HN43 Nursing Fundamentals and Practicum PDF

6.00 Understand effects of the aging process as it relates to the nurse aide role HN43 Nursing Fundamentals and Practicum  6.01C Understand cognitive, psychological, and physical changes due to aging HN43 Nursing Fundamentals and Practicum Body System Disorde...

6.00 Understand effects of the aging process as it relates to the nurse aide role HN43 Nursing Fundamentals and Practicum  6.01C Understand cognitive, psychological, and physical changes due to aging HN43 Nursing Fundamentals and Practicum Body System Disorders Due to Aging This Photo by Unknown Author is licensed under CC BY-SA-NC This Photo by Unknown Author is licensed under CC BY-SA-NC HN43 Nursing Fundamentals and Practicum  Musculoskeletal System- Overview Musculoskeletal system is composed of muscles , bones, joints, tendons and ligaments HN43 Nursing Fundamentals and Practicum  Musculoskeletal System-Overview Provides structure and movement for the body Protects and gives the body shape Body has over 600 muscles made up of elastic tissue Some are connected to bones by tendon HN43 Nursing Fundamentals and Practicum  Muscles Types Three Types of Muscles Skeletal muscles- called voluntary muscles Control body movements by contracting and relaxing. Voluntary muscle is a muscle that can be controlled voluntarily, or at will Work together, one muscle moves the bone in one direction, and another moves Example- biceps are it back. skeletal muscles that flex or Attached to the skeleton; include the arm contract when a person and legs; striated muscles (striped bends at the elbow appearance) HN43 Nursing Fundamentals and Practicum  Muscles Types Three Types of Muscles Smooth muscles- called involuntary muscles. Make up the walls of organs, such as the bladder and uterus, stomach, intestines, and blood vessels Involuntary muscles are controlled automatically and are not under a This Photo by Unknown Author is licensed under CC BY-SA-NC person’s concise control Smooth muscles can stretch without putting a lot of stress on the muscle HN43 Nursing Fundamentals and Practicum  Muscles Types Three Types of Muscles Cardiac muscles are involuntary muscles found only in the heart Cardiac muscle contract and relax from 60 to 100 Cardiac muscle is striated times each minute Striated muscles are muscles with a striped appearance This Photo by Unknown Author is licensed under CC BY HN43 Nursing Fundamentals and Practicum  Muscle- Function Power movement of the skeleton – tendons that connect muscles to bone and move bones when This Photo by Unknown Author is licensed under muscles contract (shorten) CC BY Give body form and posture This Photo by Produce most of body heat – when muscles contract, food is burned for energy producing heat; more Unknown Author is licensed under muscle activity, greater amount of heat; when body is CC BY-SA cold, rapid muscle contractions occur producing heat, called shivering HN43 Nursing Fundamentals and Practicum  Skeletal Bones- Structure The skeleton Bones 206 bones Outside is hard and rigid Covered with periosteum, which contains blood vessels Bone marrow, located inside, is soft and spongy Connected to other bones by ligaments Connected to muscles by tendons HN43 Nursing Fundamentals and Practicum  Skeleton (Bones) Function The skeleton Bones Provides Allows body to framework for move the body Stores calcium Protects organs Make and store of the body blood cells in bone marrow HN43 Nursing Fundamentals and Practicum  Joints-Structure Point where bones meet May be moveable (ankle), Made up of connective slightly moveable tissue called cartilage that (backbone), or immovable cushions bones; keeps them (skull) from rubbing together Ligaments located here hold Synovial membrane lines bones together joints and secretes synovial Types- ball-and-socket, fluid that acts as lubricant, hinge, and pivot so joints move smoothly HN43 Nursing Fundamentals and Practicum  Types of Joints-Function Pivot Joints- Hinge Joints- allows for allows turning movement in one from side to side direction- examples Example- skull elbows and knees connected to spine This Photo by Unknown Author is licensed under CC BY HN43 Nursing Fundamentals and Practicum  Types of Joints-Function Ball-and-socket Allows movement in all directions Made up of rounded and end of one bone fitted into the hollow end of another bone Example- hips and shoulders This Photo by Unknown Author is licensed under CC BY-SA HN43 Nursing Fundamentals and Practicum Musculoskeletal System- Normal Findings Ability to perform routine movements and activities of daily living Ability to perform full range of motion exercises bilaterally without pain This Photo by Unknown Author is licensed under CC BY-NC HN43 Nursing Fundamentals and Practicum Musculoskeletal System-Changes Due to Aging Muscles weaken and lose tone Bones lose density and become brittle Slower muscle and nerve interaction Joints stiffen, become less flexible, and become painful causing decrease in range of motion and flexibility HN43 Nursing Fundamentals and Practicum Musculoskeletal System-Changes Due to Aging Height decreases 1 to 2 inches, between age 20 and 70 Slowed recovery from position changes and sudden movement Pain when moving Reaction time, movement speed, agility, and endurance decrease Poorer response to stimuli HN43 Nursing Fundamentals and Practicum  Musculoskeletal System-Variation of Normal History of falls White, shiny, red, or Difficulty with holding or warm areas over a joint lifting objects Complaints of pain in Loss of muscle strength and joints or muscles tone Swelling, redness, and Generalized weakness and warmth of joints tiredness Complaints of pain with Bruising movement Slow and unsteady body Inability to move joints movement HN43 Nursing Fundamentals and Practicum Common Disorders of the Musculoskeletal System This Photo by Unknown Author is licensed under CC BY-SA This Photo by Unknown Author is licensed under CC BY HN43 Nursing Fundamentals and Practicum  Arthritis Inflammation or swelling of the joints causing stiffness, pain, and decreased mobility Two Types Osteoarthritis (degenerative Rheumatoid arthritis joint disease) Affects any age Affects the elderly starting with smaller joints then Occurs with aging or joint progressing to larger ones injury Affects weight-bearing hips and knees This Photo by Unknown Author is licensed under CC BY-SA HN43 Nursing Fundamentals and Practicum  Arthritis- Nurse Aide Role Encourage activity, follow care plan, canes, and safety rails are helpful. Encourage independence by assisting with the use of devices that help with bathing, dressing, and feeding; offer clothing choices that are easy to put on and fasten; treat each resident individually. Help maintain self-esteem by encouraging self-care as much as possible, listen Watch for and report stomach upset and heartburn, due to medicine HN43 Nursing Fundamentals and Practicum  Osteoporosis Bones lose density causing them to become porous and brittle Caused by lack of calcium in diet Lack of regular exercise Decrease in mobility Decrease in female hormones This Photo by Unknown Author is licensed under CC BY-NC-ND HN43 Nursing Fundamentals and Practicum  Osteoporosis Sign Nurse Aide’s Role Low back pain Prevent or slow the progression Stooped posture Encourage walking and simple Becoming shorter exercise per care plan or the Broken bones nurse’s directive Move resident carefully This Photo by Unknown Author is licensed under CC BY-SA HN43 Nursing Fundamentals and Practicum  Fracture Broken bone caused by an Most common- fractures of accident or osteoporosis arms, wrists, elbow, legs and Closed- does not break the hips skin Signs Open- breaks through the Pain skin, called compound Swelling fracture Bruising Limited mobility This Photo by Unknown Author is licensed under CC BY-SA-NC HN43 Nursing Fundamentals and Practicum  Fracture-Treatment Goal The bone is placed back into alignment so it can heal New bone growth develops-bone tissue grows and fuses area together Fractures are immobilized, typically by cast or brace Bone healing can take four to eight weeks Fractures can take longer to heal in the elderly This Photo by Unknown Author is licensed under CC BY-NC-ND HN43 Nursing Fundamentals and Practicum  Fracture- Nurse Aide Role Prevention of falls is crucial Follow fall prevention concepts If casted or braced, elevate arm or leg slightly higher than level of heart Observe circulation of fingers or toes (warmth, color, movement of fingers and toes HN43 Nursing Fundamentals and Practicum  Fracture- Nurse Aide Role Report swelling, tightness of cast or brace, sores, cool fingers or toes, drainage, or bleeding Report irritation from edges of cast or brace Keep cast or brace dry and assist with personal care per directive of care plan or the nurse Monitor and report if resident sticks objects in the cast or brace HN43 Nursing Fundamentals and Practicum  Hip Fracture A break in the hip Focus of care bone Healing of incision Residents with Slow strengthening of osteoporosis or arthritis are at risk muscles of the hip region Results from falls or Increased mobility, gait, simple movements and endurance Most require surgery This Photo by Unknown Author is licensed under CC BY-NC-ND HN43 Nursing Fundamentals and Practicum  Hip Fracture- Nurse Aide Role Prevention in falls is crucial Follow directives about Follow fall prevention weight-bearing limitations concepts (how much weight the resident can support (none, partial, or After surgery and during full) rehabilitation, follow care plan carefully for guidance Do not perform range of on weight bearing limitation motion until directed to do so Monitor how much resident can do, and which assistive Know the limitations of leg devices may be used and hip movements, use abduction pillow as directed by care plan and nurse HN43 Nursing Fundamentals and Practicum  Hip Fracture- Report to Nurse Incision redness Shortening or rotation Drainage o Bleeding outward of affected leg Abnormal vital signs Increased pain Resident is being non- Numbness or tingling compliant with limitations of feet and legs Decrease in appetite Tenderness or Improvements that are swelling in claves of noted legs HN43 Nursing Fundamentals and Practicum  Total Knee Replacement (TKR) Replacement of knee with a Goals of TKR prosthesis Prevent blood clots by using Performed to relieve pain special stockings and restore mobility (compression) and machines damaged by arthritis or as directed on care plan and injury nurse Speed up recovery Decrease stiffness Increase range of motion This Photo by Unknown Author is licensed under CC BY-NC-ND HN43 Nursing Fundamentals and Practicum  Nurse Aide Role- TKR) Follow care plan and the nurse’s directive regarding mobility Encourage fluids to reduce urinary infections Report pain and redness, swelling, heat, or tenderness in calves This Photo by Unknown Author is licensed under CC BY HN43 Nursing Fundamentals and Practicum Surgical removal of a body Amputation part Phantom sensation and Arm, hand, leg, and foot pain Caused by disease or Person feels the body part accident is still there and experiences pain in the area that has been amputated Do not ignore Possibly results from damaged nerve endings This Photo by Unknown Author is licensed under CC BY-SA Report to nurse HN43 Nursing Fundamentals and Practicum  Amputation- Nurse Aide Role Assist with activities of daily living Provide support if phantom pain statements are made- do not argue Assist with position changes and range of motion exercises Follow-up with plan for prosthetic care HN43 Nursing Fundamentals and Practicum  Contracture and Muscle Atrophy Contracture- muscle or tendon shortens, freezes, becomes inflexible, causes permanent disability Muscle atrophy – the muscle wastes away, decreases in size, and becomes weak, from disuse Prevention of these two conditions is critical Perform range of motion exercises Use positioning and supportive devices to maintain structure and function of extremities This Photo by Unknown Author is licensed under CC BY HN43 Nursing Fundamentals and Practicum  Control and coordinate Nervous all body functions Reflex centers for System heartbeat and Consists of two main respiration divisions Senses and interprets o Central nervous information from system (CNS) – brain outside the body and spinal cord Responds to needed o Peripheral nervous changes both inside system – includes and outside the body nerves that travel This Photo by Unknown Author is licensed under CC BY-SA throughout the body HN43 Nursing Fundamentals and Practicum  The Neuron (Nerve Cell) Basic unit of nerves and the nervous system Carry messages or impulses through spinal cord to and from the brain o Fragile and takes a long time to heal if injured o Some are covered and insulated with a protective fiber, called the myelin sheath; also allows for speed of conduction of impulses HN43 Nursing Fundamentals and Practicum The Brain one of the largest organs in the body weighing three pounds Housed within the cranium Divided into 3 parts This Photo by Unknown Author is licensed under CC BY-NC HN43 Nursing Fundamentals and Practicum  Brain- The Cerebrum Cerebrum-largest section of the brain. o Center of the brain where thought and intelligence exist. o Divided into right and left hemispheres o Right hemisphere controls movement and function of left side o Left hemisphere controls movement and function of right side Any illness or injury to right hemisphere affects function of left side Any illness or injury to left hemisphere affects function of right side HN43 Nursing Fundamentals and Practicum  Brain-The Cerebrum Cerebral cortex the outermost layer that lies on top of the cerebrum High–level functions Four lobes- on each Reasoning side of the brain Emotion Frontal Thought Memory Temporal Language Parietal Consciousness Occipital HN43 Nursing Fundamentals and Practicum  Brain- The Cerebrum Parietal lobe Frontal Lobe reading thinking body orientation speaking sensory information seasoning understanding language problem solving Occipital lobe vision Temporal lobe Memories Cerebellum Hearing coordination Brain stem balance Behavior breathing Generation vestibular temperature attention emotions heart rate This Photo by Unknown Author is licensed under CC BY-SA HN43 Nursing Fundamentals and Practicum  Cerebellum Brain Stem Controls balance Regulatory and regulates center Controls heart voluntary muscles Produces and rate, breathing, coordinates swallowing, smooth opening/closing movements blood vessels This Photo by Unknown Author is licensed under CC BY-SA-NC HN43 Nursing Fundamentals and Practicum  Spinal Cord Located within the spine Connected to the brain Conducts messages between the brain and the body by pathways This Photo by Unknown Author is licensed under CC BY HN43 Nursing Fundamentals and Practicum  Sensory Organs Includes Skin Tongue Nose Eyes This Photo by Ears Unknown Author is licensed under CC BY-NC Receives impulses from This Photo by Unknown Author is licensed under CC BY-NC environment and relays impulses to brain Skin This Photo by Unknown Author is licensed under CC BY-SA HN43 Nursing Fundamentals and Practicum  Nervous System- Normal Alert and oriented Clear short term/long-term memory Sensory function intact Ability to sense heat, cold, pain Straight gait, coordination of limbs Reflexes present HN43 Nursing Fundamentals and Practicum  Nervous System- Changes due to Aging Some hearing loss occurs Appetite decreases Less tear production Vision decreases Problems seeing blue and green Pupils less responsive to light HN43 Nursing Fundamentals and Practicum  Nervous System- Changes Due to Aging Changes in memory, most likely with short-term memory Loss of nerve/brain cells Slowed response and reflex time Jerking motions or tremors Reduced sense of touch and sensitivity to pain HN43 Nursing Fundamentals and Practicum  Nervous System-Changes Due To Aging Reduced blood flow to the brain Forgetfulness Each of the senses decrease in function Sensitivity to heat and cold decreases HN43 Nursing Fundamentals and Practicum  Nervous System- Variations in Normal Changes in gait or movement Complaint of loss of feeling or inability to move one side of the body Paralysis Seizures Confusion Speech, vision, or hearing changes Complaints of numbness, dizziness, nausea HN43 Nursing Fundamentals and Practicum Common Disorders of the Nervous System This Photo by Unknown Author is licensed under This Photo by Unknown Author is licensed under CC BY CC BY-SA-NC HN43 Nursing Fundamentals and Practicum  Cerebrovascular Accident (CVA)- Stroke Can be mild or severe EMERGENCY Severity is impacted by area of brain and size of the affected area Other symptoms Numbness Confusion Trouble seeing and or walking Severe headache HN43 Nursing Fundamentals and Practicum  After Stroke- Resident May Experience Hemiplegia – paralysis on one Emotional lability – inappropriate side of body or uncalled for laughing, crying, Hemiparesis – weakness on or expressions of anger one side of body Loss of sensations Expressive aphasia – trouble (temperature, touch) communicating thoughts by Loss of bowel/bladder control speech or writing Cognitive impairment (poor Receptive aphasia – difficulty judgment, memory loss, inability understanding spoken or to solve problems, confusion) written words Dysphagia( difficulty swallowing) HN43 Nursing Fundamentals and Practicum  Stroke- Nurse Aide Role Will vary depending on severity of stroke and region of the brain involved This Photo by Unknown Author is licensed under CC BY-SA-NC HN43 Nursing Fundamentals and Practicum  Stroke- Nurse Aide Role Assist the resident to strengthen Never refer to the weak side as muscles and keep joins mobile the “bad leg or bad arm” Provide range of motion Assist with communication Maintain correct body alignment using techniques and support extremities with recommended by speech pillows and other measures therapist or the nurse Maintain positive attitude when Understand that confusion using non-verbal and verbal and/or memory loss can be communication frightening and frustrating to the resident, may cry for no reason HN43 Nursing Fundamentals and Practicum  Stroke- Nurse Aide Role When caring for resident, smiles Be very observant for changes and simple gestures may be in skin condition especially those areas at risk for pressure helpful to decrease fear or anger injury development Encourage independence and May be at increased risk for self-esteem by letting resident do pressure injury if loss of as much care whenever sensation is present; resident possible, celebrate small cannot move a side of the victories, and make tasks as body, and report changes easy as possible immediately to the nurse HN43 Nursing Fundamentals and Practicum  Stroke- Nurse Aide Role Be aware of bath water temperature and shaving if the resident has loss of touch or sensation Adapt self-care activities to limitations of the resident’s condition by having them use assistive devices for eating and dressing Remember to put items the resident will need such as their call signal, water pitcher, and glasses on the resident’s unaffected side HN43 Nursing Fundamentals and Practicum  Parkinson’s Disease progressive, incurable Signs & Symptoms Uncontrollable tremors or shaking disease that causes a Stiffening muscles part of the brain to Gait shuffling degenerate Bent posture Pin-rolling with finger and thumb Mask-like facial expression Blinking or smiling may diminish Mood swings Gradual behavior changes Memory loss and dementia This Photo by Unknown Author is licensed under CC BY HN43 Nursing Fundamentals and Practicum  Parkinson’s Disease Nurse Aide Role Protect resident Keep out of unsafe areas Assist with ambulation- high risk for falls Assist with activities of daily living Encourage self-care- be patient with self- care and communication HN43 Nursing Fundamentals and Practicum  Head and Spinal Cord Injuries Causes may include diving accidents, sports injuries, motor vehicle accidents, and war injuries Injuries range from mild concussion to coma, paralysis, and death This Photo by Unknown Author is licensed under CC BY-NC-ND HN43 Nursing Fundamentals and Practicum  Head and Spinal Cord Injuries Head injuries may cause permanent brain damage Disabilities are related to the part of the brain injured Severity of spinal cord injuries depend on level and force of injury to spinal cord Higher the injury, the greater the loss of function HN43 Nursing Fundamentals and Practicum  Head and Spinal Cord Injuries Paraplegia – complete loss of function occurs to lower body Quadriplegia – complete loss of function occurs to lower HN43 Nursing Fundamentals and Practicum  Head and Spinal Cord Injuries- Nurse Aide Role Provide emotional support and realize that the resident may exhibit feelings of anger and frustration Encourage resident to participate as much as possible in self-care Crucial for position changes at a minimum of every two hours due to loss of function Offer rest periods during care HN43 Nursing Fundamentals and Practicum  Head and Spinal Cord Injuries- Nurse Aide Role Range of motion per directives of care plan Immobility may lead to constipation, so encourage fluids and intake of fiber, if ordered Due to nature of disability, urinary catheter may be necessary, which increases occurrence of urinary tract infection, provide catheter care and encourage fluids HN43 Nursing Fundamentals and Practicum  Head and Spinal Cord Injuries- Nurse Aide Role Immobility may lead to poor circulation Apply stockings per directive Encourage deep breathing and coughing, per order, to prevent pneumonia This Photo by Unknown Author is licensed under CC BY-SA-NC HN43 Nursing Fundamentals and Practicum  Hearing Impairment Can be born with a hearing impairment May lose hearing gradually This Photo by Unknown Author is licensed under CC BY-NC-ND HN43 Nursing Fundamentals and Practicum  Hearing Impairment- Nurse Aide Role Report to the nurse Approach resident from the Resident favoring one ear over the other front, or touch lightly on the arm one to let resident know you are near Resident avoiding movies or special events If resident has a hearing aide, due to difficulty hearing make sure resident is wearing it Complaints of and it is turned on Pain in one or both ears Look directly at the resident Ringing in the ears while speaking- may read your Trouble hearing what is said in a setting lips- Stand in front of the that has background noise resident Do not shout, speak clearly Lower the pitch of your voice HN43 Nursing Fundamentals and Practicum  Visual Impairment A loss of vision that cannot be corrected to a normal level Nurse Aide Role Knock on the door, announce yourself Do not touch the resident before identifying yourself Face the resident the entire time you are speaking Do not shout Use the face of an imaginary clock as a guide to explain positions of objects HN43 Nursing Fundamentals and Practicum  Visual Impairment- Nurse Aide Role If resident wears glasses make sure they are on Do not move personal items or furniture Read menus to the resident if needed Let the resident know when you are leaving Be empathetic Make sure there is proper lighting in the room Encourage the resident to use his other senses HN43 Nursing Fundamentals and Practicum  Cardiovascular System This Photo by Unknown Author is licensed under CC BY-NC-ND HN43 Nursing Fundamentals and Practicum Cardiovascular System-Changes Due to Aging Heart muscle less efficient Blood pumps with less force Arteries lose elasticity and become This Photo by Unknown Author is licensed under CC BY-NC-ND narrow Blood pressure increases HN43 Nursing Fundamentals and Practicum  Abnormal Findings of the Cardiovascular System Shortness of breath, changes Tachycardia in or difficulty breathing Irregular pulse rhythm Change in pulse rate and Swelling of hands and feet rhythm Pale or bluish lips, hands, or Loss of ability to perform feet ADLs Weakness and tiredness Chest pain Weight gain Bradycardia HN43 Nursing Fundamentals and Practicum  Hypertension- High Blood Pressure Major cause is atherosclerosis, or what lay people refer to as “hardening of the arteries” Arteries harden due to plaque build-up from fatty deposits May complain of headache, blurred vision, and dizziness HN43 Nursing Fundamentals and Practicum  Orthostatic Hypotension Abnormal low blood pressure that occurs when the resident suddenly stands up Complains of feeling weak, This Photo by Unknown Author is licensed under CC BY-SA dizzy, faint, and seeing spots before the eyes May be a complication from being on bed rest HN43 Nursing Fundamentals and Practicum  Orthostatic Hypotension- Prevention Follow care plan and the directions of the nurse: Ask resident to report weakness, dizziness, faintness, or seeing spots May need 2 (two) people to assist resident with activity Before standing, while sitting on side of bed (dangling), have resident cough/deep breathe and move legs back-and-forth in circles, 1 to 5 minutes Increase activity in stages: bed rest then sitting on side of bed (dangling) then walking HN43 Nursing Fundamentals and Practicum Coronary Artery Disease (CAD) condition in which blood vessels in the coronary arteries narrow, lowering blood supply to the heart and depriving it of oxygen Over time, fatty deposits (plaque) block arteries, which may result in a myocardial infarction (MI or heart attack) HN43 Nursing Fundamentals and Practicum  Angina Pectoris (Angina) Heart muscle is not getting enough oxygen This Photo by Unknown Author is licensed under CC BY-NC-ND Causes chest pain, pressure or tightness of chest, pain radiating up the jaw, and/or down the left arm, may perspire and become short of breath Exercise, stress, excitement, or digesting a big meal requires additional oxygen; with coronary artery disease, the narrowed blood vessels keep heart muscle from getting enough oxygen HN43 Nursing Fundamentals and Practicum Myocardial Infarction (MI)- Heart Attack Myocardial Infarction occurs An emergency that can result in when blood flow to an area of serious heart damage or death the heart is blocked, oxygen and nutrients fail to reach its cells. Waste products are not removed causing the muscle cells to die. The area of the dead tissue may be large or small, depending on which artery is involved HN43 Nursing Fundamentals and Practicum  Peripheral Vascular Disease A Condition affecting Signs and symptoms the legs, feet, arms or hands caused by a Nail beds and feet pale or blue decrease in blood Swelling in hands and feet supply (poor Ulcers of legs and feet circulation) Pain while walking Primarily due to build up of fatty deposits Nurse Aide should follow the (plaque) that harden care plan directive regarding blood vessels elastic stockings HN43 Nursing Fundamentals and Practicum  Congestive Heart Failure (CHF) Occurs when one or both Signs and symptoms sides of the heart stop tiredness pumping blood effectively weakness Can cause severe damage to the heart dizziness muscle rapid or irregular heartbeat Left side damage shortness of breath causes blood to back up into lungs Right edema (swelling of feet and ankles) side damage causes increased urination at night blood to back up into legs, feet, or abdomen weight gain HN43 Nursing Fundamentals and Practicum  Congestive Heart Failure Nurse Aide’s Role Assist to bathroom Respond to call signal promptly Allow rest periods Monitor intake and output Apply elastic stockings per order Provide extra pillows Keep Head of Bed (HOB) elevated Weigh resident Provide range of motion This Photo by Unknown Author is licensed under CC BY-SA-NC HN43 Nursing Fundamentals and Practicum  Edema Edema occurs when fluid intake is greater than fluid output Body tissues swell with water May occur from heart or kidney disease This Photo by Unknown Author is licensed under CC BY HN43 Nursing Fundamentals and Practicum  Nurse Aide Role- Edema Obtain accurate weights per Notify the nurse if : order Weight gain of 1 to 2 pounds in a day Restrict fluids per doctor’s Decrease in urine output order Increased heart rate If ordered, measure and Difficult breathing or shortness of record I&O accurately breath Increase pillows per Coughing resident’s request Fatigue Swelling of ankles, feet, fingers, and/or hand HN43 Nursing Fundamentals and Practicum  Cardiovascular System- Nurse Aide Role Per directive of care plan or the Prevent resident from tiring nurse, monitor vital signs (BP Layer clothing to help with warmth and P) and report abnormal Report complaints of chest pain values immediately to the nurse; stay with Assist with special diet needs resident and use call signal for (low fat, low sodium) assistance Measure intake and output if Avoid extremes in temperature, resident receives special particularly a cold room medication Reduce stressful situations; be Provide rest periods at aware of interactions between intervals; rest reduces need resident and visitors; notify the nurse extra oxygen if resident becomes upset HN43 Nursing Fundamentals and Practicum Respiratory System HN43 Nursing Fundamentals and Practicum  Respiratory System- Structure and Function Function Involves the breathing in of oxygen (inspiration) and the breathing out of carbon dioxide (expiration) HN43 Nursing Fundamentals and Practicum  Respiratory System- Structure Thorax Closed cavity of the body that contains the structures needed for respiration Extends from the base of the neck to the diaphragm, and surrounded by muscles This Photo by Unknown Author and ribs is licensed under CC BY-NC HN43 Nursing Fundamentals and Practicum  Respiratory System- Structure Upper Respiratory Tract Consists of nose, mouth, sinuses, pharynx, larynx, and top of trachea Lower Respiratory Tract Consists of lower This Photo by Unknown Author is licensed under trachea, bronchi, CC BY-SA-NC and lungs HN43 Nursing Fundamentals and Practicum  Respiratory System- Changes Due to Aging Respiratory muscles weaken Oxygen in the blood Lung tissue gradually decreases becomes less elastic Muscles of the diaphragm Shortness of breath upon become weaker exertion Limited expansion of the Lung capacity decreases chest due to changes in posture HN43 Nursing Fundamentals and Practicum  Abnormal Findings of the Respiratory System Shallow breathing or breathing Gasping for breaths through pursed lips Too slow or too fast Coughing or wheezing respiratory rate Nasal congestion or discharge, Hypoventilation or or productive cough hyperventilation Noisy respirations Need to sit after mild exertion Mild pain in the chest HN43 Nursing Fundamentals and Practicum  Common Disorders of the Respiratory System Chronic Obstructive Pulmonary Disease (COPD) A chronic, progressive disease Causes difficulty in breathing due to obstruction of the airways, during exhalation Disease is irreversible and can not be cured. Two chronic lung diseases are grouped under COPD Bronchitis Emphysema HN43 Nursing Fundamentals and Practicum  Chronic Bronchitis Irritation and inflammation of the lining of the bronchi Chronic bronchitis- caused by Two Types cigarette smoking, secondhand Acute bronchitis- caused by an smoke, and air pollution or other infection. irritants in the air Associated with severe colds and Symptoms- excessive mucus generally lasts for a short period of time production, breathlessness, and Symptoms- Coughing, yellow or green wheezing sputum, trouble breathing, wheezing Lining of the bronchial tubes become inflamed HN43 Nursing Fundamentals and Practicum  Emphysema Chronic disease of the lungs usually results from chronic bronchitis and smoking. No cure for the disease and is irreversible Symptoms- shortness of breath, difficulty breathing, coughing, and rapid heartbeat Usually requires the use of oxygen This Photo by Unknown Author is licensed under CC BY-NC-ND HN43 Nursing Fundamentals and Practicum  COPD Signs and Symptoms Chronic cough Confusion Wheezing Weakness Difficulty breathing Difficulty in finishing Shortness of breath meal because of during exertion shortness of breath Pale, cyanotic or Fear reddish-purple skin Anxiety HN43 Nursing Fundamentals and Practicum  COPD Resident with chronic lung disease may live in constant fear of not being able to breathe causing them to sit upright in attempt to improve lung expansion Resident may feel out of control and fear suffocation This Photo by Unknown Author is licensed under CC BY HN43 Nursing Fundamentals and Practicum  COPD- Nurse Aide Role Help sit up or forward Encourage pursed-lip leaning supported with breathing taught by the pillows nurse- inhaling slowly Offer fluids and small, through nose and exhaling frequent meals slowly through pursed lips (as if about to whistle) Observe oxygen in use Follow infection prevention (NEVER adjust) principles during care Be supportive of fears, Encourage rest carefully HN43 Nursing Fundamentals and Practicum COPD Resident: Report to the Nurse Signs/symptoms of colds or illness Changes in breathing, lung secretions Changes in mental state Excessive weight gain Increasing dependency on staff and family HN43 Nursing Fundamentals and Practicum  Pneumonia Inflammation of the lungs caused Signs/symptoms by a viral, bacterial, or fungus High fever infection or chemical irritants Chills Cough Due to a weaken immune systems, Greenish or yellow residents with COPD are at a greater sputum risk of developing pneumonia Chest pain Rapid pulse HN43 Nursing Fundamentals and Practicum  Asthma A chronic, episodic disorder in In response to irritation and which irritants, allergens such as inflammation, mucus pollen or dust, infection, and cold membranes produce thick cause inflammation and swelling mucus further inhibiting within the air passages in the breathing lungs, making it difficult to breathe Air is trapped in lungs causing coughing and wheezing HN43 Nursing Fundamentals and Practicum  Upper Respiratory Infection (Cold) Viral infection of nostrils, nasal cavity, sinuses and throat. Can lead to bacterial infection Signs Nasal drainage This Photo by Unknown Author is licensed under CC BY-SA-NC Sneezing Sore throat Remedy- body’s immune system, fluids, and Fever rest Tiredness Stay away from smoke May be more comfortable sitting up Stay away from residents with COPD HN43 Nursing Fundamentals and Practicum  Respiratory System Nurse Aide Role Provide rest periods at intervals Encourage exercise and regular movement Assist with deep breathing exercises Limit exposure to smoke, polluted air, or noxious odors by resident with respiratory conditions Position residents in a manner to maximize lung expansion HN43 Nursing Fundamentals and Practicum  Human Reproductive System Male Female This Photo by Unknown Author is licensed under CC BY-SA-NC HN43 Nursing Fundamentals and Practicum  Reproductive System- Normal Findings Absence of bleeding (other than menses) and vaginal discharge/penile discharge Absence of pain and itching Absence of enlarged prostate gland HN43 Nursing Fundamentals and Practicum Reproductive System-Changes Due to Aging Decreased size and function of reproductive structures Enlargement of prostate Flaccid, sagging breasts Loss of hair in perineal area Weakened muscles that hold female reproductive organs in place HN43 Nursing Fundamentals and Practicum  Reproductive System-Variation of Normal Bleeding other than menses Pain Vaginal/penile discharge Itching HN43 Nursing Fundamentals and Practicum  Pelvic Organ Prolapse Female reproductive organs held in May have incontinence place by muscles and connective Conditions range from mild to tissue severe The pelvic organs may drop down Women may have tried Kegel (prolapse) into the vaginal canal exercises to attempt to tighten Cystocele- bladder drops down pelvic muscles Rectocele-rectum shifts Nurse Aide Role downward Perineal care as needed Uterine prolapse- uterus shifts Report abnormal observations downward to the nurse HN43 Nursing Fundamentals and Practicum  Endocrine System This Photo by Unknown Author is licensed under CC BY-SA-NC HN43 Nursing Fundamentals and Practicum  Endocrine System System of glands that secrete chemicals directly into the bloodstream to regulate body functions This Photo by Unknown Author is licensed under CC BY-SA-NC HN43 Nursing Fundamentals and Practicum  Endocrine System- Structure and Function Structure Function Maintains homeostasis Glands located throughout (balance) the body that secrete Influences growth and chemicals, called development Regulates glucose in the blood hormones that regulate and calcium in the bones bodily function Regulates reproduction Regulates how fast cells burn food HN43 Nursing Fundamentals and Practicum  Endocrine System- Structure and Function Normal Findings Changes Due to Aging Skin warm and dry Levels of hormones decrease Awake, alert, and oriented Insulin production decreases Body is less capable to deal No variation of weight, with stress appetite, and urination Blurred vision HN43 Nursing Fundamentals and Practicum  Endocrine System- Variation of Normal Headache Dry skin Blurred vision Confusion Dizziness Weight gain/loss Weakness Appetite increase/decrease Hunger Tiredness Irritability Increase thirst Sweating Increase urination HN43 Nursing Fundamentals and Practicum  Diabetes Mellitus (Diabetes) Most common disorder of Without enough insulin, endocrine system blood sugar builds up in blood; causing blood Occurs when pancreas glucose levels to rise produces too little insulin or Insulin needed for glucose does not use insulin properly to move from blood into cells; cells need glucose for energy This Photo by Unknown Author is licensed under CC BY-NC HN43 Nursing Fundamentals and Practicum  Diabetes-Three Types Type 1 Type 2 Onset typically during childhood Develops after about age 35 and early adulthood Pancreas secretes insulin, but Pancreas does not produce does not use it well Develops insulin slowly Lifelong condition Usually controlled by diet and Managed with daily doses of oral medicine insulin, a special diet, and regular blood glucose testing Type 3 gestational occurs during pregnancy HN43 Nursing Fundamentals and Practicum  Diabetes- Nurse Aide Role Follow care plan directives closely; ensure meals are served and resident eats his diet, report to the nurse if resident refuses a meal, observe intake of meal and document carefully; if meal is delayed for lab or other reason, retrieve meal as soon as resident is allowed to eat Encourage resident to follow exercise program, which assists with circulation HN43 Nursing Fundamentals and Practicum  Diabetes- Nurse Aide Role Observe for signs of low blood Signs of Hypoglycemia sugar (hypoglycemia) Dizziness Signs of Hypoglycemia Fast pulse Hunger Low blood pressure Vomiting Fast respirations Weakness Shakiness Confusion Sweating Cool and clammy skin headache Convulsions Unconsciousness HN43 Nursing Fundamentals and Practicum  Diabetes- Nurse Aide Role Observe for signs of low blood Signs of Hyperglycemia sugar (hyperglycemia) Sweet breath odor Signs of Hyperglycemia Respirations rapid and deep Weakness Blood pressure low Drowsiness Skin dry Thirst Dry mouth Headache Hunger Blurred vision Frequent urination Convulsions Flushed face Coma HN43 Nursing Fundamentals and Practicum  Diabetes-Nurse Aide Role Hypoglycemia may result from refusal of meal, delay of meal or increase in exercise Report immediately to nurse Provide foot care as directed, observe for irritation or sores Report immediately to nurse This Photo by Unknown Author is licensed under CC BY-NC-ND HN43 Nursing Fundamentals and Practicum  Immune System This Photo by Unknown Author is licensed under CC BY-NC-ND HN43 Nursing Fundamentals and Practicum  Immune System Protects the body both inside and outside This Photo by Unknown Author is licensed under CC BY-NC-ND HN43 Nursing Fundamentals and Practicum  Immune System Structure Antibodies and white blood cells Function Protects the body from harmful infection-causing germs, such as bacteria and viruses Provides immunity from certain diseases This Photo by Unknown Author is licensed under CC BY HN43 Nursing Fundamentals and Practicum  Immune System Normal Findings Changes Due to Aging Body can fight infection Immune system weakens and person more prone to getting infections Person’s immune system may attack itself causing disease HN43 Nursing Fundamentals and Practicum  Immune System- Variation of Normal Signs of Infection- fever, redness, swelling Anxiety Nausea and vomiting Stiff, swollen, and painful joints This Photo by Unknown Author is licensed under CC BY-NC HN43 Nursing Fundamentals and Practicum  Acquired Immune Deficiency Syndrome (AIDS) Disease caused by Human Immunodeficiency Virus (HIV) Attacks the immune system by destroying cells of the body that fight diseases HIV is spread through bodily fluids including blood, semen, vaginal secretions, and breast milk HIV Screening is vital knowledge HN43 Nursing Fundamentals and Practicum  Immune System- Nurse Aide Role Follow Standard Precautions Encourage deep-breathing and Blood Borne Pathogen and coughing exercises as Standards directed Assist with activities of daily Encourage self-care as living as needed tolerated Provide fluids as ordered Monitor and report signs of Measure and record I&O and infection obtain weights Provide emotional support HN43 Nursing Fundamentals and Practicum Immune System- Other Common Disorders Lupus – immune system attacks tissues causing redness, pain, swelling, and damage Graves’ disease – immune system attacks thyroid gland which causes it to secrete more thyroid hormone Multiple Sclerosis - immune system destroys the protective covering of the nerves resulting in decreased communication between the brain and the rest of the body HN43 Nursing Fundamentals and Practicum Immune System- Other Common Disorders Nurse Aide Role Monitor and report signs of infection Follow standard precautions Provide for nutrition, hydration and rest for the resident HN43 Nursing Fundamentals and Practicum  Curriculum Skills 6.01 A Apply and remove anti-embolic stockings (TEDs) 6.01B Assist resident to cough and deep breath HN43 Nursing Fundamentals and Practicum  Resources BYJU'S Learning (2024, January 2). Understanding Striated Muscles in Biology. BYJU'S. Retrieved September 28, 2024, from https://byjus.com/biology/striated-muscle/ Division of Health Service Regulation. (2024, September 30). Health Care Personnel Education and credentialing section. NC DHSR HCPEC: State-Approved Nurse Aide I Curriculum, NC DHSR HCPEC: State-Approved Nurse Aide I Curriculum (ncdhhs.gov) Dugan, D. L., RN (2023). Nursing Assisting a Foundation in Caregiving (6th ed., pp. 57-58). Hartman Publishing, Inc. HN43 Nursing Fundamentals and Practicum  Resources Dugan, D. L., RN (2023). Nursing Assisting a Foundation in Caregiving (6th ed., pp. 57-58). Hartman Publishing, Inc. Dugan, D. L., RN (2023). Nursing Assisting a Foundation in Caregiving (6th ed., pp. 360-370). Hartman Publishing, Inc. Dugan, D. L., RN (2023). Nursing Assisting a Foundation in Caregiving (6th ed., pp. 386-398). Hartman Publishing, Inc. HN43 Nursing Fundamentals and Practicum  Resources Dugan, D. L., RN (2023). Nursing Assisting a Foundation in Caregiving (6th ed., pp. 401-412). Hartman Publishing, Inc. Dugan, D. L., RN (2023). Nursing Assisting a Foundation in Caregiving (6th ed., pp. 439-446). Hartman Publishing, Inc. Dugan, D. L., RN (2023). Nursing Assisting a Foundation in Caregiving (6th ed., pp. 451-455). Hartman Publishing, Inc. HN43 Nursing Fundamentals and Practicum  Resources Dugan, D. L., RN (2023). Nursing Assisting a Foundation in Caregiving (6th ed., pp. 401-412). Hartman Publishing, Inc. Dugan, D. L., RN (2023). Nursing Assisting a Foundation in Caregiving (6th ed., pp. 439-446). Hartman Publishing, Inc. Dugan, D. L., RN (2023). Nursing Assisting a Foundation in Caregiving (6th ed., pp. 451-455). Hartman Publishing, Inc. HN43 Nursing Fundamentals and Practicum