range of motion exercises with these patients. Patients who can partake in active range of motion exercises should whenever possible.
Comfort for Immobility
A nursing aide needs to ensure patients with mobility problems are comfortable. This includes repositioning a patient at least once every two hours and offering wedges and pillows to reduce stress on body areas of the body (and reduce skin breakdowns).
When someone loses their mobility they can feel stressed and depressed. They might also forge a poor self-image. It is important to encourage these patients to take part in the daily activities to improve their mental state.
Using Mobile Assistive Equipment
Some patients will be given devices to help with moving around, including crutches, canes, and walkers. It is important to encourage patients who have these devices to use the equipment whenever possible. This will help improve their mobility while reducing the potential for injury.