NURSE ASSISTANT SKILLS - Health Care - ثالث ثانوي

Link to digital lesson CHAPTER www.ien.edu.sa 3 NURSE ASSISTANT SKILLS Case Study Investigation A private hospital employs Khalid and Basmah as surgical nursing assistants. They work at a fast pace to keep up with the surgery schedule, procedures, and bedside care. At the end of this chapter, you will be asked about the skills that Khalid and Basmah will need to work in this type of medical/surgical unit. LEARNING OBJECTIVES After completing this chapter, you should be able to: Admit, transfer, or discharge a patient, demonstrating proper care of the patient's belongings. • Position a patient in correct alignment and with no bony prominences exposed. • Move and turn a patient in bed, using correct body mechanics. Perform the following transfer techniques: dangling, wheelchair, chair, stretcher, mechanical lift, observing all safety points. Make closed, open, and occupied beds, using correct body mechanics. • Administer personal care for a patient, including oral hygiene, hair and nail care, and back rub. • Administer a bed bath and help a patient take a tub bath or shower, observing all safety points. KEY TERMS alignment anesthesia catheter • Measure and record a patient's intake and output. • Assist a patient with eating and feed a patient. Administer a bedpan or urinal, and provide catheter care. • •Provide ostomy care. • Collect specimens of urine or feces. • Observe all safety precautions when handling urine or feces. • Administer preoperative care as directed. • Prepare a postoperative unit with all equipment in the correct position. Safely administer oxygen with an oxygen mask, nasal cannula, or tent. intake operative/intraoperative output pressure ulcer specimens urinary drainage unit urinate ostomy dangling defecate dehydration edema 92 التعليم CHAPTER 3 ucation GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 92 personal hygiene postoperative preoperative 14/06/2023 10:27

Г 3:1 ADMITTING, TRANSFERRING, AND DISCHARGING PATIENTS As a health care team member in a hospital or long-term care facility, one of your responsibilities may be to admit, transfer, and discharge patients or residents. Although these procedures vary slightly in different facilities, basic principles apply in all facilities. ADMITTING THE PATIENT Comm Admission to a health care facility can cause anxiety and fear in many patients and their families. Even a transfer from one room or unit in a facility to another room or unit can cause anxiety because the individual has to adjust to another new environment. It is essential for the health care team member to create a positive first impression. By being courteous, supportive, and kind, the health care provider can do much to alleviate fear and anxiety. Giving clear instructions about how to operate equipment and the type of routine to expect, such as mealtimes, helps the patient or resident become familiar with the environment. It is also important not to rush while admitting, transferring, or discharging a patient. Allow the individual to ask questions and express concerns. If you do not know the answers to specific questions, refer these questions to your supervisor. Comm Greet and identify the patient. Ask the patient if they prefer to be called by a particular name. Introduce yourself by name and title to the patient and to any family members present. If another patient is in the room, introduce the new patient. Explain the procedure and obtain consent. • Close the door and pull the curtain for privacy. Ask the patient to change into a gown. Assist the patient as necessary. Position the patient comfortably in the bed or in a chair. Most facilities have specific forms that are used during an admission, transfer, or discharge. A sample admission form is shown in Figure 3-1. In most facilities, the forms are computerized, and a laptop or tablet computer is used to enter patient information. Patient records are stored electronically and are called electronic health records. However, all forms list the procedures that must be performed, which will vary slightly from facility to facility. It is important for the health care team member to become familiar with the information required on such forms. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 93 NURSE ASSISTANT SKILLS 93 | 14/06/2023 10:27

94 CHAPTER 3 ع زو2 التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 94 PATIENT PREFERS TO BE ADDRESSED AS: MODE OF TRANSPORTATION: Ambulatory Wheelchair ☐ Other Smoker: Y NO FROM: E.R. ☐ E.C.F. Home M.D.'s Office ☐ Stretcher COMMUNICATES IN ARABIC: Well ☐ Minimal INTERPRETER (Name Person) ☐ None ☐ Not At All Other Language (Specify) Home Telephone No. ( ) Work Telephone No. ( ) ORIENTATION TO ENVIRONMENT: Armband Checked Bed Control ☐ TV Control Bathroom ☐ Personal Property Policy ☐ Call Light ☐ Phone PERSONAL BELONGINGS: (Check and Describe) Clothing Jewelry Side Rail Policy ☐ Visitation Policy ☐ Smoking Policy Money Walker Wheelchair Cane Other DENTURES: CONTACT LENSES: GLASSES: ☐ Y ☐N Upper ☐ Partial ☐ Lower ☐ None ☐ Hard □ LT ☐ Soft RT PROSTHESIS: ☐ Y ☐ N (Describe) DISPOSITION OF VALUABLES: Patient ☐ Home ☐ Placed in Safe Given To: Relationship: (Claim No.) HEARING AID: ☐ Y ☐ N IN CASE OF EMERGENCY NOTIFY: Name: Relationship: Home Telephone No. ( ) Work Telephone No. ( ) VITAL SIGNS: ALLERGIES: TEMP: PULSE: ☐ Oral ☐ Rectal ☐ Axillary Medications: None Known Food: ☐ None Known ☐ Radial ☐ Apical Respiratory ☐ Penicillin ☐ Tape Other (List) (Shellfish, Eggs, Milk, etc.) ☐ Sulfa Rate RT ☐ lodine B/P: HEIGHT: LT ☐ Standing ☐ Sitting ☐ Lying ☐ Aspirin WEIGHT: ☐ Bedside ☐ Standing ☐ Demerol ☐ Morphine (Prescription/ MEDICATIONS: Non-Prescription) Dose/Frequency Last Dose (Date/Time) 1. 23456 DISPOSITION OF MEDICATIONS: ☐ None Brought to Hospital ☐ Sent Home With To Pharmacy: (List) ADMITTING DIAGNOSIS: NURSE'S SIGNATURE: FIGURE 3-1 A sample admission form. RN/LVN Date Time • Much of the information on an admission form is used as a basis for the nursing care plan, so this information must be complete and accurate. If the patient is unable to answer the questions, a relative or the person responsible for the patient is usually able to provide the information. In some facilities, questions regarding medications and allergies are the responsibility of the nurse. . • When a patient is admitted to a facility, certain procedures are performed. These usually include measuring and recording vital signs, height and weight, and collecting a routine urine specimen. Follow correct techniques while performing these procedures. 14/06/2023 10:27

. Complete a personal inventory list of the patient's clothing, valuables, and personal items to protect their possessions. The valuables are then put in the safe or sent to security, and a receipt is given to the patient or put on the patient's chart. If a patient is transferred or discharged, the valuables are taken from the safe and checked by both the health care provider and the patient. • Orientate patients and family members to the facility. Instructions about how to operate the call signal, bed controls, television remote control (if present), telephone, and other similar equipment should be provided. Visiting hours, location of lounges, availability of services, such as religious services and activities, mealtimes, and other rules or routines in the facility, should be explained. Many facilities give patients and family members pamphlets or papers listing such information, but it is still important to explain the main information. الاسرة FIGURE 3-2 If the patient's condition permits, use a wheelchair to transfer the patient to the new room or unit. TRANSFERRING THE PATIENT TO ANOTHER FACILITY Transfers are done for a variety of reasons. A transfer is sometimes related to a change in the patient's condition. For example, a person may be transferred from or to an intensive care unit. Comm The reason for the transfer should be explained to the patient and family. This is usually the responsibility of the physician or nurse. An organized and efficient transfer helps prevent fear and anxiety in the patient. • The new room or unit must be ready to receive the patient. Clothing, personal items, certain equipment, and medications must be transferred with the patient. • The health care provider should find out how to transport the patient. Wheelchairs (Figure 3-2), stretchers, and even the patient's bed can be used for the transfer. • Correct procedures must be followed to prevent injury to both the patient and the health care provider. Many different models of wheelchairs and stretchers are available. It is important to read NURSE ASSISTANT SKILLS 95 | وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 95 14/06/2023 10:27

96 CHAPTER 3 وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 96 the manufacturer's instructions regarding the operation of any given piece of equipment. If no instructions are available, ask your immediate supervisor to demonstrate the correct operation of a particular wheelchair or stretcher. Do not use any equipment until you have been instructed how to use it. • Mechanical lifts are frequently used to transfer weak or paralyzed patients. It is important to read the operating instructions provided with the lift. Straps, clasps, and the sling should be checked carefully for any defects. Smooth, even movements must be used while operating the lift. Patients are often frightened of the lift and must be reassured that it is safe. • In home care situations, it is important to move unnecessary furniture out of the way during transfers. • If the bed does not raise or lower, it is essential for the health care provider to observe correct body mechanics and to bend at the hips and knees instead of the waist. It is possible to rent hospital beds, wheelchairs, mechanical lifts, and other similar items for home care. • Before a patient is moved or transferred, the health care provider must obtain approval or legal orders from their immediate supervisor. Never move or transfer a patient without proper authorization. Safety During any move or transfer, it is important to watch the patient closely. Note changes in pulse rate, blood pressure, respirations, and color. Observe for signs of weakness, dizziness, increased perspiration, or discomfort. If you note any abnormal changes, return the patient to a safe and comfortable position and check with your immediate supervisor. The supervisor will determine whether the move or transfer should be attempted. DISCHARGING A PATIENT A written physician's order is required before a patient or resident can be discharged from a facility. If an individual plans to leave the facility without permission, report this immediately to your supervisor. Facilities have special policies that must be followed when a person leaves against medical advice. • When an order for discharge has been received, the health care team member must check and pack the patient's belongings. The personal inventory list completed at the time of admission must be checked to ascertain that all the patient's belongings have been packed. A careful check of the unit, including any drawers, closets, and storage areas, helps ensure that all items are found. 14/06/2023 10:27

• Check to make sure that the patient has received final instructions from the nurse or physician. These may include discharge instructions and prescriptions. Assemble any equipment to be given to the patient. • Most facilities require that a staff member accompany the individual to a car. Some facilities allow patients to walk, but many prefer to transport patients by wheelchair. If a patient is to be transferred by ambulance, the ambulance attendants will bring a stretcher to the room. In this case, it is important for the health care provider to have the patient's belongings ready for the transport. • Most agencies have forms or checklists that are used during discharge to ensure that all procedures are followed. checkpoint 1. List three things that a health care team member should measure and record when a patient is admitted to a facility. 2. What are mechanical lifts used for? 3:2 POSITIONING, TURNING, AND MOVING PATIENTS As a health care provider, you may be responsible for positioning, turning, moving, and transferring many patients. If these procedures are done correctly, you will provide the patient with optimum comfort and care. In addition, you will prevent injury to yourself and the patient. It is essential to remember that improper moving, turning, or transferring of a patient can result in serious injuries to the patient or health care provider. Some patients cannot be moved safely without special assistance or mechanical devices. Other patients who have had back, neck, or hip surgeries can only be turned certain ways. If a patient has restrictions for moving or transferring, the restrictions should be posted outside the door. If you are not sure whether a patient can be moved or transferred safely, always ask your supervisor before attempting any procedure. Remember, you are legally responsible for the safety and well-being of the patient. Correct body mechanics are required for all procedures discussed here. If you cannot move or turn a patient by yourself, get help. Safety ALIGNMENT Patient care must be directed toward maintaining normal body alignment. Alignment is defined as positioning body parts in relation to each other to maintain correct body posture. The benefits of proper alignment include: وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 97 NURSE ASSISTANT SKILLS 97 | 14/06/2023 10:27

FIGURE 3-3 A contracture is a tightening or shortening of a muscle usually caused by lack of movement or usage of the muscle. FIGURE 3-4 Foot supports can be used to hold the feet at right angles and prevent foot drop, a common contracture. FIGURE 3-5 Correct alignment for a patient positioned on their back in the supine position. FIGURE 3-6 Foot protectors can help to prevent pressure ulcers on the heels. CHAPTER 3 98 اعزاز2 التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 98 • Preventing fatigue: - Correct alignment helps the patient feel more comfortable and prevents fatigue. Preventing contractures: - - A contracture (Figure 3-3) is a tightening or shortening of a muscle usually caused by lack of movement or usage of the muscle. - Foot drop is a common contracture. It can be prevented in part by keeping the foot at a right angle to the leg (Figure 3-4). - Footboards, foot supports, and high-top tennis shoes can be used to keep the foot in this position. - Range-of-motion exercises also help to prevent contractures. Preventing pressure ulcers. To align the patient who is lying on their back in a supine position (Figure 3-5): Position the patient's head in a straight line with the spine. • Place a pillow under the head and neck to provide support. 14/06/2023 10:27

• A pillow or rolled blanket may be placed under the lower legs, from the knees to 5 cm above the heels to provide support and keep the heels off the bed. Protector pads may be placed on the heels or elbows (Figure 3-6). • Toes should point upward. You may place a footboard, pillow, or rolled blanket against the soles of the feet to achieve this. High-top tennis shoes can also be placed on the feet to keep them at this angle. Precaution Check the patient for comfort, safety, and support before leaving. Make sure no bony prominences are exposed and all body parts are supported. To align the patient who is lying on their side (Figure 3-7): Place a pillow under the head and neck for support. • Flex the lower arm at the elbow. It can be placed in line with the face. . Support the upper arm, flexed at the elbow, on a pillow or rolled blanket. • Flex both knees slightly. Place a firm pillow or rolled blanket between the legs. The pillow should extend from the upper leg to the ankle. • Use a footboard, pillow, rolled blanket, or high- top tennis shoes to keep the feet at right angles (90 degrees) to the legs. • Rolled washcloths or foam rubber balls may be placed in paralyzed hands to prevent contractures. • Use pillows to support the back and abdomen. • Protector pads may be placed on the ankles, heels, and elbows. Precaution Make sure that the patient's body is not twisted and that any one body part is not applying direct pressure on any other body part. To align the patient who is lying on their abdomen (prone position): • Place the head in a direct line with the spine. FIGURE 3-7 Correct alignment for a patient positioned on their side. FIGURE 3-8 A large pillow can be used to support the feet when the patient is lying. in the prone position. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 99 NURSE ASSISTANT SKILLS 99 | 14/06/2023 10:27

و200 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 100 FIGURE 3-9A A stage I pressure ulcer. FIGURE 3-9C A stage III pressure ulcer. FIGURE 3-9B A stage II pressure ulcer. FIGURE 3-9D A stage IV pressure ulcer. • Turn the head to one side. It may be supported with a small pillow. Placing the pillow at an angle will keep it away from the patient's face. . • A small pillow may be placed under the waist for support. Place a firm pillow under the lower legs to slightly flex the knees. • The feet can be extended over the end of the mattress so that they will remain at right angles to the legs. They can also be supported in this position by pillows or rolled blankets (Figure 3–8). Place the arms in line on either side of the head. Use pads to protect the elbows. Flex the elbows slightly for comfort. PRESSURE ULCERS A pressure ulcer (also called a decubitus ulcer, pressure sore, or bedsore) is a sore caused by prolonged pressure on an area of the body that interferes with circulation. Pressure ulcers are common in areas where bones are close to the skin, such as the tailbone (coccygeal area), hips, knees, ankles, heels, and elbows. The tissue breakdown of a pressure ulcer occurs in four stages: Stage I: a red or blue-gray discoloration appears on the intact skin (Figure 3-9A). The discoloration does not disappear after the pressure has been relieved. Stage II: abrasions, bruises, or open sores develop as a result of tissue damage to the top layers of the skin (epidermis and dermis) (Figure 3-9B). 14/06/2023 10:27

Stage III: a deep open crater forms when all layers of the skin are destroyed, and fat and muscle tissues are exposed (Figure 3-9C). Stage IV: damage extends into the muscle, tendon, and bone tissues (Figure 3-9D). It is easier to prevent pressure ulcers than it is to treat them. If pressure ulcers are detected in the early stages, immediate treatment can help prevent further damage. Effective ways of preventing pressure ulcers include: • • • Providing good skin care. Using moisturizing lotions on dry skin. Prompt cleaning of urine and feces from the skin. Massaging in a circular motion around a reddened area. Frequent turning (at least every two hours). Positioning to avoid pressure on irritated areas. Keeping linen clean, dry, and free from wrinkles. Applying protectors of sheepskin, lamb's wool, or foam to bony prominences, such as heels and elbows. Pressure relief is the most important factor in preventing pressure ulcers. Over 100 different support surfaces or pressure-reducing products are available to prevent ulcers. Alternating air pressure mattresses (Figure 3-10) and continuous lateral rotation beds (that constantly turn the patient side to side) are among the most advanced pressure-reducing surfaces. Careful observation of the skin during bathing or turning is essential. If a pale, reddened, or blue-gray area is noted, this should be reported and documented immediately. Treatment of pressure ulcers: Stage I and stage II pressure ulcers are often treated with special foam or hydrocolloid dressings along with frequent turning to keep pressure off the ulcer. Stage III and stage IV ulcers can be treated with these dressings, or they can be treated with negative- pressure wound therapy using a wound vacuum- assisted closure (Figures 3-11A and 3-11B). A foam sponge is cut to fit the size of the open wound. A transparent adhesive film is placed over the sponge, and suction tubing is placed through the (B) FIGURE 3-10 An alternating air pressure mattress constantly changes the pressure points against a patient's skin. (A) (B) IN IN FIGURE 3-11 After a pressure ulcer or wound is covered with a gauze or foam dressing (A), the wound vacuum-assisted closure (B) is attached to apply negative pressure to the area to promote healing. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 101 NURSE ASSISTANT SKILLS 101 | 14/06/2023 10:27

و203 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 102 film dressing. The suction tubing is attached to the suction and a disposable collection canister. This device seals the wound and applies a negative pressure to promote healing and prevent infections. It works by drawing the wound edges together and removing exudate and infectious materials. It also reduces edema (swelling) and promotes perfusion by forcing the flow of fluid in the area. TURNING A PATIENT The patient confined to bed must be turned frequently. Their position should be changed at least every 2 hours, if permitted by the physician. Some agencies post a turning position schedule by the patient's bed; for example, 6 am: right side; 8 am: back; 10 am: left side; 12 pm: abdomen. Frequent turning provides exercise for the muscles. It also stimulates circulation, decreases pulmonary congestion, helps prevent pressure ulcers and contractures, and provides comfort to the patient. Correct turning procedures must be followed to prevent injury to both the patient and the health care provider. • Before turning or moving the patient: • - - - Comm Knock on the door and pause before entering. Introduce yourself. Identify the patient. Explain the procedure and obtain consent. Provide privacy. Close the door and pull the curtain. Wash your hands and put on gloves. Lock wheels to prevent movement of the bed and elevate the bed to a comfortable height. Safety It is important to use proper body mechanics throughout the procedure. Use the weight of your body to move the patient. Avoid back strain. After the procedure: - - - Leave the patient in good body alignment. Make sure that the patient is comfortable. Elevate the siderails (if indicated) before leaving the patient. Make sure that the call signal and other needed supplies are within easy reach of the patient. - Lower the bed to its lowest level. - Report what has been carried out and record all required information on the patient's chart, or enter it into the electronic health record. - Replace all equipment. Make sure that the area is neat and clean. Remove your gloves and wash your hands. 14/06/2023 10:27

MOVING A PATIENT UP IN BED • One person should be on each side of the bed. • Lower the head of the bed. Remove all pillows. One pillow can be placed against the headboard of the bed to prevent injury to the patient's head while moving the patient up in bed. Observe the patient for respiratory distress. If any breathing difficulty is noted, immediately raise the head of the bed. Check with your supervisor before proceeding. Safety Position the lift sheet under the patient by turning the patient to one side (Figure 3-12A). The lift sheet can be folded to the center of the bed. Make sure it extends under the patient's head, shoulders, hips, and thighs. Turn the patient to the opposite side and unfold the lift sheet so it covers the entire bed. Turn the patient on their back. • Two people use the lift sheet to move the patient. One person stands on each side of the bed. Each person positions one hand on the lift sheet by the patient's shoulders and the other hand by the patient's hips. • Each person faces the head of the bed and gets a broad base of support by putting one foot ahead of the other. Each person should be close to the patient and the bed. • If the patient's condition permits, ask the patient to flex their knees and brace both feet firmly on the bed. . • The two health care providers roll the edges of the lift sheet inward, close to both sides of the patient's body (Figure 3-12B). • At a given signal, the two health care providers lift the sheet and patient, and move the patient to the head of the bed (Figure 3-12C). Shift your weight from the rear leg to the forward leg at the same time that you slide the patient. • After the patient is positioned, each team member tucks the lift sheet back into the side of the bed. FIGURE 3-12A Position the lift sheet under the patient by turning the patient to one side. FIGURE 3-12B Both health care team members should roll the edges of the lift sheet inward, close to both sides of the patient's body. FIGURE 3-12C At a given signal, the two health care providers lift the sheet and patient, and move the patient to the head of the bed. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 103 NURSE ASSISTANT SKILLS 103 | 14/06/2023 10:27

104 و200 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 104 TURNING A PATIENT AWAY TO CHANGE POSITION . If siderails are present and elevated, lower the siderail nearest to you. Make sure the opposite siderail is raised and locked securely. • The patient should be lying on the side of the bed close to you. If so, continue to the next step. If the patient is at the center or close to the far side of the bed, move the patient as follows: - - Place one hand under the patient's head and neck. Place your other hand under the patient's upper back. Slide the upper part of the patient's body toward you. Place both hands under the patient's hips. Slide the hips toward you. Place both hands under the patient's upper and lower legs. Slide the legs toward you. If you are not able to move the patient, get help. Safety FIGURE 3-13 Place one hand under the patient's shoulder, and the other hand under the patient's hip. Use a smooth, even motion to roll the patient away. 14/06/2023 10:27

• Ask the patient to place their arms across the chest and move the proximal leg (the one closest to you) over the other leg. This will make it easier to turn the patient and helps to prevent injury. A Safety Do not cross the patient's legs if they have had hip replacement surgery. • Get close to the patient by bending your knees and keeping your back straight. Position your feet to provide a broad base of support. Place one hand under the patient's shoulder, and the other hand under the patient's hip. Use a smooth, even motion to roll the patient away from you and onto their side (Figure 3-13). • Place your hands under the patient's head and shoulders. Draw the head and shoulders back toward the center of the bed. • Place your hands under the patient's hips and gently pull them back toward the center of the bed. Then place your hands under the patient's legs and pull them back toward the center of the bed. Place a pillow behind the patient's back, between the legs to align the hips, and under the upper arm. Make sure the patient is comfortable and in good alignment. TURNING THE PATIENT INWARD TO CHANGE POSITION • Lower the siderail nearest to you, if present and elevated. • If the patient is too close to the near side of the bed, move them to the opposite side as follows: - - Place one hand under the patient's head and shoulders and the other hand under the patient's back. Slide the upper part of the body toward the opposite side of the bed. Place both hands under the patient's hips. Slide the hips toward the opposite side of the bed. Place both hands under the patient's legs. Slide the legs toward the opposite side of the bed. • Instruct the patient to cross their arms on their chest. Place the patient's leg that is farthest from you on top of the leg that is nearest to you. This prevents injury to the patient's arms and legs. Do not cross the patient's legs if they have had hip replacement surgery. وزارة التعليم Ministry of Education 2024-1446 Safety GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 105 NURSE ASSISTANT SKILLS 105 | 14/06/2023 10:27

• Get close to the patient by bending your knees and keeping your back straight. Position your feet to provide a broad base of support. Place your hand that is closest to the head of the bed on the patient's far shoulder. Place your other hand behind the patient's hip (Figure 3-14A). Use your knee to brace your body against the side of the bed. Use a gentle, smooth motion to roll the patient toward you (Figure 3-14B). • A lift sheet can also be used by one or two health care providers to turn the patient. The team members grasp the edges of the lift sheet and roll the edges inward close to the patient's body (Figure 3-14C). At a given signal, the team members use a smooth, even motion to turn the patient inward (Figure 3-14D). • Raise and secure the siderail, if indicated. Go to the opposite side of the bed and lower the siderail, if present and elevated. Place your hands under the patient's head and shoulders and draw the head and shoulders back toward the center of the bed. Place your hands under the patient's hips and draw them toward the center of the bed. FIGURE 3-14A Position your hands on the patient's far shoulder and hip. FIGURE 3-14B Use a gentle, smooth motion to roll the patient toward you. FIGURE 3-14C A lift sheet can also be used by one or two health care providers to turn the patient. FIGURE 3-14D At a given signal, the team members use a smooth, even motion to turn the patient inward. و196 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 106 14/06/2023 10:27

Place your hands under the patient's legs and draw them toward the center of the bed. • Place pillows behind the patient's back, between the legs, and under the upper arm to position the patient in good body alignment. Make sure that the patient is comfortable. DANGLING If a patient has been confined to bed for a period of time, the patient is frequently placed in a dangling position before being transferred from the bed. Dangling means sitting with the legs hanging down over the side of the bed. This allows the patient some time to adjust to the sitting position. Lower the bed to its lowest level. If siderails are present and elevated, lower the siderail on the side where the patient is to dangle. • Check the patient's radial pulse. This will serve as a guideline on how the patient tolerates the procedure (the control, or resting, rate). . • Check blood pressure to determine the patient's tolerance of the procedure. Blood pressure is taken while lying down, sitting, and standing. A patient might experience a drop in blood pressure with position changes, a condition called orthostatic hypotension. • Also observe the patient's respiratory rate, balance (the patient may complain of vertigo or dizziness), amount of perspiration, color, and other similar characteristics. Slowly elevate the head of the bed to a sitting position. Provide time for the patient to adjust to this position. • Get close to the patient by bending your knees and keeping your back straight. Position your feet to provide a broad base of support. Place your arm that is nearest to the head of the bed around the patient's shoulders. Place your other arm under the patient's knees (Figure 3-15A). Slowly rotate the patient toward the side of the bed (Figure 3-15B). Rest the patient's feet on a footstool if necessary. Safety Stand in front of the patient to prevent falls. FIGURE 3-15A Place one arm around the patient's shoulders and the other arm under their knees. FIGURE 3-15B Slowly rotate the patient toward the side of the bed. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 107 NURSE ASSISTANT SKILLS 107 | 14/06/2023 10:27

و 108 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 108 • Check the patient's radial pulse. Note any signs of distress, such as pale color, increased perspiration, labored respirations, weakness, dizziness, or nausea. Safety If the pulse rate shows an abnormal increase, the blood pressure drops measurably, respirations become labored, color becomes pale, increased perspiration is noted, or the patient gets dizzy or very weak, they should be returned immediately to the supine, resting position. Instruct the patient to flex and extend the legs and feet. This increases circulation to the area and stimulates the muscles. • Have the patient dangle for the time ordered or as their condition permits. • When the time is up, place one arm around the patient's shoulders and your other arm under the patient's knees. Gently and slowly return the patient to the bed. • Lower the head of the bed and position the patient in good alignment. • Check the patient's radial pulse again and note any major changes. Report any changes immediately. TRANSFERRING A PATIENT TO A CHAIR OR WHEELCHAIR • Position the chair or wheelchair. It can be placed at the head of the bed facing the foot or at the foot of the bed facing the head. Positioning often depends on other equipment in the room. Whenever possible, the chair should be positioned so that it is secure against a wall or solid furniture and will not slide backward. • Lock the wheels of the wheelchair. Raise the footrests so that they are out of the way (Figure 3-16A). Double-check the locks. • Lock the bed to prevent movement. Lower the bed to its lowest level and slowly elevate the head of the bed. • If siderails are present and elevated, lower the siderail on the side that the patient is to get out of the bed. Fanfold the bed linen to the foot of the bed. • Assist the patient to a sitting position on the side of the bed with their feet flat on the floor. Observe for any signs of distress. Note color, pulse rate, breathing, and other similar signs. Put socks and shoes or slippers with nonslip soles on the patient. Put a transfer (gait) belt on the patient. Keep your back straight. Place one hand on each side of the belt using an underhand grasp. Face the patient and stand close to the patient. 14/06/2023 10:27

وزارة التعليم Ministry of Education 2024-1446 Position your feet to provide a broad base of support. If the patient has a weak leg, support the leg by positioning your knee against the patient's knee or by blocking the patient's foot with your foot. If the use of a transfer belt is contraindicated, place your hands under the patient's arms and around the back of the shoulders to provide support. Comm Arrange a signal with the patient, such as counting to three. Instruct the patient to push against the bed with their hands to rise to a standing position. • At the given signal, assist the patient to a standing position. Lift up on the belt while the patient pushes up from the bed (Figure 3-16B). Place your knees and feet firmly against the patient's knees and feet to provide support. • Allow the patient to adjust to the upright position. Then, keeping your hands in the same position, help the patient turn by using several pivot steps until the backs of their legs are touching the seat of the chair (Figure 3-16C). • . Ask the patient to place their hands on the armrests and to bend at the knees as you gradually and slowly lower them to a sitting position in the chair (Figure 3-16D). Position the patient comfortably. Remove the transfer belt. Use a blanket to cover the patient's lap and legs. Lower the footrests of the wheelchair and position the patient's feet on the footrests, taking care not to hit the patient's feet (Figure 3-16E). Observe the patient for any signs of distress. Remain with them until you are sure there are no problems. If you leave the patient seated in a wheelchair or chair, make sure that the call signal and other supplies are within easy reach. Check on the patient at frequent intervals. If you are transporting the patient in the wheelchair, low down and look for other traffic at doorways. To enter an elevator, turn the chair around and back into the elevator. To go down a steep ramp, turn the chair around and back down the ramp. Use the weight of your body to push the chair. Stand close to the chair. Watch the patient closely for signs of distress while transporting. • To return the patient to bed, reverse the procedure, beginning by putting a transfer belt on the patient and raising the footrests. Safety Be sure the wheels are locked before helping the patient out of the wheelchair. Lock the bed to prevent movement. • Position the patient in good body alignment after returning them to bed. GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 109 NURSE ASSISTANT SKILLS 109 | 14/06/2023 10:27

FIGURE 3-16A Lock the wheels and raise the footrests before transferring a patient to a wheelchair. FIGURE 3-16B Lift up on the belt while the patient pushes up from the bed. FIGURE 3-16C Help the patient turn until the backs of their legs are touching the seat of the chair. FIGURE 3-16D Gradually and slowly lower the patient to a sitting position in the chair. FIGURE 3-16E Lower the footrests and position the patient's feet on the footrests. و210 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 110 14/06/2023 10:27

TRANSFERRING A PATIENT TO A STRETCHER • Place a blanket over the patient. Fold bed linen to the foot of the bed. Avoid exposing the patient. • Place the stretcher next to the bed. The bed and the stretcher should be parallel. . Lock the wheels of the stretcher. In addition to the locks, use the weight of your body to hold the stretcher against the bed during this procedure. • If the patient is conscious and capable of moving unassisted, reach across the stretcher and hold up the blanket. Ask the patient to slide from the bed to the stretcher. Hold the stretcher against the bed (Figure 3-17). If the patient needs assistance, help by moving first the patient's head and shoulders, then the patient's hips, and finally the patient's legs and feet. . If the patient is very weak, paralyzed, semiconscious, or unconscious, obtain the assistance of three or four other team members: - - - - Position a lifting sheet or blanket under the patient, extending from the patient's head and neck to the feet. Two or three people should stand by the stretcher and two or three people on the open side of the bed. - Roll the sides of the lifting sheet or blanket close to the patient's body. - Using overhand grasps, one assistant should grasp the sheet by the patient's head and waist. The second assistant should grasp the sheet by the hip and leg. The assistants on the open side of the bed should grasp the sheet in the same areas. If a third assistant is available for one or both sides, they should be positioned so the patient's weight is equally distributed among the three. - At a given signal, all assistants should lift the sheet slightly to gently slide the patient from the bed to the stretcher. Some facilities use slider boards instead of a lifting sheet or blanket. FIGURE 3-17 Hold up the blanket and use the weight of your body to hold the stretcher against the bed while the patient is moving to the stretcher. FIGURE 3-18A Team members on both sides of the stretcher should roll the sides of the lift sheet close to the patient and position themselves so all parts of the patient's body are supported. FIGURE 3-18B At a given signal, all assistants should lift the sheet slightly to gently slide the patient from the stretcher to the bed. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 111 NURSE ASSISTANT SKILLS 111 | 14/06/2023 10:27

و213 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 112 • Position the patient comfortably on the stretcher. Lock the safety belt(s). Raise both siderails of the stretcher. • To transport the patient, two persons should direct the stretcher (one at the head and one at the foot). Unlock the wheels of the stretcher. Move slowly. The stretcher patient always travels feet first. When going down an incline, the person at the foot of the stretcher should backward and use body weight to control the stretcher. To enter an elevator, push the correct button to keep the elevator door open. Back the stretcher into the elevator so that the head end enters first. To leave the elevator, push the button to keep the door open, and push the stretcher out feet end first. go • To return the patient to bed, reverse the procedure, beginning with locking the wheels of the stretcher and bed and unlocking the safety belt(s). Then proceed as shown in Figures 3-18A and 3-18B. USING A MECHANICAL LIFT TO TRANSFER A PATIENT • Safety Safety The manufacturer will indicate the weight limits for the mechanical lift. Do not use the mechanical lift if the patient weighs more than the weight limit. Most facilities require that two health care providers perform this procedure. One person operates the lift while the second person guides the movements of the patient. Check the straps, sling, and any clasps to make sure there are no defects. Check the hydraulic unit and look for evidence of oil leaks. Do not use the lift if straps or sling are torn or defective, if clasps are not secure, or if oil is leaking from the hydraulic unit. Serious injury may result. Label the defective mechanical lift with a warning or lock- out and notify your supervisor immediately. Comm Patients are often apprehensive about being transferred by lift. It is important that they be as relaxed as possible for the transfer. Constant reassurance and encouragement are necessary. • Position the chair or wheelchair next to the foot of the bed, with the open seat facing the head of the bed. Lock the wheels of the wheelchair. Raise the footrests to the upright position. • Lock the wheels of the bed. If siderails are present and elevated, lower the siderail on the side of the transfer. 14/06/2023 10:27

وزارة التعليم Ministry of Education 2024-1446 • Turn or move the patient to position the sling under the patient. The sling should be positioned under the shoulders, buttocks, and thighs. Make sure that the sling is smooth and that the center is near the center of the patient's back (Figure 3-19A). • Position the mechanical lift over the bed (Figure 3-19B). Open the base of the lift to its widest position to provide a broad base of support. • Attach the suspension straps to the sling. Insert the hooks from the inside of the sling to the outside to keep the open end of the hooks away from the patient's body. Make sure that the straps are not tangled or twisted. If clasps are present on the hooks, make sure they are secure. • Attach the suspension straps to the frame of the lift (Figure 3-19C). Check to make sure that the straps are locked to the frame or attached securely. Make sure that the straps are not tangled or twisted. Position the patient's arms inside the straps. Encourage the patient to keep their arms folded across the chest to keep the arms inside the straps. • Turn the crank or use the hydraulic control to slowly raise the patient slightly above the bed. Check the straps, sling, and position of the patient to be sure that the patient is suspended securely by the lift. • Continue to raise the patient as needed until you can slowly turn the lift to move the patient away from the bed and into position over the chair or wheelchair. Keep all movements as smooth and even as possible (Figure 3-19D). Move slowly to prevent jerking motions that may frighten the patient. Slowly lower the lift to position the patient in the chair or wheelchair. Guide the patient's legs into position on the chair (Figure 3-19E). • Unhook the suspension straps from the sling (Figure 3-19F). Remove the sling from under the patient (Figure 3-19G). At times, the sling is left in position under the patient. Carefully move the lift away from the patient. A Safety Be careful not to injure the patient with the straps or lift while moving the lift away from the chair. • To return the patient to bed, reverse the procedure. Begin by making sure the wheels of the chair and bed are locked. Attach the suspension straps securely to the sling. checkpoint 1. What stage of tissue breakdown is a pressure ulcer that has abrasions, bruises, or open sores? 2. How frequently should a patient confined to bed be turned or repositioned? GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 113 NURSE ASSISTANT SKILLS 113 | 14/06/2023 10:27

(A) (B) (C) (D) (E) (F) (G) FIGURE 3-19 (A) Position the sling under the patient's shoulders, buttocks, and thighs. (B) Position the mechanical lift over the bed. (C) Attach the suspension straps to the frame of the lift and make sure that they are locked to the frame or attached securely. (D) Use a smooth motion to lift the patient out of the bed. (E) Slowly lower the lift to position the patient in the wheelchair. (F) Unhook the suspension straps from the sling. (G) Remove the sling from under the patient. 114 ورُ21 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 114 14/06/2023 10:27

3:3 BEDMAKING Making beds correctly is a task that must be performed by many health care providers. A correctly made bed provides comfort and protection for the patient confined to bed for long periods. Therefore, care must be taken when beds are made. The bed linen must be free of all wrinkles. Wrinkles cause discomfort and can lead to the formation of pressure ulcers. Mitered corners are used to hold the linen firmly in place. Mitering corners is a special folding technique that secures the linen under the mattress (Figure 3-20). Mitered corners are also used for linen placed on stretchers and examination tables. Some agencies and homes use fitted contour sheets for bottom sheets. Following are examples of the types of beds that you may be required to make: • Closed bed: This is a bed made following the discharge of a patient and after terminal cleaning of the unit. Its purpose is to keep the bed clean until a new patient is admitted. . Open bed: A closed bed is converted to an open bed by fanfolding (folding like the pleats of a fan) the top sheets. This is done to "welcome" a new patient and for patients who are ambulatory or out of bed for short periods. (A) (B) (c) (D) FIGURE 3-20 Steps for making a mitered corner. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 115 NURSE ASSISTANT SKILLS 115 | 14/06/2023 10:27

(A) (C) NO GSWERING NO FIGURE 3-21 Making an occupied bed 116 و 215 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 116 (B) (D) NO NO SMOKING • Occupied bed: This is a bed made while the patient is in the bed (Figures 3-21A to 3-21D). • Bed cradle: A cradle is placed on a bed under the top sheets to prevent bed linen from touching parts of the patient's body (Figure 3-22). A cradle is frequently used for patients with burns, skin ulcers, lesions, blood clots, circulatory disease, fractures, surgery on legs or feet, and other similar conditions. Draw sheets (also called lift sheets or transfer sheets) are half sheets that are frequently used on beds. A draw sheet extends from the patient's shoulders to the patient's knees. The draw sheet is used to protect the mattress. If soiled, the draw sheet can be changed readily without changing the bottom sheet of the bed. 14/06/2023 10:27

FIGURE 3-22 A bed cradle supports the top linen and prevents the linen from coming into contact with the patient's legs and feet. In some settings, disposable bed protectors, frequently called underpads, are placed under the patient to protect the sheets instead of using draw sheets. Draw sheets are also used as lift sheets. To prevent injury to yourself, you must observe correct body mechanics while making beds. It is also important to conserve time and energy. Keeping linen arranged in the order of use is one way to conserve time and energy. In addition, most beds are made completely first on one side and then on the other side. This limits unnecessary movement from one side of the bed to the opposite side. It is important to limit the movement of organisms, and thus the spread of infection, while making beds: Precaution Observe standard precautions. Wash your hands frequently and wear gloves while handling linen. • Roll dirty or soiled linen while removing it from the bed. Linen may be contaminated by blood, body fluids, secretions, excretions, urine, or feces. . Hold dirty linen away from your body and uniform, and place it in a linen hamper, cart, or bag immediately. Never place dirty linen on the floor. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 117 NURSE ASSISTANT SKILLS 117 | 14/06/2023 10:27

و218 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 118 Some facilities do not allow linen hampers or carts in a patient's room. The hamper or cart is left in the hall. Soiled linen is placed in a pillowcase or plastic bag, carried to the hall, and placed in the hamper or cart. • Remove the gloves and wash your hands after handling dirty linen and before handling clean linen. . Before handling clean linen, the contaminated gloves should be removed, and the hands should be washed. Clean linen should be stored in a closed closet or on a covered linen cart. Never allow clean linen to contact your clothing. Never bring extra linen to the patient's room because it is then considered contaminated and cannot be used for another patient. Avoid shaking clean sheets. Unfold them gently. Place the open end of the pillowcase away from the door. This looks neater and also helps prevent the entrance of organisms from the hall. • If there is any chance of contamination in the room, clean gloves should be applied before handling clean linen. Many agencies have special self-dissolving plastic laundry bags that dissolve during the washing process. The contaminated linen is placed in the bag, and the bag is sealed. The bag is then placed inside another plastic bag and labeled before being sent to the laundry department. The second bag is necessary because wet linen may dissolve the water-soluble bag before it reaches the laundry department. The health care provider must be alert at all times to prevent the spread of infection by contaminated linen. checkpoint 1. Bed cradles are used for patients with what conditions? 2. What is another term for a draw sheet? 3:4 ADMINISTERING PERSONAL HYGIENE Administering personal care and hygiene may be one of your responsibilities as a health care provider. Ill patients often depend on health care team members for all aspects of personal care. The health care provider must be sensitive to the patient's needs and respect the patient's right to privacy while personal care is administered. Personal hygiene includes bathing, back care, perineal care, oral hygiene, hair care, nail care, and shaving, when necessary. Such care promotes good habits of personal hygiene, provides comfort, and stimulates circulation. Providing such care also gives the health care provider an opportunity to develop a good and caring relationship with the patient. 14/06/2023 10:27

TYPES OF BATHS Different types of baths are given to patients. The type of bath depends on the patient's condition and ability to help. • Complete bed bath: The health care provider bathes all parts of the patient's body, and also provides oral hygiene, back care, hair care, nail care, and perineal care. A complete bath is usually given to the patient who is confined to bed and is too weak or ill to bathe. • Partial bed bath: The health care provider bathes some parts of the patient's body. The term "partial bath" has two meanings, both related to the patient's ability to help. If the patient is too weak to help, a partial bath means that only the face, arms, hands, back, and perineal area, are bathed by the health care provider. If the patient is able to wash most of their body, a partial bath means that the health care provider completes the bath, usually bathing the patient's legs and back. In both types of partial baths, the health care provider prepares the supplies needed by the patient. ⚫ Tub bath or shower: Some patients are allowed to take tub baths or showers. The health care provider helps as needed by providing towels and supplies, preparing the tub or shower area, and assisting the patient as much as the situation demands. Many health care facilities have shower or tub chairs that are used for patients who cannot stand in a shower or climb into a tub (Figure 3-23). The shower chair must be cleaned and disinfected before and after every use. • Waterless bath: Some facilities use prepackaged disposable cleansing cloths instead of basins of water for baths. The cleansing cloths contain a rinse-free cleanser and moisturizer, and can be warmed in a microwave (follow package instructions) or in a special warmer. The waterless bath is less tiring to the patient and helps preserve skin moisture, prevent drying, and is more gentle to the skin than most soaps. Most packages contain 8-10 cloths. Usually, one cloth is used for the face, neck, and ears; one for each arm and each leg; one for the chest and abdomen; one for the perineum; and one for the back and buttocks. The solution dries quickly on the skin, but a towel can be used to gently remove excess moisture. Extreme care must be taken to avoid overheating the cloths. Read and follow manufacturer's instructions. FIGURE 3-23 A shower or tub chair is often used for patients who cannot stand in a shower or climb into a tub. It must be disinfected before and after every use. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 119 NURSE ASSISTANT SKILLS 119 | 14/06/2023 10:27

FIGURE 3-24 Hold the dentures securely while brushing all surfaces. FIGURE 3-25 Use a prepared swab to cleanse all parts of the patient's mouth while providing special oral hygiene. ORAL HYGIENE Oral hygiene means care of the mouth and teeth. Oral hygiene should be administered at least three times a day. If the patient's condition requires frequent oral care, it should be administered more often, usually at least every two hours. Proper oral hygiene prevents disease and dental caries, stimulates the appetite, and provides comfort. In addition, it aids in the prevention of halitosis (bad breath). • Routine oral hygiene refers to regular, everyday toothbrushing and flossing. Many times, patients are able to provide their own care. In such cases, the health care provider provides all the necessary equipment and supplies. In other cases, the provider helps the patient to brush and care for their teeth and mouth. • Denture care is necessary when a patient has dentures or artificial teeth. In some cases, the health care provider must help to clean the dentures. Patients may be sensitive about dentures, so it is important that the health care provider provides privacy and reassures the patient. Extreme care must also be taken to prevent damage to the dentures (Figure 3-24). • Special oral hygiene is usually provided for the unconscious or semiconscious patient. Because many of these patients breathe through their mouths, extra care must be taken to clean all parts of the mouth. Special supplies are used for this procedure (Figure 3-25). و 230 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 120 HAIR CARE Hair care is an important aspect of personal care that is, unfortunately, frequently neglected. Patients confined to bed often have tangles and knots in their hair. Tangles or knots can be removed by combing a small section of hair at a time and working from the ends toward the scalp. Conditioners can help prevent tangles. Brushing stimulates circulation to the scalp. Brushing also removes dirt and lint, and helps keep the hair shiny and attractive. 14/06/2023 10:28

It is also important to observe the condition of the hair and scalp. Signs of disease, redness, scaling, scalp irritation, or any other conditions should be reported. Shampooing must be approved by the physician. Various types of dry or fluid shampoos are available for patients confined to bed. Read all instructions carefully before using any of these products. Special devices are also available for use when shampooing the hair of a patient confined to bed (Figure 3-26). NAIL CARE Nail care is another often-neglected area in the personal care of the patient. Nails harbor dirt, which can lead to infection and disease. In addition, rough or sharp nails can cause injury. It is important that nail care be included as a part of the daily personal care provided to the patient. However, nails should never be cut unless you receive specific orders to do so from the physician or your immediate supervisor. Clean the nails by soaking them for 5-10 minutes in a solution of mild detergent and water at a temperature of 40.6-43.3°C. This loosens the dirt in the nail beds. Use the slanted or blunt edge of an orange stick to clean dirt out of the nail beds under the nails (Figure 3-27). A nail brush can also be used to clean the nails. Carefully check the nails and surrounding skin while cleaning the nails. Use an emery board to file the nails and shorten them. Use short strokes. Work from the side of the nail to the top of the nail. Repeat for the opposite side. Do not use a back-and-forth motion. Such a motion can split the nails. Cutting nails may cause injury. In some facilities, only licensed or advanced practice personnel are allowed to cut fingernails. If you are permitted to cut fingernails, use nail clippers, not scissors, and clip the nails straight across. Never cut below the tips of the fingers. Clip slowly and carefully to avoid accidentally damaging the skin around the nail. Then file the nails straight across to remove rough edges. Never cut toenails because injuries to the feet are prone to infection and slow healing. File toenails straight across. FIGURE 3-26 Special devices are available for use when shampooing the hair of a patient confined to bed. FIGURE 3-27 After soaking the nails, use the slanted or blunt edge of an orange stick to clean dirt out of the nail beds under the nails. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 121 NURSE ASSISTANT SKILLS 121 | 14/06/2023 10:28

(A) (B) BACK RUB Unless contraindicated by the patient's condition, a back rub is given as part of the daily bath. It can also be given at other times during the day and should be done at least once every eight hours for a patient confined to bed. A good back rub takes at least 4-7 minutes and stimulates circulation, prevents pressure ulcers, and leads to relaxation and comfort. • Rub a small amount of lotion into your hands. Begin at the base of the spine. Rub up the center of the back to the neck, around the shoulders, and down the sides of the back. Rub down over the buttocks, around, and circle back to the starting point. Repeat this step four times. • Use long, soothing strokes. Use firm pressure on the upward strokes and gentle pressure on the downward strokes (Figure 3-28A). . • • Repeat the long, upward strokes, but on the downward strokes, use a circular motion (Figure 3-28B). Pay particular attention to bony prominences. Repeat this motion four times. Repeat the long, upward strokes, but on the downward strokes, use very small circular motions (Figure 3-28C). Use the palm of your hand to apply firm pressure. Pay particular attention to the bony prominences. Do this motion one time. Repeat the long, soothing strokes used initially (Figure 3-28D). Do this for 3-5 minutes. End with up-and-down motions over the entire back (Figure 3-28E). Do this for 1-2 minutes. This provides relaxation after stimulation. Safety It is important that the health care provider keeps their nails short to prevent injury. FIGURE 3-28A-E Motions for a back rub. 122 CHAPTER 3 و233 التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 122 (C) (D) (E) ONO 14/06/2023 10:28

CHANGING A GOWN OR CLOTHING Changing a patient's gown is also important. Hospital gowns usually open down the back and are easier to position and remove. If the patient has a weak or injured arm, or if an intravenous solution is being infused in one arm, the gown must be positioned with care. Usually, the sleeve of the soiled gown is removed from the uninjured or untreated arm first (Figure 3-29). This allows more freedom of movement while removing the sleeve from the injured or treated arm. Likewise, the sleeve of the clean gown is placed on the affected arm first and then on the unaffected arm. It is sometimes necessary to leave one arm out of the gown and place the sleeve on the unaffected arm only. Some agencies have gowns with openings at the shoulders. Such a gown can be placed over a treated arm and then closed with snaps, ties, or Velcro strips at the shoulder area. In home care, gowns can be opened at the arm seam for easy application. Velcro strips or ties can then be applied so that the gown can be closed after being put on the patient. In long-term care facilities, most residents wear regular clothing during the day. It is important to help the resident as needed in choosing and dressing in appropriate clothing. If a resident has difficulty moving one side or is paralyzed, always put the clothing on the affected side first and remove it from the affected side last. FIGURE 3-29 Keeping the IV container above the level of the infusion site, pass it through the arm of the gown. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 123 NURSE ASSISTANT SKILLS 123 | 14/06/2023 10:28

124 اور23 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 124 OBSERVATIONS When administering personal hygiene, it is important that the health care provider remains alert for any signs that might be unusual. When performing any personal hygiene procedure, watch for and report any unusual observations, including: . Sores, cuts, injuries: Any injuries noted on the skin, mouth, or scalp must be reported. • Rashes: Any type of rash should be reported. Many times, a rash is the first sign of an allergic reaction to a medication. • Color: Any unusual color should be noted. Redness (erythema) of the skin is often the first sign of a pressure ulcer. A blue color (cyanosis) is a sign of poor circulation. A yellow color (jaundice) is a sign of liver disease, bile obstruction, or destruction of red blood cells. Swelling (edema): This can indicate poor circulation or disease and should be reported immediately. Pay particular attention to the hands, feet, ankles, and toes. • Other signs of distress: Difficult breathing (dyspnea), dizziness (vertigo), unusual weakness, excessive perspiration (diaphoresis), extreme pallor, or abnormal drowsiness or sluggishness (lethargy) should be reported immediately. བ་ When administering personal hygiene, standard precautions must be observed at all times. Hands must be washed frequently, Precaution and gloves must be worn. Contact with blood, body fluids, secretions, or excretions is possible. A gown must be worn if contamination of a uniform or clothing is likely. A mask and protective eyewear, or a face shield, must be worn if droplets of blood or body fluids are present, such as when a patient is coughing excessively. Health care team members with cuts, sores, or dermatitis on their hands must wear gloves for all patient contact. Preventing the spread of infection is a major responsibility of the health care provider. Always be sensitive to the patient's feelings and respect the patient's rights. Knock on the door and pause before entering a patient's room. Provide privacy during procedures by closing the door and pulling the curtain. Avoid exposing the patient when administering personal hygiene. Explain all procedures and reassure the patient as needed. Observe legal responsibilities and professional ethics at all times. checkpoint 1. How frequently should oral hygiene be administered? 2. How do you get tangles or knots out of hair? 14/06/2023 10:28

FIGURE 3-30 A nasogastric tube is inserted through the nose, down the esophagus, and into the stomach. FIGURE 3-31 An orogastric tube is inserted through the mouth, down the esophagus, and into the stomach. 3:5 Science MEASURING AND RECORDING INTAKE AND OUTPUT A record of how much fluid is taken in and eliminated by a patient often helps a physician to provide care to the patient. A large part of the body is fluid, so there must be a balance between the amount of fluid taken into the body and the amount lost from the body. In a healthy individual, the fluid balance is usually regulated by the body structures to maintain homeostasis, or a natural balance. However, if an individual has heart or kidney disease, or loses large amounts of fluids through vomiting, diarrhea, excessive perspiration, or bleeding, the fluid balance may be abnormal. If excessive fluid is retained by the body, edema (swelling) results. If excessive fluid is lost from the body, dehydration occurs. Either condition can lead to death if not treated. In such cases, physicians may order that a record be kept of all fluids taken in and discharged from the body. This record is usually called an intake and output record. An intake and output record is a means of recording all fluids a person takes in and eliminates during a certain period. Each agency has its own paper or computerized form, but most contain similar information. INTAKE Intake refers to all fluids taken in by the patient. The following routes and liquids must be considered: وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 125 NURSE ASSISTANT SKILLS 125 | 14/06/2023 10:28

FIGURE 3-32 A gastrostomy tube is surgically inserted through the abdominal skin into the stomach. 500ml 181 VOLUME FIGURE 3-33 A feeding pump is usually used to administer enteral (tube) feedings. · Oral intake is by way of the mouth. Liquids taken in orally include water, coffee, tea, milk, juices, and other beverages. In addition, soups, gelatin, ice cream, and other similar foods that are liquid at room temperature also qualify. The nurse assistant often measures and records or reports these amounts. Enteral (tube) feeding is used for patients who are unable to swallow, who are unconscious or comatose, or who have certain digestive diseases. Liquid is administered through a nasogastric, orogastric, or gastrostomy tube. - - A nasogastric (NG) tube is a tube inserted through the nose, down the esophagus, and into the stomach (Figure 3-30). An orogastric (OG) tube takes the same route but enters through the mouth (Figure 3-31). A syringe can be used to instill food or medication into the NG or OG tube. - A gastrostomy tube is surgically inserted through the abdominal skin into the stomach (Figure 3-32). A feeding pump is used to administer the solution (Figure 3-33). The solution contains all the nutrients required by the body. A nurse or another legally authorized team member will administer the enteral feeding. The nurse assistant must: - Keep the patient's head elevated 30-45 degrees during the feeding and for 30-60 minutes after the feeding. - - - - Make sure there are no kinks in the tubing. Use extreme caution when turning or positioning the patient to avoid dislodging the tubing. Provide frequent oral hygiene. - Notify the nurse immediately if the alarm sounds on the feeding pump, if the solution is not flowing through the tubing, or if the solution container is low or empty. • Intravenous (IV) feeding refers to fluids given into a vein. Blood units, IV medications, and other IV solutions are measured. This measurement is the responsibility of the nurse or another legally authorized team member. 126 CHAPTER 3 ا و138 التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 126 14/06/2023 10:28

OUTPUT Output refers to all fluids eliminated by the patient. The following routes and liquids must be considered: • Bowel movement: Liquid bowel movements are usually measured and recorded. Solid or formed feces are usually noted or described. The nurse assistant may measure and record or report this elimination. Emesis: Anything that is vomited is measured and recorded. Color, type, and other facts are usually noted. The nurse assistant often measures and records or reports emesis. • Urine: All urine voided or drained via a catheter is measured and recorded. This may be the responsibility of the nurse assistant. A urine output of less than 30 milliliters per hour must be reported. • Tubes and drains: Any irrigation or suction drainage, including drainage from nasogastric tubes, hemovacs, chest tubes, and other drainage tubes, is measured (Figure 3-34). The type, amount, color, and other facts about the drainage are noted. If an irrigating solution is injected into a tube and more solution returns, the excess amount is considered output. This measurement is the responsibility of the nurse or another legally authorized team member. RECORDING INTAKE AND OUTPUT Input and output records must be accurate. All amounts must be measured in graduates. A graduate is a container that is made of plastic or stainless steel and has calibrations for milliliters/cubic centimeters on the side. It is similar to a measuring cup and is used to obtain accurate measurements. The graduate should be held at eye level or placed on a flat surface and viewed at eye level to accurately record amounts (Figure 3-35). In addition, care must be taken when adding or totaling the columns in the record. Most records contain totals for 8-hour and 24-hour periods (Figure 3-36). Some agencies use 12-hour periods for intake and output totals. + For input and output records, fluids are measured in metric units called milliliters (ml). Math A few measurement devices might use cubic centimeters (cc). However, 1 ml and 1 cc are the same amount. Therefore, 30 ml equals 30 cc. FIGURE 3-34 Suction drainage from a hemovac, one type of wound drainage system, is recorded as irrigation output on an intake and output record. FIGURE 3-35 Place the graduate on a flat surface and obtain the reading at eye level to get an accurate measurement. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 127 NURSE ASSISTANT SKILLS 127 | 14/06/2023 10:28

INTAKE AND OUTPUT RECORD Attending Physician DR. NASSER AL-AHMED Room No. 238 Hosp. No. 54-3201 OUTPUT OTHER REMARKS Family Name AL-KHALID Date First Name SAAD INTAKE 9/30 TIME Oral I.V. Blood Urine Tube Emesis Feces 7-8 AM 100 8-9 AM 320 9-10 AM 200 420 EMESIS- GREEN LIQUID 10-11 AM 100 11-12 Noon 10 NG IRRIGATION NS 12-1 PM 240 310 1-2 PM 850 200 NASOGASTRIC GOLD-BROWN 2-3 PM 60 8 HOUR TOTAL 820 850 10 730 200 200 3-4 PM 4-5 PM 320 150 120 BROWN LIQUID 280 5-6 PM 6-7 PM 180 7-8 PM 8-9 PM 100 9-10 PM 500 240 NASOGASTRIC BROWNISH 10-11 PM 310 8 HOUR TOTAL 600 650 590 240 120 11-12 PM 12-1 AM 10 NG IRRIGATION NS 1-2 AM 180 420 2-3 AM 3-4 AM 650 EMESIS- GREEN LIQUID 4-5 AM 5-6 AM 600 6-7 AM 100 180 380 NASOGASTRIC GOLD-BROWN 8 HOUR TOTAL 280 600 10 800 180 650 24 HOUR TOTAL 1700 2100 TOTAL INTAKE 20 2120 620 850 120 3820 TOTAL OUTPUT FIGURE 3-36 A sample intake and output record. 3170 و138 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 128 14/06/2023 10:28

Various agencies have different policies for recording intake and output. In some agencies, the record is kept at the bedside. Team members note the intake and output of the patient and record the measurements on the record. At times, the patient is even taught to measure and write down the amounts. In other agencies, the record is kept on the patient's chart. Measurements are noted on a slip of paper and reported. The nurse, medical secretary, health unit coordinator, or an authorized team member then records the information on the chart's intake and output form. With computerized charting, totals are entered directly into the computer by the nurse or nurse assistant. Most computerized programs will automatically add all the columns. Comm Patients should be given careful instructions when an intake and output record is being kept. The patient must inform health care providers when they drink fluids not provided by the health care team. Sometimes, the patient records how many glasses of water or other liquids are consumed. Other times, the health care provider fills a water pitcher and then checks the quantity remaining before refilling the pitcher. The health care provider then subtracts this quantity from the total amount originally in the pitcher and records the difference as water intake. To avoid missing any amounts of oral intake, the health care provider must also think about fluid intake every time a glass, cup, or water pitcher is removed from the unit. If visitors bring milkshakes or other liquids, the amounts of these must also be recorded. Precaution Standard precautions must be followed at all times when body fluids, such as urine, emesis, liquid bowel movements, and drainage, are measured. Gloves must be worn while the fluids are being measured and discarded. Hands must be washed frequently and must always be washed immediately after gloves are removed. If splashing or spraying of fluids is possible, eye protection, a mask or face shield, and a gown must be worn. The graduate or measuring device for monitoring a patient's output must be used for that patient only. It should be discarded or sterilized when output is no longer measured. Any areas contaminated by body fluids when measurements are being obtained must be wiped with a disinfectant. The health care provider must constantly take steps to prevent the spread of infection. checkpoint 1. What are two routes that are considered for liquid intake? 2. What units are liquids measured in? وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 129 NURSE ASSISTANT SKILLS 129 | 14/06/2023 10:28

و 230 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 130 3:6 FEEDING A PATIENT Good nutrition is an important part of a patient's treatment. It may be one of your responsibilities to make mealtimes as pleasant as possible for the patient. Mealtimes are often regarded as a time for social interaction. Most people prefer to eat with others. People who eat alone often have poor appetites and poor nutrition. In long-term care facilities, patients are encouraged to eat in the dining room. This provides an opportunity for social interaction with others. If a patient is confined to bed, it is important to talk with the patient while serving the food tray or feeding the patient. Proper mealtime preparation is important. If the patient is ready to eat when the tray arrives, mealtime is likely to be more pleasant. Preparation before the tray is delivered includes: . • . • Offering the bedpan or urinal, or assisting the patient to the bathroom; clearing the room of any offensive odors by using a deodorizer or opening a window. Assisting the patient to wash their hands and face. Providing oral hygiene, if desired; many individuals want to brush their teeth before meals, especially before breakfast. Positioning the patient comfortably and in a sitting position. Clearing the overbed table and positioning it for the tray. Removing objects such as an emesis basin or bedpan from the patient's view; place such objects in the bedside stand, if they will not be needed. • If a meal will be delayed because of x-rays or other treatments, be sure to explain this to the patient. Check the tray carefully against the patient's name and room number and the type of diet ordered. If anything seems out of place (for example, a salt shaker provided with a salt-free diet, or sugar with a diabetic diet), check with your immediate supervisor or the dietitian. Never add any food to the tray without checking the diet order first. Allow patients to feed themselves whenever possible. If necessary, assist by cutting meat, opening beverage cartons, and buttering bread. If a patient is blind or visually impaired, tell the patient what food is on the plate by comparing the plate to a clock. For example, say, “Steak is at 12 o'clock, peas and carrots are at 4 o'clock, and mashed potatoes are at 9 o'clock." Make sure all food and utensils are conveniently placed. 14/06/2023 10:28

Before feeding any patient, test the temperature of all hot foods. A small amount can be placed on your wrist to check temperature. Never blow on hot food to cool it. Points to observe when feeding a patient include: • Alternate the foods by giving sips of liquids between solid foods. • Use straws for liquids unless the patient has dysphagia (difficulty in swallowing). Straws can force liquids down the throat faster and cause choking. A food thickener can be added to liquids to solidify them slightly and make them easier to swallow. A physician or dietitian must approve the use of this product. Offer only small bites of food at one time. Fill the spoon or fork one-third to one-half full. • Hold the spoon or fork at right angles to the patient's mouth so you are feeding the patient from the tip of the utensil. Encourage the patient to eat as much as possible. • Provide a relaxed, unhurried atmosphere. • Give the patient sufficient time to chew the food. Observe how much the patient eats so that a record of nutritional intake can be kept. If the patient does not like certain foods on the tray, ask your immediate supervisor or the dietitian whether a substitute can be provided. Record intake if an intake and output record is being kept for the patient. Safety Always be alert to signs of choking while feeding a patient. Take every effort to prevent choking by feeding small quantities, allowing sufficient time for the patient to chew and swallow, and providing liquids to keep the mouth moist and make chewing and swallowing easier. If the patient coughs or chokes frequently when swallowing, the feeding should be stopped to prevent aspiration of food. Notify your supervisor immediately. If a patient had a stroke, one side of the mouth may be affected. As you feed the patient, direct food to the unaffected side. Watch the patient's throat to check swallowing. Watch for food that may be lodged in the affected side of the mouth. If a patient chokes on food, be prepared to provide abdominal thrusts. checkpoint 1. What do you compare a plate to for a visually impaired or blind patient? 2. How full should you fill a spoon or fork with food? وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 131 NURSE ASSISTANT SKILLS 131 | 14/06/2023 10:28

و233 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 132 3:7 ASSISTING WITH A BEDPAN/URINAL Regular elimination of body wastes contributes to good health. Patients confined to bed must rely on the health care provider's help in meeting this important physical need. Elimination of body wastes is essential. Death will occur if wastes are not eliminated. The following terms are used in reference to elimination: • Urinate (also called micturate or void) refers to emptying the bladder, which stores the liquid waste, or urine, produced by the kidney. A urinal is used by male patients when they need to urinate (Figure 3-37); a bedpan is used by female patients. Two main types of bedpans are the fracture, or orthopedic, bedpan and the standard bedpan. • Defecate refers to having a bowel movement—the discharge of the waste through the rectum. The material is called feces (or stool). Many patients are sensitive about using bedpans or urinals. Provide privacy by closing the door, privacy curtain, and window curtain. Make the patient as comfortable as possible during this procedure. It is also important to provide the bedpan or urinal immediately when the patient requests it. In addition, a bedpan or urinal should be offered frequently to any patient confined to bed. Accurate observations of the frequency, amount, and appearance of urine and feces are important. Abnormalities in any of these factors may indicate disease or complications. Any abnormality must be reported immediately, and a specimen must be saved for examination. FIGURE 3-37 A urinal should have a lid or cover. 14/06/2023 10:28

Before emptying a bedpan or urinal, it is the health care provider's responsibility to check whether specimens are needed. In addition, amounts must be measured and recorded if an intake and output record is being kept for the patient. Check with your immediate supervisor or note the physician's orders for this information. Precaution Standard precautions must be observed when handling urine or feces. Hands must be washed frequently and gloves must be worn. Eye protection and a mask or face shield must be worn if splashing or spraying is possible while emptying the bedpan. Some health care facilities require a one-glove technique to protect the environment while assisting with bedpans or urinals (Figure 3-38). Two gloves are worn to remove the bedpan or urinal. The bedpan or urinal is covered and placed on top of an underpad or bed protector that has been placed on a chair. The bedpan or urinal should never be placed on the overbed table or bedside stand. One glove is removed and held in the gloved hand. The ungloved hand is used to elevate the siderails (if indicated), open doors, and turn on faucets. A paper towel can also be used with a gloved hand to prevent contact with items in the environment. It is important to protect environmental surfaces from contamination with substances on gloved hands. Some agencies have special spray units in the bathrooms to rinse and clean bedpans and urinals (Figure 3-39). After rinsing, the bedpan or urinal must be disinfected. It must be used for only one patient. After the patient is discharged, it must be sterilized before being used for another patient. Many bedpans are disposable and are discarded in an infectious-waste container when the patient is discharged. Any areas contaminated with urine or feces must be wiped with a disinfectant. In addition, patients should have the opportunity to wash their hands and receive perineal care after using bedpans or urinals. Taking proper precautions can help prevent the spread of infection. checkpoint 1. What is the function of the bladder? 2. What should the health care provider do before emptying a urinal? FIGURE 3-38 A one-glove technique can be used to carry a contaminated bedpan, leaving the other hand free to perform other tasks without contaminating the environment. FIGURE 3-39 Some agencies have special spray units in the bathrooms to rinse and clean bedpans and urinals. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 133 NURSE ASSISTANT SKILLS 133 | 14/06/2023 10:28

3:8 PROVIDING CATHETER AND URINARY DRAINAGE UNIT CARE FIGURE 3-40A A straight catheter is inserted into the bladder to drain urine but is not left in the bladder. FIGURE 3-40B A Foley catheter has a small balloon on the end that is inserted into the bladder. The balloon is inflated with sterile water to hold the catheter in place. FIGURE 3-40C If a male patient requires urinary drainage, an external catheter may be used. Some patients are unable to urinate. In these cases, a catheter may be inserted into the bladder to drain the urine. The catheter is usually connected to a drainage unit to collect the urine. A catheter is a hollow tube, usually made of soft rubber or plastic. There are different kinds of catheters: • A urethral, or straight, catheter is inserted into the bladder to drain urine but is not left in the bladder (Figure 3-40A). It is usually used to collect a sterile urine specimen. • A Foley catheter (also called an indwelling, or retention, catheter) is usually used to drain the bladder over an extended period. It has a small balloon on the end that is inserted into the bladder (Figure 3-40B). Once the catheter is inserted, the balloon is inflated with sterile water to keep the catheter in place. . If a male patient requires urinary drainage, an external catheter may be used (Figure 3-40C). These catheters eliminate the need for an internal catheter and decrease the chance of urinary infection. The external catheter is placed on the penis and attached to the urinary drainage tubing and collection bag. The catheter must be removed at least every 24 hours, and the skin must be cleansed thoroughly and checked for any signs of irritation. Insertion of any catheter is a sterile technique performed by a nurse, physician, or other authorized person. The catheter must be kept sterile at all times. A urinary drainage unit, or bag, is attached to the catheter to collect drained urine (Figure 3-41A). This is usually a closed unit to keep microorganisms from entering the catheter and, therefore, prevent infection. The unit consists of plastic or rubber tubing attached to the catheter and extending to a bag in which the urine is collected. Patients who are ambulatory may use a leg bag to collect the urine drained through the catheter 134 ور23 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 134 14/06/2023 10:28

4000 3750 3500 3250 MEDLINE 3000 -2750- -2500 2250 2000 1750 1500 1250 1000 CE 750 Approx Vol. ml <- 500 - FIGURE 3-41A The urinary-drainage bag is connected to the catheter and attached to the bed frame below the level of the bladder to collect the drained urine. FIGURE 3-41B A leg bag may be used for ambulatory patients to collect urine drained through a catheter. It is usually attached to the leg with straps. (Figure 3-41B). The leg bag is smaller than a urinary drainage bag and must be emptied more frequently, but it does allow the patient more freedom of movement. Most leg bags are held in place with Velcro straps. The bag must be positioned so there is a straight drop down from the catheter. When the patient returns to bed, the leg bag is removed and the catheter is connected to a urinary drainage bag. Most leg bags are discarded in an infectious waste bag after one use. To prevent infection, aseptic technique must be used while connecting and disconnecting the catheter from either a urinary drainage bag or a leg bag. Careful observation of the catheter and drainage unit is required. The following should be checked frequently: • The connection between the catheter and drainage bag is secure. The tubing is free from kinks or bends that stop the urine flow. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 135 NURSE ASSISTANT SKILLS 135 | 14/06/2023 10:28

TEMOVE With ALCOHOL NGOL TOHOOTY FIGURE 3-42A A catheter stabilization device can be used to secure the catheter to the leg. FIGURE 3-42B A strap can also be used to secure the catheter to the leg. FIGURE 3-42C The catheter may also be taped to the leg. If possible, use hypoallergenic tape. • The drainage bag is always below the level of the bladder. If it is raised above the level of the bladder, a backflow of urine into the bladder can occur. This, in turn, can lead to infection. · . The urine is flowing freely into the drainage bag. The system usually relies on gravity for drainage, so the drainage bag should be kept low enough to make use of the force of gravity. The catheter is secured to the patient's leg using a catheter stabilization device (Figure 3-42A), a strap (Figure 3-42B), or tape (Figure 3-42C). This prevents pull on the catheter, which might dislodge it or cause irritation. • The drainage bag is emptied frequently. Stagnant urine encourages the growth of microorganisms. The bags are usually emptied every eight hours, but they may be emptied more frequently, if required. • The drainage bag and tubing are not lying on the floor. The drainage bag should be attached to the bed frame. • No loops of the drainage tube are hanging below the drainage bag. Such loops interfere with the gravitational flow of urine into the bag. • The tubing leading to the drainage bag is always above the level of urine in the bag. This prevents infection and microorganisms in the urine from traveling back up the tubing and into the patient's bladder. . • If a patient complains of burning, pain, irritation, or tenderness in the urethral area, the complaints should be reported immediately to the supervisor. Precaution Standard precautions must be observed at all times when handling urine. Gloves must be worn when providing catheter care, obtaining urine specimens from a urine collection port, and emptying a urinary drainage unit. Hands must be washed frequently and immediately after removing gloves. If splashing or spraying of body fluids is possible, eye protection, a mask or face shield, and a gown must be worn. Any areas contaminated with urine must be wiped with a disinfectant. Taking proper precautions helps prevent the spread of infection. و 236 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 136 14/06/2023 10:28

checkpoint 1. What is a catheter? 2. How is a Foley, or indwelling, catheter held in place? 3:9 PROVIDING OSTOMY CARE An ostomy is a surgical procedure in which an opening, called a stoma, is created in the abdominal wall. This allows wastes such as urine or feces to be expelled through the opening. In most cases, an ostomy is performed because of tumors or cancer in the urinary bladder or intestine. An ostomy may also be done as a treatment for birth defects, ulcerative colitis, bowel obstruction, or injury. At times, an ostomy is permanent. At other times, an ostomy is temporary and is repaired when the injury heals or the condition necessitating the ostomy improves. There are different types of ostomies: • Ureterostomy: A ureterostomy is an opening into one of the two ureters that drain urine from the kidney to the bladder. The ureter is brought to the surface of the abdomen, and urine drains from the stoma, or opening. • Ileostomy: An ileostomy is an opening into the ileum, a section of the small intestine. A loop of the ileum is brought to the surface of the abdomen. Because the entire large intestine is bypassed, the feces expelled are frequent and liquid, and contain digestive enzymes that irritate the skin. Colostomy: A colostomy is an opening into the large intestine, or colon. There are different kinds of colostomies, depending on the area of large intestine involved (Figure 3-43). Feces expelled through an (A) Ascending colostomy (B) Transverse colostomy (C) Descending colostomy (D) Sigmoid colostomy FIGURE 3-43 The type of colostomy depends on which part of the intestine is removed. Areas of intestine that remain after each type of colostomy are shown in blue. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 137 NURSE ASSISTANT SKILLS 137 | 14/06/2023 10:28

و138 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 138 ascending colostomy tend to be liquid, while feces expelled through a transverse or descending colostomy are more solid and formed. Feces expelled through a sigmoid colostomy are similar to normal feces because the digestive products have moved through most of the intestine, and water and other substances have been reabsorbed. Most patients with ostomies wear a bag or pouch over the stoma to collect the drainage (Figure 3-44). The pouch is held in place with a belt or an adhesive seal. Problems that can occur include leakage, odor, and irritation of the skin surrounding the stoma. The pouch must be emptied frequently. Many pouches have areas that can be opened to allow urine or feces to drain. The drainage end of the bag is placed in a bedpan. If the patient is ambulatory, the patient can sit on the toilet and position the drainage end of the bag over the toilet. The clamp at the drainage end of the bag is opened to allow the feces or urine to drain. The drainage end is then cleaned to prevent odors, and the clamp is resealed. Some pouches are disposable and are removed and replaced. Used bags should be discarded in an infectious-waste bag. Good stoma and skin care are essential because of irritation caused by urine or feces drainage. Skin barriers such as wafers, creams, lotions, powders, and liquid films are applied to the skin around the stoma to prevent irritation from the removal of the pouch. Only a thin layer of the barrier should be applied because too much lotion or cream may interfere with sealing the bag and irritate the skin. When an ostomy is first performed, care is provided by a general nurse or wound care/ostomy nurse. For “older” ostomies, other trained and qualified health care providers may provide routine stoma care. It is essential to check the policy of your facility and to know your legal responsibilities before providing ostomy care. Eventually, most patients are taught to care for their own ostomies, if they are capable. Careful observation is essential when providing care to the patient with an ostomy. The stoma is mucous membrane with no nerve endings. A normal stoma is bright to dark red and looks wet because of the exposed mucosa (Figure 3-45). Standard precautions must be observed at all times when handling urine or feces. Gloves must be worn when emptying Precaution the pouch or providing stoma care. Hands must be washed frequently, and immediately after removing gloves. Eye protection, a mask or face shield, and a gown must be worn if splashing or spraying of body fluids is possible. The pouch must be discarded in an infectious-waste bag. If a bedpan is used, it must be cleaned and disinfected. Any areas contaminated with urine or feces must be wiped with a disinfectant. Taking proper precautions can help prevent the spread of infection. 14/06/2023 10:28

Stoma FIGURE 3-44 Most patients with ostomies wear a bag or pouch over the stoma to collect the drainage. FIGURE 3-45 A normal stoma is bright to dark red and looks wet because of the exposed mucosa. checkpoint 1. What are two reasons for creating a stoma? 2. What are two characteristics of a normal stoma? 3:10 COLLECTING SPECIMENS OF FECES/URINE As a health care provider, you may be responsible for collecting feces and urine specimens (samples). Laboratory tests are performed on the specimens to aid in diagnosis of disease. For the tests to be accurate, the specimens must be collected correctly. Types of specimens include the routine urine specimen; clean-catch, or midstream-voided, specimen; catheterization for sterile urine specimen; 24-hour urine specimen; and feces specimen. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 139 NURSE ASSISTANT SKILLS 139 | 14/06/2023 10:28

Name 83 Roorn DOB Посто Date Medical Record No. Time F/M Tighten Cap Securely FIGURE 3-46 Urine specimen containers should have a secure lid to prevent spillage. ROUTINE URINE SPECIMEN A routine urine specimen is one of the most common specimens. It is used for a variety of laboratory tests such as urinalysis (an examination of the urine to check for urinary tract infections and other diseases). A variety of specimen containers are available for collecting urine. Most containers are clear, calibrated in milliliters (ml), and disposable. The containers should have a secure lid to prevent spillage (Figure 3-46). Most routine urine specimens can be collected in a nonsterile container. Sterile containers are required if the urine is being cultured or tested for the presence of organisms such as bacteria. • • • Usually, 120 ml of urine is sufficient for this test. If the patient is unable to void this amount, obtain what is available and send this amount to the laboratory. Send the specimen to the laboratory immediately. If this is not possible, refrigerate the specimen until it can be sent to the laboratory. If a specimen container is not available, any clean container can be used. Wash the container thoroughly with soap and water, then rinse and dry it. Patients should be cautioned against using containers that previously held medications, however, because using such containers can alter the results of the test. FIGURE 3-47 Place the sterile lid on the container immediately after collecting the urine specimen. CLEAN-CATCH, OR MIDSTREAM, SPECIMEN A clean-catch (midstream) specimen is a urine specimen that is free from contamination. Because microorganisms are present on the genital area and on the specimen containers, special precautions should be used when obtaining a specimen. • The genital area is cleansed thoroughly. Prepared wipes or clean cotton sponges or gauze squares may be used. After the area has been cleaned, the patient is asked to urinate. A few drops of urine are allowed to flow into the bedpan or toilet bowl. The sterile container is then used to catch the urine that follows. The last few drops of urine should be discarded. In this way, the first and last part of the specimen are discarded, and only the middle, or midstream, urine is collected. The sterile lid should be placed on the container immediately to prevent contamination (Figure 3-47). و 240 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 140 14/06/2023 10:28

CATHETERIZATION FOR STERILE URINE SPECIMEN It is sometimes necessary to obtain a sterile urine specimen from a patient. To do this, the patient is catheterized. A narrow, hollow, sterile tube is inserted directly into the bladder. Urine from the tube is then placed in a sterile urine-specimen container. 24-HOUR URINE SPECIMEN Special tests require a 24-hour urine specimen. This means that all the urine produced by the patient during a 24-hour period must be saved. This urine is used to check kidney function (Figure 3-48). FECES SPECIMEN A feces specimen is examined by the laboratory, usually to check for ova and parasites (eggs and worms). Feces can also be examined for the presence of fats, microorganisms, occult blood, and other abnormal substances. A new feces test checks for a gene or a DNA mutation that is usually faulty in the earliest stages of colon cancer. This test can help physicians detect colon cancer at its earliest stages, when it can be treated much more effectively. LABELING All specimens must be labeled correctly, including the kind of specimen (urine or feces), the test ordered, the patient's name, room number or identification number, the date and time, and the physician's name. It is best to label the specimen container instead of the lid because errors could occur if the lid is misplaced. All required information must also be printed on the correct lab requisition form. A laboratory requisition must be sent with the labeled specimen. Health care agencies with electronic records use computer-generated labels for the specimen container and laboratory requisition form. Precaution Standard precautions must be observed when obtaining and handling urine or feces specimens. Gloves must be worn. Hands must be washed frequently and are always washed immediately after removing gloves. Eye protection, a FIGURE 3-48 A 24-hour urine specimen collector. BIOHAZARD Frozen Refrigerate Room Temp SPECIMEN BAG FIGURE 3-49 All urine or feces specimens must be placed in protective biohazard bags before being transported to the laboratory. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 141 NURSE ASSISTANT SKILLS 141 | 14/06/2023 10:28

و243 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 142 mask or face shield, and a gown must be worn if splashing or spraying of body fluids is possible. Any areas contaminated with urine or feces must be wiped with a disinfectant. To avoid contamination from spills, all urine or feces specimens are placed in special biohazard bags before being transported to the laboratory for testing (Figure 3-49). Taking proper precautions can help prevent the spread of infection. checkpoint 1. When collecting a routine urine specimen, if a specimen cup is not available, what can be used? 2. If a urine specimen cannot be sent to the laboratory right away, how should it be stored? 3:11 ADMINISTERING PREOPERATIVE AND POSTOPERATIVE CARE Providing care to patients scheduled for surgery may be one of your responsibilities as a health care team member. Surgical care is divided into three phases: • • Preoperative care: care provided before the surgery. Operative (or intraoperative) care: care provided during the surgery. Postoperative care: care provided following the surgery. Unless you work in an operating room, the nurse assistant's major responsibilities will likely involve the preoperative and postoperative phases. Comm Every patient scheduled for surgery, no matter how minor, has some fears. Fears regarding disfigurement, pain, loss of control, the unknown, length of recovery time, costs and financial problems, and a poor diagnosis after surgery create concerns for many patients. It is important to provide emotional support in addition to physical care. Answer all questions you can to the best of your ability. However, specific questions about the surgery, outcome, or anesthesia should be referred to the physician or supervisor. PREOPERATIVE CARE Preoperative care involves many aspects of care. The preparation is ordered by the physician, depending on the type of operation. Possible aspects of preparation are: 14/06/2023 10:28

• • Operative permit: This is a form signed by the patient to give permission (consent) for the anesthesia and surgery. If the patient is unable to sign due to a severe illness or confusion, the next of kin or an individual with a power of attorney can sign for them. Signatures must be witnessed by a legally authorized individual (Figure 3-50). Laboratory tests may include blood tests, urine tests, chest or other x-rays, ECG, and special tests ordered by the physician. ⚫ Baths may be given both the night before surgery and the morning of surgery. The purpose is to remove as many micro-organisms as possible in an effort to prevent infections. Some surgeries require a bath using an antiseptic skin cleanser the night before and the morning of the surgery. The antiseptic skin cleanser removes bacteria from the skin to prevent it from entering the surgical incision. Baths also give the patient a chance to talk and relieve some anxiety. • Vital signs are taken and recorded (Figure 3-51). They are used as a standard to check vital signs during and after the surgery. • Nil by mouth: The patient is allowed nothing by mouth for 8-12 hours before the surgery. The order usually starts at 12:00 am (midnight). A sign is usually placed on the patient's bed. Water is removed from the area at the appointed time. • Valuables: All the patient's valuables, including money and jewelry, should be placed in a hospital safe or with security to prevent loss. A patient is sometimes allowed to wear a wedding ring. However, it must be taped or tied to the finger to prevent loss. • Remove prosthetics: All artificial parts should be removed. This includes dentures, contact lenses or glasses, artificial limbs, and hearing aids. SCF FIGURE 3-50 Explain the procedure and make sure that the operative permit is signed. Remember that only authorized individuals can witness the signature. FIGURE 3-51 Vital signs must be taken and recorded as part of preoperative care. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 143 NURSE ASSISTANT SKILLS 143 | 14/06/2023 10:28

144 ورة التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 144 • Remove cosmetics: Nail polish, make-up, hair pins, and wigs are all removed before surgery. The presence of cosmetics can mask skin or nail bed color changes. . Clothing: Usually, the patient must remove all clothing, including undergarments. A hospital gown is placed on the patient. Most agencies also place a surgical cap on the patient to cover the hair. Name band: Before surgery, the patient's name band or identification band should be checked for accurate information. Because the patient frequently is unconscious during surgery, the name band is the only method of identifying the patient. Comm Voiding: To make sure the bladder is empty during surgery, the patient should void immediately before being brought to the operating room. For some surgeries, a catheter is used to constantly drain all urine. Only a legally qualified person should insert the catheter. Surgical checklist: Most agencies use surgical checklists to track most of the previously noted preparation items. As these items are completed, they are checked off the checklist. This provides a method for determining that the patient has been properly prepared for surgery. The checklist is usually attached to the patient's chart or entered into the computerized record. Frequently, patients are not admitted to the hospital or surgical clinic until the morning of the surgery. In this case, many of the tests such as blood work, radiographs, and ECG are performed on an outpatient basis before the day of surgery. ANESTHESIA Anesthesia is prevention of pain by way of loss of sensation. Medication is administered by an anesthesiologist, nurse anesthetist, or physician. The type of anesthetic used and the method of administration depends on the type of surgery, the length of time needed, and the physical condition of the patient. Three main kinds are: • General anesthesia: Medication is given intravenously or is inhaled through a mask. This causes unconsciousness, which continues throughout the surgery. A common postoperative problem is nausea or vomiting. • Local anesthesia: Medication is injected into the area around the operative site to stop the sensation of pain. The patient is awake when local anesthesia is used. 14/06/2023 10:28

. Spinal anesthesia: Medication is injected into the spinal canal and causes loss of sensation (feeling) in all areas below the injection. This is often used for abdominal surgery because it produces good muscle relaxation. Patients must be told that they will not have any feeling or movement in the legs for a period of time. Patients sometimes complain of headaches after this type of anesthesia. POSTOPERATIVE CARE While the patient is in surgery, the postoperative room or bed unit is prepared in such a way that all necessary equipment will be available when the patient returns from surgery. A recovery bed is made, an intravenous (IV) pole or stand, and equipment for taking vital signs is put in place, and an emesis basin and tissues are placed at the bedside. Necessary special equipment, such as a suction machine for drainage tubes or equipment for administering oxygen, is also placed in the unit. All unnecessary supplies or equipment are removed from the area. For example, the water pitcher and cup are removed until postoperative orders state that the patient can have fluids. Postoperative care is an important aspect of surgical care. Some of the factors to be considered in immediate postoperative care are: . Vital signs: These must be checked frequently and as ordered. They are sometimes taken every 15 minutes until the patient is stable. A sudden drop in blood pressure or change in pulse rate or character are often the first signs of hemorrhage or shock, so any changes or abnormal readings must be reported immediately. Dressings: These must be checked frequently (Figure 3-52). The color, amount, and type of drainage must be noted. Any unusual observations should be reported immediately. • IV: The flow rate and injection site must be checked only by an authorized individual. FIGURE 3-52 Dressings must be checked frequently FIGURE 3-53 A pillow across the abdomen after surgery. provides support when the patient is coughing and deep-breathing. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 145 NURSE ASSISTANT SKILLS 145 | 14/06/2023 10:28

146 وژه التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 146 • Level of pain: An assessment must be made of the amount of pain a patient is experiencing. Frequently, patients are asked to describe pain on a scale of 1 to 10, with 1 being mild pain and 10 being extreme pain. Patient-controlled analgesics are often used to control pain. An analgesic pump is attached to an IV line. The patient is taught to push a button when pain is felt. The pump delivers a specific dose of pain medication directly into the bloodstream to provide immediate relief. The patient cannot overdose on the medication because the pump locks out delivery of medication for a set period. A change in position can also help alleviate pain. If patients do not seem to be able to get pain relief, this should be reported immediately. • • Observations: Restlessness, color and temperature of skin, nausea or vomiting, and similar observations should be noted and reported. • Position: The patient's position must be changed when possible. Be sure you are aware of all movement restrictions. Some operations limit movement and positioning. Turn or move patients only after obtaining correct authorization. Cough and deep breaths: Most patients need to be encouraged to cough and breathe deeply after general anesthesia (Figure 3-53). This exercise helps remove mucus from the lungs and respiratory tract and helps prevent pneumonia and other lung disorders. • Tubes: Surgical patients frequently have drainage tubes in place. The tubes are connected to drainage bottles or special drainage collectors. If the tubes are not draining, if they are clamped, if the drainage solution changes or seems unusual, if a tube is not connected to a drainage source, or if any unusual observations are noted, they should be reported immediately. Care must also be taken when turning or moving the patient to make sure that the tubes are not disconnected, twisted, or pulled out. • Binders are special devices that are usually made of heavy cotton or flannelette with elastic sides or supports. They are applied to various parts of the body, but mainly to the abdomen, back, and breasts. Functions of binders include the following: - Provide support and relief from pain following surgery. - Hold dressings in place. - Limit motion. - Apply pressure to specific body parts. Binders must be applied smoothly to prevent pressure areas, which can lead to the formation of pressure ulcers. Binders should fit snugly for support but not be so tight as to cause discomfort. No wrinkles or creases should be present. The type used most frequently is a straight binder. It can be applied to the abdomen, back, or rib cage. Straight binders are secured 14/06/2023 10:28

using Velcro tabs. Binders are applied from bottom to top for optimal support. In this way, organs can be supported correctly. Circulation and breathing should always be checked after binders are applied. A binder that is too tight can cause severe complications. In addition, binders should be removed at intervals, and skin care should be provided to the skin under the binder. . Surgical (elastic) hose, also called support or compression hose, may be ordered to support the veins of the legs and increase circulation. These hose help prevent formation of blood clots in the legs. The hose must be applied correctly. If they are applied too tightly, they can interfere with circulation. Compression stockings, also called sequential compression devices, are attached to a pump that continually inflates and deflates the hose. They are frequently used to stimulate circulation in the legs by mimicking the action of the leg muscles on blood vessels (Figure 3-54). They increase the venous blood flow and prevent the formation of blood clots, or venous thromboembolism (VTE). Montgomery straps are special adhesive strips that are applied when dressings must be changed frequently at the surgical site (Figure 3-55). The skin around the surgical site is cleaned thoroughly. A skin barrier, such as a liquid or paste, is applied to the skin to protect it from being irritated by the tape. The Montgomery straps are then applied on either side of the surgical site. The centers of the straps are nonadhesive and tied together. To change dressings, the straps are untied, the dressings are changed, and the straps are then tied in place on top of the dressings. This eliminates the need to remove and reapply adhesive tape during each dressing change. It is essential that the nurse assistant follow all ་ standard precautions whenever contact with Precaution blood or body fluids is possible. This helps. prevent the spread of infection, including infection in the surgical patient after surgery. The nurse assistant must know and understand all aspects of care that have been ordered to care for the patient properly. Good operative care can mean a faster recovery with fewer complications for the patient. FIGURE 3-54 Compression stockings continually inflate and deflate to stimulate circulation in the legs. FIGURE 3-55 Montgomery straps are special adhesive strips that are applied when dressings must be changed frequently at the surgical site. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 147 NURSE ASSISTANT SKILLS 147 | 14/06/2023 10:28

checkpoint 1. What are the three phases of surgical care? 2. How frequently are vital signs taken after surgery? 3:12 ADMINISTERING OXYGEN The blood must have oxygen. The blood's supply of oxygen is normally obtained from the air, which is approximately 23% oxygen. As a result of accident, injury, or respiratory disease, however, the body may be unable to take in enough oxygen or to use oxygen effectively. In such cases, oxygen can be given to the patient by various means. The signs of an oxygen shortage are rapid and shallow respirations, rapid pulse, restlessness, anxiety, and cyanosis. A deficiency of oxygen is called hypoxia. Lack of oxygen can cause brain damage in 4-6 minutes. A physician's order is usually required for the administration of oxygen. The order will include the method of administration and the concentration to be given. In cases of extreme emergency, oxygen can be started with standard concentrations, and the physician notified as soon as possible. Most rescue teams, ambulance personnel, and others involved in emergency work follow specific orders regarding oxygen administration. METHODS OF OXYGEN ADMINISTRATION Oxygen is usually administered by one of the following methods: • Mask (Figure 3-56A): The mask should cover the nose and mouth. It should fit snugly to prevent loss of oxygen, but it should not be so tight as to cause discomfort to the patient. Oxygen by mask is the method of administration used most frequently by rescue personnel. It provides the highest concentration of oxygen. 柚 Comm Some patients are frightened by the mask. A careful explanation of its purpose along with constant reassurance are necessary. FIGURE 3-56A The oxygen mask covers the nose and mouth and provides a high concentration of oxygen. FIGURE 3-56B When a nasal cannula is used to provide oxygen, the patient must breathe through the nose. 148 و3و2 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 148 14/06/2023 10:28

The rate of flow by mask is usually 6-10 liters per minute (lpm). Masks should never be used with flow rates less than 5 liters per minute because the patient will rebreathe carbon dioxide and will feel smothered. • Nasal cannula (Figure 3-56B): The cannula consists of two small, curved, plastic tubes, which are placed one in each nostril. The other end of the cannula is attached to an oxygen tank or unit. The patient must be instructed to breathe through the nose. If the patient opens the mouth to breathe, the concentration of oxygen is reduced. The rate of flow by cannula is usually 2-6 liters per minute. • Tent: The tent surrounds the patient with a high concentration of oxygen. It is usually used for infants and small children. Oxygen and humidity are provided. A common example is a croupette used with infants and small children. The flow rate is usually 10-12 liters per minute. OXYGEN DELIVERY SYSTEMS Different systems can be used to provide oxygen. • Most hospitals pipe in oxygen through the wall. Some health care facilities, such as long-term care facilities, medical offices, or dental offices, may also pipe in oxygen. A flow meter for the oxygen is plugged into an adaptor in the wall (Figure 3-57A). When the flow meter is turned on, oxygen is delivered. Oxygen is color-coded with a green label. The wall adaptor usually has a green label with the word 'oxygen' or the symbol "“O,”. • Portable oxygen cylinders are used while transporting patients, in emergencies, in some long-term care facilities, and in home situations (Figure 3-57B). . • Health care facilities, such as long-term care facilities, medical offices, or dental offices, often use oxygen cylinders, or oxygen concentrators. An oxygen concentrator removes impurities and other gases from room air to concentrate oxygen in the unit (Figure 3-57C). The oxygen concentrator cannot be used with oxygen masks because it provides only low liter flow rates, usually 2-4 liters per minute. A filter on the oxygen concentrator must be cleaned frequently by washing it with warm soapy water, rinsing it, and squeezing it dry before replacing it in the unit. Patients can fill small, lightweight portable containers with liquid oxygen that can be carried like a shoulder bag. With a light, concentrated supply of oxygen that does not rely on an electrical source or batteries, a patient can have mobility for ten or more hours (Figure 3-57D). وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 149 NURSE ASSISTANT SKILLS 149 | 14/06/2023 10:28

Humidifier adaptor OXY OXYGEN 100 Humidifier Humidifier PER LEVEL WATER PREFERED WER LEVEL FIGURE 3-57A When oxygen is piped through a wall, the flow meter is plugged into a wall adaptor. A humidifier is used to moisturize the oxygen. FIGURE 3-57B Portable oxygen cylinders can be used to provide oxygen while transporting patients, in emergencies, in long-term care facilities, and in home situations. FIGURE 3-57C Oxygen concentrators remove impurities and other gases from room air to concentrate oxygen in the unit. FIGURE 3-57D Liquid oxygen is available in smaller containers and delivers a high concentration of oxygen. و250 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 150 14/06/2023 10:29

Science Pure oxygen is very drying and can damage or irritate mucous membranes. The current recommendation is that any oxygen flow rate above 4 liters per minute should be moisturized by passing it through water before it is administered to the patient. A humidifier is used to moisturize oxygen (see Figure 3-57A). SAFETY PRECAUTIONS Safety Safety precautions must be observed when oxygen is in use. Although oxygen does not explode, burning is more rapid and intense in the presence of oxygen. Flammable materials (those that burn) will burn much more rapidly in the presence of oxygen. The following precautions should be taken whenever oxygen is in use: • Burning candles and the use of open flames are prohibited when oxygen is in use. Most health care facilities prohibit smoking in all areas. In home situations or any areas where smoking may occur, a warning sign reading, for example, “No Smoking—-Oxygen” is placed on the door, in the patient's room, on the bed, or on the wall nearby. Warning labels are also sometimes placed on tanks used by emergency rescue personnel. Comm The sign is not enough. The patient must be cautioned against smoking. Observers at the scene of an accident or emergency situation must also be told to avoid smoking. • The use of electrically operated equipment, which could cause sparks, should be avoided. • Flammable liquids, such as nail polish remover or adhesive tape remover, should never be used while oxygen is in use. Alcohol- based aftershave lotions, hairspray, perfumes, and nonapproved lip balms should not be used for patient care. • Cotton blankets should be used in place of wool or nylon. In addition, all bed linen, bedspreads, and gowns should be cotton instead of synthetic materials. Cotton is static-free, and its use decreases the danger of static electricity. • Frequent inspections must be made of any area where oxygen is in use. Sources of sparks or static electricity should be removed. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 151 NURSE ASSISTANT SKILLS 151 | 14/06/2023 10:29

و153 التعليم Ministry of Education 2024-1446 CHAPTER 3 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 152 9783 PULSE OXIMETER PAY FIGURE 3-58 A pulse oximeter may be used to measure the level of oxygen in arterial blood. PULSE OXIMETERS Technology Pulse oximeters may be used to monitor the patient who is receiving oxygen (Figure 3-58). An oximeter measures the level of oxygen in arterial blood. A photodetector probe is clipped onto the patient's finger, toe, or earlobe. The percentage of oxygen in the arterial blood is displayed on the monitor screen of the oximeter. A normal range of blood oxygen saturation level is 95-100%. Levels below 90% are considered to be hypoxia, a deficiency of oxygen reaching the tissues. If the oxygen level falls below the minimum percentage programmed into the oximeter, an alarm will sound. Licensed personnel are responsible for programming and monitoring the oximeter. The health care assistant should make sure that the probe is not disturbed and should notify a supervisor if the alarm sounds. PRECAUTIONS Precaution • A patient who is receiving oxygen must be checked frequently. Quality of respirations should be noted. Mouth and nose care must be provided if a mask or cannula is used. The oxygen flow rate should be checked. • Watch to make sure that the patient and visitors do not change the liter flow. If a humidifier is used, the water level must be checked, and the humidifier replaced as indicated. Safety precautions must be checked frequently. 14/06/2023 10:29

وزارة التعليم Ministry of Education 2024-1446 • In many facilities, oxygen administration is the responsibility of the respiratory therapy department. However, the health care team member, who is with the patient more frequently, should always be aware of safety precautions and check patients carefully. Any abnormal observations should be reported immediately. checkpoint 1. List two methods used to administer oxygen. 2. What is used to moisturize oxygen? Today's Research Tomorrow's Health Care Gene Therapy That Cures Cancer? Hepatocellular carcinoma (liver cancer) kills many people each year. Researchers are experimenting with many different treatments for liver cancer. One treatment involves the use of gene therapy. Every human has between 50,000 and 100,000 different genes. These genes determine what a person inherits, such as hair and eye color. Genes also carry instructions that tell cells to perform certain functions, such as when to reproduce and grow. Initially, scientists researching the spread of liver cancer to the colon and rectum identified a gene called p53. This gene codes for a protein that is present in normal cells and regulates cell growth. In many types of cancer, the gene is missing or mutated (changed), allowing uncontrolled growth of the cancer cells. Another group of researchers in Japan studied hepatitis C carriers and discovered that the presence of a particular gene roughly doubles the chances that a hepatitis C carrier will develop liver cancer. Scientists also identified genes called FGF-19 and FGFR4, which become active in liver, breast, and pancreatic cancer, causing healthy cells to become cancerous. However, these scientists also found that when an experimental antibody inhibitor was applied, the gene's activity stopped, preventing the development of cancerous cells. Currently, several FGFR4 inhibitors are in initial trial studies. Other scientists found a gene called STAT3 that seems to protect liver cancer cells from the effects of chemotherapy (treatment with cancer drugs). Research to find a substance that blocks the action of this gene so chemotherapy is more effective has developed several potential inhibitors for STAT3. One of the most promising inhibitors is napabucasin because it seems to be efficient at blocking the action of STAT3 and allowing chemotherapy to be more effective. If scientists can find ways to replace missing genes or block the actions of genes that are causing cells to become malignant, they will be able to stop or decrease the growth of cancer so other treatments will be more effective. One major problem of gene therapy is the way that the gene has to be inserted into a person's cell. Scientists cannot simply inject genes into cells. They must be transported into the cell by using a carrier called a vector. The most common vectors used are retroviruses. Scientists inactivate the retroviruses to keep them from causing disease and then use them to carry the gene into cells. The problems that occur with this method are that the genes might alter, or change, other normal cells, or that the new gene might be inserted into the wrong location, causing additional damage to the body. For these reasons, scientists must identify easier and better ways to deliver genes to body cells. Scientists throughout the world are trying to solve these problems. If they are successful, many people with cancer may be cured. Case Study Investigation Conclusion What skills do you think Khalid and Basmah will need to have to deliver superior care to their patients? What skills involve asking each other for help? What communication skills will they need to use? GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 153 NURSE ASSISTANT SKILLS 153 | 14/06/2023 10:29