CNA - August Learning...

Nursing Assistant CertificationAccelerated Edition

CNA

Dr. Carrie L. Engelbright RN, CNE, CWP

eng62351_00_fm_i-xxviii.indd 1 8/11/17 9:52 AM

CNA: Nursing Assistant Certification, Accelerated EditionDr. Carrie L. Engelbright RN, CNE, CWP

© 2017, August Learning SolutionsPublished by August Learning SolutionsCleveland, OH

August Learning Solutions concentrates instructor’s efforts to create products that provide the best learning experience, streamlining your workload and delivering optimal value for the end user, the student.www.augustlearningsolutions.com

All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever, including but not limited to photocopying, scanning, digitizing, or any other electronic storage or transmission, without the express written permission of the publisher.

ISBN-13: 978-1-941626-35-1ISBN-10: 1-941626-35-1Printed in the United States of America21 20 19 18 17 1 2 3 4 5 6 7 8 9 10

Textbook activity answers, instructor resources, test bank questions, and workbook answer keys are available to professors via the Instructor Portal at www.augustlearningsolutions.com/CNA

Cover image credits: (left to right): ElenaMedvedeva/iStock/Thinkstock, August Learning Solutions, ElenaMedvedeva/iStock/Thinkstock

eng62351_00_fm_i-xxviii.indd 2 8/11/17 2:53 PM

This book is dedicated to all nursing assistant instructors and students. To my fellow instructors: Your work is so vitally important to our healthcare system. Without nursing assistants the healthcare industry could not function. Nursing assistants are the backbone of nursing care, sharing their roots with nurses in the environmental theory of Florence Nightingale’s canons. To my former students: You have taught me so much. To my future students: I am excited to learn even more from you. Nursing assistant programs can lead to a gratifying lifelong career or can be the entry point into any healthcare field that interests you. Please use this text as a platform from which to jump into the exciting world of healthcare.


Brief Contents1 Healthcare Yesterday and Today 1

2 The Nursing Assistant Role: Where You Fit In! 7

3 Communication 15

4 Professionalism and Ethics 22

5 Body Structures and Functioning Processes 29

6 Common Diseases and Disorders 43

7 Infection Control Practices 56

8 Body Mechanics and Workplace Safety 68

9 Reducing Client Injury and Falls 73

10 Restraints and Restraint Alternatives 80

11 Basic First Aid Measures 85

12 Holistic Care of Clients 95

13 Client Room Environment 101

14 Preventing Skin Breakdown 106

15 Bedmaking 114

16 Positioning, Moving, and Transporting Clients 123

17 Ambulation, Restorative Care, and Adaptive Equipment for Clients 141

18 Vital Signs 153

19 Bathing 167

20 Grooming 189

21 Nutrition 204

22 Elimination and Specimen Collection 214

23 Care for the Client with Dementia 228

24 End-of-Life Care 236

Common Medical Abbreviations and Directional Terminology 243

ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations 245

Glossary 249

Index 253


ContentsA Note to Nursing Assistant Instructors xvii

A Note to the Students xix

Visual Walkthrough xx

Acknowledgements xxv

About the Author xxvii

Chapter 1Healthcare Yesterday and Today 1

1.1 A Brief History of Healthcare in the United States 1

1.2 The Beginning of Modern Healthcare 2

The Modernization of Medicine 2

1.3 The Cost of Healthcare 3

1.4 Healthcare Today 4

1.5 Who Is Your Client? 4

1.6 Consumerism in America 4

1.7 Home Healthcare Versus Facility Care 5

1.8 Why the Nursing Assistant Needs to Know These Trends 6

Chapter 2The Nursing Assistant Role: Where You Fit In! 7

2.1–2.3 Work Settings for the Nursing Assistant 7

Acute Care Settings 7Subacute or Rehabilitation Facility 8Long-Term Care 8Assisted-Living Communities 9Home Healthcare 10Hospice Services 10Respite Services 10

2.4 Members of the Healthcare Team 11

2.5 Scope of Practice for the Nursing Assistant 11

2.6 Chain of Command 12

2.7 Delegated Tasks 12

2.8 Teaching Versus Reinforcing 14


Contentsviii

Chapter 3Communication 15

3.1 Causes of Medical Errors 15

3.2 Subjective Versus Objective Data 16

3.3 Oral Reporting 17

3.4 Written Documentation and the Nursing Assistant 17

3.5 Verbal Versus Nonverbal Communication 18

Verbal Communication 18Nonverbal Communication 19

3.6 Therapeutic Communication 19

3.7 Communication Disorders 19

3.8 Communication With the Hearing-Impaired Client 20

3.9 Communication With the Speech-Impaired Client 20

Chapter 4Professionalism and Ethics 22

4.1 Education and Certification 22Nurse Aide Registry 23Continuing Education 23

4.2 Acting Like a Professional 23Dependability 23Promptness 23Flexibility 23Hygiene 23

4.3 Employee Rights 24

4.4 Employee Responsibilities 24Following the Care Plan 24Mandatory Reporting 25

4.5 Client Rights 25Health Insurance Portability and Accountability Act (HIPAA) 25Informed Consent 25

4.6 Client Responsibilities 26

4.7 Laws 26Invasion of Privacy 26Misappropriation of Funds 26Negligence 27Abandonment 27False Imprisonment 27Neglect 27Assault and Battery 27Abuse 27

4.8 Cultural Awareness 28

Chapter 5Body Structures and Functioning Processes 29

5.1 Basic Structures 29

5.2 Tissue Types 29

5.3 Body Systems 30Integumentary System 30Musculoskeletal System 31Respiratory System 32Cardiovascular System 34Nervous System 35Sensory Organs 36Endocrine System 38Digestive System 39Urinary System 40Reproductive System 41


Contents ix

Chapter 6Common Diseases and Disorders 43

6.1 Common Diseases and Disorders 43Integumentary System 43Musculoskeletal System 44Respiratory System 46Cardiovascular System 47Nervous System 48Sensory Organs 51Endocrine System 52Digestive System 53Urinary System 54Reproductive System 55

Chapter 7Infection Control Practices 56

7.1 Chain of Infection 56

7.2 Primary Prevention 56

7.3 Hand Hygiene 57

7.4 Standard Precautions 58Personal Protective Equipment (PPE) 59

7.5 Specialty Precautions 61Airborne Precautions 62Droplet Precautions 62Contact Precautions 62Transporting a Client to and From an Isolation Room 62Blood Spill Kits 62

7.6 Drug-Resistant Infections 62MRSA Infection 62VRE 63

Chapter 8Body Mechanics and Workplace Safety 68

8.1 Exposure to Blood-Borne Pathogens and Chemicals 68

8.2 Injury Prevention 69Ergonomics 69Ways to Move Clients 69Lifestyle Choices to Prevent Back Injuries 70Slips, Trips, and Falls 70

8.3 Fire Safety 71

8.4 Natural Disasters 71

8.5 Workplace Violence 72

Chapter 9Reducing Client Injury and Falls 73

9.1 Why Falls and Immobility Are Dangerous 73

9.2 Risk Factors for Falling 74

9.3 Care During a Fall 74

9.4 Care After a Fall 75

9.5 How to Prevent Fall Injuries 75

9.6 Alarm Systems 76

9.7 Other Strategies 76


Contentsx

Chapter 10Restraints and Restraint Alternatives 80

10.1 Restraints 80

10.2 Ways to Work With Restraints 81

10.3 Types of Restraints 81

10.4 Risks of Using Restraints 82

10.5 Side Rails 82

10.6 Restraint Alternatives 83

Chapter 11Basic First Aid Measures 85

11.1 Airway Obstruction 85

11.2 Cardiac Arrest 86

11.3 Syncope 86

11.4 Seizures 87

11.5 Hemorrhage 88

11.6 Shock 88

11.7 Burns 89

11.8 Poisoning 90

Chapter 12Holistic Care of Clients 95

12.1 Holistic Care 95

12.2 Maslow’s Hierarchy of Needs 95Human Needs 96Application of Maslow’s Hierarchy to Caregiving 96

12.3 Growth and Development 97

12.4 Quality of Life 98

12.5 Meeting the Needs of Loved Ones 100

Chapter 13Client Room Environment 101

13.1 Safety 101

13.2 The Physical Environment 102

13.3 Individual Room Requirements 102

13.4 Noise and Odor Control 103Noise Control 103Odor Control and Cleanliness 104

13.5 Transfers and Discharges 104

13.6 Current Trends 105

Chapter 14Preventing Skin Breakdown 106

14.1 The Importance of Healthy Skin 106

14.2 Types of Skin Breakdown 106Rashes 107Friction and Shearing 107Pressure Injuries 107


Contents xi

14.3 Stages of Pressure Injuries 108

14.4 Risk Factors for Developing Pressure Injuries 109

14.5 Interventions for Preventing Skin Breakdown 110

Inspection and Cleanliness 110Positioning and Turning 111Pressure-Relieving Devices 111Positioning Devices 112Incontinence Care 112Nutrition and Hydration 113Reducing the Microclimate 113

Chapter 15Bedmaking 114

15.1 Linens 114

15.2 Infection Control 115

15.3 Body Mechanics 116

15.4 The Closed Versus Open Bed 116

15.5 How to Make the Unoccupied and Occupied Bed 117

Unoccupied Bed 117Occupied Bed 117

Chapter 16Positioning, Moving, and Transporting Clients 123

16.1 Frequency of Repositioning Clients 123

16.2 Basic Positions for Clients in Bed 123

16.3 Positions to Relieve Pressure Injuries 124

Supine 124Fowler’s Position 124

Prone Position 125Side-Lying Position 125Sims’s Position 126Tripod Position 126

16.4 Wheelchair Positioning 126

16.5 Method to Move a Client in Bed 127

16.6 Different Types of Transfers 127Dangling 127Footwear 127Gait Belt 128One- and Two-Assist Transfers 128Mechanical Devices Used for Transfers 129

16.7 Method to Transfer a Bariatric Client 131

16.8 Method to Transport a Client in a Wheelchair 131

Chapter 17Ambulation, Restorative Care, and Adaptive Equipment for Clients 141

17.1 Why We Move 141Self-Esteem 141Effects on the Digestive System 141Effects on the Cardiovascular System 142Effects on the Integumentary System 142Effects on the Musculoskeletal System 142

17.2 Levels of Assistance 142

17.3 Safety Measures Used During Ambulation 143


Contentsxii

17.4 Assistive Devices for Ambulation 143

17.5 Range-of-Motion Exercises 144

17.6 Therapy Services Overview 145Physical Therapy 145Occupational Therapy 145Speech Therapy 146

17.7 Activities Therapy 147

17.8 Restorative Care 147

17.9 The Client with a Prosthesis 148

17.10 Adaptive Tools 149

Chapter 18Vital Signs 153

18.1 When Vital Signs Are Taken 153

18.2 Infection Control 154

18.3 How to Accurately Measure Vital Signs 154

Temperature 154Pulse 156Respiration 156Blood Pressure 157Height 158Weight 159

Chapter 19Bathing 167

19.1 Routine Bathing 167

19.2 Distressed Bathing 168Alternatives to Tub Bathing and Showering 169Ways to Ease Distressed Bathing 169

19.3 Rinseless Systems 169

19.4 Peri-Care 169

19.5 Bed Baths 172Partial Bed Bath 172Complete Bed Bath 172

19.6 Shower and Tub Baths 173Shower 173Whirlpool Tub Bath 174Hair Care 175

19.7 Responsibilities on Bath Day 175

Chapter 20Grooming 189

20.1 Promoting Independence 189

20.2 Dressing 189Dressing a Client with One-Sided Weakness 190Dressing a Client Who Requires Anti-Embolism Stockings 190

20.3 Vision and Hearing 190Glasses 190Hearing Aids 190

20.4 Shaving 191

20.5 Oral Care 191

20.6 Nail and Foot Care 193Nail Care 193Foot Care 193

Chapter 21Nutrition 204

21.1 MyPlate 204

21.2 Nutrients Essential for Life 205Calories 205Carbohydrates 205Proteins 205


Contents xiii

Fats 205Vitamins and Minerals 206

21.3 Water and Fluid Needs 206

21.4 Food Groups 208Grains 208Fruits 208Vegetables 208Dairy Products 208Protein 209

21.5 Types of Diets 209Specialty Diets 209Mechanically Altered Diets and Fluids 210Thickened Fluids 210

21.6 How to Feed Dependent Clients 210

Chapter 22Elimination and Specimen Collection 214

22.1 Urinary Elimination via Catheter 214Types of Catheters 214The Nursing Assistant’s Role in Care of a Client with a Catheter 215Securing the Catheter 215Cleaning the Catheter 215Positioning the Client With a Collection Bag 216Protecting the Privacy of the Client Who Uses a Catheter 216Emptying the Collection Bag 216

22.2 Incontinence 216Care of a Client Who Is Incontinent 216Types of Incontinence Products 216

22.3 Bowel Elimination 217

22.4 Ostomies 217

22.5 Digestive Tract Bleeding 218

22.6 Devices Used for Elimination 218

22.7 Urine Specimens 219

22.8 Fecal Specimens 219

Chapter 23Care for the Client with Dementia 228

23.1 Types of Dementia 228

23.2 Treatment of Dementia 228

23.3 Ways to Diagnose Dementia 229Stages of Alzheimer’s Dementia 229Common Signs, Symptoms, and Behaviors Associated With Dementia 229

23.4 How to Manage the Behaviors Associated With Dementia 231

Ways to Meet Unmet Needs of the Client 231Therapeutic Interventions 231Ways to Maintain Function 232Approaches to Specific Behaviors 232Ways to Improve Meal Time 232Ways to Manage Pain 232Sleep Disturbances 233Toileting Interventions 233Bathing Interventions 234Wandering and Elopement Safety Measures 234Ways to Discourage Sexual Inappropriateness 234

23.5 Caregiver Strain 235


Contentsxiv

Chapter 24End-of-Life Care 236

24.1 Body System Changes 236Respiratory Changes 237Cardiovascular Changes 237Nervous System and Sensory Organ Changes 237Digestive Changes 237Urinary Changes 237

24.2 Special Care for the Dying Client 238

24.3 Faith and Religion 238

24.4 Care for the Family 238

24.5 Post-Mortem Care 239

Common Medical Abbreviations and Directional Terminology 243

ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations 245

Glossary 249

Index 253


Skills ContentsSkill 7.1 Hand Washing 63

Skill 7.2 Hand Sanitizing 64

Skill 7.3 Donning Personal Protective Equipment 64

Skill 7.4 Removing Personal Protective Equipment 65

Skill 7.5 Donning and Removing Gloves 66

Skill 7.6 Donning and Removing a Gown 66

Skill 7.7 Donning and Removing a Mask 66

Skill 7.8 Donning and Removing Protective Eyewear 67

Skill 7.9 Using a Blood Spill Kit 67

Skill 9.1 Assisting a Falling Client 77

Skill 9.2 Transferring a Client With a Mechanical Lift—Two Assist 77

Skill 10.1 Tying a Quick-Release Knot 84

Skill 11.1 Abdominal Thrusts 91

Skill 11.2 Assisting an Unconscious Adult With an Obstructed Airway 91

Skill 11.3 Assisting a Fainting Client 91

Skill 11.4 Assisting a Client During and After a Seizure 92

Skill 11.5 Assisting a Client Who Is Hemorrhaging 92

Skill 11.6 Caring for a Client in Shock 93

Skill 11.7 Caring for a Client With Second- or Third-Degree Burns 93

Skill 11.8 Caring for a Client Who Has Been Poisoned 94

Skill 15.1 Mitering Corners 119

Skill 15.2 Making an Unoccupied Bed 119

Skill 15.3 Making an Occupied Bed 120

Skill 16.1 Placing the Client in a Supine Position 132

Skill 16.2 Placing a Client in a Fowler’s Position 132

Skill 16.3 Placing the Client in a Prone Position 133

Skill 16.4 Placing a Client in a Side-Lying (Lateral) Position 133

Skill 16.5 Placing a Client in Sims’s Position 134

Skill 16.6 Moving the Client Up in Bed—Two Assist 134

Skill 16.7 Assisting the Client to Dangle—One Assist 135

Skill 16.8 Assisting the Client to Dangle—Two Assist 135

Skill 16.9 Applying a Gait Belt 136

Skill 16.10 Moving the Client From the Bed to the Wheelchair—One Assist 136

Skill 16.11 Moving the Client from the Bed to the Wheelchair—Two Assist 137

Skill 16.12 Transferring a Client with a Mechanical Sit-to-Stand Machine—One Assist 138


Skills Contentsxvi

Skill 16.13 Transferring a Client With a Mechanical Lift—Two Assist 139

Skill 17.1 Ambulating a Client with One Assist and a Gait Belt 150

Skill 17.2 Ambulating a Client With Two Assist and a Gait Belt 151

Skill 18.1 Taking an Oral Temperature With a Digital Thermometer 160

Skill 18.2 Taking an Axillary Temperature With a Digital Thermometer 161

Skill 18.3 Taking a Tympanic Temperature 162

Skill 18.4 Taking a Temperature With a Professional Model Temporal Artery Scanner 162

Skill 18.5 Counting Heart Rate—Radial Pulse 163

Skill 18.6 Counting Respirations 163

Skill 18.7 Taking Blood Pressure With a Stethoscope and a Sphygmomanometer 164

Skill 18.8 Measuring Height 165

Skill 18.9 Measuring Weight on an Upright Scale 166

Skill 19.1 Assisting With Female Perineal Care 176

Skill 19.2 Assisting With Male Perineal Care 178

Skill 19.3 Assisting With a Partial Bed Bath 179

Skill 19.4 Assisting With a Complete Bed Bath 181

Skill 19.5 Assisting With a Shower 183

Skill 19.6 Assisting With a Tub Bath 186

Skill 20.1 Dressing the Client With an Affected or Weak Side 194

Skill 20.2 Applying Anti-Embolism Stockings 196

Skill 20.3 Shaving a Face With an Electric Razor 197

Skill 20.4 Providing Oral Care for a Client with Natural Teeth 197

Skill 20.5 Oral Care for an Unconscious Client 199

Skill 20.6 Oral Care for a Client With Dentures 199

Skill 20.7 Fingernail and Hand Care 201

Skill 20.8 Providing Foot Care 202

Skill 21.1 Feeding a Dependent Client 212

Skill 22.1 Care of an Indwelling Catheter 220

Skill 22.2 Measuring Urine Output From a Collection Bag 221

Skill 22.3 Changing an Incontinence Garment 222

Skill 22.4 Emptying an Ostomy Bag 223

Skill 22.5 Assisting the Client With a Bedpan 224

Skill 22.6 Obtaining a Clean Catch Urine Sample 225

Skill 22.7 Obtaining a Stool Sample 226

Skill 24.1 Post-Mortem Care 240


xvii

A Note to Nursing Assistant InstructorsAdult learners have very specific traits and characteris-tics that need to be acknowledged by the instructor to optimize the learning process. In this textbook you will see various strategies to engage students and to improve upon the learning process.

To address auditory learner needs, your students will rely on your skillful classroom teaching techniques. For the visual learner you will note up-to-date photos and text boxes that incorporate major themes of the content in this textbook. For the kinesthetic learner, I incorporate “Get Up and Think” exercises throughout the chapters rather than traditional “Stop and Think” exercise boxes. These boxes encourage dyad learning and creative thinking skills. The exercises ask readers to stand up and walk through different areas of their class-room or school grounds to brainstorm new and creative problem-solving thought processes in relation to the content. The kinesthetic learner will benefit from part-nered skill-based activities within the classroom as well.

Adult learners need to be challenged with materials yet also need to know why this content is applicable.

Throughout the chapters I integrate reflection exercises to stimulate thinking and real-time application of con-tent, and case studies to apply information learned to real-world scenarios to make the information applicable to that unique student. I incorporate prioritization exer-cises to help the student manage the large amount of information that is needed to function in the nursing assistant role.

This book details the care for not just the older adult population, but also populations that are gender specific, age based, and setting specific to address the changing face of our healthcare delivery. Consumers of health-care want to look at alternative healthcare options, they want their care to be individualized to meet their specific demands and needs, and they want quality in the product they are purchasing. This book addresses these themes in relation to the changing caregiving standards of the nursing assistant. Instructor materials including exercises and case studies are available at www.augustlearning solutions.com/CNA.


xix

A Note to the StudentsYou will be responsible for many things when working as a nursing assistant. One important aspect of caregiv-ing is promoting independence. I describe in this book how to complete skills for someone who is completely dependent upon you for all care. You must keep in mind, though, that at every step of the way you must factor your client’s abilities into their care. This will keep them functioning at their highest capacity for the longest period of time. It will also give them more choices, which in turn will make them feel more in control of their situ-ation and will help maintain their sense of identity and self-esteem. This will take more time, but it is worth it. Stop and think how you would like to be treated in any of these situations. That is how you should be giving care.

For each of these skills, common starting-up and finishing-up steps need to be done. I will outline these steps here and just cite starting-up and finishing-up steps within the chapters and each skill page.

Starting-Up Steps1. Knock before entering, identify the client, and intro-

duce yourself.2. Complete hand hygiene.3. Provide for privacy.

4. Explain to the client what you will be doing before you start doing it.

5. Assemble your supplies.6. Ensure that the bed is at a good working height and

is locked; or, if the bed is not in use, that you are in an ergonomically correct position to assist the client.

Finishing-Up Steps1. Ensure that all of the client’s needs have been met

and that the client is positioned as desired.2. See to safety. Replace any alarms or positioning

devices as indicated on the care plan or individual service plan. The bed should be in the low position and locked.

3. Place the call light within easy reach.4. Clean and replace equipment and return supplies to

the designated place in the client’s room or facility storage area.

5. Leave the room clean and in order. The bed should be made. Remove trash and dirty linens from the room.

6. Complete hand hygiene.7. Report and document as required by your facility.


Skills TOC gives quick page references for each critical skill a student will need to learn to become a CNA.

A note from the author“This nursing assistant textbook holistically addresses clients as opposed to teaching narrow caregiving practices that focus on a specific disease process. I collaborated with others around the nation to ensure that the content of this textbook not only is up to date but also offers the most innovative and compassionate caregiving techniques so that we can empower a new generation of nursing assistants to provide exceptional care.”

—Carrie

Visual Walkthrough Whether you’re a student or instructor, the walkthrough will guide you through CNA: Nursing Assistant Certification, Accelerated Edition. The purpose of this guide is to serve as a visual reference for the features that you’ll encounter throughout the text. Understanding the purpose of each feature and how it works will not only guide your study but also prepare you for the state certification exam. We hope you find this walkthrough useful as you start your journey to becoming a CNA.

Skills ContentsSkill 10.1 Donning Personal Protective

Equipment 156

Skill 10.2 Removing Personal Protective Equipment 156

Skill 10.3 Hand Washing 158

Skill 10.4 Hand Sanitizing 158

Skill 10.5 Donning and Removing Gloves 159

Skill 10.6 Donning and Removing a Gown 159

Skill 10.7 Donning and Removing a Mask 160

Skill 10.8 Donning and Removing Protective Eyewear 160

Skill 10.9 Using a Blood Spill Kit 160

Skill 10.10 Double-Bagging Technique for Infectious Waste 161

Skill 12.1 Assisting a Falling Client 189

Skill 13.1 Tying a Quick-Release Knot 199

Skill 14.1 Abdominal Thrusts 212

Skill 14.2 Assisting an Unconscious Adult With an Obstructed Airway 212

Skill 14.3 Assisting a Fainting Client 212

Skill 14.4 Assisting a Client During and After a Seizure 213

Skill 14.5 Assisting a Client Who Is Hemorrhaging 213

Skill 14.6 Caring for a Client in Shock 214

Skill 14.7 Caring for a Client With Second- or Third-Degree Burns 214

Skill 14.8 Caring for a Client Who Has Been Poisoned 215

Skill 15.1 Assisting the Client With Relaxation Breathing 228

Skill 15.2 Assisting the Client With Visualization 228

Skill 19.1 Making an Unoccupied Bed 278

Skill 19.2 Making an Occupied Bed 279

Skill 19.3 Mitering Corners 281

Skill 20.1 Placing the Client in a Supine Position 292

Skill 20.2 Placing a Client in a Fowler’s Position 292

Skill 20.3 Placing the Client in a Prone Position 292

Skill 20.4 Placing a Client in a Side-Lying (Lateral) Position 293

Skill 20.5 Placing a Client in Sims’s Position 294

Skill 21.1 Moving the Client Up in Bed—Two Assist 309

Skill 21.2 Moving a Client in Bed With a Shearing Prevention Device 310

Skill 21.3 Log Rolling a Client 310

Skill 21.4 Moving the Client From Bed to Stretcher 311

Skill 21.5 Assisting the Client to Dangle—One Assist 312

Skill 21.6 Assisting the Client to Dangle—Two Assist 312

eng26306_00_fm_i-xxxvi.indd 19 8/10/17 4:02 PM

xx


114

LEARNING OBJECTIVES

At the conclusion of this chapter, the learner will be able to

15.1 Identify the linens necessary to make a bed and the order in which clean linens are collected.

15.2 Identify interventions used while bedmaking to prevent the spread of infection.

15.3 Describe body mechanic techniques of bedmaking to reduce self-injury.

15.4 Describe the difference between an open and a closed bed.

15.5 Identify when to change an occupied bed versus an unoccupied bed.

15 Bedmaking

15.1 Linens

No one wants to sleep in a bed that is soiled, wet, or wrinkled. That would be uncomfort-able. It is the nursing assistant’s responsibil-ity to keep bed linens clean, dry, and wrinkle free. Linens are the bedding that covers the mattress. Clean linens promote healthy skin, control germs from spreading, and promote comfort. Clean and dry linens also help keep the facility smelling clean.

To make a clean and comfortable bed, a fitted sheet, draw sheet (sometimes called a lift sheet), a top sheet (sometimes called a flat sheet), pillowcases, a blanket, and a bed-spread are needed. The lift sheet is used to move the client up in the bed or over to the side of the bed when positioning her (Figure 15.1). If the client is incontinent, one or two reusable incontinence pads are also used. A reusable incontinence pad is a pad that is placed under the incontinent client to protect bed linens from becoming soiled. If the cli-ent uses an alternating-pressure mattress top-per or alternating-pressure bed, a disposable incontinence pad should be used instead of the reusable pad. Reusable pads are too thick and hinder the alternating-pressure proper-ties. A mattress pad is used only in a home-care situation or in an assisted-living facility in which the clients bring their beds from

Learning Objectives provide an overview of key concepts, serve as a study guide, and are

essential tools for passing the state certification

exam.


15.5 How to Make the Unoccupied and Occupied BedChapter 15 Bedmaking 117116

When making the bed, do not flick or shake out the linens. This action can stir up germs in the room and contaminate clean sur-faces. Simply place the linen on the bed and unfold it rather than shaking it. This holds true for putting on a clean pillowcase. Do not shake the pillow into the case. Turn the pil-lowcase inside out, grab the corners of the pil-low with the case corners, and bring the case down over the pillow. Sometimes pillow pro-tectors are used. They are zippered covers that encase the pillow to prevent it from becoming soiled or wet. If a pillow without a protector on it becomes wet and soiled, it should be thrown away because there is no way to prop-erly clean it. Place the pillow on the bed with the opening of the pillowcase facing away from the door. This position will protect the pillow itself from germs.

The floor is always considered dirty. If linens fall on the floor, you must place them in the soiled linen bag and replace them with clean linens. If you collected linens that are not needed, those too must go into the soiled linen bag. Linens from one client’s room must never be taken into another client’s room. That would spread germs from one client to another.

You must put on a pair of gloves before you remove linens from the bed. The linens on the bed are considered dirty. Have your soiled linen bag close by as you change the bed. A good place to put this bag is on a chair next to the bed or on the foot of the bed. The linen bag cannot be placed on the floor. That would be a tripping hazard.

15.3 Body Mechanics

Rooms in healthcare facilities are often short on space. Usually, beds are placed against one wall to accommodate space for other furniture and medical equipment. This position can make the task of changing bed linens diffi-cult. Release the brakes on the bed and move it away from the wall and other furniture. This way, you will not have to stretch, twist, or lean over to make the bed. Once the bed is moved to where you can change it easily, raise the bed to a good working height. A good working height is about waist high. This height eliminates the need for bending and stooping. Repeated bend-ing and stooping can hurt your back.

Always bend with your knees, not at the waist. Work on one side of the bed, and then move to the other side to prevent exces-sive bending and stretching. Keep items you are using close by. Lower the side rails while you work. If you are changing an occupied bed, keep the side rail up on the side oppo-site from that where you are working. Always lower the side rails back down after you have finished changing the bed, unless the client’s care plan directs you to leave them up. When you are done changing the linens, return the bed to its original position. Place the bed in the low position, put back any alarms or safety devices, and lock the brakes.

15.4 The Closed Versus Open Bed

A closed bed is made with all the linens in place over the mattress. The top sheet, blanket, and bedspread are drawn up to the head of the bed (Figure 15.3). A closed bed is made prior to client admission. In a long-term care facility, the bed is closed after the client gets up and out of bed for the day. Maintaining a closed bed keeps the mattress and inner bed linens clean. Mitered corners at the foot of the bed ensure a wrinkle-free, tidy bed (Skill 15.1). Upon admission of a new client, or when the client wants to go to bed, the bed is opened.

An open bed invites the client to lie down. Upon admission, or when a client is ready to go to bed, the linens are fanfolded down to the foot of the bed. This place-ment ensures that the linens do not become

bunched and wrinkled when the client lies down in bed.

When a client is transferred from a stretcher to a bed, the linens are fanfolded to one side of the bed, rather than to the foot of the bed. The stretcher must be at the same height as the bed, and wheels on both stretcher and bed are locked. Cover the client with the linens. Tuck the linens back under the foot of the bed and miter the corners. Pull upward on the linens over the client’s feet to make a toe pleat. This pleat relieves the pressure from the tucked linens on top of the client’s toes, reducing the risk of a pressure injury.

15.5 How to Make the Unoccupied and Occupied Bed

Unoccupied BedAn unoccupied bed is changed when the client can get out of the bed. First, assist the client out of bed. She may sit in a chair in the room or in a wheelchair while you perform this task. The bed must be changed completely on every bath day, whenever the linens are heavily soiled or wrinkled, and upon client discharge. Skill 15.2 outlines the procedure for chang-ing an unoccupied bed.

Occupied BedAn occupied bed change becomes nec-essary when a client is unable to get out of bed or when it is uncomfortable for him to do so. This situation arises mainly when cli-ents are bed bound—for example, when the client is dying. It also occurs more frequently on the night shift. If bedding becomes soiled when the client is sleeping, it is often more comfortable for the client to stay in bed while the linens are changed. Skill 15.3 details the procedure necessary for changing a bed that is occupied.

Soiled linens are removed and replaced with clean linens on one side of the bed first. The client is then asked to roll over, and the process is repeated on the opposite side of the bed. This method limits the amount of walk-ing back and forth that you must do and limits the times the client has to roll back and forth.

The client should never lie on a bare mattress during this process. Be careful not to con-taminate the clean linens with those that are soiled. Soiled linens should be rolled inward to contain the contamination. Clean linens should be tucked under the rolled soiled lin-ens to prevent contamination. Wrinkles are smoothed in the clean linens before the client rolls back (Figure 15.4).

Ensure client safety while changing an occupied bed. Position the bed at a good working height for you, which is high off the floor. When the client rolls over, always have the side rail up in the direction she is rolling. This side rail can help with positioning. The client can grasp the rail, if able, and assist in rolling herself over to the side. The side rail is also used for safety. Raised, it prevents the cli-ent from rolling out of bed. The side rail used in this way is not a restraint; it is a temporary positioning aid. Once work is completed on one side of the bed, raise that rail, walk over to the opposite side of the bed and lower that rail back down. The rail should be up on the side where you are not working, and lowered on the side where you are. Remember to lower all side rails at the completion of the task, unless otherwise indicated on the client’s care plan or ISP. Some facilities have completely removed all side rails from the beds. If this is the case, you must always roll the client toward you, rather than away. This way, your

Figure 15.3 A closed bed is made with the top sheet, blanket, and bedspread drawn up to the head of the bed. Corners are mitered. Hongqi Zhang/Hemera/Thinkstock

Figure 15.4 When making an occupied bed, you remove and replace the soiled linens with a clean set on one side of the bed first. You ask the client to roll over, and repeat the process on the opposite side of the bed. August Learning Solutions

Learn how to perform this skill on page 119

SKILL 15.1



SKILL 15.2

SKILL 15.3

See workbook page 109 to quiz yourself on

the topics covered in this chapter.

TEST YOURSELF

Margins include key terms, skills, and ample space for note taking to promote comprehension and retention of learning objectives.

Imagery/graphics are incorporated throughout the text to illustrate the skills that are being taught.

Inside the Book

Key Terms are highlighted in the text and defined in the glossary to offer concise and accessible introductions to important topics from each chapter.


15.5 How to Make the Unoccupied and Occupied BedChapter 15 Bedmaking 117116

When making the bed, do not flick or shake out the linens. This action can stir up germs in the room and contaminate clean sur-faces. Simply place the linen on the bed and unfold it rather than shaking it. This holds true for putting on a clean pillowcase. Do not shake the pillow into the case. Turn the pil-lowcase inside out, grab the corners of the pil-low with the case corners, and bring the case down over the pillow. Sometimes pillow pro-tectors are used. They are zippered covers that encase the pillow to prevent it from becoming soiled or wet. If a pillow without a protector on it becomes wet and soiled, it should be thrown away because there is no way to prop-erly clean it. Place the pillow on the bed with the opening of the pillowcase facing away from the door. This position will protect the pillow itself from germs.

The floor is always considered dirty. If linens fall on the floor, you must place them in the soiled linen bag and replace them with clean linens. If you collected linens that are not needed, those too must go into the soiled linen bag. Linens from one client’s room must never be taken into another client’s room. That would spread germs from one client to another.

You must put on a pair of gloves before you remove linens from the bed. The linens on the bed are considered dirty. Have your soiled linen bag close by as you change the bed. A good place to put this bag is on a chair next to the bed or on the foot of the bed. The linen bag cannot be placed on the floor. That would be a tripping hazard.

15.3 Body Mechanics

Rooms in healthcare facilities are often short on space. Usually, beds are placed against one wall to accommodate space for other furniture and medical equipment. This position can make the task of changing bed linens diffi-cult. Release the brakes on the bed and move it away from the wall and other furniture. This way, you will not have to stretch, twist, or lean over to make the bed. Once the bed is moved to where you can change it easily, raise the bed to a good working height. A good working height is about waist high. This height eliminates the need for bending and stooping. Repeated bend-ing and stooping can hurt your back.

Always bend with your knees, not at the waist. Work on one side of the bed, and then move to the other side to prevent exces-sive bending and stretching. Keep items you are using close by. Lower the side rails while you work. If you are changing an occupied bed, keep the side rail up on the side oppo-site from that where you are working. Always lower the side rails back down after you have finished changing the bed, unless the client’s care plan directs you to leave them up. When you are done changing the linens, return the bed to its original position. Place the bed in the low position, put back any alarms or safety devices, and lock the brakes.

15.4 The Closed Versus Open Bed

A closed bed is made with all the linens in place over the mattress. The top sheet, blanket, and bedspread are drawn up to the head of the bed (Figure 15.3). A closed bed is made prior to client admission. In a long-term care facility, the bed is closed after the client gets up and out of bed for the day. Maintaining a closed bed keeps the mattress and inner bed linens clean. Mitered corners at the foot of the bed ensure a wrinkle-free, tidy bed (Skill 15.1). Upon admission of a new client, or when the client wants to go to bed, the bed is opened.

An open bed invites the client to lie down. Upon admission, or when a client is ready to go to bed, the linens are fanfolded down to the foot of the bed. This place-ment ensures that the linens do not become

bunched and wrinkled when the client lies down in bed.

When a client is transferred from a stretcher to a bed, the linens are fanfolded to one side of the bed, rather than to the foot of the bed. The stretcher must be at the same height as the bed, and wheels on both stretcher and bed are locked. Cover the client with the linens. Tuck the linens back under the foot of the bed and miter the corners. Pull upward on the linens over the client’s feet to make a toe pleat. This pleat relieves the pressure from the tucked linens on top of the client’s toes, reducing the risk of a pressure injury.

15.5 How to Make the Unoccupied and Occupied Bed

Unoccupied BedAn unoccupied bed is changed when the client can get out of the bed. First, assist the client out of bed. She may sit in a chair in the room or in a wheelchair while you perform this task. The bed must be changed completely on every bath day, whenever the linens are heavily soiled or wrinkled, and upon client discharge. Skill 15.2 outlines the procedure for chang-ing an unoccupied bed.

Occupied BedAn occupied bed change becomes nec-essary when a client is unable to get out of bed or when it is uncomfortable for him to do so. This situation arises mainly when cli-ents are bed bound—for example, when the client is dying. It also occurs more frequently on the night shift. If bedding becomes soiled when the client is sleeping, it is often more comfortable for the client to stay in bed while the linens are changed. Skill 15.3 details the procedure necessary for changing a bed that is occupied.

Soiled linens are removed and replaced with clean linens on one side of the bed first. The client is then asked to roll over, and the process is repeated on the opposite side of the bed. This method limits the amount of walk-ing back and forth that you must do and limits the times the client has to roll back and forth.

The client should never lie on a bare mattress during this process. Be careful not to con-taminate the clean linens with those that are soiled. Soiled linens should be rolled inward to contain the contamination. Clean linens should be tucked under the rolled soiled lin-ens to prevent contamination. Wrinkles are smoothed in the clean linens before the client rolls back (Figure 15.4).

Ensure client safety while changing an occupied bed. Position the bed at a good working height for you, which is high off the floor. When the client rolls over, always have the side rail up in the direction she is rolling. This side rail can help with positioning. The client can grasp the rail, if able, and assist in rolling herself over to the side. The side rail is also used for safety. Raised, it prevents the cli-ent from rolling out of bed. The side rail used in this way is not a restraint; it is a temporary positioning aid. Once work is completed on one side of the bed, raise that rail, walk over to the opposite side of the bed and lower that rail back down. The rail should be up on the side where you are not working, and lowered on the side where you are. Remember to lower all side rails at the completion of the task, unless otherwise indicated on the client’s care plan or ISP. Some facilities have completely removed all side rails from the beds. If this is the case, you must always roll the client toward you, rather than away. This way, your

Figure 15.3 A closed bed is made with the top sheet, blanket, and bedspread drawn up to the head of the bed. Corners are mitered. Hongqi Zhang/Hemera/Thinkstock

Figure 15.4 When making an occupied bed, you remove and replace the soiled linens with a clean set on one side of the bed first. You ask the client to roll over, and repeat the process on the opposite side of the bed. August Learning Solutions


SKILL 15.1



SKILL 15.2

SKILL 15.3

See workbook page 109 to quiz yourself on

the topics covered in this chapter.

TEST YOURSELF

Skills icons are included

throughout the text and end-of-

chapter materials for easy reference.

Test icons serve as a way to quiz students’ knowledge and understanding of chapter topics.


Skills correspond with icons throughout the chapter for easy reference. These skills are critical for learning how to become a CNA as well as preparing for the certified nursing assistant exam.

Chapter 15 Bedmaking118

SkillsStarting-Up Steps

1. Knock before entering, identify the client, and introduce yourself. 2. Complete hand hygiene. 3. Provide for privacy. 4. Explain to the client what you will be doing before you start doing it. 5. Assemble your supplies. 6. Ensure that the bed is at a good working height and is locked; or, if the bed is not in use,

you are in an ergonomically correct position to assist the client.

Finishing-Up Steps

1. Ensure that all of the client’s needs have been met and that the client is positioned as desired.

2. See to safety. Replace any alarms or positioning devices, as indicated on the care plan or individual service plan. The bed is in the low position and is locked.

3. Place the call light within easy reach. 4. Clean and replace equipment, and return supplies to the designated place in the client’s

room or facility storage area. 5. Leave the room clean and in order. Make the bed. Remove trash and dirty linens from the

room. 6. Complete hand hygiene. 7. Report and document, as required by your facility.

Skill 15.1 Mitering CornersSupplies needed:

Fitted sheet

Flat sheet

1. Unfold the clean fitted sheet on the mattress. 2. Tuck in the fitted sheet on one side of the mattress, starting at the top of the bed and

moving down to the foot of the bed. Move to the other side of the bed and repeat. 3. Unfold the top sheet on the bed with the seams facing upward and the wide hem at the

head of the bed. a. Center the middle vertical crease vertically in the center of the mattress. b. The sheet should hang over both sides of the bed evenly. c. The top sheet should be even with the top of the mattress. 4. Tuck in the flat sheet completely under the foot of the mattress. 5. Grab the hanging flat sheet on one side approximately 6 inches from the foot of the bed. 6. Lift up the flat sheet and pull it back over the top of the bed, forming a triangle. 7. While holding the triangular fold in place, tuck the hanging remainder of the flat sheet

under the mattress. 8. Bring the triangular fold down over the edge of the mattress, to let the rest of the flat

sheet hang freely at the side of the mattress. 9. Repeat Steps 6–9 for the remaining side of the bed.


xxv

AcknowledgementsWriting a textbook is a long and arduous yet reward-ing journey. Without the support and understanding of many surrounding me, this monumental task could not have been achieved. First I would like to thank my loving husband and children for always understanding and accepting the immense time commitment required to write this book. I spent many evenings, Fridays, and weekends at a computer screen. Throughout this proj-ect, they not only supported me but also cheered me on all the way. To my son, who contributed his creative genius to the text. To my daughter, whose unconditional understanding of missed swim meets and park adven-tures supported this endeavor. It is with immeasurable gratitude that I give my love and many thanks for their understanding and patience. To my parents and family: you supported me, encouraged me, and believed in me throughout this entire process. It is because of you that I was instilled with the values of hard work and per-sistence. To Ken Kasee, who had the vision for this project and who believed in me enough to entrust me with this

venture. To Jane Velker, who took my words, sentiments, and sometimes even my thoughts and molded them into this beautiful finished product. To August Learning Solutions, who brought this text to life. To the 2017–18 CCHI classes, whose open, honest, eagle eye and note-worthy contributions are immeasurable. Many thanks to the Posey Company, the makers of Bathing Without a Bat-tle; the Wy’East Medical Corporation; and the Institute for Safe Medication Practices (ISMP) for allowing their graphics, content, and ideas to be woven into the text. Thank you to the many reviewers who gave feedback throughout this project, and to Cynthia Hintze, who was such an invaluable contributor. Finally I would like to thank those at Mid-State Technical College for their con-tinued support in this venture, including administration and all the nursing assistant faculty who have given me inspiration, support, encouragement, ideas, and feed-back throughout this endeavor; and Lisa Whitley and Candace Barth, who stepped outside of their comfort zone to author the accompanying workbook.


xxvii

About the AuthorCarrie L. Engelbright is a registered nurse, certified nurse educator, thought leader, and author. She began her career as a nursing assistant and then as a registered nurse in long-term care. She then moved on to work in pub-lic health, focusing on children with special healthcare needs, childhood lead poisoning prevention, and prena-tal health. In 2006, Carrie started her teaching career as adjunct faculty in the Nursing and Nursing Assistant Pro-grams at Mid-State Technical College (MSTC). In 2007,

she became the Lead Nursing Assistant Instructor and Program Director at MSTC and is now the lead faculty in the Gerontology Program and the Health and Wellness Promotion Program.

In 2015, Carrie authored Essentials of Certified Nurs-ing Assisting textbook and workbook. She also completed a Doctorate of Nursing Practice in Systems Leadership with a focus on rural food desert conditions from Walden University.


1

Learning Objectives

At the conclusion of this chapter, the learner will be able to

1.1 Describe the history of healthcare in the United States.

1.2 Paraphrase the beginnings of modern healthcare.

1.3 Describe the causes of the rising cost of healthcare.

1.4 Identify funding sources for healthcare services today.

1.5 Identify who is the consumer in healthcare.

1.6 Describe the trend of client-driven healthcare services (consumerism).

1.7 Generalize why home health services are an important part of healthcare today.

1.8 Describe why the nursing assistant needs to understand healthcare trends.

Healthcare Yesterday and today1

1.1 A Brief History of Healthcare in the United States

Florence Nightingale is known as the founder of modern nursing (Figure 1.1). After work-ing in a field hospital during the Crimean War, which took place in the 1850s, Night-ingale used statistics to show the connection between sanitary conditions and the spread of infectious disease. She helped establish the scientific basis of nursing. She portrayed the art of nursing through her compassionate care of the sick, injured, and poor. As a result, she brought the basics of care to the nursing profession and to public health.

Nightingale felt that the nurse’s role was to help the individual make the fullest recovery possible. When giving care, she con-sidered not only the person but also the envi-ronment. She felt that a healthy environment was important to help the patient regain his health.

It is through her work that we have the basics of your training as a nursing assistant! Aspects of the environment that Nightin-gale regarded as necessary for nursing prac-tice include bedmaking; cleanliness of the patient; activities for physical, intellectual,

eng62351_01_c01_001-006.indd 1 7/20/17 1:26 PM

Chapter 1 Healthcare Yesterday and Today2

for the services in some way, family members within the home cared for the sick.

There were no hospitals during this time either—only almshouses. Almshouses were places for the poor, the elderly, the home-less, and the insane to stay. Most often these establishments were operated by donations from the community or religious orders. Ill-ness would easily spread through these alms-houses. If a medical school was located in the area, the students worked at the almshouses as part of their training. This training mainly consisted of an apprenticeship with a doctor.

1.2 The Beginning of Modern Healthcare

The concept of public health began to take hold in the mid-1800s. The goal of public health is to educate groups of people about healthy ways to live and ways to prevent ill-ness before it starts. Before the start of this idea of public health, it was common for raw sewage to flow in city streets. That raw sewage would then pollute drinking water. An exam-ple of public health is to teach communities the importance of a working sewage system and a clean water supply to prevent illness.

Public health interventions helped reduce the rate of infectious illness. An infectious illness occurs when a germ enters the body and causes sickness. Before public health, people were more likely to suffer and die from infectious illnesses, such as smallpox or cholera.

As the number of people in America dying from infectious illness decreased, people began to live long enough to develop chronic illnesses. Chronic illness is a condition or disease that people live with for a long period of time. Examples of chronic illness include heart disease and arthritis. The trend shifted in the United States from people dying mostly of infectious illness to people dying mostly of chronic illness.

the Modernization of MedicineIn the early 1900s, scientists began identifying causes of illness, how to prevent illness, and how to better treat patients if they did fall ill. A scientific basis for the practice of medicine

and mental well-being; proper food and water intake; documentation; and cleanliness of the patient’s room. These are all the things nurs-ing assistants are responsible for today. By taking care of these needs, you can help the client make the fullest recovery possible. You can also make sure the quality of life for your client is the best it can be. Nursing assistants play a large role in caring for the client!

In the early years of the United States, there were no real medical schools as we think of them today. There was no standard train-ing. There were no licensing boards or regu-lating bodies overseeing medical schools or doctors. There were no tests to pass. Although there were some medical schools, would-be physicians didn’t need to attend school of any kind! A doctor, as he called himself, was often the local tailor, clergyman, barman, or barber. Early healthcare practices mostly involved the use of herbal and home remedies.

The individual or his family paid for a doctor’s services. If the patient could not pay

Figure 1.1 Florence Nightingale, the founder of modern nursing. photos.com/PHOTOS.com/Thinkstock

eng62351_01_c01_001-006.indd 2 7/20/17 1:26 PM

1.3 The Cost of Healthcare 3

was therefore established. Medical schools, as we now know them, began to emerge. Medical training was much more demand-ing. It took a longer time to complete and involved scientific teaching rather than just an apprenticeship.

In the late 1900s, medicine became very organized. Doctors now have extensive training. They are also licensed and regu-lated strictly. There is an increase in specialty healthcare providers. Doctors are furthering their training in areas such as specialty sur-gery and cancer care. Because of this specialty training, jobs in physical therapy and occupa-tional therapy expanded, and specialty nurs-ing degrees evolved.

1.3 The Cost of Healthcare

With the increased complexity of healthcare, the costs increased also. Hospitals are now very organized entities. Some even specialize in treating certain groups of people or specific diseases or injuries. For example, hospitals can specialize in treatment for burn victims, peo-ple with cancer, pediatrics, and many more areas (Figure 1.2).

Healthcare is now a large part of our econ-omy. It is very costly to access. People often cannot pay for treatment outright. They need help to pay for services. Health insurance became a standard in American life following the Second World War. The model for health-care insurance was based on the workers’

compensation plans. These plans were offered by large manufacturing companies. Origi-nally, workers’ compensation plans would pay the employee’s wages if an injury occurred at work and the employee was unable to come to work for a certain amount of time. Over the years, this type of plan evolved into paying not only for the lost wages but also for the healthcare costs. This system grew into our modern-day group insurance plans. Group insurance provided by the employer became a standard benefit for working people.

There was a problem, though. Individuals who did not or could not work did not have access to a group insurance plan. Because they did not work, most could not pay the out-of-pocket expenses for healthcare. In 1965, Congress created the Medicare and Medicaid programs. The Medicare plan gives access to health insurance to older adults and to some younger people with certain disabilities. Medi-care is funded through federal taxes. The Med-icaid plan gives access to health insurance to eligible individuals and families—primarily the disabled and people with low incomes. The money for Medicaid comes from both federal and state taxes.

Until the 1980s, these methods of pro-viding and paying for healthcare worked well. However, several factors started to increase the costs of healthcare. One reason was the grow-ing use of technology and purchasing those technologies for practice. Another was that paying for specialty services became more fre-quent. Also, an older population with more chronic illnesses was growing. Finally, research dollars needed to create new technologies, treatments, and drugs made it more expensive.

Because of these rising costs, managed care organizations (MCOs) became the insurance providers of choice to better control healthcare costs. MCOs changed the way doc-tors and other healthcare workers were paid for their services. These large organizations placed limits on how much money healthcare agencies and providers could charge for each service. They also dictated the amount and types of services healthcare consumers could access. There were also financial reasons for providers to treat and discharge patients from hospitals quickly.

The payment system initiated by MCOs is very important to understand. It leads us to where we are today in our healthcare system.

Figure 1.2 Many hospitals now specialize in a certain type of care based on the population served, or the disease or injury the patient has. VILevi/iStock/Thinkstock

eng62351_01_c01_001-006.indd 3 7/20/17 1:26 PM


This is why we see a great increase in the number of outpatient versus inpatient sur-geries. It is also the reason that hospital stays are much shorter than they were in the past. And it is why healthcare consumers have lim-ited choices in where they access healthcare and from which providers they can receive services. In some situations, they are denied eligibility for certain types of care.

1.4 Healthcare Today

Today, the rate of healthcare costs is growing faster than that of inflation. It is becoming very expensive for employers to offer insur-ance as an employee benefit. Healthcare plan premiums may cost too much for a family or an individual to afford. A healthcare pre-mium is the cost that the individual must pay every month toward her healthcare plan. If the individual is employed, the amount of the premium is usually taken out of her pay-check. In addition to the insurance premium that is paid every month, individuals have other insurance-related expenses.

To try to keep down the cost of health insurance, people pay more for services used. Most insurance plans have co-pays. A co-pay is a specific dollar amount or percentage that the individual must pay for each healthcare service received. Deductibles are now widely used to control costs too. A deductible is a set amount of money that the individual must pay for healthcare services before the insur-ance company will start to pay for any services used. This amount is renewed at the start of every year. Often the deductible will be $1,000 or $2,500 or even $5,000.

Over the years, the number and types of people covered by national healthcare plans have increased. National healthcare plans now cover military veterans and their families. In some states, families just above the poverty level are now eligible for Medic-aid. Services to those on Medicare have also increased. The most popular of these services is the addition of the Medicare prescription drug plan in 2006.

Some people may not have health insur-ance. Therefore, everyone pays more health-care costs. If a person does not have insurance and needs an emergency surgery, most often all or part of the cost of that surgery may go unpaid. That means the price of future surger-ies goes up for everyone. This is how the hos-pital can recoup unpaid costs.

1.5 Who Is Your Client?

You can choose from many different settings when working in healthcare. Therefore, you will care for many different types of clients. Often, you will work with a client’s fam-ily members also. A client is a consumer of healthcare who utilizes the healthcare system.

Due to cost-containment strategies in healthcare, nursing assistants are widely employed today. There are more opportuni-ties in hospitals, community settings, and specialty facilities than there were in the past. In your nursing assistant coursework, you will be taught the basics of care for most clients. Once you are hired in a specific setting, you will have more on-the-job training to famil-iarize you with the specific population you will be caring for. You may prefer to work with older adults, children, infants, or postsurgical clients (Figure 1.3). Wherever you decide to work, you will meet many different people. Each of your contacts has the potential for helping or hurting the facility you work for.

1.6 Consumerism in America

Clients also have many choices. In America, healthcare is driven by consumerism. Con-sumerism is the belief that consumers drive choice and increase the number of choices that are offered to people. You can see this happen-ing everywhere you look. Doctors and hospi-tals advertise because they want your business. Hospital rooms have pleasant décor. Hospital ads boast new technologies. The environment

eng62351_01_c01_001-006.indd 4 7/20/17 1:26 PM

1.7 Home Healthcare Versus Facility Care 5

of healthcare agencies is designed to appeal to the healthcare consumer. Customer service is a key part of your job to ensure that consum-ers keep coming back.

A consumer of healthcare is anyone who accesses healthcare or interacts with a healthcare agency or provider. A consumer of healthcare is your client. We are consum-ers of healthcare. Clients choose the services provided. They choose when, where, and if they will access those services. With the advent of managed care organizations (MCOs) in the 1980s, some choices have become lim-ited. Usually, however, consumers have a choice of several local providers. Competition occurs when local clinics and hospitals vie for business. This is the root of consumerism in today’s healthcare system.

Clients now seek healthcare with knowl-edge about their needs or problems. With the growth of the Internet, healthcare information

is not just available for healthcare professionals anymore. We live in an age of information. Yet, because consumers may have more informa-tion, this does not necessarily mean that they have more knowledge. You may have to help clients and their families understand the health-care system and possibly even dispel incorrect information they may have come across.

Clients play an active role in their care. We need to complement that care rather than be indifferent deliverers of care. This means that, as nursing assistants, we need to explain more to our clients. We need to listen more. We need to allow more time for conversation. We need to allow the consumers the right to choose what is best for themselves and their situation.

1.7 Home Healthcare Versus Facility Care

Historically, sick people were cared for at home, either by a doctor or by their families. It wasn’t until the advent of the modern hos-pital that sick people were placed in one cen-tralized facility.

Due to the rising costs of healthcare and the advent of MCOs in the late 1980s, the average hospital stay has decreased. There is also an increase in outpatient, or day, sur-geries. Outpatient surgery is a surgical procedure that does not require an over-night stay. It is performed on the same day that the client is admitted and discharged from the surgical center. Outpatient sur-gery is also called ambulatory, or same-day, surgery. This type of surgery helps control costs for the insurance company and for the client.

Long-term care facilities, or nursing homes, offer the same kinds of services that a hospital offers, but for people whose health is more stable. Nursing homes do not cost as much as hospitals. Therefore, clients generally spend only a few nights in the hospital and are then transferred to a long-term care facility for ongoing treatment.

Figure 1.3 A nursing assistant works with a pediatric client. michaeljung/iStock/Thinkstock

eng62351_01_c01_001-006.indd 5 7/20/17 1:26 PM


More recently, assisted-living facilities have emerged as another option to nursing homes. Assisted-living facilities usually cost less than long-term care facilities because they do not offer around-the-clock skilled nursing care.

Another way costs have been decreased is through home health services, which are less expensive than the inpatient services. Home health agencies offer nursing care; personal care; and physical, speech, and occupation therapies in the client’s home (Figure 1.4). This service is reimbursed through Medicare and group insurance plans. It is an option for older adults who cannot travel to a clinic or a hospital for ongoing care. The cost of home healthcare is cheaper because it shifts the daily caregiving away from hospital or nurs-ing home staff to the client or to the client’s family members.

1.8 Why the Nursing Assistant Needs to Know These Trends

Clients seeking healthcare today are more involved in their care. Generally, they expect more out of the services they receive than clients did in the past. Clients are also more aware of healthcare resources. They also have a greater opportunity to educate themselves about diseases and treatment options. When caring for clients who actively participate in their own care, you must be prepared to adapt the care you give. You must do this even when it means that you must change your routine. You must be respectful of the choices that your clients make. Ensure that you communi-cate with your supervisor so that she can make updates to the plan of care or intervene when needed. You will need to communicate with and involve the family members if the client requests you to do so. You will need strong customer service skills. Remember, without the client, you would not be employed.

As a nursing assistant, you will play a role in controlling costs in healthcare today. You will have many choices with every single client contact that could potentially save healthcare dollars. Use only as many supplies as needed. Try hard not to contaminate items when work-ing. This way, you help prevent new illnesses in other clients and yourself. You also limit how many supplies are thrown away. When bringing supplies into a client’s room, label them and put them away in the correct storage area. This way, you prevent the next caregiver from charging the client for a duplicate supply.

Figure 1.4 Home health agencies offer nursing care; personal care; and physical, speech, and occupation therapies in the client’s home. Jupiterimages/Stockbyte/Thinkstock

See workbook page 1 to quiz yourself on the topics covered

in this chapter.

TeST YoUrSelF

eng62351_01_c01_001-006.indd 6 7/20/17 1:26 PM

CNA - August Learning...

Documents

Transcript of CNA - August Learning...